Barriers to Health Information Exchange

Quote of the Day:
Everything that can be invented has been invented.
--Charles H. Duell

 

In this column I often write about promoting health information exchange.

In all cases, however, we must comply with HIPAA and place barriers for confidentiality and privacy to protect patients from unauthorized access to their health records without proper authorization.

Health Insurance Portability and Accountability Act of 1996 (HIPAA) is an expansive set of rules to privacy for patient information.  The lesser known aspects of it may be largely unknown by physicians.  I came across a survey of dentists which had some interesting information, although not all aspects apply to medical offices. It is available for a full read at:Dental Survey

Several lesser known requirements are:

Inventory and Control of all hardware and software

Security and disposal of all media

Log of maintenace of hardware/software

WRITTEN work station

Further details are in the article itself.

Such questions arise such as:

Should patients have the option to specify that their medical records not be shared on a common HIE?

Should there be an audit trail for 'shared information'?

More on Health Information Exchanges

Although the advent of the RHIO as a business structure for the development of  Health Information Exchanges has largely failed to do what it was intended to do, the motivation for HIE will largely be driven by  CMS mandates and well as quality and safety concerns. 

(HealthDay News) -- "From 2004 through 2006, patient safety errors resulted in 238,337 potentially preventable deaths of U.S. Medicare patients and cost the Medicare program $8.8 billion, according to the fifth annual Patient Safety in American Hospitals Study

This analysis of 41 million Medicare patient records, released April 8 by HealthGrades, a health care ratings organization, found that patients treated at top-performing hospitals were, on average, 43 percent less likely to experience one or more medical errors than patients at the poorest-performing hospitals.

This analysis of 41 million Medicare patient records, released April 8 by HealthGrades, a health care ratings organization, found that patients treated at top-performing hospitals were, on average, 43 percent less likely to experience one or more medical errors than patients at the poorest-performing hospitals.

The overall medical error rate was about 3 percent for all Medicare patients, which works out to about 1.1 million patient safety incidents during the three years included in the analysis

"HealthGrades has documented in numerous studies the significant and largely unchanging gap between top-performing and poor-performing hospitals. It is imperative that hospitals recognize the benchmarks set by the Distinguished Hospitals for Patient Safety are achievable and associated with higher safety and markedly lower cost," Collier said. "

The entire article can be found at  Washington Post.

Of some interest to me is no mention whether their was a difference in the use of "health information technoloogy" between the "high achievers" and the underperforming" hospitals. Does anyone have statistics on this metric?

The Fifth Annual Health Grades Patient Safety in American Hospitals Study

Consumer Health Information Exchange

We as health care providers, hospitals, laboratories, emergency departments and others view health information and data exchange through a narrow prism from our side of the health care system.

Patients (consumers) also have begun to form their own virtual world of support groups and education amongst themselves. For years there have been patient oriented support groups and organizations.

Web 2.0 now has some very innovative offerings for patients.

Healing in Community Online offers a "second life" aspect to these interchanges of support and education.  It's construct is much like the real world, with provider offices, laboratories, hospitals, and all the usual everyday accoutrements of healthcare.

Diabetes Mine offers a wealth of patient oriented commentary for diabetics.

Patients Like Me offers links to specific disease entities, which include these "communities:

Motor Neuron Disease

Anxiety

Bipolar

Depression

AIDS

Multiple Sclerosis

OCD (Obsessive-Compulsive Disorder)

Parkinson's Disease

PTSD (Post-Traumatic Stress Disorder)

Quote of the Day:
Light travels faster than sound so some people appear bright until you hear them speak.
--Joe Messmore

Innovation

Quote of the Day:
If you really want to do something, you will find a way. If you don't, you will find an excuse.
--Anonymous

 

Clinicians each day face innovation, like it or not. It traverses our day from the hospital to our office and to our business engines.

Continuing medical education, and staff training are a key methodology of "technology transfer" from the boiler-rooms of academia and practice management gurus.

We are all involved in some aspect of the process, the rising impact of consumerism, monitoring of outcomes, performance measures, reimbursement based upon compliance with reporting these metrics, and the influx of information technology.

