Culled from iHealthBeat

Study: HIEs Can Help Significantly Reduce Unnecessary ED Tests

, iHealthBeat, Thursday, July 23, 2015

Leveraging data from health information exchanges can significantly reduce unnecessary emergency department tests, according to a study published in the Journal of the American Medical Informatics Association, Modern Healthcare reports.

Study Details

The study was conducted by the Brookings Institution and supported by HEALTHeLINK, a Buffalo, N.Y.-based HIE.

For the study, researchers assessed more than 2,000 ED visits in three western New York hospitals between March 2014 and May 2014 (Conn, Modern Healthcare, 7/22).  

During a six- to eight-week period, clinical liaisons from HEALTHeLINK shadowed ED doctors at:

• Buffalo General Medical Center;
• Erie County Medical Center; and
• Kenmore Mercy Hospital.

During this period, 1,450 patients were seen (Leventhal, Healthcare Informatics, 7/22).

For the study, ED patients were divided into two groups. One group of 737 patients had physicians who used HEALTHeLINK's data to find relevant clinical information, while the other group of 1,275 patients were treated by physicians who did not use the HIE data (Modern Healthcare, 7/22). 

For the first group, the clinical liaisons retrieved any potential clinically relevant data such as patients':

• Hospital admissions;
• Discharge transcripts;
• Laboratory results;
• Medication history;
• Operative reports; and
• Radiology examinations (Healthcare Informatics, 7/22).

Study Findings

Researchers found that using HIE data at the first hospital ED led to a 52% reduction in lab tests and a 36% reduction in radiology exams.

At the second ED, the HIE data led to a 25% decrease in lab tests and 26% decrease in radiology exams.

Meanwhile, the third ED saw a 47% reduction in radiology after leveraging HIE data. The HIE did not have an effect on the number of lab tests ordered at the third hospital because patients were seen for cardiovascular and neurovascular issues that required new lab tests regardless of previous results (Drury, Buffalo Business First, 7/22).

According to Modern Healthcare, the study also found using scribes proved more efficient for doctors when searching for patient information.

Comments

Niam Yaraghi, a fellow at the Brookings Institution and the study's principal researcher, noted that the use of clinical liaisons, or scribes, made it easier for doctors to find patient information.

He said, "The mere existence of them point to the user unfriendliness of our EHR systems." Yaraghi added, "If we had asked the doctors to do it themselves, they wouldn't do it. The HIE access rate is about 6% to 7% of the patient encounters. Physicians don't have the time to do it" (Modern Healthcare, 7/22).

Dan Porreca, executive director of HEALTHeLINK, in a statement said, "This study highlights just one component of the value of interoperability and doctors' access to their patients' data that HEALTHeLINK and health information technology can provide in improving the quality and efficiency of patient care and enhancing patient safety." He added, "While direct and indirect costs of these tests can vary by hospital and region, physicians ordering fewer tests because recent pertinent clinical information is available through HEALTHeLINK directly leads to overall costs savings for our local health care community" (Healthcare Informatics, 7/22).

Source: iHealthBeat, Thursday, July 23, 2015

Congress wants meaningful use to address health disparities | EHRintelligence.com

Congress wants meaningful use to address health disparities | EHRintelligence.com

Healthcare Interfaces 101

Interfaces Defined

Webopedia defines an interface as a boundary across which two independent systems meet and act on or communicate with each other.

One familiar type of an interface is a user interface, like a keyboard, mouse, etc. which allows a user to interact or communicate with a computer’s operating system. So between the user and the operating system is a keyboard that allows that communication to take place.  

There are two basic kinds of interfaces: a hardware interface and a software interface. A hardware interface consists of the wires, plugs and sockets that hardware devices use to communicate with each other. A software interface on the other hand is the language and codes that the applications use to communicate with each other and with the hardware.[1]

In all the examples above, the key function of the interface is to serve as the bridge or connections between two INDEPENDENT systems, applications or hardware devices that enables communication or messages to be passed between them. For our purpose, we will be focusing on software interfaces specifically within the healthcare industry.

Why Interfaces Exist

Interfaces exist in various industries for the same reason of being a boundary between disparate systems. In healthcare, for example, the need for interfaces is even more pressing because healthcare facilities use a variety of software applications or information systems from different vendors. There are numerous vendors, data providers, and custom applications that need to exchange information using evolving standards.  Because these applications or systems are created by different software vendors, they cannot communicate with each other and therefore need a way to exchange data. This exchange of data between disparate applications or systems is achieved through the use of an interfaces or healthcare interface engines. Healthcare interface engines connect applications by mapping and transferring data between the applications using standards and data definitions understood by each application. Interoperability or the ability for two systems to exchange data has been a key bottleneck in healthcare organizations. Interface engines have come about to resolve that issue.

