Story of an accident

It is sad story of my wife falling and dislocating her elbow .

On a wintry sunny day march 8th my wife was coming back from shopping and snow was melting and freezing in the process a slippery surface has formed in our yard .In the enthusiasm brought on by the warm sun and hope of breaking the ice my wife with several grocery bags in her both hands and 2.5 inch healed shoes was breaking the ice with both feet and slipped and dislocated her elbow.She was in extreme pain and she was making noises i had not heard of.as i went out she screamed her arm was broken and to call for 911.She was complaining of pain as she could not move her fore arm as it was loose and painful.She feared the worst and did not want me to touch her.In no time .fire dept was there with the paramedics .I had helped her up and we had walked to the ambulance .Paramedics diagnosed the situation and she was put on a stretcher with a splint to hold her arm and we were on our way to the hospital.We were glad and i had gone inside to get info on my wife's prescription and the paramedics called in to the hospital emergency room while they created her medical history.
I traveled with the driver of the ambulance to the hospital.

Soon we were in the hospital.It was about 12:30 they took her X-ray of the arm and we were in for a long wait.Doctors suggested some pain killers she refused and later she agreed to take a strong pain medicine when pain had become totally unbearable.
After inspection by emergency room doctor I thought he would relocate the elbow .No such luck he showed us the x ray and she became aware of the reason for the extreme pain.Now we were in for the wait of Bone doctor to come and relocate the elbow.In the mean time her arm had swollen making it much more difficult to relocate the bone in the slot.

They had to block the nerve to relocate the arm.In less than five minuites after pushing pulling her arm was in place . Another x ray was taken to verify doctors work.
She was released from hospital at around 8 P.M

Her arm was put in an open cast so that it may heal and instructions were given not to move arm and it was projected that she would be back to work in about six weeks if everything went well.She was not happy about the loss of mobility and was afraid that she may loose her job for this injury.She was also afraid of income loss as she may have to wait for TDI( temporary Disability insurance).If one is out of work for injury many things happen.
1.In spite of income loss health insurance weekly payments keep coming ,which in our case with employer contributions for a family plan are about 120 dollars per week.
2.Hospital emergency room co-payment is Hundred dollars.
3.Doctor visits co payments are 30 dollars per visit
4. Physical therapy co payments are also 30 dollars .Three times a week that is 90 dollars.

Not only these payments are extra from weekly insurance they are also stress on people with limited incomes or high responsibilities.

So these are knowable and hospital bills put extra stress on finances .Soon we got a bill stating hospital had charged 7200 dollars for that days services and with our co payment dollars and Insurance paying about half of it ,it seems half about 3500 dollars remain hanging on our head .This is after we have made several hundred dollars of co payments and paying 6000 dollar a year part of our premiums .Other co payments fro drugs and physician payments are additional 1500 dollars per year.

I thought we were doing OK till we got balance of payment notice from the xray shop connected to our orthopedic doctor whose helper a younger physician had put elbow in place.This xray shop has billed four hundred or so dollars and insurance had paid three hundred dollars and this poor doctor was insisting that we pay the balance of 106 dollars.
Seems like a big machinery is in operation in the hospital system just to bill and harass the patients their job is to squeeze every penny of nourishment from the rocks.
I am sure they have forgotten the oath not to do no harm.

I remember that when my daughter had a major operation in Boston Children's hospital they took our insurances and never billed any excess fees for any of the services provided.We were not asked to pay even when she had gone to give her blood in case of the need.
It is time somebody makes such an approach.One of the richest groups in society should become part of the cost containment need where we can deliver great care at reasonable cost and without driving the customers crazy.

It is time cost containment was implemented in health care. Patients co payments must be limited and insurance policies with high co pays should be prohibited with no more than 10 percent of the annual premiums.

continues

Patents for drugs and innovation

Monday, March 7, 2011
about patents for drugs and innovation

Lipitor a 10 billion drug is going off the patent and Pfizer will lose the cash stream from this patent.Somehow the media is feeling sorry for them. The whole drug innovation and patent system has served the drug industry and all inventors reasonably well.
Now it has become a racket to try to increase the time for the patents by filing appeals against the generic manufacturers.We should all CELEBRATE this going of the patent with a party.Cost savings to the nation will be from this one drug will be in tune of 6 to 8 billion dollars. Worldwide savings will be even higher.

The questions have been raised by several studies in Canada where it has been found that the positive effects of lowering Cholesterol by medication is minimal for generally healthy citizens.It may be asked if we are creating Mega drugs with little benefits to the public.It is time that we study how any billion dollars in expenses for the society can benefit the nation.

This argument is not against the special care given to patients in USA.But is about public funds spent on all the systems from aggressive prenatal care to aggressive end of life care.

The money saved by one drug going generic is enough to end one major killer of humanity like Malaria (over 2 million deaths a year).

We need to reduce human suffering and improve quality of life not extend marginal lives by few hours in vegetative state.Given the choice like all informed people we will choose life of Independence over life dependent on even inanimate machines.

Duff Wilson writing for New York Times states that ten drugs with sales of 50 billion dollars will go of patent this year.We have a potential of saving 40 billion dollars now on per year.If we look at the benefits from this protection ending we could wipe out many diseases from the poorest parts of the world so in a global village we will protect us from those diseases becoming epidemics .

The new drug innovation should be speeded and efforts be mad that new drugs be reasonably priced to benefit the patients otherwise we will have two tier service and cost for medical care.I was checking that the drug cocktail needed as first line of defence against Aids is 3500 hundred dollars per month in US and in India though it is very difficult for people without health care to afford the drugs a months supply is 40 us dollars per month.We will be hard pressed if poorer nations did not honor our drug patents to protect the lives of Its citizens.

In USA we had paid Bayer several billion dollars for Cipro for the Anthrax scare while a Pharmacology specialist friend had told me that drugs could have been manufactured by National health services for only a few million dollars and stored for use in case of eventual emergency .If it would be still under patent protection royalty could be paid to the rightful owners. He told me that Cipro was not under any such protection.

Pricing confidentiality clause and its cost to us.

Many of the hospitals,Insurers and suppliers connected with healthcare delivery have Pricing confidentiality clauses in their sales agreements. These clauses are simply ways to have unfair pricing in the market place.Many times large insurers feel that they have advantage in the marketplace as they get better pricing from the large companies for the size and scope benefits.In reality many times winners and loosers are picked up in devices on the cost and connection basis.

In the public interest while sixty percent of health care dollars are being spent by tax dollars .It is important in order to protect the week and to keep the costs in control all charges be made public and scrutinsed.

Many Doctors and other health care providers are very dedicated people and serve the community well.To reduce the cost of health care In america we will have to do the following
1.Use technology only when it improves the outcome of the healthcare.
2. Use IT and its processes for communication, data sharing and prescription and compliances help.
3.Combine ER and primary care to reduce costs for ER by providing primary care at the ER.This as pre thought not after thought.
4.Giving each patient a usb stick with healthcare data .to save time and costs in ER.
5.

Patient specific Education and diversity

Most of the EMR's are starting to recognise Diversity in creating patient Demographics.

One of the fastest growing demographic groups in our society are bi/multi racial category.Traditionally language defines us more than the ethnicity.It is true even in America for the new immigrants.As the immigrants become more English language proficient. Ethnicity start taking priority over language, suddenly Colombians who themselves identify as the people of that nation start seeing themselves as black ,white or native people.In a strange way we find that as Moroccans and french speaking Quebec people loose their french they are lumped away from each other with Germans and may be with blacks.

