June 22, 2017

Godfather of the Structured Medical Record Dies

Filed under: Data standards,EMRs,Medical Records — HankMayers @ 12:27 pm

For anyone who has worked to improve the understand-ability and availability of medical records, their godfather was always Dr. Larry Weed. Well, with his passing at 93, he now becomes our ‘patron saint.’ He died on June 3rd in Underhill, Vermont.

His passion for understandable (even helpful!) medical records has saved untold millions of patients over the years. He was truly a trailblazer, and will be missed.

January 9, 2016

Turning to the Problems Inherent in Getting to the Right Diagnosis

Late in 2015, the National Academy of Medicine (formerly, the Institute of Medicine a/k/a the IOM) generated an important follow-up report to their earlier To Err is Human: Building a Safer Health System.  Their 2015 report is entitled Improving Diagnosis in Health Care. The report starts out acknowledging that, in spite of its importance to the value of care, the diagnostic process remains a rarely studied subject.

Errors in diagnoses remains a significant problem. The report cited some study data that concluded:

  • Diagnosis errors contribute to around 10% of all deaths
  • 17% of adverse events in a hospital setting had diagnosis errors
  • An analysis of malpractice claims indicated that diagnosis errors were the leading type of paid claim

As significant as this problem is, the authors, Erin P. Balogh, et. al., found that there was limited research on this topic. The authors identified 3 themes that repeat in their findings on what inhibits study in this area of medical practice. Those themes are

  1. Data is sparse
    1. Few reliable measures exist
    2. Errors are identified only in retrospect
  2. Patients play a big role in the diagnosis, and often are not adequately factored in
  3. Reaching a diagnosis is typically a collaborative process, and support for such collaboration remains a challenge in healthcare

The study produced the following 8 goals that they believe can lead to improvement in the diagnosis process and reduce diagnostic errors.

  1. Facilitate more effective teamwork in the diagnostic process among health careprofessionals, patients, and their families
  2. Enhance health care professional education and training in the diagnostic process
  3. Ensure that health information technologies support patients and health care professionals in the diagnostic process
  4. Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice
  5. Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance
  6. Develop a reporting environment and medical liability system that facilitates improved diagnosis by learning from diagnostic errors and near misses
  7. Design a payment and care delivery environment that supports the diagnostic process
  8. Provide dedicated funding for research on the diagnostic process and diagnostic errors

What I find especially encouraging is that these goals reveal the systemic nature of the challenge in improving diagnoses. We need to make progress on a number of fronts. Like so much in the health care system, the challenges flow from the fact that healthcare is a team sport. And, as the first goal makes clear, central to the team is the (engaged) patient.

In all settings, the bedrock for effective team work is participant engagement and respect, backed up by effective communications. While not listed as a goal, the study rightly touches on the need for healthcare entities to become continuously learning organizations. Being able to learn from one’s mistakes, in healthcare, requires overcoming cultural barriers, achieving some simultaneous changes in how liability is addressed, and understanding what it means to be accountable in our complex healthcare system.

Not surprisingly, Goal number 3, Ensure that health information technologies support patients and health care professionals in the diagnostic process, clearly asserts that HIT must play a significant role. In addition, closer examination of the report details on Goals 1, 2, 4, 5, 6, and 7 reveals the need for new or enhanced HIT applications to meet those goals as well. Some examples of those related HIT applications or enhancements are [I acknowledge having elaborated on a few of these items to make them a bit clearer]:

  • Technologies (Portals/PHRs) that allow patients (1) to contribute valuable input to diagnoses, and (2) enable patients to provide feedback on diagnoses
  • Technologies that enable close collaboration amongst practitioners – electronic data exchange and interoperability were mentioned as an exceptionally high priority within the HIT realm
  • Within the educational/training settings, a need to include HIT applications that are typically used to support diagnosis within the live clinical setting
  • Move on from the present focus of EHR clinical documentation, which is mostly data that supports billing, to presenting and recording data that supports the diagnosis process
  • EHRs, Radiological, and Laboratory applications all must do a better job at focusing on the diagnosis process and providing better capabilities for tracking the evolution of a patient diagnosis and incorporating second opinions.
  • PHRs can play a stronger role in engaging the patient in the diagnosis process. The report also touched on the emerging opportunities and special challenges in incorporating mHealth-based data.
  • Radiological and Laboratory applications need good access to clinical information that resides in EHRs
  • Identification and tracking of performance measures specific to the diagnostic process
  • Expand the concept of entity-specific, and national, registries for never events to include diagnostic errors. Envision applications that can systematically gather relevant clinical data on diagnoses from clinical & other applications so to enable systematic analysis, feedback, and workflow improvement for the diagnosis process
  • Improved patient access to clinical documentation for the purpose of identifying and correcting diagnosis errors
  • More consistent use of human factors engineering and ergonomics to identify application design flaws that actually are contributing to diagnosis errors
  • Systematically leveraging and communicating the knowledge of the professional liability insurance carriers regarding diagnosis errors

I believe that the National Academy of Medicine with its Improving Diagnosis in Health Care report has done a good job of helping all of us think about the web of HIT applications and how it can be enhanced to improve one of the most important tasks in healthcare – getting the right diagnosis for a patient as quickly as possible. It will take years of effort, moving on multiple fronts. The good news is that what is being recommended is not blue sky, just very complicated.

