Mental Health Data Missing from Electronic Health Records

The article in HealthLine underscores the issues of developing a total electronic health record. 

Despite federal desires (CMS & HHS )to totally wrap medical records into an electronic format there remain several critical issues important to guarding privacy of patient mental health information. The Federal Definition of an EHR is extends beyond the aspects of recording patient data. They define an EHR with a broad pen including capabilities of meaningful use capturing data for analytic purposes.

By convention, and a long ethical history, providers have always guarded the privacy and protection of patient’s medical records, especially for emotional disorders. The physician has always been the health information collection agent in a fiduciary manner.  If the emotional and behavioral aspects were put into the EHR it would greatly endanger patient’s reputations, employment, and even  discrimination by health plans.  The Affordable Care Act  has markedly reduced the risk of non insurability by law. The other issues have not been addressed.

There is a spectrum of behavioral disorders ranging from severe organic brain disease resulting in schizophrenia and bipolar disorders to mild neurosis and anxiety disorders.  It is a gray playing field and somewhere in the middle it crosses over from ‘medical disorder’ to ‘behavioral disorder" in the reimbursement system. (What's in an ICD code?)

Health Plans discriminate between the two on a reimbursement basis as well. Co-pay for visits to a psychologist are higher than medical visits. In some cases even when an MD psychiatrist is involved the visiit is not treated as a medical visit even if medications are managed by the psychiatrists.

Often the staff at a ‘behavioral clinic’ do not discern the difference and bill improperly.

The federal government is interested in interoperability for purposes of data analytics. The experts who advise congress and HHS are misguided and naive, positing that developing this system will improve the quality of health care.  

Mental health issues should have a higher level of privacy protection. Not every provider should have access to the mental health record of every patient. That is a shot gun approach prone to much collateral damage. Mental health records should only be in the EHR in a higher level of protection with additional access granted only by the patient. The level of emotional dysfunction will be a major determinant in the importance of the information.

In a time when medical care has become patient centered the patient will have the final word on release of potentially harmful behavioral information. It is now established that the patient owns his own data even while it resides in the EHR program. He owns it and no one can take it without the patient's permission. (case precedence ?)

There was a time when public figures could enter a hospital and/or a provider's office and be certain the visit would not be made public. . Politicians, celebrities and other high level people expected this as the normal course of the day.  So too should it extend to all patients with equanimity. Placing this information in the EHR in an unrestricted fashion is not a good thing to consider.

Neither can a metric be applied in this gray zone. Most of it is ‘judgment’  The word that EBMers do not have in their vocabulary.

Unexpected release of protected information either medical or emotional can result in a serious alteration of a patient’s life, and/or employment. Employers like to have this information to determine suitability for employment. Allowing employers or any non medical person not directly involved in the patients health care would be akin to opening Pandora's box.

The Feds are wrong about this, as they have been in most health quality and reimbursement issues. There is no real necessity for inclusion in the EHR the Feds would like it but they are not going to get it unless providers cave in and are once again blackmailed and extorted by another carrot and stick scheme so common to our corrupt system of governing.

One in 10 U.S. Residents Affected by Large Health Data Breaches

Monday, June 16, 2014

TOPIC ALERT:

• Privacy and Security

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More than 1,000 medical record breaches involving 500 or more people have been reported to HHS since federal reporting requirements took effect nearly five years ago, according to HHS,Modern Healthcare's "Vital Signs" reports (Conn, "Vital Signs,"Modern Healthcare, 6/13).

HHS has been tracking data breaches since September 2009, when the HIPAA breach notification rule went into effect. The agency reports health information breaches affecting more than 500 individuals on its "wall of shame" website (iHealthBeat, 4/1).

Since 2009, HHS has received:

• 1,026 reports of breaches involving 500 or more individuals; and
• More than 116,000 breach reports involving records of fewer than 500 individuals through March 1, 2013.

In total, large health data breaches reported by health care providers and their business associates have affected the medical records of about one in 10 U.S. residents, or 31.7 million people. 

