HIT - naysayers & skeptics

Anyone who has engaged in Information Technology business for some time knows that most IT investments do not generate significant benefits until sufficient years have passed. In most cases, even 5-year ROI models are flawed since it may take a decade before significant gains from the investment are seen. That is what we know. Then, why would we treat HIT differently? I would challenge anyone who dismisses investing in EHR/HIT technologies solely because evidence of its positive impact on quality of care cannot be visualized over the short-term horizon.

Do not dismiss before you explore. The inclination to "do nothing" in face of mounting challenges and insistence on availability of absolute evidence prior to investment could be disastrous.

A case for modular EHR

Came across a great article on plug-and-play modular EHR by David C. Kibbe, MD, MBA, senior advisor to the AAFP’s Center for Health Information Technology. The author questions the push for adoption of comprehensive EHRs when in fact that the needs of a practice (market) might be for some its components such as e-prescribing or a registry function. He proposes a shift from vendor-centric approach to platform-centric one where the practices are able to purchase and adopt EHR "modules" that follow industry standards.

This idea is certainly not new, consider this blog post by John Halamka where he states that Partners Healthcare and Beth Israel Deaconess are using a platform-centric approach for EHR and quality reporting, and are on their way to meet the meaningful use criteria.

Interoperable plug-and-play modules make sense to me. Buy components (modules) you need, connect new components with ones you already have on the platform.

Ethical use of data for Clinical Decision Support

Noticed this ethics-related question on LOINC website http://loinc.org/articles/Bonney2009

“Is it appropriate, or ethical , to use health data collected for the purpose of direct patient care to develop computerized predictive decision support tools?”

I do not have access to the complete article, but the question itself triggered some thoughts in my mind. I guess the first question to ask is – does the end justify the means? Since use of CDSS (Clinical Decision Support Systems) has been shown on average to lead to better clinical decision-making for providers and hence impact patient care, is it okay to use patient care data for development of such tools?

I will attempt to answer this question using the ethical framework governing the research on human subjects to see if it may apply to this situation (source of framework: Emanuel EJ, Wendler D, Grady C. What makes clinical research ethical? JAMA. 2000;283:2701-11. [PMID: 10819955]).

Here is the list of 7 framework requirements and their applicability to CDSS development as assessed by me –

1. Social or scientific value: Benefits from CDSS should justify the resources spent and risks imposed on patients whose data has been used
2. Scientific validity: Predictive decision-making methodology used by CDSS should be properly structured to meet its objectives
3. Fair participant selection: Participant data should be selected to achieve a fair distribution of the burdens and benefits of CDSS.
4. Favorable risk-benefit ratio: CDSS should be designed to ensure that the risks to an individual human participant are balanced by expected benefits to the same participant
5. Respect for participants: Privacy of participant should be protected and confidentiality of their data should be maintained. This can be achieved by using de-identified data and obtaining patient consent for collection, use, and sharing of data
6. Informed consent: Participant consent to include data in development of CDSS must be obtained. The risk to participant should be measured relative to risk associated with receiving care without use of CDSS. This risk should be communicated to the participant when obtaining informed consent.
7. Independent review: CDSS development should receive independent ethical review that is appropriate to the level of potential risk it poses to participants.

Medical vs. Nursing Informatics - Part 3 (final)

Here is the final part of the comparison between medical and nursing informatics. Part 1 and Part 2 can be found here.

Medical and Nursing Vocabularies:

Number of medical vocabularies such as MeSH, SNOMED, LOINC have been developed over the years. 100+ separate controlled vocabularies were conceptually linked in 1986 to form a meta-thesaurus called the UMLS (Unified Medical Language System).

Some nursing products such as CINAHL (Cumulative Index of Nursing and Allied Health Literature) use a medical vocabulary MeSH as an underlying vocabulary for diseases, drugs, anatomy, and physiology, and have expanded the vocabulary to include unique nursing terms in the vocabulary http://www.universityhealthsystem.com/Research/docs/Searching%20sEBSCO%20CINAHL.pdf

Growth opportunities: Lastly, both medical and nursing informatics domains are ripe for innovation and improvement. Consider the emerging health care models such as Patient Centered Medical Home that are likely to impact the physicians and nursing professions, in addition to impacting the related informatics domains as well.

Medical vs. Nursing Informatics - Part 2

Here is the second part of the comparison between medical and nursing informatics that highlights the similarities and differences between their information needs. First part can be found here.

Physician vs. Nursing Information needs:

It is important to compare and contrast physicians’ and nurses’ information needs to appreciate why we need to two separate informatics disciplines.