Healthcare Messaging Standards

There are many standards in healthcare, with a diverse range of protocols and types of data. There are different health information systems such as labs, pharmacies, clinics, hospitals, and many others. For an electronic medical record system, for example, to transmit lab orders to a lab system and receive results back into the EMR, an interface is required. For these two systems to exchange data, they must adhere to a standard or agree on a common protocol or data formats. Examples of such standards are HL7 for Health Level 7, XML or Extensible Markup Language and CCD or Continuity of Care Document.

Health Level 7 (HL7) is the most widely used messaging standard in the healthcare industry. "Level Seven" refers to the seventh level of the International Organization for Standardization (ISO) seven-layer communications model for Open Systems Interconnection (OSI) - the application level. The application level interfaces directly to and performs common application services for the application processes. [2] 

XML is similar to HL7 except that unlike HL7, XML is  web based. CCD on the other hand, is used to exchange clinical documents like in health information exchanges or HIE.

Directions of interfaces

There are  two basic directions an interface may take. An interface may be implemented to go in one direction or unidirectional or to go in both direction known as bidirectional. As I alluded to earlier, a physician practice may want to submit lab orders electronically to a hospital or other lab systems and receive results electronically back into their EMR system. That is an example of a bidirectional interface. Alternatively, a physician practice may print orders and give to their patient to physically take to the lab and the results can be sent electronically back to the physician practice. In that case, it is a unidirectional or Results only interface. Depending on a variety of factors not limited to workflow or budget, a practice may implement a unidirectional or bidirectional interface. A unidirectional interface can either be outbound or inbound relative to a given system.

Kinds of Interfaces

There are also many kinds of interfaces in healthcare. One example is a practice management interface and this include demographics or ADT (Admit Discharge and Transfer Message) interface, Scheduling or SIU (Scheduling Information Unsolicited) interface and Charges or DFT(Detailed Financial Transactions) interface. There can also be a Lab/Rad Orders or ORM (Order Message) Interface, Lab/Radiology ORU (Observation Result Unsolicited Message) interface, Progress Notes interface, Electronic Health Exchanges (eHX), among several others.

Flavors of PM Interfaces

Depending on the need of the organization, it will request a particular type or kind of interfaces and a particular flavor of a given interfaces. Take practice management (PM) interfaces for instance. A demographics or ADT interface can either be inbound, outbound or bidirectional depending on the organization’s workflow, needs and the systems involved.

There are some healthcare organizations that have been using a certain practice management system for patient registration long before they acquired an EMR. As a result, the organization may decide to continue patient registration in one system and document their progress notes in another system-the EMR.  In that case there need to be a flow of patient demographics from the PM system to the EMR. Normally the PM system and the EMR are by different vendors and therefore an ADT Outbound (with respect to the PM system) interface is required to facilitate the exchange.

The same system in which patients are registered is best for scheduling (although not mandatory) and so when appointments are created in the PM system, a Scheduling or SIU Outbound interface is required to transmit patient schedules to the EMR system.

Depending on which system is used for billing, let’s assume the PM system is used for billing, progress notes are documented in the EMR entering assessments, treatments and charges. In such instance, a DFT or Charges interface is required to send charges from the EMR back to the PM system. The scenarios described above can be summarized and normally implemented as ADTout, SIUout and DFTin Interface. See diagram below: 

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[1] http://www.webopedia.com/TERM/I/interface.html

[2] http://www.hl7.org/about/index.cfm?ref=common

What is Healthcare Informatics

Health Informatics is the study of resources and methods for the management of health information. It concerns the use of information and information and communication technologies within healthcare. It is defined generally as understanding the meaning, relationships and properties of health care information as a basis for biomedical knowledge discovery, information retrieval, storage and dissemination for purposes of supporting the process and evaluation of health care of the public.[1]

Health Informatics deals with the resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine. Its tools include computers, clinical guidelines, formal medical terminologies, and information and communication systems. It is applied to the areas of nursing, clinical care, dentistry, pharmacy, public health, occupational therapy, and (bio) medical research.[2]

This area of study supports health information technology (HIT), medical practice and medical research. Health Informatics involves systems such as electronic health records (EHR) and electronic medical records (EMR), health information exchange standards such as Health Level 7 (HL7), medical terminologies such as Systematized Nomenclature of Medicine, Clinical Terms (SNOMED CT), and portable medical devices for the collection of data.

