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EHRs and patient safety

If you wonder where I’ve been, I’ve, for one thing, been blogging a bit for (very little) pay over at Forbes.com and writing a lengthy cover story for the September issue of Healthcare IT News.

The Healthcare IT News piece actually breaks down into a fairly short lead story and several sidebars, which aren’t all that evident from the traditional Web version. (The digital edition has everything.) For the sake of convenience, here are links to all elements of the cover package:

Main story: “Patient safety in the balance: Questions mount about EHRs and a wide range of patient safety concerns”

Sidebars:

The issue also contains a reprint of my May 2012 blog post, written just a week after my father’s death: “Medical errors hit home.”

Happy reading, and happy Labor Day weekend.

August 29, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Adelphi U ad spreads health reform fallacy

The following ad has popped up several times on my mobile Facebook app recently:

Adelphi Facebook ad
That’s from Adelphi University in Garden City, N.Y., and the first sentence of that ad is absolutely false, not to mention poorly written. There is no government mandate for any healthcare facility to go paperless at all, much less by 2015.

As people in health IT and in healthcare management probably know, the federal Meaningful Use EHR incentive program calls for Medicare penalties starting next year for any provider that hasn’t achieved at least Stage 1 of Meaningful Use. But that’s not a mandate; hospitals and other providers still have the option of participating. Those who don’t see Medicare patients don’t face penalties anyway.

Even those that are able to meet all the Meaningful Use requirements still don’t have to be paperless, at least not according to the Stage 1 and Stage 2 rules. Nor have I seen any evidence that Stage 3 would contain such language, and even if it does, that phase does not start until 2017.

There are plenty of reasons why those who start work on a master’s in health informatics this year will be very much in demand next year. Why does Adelphi need to mislead people in an apparent attempt to create demand for its program?

June 29, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Digital health should get in on Health Affairs innovation action

The policy journal Health Affairs puts out an e-mail update every Sunday, for those of us who can’t get enough of reading work e-mail during the week. Today’s contained the following solicitation:

Health Affairs is planning a theme issue on health care and medical innovation in early-2015. The issue will span the fields of medical technology and public policy as well as private sector innovations that promote improvements in the delivery of care, lower costs, increased efficiency, etc. We plan to publish 15-20 peer-reviewed articles including research, analyses, and commentaries from leading researchers and scholars, analysts, industry experts, and health and health care stakeholders.

We invite interested authors to submit abstracts for consideration for this issue. To be considered, abstracts must be submitted by Wednesday, June 25, 2014. We regret that we will not be able to consider any abstracts submitted after that date. Editors will review the abstracts and, for those that best fit our vision and goals, invite authors to submit papers for consideration for the issue. Invited papers will be due at the journal by September 2, 2014.

Abstract submission requirements. Abstract submissions should not exceed 500 words, and should include (in this order): proposed title, author names and affiliations, abstract, name and contact information for the corresponding author below the abstract. Please consult our online guidelines for additional formatting instructions. http://www.healthaffairs.org/Abstract_Submission_FAQ.php

If you wish to submit an abstract, please send it as an e-mail attachment to abstracts_innovation@projecthope.org (note: there is an underscore between “abstracts” and “innovation”).

We thank you for your time and consideration. Please feel free to pass this invitation along to colleagues who might be interested. If you have questions about this request, please contact Senior Deputy Editor, Sarah Dine, at sdine@projecthope.org.

Presumably, a lot of the submissions will come from traditional medical device manufacturers, the pharma industry and managed care, but this seems like a perfect opportunity for some from the realm of digital health to prove that they really are disruptive, game-changing, revolutionary or any of a number of buzzwords and clichés the marketing people like to throw around.

The June 25 deadline doesn’t leave a lot of time, but that’s just to submit an abstract. The full description can come later. So get to work, digital health innovators. It’s time to prove to the establishment that your ideas are real and effective.

Click here for more information.

If you’re looking for my writing this week, I’ll be at WTN Media’s Digital Health Conference in Madison, Wis., Tuesday and Wednesday, helping WTN with its coverage. I’ve got to write at least three stories from that conference, which will be my priority once the meeting starts, though that doesn’t preclude me from posting elsewhere once that work is done.

