Last week my mother fell and broke her hip.
She was taken to a very good local hospital and received excellent orthopedic care.
The hospital used certified EHR technology and did their best to reconcile her medications.
They used data sources such as historical prescribing records, previous hospitalization records, and calls to a few of her physicians who are not affiliated with the hospital (her primary caregiver is in downtown Los Angeles where she worked, not near the South Bay where she lives).
Although are her physicians use electronic health records, the state of California does not yet have a widely deployed healthcare information exchange (although they are trying hard). There was no way to seamlessly exchange and synthesize all her data from various sites of care.
Meaningful Use Stage 1 did not mandate view/access/download/transmit data for patient/family mediated data reconciliation. OpenNotes is not yet universally adopted across the country.
When she arrived at the ED with a right hip femoral neck fracture, she was in a great deal of pain and was given morphine IV.
After receiving medication, she was not able to accurately reconcile her own medications.
My father had handwritten notes, but did not have the benefit of electronically accessing her records and had limited knowledge of her current medication list. The best he could do in addition to his notes was to bring in every medication bottle he could find at home.
By the time I arrived at the hospital she had been placed on 22 medications because there was history that she had been on them at some time.
Her mental status on 22 medications was such that she was not oriented to person, place, or situation.
To give family members access to her hospitalization records, she needed to sign a consent. This was challenging because "meaningful consent" requires a full understanding of what she was signing at the same time she had an altered mental status. Once she signed, I reviewed her problem list, medication list, operative notes, history/physical, and care plans.
My role as her son and her healthcare advocate was to assemble the care team and explain that she was TWO medications at home, not TWENTY-TWO. How did this happen? In an effort to address various symptoms because of last year's gall bladder surgery and recurring headaches, various doctors had tried short "as needed" courses of various medications. In an effort to be complete, the hospital placed her on all of them in standing doses. Complying with this regimen caused mental status changes and further made it impossible for her to offer input as to what she should be taking. She ceased to be able to participate in physical therapy because of difficulty understanding the training.
Once each member of the care team understood the poor quality of the data they had reconciled and the lack of coordination among caregivers, they agreed with me to discontinue everything except Tylenol and an anti-hypertensive.
The next morning, my mother asked why she felt so foggy. She had no recollection of the previous two days or any of the visitors who spoke with her. She regained her involvement with the rehabilitation process and became a partner in her care planning.
Under stage 2 of Meaningful Use, patient and family view/access/download/transmit to her various data sources will be required. Data exchange at transitions of care will be required. Decision support that would likely have offered best practices for medication management in the elderly would have prevented the cocktail that altered her mental status.
As I wrote yesterday, while reflecting on the need for optimism, the country is on a great healthcare IT trajectory. We need to walk before we can run. Clinicians throughout the country are rapidly adopting more advanced EHRs which support the workflow needed to prevent the problems my mother experienced. Stage 2 is a natural evolutionary step that requires data sharing, patient/family engagement, and decision support. These changes are occurring at fast pace but an appropriate pace. The technology, policy, and education/training needed to safely implement them is straining all healthcare stakeholders, so I do not believe Meaningful Use can or should be done faster than the current timelines.
To those who say that the industry should have solved all these issues years ago, I respond that 9 women cannot grow a baby in a month. It takes the focused energy of 1 woman for 9 months.
I look forward to Meaningful Use Stage 2 and 3. My own family experiences illustrates why the path we're on is so appropriate and so essential.
Wednesday, October 10, 2012
Tuesday, October 9, 2012
A Time for Boundless Energy and Optimism
On the personal side, my wife had cancer. Together we moved two households, relocated her studio, and closed her gallery. This week my mother broke her hip in Los Angeles and I'm writing from her hospital room as we finalize her discharge and home care plan before I fly back to Boston.
On the business side, the IT community around me has worked hard on Meaningful Use Stage 2, the Massachusetts State Health Information Exchange, improvements in data security, groundbreaking new applications, and complex projects like ICD10 with enormous scope.
We did all this with boundless energy and optimism, knowing that every day we're creating a foundation that will improve the future for our country, communities, and families.
My personal life has never been better - Kathy's cancer is in remission, our farm is thriving, and our daughter is maturing into a fine young woman at Tufts University.
My business life has never been better - Meaningful Use Stage 2 provides new rigorous standards for content/vocabulary/transport at a time when EHR use has doubled since 2008, the State HIE goes live in one week, and BIDMC was voted the number #1 IT organization the country.
