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Some patients fear Trump administration may use EHRs to discriminate against them


With the relentless hacking and infamous cybersecurity breaches becoming increasingly worrisome, patients are quite right to be leery of  having their personal information go into electronic health records. And now, with the Trump administration about to take over in Washington, there’s even more fear.

Writes Marla Durben Hirsch in Fiercehealthcare,  “{T}here is a deeper, darker reason patients might withhold information: the apparent imminent change of our society and its laws post-election.

“President-elect Donald Trump campaigned on a promise he would crack down on immigrants and Muslims. The turn of the nation to the right will likely also affect the LGBTQ community.

“Now it’s not just the fear that an EHR breach will reveal a patient’s medical information and cause financial harm or medical identity theft. Now a breach could affect a patent’s personal safety if information is used against them.

“For instance, section 1557 of the Affordable Care Act prohibits providers from discriminating against patients on the basis of sex, including sexual identity. The rule implementing this provision was just finalized. Providers are being encouraged to add to their EHRs preferred names of transgendered patients if they differ from the gender on their drivers’ licenses and include other identifying information into the systems.

“But if the Affordable Care Act is repealed and LGBTQ people lose these protections, they may face discrimination or harassment. So what happens if patients don’t tell providers that they are LGBTQ? Physicians could miss conditions that affect their patients at a higher rate, such as depression and substance abuse. A physician might miss important cancer screening tests if transgender patients don’t feel safe sharing personal information.”

To read more, please hit this link.

Novant Health chief says physicians at center of its decision-making



Novant Health Brunswick Medical Center, in Bolivia, N.C.

Modern Healthcare reports that Carl Armato, president and CEO of 14-hospital Novant Health, in North Carolina, has worked with its employed and affiliated physicians “to put them at the center of decision-making, a model he says has facilitated a systemwide embrace of electronic health records.”

Mr. Armato recently spoke with the publication about that physician-administrative partnership, Novant’s effort to improve its hospital operations and North Carolina’s efforts to provide price transparency for healthcare consumers.

He said that a big differentiator of Novant from many other health systems is its physician-administrative partnership.

” Let’s start with the Novant Health Medical Group, which has a vast ambulatory-care footprint. Probably 10,000 providers, all using the same technology platform. In the medical group alone, we have 1,300 physicians and 700 advanced practitioners. And 60% of that base is primary care. You hear a lot of systems talk about patients being at the center of care. But we place key physician leaders in partnership with administrators at the market level and submarket level. We have physician leaders in every business decision, financial statement reviews, decision about how and where to deploy capital, decisions about how and where to deploy ambulatory clinics. So there’s a culture of physician engagement and transparency.”

To read the whole article, please hit this link.


Lessons for healthcare system from treatment of the homeless


An article in STAT notes that “to make health care more accessible and higher quality, insurers and providers are experimenting with a number of new approaches — from storing patient information in the cloud to opening clinics inside of grocery stores.

“Close cousins to many of these tactics, however, were implemented even earlier in the homeless health care system. Homeless patients’ unique characteristics — they frequently have multiple chronic conditions, they move around often — overlap with some of the pressures driving medicine’s evolving care model today. And the cost and time constraints of the homeless revealed the weakness of the healthcare system before others saw it.”

Here are four elements in the treatment of homeless people applicable to other parts of healthcare:

  • The use of electronic health records.
  • Mixed providers in one setting.
  • Transitional care.
  • Bringing care to the patients.

To read the story, please hit this link.


For these patients, look beyond big data

Big data has its limits in predicting how patients with chronic conditions will need and use healthcare, says this HealthAffairs blog post. The authors say more focus should be put on understanding patient-reported information.

They conclude:

“By asking patients about their ability to manage chronic disease, we stand a better chance of identifying which patients are most in need of additional services. Patient-reported outcome measure instruments have been costly to administer, but this will be less of an issue as we transition to electronic health records and more routinely capture patient-reported measures in daily practice. Going forward, we need to determine how patient-reported data can best contribute to prediction tools and to design and validate instruments that can reliably connect patient data to actionable outcomes.

“Provider intuition and patient self-knowledge are valuable additions to the data bytes collected from medical claims and clinical information systems. Today, capturing and applying this information is largely an art. Going forward, analytics will need to adapt so that this valuable but nuanced information can more readily and effectively blend with clinical and financial data, allowing provider organizations to better care for the highest risk patients.”

The EHR holdouts

This piece in  discusses why some physicians don’t use electronic health records. One example is Michael Ciampi, M.D., a family practitioner in Portland, Maine, who says he doesn’t have anything against technology but says that  when he tried EHRs several years ago:

“{W}e found was a system that just wasn’t patient-centered.The primary function was to enhance billing, not to build a physician-patient relationship. Our productivity went down 25 percent.”

So he went back to paper, joining the  fifth of doctors don’t have an electronic health record system, commonly called an EHR, in their offices. But then,  only 34 percent of doctors surveyed by the American Medical Association said  that they liked their electronic systems.