June 22, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Video: StartUp Health co-founder talks Health Datapalooza on CNBC

Unity Stoakes, co-founder and president of entrepreneurship academy StartUp Health, was in Washington this week for Health Datapalooza. Tuesday morning, with the Capitol dome serving as a picturesque background, he appeared on CNBC’s “Squawk Box” to talk innovation in digital health. Stoakes used more than a couple of buzzwords, such as “revolution” (see my commentary for Forbes on Apple’s just-announced HealthKit mocking the notion of a revolution) and “creative destruction,” and CNBC added a few more, like “disruptive” and “tectonic shift”

But he did temper the enthusiasm with a reality check. “To be quite honest, there’s a lot of uncertainty,” Stoakes said when asked about who the losers would be in the new healthcare world. Have a look, and share with your friends outside of healthcare so they get a bit of a sense about what digital health is and where true healthcare reform might come from.

Visit NBCNews.com for breaking news, world news, and news about the economy

In case you missed it, I interviewed Stoakes last month for a story in Healthcare IT News about breaking down data silos in digital, mobile and “connected” health.

June 5, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Video: Aneesh Chopra on ‘The Daily Show’ for a long interview

Everybody else has the news about CMS offering leniency with Stage 2 Meaningful Use, letting providers use EHRs with 2011 certification to meet Stage 2 standards because so few vendors have been certified to the 2014 standards previously required for Stage 2. I won’t rehash here.

I will, however, share the very extended interview Jon Stewart had last night with former White House CTO — and, before that, HHS CTO — Aneesh Chopra on “The Daily Show.” Stewart is a comedian with a known liberal bias, but he is not a bad interviewer when dealing with a serious subject.

Stewart has been hammering the VA over its backlog of new registrations, and stepped it up in the wake of the recent revelation that VA bureaucrats in Phoenix were gaming the system to make it look like waits weren’t as bad as they really were. He’s also criticized the federal government for failing to link medical records between the Military Health System and the VA — you know, what we in health IT call interoperability. (In Part 4, Chopra discusses lack of interoperability in the broader healthcare sense.)

I found out about Chopra’s appearance last night shortly before the show aired. Unfortunately, we were having heavy rain at the time, and my satellite TV got knocked out, so I missed it. It’s OK, because the Chopra interview was long — more than 22 minutes — and the version that was on TV is heavily edited. Here’s the full interview of the “Indian Clooney,” as Stewart called Chopra, from the show’s Web site.

Part 1  (4:41)

 

Part 2 (7:27)

 

Part 3 (5:19)

Part 4 (5:35)

 

May 21, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

APSO vs. SOAP, continued

A couple weeks ago, I had a story in Healthcare IT News about the growing use of the “APSO” notes for documenting patient encounters. APSO flips around the traditional SOAP format (subjective, objective, assessment, plan), ostensibly making it easier to view progress notes in electronic health records.

As I reported, APSO is in wide use at University of Colorado Health and at Lucile Packard Children’s Hospital in Palo Alto, Calif. Baystate Health in Springfield, Mass., found that hospitalists focused most of their attention on the “impression and plan” sections of patient records, essentially the AP part of APSO/SOAP. Physicians at Epic Systems, according to University of Colorado’s Dr. C.T. Lin, are recommending APSO as a best practice.

Yet, the inventor of the SOAP note, Dr. Larry Weed, still believes his format is superior. You saw his comments in the Healthcare IT News story. But every time I have the privilege of speaking to the nonogenarian Renaissance man, he always has more to say than I can fit into the average article. I often can’t keep up in my note taking, but, fortunately, in this case, Weed and his son/occasional co-author Lincoln, took the time to put their thoughts in writing for me.

I left most of their comments out of the story due to space limitations. I don’t have that problem here, so I present their entire statement to me:

The following represents our collective thoughts, including references to relevant portions of Medicine in Denial [their 2012 book].

