SHM 2009: Hospitalist-Run Geriatrics Service Improves Processes of Care

A hospitalist-run medical service for elderly inpatients improved recognition and treatment of abnormal functional and cognitive status without increasing resource consumption, a new study has found. The results were presented here at Hospital Medicine 2009: Society of Hospital Medicine Annual Meeting, during its Academic Track Session.

"Hospitalization of older persons is accompanied by a disproportionate risk of poor outcomes and adverse events, such as functional decline, delirium, and falls," said presenting author Heidi Wald, MD, MSPH, a geriatrician and hospitalist at the University of Colorado Hospital and assistant professor of medicine at the University of Colorado Denver School of Medicine, both in Aurora. "Hospitalists may be the answer to some of these problems."

The study found improved processes of care with the use of a modified acute care for elders (ACE) service, which Dr. Wald called a hybrid of a general medical service and an inpatient geriatrics unit. Unlike a standard ACE unit, which is exclusively staffed by geriatric specialists, she told Medscape Internal Medicine, their service was staffed by hospitalist attendings with an interest in geriatric medicine. All patients were older than 70 years (mean age, 81 years) and were on a single medical inpatient unit when possible. Each patient received a standardized geriatric assessment.

Dr. Wald and colleagues compared processes and outcomes of care for patients (excluding transferred patients) who were assigned to either the ACE service (n = 122) or usual care (on a general internal medicine floor; n = 95) for a period of nearly 6 months between November 1, 2007, and April 15, 2008. The ACE service began at their hospital July 1, 2007, and used existing staff, although it required restructuring of the residency program. For care processes, the researchers studied recognition of abnormal functional status, cognitive function, and delirium; use of physical restraints; use of sleep aids; and documentation of code status. They studied the following outcomes of care: falls, hospital charges, length of stay, and 30-day readmission rate.

The 2 groups were similar in age, sex, diagnosis at admission, and severity of illness (case mix index), the abstract showed. However, results differed for several processes of care.

"We nearly doubled the recognition of abnormal functional status [of patients] on the ACE service vs usual care," Dr. Wald told the audience.

That difference (65% for ACE vs 32% for usual care) was statistically significant (P < .0001), according to the abstract. Patients in the ACE group also had significantly greater documentation and treatment of abnormal cognitive status (57% vs 36%, respectively; P < .01), including delirium (28% vs 15%, respectively; P < .05).

There were no statistically significant differences between groups for the other care processes studied (physical restraints, sleep aids, and code status) or for any of the outcomes of care, including length of stay. Patients on the ACE service had a slightly higher rate of readmission within 30 days (12% vs 10%; not significant), but the authors have not yet studied why, Dr. Wald said.

A study limitation, according to Dr. Wald, is that some of the measures examined are sensitive to the quality of nursing care rendered in addition to physician care. The ACE service has a dedicated nurse.

"It's clearly impractical to expect that all hospitalists would focus their care to vulnerable elders to this degree," Dr. Wald told Medscape Internal Medicine. "But we are continuing our ACE unit. Nursing staff loved this model, and patient satisfaction was quite high."

However, despite their popularity with patients and staff, ACE units have not been universally accepted, said the session comoderator, Margaret Fang, MD, in an interview with Medscape Internal Medicine. Dr. Fang, assistant professor of medicine at the University of California San Francisco (UCSF) School of Medicine and a hospitalist at the UCSF Medical Center in San Francisco, said the reason for slow acceptance is probably logistical issues, such as the need to consolidate patients onto a single floor staffed by geriatrics-trained care providers.

"But as long as the ACE model of care is cost-neutral [as this study shows], it is an alternative," she said.

Dr. Fang stressed, however, that this study does not show improved care but rather improved processes of care. "I think it will be important for Dr. Wald and her colleagues to prove that this type of unit actually improves care," she said.

She would like to see the effects of this care model on patient satisfaction and, if a larger patient population is studied, mortality, as well as additional process-oriented measures, such as accuracy of medication reconciliation.

