Grass Roots HIT in the Hospital and Clinic

Clinicians are an innovative group. From physicians, nurses, pharmacists, administrative personell, all are users of mobile apps at home and/or work.

mHealth News reports that there are some "apps that clinicians can't quit". Patients at the Hospital of the University of Pennsylvania (HUP) might wonder why their nurses are always on their smartphones — until they learn those nurses are actually sending secure messages to everyone on a patient’s care team.

It’s part of a highly successful pilot that began more than a year ago, and one that caregivers don’t ever want to see end.

What made this pilot unique is that it was grassroots-driven,” said Neha Patel, MD, one of the pilot’s developers.

Patel, an assistant professor of medicine at HUP, partnered with the information systems department at Penn Medicine to develop an mHealth strategy that would not only improve communication among a patient’s care team, but also save clinicians time.

Patel and a colleague will discuss the pilot at the upcoming mHealth Summit in December outside Washington, D.C.

For the pilot, which began in May 2013, residents, faculty physicians, pharmacists, social workers and discharge planning nurses were provided with iPhones or iTouches in four of the hospital’s departments: three general units and one surgery outfit. They used a secured-messaging mobile application called Cureatr to communicate everything but emergency messages with a patient’s entire team. As shifts changed, the phone was passed on. Communication remained fairly seamless, Patel said.

Now, nearly a year and a half after the pilot started, staff at HUP refuse to let go of their phones or Cureatr. When house staff rotate to units that don’t use the app, Patel explained, they complain that communication is “archaic.” 

It’s no wonder. A HUP time-motion study showed residents were spending about 20 percent of their day communicating with other healthcare providers, either face-to-face or on the phone

Another home-grown application, Connexus.(Connexus®, the Education Management ,  an app that allows providers to pull up patient data on their smartphones.

System(EMS). Connexus has been adopted by various user groups for purposes beyond the original design scope:. “Anesthesiologists, for example, are using it for pre-op evaluation, ancillary providers to follow the ‘thinking’ of the primary team, and consultants to quickly evaluate a new patient.".

The lesson is that iit does not take a million dollar investment to design HIT solutions for the hospital, or clinic. Individual initiative and grass roots trials are often more creative and functional than a poorly designed commercial medical app

Why the Government Prejudice regarding Specialty Electronic Medical Records

The past decade saw the development of electronic medical records, both in number and level of sophistication During this decade there was a steep learning curve by vendors with frequent and arbitrary regulations regarding EHRs.

Successfully Choosing Your EMR: 15 Crucial Decisions 

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EHR development has been overly influenced not by it's functionality but by parameters of HHS and CMS in regard to data structure and interoperability.

The regulations included a mandate for interoperability and items called 'meaningful use'.. The term 'meaningful use' is a misnomer.  Meaningful use in their terms only had to do with it's utility in garnering information from an EMR which may or may not be useful for it's designed purpose.

The following statement from Ophthalmology Management specifies some items:

"Switching electronic medical records (EMR) systems is a big decision, even if you feel like throwing your existing system against a wall. So don't ditch your EMR system before you download the paper that includes an eight-question assessment to help you decide - and to protect you from making the same mistake twice.  (this statement is from Ophthalmology Management and is a quote from EMA, a specialty EHR for ophthalmology.)"

In many specialties there are fields and specific information unique to that specialty. Clinical work flow must be considered, since a poorly designed software can radically alter efficiency and disrupt the clinic volume and income. Numerous studies have revealed that efficiency can be reduced for several months by a factor of 20-30%.

Medical practices chose to accept incentive payments for consenting to meet meaningful use criteria with their EHR.  This occured by an angst of 'not being left behind' despite serious reservations and advice for HHS and ONCHIT. Several deadlines have been delayed and doubts remain about the implementation of MU Stage III.

Many medical practices have invested in EHRs. Some installations were obsolete at the time of purchase.

Some medical practices decide to purchase a new system despite the added costs, preferring to write off an older system with accelerated depreciation. These decisions are supported by a record of decreased patient volume.  Most physicians report an additional hour of work each day and a reduction in patient volume.

Many physicians have expressed their extreme unhappiness with their electronic health records. Management surveys continuously confirm dissatisfaction. Despite this, EHR use has grown.  Imagine using a defective hammer to drive in a nail. Regulators have taken their eyes "off the ball" ignoring patient care, and equating paperwork with 'quality of care'.  This has become a fundamental failure of the entire American health care system.  Poor patient care can easily be disguised if all the information which is entered is designed to thwart the 'required entries' to proceed, or satisfy an algorithm for a complete medical record.

