Digitized Medicine

Safe Use of EMRs: Physicians Should Ensure Proactive IT Management of EMR Hardware / Software and Plan For Downtime With Mock Drills

This case study is the first of six cases used to illustrate aspects of EMR use that pose risks to patient safety.   The risks discussed in this case pertain to EMR hardware and software failures.  As with most EMR-related problems, the majority of patient safety issues associated with hardware/software failures can be traced back to controllable factors.  The safe and meaningful use of EMRs is facilitated by awareness of these risks and controllable factors.

Case Study:  At 0900 physicians in hospital-based ambulatory offices were suddenly unable to access their web-based EMR. The hospital’s IT Service Desk reported a wide outage of internet access due a “hardware failure” and the estimated time of repair was “unknown”.  The offices activated their paper-based downtime plans, but many patient safety issues were encountered.  For example, physicians were solely dependent on the patient’s recollection of allergies because they had no access to allergies recorded in the EMR.  A process was developed “on-the-fly” to use a laptop with mobile broadband connectivity to access the EMR, but before these were ready the original problem was resolved at 1130.  It was discovered that an IT employee installed a planned “Windows update” to the hospital’s networking hardware that morning with unexpected results.  After the problem was identified the update was “backed out” and the problem resolved.

Key Points:

• Hardware and software technology problems will occur, but most are preventable and can be minimized with proactive IT management

Access to secure and reliable patient data in an EMR is dependent on hardware and software that is properly sized, configured, managed and functioning.  Power outages, running out of data storage space, network outages, software conflicts, malicious intrusions and computer device failures are examples of technical problems that threaten safe use of EMRs.  Most technical problems, however, are preventable through proactive IT management.   For example, an old computer that burns out could have been prevented by proactively replacing old technology equipment at specified intervals.  Reputable IT experts know the “best practices” for proactive IT management (such as ITIL and COBIT).  In this case basic change management practices were not followed.  Physicians should make sure that their EMR hardware and software, whether physically located in their office or located elsewhere, are proactively managed by reputable IT experts.

• Physicians are responsible for developing “downtime plans” that describe how the office will safely care for patients when the EMR is unavailable

HIPAA requires patient data to be “backed up” and physicians need to be able to restore their EMR in the event of a complete hardware or software failure such as a flood, tornado or fire that destroys computer equipment and software.  “Disaster planning” addresses these needs and primarily requires the EMR vendor’s technical expertise and advice.  “Downtime plans”, on the other hand, primarily need the physician’s expertise to define what needs to happen in order to safely care for patients (what I call clinical continuity) and maintain business operations (commonly referred to as business continuity) when the EMR is unavailable.  Downtime planning should identify the critical patient data that is needed when the EMR is down and have written procedures on how that data will be accessed.  The plans should also describe procedures for the use of downtime paper forms for patient care tasks, medical record documentation and practice operation tasks (appointments, claims and billing) as well as what to do with them after the downtime.

• “Mock downtime drills” are an effective way to determine whether an office is prepared for an EMR downtime

In this case the physicians deserve applause for developing written downtime plans.  However, if they had previously simulated a downtime, then they would have been prepared with back-up laptops ready and available.  Although mock drills in themselves create risks, they are much more controllable than the risks inherent to unplanned EMR downtimes.

Physicians and Social Media: What's Up, Doc With Unprofessional Behavior?

I wonder how many physicians who used social media for the first time yesterday were aware of the risk they were taking?   Did they realize that unprofessional behavior involving social media could actually threaten their license to practice medicine?   These thoughts motivated me to blog about the risks of social media that are unique to physicians.   My intent is not to cause Henny Penny alarmism and avoidance of social media.   After all, I obviously engage in social media for leisure as a practicing physician myself and enjoy it very much.   Instead, I want my colleagues to feel confident using social media, but with full awareness of the inherent risks, all of which are manageable including many that are avoidable.   

I'm just sayin'...

Social Networking Risks

Social networking sites will often publically display personal identifying information unless one actively omits them from public view including home address, e-mail addresses, home phone number, mobile phone number, race, religious preferences, sexual orientation and political views.   Also, when you associate with someone on a social networking site you provide them access to personal content that is not available to others on your public page.   The personal content could include personal identifying information, pictures, personal messages and even messages posted to your page from other people.  

