HHS Strategy to Address Information Exchange Challenges Lacks Specific Prioritized Actions and Milestones
Could subtle psychological cues lead to better medical decision-making?
Mike Miliard, Managing Editor
COLUMBIA, MO | February 17, 2014
When it comes to America’s healthcare costs, spiraling ever upward, one of the main culprits is unnecessary testing.
Some 130 oft-overused screenings and treatments should be curtailed, according to the two-dozen organizations affiliated with the American Board of Internal Medicine Foundation’s “Choosing Wisely” campaign.
Indeed, as Scientfic American pointed out in its article about that initiative, the Instiute of Medicine estimates that $750 billion – three-quarters of a trillion dollars! – was spent on unnecessary services and excessive administrative costs in 2009.
“We are, I hope, at a turning point in American health care where we’re realizing you want to have the right health care, not just more health care,” Baylor College of Medicine pediatrics professor Virginia Moyer told the magazine.
Well, not quite yet. Many thousands of docs are all too happy to order excessive lab work and imaging – and defensive medicine may be a big reason why. As Doug Campos-Outcalt, a Phoenix, Ariz.-based family physician, told Kaiser Health News, “Nobody ever gets sued for ordering unnecessary tests.”
Or what if that wasn’t the reason? What if reducing these excesses is a bit easier to explain, if a bit more deeply rooted?
Victoria Shaffer, assistant professor of health sciences in the University of Missouri School of Health Professions, has been working on research related to the psychological roots of how physicians make decisions.
With a degree in quantitative psychology, Shaffer says she’s long been interested in studying human judgement in decision-making.
Specifically, she’s keen on what makes clinical decisions tick – those made by both doctors and patients in the exam room. Her research is “essentially taking a broad range of academic research in psychology and applying it to specific judgements from the physician and patient perspective,” she says.
One of Shaffer’s recent projects has shed some interesting light on what drives physicians to order tests – and suggests that the reasons may be more subconscious than we may have thought.
In a study first published in Health Psychology, Shaffer, working with Adam Probst, a human factors engineer at Dallas-based Baylor Scott & White Health, and Raymond Chan, MD, a pediatrician at Children’s Mercy Hospitals and Clinics in Kansas City, Mo., took a look at how the lab tests from which a doctor could choose are presented in electronic medical systems.
Shaffer and her team studied how docs picked lab tests using three different designs of order set lists. The first was an opt-in version with no tests pre-selected, as is found on most electronic health records. The second was an opt-out version, in which physicians had to de-select lab tests that weren’t clinically relevant. The third had just a few tests pre-selected, based on experts’ recommendations.
Paul Hsieh Contributor
It isn’t often that a doctor is mistaken about how many feet his patient has.
But that’s the mistake this young doctor made by relying too heavily on an erroneous electronic medical record. According to Dr. Richard Gunderman:
An intern recently presented a newly admitted patient on morning rounds, reporting that the patient was “status post BKA (below the knee amputation).” “How do you know?” the attending physician inquired. “It has been noted on each of the patient’s prior three discharge notes,” replied the intern, looking up from his computer screen. “Okay,” responded the attending physician. “Let’s go see the patient.”
When the team arrived in the patient’s room, they made a surprising discovery. The patient had two feet and ten toes. Where did the history of BKA come from? It turned out that four hospitalizations ago, the voice recognition dictation system had misunderstood DKA (diabetic ketoacidosis) as BKA, and none of the physicians who reviewed the chart had detected the error. It had now become a permanent part of the electronic medical record — as if written in stone.
Fortunately, this error could be easily corrected. But the intern’s mistake highlights a growing problem with government-mandated electronic medical records. Doctors are spending more time in front of computer screens and less time with actual patients. This affects how doctors interact with patients. Inevitably, errors creep into their patients’ charts. Prudent patients should be aware of this trend and take steps to ensure the accuracy of their medical records.
The HITECH (Health Information Technology for Economic and Clinical Health) Act of 2009 essentially mandates that physicians and hospitals adopt electronic records by 2014, or face penalties in the form of reduced Medicare/Medicaid payments.
At first glance, adopting electronic medical records (EMRs) would seem a no-brainer for doctors and hospitals. After all, electronic records are the norm for many successful businesses, assisting with sales, inventory, and billing. In theory, electronic medical records should allow doctors to work more efficiently. But in practice, many doctors are finding that EMRs hinder their ability to practice good medicine.
A recent study from Northwestern University found that, “physicians with [EMRs] in their exam rooms spend one-third of their time looking at computer screens, compared with physicians who use paper charts who only spent about 9% of their time looking at them.” According to Enid Montague, PhD, first author of the study, “When doctors spend that much time looking at the computer, it can be difficult for patients to get their attention… It’s likely that the ability to listen, problem-solve and think creatively is not optimal when physicians’ eyes are glued to the screen.”