There are several certifying standards, the most onerous are those mandated by CMS and regulated by  

Adding to this frustration is that many large organizations will select a vendor whose reputation has been built upon usability for primary care and/or internal medicine/pediatrics.  Population Health has become a new 'buzzword" in the HIT workspace.  A large or medium sized multispecialty group may select a system which their specialists can not use.  Interoperability has become a deserved design requirement.

When designing or selecting an EHR, every department must have input on decision making. Some IPAs and loosely organized primary care groups have offered to 'give' an EHR to their specialists t
o encourage acceptance of a group EMR.  This in many instances has been disastrous.

Their are other choices.

1. Utilize a specialty specific EHR based upon:

     User testimonials
     Site visits
     Demonstrated user functionality and efficiency in actual operations.

2. The requirement for interoperability are clearly defined by ONCHIT which should make disparate systems interoperable.

3. The realities however are quite different from a vendor point of view, leaving users holding the proverbial 'bag'.

Does your EHR need a tweak or a trashing?

How to tell if your system is already in need of a major goose.

BY ROBERT N. MITCHELL

Need an EHR plan?

Whether it’s your practice’s first foray into EHRs or your practice is upgrading to a new version of the software or a new system, the HealthIT.govwebsite provides ophthalmology practices valuable insight. This includes these six steps:

1. Assess your practice readiness
2. Plan your approach
3. Select or upgrade to a certified EHR
4. Conduct training and implement an EHR system
5. Achieve Meaningful Use
6. Continue quality improvement

On the www.HealthIT.gov website, each step is a link that users may click on for a detailed explanation.

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

Monday, June 16, 2014

TOPIC ALERT:

• Privacy and Security

Click on topic to receive periodic emails.

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.

The Evolution of Health Information Exchange, 2014

It can be said that the first part of the 21st Century in medicine has been the wave of information technology.  The capitalization of this relatively new department has diverted much funding from other needs in the health care industry.

The addition of HIT required federal underwriting. The ‘incentive’ was more of a negative reward/penalty instrument to force adoption of IT.  In order to maximize reimbursement from CMS hospitals are incentivized to reduce readmissions, and report meaningful use. Meaningful use follows a progressive course, escalating over time until fully implemented. Hospitals have many more stages than clinics or individual providers. Providers and hospitals alike must ‘attest’ to this functionality and demonstrate they are reporting. Failing to do so by a specific date is penalized by a reduction in reimbursement for services.

Much importance has been assigned to this effort, including improved outcomes, decreased expenses, improved patient experiences, transparency of information, accessibiliity of information for patients and providers and the unproven promises of ‘BIG DATA’

It will take some time to determine if these processes will  reduce expense or flatten the rate of inflation of health cost.  Built into and hidden from view is the cost of obtaining the data, and analytics.  A substantial IT investment and personell are added to the equation.  

The peverse nature of government is to spend more to save more…Government is fueled to expand and self-replicate ad infinitum.

Other industries such as the automotive business have profitted from BIG DATA, and it is hoped that by translating it to health care there will be dividends in treatments, cost reduction, safety, and better outcomes.

The Evolution of Health Information Exchanges

My  experience in this area began in 2005 as I led a group of physicians to consider a regional health information exchange.  It was a slow but fertile beginning.

We all focus on what is now and what lies ahead, that challenge can be justified by a brief but important look at our past accomplishments which are considerable.

Much has been accomplished, by many, and at relatively little expense in the planning phases of  HIE.  Early planning and project management time expenses were donated at no charge by physician leaders, medical societies, and interested vendors.

Well intentioned leaders do not have to spend billions of dollars to study or plan a project of this scope.  

These thoughts were corroborated as reviewed written and verbal correspondence for the early meetings of the Inland Empire Health Information Exchange (Riverside, Callifornia)

Neither can one forget the prescience of  President George W. Bush by forming the Office of the National Coordinator of Health Information Technology, Don Berwick M.D. and their successors.

Physicians were dragged into the mix as naysayers, not wanting more complex procedures to interfere with patient management responsibilities. We are now well along the way and there will be no turning back.

Even more than the abilit fo providers to exchange medical information is the added dividend for analytics, and support for accountable care organizations.

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

Health IT in Asia at Health 2.0 India

Read more about it at Health Train Express including these topics of interest

• Designing an improved patient experience for a Billion people

• Trending – Startups, Funding and Accelerating Health 2.0

• Health 2.0 in the village

• Quantified self, wearable sensors and trackers

• Mobile health in real life

• Rise of big data and better decisions

• Pharma and better outcomes

• C-Level executives unplugged

• Unmentionables amplified – Sex, Sport & Rock n’ Roll

Visit Health Train Express to learn more........