A recent survey (JAMA. 2009;302(12):1309-1315) revealed that a significant number of medical students have personal Facebook accounts with personal identifying information available to the public.  In addition to this privacy exposure, some had also posted unprofessional content on Facebook such as:

• Violations of patient confidentiality
• Pictures of illicit drug use or unethical behaviors
• Use of profanity
• Use of sexually-suggestive language
• Criticisms of other people or institutions
• Satirical or sarcastic material

Posting unprofessional content on a social media website could be judged by a credentialing body, such as the Texas Medical Board, as a reason for disciplinary action that could place the physician’s license to practice medicine at risk.  

Social Networking Risk Management

“Unprofessional content” can be defined to be any content that shows, implies or suggests that a physician has failed to adhere to professional behavior.   Content posted on a social media site that explicitly shows a physician engaged in illegal or unethical behavior is obviously unprofessional.   But how can physicians  distinguish the border that separates "acceptable" content from "unprofessional" content?

Consider the core curriculum on “Professionalism” that the Accreditation Council for Graduate Medical Education (ACGME) uses for physicians-in-training.   This curriculum includes training on professional behavior in areas such as:

1. Compassion, integrity, and respect for others
2. Responsiveness to patient needs that supersedes self-interest
3. Respect for patient privacy and autonomy
4. Accountability to patients, society and the profession
5. Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation

The line that distinguishes sensitivity from insensitivity to human diversities is perhaps the most difficult one for physicians to discern when communicating on the Internet.   Content that includes insensitive comments on gender or other human diversities falls into the category of unprofessional behavior.   Unfortunately, the diverseness of individuals and cultures can sometimes make it very difficult to anticipate a perception of insensitivity.   The best advice is to avoid comments that have even a remote possibility of offending someone.

Also, physicians who understand and adhere to patient confidentiality in their daily practice will be vulnerable to breaches of privacy when using social media if they fail to understand the lack of anonymity when using social media sites and the permanence of any content they post.   In spite of using “alias” names, no one is really anonymous on the Internet.   There are many examples of people (including doctors) who presumed anonymity but ended up with serious legal difficulties.   The permanence of posted content is due to the nature of social media.   Even if one deletes their entry, it is possible that other social media sites have already linked to that content and/or reposted it elsewhere. 

The bottom line is that physicians should realize that whatever they write on the Internet not only is permanent, but is also traceable to their actual identity.   Physicians are wise to gain more insights on social media risk management by discussing it with their personal lawyers and seeking information from their professional organizations and journals (such as these articles from the American Medical Association and New England Journal of Medicine).  

Raising awareness of the risks that social media present to physicians is prudent, not alarmist.  I want other physicians to safely enjoy social media as I do.    BTW, I expect you to now read my Terms of Use, Disclaimers, Warranties and Waivers.   And agree to hold this Author harmless.

I'm just sayin'.

Work Flow Analysis Helps Physicians Select Ambulatory EMR That Meets Needs

In a previous blog the methods used to perform a work flow analysis in a physician's office as a part of the EMR selection process were described.  The  next steps are to:

Determine at a high level the future desired work flows (when an EMR will be used)

Prioritize this list of work flow desires

Develop a prioritized list of EMR functionalities needed to meet those  desires 

Compare EMR products based on these priorities

Document Future Desired Work Flows

An analysis of current work flow identifies bottlenecks in the physician's practice.  Changes in work flow may alleviate those bottlenecks.  Some of the identified changes may not be dependent on having an EMR and could be made immediately.  The other work flow changes that are dependent on using an EMR and will later become part of the EMR implementation.   

It is not readily apparent to many physicians how an EMR could improve work flow in their office.  There may also be unrealistic expectations about how an EMR could improve things.  Therefore, it is helpful to first gain knowledge about the "best uses" of ambulatory EMRs as experienced by other physicians before identifying desired future work flows.  To gain insights on the realistic and best uses of EMRs physicians may be wise to engage a knowledgeable IT consultant.  Alternatively, physicians may use other resources  to gain insights such as:

• DOQ-IT's Operational Redesign Workbook
• AHRQ Health IT Toolbox
• CCHIT
• Networking with colleagues
• Physician professional organizations

The knowledge gained on EMR "best uses" and the identified work flow  bottlenecks can now be analyzed together to determine at a high level what future work flows are desired for the practice. 

