Archive for the Uncategorized Category

Barriers: Providers and Patients

Posted in Uncategorized on February 22, 2013 by Matthew Levy

There are many reasons why the healthcare system might never reach the potentials being presented by ONC experts and proponents of advancing the doctor-patient relationship to a new level. There are barriers, both large and small, that exist throughout the field, amongst all relationships. Provider-patient is the oldest relationship in healthcare. As long as there have been doctors, they have had patients to treat. This history brings with it an entrenched relationship and some rigidly defined roles. This might include providers who are simply not interested in doing more than is required in the exam room to address their patients’ questions and concerns.

If this was the only limitation, we could work on breaking the barrier by providing hospitals proper levels of training and support to encourage a more open patient provider relationship. The difficulties, however, go deeper than this. Some of the greatest issues, even during an on-site appointment, are communication barriers. Studies have shown that Americans have a lower than average level of literacy when it comes to healthcare. This means they cannot fully interpret information given to them to make proper health care decisions. The only health literacy study done on a national level has shown that 12% of patients are proficient in completing the tasks we consider essential to understanding and acting on healthcare knowledge given to them.

In addition, on the other side, providers frequently do not realize their patient cannot understand. Often they ask the patient a “any questions?” instead of trying to truly ascertain comprehension. People of all classes are reluctant to do anything that they think might expose them as being less intelligent, and what does this more than admitting you do not understand what someone is saying to you? Now imagine the difference between the previous scenario happening in the doctor’s office, where a well-trained provider might be able to see or ask if the patient understands what has just been said, and a remote exchange, or an occurrence like the patient reading highly technical results. This is exactly the type of barrier that might make a patient prefer to avoid an online encounter.

In response to this problem, the Institute of Medicine has suggested that organizations become “health-literate organizations” that is organizations that attempt to present information at all times in a way to help patients with low health literacy understand and use information about their health. This means, for one thing, applying a “universal precautions” approach to health literacy: assuming that low health literacy may exist in all health systems or provider- patient interactions.

The issue as it currently exists is similar to what we see quite frequently throughout Health IT. It is difficult to break out of the everyday routine that has become very easy for healthcare workers. Embracing a new system is difficult, even with the knowledge that it will improve care and make for a better business.  It will require proper support and training for doctors, administrators and patients to break through the inertia.

Further Reading:

Health Affairs: “A Health Literate Care Model”

Institute of Medicine: “Ten Attributes  of Health Literate Health Care Organizations”


Barriers to Patient Engagement

Posted in Uncategorized on February 21, 2013 by Matthew Levy

The EHR effort, and patient engagement initiatives in particular, are meant to transform healthcare in a meaningful way. But the concept is not new. While there are different degrees of patient interaction, for example, several hospitals have made efforts to offer patients electronic access to their own records as well as personal electronic communication with their provider. And people have observed that patients with greater involvement in their own healthcare are, on the whole, healthier.  However, as we have pointed out, despite these efforts at larger organizations to create a patient engagement system, the goals set out under Meaningful Use require very little achievement. A larger effort must be made throughout the healthcare system in order to push further patient engagement.

This raises an important question. If so many elements of the healthcare process are interested in pushing patient engagement, what are the barriers to moving forward? To begin to find an answer to this question, we can explore the interconnecting elements that make up the healthcare system. They can be loosely categorized into three: Providers, Patients, and Administrators. Administrators does not just include people running a hospital, but also the people responsible for creating and selecting Electronic Health Records, as well as government elements and those that control the purse strings.

Former surgeon general C. Everett Koop once observed, “Drugs don’t work in patients who don’t take them.” This can apply here as well. If we cannot get patients engaged, we cannot fully reap the benefits of the EHR. Each participant within the healthcare field, as well as relationships and interactions between them, can potentially have its own barriers to moving forward. In the next few posts, we will address some of these barriers.

How Government is Driving Patient Engagement

Posted in Uncategorized on February 19, 2013 by Matthew Levy

As discussed both here and elsewhere, as Meaningful Use goes forward, increasing levels of patient engagement are required.  The latest issue of the journal Health Affairs is dedicated entirely to the idea of promoting patient engagement throughout healthcare. Unsurprisingly, the recent efforts to promote greater use of technology and Electronic Health Records come into play. One article is written by members of the Office of Consumer eHealth, part of the Office of the National Coordinator for Health Information Technology (ONC). They discuss their understanding of why this engagement is important and where we are now.

They then turn to the current federal strategy for increasing consumer engagement with e-health. A major focus is the “Three A’s” strategy developed by the ONC to fulfill its goal to empower people to improve their health and health care through health information technology. The three parts of the strategy are to increase patients’ Access to their health information; to enable consumers to take Action with that information; and to shift Attitudes so that patients and providers think and act as partners in managing health and health care using health information technology.