Meanwhile, more than 32,600 HIPAA complaint cases have been investigated, with more than 22,500 of them closing with corrective action, according to HHS Office for Civil Rights spokesperson Rachel Seeger ("Vital Signs," Modern Healthcare, 6/13)

Privacy Penalties on the Rise

In related news, HHS Chief Regional Civil Rights Counsel Jerome Meites at an American Bar Association Conference last week said he expects penalties under HIPAA to increase drastically in the next year, The Hill reports.

Since June 2013, HHS has received more than $10 million for HIPAA violations, according toLaw360. However, Meites said, "I suspect that that number will be low compared [with] what's coming up" (Viebeck, The Hill, 6/13).

Many EMR and EHR services are cloud based, and dependent upon internet connectivity.  Despite HIPAA we can expect breaches from otherwise secure sites. It is important to notify patients when breaches occur.

Health Reform to 2014 and Beyond or Back to the Future

The More You Understand About the 2014 Changes,  The Better.

If you had not noticed.

I am retired from clinical practice, and  admit I miss seeing patients.  My career goals have changed as some of you have noticed.

During the last decade I became interested in health information technology and set out to communicate with fellow professionals.  Readers of Health Train Express and it's predecessor will see an evolution, beginning with electronic medical records, health information exchange, health reform, mobile health applications, remote monitoring, and telehealth. They all serve to integrate our health communications for providers and patients.

During the last 12 months I was diverted by the Affordable Care Act and  the promises of Accountable Care Act. The potential for these new paradigms are great, however the day to day activities of providers and hospitals will  increase their load, and without additonal reimbursements. Providers have been expected to make huge capital outlays for health IT, design,implement and use these new systems.  They are directed at reductions in reimbursements to allow the large growth in patient access.  i doubt whether there will ber an actual decrease in the gross outlays for health care.  However during the past two years there have been reports of a decrease in the rate of growth.

There are some key actions to implement changes:  These webinars are designed to address specific areas that will require action.

Understanding Payment Reform - Beyond Fee For Service 

In the past decade there were some pre-paid and capitated models. The new paradigm is to approach payments connected to outcomes.  How they will be measured is open to great debate, and the subject should be addressed actively and with transparency before changes are made to avoid a catastophe such as the Health.gov benefit exchanges.  Some of these issues may be addressed by a 'global fee to hospitals and providers and/or medical groups as part and parcel of integrated medical systems.

Understanding The 2014 EHR Incentive Program 

The webinar addresses objective information for non-acute providers,practice and clinics on how to prepare for 2014 changes to the CMS EHR Incentiviei Programs.

An ICD-10 GEMS Crosswalk Overview

GEMS is a term which most providers are not familiar. CMS on it's web site offers these white papers. 

• 2013 General Equivalence Mappings - Diagnosis Codes and Guide [ZIP, 583KB]
• 
  

     The compressed zip files contain 3 white papers.

     The Dxgem file addresses specifics of conversion from ICD9 to ICD10.

MDs Everywhere's Vice-President of Development, Doug Salas explains the impact of 14,000 ICD codes expanding to 70,000 will have on documenting

Understanding HIPAA Requirements and Safety Measures 

HIPAA has been around since the mid 1990'. Providers have always known the standards of ehtical private confidentiality.  HIPAA was designed for others, institutions who deal with large amounts of patient health and financial data.  Penalties and fines are impressively high and the law has been enforced agains several large hospitals and other custodians of health records.

Recording and Archived:  (In case  you cannot attend the webinar at it's schedule time) At the time of registration you will receive a link and a date, which can be downloaded to an Outlook  .ics file.

All of the webinars will be archived for later viewing

Accountable Care Organizations and Health Information Exchange

No surprise here.  Accountable Care Organizations are going to require massive amounts of data sharing between the hospital, it's medical staff either as a whole or by  specialty.

Electronic health records and health information exchanges are an early beginning to having meaningful data, although the true nature and scope of HIE is limited by the fields that are interoperable and visible to users. Many health information exchanges only allow sharing of limited data....ie diagnosis, medications, and perhaps a discharge summary.  That in itself would be a helpful and very useful study.

Accountable Care Organizations will be searching for information systems to accomodate the needs of an ACO.