Prioritize this list of work flow desires

The physician practice may now discuss these desired work flow changes and prioritize them.  For the purposes of discussion let's suppose the practice has identified a top ten list of desired work flow changes that they want make when they implement an EMR.

Develop a prioritized list of EMR functionalities

The prioritized top ten list of desired work flow changes will naturally translate into a list of EMR functionalities that are top priority.  For instance, a practice that determines "refilling 80 prescriptions/day" is currently their top bottleneck, then the most important EMR functionality to compare among products is the usability of the EMR's e-prescribing feature.  A different practice may identify their top bottleneck to be getting patients through the check-in processes and determine that they want to reduce time patients spend filling out papers on clipboards by providing online registration forms and using a self-serve kiosk in the waiting room.  They also desire an EMR that can quickly register and check-in patients.  In that practice the most important EMR functionalities will be a robust patient portal, efficient integration with kiosks and the fewest number of necessary screens and "clicks" when registering or checking-in patients at the front desk.

Compare EMR products based on these priorities

EMRs have hundreds of functionalities.  It is not humanly possible to effectively compare hundreds of functionalities between different EMRs.  Comparing EMRs without focusing on specific needs easily leads to frustration and/or confusion.  Using the described list of prioritized EMR needs will improve the comparison process. 

Physicians might consider limiting their comparison to EMRs that have been certified by CCHIT (and soon to those certified for "Meaningful Use" as well).  One can be confident that a CCHIT-certified EMR has all of the functionalities that are described on the CCHIT website.  There are hundreds of such functionalities.   However, CCHIT does not necessarily quantify how well the EMR performs each function.  So, if a physician practice limits their comparison to CCHIT-certified EMRs, they can be assured the EMR can do those hundreds of things an EMR should be able to do and instead spend their time comparing how well the EMRs meet their own, identified "top ten" needs.  

Using an earlier example of an identified "top ten" EMR need, a comparison may find that EMR Product "A" allows prescription refills to be completed in 45 seconds using three screens and 17 clicks, while Product "B" refills prescriptions in 15 seconds (30 seconds faster) on one screen with 6 clicks.  Since the work flow analysis revealed that the practice has 80 refills/day, refilling prescriptions using Product "B"" would take 40 minutes less each day as compared to Product "B".  

In summary, it is helpful for a physician practice searching for an ambulatory EMR to perform a work flow analysis to identify the major bottlenecks in the office, gain insights on how EMRs can improve work flow, use this knowledge to develop a prioritized list of desired future work flows, identify the "top ten" things an EMR needs to do to meet those desires and then compare CCHIT-certified products based on this prioritized list of EMR needs.

EMR Selection Guide provides an outline of other topics on the selection process

EMR Implementation Guide provides an outline of topics on the implementation process

Physicians, EMR Implementations and the Science of Project Management

For those who enjoy the ease and convenience of online shopping or use of self-pay kiosks for everyday activities like purchasing gasoline and groceries, it is hard to understand why medicine has remained so heavily paper-based.   On the other side, those who work closely with healthcare providers during and after technology projects recognize how complex and difficult it is.   Almost two thirds of technology projects fail as they run into problems such as unplanned costs, excessive delays, poor quality, expectations not being met and excessive numbers of unresolved issues.   When such “failures” are analyzed it is common to discover preventable causes such as poor planning, inadequate testing, poor work flow redesign, failure to identify and manage risks, poor communication, faulty implementation strategies, selection of the wrong technology products or the use of good technology in a way it was not designed to be used.   Although there are not simple recipes to follow that guarantee successful health IT implementations, there is a large body of knowledge regarding how best to manage technology projects in general.   A major resource for this knowledge is the Project Management Institute which promotes the science of project management throughout the world.   Although the details of project management are beyond the scope of blogging, there are eight knowledge areas that describe the principles of project management:

Procurement management	Obtain/purchase products and services, contract management, vendor management
Cost management	Budget and monitor costs
Project integration/communication	Objectives/goals, project plan, execution, monitoring status; managing changes; managing internal and external communications;  review/close project
Scope management	Establish scope of work needed, monitor and manage all processes and changes related to scope
Time management	Establish timeline based on work required, resource availability and scope; monitor and manage time constraints and schedule changes
Resource management	Who does what, when, where and how; establish project team; monitor and manage resource constraints and bottlenecks
Quality management	Test the application/product; follow project management principles
Risk management	Risk analysis, work flow analysis, risk mitigation planning, work flow redesign; change management

Understanding the basics of project management is more important for physicians than to understand the technology.  