The implementation of each of these is just starting, but several things are clear: Access alone, even if it were universal which it will never be, is insufficient and that success in this area requires a partnership between patients/providers/government/EHR providers and others in a way that is unique in health care. A “cultural shift” is required on the part of patients and providers. For example, they say  “patients need to feel comfortable requesting electronic access to their health records, asking providers questions, sharing their own health knowledge, and weighing in on treatment options. “ Successful implementation in this area requires acknowledging barriers that may exist at many levels and trying to study and reduce them. This work is just beginning. Going forward, we must address these barriers to a world of greater patient engagement in healthcare.

The EHR Shortage

Posted in Uncategorized on January 28, 2013 by Matthew Levy

Although EHR usage increased in 2012 from 22 percent of providers to 35%, that still leaves 65% of practicing physicians who are not yet using computerized records. The vast majority of these are in small, doctor owned practices. Large healthcare organizations, including hospitals and university medical systems that own medical outpatient practices often find it in their best interests to purchase a new system and influence or require their practices to implement an EHR. This decision is likely made as much for the Meaningful Use incentives as it is for the potential improvements in healthcare. Providers can earn up to $44,000 from Medicare incentives for continually hitting meaningful use targets over several years, and for larger groups, this can add up. In a small practice, one featuring at most a few providers, the practice itself needs to shoulder the costs to purchase and implement an EHR. These, combined with the potential for lost productivity as all the staff becomes acclimated to new roles, do not necessarily outweigh the incentives provided for Meaningful Use incentives. This might provide one reason why smaller practices are less likely to embrace EHR opportunities for their offices.

Of course, a practice willing to embrace the changes that come with an EHR, rather than trying to keep things the same will hopefully realize that the benefits are not limited to meaningful use incentive payments. There are more reasons why health policy experts have encouraged EHR usage. Some of these things include an increased focus on quality, reduced administrative costs and ideally, a patient centered system that improves the doctor-patient relationship and encourages patients to stay active with the practice. Several other industries, including banking and travel, allow their customers to access to their accounts at all times and encourage integration. There are some healthcare systems that have embraced this as well, though perhaps not enough.  This is a major centerpiece of EHR benefits. While efforts to increase quality and reduce costs could be handled with great difficulty without electronics, real patient engagement cannot. Patients are limited to calling their doctors or waiting anxiously for a call with results. With electronic records, they can access lab and test results, send quick messages, and view appointment schedules quickly and at any time that is acceptable to them. This instant access to their data is what should be encouraged.

So how can we move forward in increasing the prevalence of EHR usage? There are four major players in this game. The government has done its part, both in the creation of Meaningful Use incentives and efforts as part of the Affordable Care Act to promote HIT. This leaves three groups, HIT professionals, the healthcare delivery system, and the patients. The first two groups need to work together to develop a system that encourages providers to take advantage of the benefits of IT while making it easy to make the switch over without alienating the patient through increased costs or time. And the patients need to buy in, as a patient centric system with no actual patient engagement serves no one. At the same time, healthcare professionals also need to be willing to embrace this system, to actually be willing to attempt the changes necessary so that the benefits may be seen, even if it does take some time.

Further Reading:

Health Affairs: “HIT’s Unfulfilled Promise”

Information Week: “EHRs, Practice Consolidation Can Alleviate Doc Shortage”

EHR: Working Towards Improvement

Posted in Uncategorized on January 22, 2013 by Matthew Levy

The year 2012 was the largest so far in terms of EHR use and implementation. At the end of December, the Centers for Medicare and Medicaid Services paid out an estimated 1.2 billion dollars to hospitals and providers for EHR related incentive payments. And more groups are getting into the game. At the beginning of 2013, on the first eligible day to file, an additional 2,000 eligible professionals filed claims. It is clear that EHR usage is growing and will continue to do so as we move forward through the various stages of HITECH.

However, just adopting an EHR is not sufficient. The idea behind promoting EHR is to take advantage of several areas in which healthcare can be improved. These areas include reducing repetitive tests, improved quality through decreased adverse drug effects, improved preventive care, and greater patient compliance. But is all of this money being paid out to hospitals actually serving to improve healthcare? Or are providers and hospitals doing the bare minimum to qualify for payments and making little to no effort to ascertain whether it does anything? Early on, there were more indications that the money wasn’t doing as it was intended. A NY Times article in September indicated that providers were taking advantage of the ease of ordering and not checking for repeats. Although this data was drawn from before Meaningful Use guidelines were finalized, there are, as there should be, some concerns over whether this program is effectively designed, implemented and executed.