The supposed advantage of the APSO alternative — that it begins with the physician’s assessment rather than data — is actually a failing. This sequence tends to make the note provider-centered rather than patient-centered, and judgment-based rather than evidence-based.  In contrast, beginning the progress note with data disciplines the provider’s assessment. The provider must think in terms of specific data, specific problems on the problem list to which the data relate, and the interrelationship of each problem to the other problems on the list. Moreover, it’s important to begin the progress note with subjective (symptomatic) data from the patient rather than so-called “objective” data,  As Medicine in Denial states (p. 168):
“… progress notes should begin with subjective data, because progress should be assessed from the patient’s point of view.  Practitioners should be alert to discrepancies between subjective and objective data (for example, where the patient does not feel better when lab results show improvement). These discrepancies may signal an error in data or misstatement of the patient’s problem.”
In short, provider thinking can be disciplined with problem-oriented SOAP notes as a standard of care. Yet, regulators and academics who are in a position to act on this issue have shied away from the whole notion of standards of care for organizing data in medical records. See our comments on ONC’s Stage 2 regs and our comments on the PCAST Report.
The need for standards of care in medical records goes far beyond the SOAP vs. APSO issue in progress notes. In fact, that issue is secondary. Two more fundamental issues for medical records are the following:
  1.  Determining initial inputs to the record. Initial inputs are determined by selection of data needed for the patient’s problem situation, and once the data are collected, analysis of the results.  Both selection and analysis are fatally compromised when determined by the physician’s clinical judgment. External standards and tools, based on a combinatorial standard of care, must govern the selection and analysis. Once that happens, then judgments of patient and practitioners (not just physicians) may supplement the combinatorial minimum standard.  See Medicine in Denial, pp. 53-61, 69-79, 136-37, 145-52.
  2.  Organizing the medical record around the problem list. Once initial data are collected and a complete problem list is defined, then care plans, orders, and progress notes should be problem-oriented, that is, labeled by the problem(s) to which they relate on the problem list. This disciplined practice is essential to justifying provider actions in terms of defined patient needs. Yet this practice is not followed or enforced with consistency. Indeed, some EHR systems do not even enable electronic links between the problem list and care plans, orders and progress notes. See Medicine in Denial, pp. 134-35, 144, 159-60, 166-67.
Like so much else in medicine, medical record practices are a Tower of Babel. Medicine need standards of care for managing clinical information (knowledge and data) no less than the domain of commerce needs accounting standards for managing financial information. This failing is a primary root cause of the health care system’s failures of quality and economy.

For that matter, Lin had more to say than what you saw in the story. He discussed the supposed importance of the subjective and objective elements. “That’s true in cases where there is diagnostic uncertainty,” Lin said. But he added that those components are still there for reference, jut not up front.

Lin called SOAP “a phenomenal innovation,” but suggested that EHR complexity sometimes makes it difficult to find the assessment and plan. For example, he said that a non-Epic EHR in the emergency department at UC Health has as many as 17 different screens for progress notes. “At least with APSO, you would collect the assessment or plan in the first half,” Lin said.

Because SOAP is so entrenched, Lin ran into much resistance when he proposed switching to APSO at 40 affiliated practices. He, of course, heard the tired, “But we’ve always done it this way” defense.

“I learned myself about culture change very acutely,” Lin said. “I was literally shouted out of the room by our physician leadership.” He had neglected to prepare the heads of various departments and clinics for the change in advance of the meeting where he announced the plan.

He subsequently had to have individual conversations with all 40 practice directors. And then Lin dropped a great quote from none other than Niccolo Machiavelli (speaking of Renaissance men): “Those who benefited from the old order will resist change very fiercely.”

Yes, that’s absolutely perfect for an industry as resistant to change as healthcare. But is APSO superior to SOAP? I’d love to hear your thoughts.

May 20, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Some truths about health IT and innovation

This morning at the annual SAS Health Analytics Executive Conference in Cary, N.C., former national health IT coordinator Dr. Farzad Mostashari dubbed Dr. Eric Topol “the high priest of personalized medicine.”

That reminded me of an e-mail I received a couple weeks ago, suggesting that someone should start a blog called, “What’s Eric Saying?” As this correspondent explained it, all you need to do is read Topol’s Twitter stream to know where health IT and the practice of medicine are headed. I checked it out. It’s true.

Some examples:

 

 

 

And that’s just since Monday.

Meanwhile, Mostashari added some truisms himself this morning. “Med speed is slow. Tech speed is fast,” he said, apparently paraphrasing current TEDMED owner Jay Walker. Then, speaking as a physician, Mostashari said, “Most of what determines our outcomes isn’t what happens in our office.” Which is kind of what Topol has been trying to get across for several years.

If only the financial incentives would encourage care outside the office, we might be getting somewhere. It’s starting to happen, but, as it says above, med speed is slow.

May 14, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

About those Obamacare numbers and the ICD-10 delay

While I’ve been busy writing a couple of stories on different topics, you’ve probably heard two pieces of news that will affect healthcare providers nationwide: the close of the first open enrollment period for Patient Protection and Affordable Care Act insurance exchanges and the Congressional “fix” (read “Band-Aid”) to the Medicare sustainable growth rate that statutorily delays the ICD-10 compliance deadline for another year, until October 2015.