Before selecting a technology product, these principles direct the physician to first identify the goals (or “objectives”) that are expected to be achieved by using the technology.   Defining the expected objectives allows the physician to then determine what the technology product specifically needs to do (the “requirements”) in order to achieve those goals.  This aligns technology purchases with the physician’s actual needs and expectations.  A common error is to select a technology product first and then figure out how to use it.   The risk with this faulty strategy is that, even if some value is gained, the physician’s actual goals and needs may remain unmet.  

The scope of a project is defined by what needs to be implemented in order to meet the identified goals and requirements.   A project plan and timeline can be created by determining how much work is required, within this defined scope, who is available to do that work (physicians, staff, temporary labor, vendor resources, consultants) and how much time those people have available to do project work.   Project management principles keep technology implementations “on track” by monitoring the scope and maintaining a balance between known work, known resource availability and established timelines.  It is easy for physicians or staff to become enamored with potentially valuable, but initially unplanned, uses of new technology during an implementation.  If these unplanned uses are piled onto the original scope of a project, then there is more work to do.   

The consequence of more work is the need for more people or time to complete the project.   Sometimes the additional work results in unbudgeted costs such as paying a consultant for additional hours to do the unplanned work.   Unplanned “scope creep” like this is a common malady that derails technology projects but can be avoided or contained by adherence to project management principles.  

And finally, an important aspect of project management is attentiveness to policies and procedures.   Policies and procedures that successfully manage risk within a paper-based work flow will become obsolete if technology creates a new electronic work flow.   A comparison of current work flow to future work flow along with a risk assessment during the project will identify needed changes to policies and procedures.

Search this site for other blogs on EMR Selections and EMR Implementations

 

 

ARRA Clarification Opens Door of "Meaningful Use" Incentive Payments for Physicians in Hospital-Based Outpatient Clinics

On April 15th President Obama signed into law legislation that allows the Department of Health and Human Services (HHS) to include physicians who treat patients in hospital-based outpatient clinics among the physicians eligible for “Meaningful Use” incentive payments.   These incentives are authorized by the HITECH Act portion of the 2009 American Recovery and Reinvestment Act (ARRA).   Under ARRA, “hospital-based physicians” are not eligible for health IT incentive payments because they depend “substantially” on a hospital’s “facilities and equipment, including qualified electronic health records”.   The new legislation clarifies the definition of “hospital-based” so that it may include physicians working in hospital outpatient clinics as opposed to the inpatient units, surgery suites or emergency departments.

As I wrote in “Academic Physician Incentives Needed to Catalyze White Coat-Driven Transformation of Medical Practice Using Health IT”, it appeared that the original intent of ARRA eligibility was misinterpreted by HHS.   The new clarifying language resolves this issue.

The new bill’s clarifying language:

 

"SEC. 6. EHR CLARIFICATION.

(a) QUALIFICATION FOR CLINIC-BASED PHYSICIANS.—

(1) MEDICARE.—Section 1848(o)(1)(C)(ii) of the Social Security Act (42 U.S.C. 1395w– 4(o)(1)(C)(ii)) is amended by striking ‘‘setting (whether inpatient or outpatient)’’ and inserting ‘‘in- patient or emergency room setting’’.

(2) MEDICAID.—Section 1903(t)(3)(D) of the Social Security Act (42 U.S.C. 1396b(t)(3)(D)) is amended by striking ‘‘setting (whether inpatient or outpatient)’’ and inserting ‘‘inpatient or emergency room setting’’.

(b) EFFECTIVE DATE.—The amendments made by 15 subsection (a) shall be effective as if included in the enact- 16 ment of the HITECH Act (included in the American Re- 17 covery and Reinvestment Act of 2009 (Public Law 111– 18 5)).

(c) IMPLEMENTATION.—Notwithstanding any other 20 provision of law, the Secretary of Health and Human 21 Services may implement the amendments made by this 22 section by program instruction or otherwise."