A worthy challenge indeed.


April 10, 2015

Standards-Based Interoperability Is Finally Being Candidly Addressed

Filed under: CHERT,Data standards,EHR Record Portability,EMRs,HIEs,Interoperability — HankMayers @ 9:29 pm

It appears that National Coordinator DeSilva has laid down the gauntlet over the obstacles that the software industry has often (tho not universally) placed in the way of true, open standards, interoperability. In the ONC’s own words from their report to Congress, Health Information Blocking:
“While many stakeholders are committed to achieving this vision, current economic and market conditions create business incentives for some persons and entities to exercise control over electronic health information in ways that unreasonably limit its availability and use. Indeed, complaints and other evidence described in this report suggest that some persons and entities are interfering with the exchange or use of electronic health information in ways that frustrate the goals of the HITECH Act and undermine broader health care reforms. These concerns likely will become more pronounced as both expectations and the technological capabilities for electronic health information exchange continue to evolve and mature.”

And the former Coordinator Mostashari tweeted substantial agreement later today when he said:
“The second interoperability challenge that is really top of mind for these practices, in many cases, that they have spent years inputting data in to the systems that they have paid for, and now, to get their own data out of these systems, they are having to pay the vendor $5,000 to $10,000 for an interface. We’re covering that cost, but it’s outrageous. What we really want is basically the CCDA that they, for certification purposes, are supposed to be producing anyway.”

It has generally been understood that leadership has been quiet on this major problem because of its complexity, and the need for the solutions industry to truly get behind electronic medical records. Well, after $28 billion in EHR Incentive Funds (and untold billions by others to address electronic records needs for sectors of healthcare that were not eligible for HITECH funds), it is safe to assert that the market is no longer in its infancy. There are important elements in the healthcare information highway that must no longer be ignored, and agnostic interoperability is one of them.

This is precisely the thrust of the remarkable letter of January 21, 2015 wherein 22 medical specialty boards and the AMA said enough was enough to the National Coordinator and the Secretary of HHS. One of their major complaints was the absence of any meaningful (my intentional wording) agnostic interoperability readily available by federally certified medical records systems.

The S&I Wiki and HL7 have made great progress in providing agnostic interoperability concepts and standards. We now need the political will and the sense of common purpose to designate those standards that the industry must use to gain CHERT (now, HIT Certification Program) certification on the matter of interoperability. While there is still ways to go to reach our ultimate interoperability goal(s), we can set a starting point with what we have now, and incrementally reach where we need to be.

This is one of those areas where we must place aside our national zest for competition, and cooperatively build that which we all must ultimately share.

I am going to be very interested in the buzz at HIMSS15 in Chicago next week.

Comments, anyone?

March 22, 2014

Federal HIT Policy Committee Advises that MU3 Objectives Be Reduced By 8

Filed under: EHR Incentive,EMRs,Meaningful Use — HankMayers @ 8:15 pm

At its March 11, 2014, the HIT Policy Committee to the ONC recommended that the number of objectives for Stage 3 be reduced by nine (9). The objectives that they believe should be removed include the following:
• Reminders via patient preference
• Handling patient requests for amendments to their record
• eMARs
• Automated Case Reports for the CDC
• Medication Adherence- tracking what is actually administered
• Syndromic Surveillance by EPs
• Access to Images
• Recording Family History

These changes leave the following as recommended Stage 3 MU Objectives:

Improving Quality of Care & Safety
1. Clinical Decision Support
2. Order Tracking
3. Demographics/patient information
4. Care planning – advance directive
5. Electronic Notes
6. Hospital labs
7. Unique device identifiers

Engaging Patients & Families in Their Care
8. View, download, and transmit records
9. Patient generated health data
10. Secure messaging
11. Visit summary/clinical summary
12. Patient Education

Improving Care Coordination
13. Summary of Care at transitions
14. Notifications
15. Medication Reconciliation

Improving Population & Public Health
16. Immunization history
17. Registries
18. Electronic lab reporting
19. Hospital syndromic surveillance

Next step: ONC final decision-making and the Publication of final NPR

April 10, 2013

CMS Releases Final Electronic Clinical Quality Measures [eCQMs] for 2014

Filed under: EHR Incentive,EMRs,Meaningful Use,PQRI — HankMayers @ 7:52 pm

After much input from a wide array of stakeholders, CMS has just released the final regulation on the eCQMs that will be acceptable for meeting Meaningful Use at Stage 2 of the EHR Incentive program. The measures can be obtained at:

November 7, 2011

Secrets For Coming Up With the HIT Solution With the Best Fit

Filed under: EMRs,Uncategorized — HankMayers @ 10:46 am

Recently, I got into an exchange with a colleague that was bemoaning the fact that healthcare entities frequently find thyemselves having to adjust to a vendor’s HIT product, rather than being able to use a solution specifically built for their needs.