New York Times health writer Dr. Pauline Chen similarly described that young doctors in training are so busy filling out obligatory electronic forms, they spend only 8 minutes per patient each day. As a result, they cut corners:
When finally in a room with patients, they try to [rush through interviews] by limiting or eliminating altogether gestures like sitting down to talk, posing open-ended questions, encouraging family discussions or even fully introducing themselves.
As Dr. Chen noted, the bad habits they learn in training will carry over to when they become independent practitioners.
(Some doctors are coping with this problem by hiring “scribes” — additional clerical people to enter data into the computer, while the physician converses with the patient. But this requires physicians or hospitals to hire additional personnel. As the New York Times noted, “In most industries, automation leads to increased efficiency, even employee layoffs. In health care, it seems, the computer has created the need for an extra human in the exam room.” The “solution” of scribes doesn’t eliminate the inefficiency caused by electronic medical records — it merely shifts the problem elsewhere.)
One source of error in electronic medical records is when doctors spend insufficient time with patients. According to Dr. Elizabeth Toll, another source of errors is perverse payment incentives coupled with physician sloppiness. In her words, “The records are full of lies”:
The EMR was designed to demonstrate the pieces of the record that you have to attend to in order to bill at a certain level. If you just enter a few questions and you only enter part of the exam, and you only add medicines and you only do this or that, you can only be reimbursed a certain amount. But if you asked about, for instance, the family history, the surgical history and the social history, then you have all the elements to charge more. So there’s an incredible temptation to just push, push, push and bring forward everything from the previous notes without re-asking the questions.
This creates a huge problem: The records are full of lies. They’re full of things that [physicians] have said they’ve done but truly haven’t. The patient has been in eighth grade for three years. The patients are divorced, but in the record they’re still married. The patient used to work as a nurse and now works as a librarian, but it hasn’t been changed in the record because people are giving quick, push-button answers to save time, and they don’t update the info. You can see this as you go through small things in the social history but also in [clinical histories]. Yesterday, someone sent me a letter about an amputee patient he sent to a podiatrist. He got a report back on both the patient’s feet. This patient only has one foot.
Even when doctors are conscientious, EMRs don’t eliminate medical errors. They merely change the kinds of errors made. For example, EMRs eliminate the problem of doctors’ illegible handwriting on prescriptions. Instead, physicians might (and sometimes do) accidentally click on the wrong medication on the menu.
(Note: EMRs are not inherently bad. A well-designed EMR can add tremendous value to many medical practices. But the choice of whether and when to purchase an EMR should be left up to each individual hospital and medical group. The government should not be pressuring doctors into adopting EMRs any more than it should pressure citizens into purchasing smartphones they might not need. But that’s a topic worthy of a separate column.)
So how can patients protect themselves from errors in their electronic medical records? I recommend four simple steps:
1) Get a copy of your own medical records at regular intervals and review it thoroughly. This is especially important if you’ve had recent major surgery or developed a serious new medical condition (such as a new diagnosis of cancer). If you find an error, contact the appropriate hospital or doctor’s office and ask that it be corrected.
2) Make sure you understand all your prescription medications. The most common errors in electronic medical records involve patient medications (either a wrong medication or a wrong dose). Discuss each medication with your doctor and/or pharmacist until you understand why you are taking it, the proper dose, how often, for how long, and what side effects to look out for.
3) Whenever you undergo laboratory or radiology testing, request a copy of the results for your own personal files. Most radiology offices will gladly burn a CD of your radiology imaging tests for you (either for free or for a small fee). That way, you can review the results at your leisure or seek second opinions at your discretion.
4) Whenever you have a doctor’s appointment, consider bringing a small voice recorder to record any discussions. (Many smartphones also have a voice recorder app.) Most doctors are glad to let patients record their conversations, so they can replay them when they get home or go over them with family members unable to attend.
Electronic medical records can be powerful tools when designed properly and used wisely. And errors certainly occurred in the era of paper records. But electronic medical records can create new risks for patients. Prudent patients will want to ensure their own records are accurate. Someday, your life may depend on your diligence.
Are doctors suffering at the hands of the Herzberg principle–which says that the best way to discourage workers is to subject them to policies and procedures that don’t make sense?
An article in the Atlantic explores how changes in the healthcare payment model, health IT and the doctor-patient relationship are discouraging docs.
“It is easy for many healthcare leaders to forget that doctors go into medicine not because they enjoy entering data into complex electronic health records and ensuring that their employer gets paid for everything they do, but because they want to make good diagnoses, prescribe appropriate treatments and help patients,” the article states.