 

So, the change in section 1848 looks like this:

‘‘ (C) NON-APPLICATION TO HOSPITAL-BASED ELIGIBLE PROFESSIONALS.—

‘‘(i) IN GENERAL.—No incentive payment may be made under this paragraph in the case of a hospital-based eligible professional. H. R. 1—355

‘‘(ii) HOSPITAL-BASED ELIGIBLE PROFESSIONAL.—For purposes of clause (i), the term ‘hospital-based eligible professional’ means, with respect to covered professional services furnished by an eligible professional during the EHR reporting period for a payment year, an eligible professional, such as a pathologist, anesthesiologist, or emergency physician, who furnishes substantially all of such services in a hospital setting (whether inpatient or outpatient) inpatient or emergency room setting and through the use of the facilities and equipment, including qualified electronic health records, of the hospital. The determination of whether an eligible professional is a hospital-based eligible professional shall be made on the basis of the site of service (as defined by the Secretary) and without regard to any employment or billing arrangement between the eligible professional and any other provider.

‘‘(D) PAYMENT.—

 

Under these changes hospital-based physicians remain excluded from ARRA incentives, but the definition of “hospital-based” physicians changes from those who practice in inpatient or outpatient settings to those who practice in inpatient or ER settings.   This still excludes pathologists, anesthesiologists, ER physicians, hospitalists and others who see most of their patients in the ER as outpatients or as hospital inpatients.   But this opens the door for HHS to interpret ARRA to mean that those who practice in hospital-based clinics using ambulatory EMRs are eligible…a setting common for many academic physicians and others who are closely associated with the ambulatory side of hospitals.   This is really good news for many physicians who work in hospital-based outpatient clinics whether they are in academia or private practice.

What Physicians Need to Know about Work Flow Analysis Before Selecting and Implementing an Ambulatory EMR

Work flow analysis is valuable when selecting and implementing an ambulatory electronic medical record (EMR).   The results of this analysis will help the physician identify which EMR products are best suited to meet their expectations.   Physicians should have an understanding of the effort involved and prepare their practice for this important assessment.

Work flow analysis is hard work and takes a lot of time.  With time pressures on physicians to see patients and a payment system that rewards them more for higher numbers of patient visits than for higher quality of care, many physicians find it difficult to carve out enough time in their day for efforts like this.    As a result, work flow analysis is often not performed or is less than comprehensive during an ambulatory EMR selection and implementation.

Physicians essentially have two options to obtain a work flow analysis:

1. Hire a consultant
2. Perform the work flow analysis themselves

Hiring an IT consultant who is experienced with work flow analysis at the beginning of the EMR selection process is a more expensive option but will likely result in a more comprehensive analysis.  The consultant will interview key physicians and staff, create work flow descriptions and maps, analyze the results, review them with the practice and develop recommendations.  The physicians and staff will spend time with the consultant during this process, but most of the time and effort necessary for the documentation and assessment will be done by the consultant.

Alternatively, physicians may decide to perform work flow analysis on their own.  If so, there are a variety of methods and tools available to assist the effort.  These include:

1. AHRQ’s Health IT Tool Box website
2. DOQ-IT Operational Redesign Workbook
3. PITO Physician Information Technology Office Needs Assessment

These tools will guide the physician through the documentation of current work flows, an analysis of them and then considerations of redesigned future work flows.  The initial tedious steps to document current work flows are to:

1. Collect all paper forms used in practice
2. Select a workflow guide to facilitate analysis (i.e. one of the three listed above)
3. Identify major processes to map out (key processes vs. all processes)
4. Gather information on each process by interviewing people involved in each process
5. Write detailed descriptions of each process
6. Create detailed work flow maps (at least for the major processes)

Collecting paper forms will help identify specific paper-based processes that are unique to the practice.  The purposes of paper-based processes are important to understand and account for when future work flows are redesigned.  If the new technology tools and work flows do not account for the purpose of a paper-based work flow, and that purpose remains pertinent, then a work-around will need to be discussed and designed.  The goal should be to convert all paper processes to electronic ones, but the limits of technology or the costs involved will limit the ability to fully achieve this.