There is significant overlap between nurses’ and physicians’ needs for information – drug-drug interaction, pill identification, etc. However, there are certain information needs that are very specific to nurses’ needs – nursing procedures, nursing care plans, etc. Arguably, a nurse may need access to both information sources created for physicians (such as MD Consult, UpToDate, VisualDx, MediSpan, Micromedex, EMBASE, etc.) as well as those created specifically for nurses (CINAHL, NursingConsult, etc.) in order to do his/her job. For instance, a nurse administrator creating or updating a training program for practicing nurses may need current educational materials. Or, when a patient is being discharged and nurse wants to provide educational or instructional material for patient’s care at home.

Similary, there is an overlap on evidence-based information needs but some of the needs for evidence are unique to nursing. For instance, each Evidence-Based Nursing monograph available on Mosby’s Nursing Consult (www.nursingconsult.com) contains a concise review of the current evidence available on a clinical problem and presents specific recommendations for nursing care. Another such example is Nursing Reference Center by EBSCO. See the related press release http://www.ebscohost.com/uploads/thisTopic-dbTopic-871.pdf

In clinical settings, physician and nursing workflows are quite different, so their information needs at the point-of-care differ. For instance, a nurse may enter patient symptoms and signs in a nursing information product that returns what other observations should be made, not for diagnosis, but to know what to report to physician. In research settings, information needs of nurses and physicians may differ as well. These differences impact the human-computer interaction (HCI) concepts that are used to design and implement systems built for physicians and nurses within these settings.

From administrative perspective, information needs of CNIO and CMIO would be different. For instance, in a hospital different policies may be created by CNIO and CMIO for nurses and physicians respectively to impact their productivity.

Lastly, education needs of a nurse and a physician would differ based on certifications they would like to pursue, specialty-specific training required for a floor nurse, etc. For instance, a nurse administrator creating or updating training program for practicing nurses may retrieve information related to procedures, processes, general discussion information that is usable for nurse education.

In the third and final part, I will discuss medical and nursing vocabularies as well as growth opportunities.

Medical vs. Nursing Informatics - Part 1

Here are a series of articles contrasting Medical informatics with Nursing informatics. I present the first part below -

Medical Informatics deals with the storage, retrieval, and optimal use of biomedical information, data, and knowledge for problem solving and decision making (as defined by Dr. Shortliffe). Nursing Informatics is defined as a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge into nursing practice. (source: American Nurses Association)

Both definitions sound very similar. In fact, both medical and nursing informatics fields are similar in many respects:

Ø Support for improvement in quality of care and patient outcomes

Ø Availability of contextual information – right information to right person at right time

Ø Support for security and privacy of data

Ø Inter-relation to other health informatics specialties – public health informatics, bioinformatics, pharmacy informatics

Ø Inclusion of both clinical and non-clinical areas (such as medical research, nursing research)

History:

Medical Informatics has a rich and long history. Some of the significant milestones in development of this practice include the following:

Ø Establishment of NLM and Index Medicus by John Shaw Billings (1890)

Ø Development of MEDLINE (1966)

Ø Development of Mycin, first CDSS by Dr. Shortliffe (1970)

Ø Development of MUMPS, the first programming language designed specifically to deal with medical data (1986)

In contrast, as a formal specialty practice, Nursing Informatics is fairly recent. In fact, for many years before a dedicated and concerted effort to Nursing Informatics was established, nurses relied on retrieval of information using same systems that were developed primarily for physician users. However, nurses have significant unique information needs that are not met by physician-focused information systems. Consider the number of print journals that have been developed uniquely for nurses – Nurse Leader, Journal of the Association of Nurses in AIDS Care, Newborn & Infant Nursing Reviews, Journal of Radiology Nursing, Journal of Pediatric Nursing, Applied Nursing Research, etc. Large subscriber base and high usage of these journals amongst nurses suggests the uniqueness of nurses’ needs. Over the past few years, the number of nursing-focused CDSS (Clinical Decision Support Systems) such as Nursing Consult (http://www.NursingConsult.com) with support for nursing point-of-care and research needs has been steadily increasing over the years.

In part 2, I will discuss physician vs. nursing information needs. Stay tuned.

PowerPoint 2010 - sneak preview

According to Microsoft PowerPoint team's blog, new features include:

• Completely revamped their media playback technology
• Improved the media workflow: insertion, editing, presenting and distribution
• Added features to help trim media, integrate with the animation timeline, and export PowerPoint presentation to video

Here is a sneak peek at PowerPoint 2010. Looks good!

Choosing health care in MN based on best quality and cost

Want to compare health care providers in Minnesota for the quality of care they provide and total health care cost? Use Minnesota HealthScores, a non-profit Web site that helps consumers choose the best MN health care providers for them and their family based on cost and quality of health care they provide.