The main reason for this strange mix of data is US Census which has been taken every ten years from the inception of our nation.This flawed census ethnic data is least useful for Meaningful use in creation of EMR and its mandate.We recognise that Irish whites from Boston may have least in common with Hasidic Jew from southern Spain. This need to collect a detailed ancestry record is an effort to find our unique health traits and help the patient(us).

I was told by a very reputed heart Surgeon of Indian descent that natives of India in US should lower their Cholesterol below 160 as we have narrower arteries .This type of information while not currently available could be norm if we collected ethnicity specific data for the patients.

An anomaly has been found the Hispanics Live five years longer than Whites in America even while the health care availability and Obesity is worse in their population.It is also an opportunity for us to study what factors make it possible for them to live longer and could we duplicate those conditions.It has been speculated that diet though high in meat and fat content may play some role as well as involvement in the society.

For Diversity organizations it is a challenge as well as opportunity to be part of the Discussion of EMR software for better outcome.

LET US NOT MISS THIS OPPORTUNITY.

Can Polio Be Eradicated? A Skeptic Now Thinks So.NYT,

Donald Mcneil writes in NYT article that now Octogenarian Donald Henderson who is believed to be the strongest force in elimination of Small Pox. He at times is very skeptical that Polio can be eradicated in a short time.

Polio has a strange history now it is eliminated from 99 percent of the population. Yet polio Occurs in India ,Pakistan and Nigeria.Other reason is it is very difficult and arduous process to identify patients with it.To immune patients you have to use oral drops three times.

Dr. de Quadros, a former director of the Pan American Health Organization, has his own mantle: “The Man Who Found the Last Case of Smallpox in Ethiopia and Chased Polio and Measles Out of the Western Hemisphere.” It was the conversation with Dr Quadros which changed the mind of Dr Donald Henderson. With commitment of Bill Gates and his foundation ,WHO and help of group of eminent scholars and scientist it is time and Dr Henderson believes that stars have lined up for elimination of Polio.

FROM BILL GATES TALKING ON CHARLIE ROSE ONE FEELS THAT THERE IS NO FEATHER HE RATHER HAVE THAN ELIMINATION OF POLIO, SECOND DISEASE TO BE ELIMINATED .
for HUMANITY SAKE I HOPE HE GETS IT.

First in Asia. Transexuals along with others to be flight attendants,The Tribune , Chandigarh.

I thought i would like to share this news in Tribune a daily English language News paper from Chandigarh.

Transsexuals flight attendants
KUALA LUMPUR: A newly formed Thai airline is employing transsexuals as flight attendants, in a bid to provide them equal opportunity. "Ketoeys" or ladyboys, who are highly visible in mainstream jobs in Thailand, will work as flight attendants on the Asian routes of a charter airline "PC Air", starting April this year. PC Air earlier decided to hire males and females for the job but later changed its plan after it received more than 100 applications of transgenders, media reports said. — PTI

My niece and her blog about homosexuality

I am very impressed by writings of my 16 year old niece in India.She is a new blogger Kudratduttachaudhary.blogspot.com.

In India gays and lesbians are not integrated in society like they are being done in USA.Even basic understanding of sexuality is many times very limited.

Hijra's or Khusra are normally Hermaphrodite,that means people having male and female sexual organs or not developed sex organs.They have had there own colonies and make a living by dancing and entertaining others.Some of them work as male prostitutes.
and though accepted have a very low status in society.Traditionally as no hormonal and surgical solutions were available to this group of people they supported each other and created Strong community.members of this group are some times called as the third sex.In that sense they are much different than Homosexuals in America.

Homosexuals are people who like people of the same sex as there partners. Physiologically they are clearly male or female.It is a choice may be based on some psychological or hormonal variation we do not yet understand.

Kudrat might be thinking of the third sex as she has used those words.She is encouraged by the Acceptance of Homosexual soldiers in American Military as a major change.
Talking about Taboo subjects by a young person is always commendable.
here is her blog


HOMOSEXUALITY ....start accepting !
Everything around us offers variety, that’s why all of us are DIFFERENT , because our likes and dislikes are varied ,there is difference in our opinions and also there is a HUGE distinction in how we PERCIEVE life . But no matter how assorted all of us are, we all are binded together under a common term called HUMANITY .
We all are humans , irrespective of the fact that somebody is a girl or boy ,black or white ,hindu or muslim, gothic or preppy, straight or bisexual or maybe something else ,our ways of life or even our thinking cannot segregate one section of the society from the other . From a lot many years we have been hearing or rather experiencing cases of discrimination on the basis of caste ,colour and creed .If you were a BLACK or BROWN you were not considered fit to access the privileges of the fairer community .If you were a girl ,you were not considered INTELLEGENT enough to compete with the stronger sex. We all brag about living in the TODAY’S time and proudly being a part of the 21st century , which I presume would have opened our thinking capsule and brought a sense of equality towards ‘everybody’ in our minds.
Sadly , all of my presumptions are proved false by the ongoing conditions around me .Thankfully we have feminists and other social activists to fight against discrimination against women and the coloureds ,but what concerns me is that do we have ENOUGH support and a felling of acceptance for people who are generally graded as “THE THIRD SEX” ?
The answer to this is that, many of us calling ourselves advanced are scared of GAYS AND LESBIANS ,for reasons best known to individuals themselves .Many a times we would maintain distance from them just because they are not the ones belonging from the COMMON genders. I mean if we deeply look into the case, and analyse the differences between them and us all I can point out is the BASIC VARIENT that they are attracted to their own gender .The the weirdness of our reaction makes them fear to come out with the truth and live openly with their INDIVIDUAL IDENTITY. Many of us would frown at the thought of someone known to us being a gay but the question is that was this their own CHOICE ?
Tomorrow your son can be a gay to, does that mean you would behave the same way like you would do NOW after meeting someone belonging to the third sex ? The good news is that now it has been legalised in our extremely cultured nation ,which found HOMOSEXUALITY as something corrupting the minds of the population .As a fact many kings of the historical legacy were gays, but were married to women to save the name of the family thus, spoiling an innocent girl’s life and therefore forcing her to enter into an extra marital relation .
I am grateful to people who made consensual sex between homosexuals LEGAL .I mean how can we CRIMINALIZE one’s physical demands and acts of satisfying them with someone who feels the same.
It’s supposed to be a free world and in that, NARROW thoughts which classify homosexuality as vulgar and cheap have no place and room for survival .
THIS IS FOR ALL OF YOU, START EMPATHISING ,START ACCEPTING .......................
TOMORROW YOUR PRODUCE CAN BE A HOMOSEXUAL TOO AND IT ISN’T SOMETHING TO FROWN ABOUT BUT SOMETHING TO BE REFLECTED UPON ...
HOMOSEXUALS ARE A VITAL PART OF THE HUMANITY ........
Posted by Kudrat Dutta Chaudhary at 1:42 AM

Here is a great post about the Stimulus payments By JOHN HALAMKA

HERE IS A GREAT SIMPLIFIED ARTICLE BY DOCTOR JOHN HALAMKA ABOUT STIMULUS PAYMENTS.


MONDAY, JANUARY 24, 2011

Obtaining Meaningful Use Stimulus Payments
Many clinicians and hospitals have asked me about the exact steps to obtain stimulus payments.

On January 3, 2011, CMS began registering clinicians for participation in meaningful use programs. Every region of the United States has Regional Extension Centers which can help answer any questions. Here's an overview of the steps you need to take.