A work flow analysis guide will help the practice identify other key work flow processes that are generally known to be important for physician practices to assess when selecting and implementing an EMR.  As shown in the snapshot below of part of the DOQ-IT Workbook, these guides will lead the practice through questions to ask about each process:

After interviews with people involved in the process are completed, a description for each process is documented and then used to synthesize current work flow maps. A work flow map serves as a visual representation of the described workflow.  As described in a previous blog, these maps are useful when analyzing current work flow and redesigning them into future work flows.  My next blog will describe how the results of work flow analysis will facilitate the selection of an EMR that meets the needs of the physician office.

Why Work Flow Analysis, Redesign Are Keys to Successful EMR Implementation...and EMR Selection

Work flow analysis and future work flow redesign are often cited as key factors of successful implementations of ambulatory electronic medical records (EMRs) in physician practices.  This is the first in a series of blogs to discuss the value of performing workflow analysis before selecting an ambulatory EMR.

It is unfortunate that work flow analysis, if performed at all, is typically not done until an EMR has been selected and the implementation initiated.  Although physicians intuitively understand the value of good workflows in the office, how workflow analysis helps the physician choose an EMR is not so obvious. 

Workflow analysis can provide the physician practice insights on what to look for in their new EMR product if done early in the selection process.  To get the most out of a work flow analysis it is best to start with a clear purpose in mind.   Some important reasons for initiating work flow analysis before selecting an EMR are to:

• Identify current office inefficiencies
• Initiate critical thinking about desired future work flows
• Develop a prioritized list of desired future workflows (what are the most important ways an EMR is expected to help the practice?)
• Develop a prioritized list of the most important EMR functionalities that are needed in order to realize these desired future work flows
• Set realistic expectations on how the EMR is expected to help achieve goals and attain better workflows 

When a work flow analysis is completed the physician practice should expect to see: 

• Detailed descriptions of current office work flow
• Detailed work flow maps of key office processes
• An analysis that identifies current inefficiencies, bottlenecks and opportunities for improvements
• A high-level outline of desired future workflow redesigns (how the office will work when a EMR is operational)
• A list of changes that could be made now...even before selecting an EMR

A workflow analysis will initially result in written descriptions of the key processes that the physician practice thrives on each day.  These written descriptions are then synthesized into a workflow map that may look something like this:

 

This current workflow map can be used by the practice to design better workflows.  Using the current workflow example from above, the draft development of a future workflow map might initially look something like this:

Developing workflow descriptions and critically thinking about desired future workflows will help identify what an EMR needs to be able to do well for the practice.  Knowing what the EMR needs to do well will help the practice identify and prioritize needed EMR functionalities.  This knowledge will simplify the comparison of EMR products as discussed in the next several blogs.

EMRs create a new medical liability risk-- physician's failure to chase after the non-compliant patient

It is clear that electronic medical records (EMRs) improve patient safety and quality of care in many ways.  It is unclear, however, whether these improvements will result in an overall reduction in medical liability risks and costs.  Consider the following scenarios:

Scenario 1: You are the doctor and you have a 20 year-old female patient, Ann, with insulin-dependent diabetes mellitus who has been an ideal and compliant patient.  When you last saw her 3 months ago you wrote an office note about how her paper log of glucometer readings (that she faithfuly brings in each visit) showed an exellent trend of glucose levels and compliance with her diet and insulin regimen.  A Hgb A1C test was done and the result satisfactory.  Today an emergency room doctor calls you and reports that Ann is comatose with a blood sugar of 650 with other signs of severe ketoacidosis.  You admit her to the intensive care unit where she is treated aggressively but cerebral edema develops resulting in a stroke.  Upon recovery from her metabolic crisis she requires rehabilitation for residual left-sided weakness.  As you piece together her story you discover that since you last saw her she had apparently become acutely depressed after breaking up with her boyfriend.  She now admits to straying from her usual dietary restrictions, failing to take her insulin regularly and not monitoring her blood sugar.  You explain to Ann and her family that her depression obviously led to non-compliance with her diabetes therapy which unfortunately resulted in her poor outcome.