Building on our first review of multi-ology, multi-site, vendor neutral solutions, this webinar will look to the specifics of more advanced VNA solutions. The webinar will begin with a summary overview of how to transform rigid departmental information silos into fluid, consolidated, information sharing systems. Join us and our IBM partner to learn how to get started with a VNA. Register Now!
Technology is made with engineers in mind, not doctors, Weygandt says. It’s often reported that doctors and nurses are left out of the design phase of building new technology.
One example of this is the need to give nurses a seat at the health IT development table, since they actually know what’s necessary to achieve optimal patient care. In particular, Elizabeth “Betty” Jordan, R.N., an assistant professor at the University of South Florida College of Nursing, told FierceHealthIT in a recent interview. Nurses are often given demonstrations on IT tools that already exist–including tablets and other monitoring devices–but are not given the opportunity to join in on such conversations during the technology planning and development stages.
This is where doctors’ input would come in handy. Of course, new technology can help doctors practice better medicine, but change isn’t easy, Weygandt notes.
“Every innovation should be tested not just to see if it increases revenue or cuts costs,” he says, “but also to ensure that it enhances the doctor-patient relationship.”
In another example of docs’ attention being diverted by technology, doctors who use electronic health records in the exam room spend about one-third of their time looking at the screen, which might detract from patient communication, according to research from Northwestern University.
However, in summer 2012, it was reported that eighty percent of physicians in a MedPage Today survey say technology has improved communication with their patients.
To learn more:
– read the article in the Atlantic
AMA: Computers in exam room don’t have to be disruptive
EHRs call for tech etiquette in the exam room
80% of docs say technology improves provider-patient communication
Docs using clinical decision support tools seen as less capable
mHealth13: Technology knowledge key to telehealth deployment
Telemedicine allows for effective care of Parkinson’s patients
HIT from a nurse’s perspective: Put us at the development table
The healthcare reformer David Blumenthal explains why the medical system can’t move into the digital age.
While the U.S. continues digitizing its healthcare industry, a huge challenge is arising: not only securing those systems but verifying identities.
With a steady stream of HIPAA-covered data breaches continuing over the past few years, not to mention the debacle of Target’s recent customer financial information loss, some argue that current identity security approaches just aren’t adequate — especially considering that criminal attacks on hospitals are increasing substantially.
“Protecting sensitive personal information with passwords is akin to building a massive stone fortress and then securing the front door with the kind of lock I use to keep my two-year-old out of my bathroom,” said Jeremy Grant, a senior advisor on identity management at the National Institute of Standards and Technology, heading up the National Strategy for Trusted Identities in Cyberspace.
April 2014 marks three years since the Obama Administration launched the NSTIC, a public-private initiative aimed at spurring the private sector to increase privacy, security and trust in online transactions across industries.
Speaking at a public hearing held by the federal Health IT Standards Committee’s Privacy and Security Workgroup, Grant argued that while there has been progress in a number of pilots — with six of 12 relating to healthcare — the private sector, particularly health organizations, need to start agreeing on standards.
[See also: EHR incentive payments soar toward $22 billion.]
The National Strategy “will only succeed if sectors in need of better identity solutions step forward and demonstrate a willingness to roll up their sleeves in support of the collaborative effort,” said Grant, the former chief development officer at ASI Government.
Personal health record sharing options like the Blue Button will only work “if patients have an easy way to assert that they really are themselves online,” Grant explained.
Though not the only layer of security needed, identity is perhaps the most important and difficult, Grant argued. Identity solutions “can’t simply be secure,” he said; they have “to be easy to use, or else users won’t bother.”
Grant urged the Private and Security Work Group to bring a message back to the rest of the Health IT Standards Committee and the broader health and health IT communities: Even though standards may not be as mature or technologies as widely-available as some would hope, don’t wait.
“If the Workgroup or the broader health sector are of the view that this marketplace will soon be created while everybody sits back and watches,” Grant continued, “I believe folks are going to be waiting for a long time.”
Bringing that vision of secure and accessible identification technology to reality is going to take a lot of work, though.
“Privacy and Interoperability are among our most pressing concerns and they often conflict in the real world,” argued Thomas Sullivan, MD, the chief strategy officer at the e-prescribing company DrFirst, and a past president of the Massachusetts Medical Society. “There are far too many examples of unnecessary redundancy in IDP and identity management of both providers and patients,” leading to “higher costs, inefficiency, errors, fraud and frustration throughout the industry.”
The problem can manifest in multiple ways for patients and providers. Sullivan offered two examples.
For patients who decide what providers to share their information with, there is great privacy, yes, but also a “risk of danger and harm” if the information is incomplete or not shared in the event of emergencies.