The past three years as a health informatics researcher, I have devoted much time by interviewing vendors and the different approaches they use for their own business models.  Understandably they are in it to make a profit.

Most observers realize that HIT has undergone a rapid evolution with many failures, and some successes.

In past years some vendors would offer "beta" systems to practices for a reduced amount to build their software. There were many problems with this approach. A clinical practice setting operates on a daily basis and does not have the IT resources to support the many software and/or hardware "bugs" that are part and parcel of poorly written or undeveloped software.

In the development of Health Information Exchanges I have seen many different approaches to this new challenge.

An early question from the vendors is "who are your stakeholders"

Sales people like to develop lists of hospitals and clinicians they can approach to display their wares. Some are ethical and truly are dedicated to improve health care by using HIT.  As a consultant and physician working with a company the company gains some credibilty by having a fellow physician "vette" their offering.  Unfortunately in this process I have investigated multiple companies and have disqualified most.  Many are smaller companies who do not have  adequate support. Many of their "demos" are fancy power point presentations which do not truly exhibit the flaws in the actual operation of their system.

Many of them are very "defocused" attempting to have a large marketing department and not focus on truly developing a pilot program to demonstrate their offering(s).  Some are not focused on health information exchanges and want to  use this as a marketing bridge for EMRs, transcription systems.  Many are the result of mergers, acquisitons, to expand the functionality of their offerings.  In some cases they market systems that are not truly connected.  In some cases they will offer a complete solution when they do not  have the pieces integrated, other than fancy tricolor glossy marketing pieces.  They often speak in terms that are unfamiliar to clinicians, such as "revenue cycle management".

They imply practices can "plug and play" as if it operates like a usb port on a personal computer.  This is inherent in their asp online solutions (also known as web 2.0). On the surface this has been offered as a "hosted application" residing elsewhere much like a "mainframe"  All the practice needs is a "thin client" (formerly known as a workstation. This is connected via the internet. We have al witnessed significant decline in internet performance which degrades swift data entry and/or retrieval.

Initially it is offered on a reasonable monthly subscription cost, much less than the investment of a inhouse client-server system

As the offer evolves you will find surcharges for training and maintenance charges.

If one truly wishes to research health IT, it is worthwhile to attend one of the annual HIMSS meetings.  www.himss.org

The Healthcare Information and Management Systems Society (HIMSS) is the healthcare industry's membership organization exclusively focused on providing leadership for the optimal use of healthcare information technology (IT) and management systems for the betterment of healthcare. more >

Attend in the role of an interested observer, not as a place where  you select a vendor.

In my next blog we'll discuss weblog's that are resources for innovative ideas, and most important written by knowledgable experienced thought leaders.

AMERICAN MEDICAL NEWS -What's in a Name?

Washington -- The jumble of terms in health information technology soon could be simplified. The National Alliance for Health Information Technology announced March 24 that it finished proposed definitions for five key HIT terms and will seek public comment on them until April 9.

The ONC chose the terms because they are the most often confused. Lawmakers have proposed bills that use the terms in different ways, said Karen M. Bell, MD, director of the ONC's Office of HIT Adoption.

 

After the definitions are finalized, the ONC will officially adopt them and use them in its contract language, said alliance Vice President and Chief Marketing Officer Jane Horowitz, who leads the project. Organizations and companies should follow and operationalize the definitions throughout health care, she said

One of the most significant developments would be distinguishing EMRs from EHRs. The two are frequently used interchangeably. The alliance proposed identifying an EMR as medical information on an individual patient from a single organization, including affiliated settings. EHRs would be data on a patient aggregated from multiple organizations.

The National Alliance for Health Information Technology has proposed definitions for several common health IT terms:

Electronic medical record: A computer-accessible resource of medical and administrative information available on an individual collected from and accessible by health care professionals involved in the patient's care within a single care setting.

Electronic health record: A computer-accessible, interoperable resource of clinical and administrative information pertinent to the health of an individual. The information, drawn from multiple clinical and administrative resources, is used by a broad spectrum of clinical personnel. This enables them to coordinate the patient's care and promote wellness.