1. Choose between Medicare and Medicaid programs. If you qualify, Medicaid offers greater incentives and does not require you to achieve meaningful use before stimulus payments begin.
a. To qualify for Medicaid, 30% of your patient encounters must be Medicaid patients. (20% for pediatricians)
b. To qualify for Medicare, keep in mind that meaningful use payments are made at 75% of Medicare allowable charges for covered professional services in the calendar year of payment, per the payment maximums below:

Year 1 $18,000
Year 2 $12,000
Year 3 $8000
Year 4 $4000
Year 5 $2000

Thus, a total of $44,000 is available at maximum, but could be less if your allowable Medicare charges are less than

Year 1 $24,000
Year 2 $16,000
Year 3 $10,667
Year 4 $5333
Year 5 $2667

Also, if 90% of your Medicare charges take place in inpatient or emergency department locations, you cannot qualify for the meaningful use program. This means that emergency physicians, anesthesiologists, radiologists, and pathologists generally cannot participate. Some professionals may also find that they do not have enough Medicaid or Medicare charges to benefit from either program.

2. Once you've chosen Medicare or Medicaid, you must register to participate
a. You need a National Provider Identifier and password. If you do not have one, go to the NPPES website.
b. One you have a password, go to the CMS EHR Incentives Website and register as an eligible professional
c. Two valuable resources include the Registration User's Guide and the CMS overview of the EHR incentive programs.

3. The Meaningful Use demonstration period is 90 days beginning January 1, 2011 so the first date that you can attest to meaningful use of Certified EHR technology is April 1, 2011. Note that the EHR technology you use must be certified by the time you attest. You can begin your meaningful use reporting period using uncertified EHR technology as long as it is certified by the end of your reporting period.

Medicare payments will begin in May. Medicaid payments are administered by states and will begin when state governments are ready to administer the program. Some states are ready now and others will not be ready until August. Remember that Medicaid payments start before meaningful use is achieved so there is no need to wait for meaningful use measurement and attestation for the Medicaid program.

Hospital requirements are similar
a. First, you must locate the following, which your Revenue Cycle staff are likely to have:
CMS Identity and Access Management (I&A) User ID and Password.
CMS Certification Number (CCN).
National Provider Identifier (NPI).
Hospital Tax Identification Number.
b. Go to the CMS EHR Incentives Website and register as an eligible hospital
c. The Hospital Registration User's Guide is a valuable resource

Here's a summary of the key dates for the program:

January 1, 2011 – Reporting year begins for eligible professionals.
January 3, 2011 – Registration for the Medicare EHR Incentive Program begins.
January 3, 2011 – For Medicaid providers, states may launch their programs if they so choose.
April 2011 – Attestation for the Medicare EHR Incentive Program begins.
May 2011 – EHR Incentive Payments expected to begin.
July 3, 2011 – Last day for eligible hospitals to begin their 90-day reporting period to demonstrate meaningful use for the Medicare EHR Incentive Program.
September 30, 2011 – Last day of the federal fiscal year. Reporting year ends for eligible hospitals and CAHs.
October 1, 2011 – Last day for eligible professionals to begin their 90-day reporting period for calendar year 2011 for the Medicare EHR Incentive Program.
November 30, 2011 – Last day for eligible hospitals and critical access hospitals to register and attest to receive an Incentive Payment for Federal fiscal year (FY) 2011.
December 31, 2011 – Reporting year ends for eligible professionals.
February 29, 2012 – Last day for eligible professionals to register and attest to receive an Incentive Payment for calendar year (CY) 2011.

I hope this clarifies your next steps. May your stimulus funds flow quickly in 2011!
POSTED BY JOHN HALAMKA AT 3:00 AM

Stage 2 and 3 meaningful use recommendations,dr Halamka

Tuesday, January 18, 2011
The Proposed Stage 2 and 3 Meaningful Use Recommendations

On January 12, the Health Information Technology Policy Committee published its proposed Stage 2 and 3 Meaningful Use recommendations for public comment.

Robin Raiford from Allscripts created a Quick Guide to the recommendations, making it easy to compare Stage 1, 2 and 3 in a single PDF.

Here's my analysis of the proposed Stage 2 and 3 criteria.

1. CPOE - Stage 1 requires more than 30% of unique patients with at least one medication in their medication list have at least one medication order entered using CPOE Stage 2 expands this to 60% of patients for at least one medication, lab or radiology order. Stage 3 expands this further to 80%. CPOE orders do not need to be transmitted electronically to pharmacies/labs/radiology departments. This is a very reasonable rate of CPOE adoption. The hardest part of implementing CPOE is getting started, which happens in Stage 1. Adding different types of transactions (without requiring electronic transmission to back end service providers) is more about workflow and behavioral change than technology change.

2. Drug-drug/drug-allergy interaction checks - Stage 1 requires that interaction technology be enabled. Stage 2 adds that it will be used for high yield alerts, with metrics for use to be defined. The idea is that many drug databases contain too many false positive interaction rules, so adoption is slowed by alert fatigue. If only high yield alerts are required (here's what we've done at BIDMC ), clinicians are more likely to trust drug interaction decision support. Stage 3 adds drug/age checking (such as geriatric and pediatric decision support), drug dose checking, chemotherapy dosing, drug/lab checking, and drug/condition checking. These are all reasonable goals, but automating chemotherapy protocols is quite challenging. BIDMC built an Oncology Management System and added a full time research nurse to ensure all chemotherapy protocols are updated and accurate. It may be asking too much to require chemotherapy dosing decision support nationwide by 2015.

3. e-Prescribing - Stage 1 requires e-prescribing of 40% of non-controlled substances. Stage 2 expands this to 50%. Stage 3 expands it further to 80%. Electronic faxing is permitted if pharmacies cannot accept e-prescriptions. These are very reasonable goals and easily achievable if e-prescribing systems are in place, which is required for Stage 1. E-prescribing of controlled substances, which requires more effort including two-factor authentication, is not specifically mentioned.

4. Demographics - Stage 1 requires capture race/ethnicity, primary language, and other demographics for 50% of patients. Stage 2 expands this to 80%. Stage 3 expands this further to 90%. Most institutions are already near 100% since they capture this information as part of existing registration and billing processes.

5. Report quality measures electronically - Stage 2 and 3 will be specified by the Quality Measures Workgroup and CMS. No further detail is offered at this time. The hardest part of quality measure reporting is computing the numerators and denominators as is required for Stage 1. Generating the PQRI XML to send the data to CMS is quite easy.

6. Maintain problem lists - Stage 1 requires documentation of at least one problem for 80% of patients. Stage 2 is unchanged. Stage 3 requires that problem lists be up to date. This is reasonable. Clinicians will be motivated to update them because the problem list will be included in clinical summaries sent to the patient after every visit. I hope that EHR vendors improve the usability of problem list management functions by creating natural language translation into the required SNOMED-CT or ICD9/ICD10 vocabularies.

7. Maintain active medication lists - Stage 1 requires documentation of at least one medication for 80% of patients. Stage 2 is unchanged. Stage 3 requires that medication lists be up to date as part of medication reconciliation, which per requirement 31 below will be a core requirement with 80% compliance in Stage 2 and 90% in stage 3. In my view, the greatest strength of EHRs should be medication management.

8. Maintain active medication allergy lists - Stage 1 requires documentation of at least one allergy for 80% of patients. Stage 2 is unchanged. Stage 3 requires that allergy lists be up to date. Clinicians will be motivated to update them because the allergy list will be included in clinical summaries sent to the patient after every visit.

9. Vital signs - Stage 1 requires vital sign recording for 50% of patients. Stage 2 expands this to 80%. Stage 3 is the same as Stage 2. This is reasonable.