Scenario 2: You are the doctor and you have a 20 year-old female patient, Ann, with insulin-dependent diabetes who has been an ideal and compliant patient.  You last saw her 3 months ago and in your EMR you noted an excellent trend in her daily blood sugar readings that she faithfully sends to your office in real-time (by connecting her home glucometer to the internet through her Xbox).   A Hbg A1C test was done and the result satisfactory.  Today an emergency room doctor calls you and reports that Ann is comatose with a blood sugar of 650 with signs of severe ketoacidosis.  You admit her to the intensive care unit where she is treated aggressively but cerebral edema develops resulting in a stroke.  Upon recovery from her metabolic crisis she requires rehabilitation for residual left-sided weakness.  As you piece together the story you discover that since you last saw her she had apparently become acutely depressed after breaking up with her boyfriend.  She now admits to straying away from her usual dietary restrictions, failing to take her insulin regularly and not monitoring her blood sugar.  When you look in your EMR it is obvious that she stopped sending in her glucose levels 8 days ago.  You were on vacation and the alerts generated by the IT tools were somehow missed by your office personnel.  You explain to Ann and her family that her depression obviously led to non-compliance with her diabetes treatment which led to a severe ketoacidosis complicated by a stroke.  Ann’s parents ask why you would not have checked up on her when she stopped sending in the glucose readings.  They blame you for the poor outcome and file a medical liability suit against you for failing to follow-up on their daughter after your records showed she had become non-compliant. 

The above scenario demonstrates one of several new liability issues raised by the use of electronic health records (EHRs) and other health information technology (IT) tools.  Technology not only changes the way clinicians manage patient care, but also creates new patient care issues to manage.  Other situations prompted by health IT and prone to liability issues include: 

1. New ways physicians manage population health
2. Access to previously unavailable patient information through the use of health information exchange (HIE)

EMRs have been shown to improve patient care and patient safety which will hopefully serve as a strong counterbalance to any new liability risks.  However, if medical liability insurance companies discover a need to raise premiums on physicians who adopt health IT tools, then there needs to be open dialogue over who pays for the increase.  Any rise in liability premiums due to health IT adoption needs to be shared by all stakeholders (liability insurance companies, health plans, consumers, employers, hospitals, government, etc...) and not just the doctors.  The rule of thumb for health IT adoption is that, since it is for the public good, all stakeholders get to play and all stakeholders have to pay

See Live Streaming Video of Bipartisan Meeting on Health Reform Thursday, February 25, 2010, 10:00AM EST

Return here on February 25th, 2010 at 10:00am EST for live streaming video coverage of the bipartisan discussion on health reform.  Listen for issues where health information technology provides solutions especially during discussions about quality of care.  A White House website provides more information on this meeting. 

JOIN THE LIVE CHAT

VISIT WHITEHOUSE.GOV

Texas Physicians With Other Stakeholders Collaborate on Local and Statewide Health IT Funding Decisions

New federal funding for the adoption and use of electronic medical records (EMRs) is accelerating progress on many existing health information technology (HIT) initiatives, providing a jump-start for some languishing HIT efforts and triggering other innovative activities.   Most of the additional funding is designated as incentive payments to physicians and hospitals that successfully adopt and use EMRs.   Some of the new funding is targeted for the development of technical infrastructure and processes that are needed to maximize the value of EMR usage by clinicians. 

Over the next year decision-makers at the federal, state and local levels will determine how billions of dollars will be spent on HIT over the next decade.   Physician participation in these decisions will help maintain a focus on using HIT to improve quality of care and patient safety.  The following information is an overview of the HIT landscape at the federal, state and local levels.

Physician Incentives

The American Recovery and Reinvestment Act of 2009 (ARRA), commonly referred to as the $800 billion Recovery Act, designates $19 billion toward the adoption and use of EMRs.  In particular, the bill provides $17 billion of incentive payments to individual physicians and hospitals who demonstrate "meaningful use" of EMRs.  Medicare physicians may qualify for a maximum of $44,000 based on 75% of their annual Medicare payments (see chart below).  The Medicaid incentive payment formula is different and based on the actual implementation and operating costs of the office EMR.  Physicians with a Medicaid patient mix >30% may qualify for up to $63,750 and those with a Medicaid mix of 20-30% may qualify for 2/3s of that amount. 