The White House yesterday reported that 7.1 million people had signed up for health insurance through healthcare.gov or state-run exchanges, barely exceeding the Congressional Budget Office’s projection of 7 million. Independent tracking site ACAsignups.net says it’s more like 7.08 million, but still just above the goal. That site also tallies the following sign-ups as a result of the ACA:

  • 6.37 million – 12.45 million in private “qualified health plans” (plans that meet ACA standards) via private exchanges, insurance agents or direct purchases from insurers, including deductions for the estimated 3.7 million whose “noncompliant” policies were canceled;
  • 4.71 million – 6.49 million through Medicaid/Children’s Health Insurance Program expansions;
  • 2.5 million – 3.1 million “sub-26ers,” young adults whom the ACA allows to stay on their parents’ health insurance until age 26; and
  • 1.8 million “woodworkers,” those who came out of the woodwork because they did not know before the Obamacare enrollment push that they were eligible for Medicaid or CHIP.

ACAsignups.net places the total range at 14.6 million – 22.1 million as of March 31, not counting the healthcare.gov numbers, though my math puts it at 15.38 million – 22.06 million. Add in the healthcare.gov sign-ups and you get about 22.5 million to nearly 29 million newly insured people. However — and this is a big however — we do not know how many of the beneficiaries are newly insured and how many were replacing previous coverage.

Personally, I bought a high-deductible, ACA-qualified health plan through an independent agent to replace a rather restrictive high-deductible plan that was grandfathered in, and should save about $70-$80 a month on premiums starting in May. The new insurer rejected me several years ago due to a pre-existing condition; the ACA assures that I can’t be denied for that reason anymore. I imagine there are millions in the same boat as I am.

The U.S. Census Bureau placed the number of uninsured for 2012 at about 48 million, or 15.7 percent of the population. (The same year, 198.8 million had private insurance.) Until we see new figures for uninsured Americans, we will still just have “gross” statistics, not a net figure to show if the insurance part of the ACA is working.

By the way, the ACA is about much more than insurance coverage, despite what the national media have focused on. I encourage you to read up on this before you say Obamacare is saving or ruining our country.

Now, as for the temporary SGR fix, the ICD-10 delay kind of came out of nowhere last week when it got slipped into the House version of the legislation, but the Senate adopted the same language — reportedly without debating ICD-10 at all — and President Obama today signed it into law. I’ve said before that ICD-10 and other transactional elements of healthcare stopped mattering to me as I watched my dad being mistreated in a hospital due to broken clinical processes in his last month of life. I still think this way. However, this sneaky move shows that the AMA, AHA and other groups more intent of protecting the status quo than fixing healthcare still have enormous sway in Washington.

It makes me wonder whether lobbyists haven’t already started pushing hard for Congress to delay the Medicare penalties for not achieving Meaningful Use that are due to kick in next year. Actually, I don’t wonder. I’m sure it’s happening.

All delaying real reform of a broken industry does is prolong the agony, and ensure that millions more people will be affected by errors and neglect in institutions that are supposed to “do no harm.” The status quo is not acceptable.

 

April 2, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

eHealth Initiative ’2020 Roadmap’ panel needs consumers

This press release showed up my inbox on Tuesday:

eHealth Initiative Launches 2020 Roadmap Process

Framework to Change the Future of Nation’s Healthcare System

March 25, 2014, Washington, D.C. – The eHealth Initiative (eHI) announced the launch of the eHealth Initiative 2020 Roadmap, a public-private collaboration that will help guide the  transformation of the nation’s healthcare system by 2020. With the help and support of a  wide array of leading healthcare associations, organizations, and federal agencies, 2020 Roadmap will propose key policy recommendations to implement at a federal level and actions for the private sector to help transform healthcare.

“Health reform calls for transformation to a value-based interoperable system, but there is no direction on how to transition from our current work processes and systems. Clinicians, payers and providers are in dire need of leadership to help transform delivery systems and control cost,” said Jennifer Covich Bordenick, Chief Executive Officer of the eHealth Initiative. “The goal of our new initiative is to craft a multi-stakeholder solution that coordinates the efforts of both the public and private sector so that we can make this transition successfully.”