10. Smoking status - Stage 1 requires smoking status documentation for 50% of patients. Stage 2 expands this to 80%. Stage 3 expands it to 90%. This is reasonable.

11. Use Clinical Decision Support to improve performance on high-priority health conditions - Implemented properly, decision support can save time while enhancing safety. Maintaining rules can be challenging and I hope companies evolve to provide cloud-based approaches to decision support.

12. Formulary checks - In Stage 1, formulary checks are in the menu set with the requirement that clinicians and hospitals have access to at least one internal or external drug formulary for the entire EHR reporting period. Stage 2 moves this to core. Stage 3 requires the functionality to be applied to 80% of medication orders. Formulary checking is generally a part of e-prescribing, so this is reasonable. The only unknown is how formularies vary in different regions. Since Massachusetts has only 3 major payers, all regional, formularies have been relatively easy to manage.

13. Advanced directives - In Stage 1, Advanced Directives are in the menu set with the requirement that 50% of patients 65 and older have advance directive documentation. Stage 2 moves this to core. Stage 3 requires 90%. I believe this is a laudable but a challenging goal to achieve. My experience is that most hospitals have advanced directives recorded for less than 25% of their patients.

14. Incorporate lab results as structured data - The Stage 1 menu set requirement is that lab results are incorporated into EHRs as structured data for more than 40% of all clinical lab tests ordered. Stage 2 moves this to core. Stage 3 expands the functionality for 90% of tests ordered and requires they be reconciled with structured orders. Lab workflow improvement is one of the best ways to save clinicians time and ensure followup of abnormal results. My only reservation with this requirement is that the standards for content and vocabulary (lab compendiums) are still a work in process, so reconciliation with electronic orders may be premature.

15. Generate patient lists - The Stage 1 menu set requirement is to generate at least one report listing patients with a specific condition. Stage 2 moves this to core. Stage 3 requires such lists are used to manage patients for high priority health conditions. EHRs must include business intelligence capabilities as part of Stage 1 certification, so these recommendations should be easily achievable.

16. Send patient reminders - The Stage 1 menu set requirement is to send reminders to more than 20% of all unique patients 65 years/older or 5 years old/younger. Stage 2 makes this core. Stage 3 requires 20% of all active patients who prefer to receive reminders electronically receive them. I'm supportive of this requirement if I can fulfill it by offering all our patients secure web-based reminders via our PHR. Offering multiple electronic notification options (phone, fax, secure email, PHR, Facebook, Twitter, SMS texting) would be hard to manage.

17. Electronic outpatient notes - Stage 2 adds a new requirement for eligible professionals that 30% of visits have an electronic note. Stage 3 requires 90%. This note can be scanned, free text, structured etc. Offering the option of scanning, dictating, structured and unstructured makes this requirement very reasonable.

18. Electronic inpatient notes - Stage 2 adds a new requirement that 30% of hospital days have at least one electronic note by a physician, NP or PA. As with outpatient notes, this can be scanned, free text, structured etc. Very few hospitals have electronic inpatient documentation. Offering the option of scanning paper notes makes this requirement very reasonable.

19. Electronic Medication Administration Records - Stage 2 adds a new requirement that 30% of medication orders are tracked via an EMAR. Stage 3 makes this 80%. The definition of EMAR will be key. I think of an electronic medication administration record as positive patient identification of every patient, every drug and every staff member with mobile devices to record all medication events in real time. Requiring this for the entire country by 2015 is aggressive.

20. Provide an electronic copy of health information - Stage 1 requires this for 50% of patients who request it. Stage 2 is unchanged. Stage 3 requires 90%. The challenge is implementing the workflow to support this requirement, which has to be done for Stage 1. Thus Stage 2 and 3 are reasonable.

21. Provide a copy of discharge instructions - Stage 1 requires this for 50% of patients who request it. Stage 2 expands this to 80%. Stage 3 expands it to 90%. Since printed discharge instructions meet the criteria, this is reasonable.

22. Patient specific educational resources - Stage 1 requires this for 10% of patients. Stage 2 is unchanged. Stage 3 expands this to 20% in common specific languages. This key question is what is a common language? BIDMC supports 37 different languages. Offering educational resources in all these languages would be challenging.

23. Web-based download of inpatient records - Stage 2 adds the ability to view and download inpatient summaries for 80% of patients. Stage 3 is the same. Since BIDMC already has a PHR offered to all its patients, this requirement is actually an easier workflow than providing inpatient record summaries upon demand via a manual process. This requirement will be challenging for organizations which have not yet widely implemented personal health records.

24. Provide clinical summaries for each office visit - Stage 1 requires this for 50% of all patients (not just those who ask). Stage 2 expands this to "view and download" within 24 hours. Stage 3 is the same. The challenge is that records may not be completed and signed within 24 hours, especially if dictation or scanning processes are used to generate the electronic record.

25. Timely electronic access - The Stage 1 menu set requirement is that more than 10% of all unique patients seen by the clinician are provided timely electronic access to their health information subject to the clinician's discretion to withhold certain information. Stage 2 and 3 make this core and include the requirement that patients should be able to filter or organize information by date, encounter, etc. More detail is need about the requirement to organize the data to determine just how difficult this will be. This requirement will be challenging for practices which have not widely implemented personal health records.

26. Measures for clinical summaries and timely electronic access - Stage 2 requires that 20% of patients use a web-based portal and Stage 3 expands this to 30%. It seems a bit odd to measure clinician performance based on patient behavior. BIDMC has offered comprehensive secure email, timely access to all inpatient/outpatient data, and even full text notes. After 10 years, no more than 20% of our patients use these functions. I think a better approach is to require such functions be offered to all patients criteria is that all patients. Adoption is something beyond clinician control.

27. Online Secure messaging - Stage 2 and 3 adds a new requirement that online secure messaging be in use. Our experience with online secure messaging is that it reduces clinician time returning phone calls and enhances both clinician and patient satisfaction. This is a reasonable requirement.

28. Patient preference for communication medium - Stage 2 adds a new requirement that patient preference for communication be recorded for 20% of patients. Stage 3 expands this to 80%. Per my comment in Timely Electronic Access, I would prefer offering all patients web-based communications rather than trying to manage multiple communication approaches.

29. Patient Engagement - Stage 3 includes multiple new patient engagement requirements - electronic self management tools, EHR interfaces to PHRs, patient reporting of care experiences online, and patient generated data incorporation into EHRs. These need to be defined in much greater detail before their implications can be assessed.

30. Perform test of HIE - Stage 1 required one test. Stage 2 expands this to at least three external providers in primary referral networks (but outside the delivery system that uses the same EHR) or a bidirectional connection to at least one health information exchange. Stage 3 expands this to 30% of external providers or a connection to a health information exchange. Stage 2 and 3 require the HIE to connect to an entity-level provider directory. Although some regions with well developed HIE capabilities will find this easy to achieve, many will await the functionality promised by the Direct Project in order to exchange data.

31. Perform Medication reconciliation - The Stage 1 menu set requirement is medication reconciliation in 50% of care transitions. Stage 2 moves this to core and expands it to 80%. Stage 3 expands this to 90%. Since the Joint Commission required this over 3 years ago, it is very reasonable. Hard to operationalize, but the right thing to do.

32. Provide summary of care record - The Stage 1 menu set requirement is a summary of care record for more than 50% of transitions of care and referrals. Stage 2 makes this core. Stage 3 expands this to 80%. The challenge will be defining how this content is transmitted from provider to provider.