Personal health record: A computer-accessible, interoperable resource of pertinent health information on an individual. Unlike the EHR, however, the PHR is managed by the patient, and the patient determines who has the right to access and use it. The information originates from multiple sources and is used by individuals and their authorized clinical and wellness professionals to help guide and make health decisions.

 

The terms health information exchange and regional health information organization have overlapped, the alliance said. It based its definitions on their root meanings. HIE reflects the technological aspects of sharing data, while RHIO reflects the drive for better health care quality and efficiency within a region.

So the alliance defined HIE as the electronic movement of health-related data across nonaffiliated organizations in a way that protects privacy and security.

It defined a RHIO as a multi-stakeholder governing entity responsible for electronic information exchange within a geographic area. A RHIO must involve data sharing between separate entities in a defined area whose collaboration crosses organizational boundaries. It also must be focused on the greater good of a defined population area, instead of specific disease communities, such as a network exchanging information only on diabetics.

The Chart at the Foot of the Bed is Gone

Sorry for being absent the past several weeks. Recently I had the unexpected opportunity to catch up on technology at the bedside (in the bed) at my local community hospital which I had been on the staff 16 years ago.  I had been away in another community and only recently had returned to the area but practice in a more rural community in the same town.  Some things change, and others never change. Chest pain is chest pain and shortness of breath are the same complaints.  My arm band now had a bar code on it. The nurses all used wireless laptops for charting and reading orders.

The doctors were all still at the nursing stations either dictating or writing their chart notes. The doctors seem to be the last link in the chain of IT.  I definitely had the feeling IT was "leaking in".

At my post operative visit in the cardiologist's office he was able to retrieve summaries, op reports and demographics via a portal, although he had not yet implemented EMR in his office.

I am now the beneficiary of a cardiac stent, placed into a ten  year old coronary vein graft which had only 1% flow through it. Although ten years had passed without incident the old leg scar is still quite evident, more so than the long chest scar.

At the end of the rather prolonged angioplasty I was given a CD with a DICOM viewer and video for my own personal health record.  Pictures are worth a thousand words and in the future if I have to have any other procedures this will be instantly available.

This was a far cry from the CABG (4 vessels) that was performed on me ten years ago.  I was given a hand sketch of that procedure, which was lost many years ago and unavailable on short notice.

(not many patients are given advanced notice of acute coronary syndrome).

Just six months ago I had returned to near full time ophthalmology practice......the volume was up from 40 patients a day to over 50 patients a day. The practice had no EMR. Those are the numbers in productivity that are needed in some setting with capitation and/or heavy managed care intrustion, unless one adds cosmetic and/or refractive surgery to the mix.  Most doctors want one thing from an EMR....improved efficiency and reduced cost, and not over a pay back of more than one year. ROIs must be short because the only predictability of reimbursement is that it will decrease and bureaucracy will increase.  Common sense must intrude into the mix of the business of medicine.

Too many think tanks and doctor wannabees are draining dollars from patient care. Much of medicare's "fraud and abuse" mechanism revolve around inaccurate coding (obsolete ones), and complex schemes that require a graduate level education to understand.

My outlook is rather dismal....I used to be one of those optimistic "the glass is half full", now it is the other way around..."it is half empty".  Yes, those who can negotiate the system get excellent care.....there will be more care for fewer patients.

The economic engine for a typical practice bears no relationship to how doctors are trained, nor how they want to practice medicine.....Non practitioners have no idea of the stresses involved and why doctors burn out from a profession that initially was very gratifying and rewarding. 

I remain hopeful that IT will assist us all in patient care, and not become another misguided burden in caring for patients.

And, oh, by the way the bar coder broke and the nurse was delayed by over an hour trying to get medication for me. Imagine what it will be like when the server "crashes" (not if)

Happy Passover and Easter to all

CMS RESPONSE

Readers of my last commentary will be pleased to hear of the very quick response I received from CMS regarding the exclusion of California from the new Electronic Health Record Grant announcement.

 

" 

Thank you for your inquiry about CMS' new EHR demonstration.