The 2020 Roadmap will be developed over the next six months through a series of surveys, webinars, executive roundtables, and events with key constituencies; the outcome will be a consensus on how to shape the future of our healthcare system.  Individuals are welcome to complete surveys, participate in upcoming events, and provide general feedback. A new survey is currently being fielded to gather information from the industry.

The 2020 Roadmap will focus on recommendations that:

•        Identify a sustainable glide path for meaningful use;

•        Promote interoperable systems;

•        Transform care delivery; and

•        Balance innovation and privacy.

Several advisors representing different stakeholders are leading the 2020 Roadmap activities, including:

·         John Glaser, PhD, Chief Executive Officer, Health Services, Siemens (representing vendors)

·         Sam Ho, MD, Executive Vice President and Chief Medical Officer, UnitedHealthcare, Chair eHI Board of Directors, (representing payers)

·         Christopher Ross, MD, Chief Information Officer, Mayo Clinic (representing providers)

·         Susan Turney, MD, Chief Executive Officer, Medical Group Management Association (representing clinicians)

·         Micky Tripathi, PhD, President and Chief Executive Officer, Massachusetts eHealth Collaborative (representing information exchanges)

·         Joseph Touey, Senior Vice President, North American Pharmaceuticals, Information Technology, GlaxoSmithKline (representing pharmaceutical manufacturers)

“The impressive caliber of individuals leading our effort reflects the importance of the 2020 Roadmap,” said Jennifer Covich Bordenick. “We invite all organizations to participate in this important process and bring the best thinking to the table.”

Visit the 2020 Roadmap webpage for more information at http://www.ehidc.org/2020-roadmapMore information about the eHealth Initiative is available online at www.ehidc.org.

###

About the eHealth Initiative: The eHealth Initiative (eHI) is a Washington D.C.-based, independent, non-profit organization whose mission is to drive improvements in the quality, safety, and efficiency of healthcare through information and information technology. eHI is the only national organization that represents all of the stakeholders in the healthcare industry. Working with its membership, eHI advocates for the use of health IT that is practical, sustainable and addresses stakeholder needs, particularly those of patients. www.ehidc.org .

What immediately jumped out at me was the list of advisors. I’m familiar with most of the names, and I am sure all are qualified to provide valuable input on how to promote interoperability and improve our nation’s broken healthcare infrastructure. But the notes on representation raise an important question: How come nobody is representing consumers?

It’s after hours as I read the press release and I post this commentary, but I’ve e-mailed the press contact to see if the eHealth Initiative has a good answer. I will report back as soon as I hear anything. In the meantime, consumer and patient advocacy groups should take Bordenick up on her offer to participate.

UPDATE, March 27, 11 am CDT: I’ve just received this response directly from Bordenick:

Please know that the news release just highlighted just a few of the individuals and groups that will be involved.  We absolutely welcome the representation and involvement of patient and advocacy groups, and any stakeholder groups who want to participate— that is one of the reasons we put the announcement out, and asked people to fill in contact info in the survey. We are at the very start of this process, so now is definitely the time to get engaged. We currently work with National Partnership for Women and Families, Center Democracy & Technology, American Cancer Society, and have just started work with Smart Patients, and many others. We expect all of these groups to continue working with us, and many others to join in the process.

So there you have it. As I said in the original post, consumers and patient advocacy groups should take Bordenick up on the offer. It sounds like she would appreciate it.

March 26, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Video: Farzad Mostashari on patient engagement, ‘physician ACOs’

As I alluded to earlier, I was leaving the press room one afternoon at HIMSS14, and there I see former national health IT coordinator Dr. Farzad Mostashari hanging around Gregg Masters and Dr. Pat Salber of Health Innovation Media. It turns out, Masters and Salber had just pulled Mostashari aside to do an interview on video, but they didn’t have anyone to interview him on camera, so they asked me right there on the spot to be the interviewer. Here is the result.

Mostashari, now a visiting fellow at the Engelberg Center for Health Care Reform at the Brookings Institute in Washington, discussed how the years of searching for a business model to coordinate care and engage patients is finally starting to pay off. Always the champion of the little guy in healthcare, Mostashari also brought up the notion of physician-led ACOs, or, as he called it, the “Davids going up against the Goliaths.”

 

I had pretty much no preparation for this interview. It probably shows. I still think it worked out well.

Here’s a link to Salber’s post about the interview because I don’t want to steal page views. :)

March 14, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.