33. List Care members - Stage 2 adds a requirement to provide a list of care team members (including PCP) for 10% of patients. Stage 3 moves this to 50% via electronic exchange. Once more details about the electronic exchange are provided, I can better assess this requirement.

34. Longitudinal care plan - Stage 2 adds a requirement to record a longitudinal care plan for 20% of patients with high-priority health conditions. Stage 3 expands this to 50%. Although I'm familiar with pilots in which clinicians and patients jointly develop care plans, I have not seen it widely implemented. This may be a bit aggressive.

35. Submit immunization data - The Stage 1 menu set requirement was a single transaction. Stage 2 moves this to core and requires ongoing submission. Stage 3 requires query and review of immunization registry data. The challenge is that many state and local public health departments do not offer the ability to receive and query immunization data.

36. Submit reportable lab data - The Stage 1 menu set requirement was a single transaction. Stage 2 moves this to core. Stage 3 includes the requirement for hospitals to include complete patient contact information in 30% of reports. As with immunizations, state and local public health departments may find this challenging to support.

37. Submit syndromic surveillance data - The Stage 1 menu set requirement was a single transaction. Stage 2 moves this to core. Stage 3 includes patient self report and something called the Public Health button, which is not defined. Public Health Departments may find this challenging to support.

38. Ensure privacy - Nothing new was specified but additional privacy and security objectives are under consideration by the HIT Policy Committee’s Privacy and Security Tiger Team.

Thus my areas of concern are chemotherapy automation, recording patient communication preferences, judging clinician performance based on patient adoption of PHRs, EMAR implementation, maturity of HIE capabilities, widespread rollout of longitudinal care planning, and public health readiness.

The comment period ends Feb. 25 and the Health IT Policy Committee will consider all of the comments in making its final recommendations this Summer to the Office of the National Coordinator for Health Information Technology at HHS. Here's the work plan as I understand it

Jan, 12, 2011: release draft Meaningful Use criteria and request for comment
Feb-March, 2011: analyze comment submissions and revise Meaningful Use draft criteria
March, 2011: present revised draft Meaningful Use criteria to the HIT Policy Committee
2Q11: CMS report on initial Stage 1 Meaningful Use submissions
3Q11: Final HIT Policy Committee recommendations on Stage 2 Meaningful Use
4Q11: CMS Meaningful Use NPRM

It's great to have a roadmap so we know where we're going between now and 2015. At present BIDMC is completing its certification inspection tests and is working hard to achieve meaningful use by the end of March so we can attest in April. Given the challenges of achieving certification and meaningful use for Stage 1, we welcome a two year window to prepare for Stage 2.
Posted by John Halamka at 3:00 AM 0 comments

Drug Interactions and other systems solutions By Dr Halamka

Tuesday, April 22, 2008
Decision Support for Inpatient Systems
I've written about the 10 projects that keep me up at night and published my clinical systems mid year strategic update. In addition, as a physician CIO, I tend to have a few projects that receive more attention and guidance from me than others.

The three areas that are my passion and focus in 2008-2010 are Clinical Documentation, Decision Support, and an Integrated Electronic Record throughout the community. I wrote about Clinical Documentation last week. The Integrated Electronic Record is next week. I've covered Outpatient Decision Support earlier, so this week is an overview of all our Inpatient Decision Support efforts at Beth Israel Deaconess. You'll see that we have thousands of decision support rules, updated regularly, which are fully integrated into our inpatient systems.

Drug interactions and alerts
a) Drug duplicate warnings - Identifies duplicates using chemical component information that is included with First Data Bank (FDB), the commercial drug database underlying our pharmacy and provider order entry systems. Component information is updated via monthly FDB updates.
b) Drug-drug interactions - Identifies interactions using chemical components and rules included with the FDB database. Displays only the classes of alerts identified as clinically significant by Pharmacy, to ensure clinicians are not overwhelmed with minor interactions. Rules are updated via monthly FDB updates. Clinical significance filters are maintained in a dictionary by Pharmacy.
c) Drug-allergy interactions - Identifies interactions using chemical components included with the FDB database. Components are updated via monthly FDB updates.
d) Drug Substitutions – Alerts the ordering provider with suggested substitutions for therapeutic equivalents on the inpatient formulary, which is maintained by Pharmacy.

Default dosing
There are currently 1,545 entries in the Pharmacy Provider Order Entry dictionary with default dosing schemas defined. These are maintained by Pharmacy.

Renal Dosing
Targeted drugs, rules and default dosing are maintained in a dictionary by Pharmacy. There are currently 48 renally dosed drugs.

Diagnosis or Indication based dosing
Target drugs, rules and default dosing are maintained in a dictionary by Pharmacy, such as ciprofloxacin and chemotherapy agents used for non-oncological reasons such as cytoxan.

Geriatric alerts
Beers criteria are used to alert physicians to age-specific medication issues. Information is updated via monthly FDB updates.

Heparin, insulin and enoxaparin
Ordering of these high risk medications is done via automated protocols and guidelines to promote best practice dosing. These are updated as best practices change.

Information Displayed on Medication Ordering Screens
a) Screens display the patient’s most recent relevant labs specific to the drug being ordered. The relationship between drug and lab(s) to display is maintained in a dictionary by the Pharmacy
b) Informational text about ordering parameters for the drug is displayed. These are maintained in a dictionary by the Pharmacy. A link to Micromedex is also available on the ordering screen.

Nurse instructions for drug handling
Custom instructions are displayed on Medication Administration Record labels. These are maintained by the Pharmacy.

Information Displayed on Lab Ordering Screen
a) Messages appear during ordering that inform clinicians about best practices such as guidance for ordering heparin dependent antibodies. These are maintained in a dictionary by the Lab.
b) Links appear to the online lab manual for each test ordered. Thousands of lab tests are documented including all the details on how the specimen is collected and processed. The Lab updates this manual regularly.

Blood bank
Specialized screens appear to provide pertinent clinical information when blood products are ordered.

Total Parenteral Nutrition
Guidelines, relevant labs and prior day’s TPN order appear automatically.

Consequent Orders
a) IV access flush ordering -POE automatically generates the correct flush order when documenting IV status
b) Blood products – POE gives current information about active specimens in the blood bank and can generate a type and screen if necessary
c) Mechanical ventilation- POE automatically suggests mouth care orders after ventilation is ordered

Quick access to reference/informational screens
Specific links to guidelines/web sites appear on many POE screens. For example, a link to the current weaning protocol is available directly on the mechanical ventilation order screen.

Quick access to patient specific data in other clinical systems
Specific links to data in other information systems appear on many Provider Order Entry screens. For example, a link to display transfusion restrictions available in the Blood Bank system appears on the blood product ordering screen.

Alerts and reminders for items such as pneumovax and influenza
Providers are prompted at appropriate points over the course of a hospital admission to order and document outcomes.

Order sets
"Packages" of orders that can be rapidly entered as a group are available to all clinicians. These are updated as clinical practice changes. There are currently 95 inpatient admission, postoperative, transfer and procedure order sets (5 megabyte download) and 195 outpatient chemotherapy regimens.

Hydration protocol to minimize risk of iodinated contrast nephropathy
Provider Order Entry recommends specific IV fluid orders when ordering pre-procedure prep orders.