It's clear that many have discounted the amazing accomplishments that we've all made, overcoming technology and political barriers with questions such as "how can we?" and "why not?" rather than "why is it taking so long?" They would rather pursue their own goals - be they election year politics, academic recognition, or readership traffic on a website.
As many have seen, this letter from the Ways and Means Committee makes comments about standards that clearly have no other purpose than election year politics. These House members are very smart people and I have great respect for their staff. I'm happy to walk them through the Standards and Certification Regulations (MU stage 1 and stage 2) so they understand that the majority of their letter is simply not true - it ignores the work of hundreds of people over thousands of hours to close the standards gaps via open, transparent, and bipartisan harmonization in both the Bush and Obama administrations.
I spoke with the authors of the Wall Street Journal article "A Major Glitch for Digitized Health-Care Records" and discovered that their issue was not interoperability standards but a lack of usability in non-standard EHR user interface design. When a clinician goes from Epic to Cerner to Meditech and tries to perform the same task (e-prescribing, managing a problem list, or looking up a lab), the learning curve can be steep. The authors and I reviewed the Consolidated CDA specification that is required by Meaningful Use Stage 2 and they are completely satisfied that interoperability standards gaps are no longer a rate limiting step.
Many reporters have asked me about the New York Times article "Medicare Bills Rise as Records Turn Electronic"
I've said three things:
1. In the past, paper documentation lacked details to accurately document acuity. As we make the multi-year journey from simple EHRs that support electronic billing to complex EHRs that include decision support, interoperability, and patient/family engagement, there will be an interim period when increasing detail in documentation results in higher acuity, which results in increased reimbursement.
2. These trends long pre-date the health IT incentive program. Meaningful Use re-orients the healthcare IT industry away EHRs supporting billing to EHRs which focus on prevention, care coordination, population health management. It is these functionalities that will both enable, and be incentivized by the shift in payment policies towards value, and away from volume. In a healthcare reform world, clinicians will be paid for wellness not sickness and the EHR will help them increase efficiency, safety, and quality, which will be required for reimbursement.
3. As quoted in the Center for Public Integrity's Cracking the Code series, Donald Berwick said he believes that only a small portion of the upswing in coding is the result of fraud. In most cases, he said, the hospitals have learned “how to play the game,” and are targeting the vulnerabilities of the Medicare payment system. “If you create a payment system in which there is a premium for increasing the number of things you do or the recording of what you do, well, that’s what you’ll get”.
As the cartoon above illustrates, our current society tries to find fault in everyone and everything. Social media and our increased connectedness has turned criticism into a spectator sport.
If everyone could align their efforts into an agenda of optimism, we'd all be better for it.
I may be asking too much to expect positive energy and optimism from Congress, the Wall Street Journal, and the New York Times, but as 2012 has proven to me, anything is possible if you try hard enough.
Friday, October 5, 2012
Cool Technology of the Week
As readers of my blog know, my wife was diagnosed with Breast Cancer in December 2011 and is now in full remission.
She picked up the presence of the tumor (a very fast growing aggressive type) by self examination.
Recently, I heard about an electronic tool called SureTouch which records breast examination via an array of pressure transducers, producing a digital signal as the sensor is pressed and moved over the tissue. The data is then presented in a useful visualization.
The result is objective, repeatable, and painless.
Although this does not replace standard mammography screening exams, it is a very interesting electronic approach to performing and documenting the clinical breast exam.
Objective digital data gathered as part of the physical exam. That's cool!
Thursday, October 4, 2012
Building Unity Farm - Hay and Other Foods
Over the past few months, we've become experts, purchasing five tons of fine, grassy, second cut hay from Western New York and a ton of legume rich hay. It's stacked neatly in the hayloft of our barn, pictured above.
Our first experience with hay was buying a small amount of first cut, harvested in June, which tended to have less green and more stems than our alpaca would eat. We had a lot of waste and our manure management pile filled fast because our barn sweepings included so much uneaten hay.
In August we found green, sweet, tender second cut hay - a mixture of timothy and orchard grass. The alpaca eat it out of our hands. It's high in protein and very low in waste. At this point, the alpaca eat their feeders clean. We saved a dozen bales of first cut hay to use as bedding material and donated the left over first cut to horse rescue.