MNHealthScores.org compares cost and quality of care provided by medical groups and clincs for the following conditions:

* Asthma

* Breast cancer screening

* Cancer screening

* Cervical Cancer Screening

* Chlamydia screening

* Colorectal cancer screening

* Depression

* Diabetes

* High blood pressure

* Vascular disease

MNHealthScores.org also provides cost reports that display payment amount for physician services, including amount a health plan pays for a procedure such as colonoscopy or office visit plus the amount a health plan tells the physician to collect as a copayment from the patient.

MNHealthScores.org uses data provided by MN health plans and data submitted by more than 300 medical clinics statewide.

Here are some ways consumers can use MNHealthScores.org:

* determine how well care is being delivered by your clinic

* learn about what type of care or "standard of care" consumers should expect from the health care system, so that they can discuss it with their health care team

* search for a new medical group or clinic

* If you have a specific condition, such as diabetes, review the scores for the diabetes measure to determine which medical groups in your area had the highest scores. Groups with the highest scores performed better in giving patients the right care for this health condition.

* determine payment amount for physician services

MN HIE

Being a Minnesota resident, I decided to learn about the state's HIE efforts. MN HIE is operational and has ~3 million residents (or 58% of MN population) in its patient directory. It provides medication history for past 12 months via provider's EMR or via a secure web application, and will provide following additional services starting this fall:

* patient eligibility
* lab results
* immunization history
* exchange of medical record information

Since medication history is based on pharmacy claims data, clinical data exchange will be possible starting this fall when medical record information exchange is offered as a service by MN HIE.

Do you know the "state" of your state's HIE?

Disease registry: "Chronic disease tracking system" for those who cannot afford an EMR

For practices that do not plan to purchase an EMR and want to proactively manage the health of population, a registry can be used instead. This registry can be used to track a practice's diabetes patients, including their required labs and preventive services. This information can then be used to manage population health proactively.

A simple MS-Excel based Disease registry can be found here at AAFP.org. This file tracks interventions and clinical parameters that are important in diabetes management. In case problems are encountered, an alert is displayed. For instance, if the date of a patient's last A1C was more than 90 days ago, that date cell turns yellow as a warning; and turns red if more than 180 days ago.

Identifying all patients in the practice with a chronic disease such as Diabetes type 2 and initial data entry of this registry excel sheet are identified as major challenges to achieving a complete and functional disease registry. However, once the registry is complete, it provides many advantages:

• Proactive management of chronic diseases
• Use for preventive services and screenings such as Pap smears, mammograms, colon cancer screening etc. for general patient population
• Increased compliance with recommended services
• Improved patient care
• Document performance as part of p4p activities

Dr. David Ortiz who created this registry worksheet recommends:

• Start small, pick a chronic condition that you want to improve
• Involve your practice staff. Get their buy-in and agreement before operationalizing the plan

IT critical to improving care of patients with chronic diseases

There are those who suspect the power of health IT to significantly improve cost and quality of care. Quite likely they may also consider funneling multi-billion stimulus funding to HIT a colossal waste. Here is evidence that proves otherwise and might even force such detractors to rethink their opinion.

Results of a 5-year Medicare Physician Group Practice Demonstration study involving 10 large MD practices were published that attributed improved quality of care for patients with chronic diseases to use of HIT. This Medicare Physician Group Practice Demonstration study is also mentioned as the "first" P4P project to work directly with physician practices. Here are some impressive figures from this study.

* Geisenger improved care on all 32 categories that include continuing programs for diabetes and coronary artery disease, adult preventative care, and hypertension

* University of Michigan (UM) Family practice group improved care on 29 categories. Care improvements were made in areas that included diabetes, congestive heart failure, coronary artery disease, hypertension, and breast and colorectal cancer screenings.

* UM Family Practice group claims $2.9M in Medicare savings surpassing the CMS target

How did they get this done?

* Provided clinical decision support through alerts/reminders within the EHR

* Start small and then expand the program - First year focus on Diabetes. Congestive heart failure and coronary artery disease were included in second year. Hypertension in year three.

* Commitment of physicians and administrators within the practices

Reducing costs while improving care -- who says it can't be done!! Studies such as the one cited above have far-reaching consequences considering chronic diseases account for ~60% of the deaths worldwide and half of them can be prevented!

EHR video tutorial

Here is an EHR tutorial from The Forbes.com Video Network.

EMR | EHR | PHR | HIE | RHIO defined

NAHIT (National Association for Health Information Technology) is shutting down Sep 30th. It published HIT terminology definitions, including those for EMR EHR HIE and RHIO. Complete report can be found here.

HIEs and their status

Here is a directory of HIEs compiled by eHealth initiative. HIEs in Stage 5, 6, and 7 are operational HIEs. This is one of the most comprehensive and updated HIE directory I have come across.

If you find your HIE is not included, please use the link on the directory page to submit your HIE informaiton.