You can see that the task of providing comprehensive decision support for our inpatient systems involves thousands of rules, kept updated by pharmacy, lab, and IS staff, as guided by our various steering committees. Only through the use of this much decision support can we ensure that data is transformed into information, knowledge and wisdom

Review of "Deadly Spin" by Wendell Potter

Doctor and Patient
When Insurers Put Profits Between Doctor and PatientBy PAULINE W. CHEN, M.D.
Published: January 6, 2011

Late in 2007 I found myself riveted by a case playing out at the University of California, Los Angeles, the medical center where I trained and had once worked as a transplant surgeon. A 17-year-old girl named Nataline Sarkisyan was in desperate need of a transplant after receiving aggressive treatment that cured her recurrent leukemia but caused her liver to fail. Without a new organ, she would die in a matter of a days; with one, she had a 65 percent chance of surviving. Her doctors placed her on the liver transplant waiting list.

Nataline’s case was not all that different from the more than 200 liver patients I had seen successfully transplanted every year at that institution. She was critically ill, as close to death as one could possibly be while technically still alive, and her fate was inextricably linked to another’s. Somewhere, someone with a compatible organ had to die in time for Nataline to live.

But even when the perfect liver became available a few days after she was put on the list, doctors could not operate. What made Nataline different from most transplant patients, and what eventually brought her case to the attention of much of the country, was that her survival did not depend on the availability of an organ or her clinicians or even the quality of care she received. It rested on her health insurance company.

Cigna had denied the initial request to cover the costs of the liver transplant. And the insurer persisted in its refusal, claiming that the treatment was “experimental” and unproven, and despite numerous pleas from Nataline’s physicians to the contrary.

But as relatives and friends organized campaigns to draw public attention to Nataline’s plight, the insurance conglomerate found itself embroiled in a public relations nightmare, one that could jeopardize its very existence. The company reversed its decision. But the change came too late. Nataline died just a few hours after Cigna authorized the transplant.

Not long afterward, I spoke with a former nursing colleague who had cared for Nataline. The anger in her voice was still palpable as she recounted the protests in which she had been involved. “This was a 17-year-old girl,” she said. “How could anyone with a conscience — anyone who is human — do this to another person?”

While the public fury over Nataline’s death has abated, that question of conscience in a health care system dependent on for-profit insurers has lurked behind nearly every debate over health care reform. While few politicians have dared to openly address this inherent conflict of interest, one unlikely individual has consistently spoken up over the last year and a half to remind us of this moral dilemma.

In articles, interviews, op-eds and testimony on Capitol Hill, Wendell Potter has described the dark underbelly of the health care insurance industry — unkept promises of care, canceled coverage of those who get sick and fearmongering campaigns designed to quash any change that might adversely affect profits.

He should know what he is talking about. For 20 years, Mr. Potter was the head of corporate communications at two major insurers, first at Humana and then at Cigna.

Now Mr. Potter has written a fascinating book that details the methods he and his colleagues used to manipulate public opinion and describes his transformation from the idealistic son of working-class parents in eastern Tennessee to top insurance company executive, to vocal critic and industry watchdog. Using little of the fiery rhetoric or lurid prose that usually marks corporate exposés or memoirs of redemption, the book, “Deadly Spin” (Bloomsbury, 2010), is an evenhanded yet riveting account of the inner workings of the health care insurance industry, a cautionary tale that doctors and patients would be wise not to miss.

For a man who has spent his professional life tinkering with impressions, Mr. Potter has astartlingly straightforward narrative voice; he wastes no time cutting to the chase: “It was my job to enhance those firms’ reputations. But as one of the industry’s top public relations executives and media spokesmen, I also helped create and perpetuate myth that had no other purpose but to sustain those companies’ extraordinarily high profitability.”

Mr. Potter goes on to describe the myth-making he did, interspersing descriptions of front groups, paid spies and jiggered studies with a deft retelling of the convoluted (and usually eye-glazing) history of health care insurance policies.

The most moving section is devoted to Nataline Sarkisyan. We learn that executives at Cigna worried that Nataline’s situation would only add fire to the growing public discontent with a health care system anchored by private insurance. As the case drew more national attention, the threat of a legislative overhaul that would ban for-profit insurers became real, and Mr. Potter found himself working on the biggest P.R. campaign of his career.

As busy as they might have felt in the days leading up to Nataline’s death, he and his staff were inundated with calls from the news media immediately afterward. To bolster what was seen as a fight for its survival, Cigna hired a large international law firm and a P.R. firm already well known to them from previous work aimed at discrediting Michael Moore and his film “Sicko.” Together with Cigna, these outside firms waged a campaign that would eventually include the aggressive placement of articles with friendly “third party” reporters, editors and producers who would “disabuse the media, politicians and the public of the notion that Nataline would have gotten the transplant if she had lived in Canada or France or England or any other developed country.” A “spy” was dispatched to Nataline’s funeral; and when the Sarkisyan family filed a lawsuit against the insurer, a team of lawyers was assigned to keep track of actions and comments by the family’s lawyer.

Nurse and Doctor neighbor by Theresa Brown R.N.

January 12, 2011, 12:01 pm Nurse and Doctor, Neighbor and Friend
By THERESA BROWN, R.N.
“Something there is that doesn’t love a wall,” begins Robert Frost’s poem “Mending Wall,” about two neighbors who meet to repair the gaps and holes in the stone wall separating their properties. They walk on either side of it, picking up and replacing fallen stones as they go.


Jeff Swensen for The New York Times

Theresa Brown, R.N.The poem came to mind one recent day on the oncology floor where I work. It’s a medical oncology floor, where we tend to medical issues that go along with cancer, like giving chemotherapy and dealing with complications of metastatic disease. But it turned out that one of my patients had a serious surgical problem.

Surgical oncology is several flights of stairs below us. Even if they were next door, though, I imagine we’d still be inhabiting different worlds. There’s “med onc” and “surg onc,” and never the twain shall meet.

Except that sometimes they do. My patient, a middle-aged woman, had been admitted because of a blood disorder. She was also having some belly pain, so we did a CT scan. I’ve had patients in much more apparent distress, where the scan turns up nothing more than a touch of diverticulitis. But this patient had a hole in her intestine: a true medical emergency.
The next thing I knew, the patient had been put under surgical supervision, though she would stay on our medical floor for the time being. I listened, trying to learn, as the surgical attending physician talked to the medical attending physician about the patient’s blood problems, and what could be done to make it safe to operate on her. They also wanted to increase the rate of IV fluids, to make sure the patient’s blood pressure stayed high enough.

Later, as I updated one of the doctors on our floor on the patient’s latest status, a dismissive look came over his face. “Surgeons!” he scoffed, a tone I’d heard before when medical doctors talk about surgical teams, implying it’s a specialty staffed by overly aggressive people. I might have joined in his derision, except that the surgical resident newly in charge of the case was my real-life next-door neighbor.

When he had first appeared on our floor, I had greeted him warmly by his first name. It never crossed my mind that this man, who had talked helpfully to me about work, invited us to parties in his home and even taken care of my kids’ sea monkeys when we were on vacation, should be addressed as “Dr.” The familiarity drew looks of surprise from some of my fellow nurses, until I explained he lived next door.

But being neighbors at home allowed us to be more than just friendly in the hospital. It turned a potentially tense emergency collaboration into an easy professional exchange. Did the patient need a bigger IV? Should we put in a urinary catheter? How quickly could they get her into surgery? And perhaps most important, could he talk to the terrified patient and her family?

He asked me to call him on his cellphone once the patient was on her way to the operating room. It’s the kind of request you can make of a friend, or a neighbor — but not something that usually happens in the hospital, where we rely on pagers.