I thought I’d further share my thoughts here on my blog…..

The conundrum that the industry faces is that any vendor HIT product has to be built with a vision of what the users need. The “users” in this case are the entire market. As a for instance, in the ED space, that means such products are built for most EDs of a particular scale. Yet such generalizing also means that the design is based upon design presumptions. If the vendor worked with an empowered user design team (regrettably, often it is a single medical adviser, or the product author), we can expect a design that will make sense to most of that market.

Even so, there will be compromises and the ultimate users will have to adapt to the product nonetheless. Otherwise, modifications to the product must be made to fit a particular customer’s ED, and either the customer takes over the maintenance of this customized product, or outsources this maintenance work to the vendor. As of right now, very few healthcare organizations are willing to make this kind of financial commitment. And given the current healthcare cost containment policy fixation (government, employers, and consumers), this financial limitation will be with us for a very long time.

It is my view that the upshot of all of this is that successful implementations of vendor products will require: (1) investment of serious/substantial effort by users in the evaluation selection of the vendor product (to find the least-disruptive solution), and (2) careful/adequate current state and future state process analysis by the clinical side under the watchful eyes of the CMO/CNO/CMIO, and (3) realistic resource (clinical staff time and funding) allocation so that the clinical organization is truly ready for the implementation.

There is an all-too-frequent tendency for the clinical side to simply pile on these kinds of assignments to current clinical staff who get no relief from ongoing care delivery duties. Because there are ALWAYS daily operational crises in healthcare, adding project duties to staff guarantees that the organization will not be adequately ready for implementation.

When we consider the nature of these business-intensive technologies, it is only natural that the “business” (clinical organizations) side be expected to make this kind of investment of its resources. However, most of our organizations are not used to thinking about information technology projects in this way. And, it’s not like the clinical organizations are flush with staff. Nonetheless, this is one of the implied commitments that are unavoidable with the newer, more valuable, clinical HIT solutions.

August 10, 2011

Why I Am Passionate About Healthcare Information Technology

Filed under: EMRs — HankMayers @ 11:19 am

As most of my followers know, I have spent the past few years engaged in motivating physicians in adopting electronic medical records and particiapting in opportunities to electronically integrate their care (and their electronic records) with other practitioners caring for their patients. Like most people in this field, the persisting lower-than-predicted adoption rates can be rather discouraging and financially disappointing. However, as I recently experienced the risks that the world of paper records create for anyone receiving care in today’s paper-based healthcare system. I thought I’d pass it along as an energy booster-shot for those of us pushing the HIT ball up the steep hill of physician adoption.

Because of my professional knowledge of the risks associated with today’s largely paper-based inpatient care system, I take a very active role in monitoring the care and recordkeeping of any loved one who I visit at a hospital (with my aunt, I have MDPOA). My aunt, who suffers from a life-long mental illness, was recently admitted to a hospital with pneumonia. Midway thorugh her stay, my aunt’s provider was going to restore my aunt’s Zyprexa dosage to her ambulatory norm of 10mg/day (from the earlier 5mg per day), I was curious to make sure that it had actually occurred. I found that her paper Medical Administration Record indicated that her order had indeed been increased – to 10mg 4 times/day. I oversee all care provided to my disabled aunt, so I knew this was an extraordinary level of medication. The 1st 10 mg dose had already been administered, and she was due to get the 2nd in 3 hours.

Upon arriving home, I jumped on the web and confirmed that was a dangerous situation. I immediately called the nurse’s station at the hospital and directed that they not administer the next dose until after they personally spoke with my aunt’s psychiatrist who was part of the official care team (I was adamant that the hospitalist would not be sufficient). I then placed an urgent call with the psychiatrist’s service as a precautionary measure. 20 minutes later I received a call from the nurse that my aunt’s MAR and chart were being revised to reflect 10mg per day.

Being a firm believer in the importance of modern HIT, I returned to the hospital the next day to see how this error happened. My conversation with the nurse, who was very helpful, revealed that someone had interpreted a 10mg qd sig (Yes, it was a hand written order, though not particularly indecipherable) as 10mg 4 times a day (qid). One of the particularly surprising side elements of this story, is that the hospital has a modern in-patient pharmacy system that should have fired a dosing alert to the pharmacy staffer that filled/dispensed the order. If it did, there was no chart record of a clinical warning having been waived.