Dr. Wald said the authors did not include data on patient satisfaction because they did not study it on the usual-care service.

Any hospital considering starting this model of care, she added, needs to get "buy-in" from multiple specialties and have interdisciplinary rounds, so as not to add extra time for staff meetings.

Source : http://www.medscape.com/viewarticle/702962?src=mpnews&spon=34&uac=133298AG

SHM 2009: Multimodal Initiative Improves Quality of Discharge Documentation Across 5 Hospitals

May 20, 2009 (Chicago, Illinois) — The percentage of hospital-discharge documents that contained all required information rose from 65% to 96% during a 31-month quality-improvement process at an integrated healthcare system, a new study from Partners HealthCare of Boston, Massachusetts, found. The results were presented here at Hospital Medicine 2009: the Society of Hospital Medicine (SHM) Annual Meeting.

The large improvement in discharge communication resulted from a multidisciplinary, multimodal effort at 5 Partners HealthCare–affiliated hospitals, without financial incentive to the physicians, said the principal author, Esteban Gandara, MD, a research fellow in the Division of General Internal Medicine and Primary Care at Brigham and Women's Hospital and at Harvard Medical School in Boston.

This quality-improvement initiative was an attempt to better comply with Joint Commission requirements for what information needs to be included in discharge communications, he said during his presentation. Previous research from his hospital found "important deficits" in medication reconciliation lists and several other critical data elements, Dr. Gandara said.

Ahead of the Field

Their progress during less than 3 years was "impressive," according to a member of the audience who was not involved in the study, David Meltzer, MD, PhD, chair of the SHM Research Committee. Dr. Meltzer, associate professor and chief of the Section of Hospital Medicine at the University of Chicago in Illinois, told Medscape Internal Medicine in an interview that Brigham and Women's Hospital "is probably somewhat ahead of the field in addressing problems in discharge documentation."

The new study reviewed discharge-documentation packets for 3101 patients being discharged to subacute-care facilities from Brigham and Women's and 4 other hospitals in the Partners HealthCare system between March 2005 and September 2008, the authors report in their abstract. Documentation for at least 50 patients from each hospital was selected for review for each of the 11 quarters during the study period (quarterly mean, 281.9). Discharge documents included discharge summaries, discharge orders, and nursing instructions. A trained resident physician or nurse practitioner from the acute-care sites reviewed the discharge documents. The 5 acute-care sites were a mix of academic medical centers and community hospitals.

Data elements that Partners HealthCare requires for all discharges to subacute-care facilities are as follows: treatment rendered, the patient's response to treatment, procedures and tests given, preadmission medications, medications at discharge, allergies, follow-up information, the hospital physician's contact information, and warfarin use. (Data elements for warfarin use included the indication, duration of therapy, target international normalized ratio, and sufficient dosing and monitoring information to safely prescribe warfarin for the subsequent 72 hours, according to the abstract.) A discharge document that included all of these elements was considered "defect free."

Quality-improvement interventions included computer-technology improvements to discharge-ordering systems, such as the ability to auto-import required information into discharge documents, creation of discharge templates, physician education, predischarge review of documentation by nurse coordinators, and ongoing feedback about the quality of discharge documentation to clinicians and their section chiefs. The discharge template differed by hospital, but had to include the required data. Some sites used only some of the interventions, and 1 community hospital did not employ technological improvements, Dr. Gandara told the audience.

The improvement in the defect-free rate from 65% to 96% was statistically significant (P < .001 for trend), according to the abstract. All sites observed higher defect-free rates, with academic medical centers improving slightly more than community hospitals, Dr. Gandara reported. The data component with the largest improvement was preadmission medications, which had a 19% increase, from 81% to 100% (P < .001). Response to treatment and follow-up information did not achieve a 100% defect-free rate by the end of the study because of incomplete data fields or unchecked boxes, he explained in response to a question.