We all work in the same hospital, but surgeons on a medical floor can feel like strangers in a strange land. Medical staff can feel the same way on a surgery floor. We nurses in medical oncology can hang chemo and talk knowledgeably about the risks and benefits of stem cell transplants, but we’d prefer not to take care of surgical patients. Neither group understands the routines and concerns of the other as well as we might, and that gap in experience and knowledge can make staff anxious and aggressive.

“Good fences make good neighbors,” the wall-mending neighbor in Frost’s poem says, and in the hospital we seem to have embraced that idea with a vengeance. Divisions arise not just between the medical and surgical teams, but between doctors and nurses, oncologists and cardiologists, intensive care nurses and floor nurses, and friction can accompany interactions between the groups.

A few days after the operation, I went to visit the patient in the surgical intensive care unit. As I walked to her room in my white scrubs, the I.C.U. nurse grabbed my ID badge, lifting it off my chest, and said, “Who are you?”

I nervously mumbled something about having taken care of the patient on the medical floor and asked how she was doing. The nurse’s eyes slid toward the patient’s room, then narrowed in concern.

Suddenly I understood. The nurse’s look was not one of rudeness or aggression, but of worry. She seemed genuinely torn between filling me in on the patient’s condition and going back into the room, where the patient needed her care.

I nodded at her. “You’re busy,” I said, and she nodded back. I told her I’d come back at a better time.

In “Mending Wall,” the narrator goes on to challenge his neighbor’s belief that good fences make good neighbors, saying:

Before I built a wall I’d ask to know
What I was walling in or walling out,
And to whom I was like to give offence.

In the hospital, it’s as if we’re walling in our worry, and walling out potential threats to our competence. We build walls, and maintain them, to buttress our authority, and to prevent being challenged by staff from other floors.

But then one day I met my neighbor at the hospital, and suddenly the wall was down. And that, as Frost put it in another poem, made all the difference.

RXNT.com is EMR provider with 650 dollars Yearly charges.

It seems like a good system .
I have not checked it thoroughly yet.
Its certified to medicare medicaid payments.
It says that it can be used with Iphone.tablet computer .
I have not looked at other requirements like hardware additinal software requirements.

NYT racial Disparities in broad array of health problems

By DONALD G. McNEIL Jr.NYT
Published: January 13, 2011
Whites in the United States die of drug overdoses more often than other ethnic groups. Blacks are hit proportionately harder by AIDS, strokes and heart disease. And American Indians tend to die in car crashes.

Health Guides: AIDS | Stroke | Heart DiseaseTo shed more light on the ills of America’s poor — and occasionally its rich — the Centers for Disease Control and Prevention on Thursday released its first report detailing racial disparities in a broad array of health problems.

While some are well known, others have had little attention; there were also a few surprises.

The agency did not delve into why suffering is so disproportionate, other than to note the obvious: that the poor, the uninsured and the less educated tend to live shorter, sicker lives. (Some illnesses were also broken down by income level, by region, by age or by sex, but the main focus was on racial differences.)

“Some of the figures, like the suicide rate for young American Indians, are just heartbreaking,” said Dr. Thomas R. Frieden, the C.D.C. director, who ordered the report compiled.

He ordered it, he said, after promising at his agency’s African American History Month celebration last February that he would do so.

“We wanted to shine a spotlight on the problem and some potential solutions,” he said.

Many of the differences are large and striking:

¶Babies born to black women are up to three times as likely to die in infancy as those born to women of other races.

¶American Indians and Alaska Natives are twice as likely to die in car crashes as any other group.

¶More than 80 percent of all suicides are committed by whites, but young American Indian adults have the highest suicide rates by far — 25 per 100,000 population at age 21, compared with 14 for whites, 10 for blacks and 8 for Asians and Hispanics.

¶Overdoses of prescription drugs now kill more Americans than overdoses of illegal drugs, the opposite of the pattern 20 years ago. Overdose death rates are now higher among whites than blacks; that trend switched in 2002, after doctors began prescribing more powerful painkillers, antidepressants and antipsychotics — more easily obtained by people with health insurance.

¶Blacks die of heart disease much more often than whites, and die younger, despite the availability of cheap prevention measures like weight loss, exercise, blood-pressure and cholesterol drugs, and aspirin. The same is true for strokes.

¶High blood pressure is twice as common among blacks as whites, but the group with the least success in controlling it is Mexican-Americans.

¶Compared with whites, blacks have double the rate of “preventable hospitalizations,” which cost about $7 billion a year.

¶People in Utah, Connecticut and North Dakota report the most “healthy days” per month — about 22. People in West Virginia, Kentucky and Tennessee report the fewest, about 17.

¶Blacks, Hispanics and American Indians, whether gay or straight, all have higher rates of new infection with the AIDS virus than whites, and the situation is getting worse for blacks and Indians. Asians have the lowest rate.

¶Binge drinking — defined as five drinks for men and four for women — is increasing. In a switch from the norm for health problems, it is more common among the better-educated and more affluent, including college students. But poor people, and especially American Indians, drink much more heavily when on binges.

¶Teenage pregnancy is holding steady or falling for all ethnic groups, but is still three times as common among Hispanic girls as among white girls, and more than twice as common among black girls as among whites.

Dr. Frieden said the purpose of the report was not to nudge the White House or Congress to take any particular action. But said that two relatively new laws had greatly improved the nation’s health and narrowed the racial gaps.

One was the 1994 Vaccines for Children program, which pays for poor children’s immunizations. The second was the earned-income tax credit, which motivates poor people to find jobs. It was first passed by Congress in 1975 but was strengthened several times, and some states and cities have created their own.


PS, DEVELOPMENT OF EMR SHOULD HELP US CONTINUE THE STUDY AND IMPLEMENT THE REMEDIES THAT WILL BE REAL BENEFIT OF EMR MANDATE.

Will HITECH exacerbate differences in quality and outcomes?

MONDAY, JANUARY 3, 2011

Will HITECH exacerbate differences in quality and outcomes?
In an open letter to the vendor community National Coordinator for Health IT Dr. David Blumenthal appealed for assistance in overcoming the digital divide, asking health IT vendors to "include providers who serve minority communities in their sales and marketing efforts".

"It is absolutely necessary that the leading EHR vendors work together, continuing to provide EHR adoption opportunities for physicians and other healthcare providers working within underserved communities of color. Despite our best efforts, data from the National Ambulatory Medical Care Survey indicates that EHR adoption rates remain lower among providers serving Hispanic or Latino patients who are uninsured or relied upon Medicaid. Moreover, this data also identifies that EHR adoption rates among providers of uninsured non-Hispanic Black patients are lower than for providers of privately insured non-Hispanic White patients."

Blumenthal's letter goes on to acknowledge the critical roles played by the administration and REC's in addition to the IT vendors to "work together and focus substantial efforts on these priority populations."

Properly applied, electronic health records will raise the quality of care and outcomes wherever they are deployed. However, will EHR's, unequally deployed, heighten the appalling differences in care quality and outcomes that exist today among races and regions in the U.S.?

To address this question, its helpful to understand these baseline differences. The Dartmouth Atlas Project has released its Primary Care Report, examining disparities in health care quality and outcomes.

The report found that primary care access and the probability of hospitalization varied dramatically by region and race. "Although blacks were as little as half as likely to see a primary care clinician and up to 84% more likely to be hospitalized than whites within areas, these racial disparities were less pronounced than the differences across locations...

"Blacks had much higher rates of leg amputation, a grave consequence of poorly controlled diabetes and peripheral vascular disease. Amputation rates were 4.7 times greater in blacks than in whites nationally during the study period from 2003 to 2007. Among U.S. hospital referral regions (HRRs), rates of amputation for all Medicare beneficiaries differed by a factor of 10, an extraordinary degree. In a closer look at the 44 hospital service areas (HSAs) within a single HRR, Atlanta, Georgia, there was almost a fourfold variation in leg amputation rates."