We also purchased second cut orchard grass hay mixed with legumes (clover and alfalfa) for use in winter when the alpacas need a bit more fattening food.
Here's a great guide to evaluating hay quality
Now that we've experienced the difference between course, stem filled hay and fine, grassy hay, we'll never make the mistake of buying poor quality hay again.
We place the hay in feeders that minimize waste and protect it from the rain
As a special treat, we feed our alpacas and llama a small serving of grain pellets - Poulin Grain Milk and Cria. They have such an affinity for this food that we need to lock our storage bins.
We use Poulin and Blue Seal grain products to feed our chickens and guinea fowl. The guineas receive a high protein game bird mix as a supplement to their daily foraging for ticks and other insects.
We store all these food products in cool, dry, dark places. Our hayloft has a ventilator fan to minimize overheating and mold formation. Our grains are stored in waterproof metal trash cans, sealed with metal bungee cords to prevent our livestock and forest creatures from feeding on them.
After a few months, we've figured out what to feed, how much to feed, and how to feed.
The winter will be a great learning experience for us, since we've not had the opportunity to keep our animals fed and warm in blustery New England weather.
When you're running a farm, the learning never stops. And whoever thought rolling in the hay was a good idea has never had to do laundry after hauling 5 tons of hay into the loft!
Wednesday, October 3, 2012
Open Notes
An important article was published in the Annals of Internal Medicine yesterday about the OpenNotes study, Inviting Patients to Read Their Doctors' Notes: A Quasi-experimental Study and a Look Ahead
There are also two accompanying editorials:
A Patient's View of OpenNotes
Pushing the Envelope of Electronic Patient Portals to Engage Patients in Their Care
Here's a BIDMC video about it.
We're all enthusiastic about expanding this access to all BIDMC patients. Here's the press release:
BOSTON – Patients with access to notes written by their doctors feel more in control of their care and report a better understanding of their medical issues, improved recall of their care plan and being more likely to take their medications as prescribed, a Beth Israel Deaconess Medical Center-led study has found.
Doctors participating in the OpenNotes trial at BIDMC, Geisinger Health System in Danville, PA and Harborview Medical Center in Seattle reported that most of their fears about an additional time burden and offending or worrying patients did not materialize, and many reported enhanced trust, transparency, and communication with their patients.
The findings were published in the Oct. 2 issue of the Annals of Internal Medicine.
“Patients are enthusiastic about open access to their primary care doctors’ notes. More than 85 percent read them, and 99 percent of those completing surveys recommended that this transparency continue,” says Tom Delbanco, MD, co-first author, a primary care doctor at BIDMC and the Koplow-Tullis Professor of General Medicine and Primary Care at Harvard Medical School. “Open notes may both engage patients far more actively in their care and enhance safety when the patient reviews their records with a second set of eyes.”
“Perhaps most important clinically, a remarkable number of patients reported becoming more likely to take medications as prescribed,” adds Jan Walker, RN, MBA, co-first author and a Principal Associate in Medicine in the Division of General Medicine and Primary Care at BIDMC and Harvard Medical School. “And in contrast to the fears of many doctors, few patients reported being confused, worried or offended by what they read.”
The findings reflect the views of 105 primary care physicians and 13,564 of their patients who had at least one note available during a year-long voluntary program that provided patients at an urban academic medical center, a predominantly rural network of physicians, and an urban safety net hospital with electronic links to their doctors’ notes.
Of 5,391 patients who opened at least one note and returned surveys, between 77 and 87 percent reported open notes made them feel more in control of their care, with 60 to 78 percent reporting increased adherence to medications. Only 1 to 8 percent of patients reported worry, confusion or offense, three out of five felt they should be able to add comments to their doctors’ notes, and 86 percent agreed that availability of notes would influence their choice of providers in the future.
Among doctors, a maximum of 5 percent reported longer visits, and no more than 8 percent said they spent extra time addressing patients’ questions outside of visits. A maximum of 21 percent reported taking more time to write notes, while between 3 and 36 percent reported changing documentation content.
No doctor elected to stop providing access to notes after the experimental period ended.
“The benefits were achieved with far less impact on the work life of doctors and their staffs than anticipated,” says Delbanco. “While a sizeable minority reported changing the way their notes addressed substance abuse, mental health issues, malignancies and obesity, a smaller minority spent more time preparing their notes, and some commented that they were improved.”
