A recent eye health study found that patient-reported data doesn’t always get recorded in a patient’s electronic health record (EHR), raising questions about the accuracy of clinical documentation.
Investigators from the Department of Ophthalmology and Visual Sciences at the University of Michigan Medical School compared patient-reported symptoms with the symptoms recorded in the EHR. The researchers found that of 162 patients surveyed, there were only 38 exact matches between the patient-reported symptoms and the EHR documentation. When the patient reported three or more symptoms, the EHR never had exact agreement.
While the major mismatch between patient-reported data and EMR documentation was the failure to capture patient-reported symptoms, there were also instances of symptoms incorrectly being recorded for patients who did not report that problem. For example, blurry vision was inaccurately identified as a symptom for 29 patients, but was only accurately recorded for 26 patients.
The inconsistency between patient-reported data and clinical documentation led the researchers to conclude, “documentation of symptoms based on [EHR] data may not provide a comprehensive resource for clinical practice or ‘big data’ research.” In other words, since EHR data may not provide a complete view of a patient’s health, it can impact the quality of care the patient receives. Inaccuracies in EHR data could also preclude its use in research studies until it is consistent with patient-reported data.
Maria Woodward, M.D., assistant professor of ophthalmology and visual sciences at the University of Michigan, said in a release, “Many parties in health care use the electronic health records now, and they expect the data to accurately reflect the interaction with the doctor.”
Woodward said neither the patient nor doctor is at fault for the inconsistency, but that it highlights an opportunity to improve doctor-patient communication. Woodward said by using a self-reporting system prior to a visit, the doctor and patient can spend more time talking about symptom management rather than identifying symptoms.
Cries of protest arose when the Joint Commission prohibited secure texting of computerized physician order entries, but now the level of disenchantment among some in the secure text messaging business has ratcheted up with one prominent vendor calling for an straight up reversal of the CPOE ban.
In December, the commission, in conjunction with CMS, clarified its recent statements on secure texting by allowing a range of healthcare uses for texting, but explicitly barring it for CPOE. That move spurred much grumbling among the growing ranks of secure messaging vendors.
Now, Galina Datskovsky, CEO of Vaporstream, a Chicago-based secure messaging vendor, is calling on the commission to reconsider and reverse the CPOE prohibition.
“You need to drop the ban, but you can’t allow just any kind of messaging either,” Datskovsky said, adding that it’s reasonable for the commission to mandate such safeguards as read-and-receipt or automatic feed to EHR features. “To outright ban it seems out of touch with the times and reality.”
Datskovsky noted that HIPAA-compliant secure messaging companies such as Vaporstream and others provide permanent records of text messaging strings that can be used to later verify if physicians or nurses submitted or transcribed orders accurately.
She maintained that while the commission allowed phone CPOE, phone communications are usually not recorded or preserved and can often lead to inaccuracies due to bad connections, dropped or static-marred lines and other problems.
“Voice can be ambiguous,” she said.
Also, Datskovsky said text and chat have become so prevalent in the increasingly mobile-first worlds of healthcare and other industries that it has almost reached the status of the preferred communication mode for professionals across many industries. Vaporstream sells into various vertical industries, but healthcare is its biggest sector, she said.
Texting is also usually faster than calling, she said, an advantage in many medical situations when speed is of the essence.
“Everybody texts. It’s just the way of the world,” Datskovsky said. “It’s really difficult in today’s world to get someone on the phone expeditiously. I think it’s actually more dangerous for the patient if you have to wait for a voice confirmation.”
The commission in its December 2016 statement cited, among other reasons, these rationales for the CPOE texting ban:
- A burden on nurses to manually transcribe text orders into the EHR
- Verbal orders can be clarified but texting is asynchronous and requires an extra step
- Texting may add other extra steps by requiring the doctor or nurse to text multiple times for clarification
In any event, the expectation in the wider health IT community is the commission’s ruling will stand.
But don’t be too sure. The commission has reversed itself before.
In 2011 it banned all texting in healthcare, and then in May 2016 lifted that blanket ban, citing technology advances in secure messaging.
President Donald Trump has already begun the process of repealing the Affordable Care Act, known as Obamacare, by signing an executive order that allows certain government officials and entities to begin the process of dismantling the law.
Some health IT experts have said that they believe, despite Trump’s mission to repeal Obamacare, the effort towards value-based care will remain largely untouched. These experts explained that this is because regulations like the Medicare Access and CHIP Reauthorization Act (MACRA), which pushes healthcare towards value-based care, received strong bipartisan support when Congress approved the law in 2015.