For evidence-based, recommended services, such as appropriate testing for diabetes and mammography, variations across the nation’s HRRs were substantially greater than the disparities by race within a given region. We found similar results across the smaller HSAs, and we demonstrate this with data from the HSAs within the Atlanta, Georgia HRR. In other words, where patients live has a greater influence on the care they receive than the color of their skin. Indeed, in a few locations, blacks received equal or better care than did whites, but care for all patients was less than ideal."

To address these disparities, The Dartmouth Atlas Project properly highlighted the need for focus on the "full spectrum of health determinants, ranging from lower levels of schooling and limited health literacy, to inadequate housing and lack of transportation, as well as lack of access to high-quality primary care that is well-coordinated with specialty care."

Implications for Meaningful Use

Meaningful use will raise the level of provider capability to proactively manage the health of patient populations. There's the real possibility that Stage 1 Meaningful Use can uplift the level of care and outcomes for millions, giving providers systematic visibility to quality measures that matter for better managing chronic conditions that drive 75% of the national health care costs. This can, over time reduce the number of amputations as an example.

Perhaps it will be Health Information Technology combined with health-care-reform-fueled accountable care organizations that will finally overcome some of the intractable problems of care coordination that Dartmouth Atlas suggests may be behind these stats.

Even as HITECH raises the potential for better health outcomes nationally, might it also cause increasing disparities at the same time?

There are signs that smaller physicians are now starting to invest in EHR's in larger numbers. This will be a great equalizer to be sure, as primary care practices are enabled with the tools that heretofore have been thought to be beyond the reach of most small practices. Other equalizers include the special incentives for rural providers and federally qualified health centers. David Blumenthal's efforts to focus all parties on underserved populations should be lauded and supported.

There is reason for concern. Meaningful use is incentive-based and voluntary. So while meaningful use will raise the levels where it's applied, might that investment occur unequally? Might the regions that are already achieving better health outcomes be the ones most likely to become meaningful users of EHR's? Will supplemental hospital (Stark relaxation) incentives be unequally and similarly applied by area? Might this actually exacerbate the differences in care and outcomes across regions and races?
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POSTED BY HEALTHCARE TECHNOLOGY NEWS AT 12:00 P

John Halamka blog for meaningful use and payment.

MONDAY, JANUARY 3, 2011

BIDMC's Meaningful Use Email
As hospitals and eligible professionals prepare for their meaningful use reporting period (registration begins today), they will want to communicate the details of the program to stakeholders. Here's the email we're sending out today. Feel free to use any part of it for your organization.

"As part of the Stimulus Package, the federal government has allocated $19 billion to encourage the health care industry to adopt Electronic Health Records. Demonstrating "meaningful use" of our electronic systems will mean several million dollars in additional reimbursement from CMS for the medical center, and additional funds for physicians. To be eligible for these additional payments, we must do 3 things:
1. Be an eligible professional or hospital
2. Implement a certified Electronic Health Record (EHR)
3. Use the certified EHR in a meaningful way

Who qualifies as an eligible professional?
Eligible professionals include doctors of medicine, osteopathy, dental surgery, dental medicine, podiatry, optometry, and chiropractors. Professionals who perform 90% or more of their services in the inpatient or emergency setting are considered “hospital-based” and are not eligible.

Are we using a certified Electronic Health Record?
Collectively, all of the clinical systems we use here at BIDMC make up our Electronic Health Record. The hospital is in the process of having our collective systems certified by the Certification Commission for Health Information Technology (CCHIT) via their EACH program for hospitals. We expect to be one of the first hospitals in the country to do so.

What does it mean to use our systems in a Meaningful Way?
Simply put, 'meaningful use' means hospitals and professionals need to show they are using a certified EHR in ways that can be measured significantly in quality and quantity.
Hospitals have 14 required ('core') criteria and eligible professionals (clinicians) have 15 required criteria. There is 100% overlap, with the only difference that the hospital is not measured on e-prescribing because that is seen as an ambulatory clinician activity.
There are 10 optional ('menu') criteria of which hospitals and eligible professionals must choose 5. There is 100% overlap except that reporting lab results to public health and advanced directive management is hospital only.

A grid of the criteria is available here. We have completed an assessment of the criteria and how well BIDMC is doing in meeting the required metrics. Good news! As of January 1, 2011 BIDMC has the necessary system functions to meet meaningful use criteria and with few exceptions we, collectively (hospital and eligible professionals), are doing well in meeting the required metrics.

When does this program begin?
The earliest possible 'reporting period' for demonstration of meaningful use is January 3-March 31, 2011. Measurement of performance on the 15 required and the chosen 5 optional criteria is done during this time. CMS will make a website available to register hospitals and eligible professionals for participation in the meaningful use program. The process for registering is being launched by CMS today, and BIDMC/BIDPO will act swiftly to ensure all eligible providers are enrolled. In April, the hospital and eligible clinicians 'attest' that they have achieved meaningful use, with additional reimbursements starting in May.

What do I need to do on January 3, 2011?
For Core Requirements:
As mentioned above, we are collectively doing well in meeting most criteria as the information collected is required for a patient to receive care here at BIDMC or part of our standard workflow. Here is where we need your help in collecting and documenting additional information within webOMR/other points of entry systems:
Problem Lists: Requirement: 80% of all unique patients must have at least one entry or an indication that the patient has no known problems documented as part of the problem list in webOMR.
Medication Allergy List: 80% of all unique patients must have at least one entry or an indication that the patient has no known allergies/ADRs documented in the Allergy module in webOMR
Smoking Status: 50% of patients age 13 or older must have smoking status recorded in webOMR (within Sheets).
Clinical Summaries: Clinical summaries must be provided to patients for 50% of all outpatient office visits within 3 business days. This is not currently standard practice throughout our outpatient practices. With the help of the webOMR User Group, a standard clinical summary will be available for printing from webOMR and other CCC applications. Your administrative staff will be briefed on this within the next few days and are ready to help implement this within the outpatient practices.
Within the next few days you will receive additional information from OMR Support describing how you can use the system to meet the criteria. In the meantime if you have questions or concerns about webOMR functions, please contact: omrsupport@bidmc.harvard.edu.

Ideally, we believe that the documentation requirements needed to meet meaningful use are in the best interest of providing safe patient care and allowing clinicians to communicate with each other and patients effectively and efficiently. Therefore, we support the continued use of webOMR and other BIDMC systems for Problems, Medications, Allergies, Smoking Status, etc. So although the reporting period ends in March/April of 2011, we request your ongoing use of our systems for this documentation.

How do funds flow?
Assuming we begin our measurement period on January 3rd and we complete attestation in April: Beginning in May, increased Medicare payments to the hospital and to the clinicians begin to flow. For the hospital, the value of these increased payments will be approximately $2 million per year. For clinicians, the value is:
2011 $18,000
2012 $12,000
2013 $8000
2014 $4000
2015 $2000

Thus, the flow of funds will follow whatever path Medicare payments to the hospital and clinicians have in place today.

Note that Meaningful Use Stage 1 is 2011-2012, Stage 2 is 2013-2014 and Stage 3 is 2015. This means that the criteria for meaningful use will get more challenging to meet over time and that the hospital and eligible professionals will need to repeat the "reporting period" and attestation in 2013 and 2015."
POSTED BY JOHN HALAMKA AT 3:00 AM 0 COMMENTS