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
Tuesday, January 18, 2011
Friday, January 14, 2011
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.
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.
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.
Thursday, January 13, 2011
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.
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.
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.
Tuesday, January 4, 2011
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
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
Monday, January 3, 2011
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
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
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