However, it seems some major healthcare organizations are concerned about the future of value-based care. On January 25, the groups—including the American Hospital Association, the American Medical Association, Blue Cross Blue Shield and others—sent a letter to President Trump and other political leaders urging them to accelerate the transition from fee-for-service to value-based care, not impede it.
In the letter, the healthcare organizations outlined 10 principles for value-based care:
- Empower and engage patients to make healthcare decisions with information and support from their healthcare team.
- Invest in engaging patients in the development of measures of provider performance that are relevant to them and consistently and transparently reported by all public and private payers.
- Improve clinician and provider access to timely, accurate and complete claims data to better perform care management.
- Recognize that the socioeconomic status of many patients creates challenges in providing care and adjust payments to providers as appropriate.
- Design voluntary payment models that incentivize more participation and achieve the highest quality and cost value based on patient choice and competitive markets.
- Expand the use of waivers from fee-for-service legal and regulatory requirements that impede collaboration and shared accountability, while preserving consumer protections and safeguards against fraud.
- Build on and expand payment models that promote collaborative financial and care coordination arrangements using incentives that align payers, healthcare providers, providers of long-term care services and clinicians.
- Appropriately incentivize access to medical innovations and treatments that could improve quality of care and reduce overall system cost
- Promote public and private investment in the evidence-based testing and scaling of new alternative payment models as directed in MACRA so that clinicians, other healthcare providers and payers can learn how payment models work.
- Ensure alignment between private and public sector programs, which is important to a value-based payment marketplace.
With its leadership and programs in flux because of uncertainty accompanying the new administration, ONC has produced a flurry of activity lately punctuated by a slate of sessions scheduled for HIMSS 2017 in Orlando coming up Feb. 19.
But even as remaining ONC officials (the top ones have departed) prepare for an active HIMSS presence, the administration of President Donald Trump has already made preliminary moves that appear to strike at some of ONC’s key initiatives and programs.
In any case, ONC is planning no less than eight sessions at the Orange County Convention Center:
- A Town Hall event with the ONC leadership team (more about this later) about ONC’s role in the national health IT agenda
- A demonstration of the SMART App gallery, a market developed under a cooperative agreement between ONC and SMART Health IT, an open standards based technology platform developer, about the gallery’s collection of apps that use FHIR (Fast Health Interoperability Resources), the HL7 International standard, and APIs
- An update from ONC leaders about policy activities now underway at ONC, including 2015 Edition Health IT Certification program and alternative payment models, and upcoming health IT initiatives
- An education session with the agency’s Office of Standards and Technology about health IT testing operations, pilot programs and standards coordination
- A live demonstration by FHIR app developers of systems to allow patients and healthcare providers to share medication lists
- A “fireside chat” on value-based care with Jon White, M.S., the acting national coordinator for health IT, and Kate Goodrich, M.D., director of the CMS Center for Clinical Standards and Quality and CMS chief medical officer
- “Rock Stars of Blockchain in Healthcare,” a discussion with White and Steve Posnack, director of the Office of Standards and Technology, about the fast-growing blockchain encryption technology’s potential for creating a secure and interoperable nationwide health IT system
- An information session about ONC’s efforts to help providers and patients in using health IT for high-quality care
That’s a lot of health IT content from an agency that is little known to the general public, but wields plenty of clout in the industry and seems already to have drawn some perhaps unwelcome attention from the Trump administration in its first full week.
ONC’s parent agency, the giant Department of Health and Human Services, has asked that several ONC notices issued in recent weeks be withdrawn for more review, Politico’s Morning eHealth reported Jan. 25.
I should also note that Trump’s executive order freezing all new regulations extended to plenty of other agencies within HHS, and, indeed, to all federal departments and agencies.
As for the ONC provisions, they include one ONC was preparing to publish imminently that would trigger measures of the 21st Century Cures Act related to ONC’s EHR certification program’s updated usability and interoperability measures, and a rule that would set off a new process for refining quality metrics used in healthcare reimbursement.
HHS also withdrew a provision relating to how ONC selects the third-party certification bodies it uses to review EHRs and other health IT systems for eligibility in federal reimbursement programs, Politico reported.
The current certification bodies’ contracts expire in June and need to be renewed for three years.
The whole thrust of ONC’s health IT certification program is regulatory, and Trump, who as a candidate often criticized over government regulation, may be targeting just that if he views ONC’s regulatory efforts as unneeded or heavy handed.