Reasons for Success

Because the community hospital that did not use technological improvements experienced the lowest quality improvement, Dr. Gandara told Medscape Internal Medicine, "information technology was most important to our improvement."

This study shows that this approach to improving the quality of discharge documentation works, said the University of Chicago's Dr. Meltzer. "But as with all quality-improvement activities, you have to ask what the value is and whether it is worth the effort," he told Medscape Internal Medicine.

"My guess is that the 100% defect-free discharge summary will never happen," Dr. Meltzer said, explaining that the extra time to ensure such completeness would likely need to come at the expense of neglecting the care of hospitalized patients.

However, he pointed to components of the reported approach that he believes helped its success, including the use of discharge templates and a set of quality-improvement interventions that the hospitals could customize to their needs, rather than a single required intervention.

"It's crucial not only to improve quality but also to make change as easy as possible . . . and to do it in ways that are important locally," Dr. Meltzer said.

Source : http://www.medscape.com/viewarticle/703082?src=mpnews&spon=34&uac=133298AG

World Health Organization Issues Guidelines on Hand Hygiene in Healthcare

May 6, 2009 — The World Health Organization (WHO) has issued Guidelines on Hand Hygiene in Health Care, offering a thorough review of evidence on hand hygiene in healthcare and specific recommendations to improve hygiene practices and reduce transmission of pathogenic microorganisms to patients and healthcare workers (HCWs).

The guidelines target hospital administrators and public health officials as well as HCWs, and they are designed to be used in any setting in which healthcare is delivered either to a patient or to a specific group, including all settings where healthcare is permanently or occasionally performed, such as home care by birth attendants. Individual adaptation of the recommendations is encouraged, based on local regulations, settings, needs, and resources.

Hand Hygiene Indications

Indications for hand hygiene are as follows:

• Wash hands with soap and water when visibly dirty, when soiled with blood or other body fluids, or after using the toilet.

• Handwashing with soap and water is preferred when exposure to potential spore-forming pathogens, such as Clostridium difficile, is strongly suspected or proven.

• In all other clinical situations, use an alcohol-based handrub as the preferred means for routine hand antisepsis, if hands are not visibly soiled. Wash hands with soap and water if alcohol-based handrub is not available.

• Hand hygiene is needed before and after touching the patient; before touching an invasive device used for patient care, whether gloves are used; after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; if moving from a contaminated body site to another body site on the same patient; after touching inanimate surfaces and objects in the immediate vicinity; and after removing gloves.

• Hand hygiene is needed before handling medication or preparing food using an alcohol-based handrub or handwashing with water and either plain or antimicrobial soap.

• Soap and alcohol-based handrub should not be used together.

Hand Hygiene Techniques

Specific recommendations for hand hygiene technique are as follows:

• Rub a palmful of alcohol-based handrub over all hand surfaces until dry.

• When washing hands, wet hands with water and apply enough soap to cover all surfaces; rinse hands with water and dry thoroughly with a single-use towel. Whenever possible, use clean, running water. Avoid hot water, which may increase the risk for dermatitis.

• Use the towel to turn off the tap or faucet, and do not reuse the towel.

• Liquid, bar, leaf, or powdered soap is acceptable; bars should be small and placed in racks that allow drainage.

Surgical Hand Preparation

Specific recommendations for surgical hand preparation are as follows:

• Before beginning surgical hand preparation, remove jewelry. Artificial nails are prohibited.

• Sinks should be designed to reduce the risk for splashes.

• Visibly soiled hands should be washed with plain soap before surgical hand preparation, and a nail cleaner should be used to remove debris from underneath the fingernails, preferably under running water.

• Brushes are not recommended.

• Before donning sterile gloves, surgical hand antisepsis should be performed with a suitable antimicrobial soap or alcohol-based handrub, preferably one that ensures sustained activity. Alcohol-based handrub should be used when quality of water is not assured.

• When using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the maker, usually 2 to 5 minutes.