This demonstration is being conducted by Medicare’s Office of Research, Development & Information. The EHR demonstration is one of many demonstrations across the country that the Demonstrations Program Group is conducting to examine ways to improve how care is provided to Medicare beneficiaries. Such initiatives are conducted to inform policy decisions about the Medicare program.  Because these are research projects, it is often important not to have multiple demonstrations being conducted in the same area if one project could affect the results of another. In addition, as part of this research, areas where demonstrations are being conducted are often compared to similar areas where there are no special projects going on.  When planning new demonstrations, we try to stay away from areas where there are similar existing projects or areas serving as comparison regions for these projects so as not to confound the results of those demonstrations and influence the integrity of the evaluation of these initiatives. Therefore, the list of states and counties excluded from applying to participate as community partners for the EHR demonstration reflect areas where Medicare already has similar projects and evaluations underway.

California is excluded from the EHR demonstration because primary care physicians in that state are already participating in another, similar demonstration: the Medicare Care Management Performance (MCMP) demonstration. This 3-year demonstration began last July and over 200 small to medium-sized primary care practices in the state are participating. Therefore, the decision was made not to implement this new demonstration in California or any of the other states where this or similar demonstrations are being conducted.

If  we can answer any other questions for you regarding this demonstration, please do not hesitate to contact us.

Jody Blatt

Debbie Van Hoven

Project Officers, EHR Demonstration

Medicare Demonstrations Program Group  "

A LETTER TO CMS

Inland Empire Regional Health Information Organization

Gary M. Levin MD, Coordinator

20032 Sweetbay Road

Riverside, Ca.

Email: gmlevinmd@gmail.com

Tel: 951-746-9145

Press Release: A Letter to CMS regarding Electronic Health Records

CMS Demonstration Project: Electronic Health Records Demonstration 2008

Dear sirs;

For the past four years I have been involved with promoting and developing a regional health information exchange for the Riverside and San Bernardino County region of Southern California. This is a rather large geographic area east of Los Angeles and includes some rural and remote desert communities as well as urban and suburban areas.

I also publish a weblog devoted to information technology as a resource for area physicians and interested parties regarding RHIO progress in our area, which I might add has had dismal response. http://healthtrain.blogspot.com .

Despite the encouragement of the California Regional Health Information Organization and their “framework” for developing such entities there has yet to be made any significant progress, with multiple failures as we have seen in other RHIO efforts.

In my search for funding I was very encouraged to see the projected CMS Electronic Health Record Demonstration Project that was announced several weeks ago. However your recent email update surprised me and discouraged me greatly. The entire state of California is excluded from applicants and eligibility for these grant(s).

I am curious as to how and why this decision was made by policy makers? California represents a spectrum of health providers and has a large population as well as regional diversity. There is also a significant taxpayer base here, as well as CMS recipients. While there are several large health care entities who are adopting electronic heatlh records here, the adoption of EMR in smaller practices is very low. There also remains no connectivity between these groups and individual providers as well as academic medical centers.

California in the past has been on the forefront of developments in healthcare. Our state is certainly stressed in regard to healthcare for all its’s citizens. It’s hospital system has been decimated by reduced reimbursement as well as caring for uninsured as well as undocumented aliens. Our chaotic health insurance underwriting is chaotic and discriminatory for those who lose employment or have pre-existing conditions. The secondary economic toll is staggering and saps our potential wasting many lives.

The impact of granting CMS grants to our region would be great. The funds would do the greatest good for the most people. Most CMS grants seem to go to rural, underserved, or disadvanated counties or subsets of health issues. There has been a definite bias against the vast majority of insured and seemingly independent citizens who are imagined to be able to produce a system for Health Information Exchange.

The recent increased interest has produced a “feeding frenzy” amongst IT vendors whose main interest is “great profit” from medical providers . Numerous health care interests, insurance providers, CMS, have projected enormous savings and improved quality of care from health IT. Yet, some studies have failed to demonstrate this as true.

The adoption of EMR and HIE is much more than installing systems. It requires “change management” and few smaller practices have these resources available. Estimates for cost effectiveness fail to include training expenses, nor maintenance of systems which can amount to 15 or 20 percent/annum of the initial investment.