On the other hand, this could also just be a blip for ONC.
As for the ONC leadership, the agency’s masthead is filled with plenty of officials with “acting” before their titles, reflecting a management corps that has been trimmed by departures.
The top leadership positions at ONC are filled with political appointees.
So former national coordinator Vindell Washington, M.D., Lucia Savage, former chief privacy officer, and Megan Roh, former communications and public relations director, all were political appointees and all left in concert with the end of the Obama administration.
Those positions have not yet been filled by the new administration.
Savage’s job is being done temporarily by Deven McGraw, who is on loan from the HHS Office for Civil Rights.
Andrew Gettinger, M.D., is still acting principal deputy national coordinator for health information technology, a title he has held for a couple of years.
Teresa Zayas Caban is chief scientist and acting chief of staff.
Thomas Mason, M.D., is acting director of the Office of Clinical Quality and Safety and chief medical officer.
Zhan Caplan is acting director of the Office of Public Affairs and Communication.
For a rundown of other top ONC officials, check here.
Healthcare data breaches cost the industry $6.2 billion a year, while the average cost of a single data breach across all industries is $4 million, according to Protenus. Additionally, nearly 90% of healthcare organizations have reported a data breach in the past two years.
Healthcare data breaches include, but are not limited to, phishing attacks, “snooping” by employees and compromised credentials.
Protenus also detailed seven potential costs of a healthcare data beach:
- Forensics – $610,000
- Notification – $560,000
- Lawsuits – $880,000
- Lost business/revenue – $3,700,000
- Brand value – $500,00
- HIPAA fines – $1,100,000
- Post-breach costs – $440,000
The $3.7 million price tag for lost business can be attributed to the fact that nearly a quarter of patients have said they would switch providers due to a data breach, according to a 2015 survey by software advertising firm Software Advice. Patients have also said they withhold information from physicians due to fear of a breach. Beyond the loss of revenue, data breaches can also cause patients to lose trust in a hospital or healthcare organization.
The high cost of healthcare data breaches emphasizes the importance of being proactive in securing patient data and identifying potential external and internal threats. If an organization is breached, it is imperative to notify affected patients as soon as possible. Transparency after a breach can help reduce lawsuits and damage to the organization’s brand.
Telemedicine has the potential to help diverse patient groups – from nursing homes to rural communities – get better healthcare; One place where telemedicine can minimize the disruption to a patient’s life is in schools, according to a Huffington Post story.
The article gives an example of a girl who had trouble breathing at recess at a school in Maryland. The school was outfitted with telemedicine equipment about a year ago. The girl went to the nurse, who determined that the girl was having an asthma attack. The girl’s father was an hour away and there was no time to wait for him to come get his daughter. The nurse could have also called an ambulance but that would have meant the girl would miss the rest of the school day.
Luckily, the girl’s parents had has agreed to enroll their daughter in the school’s telemedicine program, allowing the nurse to set up an online video and audio link with an emergency room pediatrician at a nearby county general hospital.
The doctor confirmed the school nurse’s diagnosis, the nurse administered the necessary medicine, and the girl was breathing normally again within 10 minutes and was able to go on with her day.
According to a study in the Annals of Allergy, Asthma and Immunology, children with asthma who were given treatment via telemedicine were able to gain control over their asthma just as well as when children saw a doctor in person to address their asthma.
IBM Watson Health and the FDA are collaborating on a research initiative that aims to define a “secure, efficient and scalable exchange of health data using blockchain technology,” according to an IBM release.
The two-year initiative will initially focus on oncology-related data. Blockchain has the potential to make it easier for cancer patients to share their health data securely with providers and researchers. One barrier to cancer research is the lack of a national infrastructure to which patients can contribute their data. To remedy that issue, the Cancer Moonshot has called for a National Cancer Data Ecosystem. By connecting data that often exists in separate databases, cancer research can move more quickly because all of the information is available in an easily accessible and centralized location. This will then allow providers and researchers to identify new and more effective treatments.
The joint initiative will explore how blockchain can be used for health information exchange across data types such as clinical trials. Patient-generated data from wearables and other connected devices will also be analyzed for population health management. The collaboration will also explore a “secure owner-mediated data sharing ecosystem” that could improve public health and lead to new discoveries, according to the release.
The FDA and IBM Watson Health will share their initial research findings in 2017.