For providers controlling identity attributes of patients, there are administrative efficiencies and “a certain element of patient safety added since it is easier to discover aggregate data that may bear on treatment decisions.” At the same time, “the patient loses a certain element of control regarding data sharing and thus, perhaps [there will be] less privacy protection,” Sullivan said.
Now, some see the solution to those identity and security problems as one with few risks, albeit with lingering controversy: a national patient identifier system.
While “some members have proposed that as one of several solutions, I’m sure we’re not trying to provide a national ID for all patients,” Sullivan said, referring to the Identity Ecosystem Steering Group he is also a member of. “Back when the HIPAA debate took place, it was clear we would not have a national patient identifier until Congress acted. But we are looking at ways to identity-proof patients and providers and to make those attributes a lot more usable.”
Indeed, the Healthcare Information and Management Systems Society (the parent organization of HIMSS Media, publisher of Government Health IT), the American Health Information Management Association and others are pushing a new idea as an alternative to a national patient ID system — a national patient matching system, options for which HIMSS in collaboration with HHS innovation fellows are currently exploring.
Whatever the outcome of those or other standards efforts, practitioners like Sullivan are just glad to see the problem of identity management starting to be addressed.
“It’s pretty rare that a physician would agree with anyone on anything,” he said, “but I completely agree that we need to collaborate more between commerce and HHS.”
Patient management of their own health information is a much discussed topic in health IT. Patients with the power to access their health information and actively direct its flow have the tools to take charge of their health care and make more informed decisions. A great example of this is a patient who downloads her hospital discharge summary and electronically sends it to both her primary care physician and her adult daughter who helps her manage her condition.
Nikolai Kirienko, a patient advocate (@nikolaikirienko) and co-director of Chronology.MD has referred to this concept as patients becoming a “Health Information Exchange (HIE) of One.” A successful implementation of the HIE of One concept is the Blue Button program. Originally implemented by the VA and since expanded to TRICARE and Medicare, Blue Button provides the patient with a simple online button to view and download their health information. An updated version of Blue Button, known as Blue Button Plus, will provide patients with the ability to transmit health records to a provider or caregiver and to set automatic downloads or uploads into a mobile app or a personal health record tool.
HIPAA has always given patients the right to obtain copies of their health information, and once patients have this information, they can share it with whomever they please. Congress improved on this right inHITECH by requiring HIPAA-covered entities to provide patients with an electronic copy of their electronic health information and to have that digital copy directly transmitted to a third party – such as a personal health record, a mobile health app, or a health provider or family member. The Office for Civil Rights (OCR), which oversees HIPAA, released final rules last January implementing this right. Patients who want to have their health information directly transmitted to a third party must submit that request in writing (which can be electronic). OCR also clarified that if a patient wants to receive their digital information via a mechanism that is convenient for them but is not secure (such as by unsecure e-mail), the patient has the right to receive their health information in the format they want.
While these changes to HIPAA’s patient access rights are welcome and prioritize the needs of patients, the regulators fell short of creating the ideal environment for facilitating patient HIEs of One. Providers are still permitted to take up to 30 days (and in some cases, up to 60 days) to provide a patient with access to electronic health information, and this timeframe also applies to the direct transmission of this data (per patient request). This is hardly fast enough to permit the patient to meaningfully exchange their current health information with others.
Beginning in 2014, the federal Meaningful Use program will enable some of us to have much more timely ability to electronically view, download and transmit our digital health data. For example, physicians participating in the Meaningful Use program (and using Certified EHR Technology) will have to provide patients with the ability to view, download and transmit (V/D/T) relevant health data within 4 business days. In addition, hospitals participating in the program must provide patients with their discharge summaries within 36 hours.
That timeframe comes much closer to enabling patients to be HIEs of One. It is the case, however, that fewer patients will be impacted by these new Meaningful Use Requirements. The Meaningful Use Requirements only require that 50% of patients be offered and more than 5% of patients use the V/D/T capabilities. But it’s a great start to building the movement.
Regulators may need to tie up a few loose ends. For example, the EHR 2014 Certification Requirements should be checked to ensure they are consistent with the new final HIPAA regulations. Since a patient’s request to transmit data to a third party must be in writing, certification criteria should specify a standard or require a functionality for capturing this information. Health care providers offering these capabilities to patients also would benefit from specific guidance from regulators about how to deploy the V/D/T capabilities consistent with both HIPAA and Meaningful Use requirements. Finally, when there is more experience with deployment of Blue Button and Meaningful Use, there will be a more hospitable climate for revising the baseline HIPAA rules, so that all patients have the capability to take control of their health care.
Christopher Rasmussen is a policy analyst at the Center for Democracy & Technology, which originally published this blog post.