Health information technology (HIT) is the area of IT involving the design, development, creation, use and maintenance of information systems for the healthcare industry. Automated and interoperable healthcare information systems are expected to lower costs, improve efficiency and reduce error, while also providing better consumer care and service.

The electronic health record (EHR) is the central component of the health IT infrastructure. An EHR is an individual's official, digital health record and is shared among multiple facilities and agencies. The other essential elements of the HIT infrastructure are the electronic medical record (EMR), which is an individual's health record within a healthcare provider's facility; the personal health record (PHR), which is an individual's self-maintained health record; and a Regional Health Information Organization (RHIO), which oversees communications among the other elements and unifies them geographically.[3]

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[1] http://www2.kumc.edu/healthinformatics/

[2] http://en.wikipedia.org/wiki/Health_informatics

[3] http://searchhealthit.techtarget.com/definition/health-informatics

Business Case for a Clinical Trial Alert System

by Dennis Jah

Introduction/Background

KANDEH GLOBAL (a fictitious contract research organization) is a proven and committed partner to drug developers and medical device manufacturers looking to bring innovative new products to market.  Its patient recruitment service  focuses on an array of activities leading to filing clinical trials. Despite these recruitment tactics and activities, the problem of patient recruitment continues to grow at an alarming rate due to the limitations and inefficiencies inherent in traditional patient recruitment methods. Doctors, who patients trust to refer them to clinical trials, often cite limited time, lack of support staff, lack of awareness of trials, and complex enrollment procedures as reasons for not recruiting patients for trials.  Normally, it often takes longer than planned to complete a trial due to difficulty recruiting enough patients in a timely fashion.

Recent studies by Gartner demonstrated that improvements in automating clinical trials processes can improve efficiency by 30-50 percent and result in cost savings of $5.8 to $6.6 billion.[1] A software solution integrated with the provider’s health information system to alert doctors to the existence of a clinical trial that some of their patients might be eligible for overcomes those limitations to speed and improve the recruitment thereby increasing business.

Business Objective

KANDEH GLOBAL strives to be the premier provider to the bio/pharmaceutical and medical device industries for development and commercialization of new medical therapies worldwide and a commitment to advance the worldwide success of the bio/pharmaceutical and medical device industries in preventing and curing diseases. The project supports these goals by leveraging technology to improve patient recruitment which has been a critical bottleneck in clinical research and drug development. The recommended solution overcomes the known obstacles of patient recruitment by automating the identification of potential eligible patients. The project will improve profitability by reducing internal costs spent on patient recruitment and losses resulting from the closure of sites that are unable to enroll the required number of patients for a trial or violate trials protocols.

Use of a clinical alert system integrating with provider’s EHR systems is expected to reduce study start up times by 70-90 percent and reduce overall cycle time for a project by 60 percent. This amounts to an estimated cost savings of about $6.7 million per study and about 6 months of recruitment time per study.

Current Situation and Problem/Opportunity Statement

In a paper written by an industry consultant, it is claimed that “only 15% of clinical trials are completed on time, with over 50% of delays attributed to patient recruitment. The authors also suggest that the “estimated cost of patient recruitment is $1.89 billion. These costs are subject to further increases with each day’s delay in bringing the product to market.”[2] KANDEH GLOBAL provides a complete range of patient outreach and site-support services such as information, training, and other forms of assistance designed to minimize delays but they don’t go far enough. Its media consultants work directly with clinical site to analyze the local advertising market, the patient demographic, and available media and then develop a solid and systematic media plan and also help sites buy the media at more competitive rates.

Unfortunately, the identification and recruitment of subjects on a busy clinical practice can be difficult. In order to successfully recruit patients, physicians engaging in traditional recruitment have to remember which local clinical trials is active, recall the trial details in order to determine the patient eligibility, take time to explain trial details to potentially eligible patients and often take more time to perform other recruitment activities. Doing all this while also attempting to provide the individual patient with good care during a short clinic visit can be difficult. KANDEH GLOBAL has an opportunity to breaking down barriers for provider’s participation in clinical trials and maximize profit by automating these time-consuming and error-prone manual tasks.