It turns out the transition to ICD-10 didn’t go quite as smoothly as previously thought, particularly for the small practice physicians who were most anxious about the changeover from ICD-9 on Oct. 1, 2015.
What happened apparently is that some ICD-10 medical codes used in the Physician Quality Reporting System (PQRS) were not updated in time for CMS to process data reported on certain quality measures for eligible practitioners (EP) for the fourth quarter of calendar year (CY) 2016.
As a result, CMS is waiving reimbursement penalties for physicians and group practices that were affected by the ICD-10 glitches.
According to a CMS message released Jan. 9, “CMS will not apply the 2017 or 2018 PQRS payment adjustments, as applicable, to any EP or group practice that fails to satisfactorily report for CY 2016 solely as a result of the impact of ICD-10 code updates on quality data reported for the 4th quarter of CY 2016.”
The influential American Academy of Family Physicians (AAFP) is among the groups hailing the CMS move.
“CMS is saying that while considerable work was done to incorporate ICD-10 changes into the measure specifications, there are still some problems and that work is still incomplete,” Sandy Pogones, the AAFP’s senior strategist for healthcare quality, was quoted as saying in a story on the AAFP’s web site. “Those codes have to be fully accounted for in the specifications and documented in the medical record for a physician to accurately report quality data.”
Pogones noted, however, “if a physician fails to meet reporting requirements for other reasons — say a physician just chooses not to report, or a group fails to meet the reporting threshold — then the penalty waiver doesn’t apply.”
CMS has published this FAQ to help physicians navigate PQRS requirements related to ICD-10.
As many in health IT know, the theft of patient health data has developed into an epidemic with breaches involving millions of health records in 2016, according to the Department of Health and Human Services (HHS). Among the biggest breaches were the Anthem and Premera Blue Cross hacks, and HHS even released guidance on ransomware attacks. At the same time, however, many patients are unable to get access to their own health data.
This situation has created quite a paradox, wrote Kathryn Haun, a prosecutor with the U.S. Department of Justice, and Eric Topol, a professor at the Scripps Research Institute in La Jolla, Calif., in an op-ed piece in the New York Times.
It doesn’t seem right that cybercriminals can so easily steal this private information while the person the information belongs to cannot access it.
“We need to move on from the days of health systems storing and owning all our health data,” Haun and Topol wrote. “Patients should be the owners of their own medical data. It’s an entitlement and civil right that should be recognized.”
In addition to being a civil right, Haun and Topol argue that patients owning their own data could also help quell cyber attacks.
The authors say that one solution is disaggregation, or medical data being stored in individual or family units in a personal cloud or digital wallet, as opposed to being kept in centralized databases and handled by healthcare organizations and vendors.
Haun and Topol also lauded blockchain as one possible approach to this solution.
“One approach, known as a blockchain, is an encrypted data platform that would give patients digital wallets containing all their medical data, continually updated, that they can share at will,” they wrote.
“Their business is to sell proprietary information software to health systems to create large centralized databases for such things as insurance reimbursements and patient care,” they wrote. “Their success has relied on an old, paternalistic model in medicine in which the data is generated and owned by doctors and hospitals.”
I caught up with Intermountain Healthcare CIO and vice president Marc Probst at the CHIME16 Fall CIO Forum and got a chance to ask him about Intermountain’s role in what is one of the biggest EHR implementations ever.
And no, it’s not the installation of Cerner Corp.’s Millennium EHR platform across the Salt Lake City-based health system’s 22 hospitals and nearly 200 clinics, which is about half done.
That started last year and was a coup for the Kansas City, Mo. EHR giant, as was, of course, the awarding of a more than $4 billion federal EHR contract in 2015 to Cerner and its partners. In both cases, Cerner beat out archrival Epic Systems. Corp.
While the key players are Cerner and its systems integrator partners, Accenture and Leidos, Intermountain has more than a bit part in the undertaking.
Probst told me that Intermountain’s main role as a subcontractor to Cerner is to provide its own EHR content and workflow processes and “care process models,” (CPMs), for the building out of the military health records system.
CPMs are evidence-based guidelines summarizing clinical literature and providing expert advice for the diagnosis and management of certain diseases and conditions, including:
- Bipolar disorder
- Pediatric upper respiratory problems
“I don’t think that the DoD will adopt everything we’ve done, but they have a baseline to move from, from what we’ve developed at Intermountain Healthcare,” Probst says in part of a video interview I recorded with him in Phoenix at the annual fall meeting of the College of Healthcare Information Executives.