One interesting post-script: While the nurse was most apologetic, I never received an apology from someone in management at the hospital.

Anyone have a similar story they’d like to share?

May 28, 2011

Meaningful Use is Hip?

Filed under: EHR Incentive,EMRs,HIEs,Meaningful Use — HankMayers @ 10:09 am

Hi Friends,

Check this site our for a little EHR entertainment!


May 21, 2011

EHR Incentive Money Begins to Flow & Adoption Patterns Begin to Emerge

Filed under: CMS,EHR Incentive,EMRs,Meaningful Use — HankMayers @ 9:09 pm

CMS has just released stats on how the EHR Incentive enrollment is going, as well as how the dollars are flowing:

Total Medicare Physicians Registering – 40,379
Total Medicaid Practitioners Registering – 2,014

Medicaid has paid out $5,525,000.00 to 260 practitioners for AIU-level activity
Medicare has not yet paid out any funds to physicians, as we are only now reaching the time window where 90 days of meaningful use could have been achieved in CY2011.

For the skeptics, please take notice that the federal funds are actually being disbursed!

The low rate of enrollment of Medicaid practitioners is probably a confirmation of the market claims that a Medicaid patient load of 30% generally means such a practice is running in the red. Most practitioners I have talked with foresee themselves as only eligible for the Medicare incentive.

A further interesting piece of data is that, of the 2,014 incentive registered Medicaid practitioners, only 260 are seeking AIU eligibility. The remaining 1,754 appear to be registering for full Meaningful Use. It would seem to follow that, at least up to April 2011, very few Medicaid practitioners are choosing to launch an EHR initiative as a result of the Medicaid EHR incentive dollars. Rather, the incentive is going to practitioners that already have an EHR. This piece of data warrants very close observation by Medicaid incentive program administrators who are committed to motivating their practitioners into EHR technology.

As the state RECs have generally shifted from marketing to service delivery, as of 1/1/11, it would seem that they could provide additional “pipeline” data on Medicare and Medicaid practitioners launching EHR initiatives. Hopefully, they’ll make such data available on the ONC website soon.

Nonetheless, it is good to see evidence of the EHR Incentive flowing.

Comments anyone?

March 21, 2011

New HIT Resources: How Deep Must Entry Experience Be?

Filed under: EMRs,HIT Workforce Training — HankMayers @ 9:24 pm

I just scanned some posts on a LinkedIn group focusing on the new Workforce Training programs funded by the ONC. Generally, the comments were very critical of the design and assumptions of the program. As I am an instructor at one of the community college, delivering this program, I was struck by how different some of the programs appear to be.

A noted real Achilles-heel to the program is its short duration. While the hours required (classroom time plus readings, plus on-line events, and test taking) is rather substantial (tho the duration is short: 20 weeks or so), the broad array of material means that the graduates will not have great depth on the topics. HOWEVER, I think all of us must get a bit more realistic about the competency levels that should be expected of the new entrants into the HIT field. Healthcare has always been rather demanding over the depth of background it expects of its entrants into the field. HIT staffing has generally had the luxury of acquiring fairly experienced staffing from the served departments or ancillaries within the hospital. For instance, I challenge anyone to find any HIT job posting where the minimum experience level required was less than 3-5 years! And where does one go to get that initial experience?? Frequently, it was vendor or contract personnel that were ready to give up the road.

As I see it, the rapid escalation of demands for HIT resources that we can foresee for the next 3-5 years means that (1) we need to accept that new hires will have lower levels of healthcare experience, and (2) that OJT, combined with more rigorous levels of immediate supervision, is essential to succeed in the coming years.

The ONC-funded workforce training is going to produce a wave of individuals who have a good grounding in how healthcare operates, how HIT is being harnessed (and why) in such places as hospitals and ambulatory practices, and a good starting knowledge base on such things as project management, or work process (especially clinical) engineering, or technical support services, or user training. But these individuals will frequently have limited healthcare experience. [It should be noted that current healthcare employees make up significnat percentages of some of these classes]

If the Lansing, Michigan program is typical, I can also tell you that most of these students are individuals with considerable workplace experience and evident excitement at the prospect of becoming part of their local healthcare delivery system and making HIT projects happen.

The remaining challenge is to plug these high-potential resources into jobs that will both challenge them AND provide them with the kind of resources and guidance that can assure everyone’s success.

I witnessed the remarkable ramping up of non-IT background resources into effective entry-level HIT resources for Y2K software remediation and client-server applications during the late 1990’s. The parallels for the current HIT industry are substantial. If we are not prepared to launch similar efforts within our respective healthcare entities, we face the real prospect of failing to meet the urgent needs of our clinical colleagues.

Comments anyone?


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