In the area of improved quality, the idea is that items such as drug interaction checking, a comprehensive list of medications and allergies will help avoid some of the major quality lapses that lead to higher costs and unnecessary medical treatment. Studies exploring a link have been sparse. A recent study, however, has found a link between quality and EHR usage. In 2013, Health Affairs published the results of an investigation involving primary care practices in New York City. The Primary Care Information Project provided subsidized EHRs for practices in underserved NYC neighborhoods. It found that mere participation in the project was not enough to show quality improvement, but practices with extensive technical support, and perhaps more importantly, time to learn, were able to achieve their goals.

What we see is that EHR use is still a work in progress. Systems on their own are not capable of bringing about the improvements required to improve healthcare. What is needed are providers who are dedicated to changing the way they practice and enough support to help them focus on these changes in order to ensure that they happen.

Further Reading:

Modern Healthcare: Whopping $1.2 billion in EHR payments in December:

Small Physician Practices In New York Needed Sustained Help To Realize Gains In Quality From Use Of Electronic Health Records:

The EHR Employment Drive

Posted in Learning Center, Uncategorized on January 16, 2013 by Matthew Levy

When it was passed in 2009, the HITECH act was part of the American Reinvestment and Recovery Act, which had a stated goal of using government investments in order to help fight the recession that had begun in 2008. While many people have many different ideas for why EHR adoption is necessary, its presence within the ARRA indicates the focus is to create new jobs. As the elements of the act take effect and more healthcare organizations are preparing to implement EHR’s and attest for meaningful use, they need people with the knowledge and skills to assist in these endeavors.

According to a survey by Wanted Technologies earlier this year, the EHR skillset is the most demanded among healthcare jobs, with over 15,000 positions listed online in the month of August asking for these abilities. Further, the number of advertised jobs requiring EHR skills has risen close to 90 percent over the past two years as hospitals prepare for the transitions. All the major roles in a hospital require some degree of electronic knowledge in order to succeed within the new look healthcare models. In addition to the jobs created for existing healthcare professionals, Health IT and EHR jobs are becoming more popular among college graduates.

However, it is not as simple as just hiring people for the jobs. Each organization has its own version of an EHR and its own workflow. Training therefore becomes key. An IBM study has found that an IT organization choosing to train new employees can cost one-fifth as much as hiring so called “skilled” workers. The trained individuals needed less IT support, performed tasks more efficiently and required less help from peers. Well-trained employees can be up to five times as efficient and therefore good training can save the employer money in the long run. As EHR implementation goes forward, training of employees will be key for efficient use of the systems.

Further reading:

What’s Meaningful About Meaningful Use?

Posted in Uncategorized on November 15, 2012 by Matthew Levy

As of 2011, about 57% of providers in the United States were using some sort of EHR/EMR system in their office-based practice, but only 33% were using a system meeting basic requirements and even fewer had a fully functional system with advantages needed to fully aid healthcare.  The HITECH act set out payment scenarios allowing for (Medicare/Medicaid) payments to healthcare providers who demonstrate that they are “Meaningful EHR Users.” But what constitutes meaningful usage of an EHR? And perhaps more importantly, how does it allow a healthcare provider to offer better, more cost-effective healthcare?

Many of the requirements in stage 1 are simple; asking the providers to ensure data collection is complete and accurate. But stage 2 also raises the bar on the percentage of successfully reaching stage 1 goals. This includes confirming that allergies and active medications are accurate and up to date, doubling the number of electronic prescriptions (to 60%) as well as requiring some (30%) electronic ordering of lab and radiology tests. If these things are done, the EHR can ensure that new medications do not conflict with existing medications. A good EHR system will contain reminders and checks to make sure that not only are the proper procedures being followed, but also that nothing is being left out on each visit and that new orders, problems, and prescriptions are not repeated elsewhere in the record.

From the providers’ point of view, using an EHR to keep track of medications and allergies should ultimately provide a more accurate and easier way of keeping up to date with this clinically important information. But it also is important from the payers’ point of view because adverse drug effects (ADE’s) are considered both a significant, and costly, cause of hospitalizations and re-hospitalizations as well as, according to the Institute of Medicine, (IOM) a leading cause of morbidity and mortality. According to a recent IOM report, ADE’s harm 1.5 million people each year and can add up to $3.5 billion in costs each year. Some of these errors are due to bad handwriting, ignorance of drug interactions or lack of a full list of what the patient is taking. This is why electronic prescriptions and medication tracking are such an important part of MU and why the government is interested in paying for adherence to this requirement.

Therefore it becomes clear that using an EHR meaningfully means doing such things as ensuring that the record is kept completely up to date upon every visit, making sure there are no changes, and that the patient is not in danger of medical problems that can be avoided by keeping every record accurate and up to date. It may seem unnecessary to some, but in reality, it represents a momentary task that goes a long way towards ensuring proper and consistent payments for healthcare provided.

Further Reading:

IOM Report: “Health IT and Patient Safety”

Health Affairs: “A Survey Of Primary Care Doctors In Ten Countries Shows Progress In Use Of Health Information Technology, Less In Other Areas”