A new challenge is that the federal financial incentive program to encourage clinicians to adopt EHRs will be phased out by the end of  this year.

And, as the Governing piece notes, “For a five-physician clinic, the initial cost to implement an EHR is around $162,000. Additional maintenance expenses in the first year can be around $85,000.”

Further, “rural physicians often have trouble getting IT support and access to high-speed broadband, which is necessary to run an EHR properly.”

Readers might enjoy the Rube Goldberg movie short Something for Nothing about the ambiguous charms of technology. Sometimes it’s technology for the sake of technology.


Alliance to push to make EHRs easier to use

The Obama administration has announced that  tech companies, hospital systems and physician groups have agreed to act to make electronic health records (EHRs) easier for consumers to  use.

EHRs systems often don’t talk to each other, limiting their usefulness to patients, especially those with complex health problems.

“Now is the time for this data to be free and liquid and available,” said Karen DeSalvo, head of the  Department of Health and Human Services  office overseeing the transition to computerized medical records from paper ones.

The Minneapolis Star Tribune noted that “Taxpayers have ponied up about $27 billion in subsidies to encourage the adoption of electronic medical records by hospitals and doctors’ offices. But the results so far have fallen short of the data-driven transformation that proponents envisioned. With new personal health applications for mobile devices hitting the market, there’s a renewed push to clear obstacles rooted in different technologies and clashing competitive priorities among vendors and healthcare providers.”

Those in the agreement said they’d work to:

  • Improve consumer access. “Theoretically, patients would be able to easily access their records from one provider and transfer them to another. That second provider would be able to seamlessly import the earlier records into its system,” the Star Tribune reported.
  • Stop blocking health-information sharing. “A report last year  found that some healthcare organizations were blocking the sharing of information outside their group.”  But “some experts say that’s already changing with greater use of something called ‘direct exchange,’ a secure messaging pathway between registered medical providers,” the paper reported.
  • Put standards for secure, efficient digital communications into effect.


The challenge of matching EHRs with the right patients

Providers are still trying to find  cost-effective ways to precisely match electronic health records with the right patient.

Many EHR systems can’t accurately match EHRs without costly and time-consuming human intervention to resolve confusion over patients with similar names.  Thus, this Modern Healthcare article notes, “The result is a failure to maximize the clinical care and patient-safety benefits of EHRs. It also limits future research opportunities, experts say.”

“According to surveys and published reports, the error rates for automatic patient matching range from 1% to over 50%, depending on whether a requesting provider is querying patient records within an organization, from another provider or from a health information exchange.”

Surging use of medical scribes but standards lag


By LISA GILLESPIE, for Kaiser Health News.

A national campaign for electronic health records is driving business for at least 20 companies with thousands of workers ready to help stressed doctors log the details of their patients’ care — for a price. Nearly 1 in 5 physicians now employ medical scribes, many provided by a vendor, who join doctors and patients in examination rooms. They enter relevant information about patients’ ailments and doctors’ advice into a computer, the preferred successor to jotting notes on a clipboard as doctors universally once did.

The U.S. has 15,000 scribes today and their numbers will reach 100,000 by 2020, estimates ScribeAmerica, the largest competitor in the business. After buying three rivals this year, it employs 10,000 scribes working in 1,200 locations.

Regulation and training are not rigorous. Scribes are not licensed. About a third of them are certified and that’s voluntary, according to the sole professional body for scribes. The American College of Scribe Specialists was created by ScribeAmerica’s founders in 2010..

“This is literally an exploding industry, filling a perceived gap, but there is no regulation or oversight at all,” said George Gellert, regional chief medical informatics officer at Christus Santa Rosa Health System in San Antonio, which uses scribes.

Others suggest that scribes can be a benefit to doctors and patients by shouldering the minutia of recording many of the details on a computer. “They’re capturing the story of a patient’s encounter — and afterward, doctors make sure everything is accurate. That way, the doctor can focus on interacting with the patient and give them good bedside manner,” said Angela Rose, a director at the American Health Information Management Association, a professional group that has published a set of best practices for scribes.

The minimum qualification to be a scribe is generally a high school diploma, but some pre-med students take the jobs to gain experience from shadowing doctors. One company, SuperScribe says it prefers candidates with at least two years of college and it only hires pre-med, nursing or EMT students. ScribeAmerica provides two weeks of training to new scribes while a large rival, PhysAssist, gives one week. That’s followed by close supervision in care settings for one week at ScribeAmerica and 72 hours at PhysAssist.

Vendors stress the potential benefits for doctors when they spend less time on record keeping. “Don’t let paperwork stand between you and your patients,” PhysAssist tells physicians on its Web site. “Imagine a doctor not being able to make correct diagnoses because documentation distractions caused her to miss a symptom.”