I and all the other health care providers will be interested in your important response to my question

Very truly yours,

Gary M. Levin MD

WHO ARE THE 'WE'S?

Can physicians make the changes necessary to continue to provide quality care, while at the same time beseiged by increasing demands on the part of insurers, CMS, patients,etc.

 

There is no doubt there are many others willing to "steer" the boat, and relatively few physicians participate in organized medical associations. We are divided, fractured and all but trampled upon.  Chaos reigns supreme....mostly because we are not pro-active. 

Our political leaders are all chanting "CHANGE"  !!

The initial phases of information technology and how it applies to the medical industry has just begun.  Although it has not yet reached critical mass the "growth curve" indicates a steady incremental increase in the number of users of health information systems, of which  EMR is only a part.

The Annual HIMSS meeting which is taking place this week has progressively increasing attendance, a reflection of the market potential of this technology.

Many "hospital systems", large groups have or in the rollout phases of their EMRs. 

There can be no doubt that once a "critical mass" is obtained, those providers who do not utilize this tool will be at significant risk of economic and referral disadvantage.  As true of most decision-making it is much better to be proactive and be on the leading edge rather than the trailing adopter.

Adopting EMR is far more than purchasing a system. It requires "change management" of how your support system flows.

For those using EMR, despite the transitional challenge, most say they would  "never go back ".

So, who are the We's?? In my opinion it is YOU and I.

A Word of Caution

 

I have read that some physicians are acting proactively in installing EMR to preclude the possibility of having their reimbursement reduced by payors and CMS for not having electronic health records.

Payor and CMS requirements have not defined what they consider as electronic health records. They do not define how inclusive or what data needs to be in the EMR.  Does a document manager of scanned files fulfill their requirments??

I maintain that providers need to do what is best for THEIR PRACTICE, and not jump off an expensive cliff to satisfy some " entity", which wants data for their  own ends. 

If EMR grows and takes hold it must be led and driven by providers.

Good News

Mike Leavitt, the head of HHS announced the privatization of the AHIC group. He also announced the steady increase in the number of EMR vendors who are complying with, and becoming certified by CCHIT. This is no small accomplishment because it requires a substantial fee, for the smaller vendors. According to Leavitt about 75% of EMR vendors are now CCHIT certified.

 

Secretary Leavitt elaborated on the progress toward interoperabilty.

 

"

• We’ve established an infrastructure to drive our work on the ground in the form of work groups and nonprofit organizations.
• Together, we’ve harmonized dozens of standards.  As of today, I’ve officially recognized 34 interoperability standards that lay a foundation for standards-based health information exchange.  This is not work we’ve done alone.  We’ve had the help of thousands of volunteers participate with HITSP [Health Information Technology Standards Panel] to help get us to this point.
• We have grown our number of Use Cases from which more standards will flow. We had three in 2006, four in 2007, and six for 2008, which shows that we are accelerating..
• To date, C-C-H-I-T has certified roughly 75 percent of the outpatient EHR products being used by doctors today. They have also certified more than a third of the vendors with C-P-O-E (Computerized Physician Order Entry) products for use in the inpatient setting.  In fact, just today, CCHIT is announcing its latest group of certified inpatient EHRs.
• We have also launched trial implementations for the Nationwide Health Information Network to demonstrate possible configurations for secure interoperability.

To move this work even faster, HHS has put the considerable weight of Medicare behind it.

• In October, we announced a new Medicare demonstration program that will incent providers in small to mid-sized physician practices to adopt interoperable EHRs.  We recognized that was the group we needed to build momentum. We’re going to pay them more if they can use certified EHRs to deliver high-quality care to patients.  By involving up to 1,200 of these providers in the demo, we expect to see 3.6 million Americans receive better care."

What didn't Occur in 2007!

As 2008 begins I started out to clean house. This included defragmenting my hard drive, checking on my windows updates, deleting about 1 GB of uneeded files, running my AV program, anti-spam program, tuning my router, checking my download speeds, and other mundane tasks.