 "Meaningful Use"

In order to qualify for incentive payments ARRA requires physicians  to demonstrate "meaningful use" of an EMR.  The Department of Health and Human Services (HHS) is defining "meaningful use" based on the following guidelines:

Qualifying physicians must:

 

1. Use an EMR certified for "meaningful use" by HHS (different than CCHIT certification)
2. Use e-prescribing
3. Be able to "connect" their office EMR to other health IT systems (such as a lab or a state immunization registry) and exchange data
4. Be able to report on specified quality measures

HHS has released details on the preliminary definition of "meaningful use" and the final definition is expected later this winter or early spring.  A website hosted by the Office of the National Coordinator of Health IT (ONC) provides more details and ongoing updates on physician incentives and meaningful use. 

HIT Regional Extension Centers (RECs)

ARRA funds are also available to create about 70 RECs spread geographically across the nation.  Their purpose is to provide assistance to physicians in the successful selection, implementation and meaningful use of EMRs.  RECs will focus assistance on small physician groups and rural physicians. 

In Texas there are four non-profit entities that are collaborating with each other and have segmented the state to assure full coverage of every county.  These four grant applicants are anchored by UT Health Science Center Houston, the Dallas-Fort Worth Hospital Council, Texas A&M Health Science Center and Texas Tech Health Science Center.  The Texas Medical Association (TMA) and other state organizations are working collaboratively with each of the grant applicants.   Each REC has committed to a 50% physician representation on their governance boards.  Under the proposed plans local Tarrant County physicians will have access to the North Texas Regional Extension Center (NTREC) where Matt Murray, MD (Fort Worth), David Bragg, MD (Dallas) and Kenneth Haywood, MD (Tyler) are physician board members.  The federal REC grants are expected to be announced in March 2010. 

Health Information Exchanges (HIEs)

Technology and processes exist that can provide physicians access to a consolidated set of patient data that was entered into electronic systems at hospitals, labs, pharmacies, radiology centers, emergency rooms or even other physician offices who use different EMRs in the community.  An entity that provides this "connecting" infrastructure is called a health information exchange (HIE).  The value of an ambulatory EMR increases significantly if there is a local HIE to connect to that provides the physician online access to data about his patients that has been entered in other systems across the community. 

At a national level the National Health Information Network (NHIN) effort is establishing standard models for the exchange of health information between EMRs.  The federal HIE Cooperative Agreement Program created in 2009 will provide federal grants to each of the 50 states to develop HIE infrastructures at the state level.  In return the states are expected to align their HIE models with NHIN standards.  

HIE Cooperative Agreement Program Funds in Texas

In December, 2009, HHS announced that the Texas Health and Human Services Commission (HHSC) will receive $28.81 million over four years to fund the planning and implementation of HIE networks.  HHSC contracted with the Texas Health Services Authority (THSA) to develop strategic and operational plans that describe how Texas will create a robust HIE infrastructure.  THSA consequently created four workgroups and, with assistance from the TMA, appointed at least one Texas physician on each workgroup:

Governance and Finance:   Susan Blue, MD (Fort Worth)

Technical Infrastructure:   Matt Murray, MD (Fort Worth) and James S. Walker, MD (Refugio) 

Privacy and Security:   James Merryman, MD (Austin)

EHR Adoption and Consumer Engagement:   Tim Barker, MD (Waco)

There are currently over a dozen HIE entities in Texas in various stages of development.  Sandlot is an operational HIE in Fort Worth.  The DFW Hospital Council is leading another local HIE effort that is in a developmental stage.  Lessons learned and work already completed by existing HIE entities will be leveraged as the Texas HIE model develops.

Texas Medicaid HIE Pilot 

House bill 1218, 81st Legislature, Regular Session, 2009, requires HHSC to establish an HIE pilot for the exchange of Medicaid-related data.  A 16-member HIE Advisory Committee with Joe Schneider, MD (Dallas) serving as chairman was appointed to assist with the development and implementation.  The TMA worked to ensure adequate physician representation on this advisory committee as it is likely that the Medicaid pilot project will influence the statewide HIE model development going forward.

Building consensus among providers, payers, consumers, HIT vendors and other public, private and government entities is difficult but vital for technology to be successfully used in health care.   Perhaps the most encouraging trend over the past year is the increasing number of successful collaborative efforts such as those outlined in this overview. 

First published in Tarrant County Physician, January 2010 (reprinted with permission)

by Matt Murray, MD