Hospital EMR & EHR reports

With accountable care becoming the standard for providers, more and more are seeking out best-of-breed vendors that can fill in the gaps in their health IT lineup and meet expected ACO requirements. It seems that just having it EMR in place doesn’t do the trick by itself. 

Management of an ACO is an entirely new industry, one that is very immature and the availabliity of experienced ACO  CEOs is very limited.  I am not sure what 'best of breed vendors means in such an immature market, nor how to compare or rate vendors.  This sounds much like a repeat of EHR software or Health Information Exchange offerings.

KLAS, a large consulting firm describes its mission, helping healthcare providers make informed technology decisions by reporting accurate, honest, and impartial vendor performance data.  The Best in KLAS Awards for Medical Equipment report is published June 15 and the Best in KLAS Awards for Software and Professional Services report is published December 15. 

 KLAS spoke with 73 organizations – mostly medium- to large-sized IDNs and hospitals –  to gauge where they are in their migration from volume to value and accountable care. The goal is to eliminate reimbursing for procedures to eliminate or minimize the 'do more' to gain  income mindset that has been embedded in the economics of medical reimbursement.

That's the conclusion from the newest KLAS report, "Accountable Care Timing 2013: Migration from Volume to Value Speeds Up," which shows that more than 65 percent of providers interviewed are looking to niche vendors to address the critical areas of population health, health information exchange and business intelligence.

We’ve known all along that the ACO game was going to be an expensive one. If KLAS is right, it’s going to be a whole new independent marketplace, in which providers shop for calls that fill in huge gaps in their existing ACO toolkit. If I were CIO, however, I’d be pretty annoyed that the huge investment made situation made in an EMR can’t get the job done all by itself.

Now the question is which health IT areas hospitals and medical practices will take on first; after all, there’s lots of ways to attack the question of how to prepare for the new, bold ACO world. My guess is that tools supporting population health measures will be particularly popular, as population health management is a key capability ACOs bring to the table that health systems alone may not.

The end game is complex, how to extract the data for analysis and merge it with population health measures, comparing expense with outcomes and maximizing better outcomes while holding expense flat, or decreasing it.

Some early ACO organizations are claiming some success in managing this goal, and it would be useful to survey what vendors and/or software combinations they use. Is it done in real time, or does it require separate data entry? 

The other big question is much like the analysis of ROI for EHR and HIX.  If the ACO will require new software, it will certainly be very expensive and no one can tell for certain what the ROI will be.

Several hospitals and INDs have lost considerable sums adopting well known EHR systems such as EPIC and/or Cerner. The failure of a central software infrastructure would be a fatal blow to a young ACO.  One that would rival the near catastrophic rollout of the national health benefit exchange in October 2013.

"This is a major shift from what we are seeing in most healthcare IT areas," said report author Mark Allphin. "What we are seeing in many areas is a migration toward integration. The fact that providers tell us that they will be looking to niche vendors over their EMRs tells us that the ACO market very likely is still up for grabs.”

So, this post raises more questions rather than answers. , 

Those early IDNs and early Pioneer ACOs may be ahead in discovering the answers to our questions.

Becker's Hospital Review lists 100 early ACOs, and CMS listed  32 initially, now down to 20 due to ACO dropouts.

Much of this information is open to question, a term which I call  "Truthiness'. CMS is claiming how successful their model is working.

According to CMS Nine of the 32 Pioneer ACOs are leaving the program, but the majority will continue. It is not surprising that some health care systems would re-evaluate their participation and choose to move on. The program does not guarantee that it will be the right fit for every health system. That’s the nature of innovation. And no model may be right for every population in every community.  It is important, however, to examine these departures for the lessons they offer.

Further commentary from CMS:

"We remain optimistic. ACOs represent one innovative model with the potential to improve care coordination, ideally leading to improved quality and lower costs. Testing of that model should continue, and we are pleased that the Medicare ACO program has given a boost to the development of ACOs, which are now proliferating among private health plans and provider groups"

Is this the message of idealogues, who will forge forward no matter the variability of success or failure.

We have seen the early missteps of Health Benefit Exchanges and there should be no reason to trust  CMS plans and/or statements.

Digital Health Space will be watching this niche carefully.