Another selling point involves money. ScribeAmerica says physicians using scribes can gain enough time to see five to eight more patients a day, boosting a primary care practice’s annual revenue by $105,000.

Not everyone is sold. Patrick Tempera, M.D., a gastroenterologist in Union City, N.J., said he uses scribes but does not allow them to come into the exam room with him because patients discuss sensitive health matters with him.

“Patients might not tell the doctor in full disclosure certain personal things if there’s someone else in the room,” he said.

Federal law limits some of the work that scribes can do. The Health Information Technology for Economic and Clinical Health (HITECH) Act, which was part of the 2009 stimulus package and sent $32 billion to doctors, hospitals and other providers to spur them to move to electronic health records (EHRs), mandated that unlicensed workers, which includes scribes, not enter orders such as those for prescriptions and X-rays. However, sometimes scribes are allowed to enter pending orders, subject to a doctor’s review and approval.

A key hospital accreditation group also stresses those limitations. The Joint Commission, which accredits hospitals, said in 2012 guidelines that scribes can enter information such as family history, symptoms and doctors’ tentative diagnoses into EHRs. But it said scribes should not put in orders for prescriptions, X-rays or tests.

One concern is that scribes don’t have the background to make sure they put the right information in the orders.

Doctors are also responsible for reviewing scribes’ entries, making corrections if needed and signing off before leaving the patient care area, according to the guidelines.

But there is no enforcement mechanism to ensure adherence.

Some health care experts have raised concerns that sometimes scribes could be pressured to make the entries to save doctors time.

“We’re concerned that there will be a situation where inevitably these scribes are used to enter an order,” Gellert said.

Lap-Heng Keung, a scribe at MetroSouth Hospital in Blue Island, Ill., said he’s never been asked to enter orders and wouldn’t be comfortable doing so.

“We don’t have the same expertise as providers…there are so many drugs that sound the same but have one letter difference. It’s not within our scope of skill,” said Keung, who is studying information technology and taking pre-med courses at the Illinois Institute of Technology.

Even so, some scribes may face pressure to go beyond their training.

“Put yourself in the position of a 21-year-old pre-med student, here’s a doctor in the ER, you want a letter of recommendation so you can go to medical school — it’s a lot of pressure,” said Cameron Cushman, a vice president at PhysAssist. He said company officials work with scribes to help them know how to handle that situation. “We [say] …’you’re going to be starstruck by these doctors, but you have to play your role and if you don’t, there will be consequences.’”

Cushman says the company has been fired by clients 10 to 20 times — mostly by smaller emergency room providers and outpatient clinics — because it refuses to let scribes enter orders into electronic health records.

Surgeon Richard Armstrong of Newberry, Mich., said doctors are still coming to grips with the demands of electronic health records. Armstrong uses a transcriptionist to type his notes, but he enters all EHR information himself. A doctor for 34 years, Armstrong said he doesn’t use scribes because he’d have to check their work, and he’s more confident in his ability to do the job accurately.

“We’re forcing a technology into primetime onto physicians who don’t know how to handle it. And they’re using scribes because they need assistance,” Armstrong said.


Study: High clinician computer use lowers poor patients’ satisfaction


This  study published in JAMA Internal Medicine reports that “high computer use by clinicians in safety-net clinics {mostly serving the poor}  was associated with lower patient satisfaction and observable communication differences.”

The researchers found:

“Safety-net clinics serve populations with limited proficiency in English and limited health literacy who experience communication barriers that contribute to disparities in care and health. Implementation of electronic health records in safety-net clinics may affect communication between patients and health care professionals. We studied associations between clinician computer use and communication with patients with diverse chronic diseases in safety-net clinics.”

‘The real cues come from the patient,’ not the EHR



Here’s a look at nurse practitioners’ attitudes to electronic health records.

Tim G. Bartol,  N.P., the author, concludes:

“EHRs can track such easily measured tasks as diabetic foot screening, urine microalbumin measurement, or the patient’s smoking status. However, no research has shown that documenting these measures makes a difference in long-term patient outcomes. The EHR does not effectively measure other things that may have important implications for patient care, such as relationship, empathy, support, and caring between clinician and patient. It does not measure the value of the information produced on continuity of care for a patient over time.

“Rather than complaining about the EHR, I believe that we should use our energy and efforts to find ways to work around the challenges by talking with colleagues, sharing ideas, and trying to maintain high-value continuity of care. My perception of the effect of the EHR on clinical practice is that it has brought new challenges to providing high-value, patient-focused healthcare. There are many benefits, including legibility and easier access (for clinicians using the same system).

“But we also face challenges with integration of this technology. We must strive to maintain a personal, caring relationship with our patients and develop useful notes for continuity of patient care. We must resist being more focused on the device than on the person in front of us. What might seem to be quality care—documenting all of the recommended care and checking all of the boxes—can distract us from what the patient actually wants or needs at that particular visit.

“The real cues or reminders for quality care should come not from the EHR but from the patient.”


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