“As one doctor noted: ‘My fears? Longer notes, more questions and messages from patients … In reality, it was not a big deal.’”
Walker suggests that so few patients were worried, confused or offended by the note because “fear or uncertainty of what’s in a doctor’s ‘black box’ may engender far more anxiety than what is actually written, and patients who are especially likely to react negatively to notes may self-select to not read them.”
“We anticipate that some patients may be disturbed in the short term by reading their notes and doctors will need to work with patients to prevent such harms, ideally by talking frankly with them or agreeing proactively that some things are at times best left unread.”
“When this study began, it was a fascinating idea in theory,” says Risa Lavizzo-Mourey, MD, president and CEO of the Robert Wood Johnson Foundation, the primary funder of the study. “Now it’s tested and proven. The evidence is in: Patients support, use, and benefit from open medical notes. These results are exciting – and hold tremendous promise for transforming patient care.”
Tuesday, October 2, 2012
Security Assessment Kickoff
"Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1), including addressing the encryption/security of data at rest in accordance with requirements under 45 CFR 164.312 (a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the provider's risk management process."
Yesterday, we kicked off the enterprise security audit at BIDMC.
Every audit requires a framework. For security, framework choices include NIST, ISO 27002, HITRUST, PCI and COBIT. We've elected to use a NIST approach.
NIST is the National Institute of Standards and Technology, a component of the Department of Commerce (formerly National Bureau of Standards). One of the NIST subject areas is Information Technology - the "800" series.
NIST publishes hundreds of Bulletins, Standards and Guidelines related to Information Technology. Topics range from "What about Cloud Security" to "Smart Grid Interoperability". Relevant to security audits is the NIST 800-30 "Guide for Conducting Risk Assessments".
Why did we choose NIST?
NIST is mandated within the Federal Government. It is gradually being extended to contractors, including Medicare providers. Recently, several NIH grants I've reviewed have included the need for a NIST-based risk assessment. The Center for Medicare and Medicaid Services (CMS) increasingly refers to NIST assessments in their compliance efforts.
All security frameworks, including NIST 800, share common themes. For example, risk is defined in terms of threat, vulnerability, likelihood of occurrence, and impact.
"Threat" could be malware, a natural disaster, disgruntled employee or a myriad of other things
"Vulnerability" is a weakness that makes a system susceptible to the threat
"Likelihood" is the probability the threat and vulnerability will come together
"Impact" is the consequence to the organization of an occurrence
For example,
- Threat = thief
- Vulnerability = laptop visible on front seat of a car parked in a public lot
- Likelihood of Occurrence = high,
- Impact = significant if the laptop contains ePHI
NIST 800 also provides recommended controls for mitigating risk. NIST 800-53 describes 194 security controls that roll up into 18 families. (see the above graphic)
I'll report back on the results of our audit and lessons learned when it is completed in November.
Monday, October 1, 2012
Solving the Provider Directory Standards Gap
In 2012, the HIT Standards Committee evaluated the provider directory standards suggested for the Nationwide Health Information Network and concluded that none of the current implementation guides was sufficiently mature and adopted to mandate as a certification criteria for Meaningful Use Stage 2.
This means that vendors and HIEs will continue to pilot various approaches to provider directories until Stage 3.
In Massachusetts, we chose a simple web-friendly implementation that goes live across the Commonwealth in two weeks.
We created a SOAP 1.2-based API that enables any trusted partner to query the state-wide provider directory via HTTPS per this specification.
The provider search web service provides following parameters to search a provider.
First Name
Last Name
Middle Name
Specialty
Type
Gender
Street
City
State
Zip
Phone
Language
Id
but requires one of the elements in the list below in order to perform a successful search.
First Name
Last Name
ZIP
Specialty
Id
Street
Phone
With a simple SOAP query response approach and a WSDL, we have everything we need - no complicated implementation guide or non-standard use of LDAP/DNS required.
If this works well in production, it could be a model for the country.
How will we load the provider directory?
Each organization will be registered via an identity proofing process that ensures we have a fabric of trusted entities which have signed participant agreements.
As part of the registration process, the organizations will pre-load their provider data into the state directory using this spreadsheet.
Ongoing updates (adds/deletes/changes) can be sent via the same template.
Once in production, I'm sure we will refine our approach, but creating a simple SOAP-based query/response and a template for loading/updating data in batch seems to solve the Provider Directory standards gap nicely.
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