I also updated my list of goals for 2008 and beyond. Looking back on 2007 and further beyond I realized a great number of things had not occurred.

1.Universal Health Care. Except for Massachussetts, had not occured.

2. The number of uninsured  had not decreased.

3. There still was no worldwide epidemic of SARS virus. The pandemic event that was predicted to "thin" the human population still lurks.

4. RHIOs had a very dismal year.

5. Adoption of EMR has failed to "take off" as predicted.

5. CMS and Social Security had failed to go bankrupt, However the bean counters, statisticians and others continued to "see the future" as bleak.

6. The annual SGR adjustment did not go into effect on January 1, 2008 as scheduled.

7. Physicians have not stood together regarding opposition to pay for performance, (or reporting).

8. The number of medical school applicants stopped it's five year decline.

9. I did not quit practicing medicine. (I still like patients)

10 I did not get recertified

11. I did not lose my medical license.

12. I did forget to renew my DEA.

13. HMOs and insurance carriers did not raise my reimburment but did warn us that they will reduce our reimbursement if we don't adopt P4P and HIT.

Merry Go Round or Roller Coaster??

Happy New Year to all.

2007 was a year of up and downs for RHIOs and EMRs in the United States. A small number of RHIOs have made some progress and some group practices and hospitals have adopted or are moving toward  EMRs.  Many RHIO efforts have stalled due to lack of stakeholder enthusiasm.

Analysts like to point out how far behind the U.S. lags in EMR implementation.  Their statistics are flawed and reveals how statistics can be manipulated to prove almost anything.

First of all European nations have healthcare systems which are much more socialized and run by central governments.. If one analyzes their EMRs, they are focused on complications, adverse reactions and limited to primary care.

This article from Health affairs expands on my statements:

 

""UK practices best for IT to track medical errors

20 Nov 2006, e-Health Insider Primary Care

GPs in the UK are well ahead of colleagues around the world in having information systems which track medical errors, according to a survey of primary care doctors in seven countries.

The survey of primary care doctors’ office systems in seven countries, the 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians, reveals striking differences in primary care practice internationally.

Family doctors in Holland are the most likely to have systems that enable sharing of records electronically with other clinicians and New Zealand doctors were the most likely to say that they can access records when outside the office although even in New Zealand only one-third reported such access.

A total of 79% of UK GPs questioned for the survey reported that they have systems to document all adverse events compared with 7% to 41% in all other countries. More than 6,000 physicians took part in the survey from Australia, Canada Germany, Holland, New Zealand and the US as well as the UK.

The study found that Canadian and US primary care physicians lagged well behind doctors from other countries in terms of access to electronic medical record (EMR) systems. Top performers were again Holland where 98 % of family physicians said they use EMRs followed by New Zealand (92%), the U.K. (89%), and Australia (79%). A total of 42% of primary care physicians in Germany said they used EMR compared with only 28% of US doctors and 23% of Canadian doctors.

Canadian and US doctors were also the least likely to have systems that provided decision support. Only 10% of Canadian doctors and 23 % of US doctors receive computerised alerts compared with 93% in the Netherlands and 91% in the UK. At least two of five US and Canadian doctors also find it "very difficult" or "impossible" to identify patients overdue for a test or preventive care, versus one out of five or fewer in the other countries.

The researchers commented that while Germany and Canada lag behind the leading countries on EMRs, each has national plans to move forward. Germany is planning an “e-health smartcard” capable of including information about medications, allergy and blood type and Canada working on a project to link clinicians and provinces across sectors.

The researchers state that to date the US has built IT capacity by relying mainly on market-driven individual care systems such as Kaiser Permanente or that developed by the US Department of Veterans Affairs, together with physician investment. They add: “The United States appears to be the only country without a national plan to support expanded primary care IT capacity. “

This last statement is flawed and untrue. By order of the executive branch of the United States,  ONCHIT (The office of the National Coordinator for Health Information Technology) was established in 2003.  Congress has mandated Health IT, but has failed to fund it for several years.

The "Golden Rule" applies here.  "He who has the Gold rules!!"