Critical Assumption and Constraints

The proposed clinical alert system must be an invaluable tool in KANDEH GLOBAL’s patient recruitment endeavor. The product must be able to pay for itself within one year by shortening the time it takes to recruit the required number of subjects for a study, reducing the rate of screen failures and protocol violations that often result into site closure and overall speed up the time it takes for a clinical trial. The project management director must lead the effort and the team must include participants from several parts of the company including patient recruitment and Software Development. Also there must be participants from our clients, physicians and site monitors. The new system must integrate with the existing information system especially electronic medical record of provider organizations that will also serve as clinical sites. The technology must be easy to use by physicians and be able to interface with other systems to be able to send secure messages to site coordinators.

Analysis of Options and Recommendation

Three options were examines for addressing this opportunity:

1.      Continue the present manual process - Consistent with KANDEH GLOBAL’s commitment to innovation, consistently questioning the status quo and seeking opportunities for continuous improvement, doing nothing to improve the existing patient recruitment system is not an option to consider.

2.      Purchase vendor driven electronic medical record - A vendor driven EMR with clinical alert system is not cost effective and may not fit our specifications without significant customization leading to higher cost. It will take longer time and cost maybe five times more to implement a complete EMR solution for providers

3.      Develop a product in house using our software development department - Many healthcare organizations are now investing in EMR and therefore it would be prudent to develop a software solution using internal resources that can interface and interoperate with providers’ existing health information system. Based on discussions with stake holders, this is our recommended alternative.

Preliminary Requirements

The Clinical alert system must be able to interoperate with the provider’s computerized health information system. The system must be able to trigger an alert to pop up whenever care provider accesses or enters the records of patients with characteristics that match criteria related to a specific clinical trial underway.

 Care provider must be able to ignore the alert or respond to it in one of three ways: refer the patient to the trial (with the patient’s permission), indicate that the patient wasn’t eligible, or indicate that the patient wasn’t interested in taking part in the trial.

When the doctor referred a patient, the system must be able to send a secure message to the person in charge of recruitment for the trial. The message must include confirmation that the patient had given his or her permission for the trial coordinator to view the patient’s electronic chart, and also provide a link to the chart. 

Budget Estimate and Financial Analysis

There is not enough information available at the present to come up with an estimated budget. Initial analysis reveals that most of the cost will go into planning, research and development and personnel hours for project management team and development. Effort is ongoing to meet with various stakeholders and develop a detailed financial analysis and budget estimate.

Schedule Estimate

A proof of concept must be developed within six months and development work begins after one year of preliminary analysis and ready for unit testing within a year. There is an assumption that the new system will have a useful life of at least five years.

Potential Risks

First and foremost, there must be providers who will agree for our software to interoperate with their electronic medical record for the solution to work. Additionally, there must be cooperation from EMR vendors to be able to tweak their product if need be so as to integrate with our solution. Also there must be interest on the part of care providers to participate and respond to alerts positively. There is some risk involved in the type of system developed that will first be able to integrate, interface and interoperate with the existing health information systems of providers. There is risk of security and privacy with patient data making some providers organization unwilling to accept an outsider querying their data. The main business risk is investing all the time and money in developing a product without realizing its benefits.

© 2010

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[1] Downing-UMPClincalResearch.pdf  

[2] http://www.law.ualberta.ca/centres/hli/userfiles/07_Caulfield.pdf

Overturning the new Healthcare Law - Implications and Impact on Health IT

The individual mandate is a central part of the Affordable Care Act also known as the new healthcare law. The individual mandate requires every working working adult to acquire health insurance or pay a penalty. Such mandate is essential for insurance companies whom under the law are barred from not providing coverage to individual with pre-existing conditions. Below are CSPAN videos of the new healthcare law before the Supreme Court. With the Health IT running on the wheels of the Affordable care Act (eg. Accountable Care Organization) what would happen to Health It if the entire healthcare law were overturned.  Please share your thoughts.
Healthcare Law Individual Mandate
Healthcare Law and the Anti-injunction Act
Inside the Supreme Court
Review of the Healthcare Law Oral Arguments

Healthcare Reform Law Tutorial

What I also try to do on this blog is to provide resources for those who may not be able to find all the materials they seek. below is an over view of the new healthcare law presented by Jennifer Tolbert, Associate Director of the Kaiser Commission on Medicaid and the Uninsured:

Healthcare Reform Law Explained