• When using an alcohol-based surgical handrub, follow the maker's instructions; apply to dry hands only; do not combine with alcohol-based products sequentially; use enough product to keep hands and forearms wet throughout surgical hand preparation; and allow hands and forearms to dry thoroughly before donning sterile gloves.

Selecting Hand Hygiene Agents

Some specific recommendations for selection and handling of hand hygiene agents are as follows:

• Provide effective hand hygiene products with low potential to cause irritation.

• Ask for HCW input regarding skin tolerance, feel, and fragrance of any products being considered.

• Determine any known interaction between products used for cleaning hands, skin care products, and gloves used in the institution.

• Provide appropriate, accessible, well-functioning, clean dispensers at the point of care, and do not add soap or alcohol-based formulations to a partially empty dispenser.

Skin Care Recommendations

Some specific recommendations for skin care are as follows:

• Educate HCWs about hand-care practices designed to reduce the risk for irritant contact dermatitis and other skin damage.

• Provide alternative hand hygiene products for HCWs with confirmed allergies to standard products.

• Provide HCWs with hand lotions or creams to reduce the risk for irritant contact dermatitis.

• Use of antimicrobial soap is not recommended when alcohol-based handrub is available. Soap and alcohol-based handrub should not be used together.

Recommendations for Glove Use

Some specific recommendations for use of gloves are as follows:

• Glove use does not replace the need for hand hygiene.

• Gloves are recommended in situations in which contact with blood or other potentially infectious materials is likely.

• Remove gloves after caring for a patient, and do not reuse.

• Change or remove gloves if moving from a contaminated body site to either another body site within the same patient or the environment.

"In hand hygiene promotion programmes for HCWs, focus specifically on factors currently found to have a significant influence on behaviour, and not solely on the type of hand hygiene products," the guidelines authors write. "The strategy should be multifaceted and multimodal and include education and senior executive support for implementation. Educate HCWs about the type of patient-care activities that can result in hand contamination and about the advantages and disadvantages of various methods used to clean their hands."

Four of the guidelines authors have disclosed various financial relationships with GOJO, Clorox, and GlaxoSmithKline, and other companies and institutions. A complete description of their disclosures is available in the original article. The other guidelines authors have disclosed no relevant financial relationships.

WHO Guidelines on Hand Hygiene in Health Care. May 2009.

Clinical Context

In 2004, WHO convened a group of international experts in infection control to prepare guidelines for hand hygiene in healthcare. In 2002, the Centers for Disease Control and Prevention Guideline for Hand Hygiene in Health-Care Settings was adopted. Following a systematic review of the literature and task force meetings, the Advanced Draft of the WHO Guidelines on Hand Hygiene in Health Care was published in 2006. An Executive Summary of the Advanced Draft of the Guidelines is available separately (http://www.who.int/gpsc/tools/en/). Pilot testing of the advanced draft occurred, with subsequent updating and finalization of the guidelines.

The WHO Guidelines on Hand Hygiene in Health Care includes a review of scientific data, consensus recommendations, process and outcome measurements, proposals for large scale promotion of hand hygiene, patient participation in promotion of hand hygiene, and a review of national and subnational guidelines. The recommendations are expected to be valid until 2011 and will be updated every 2 to 3 years.

Study Highlights

• Indications for washing hands with soap and water include visibly dirty hands, hands visibly soiled with body fluids, or after using the toilet.
• Handwashing with soap and water is preferred after exposure to potential spore-forming pathogens, including Clostridium difficile outbreaks.
• Alcohol-based handrub is preferred in the following situations if hands are not visibly soiled: before and after touching a patient; before handling an invasive device for patient care; after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; between contact with a contaminated body site to another site on the same patient; after contact with inanimate surfaces and objects; and after removing sterile or nonsterile gloves.
• Handwashing with soap and water is recommended when alcohol-based handrub is unavailable.
• Alcohol-based handrub or soap and water can be used before handling medication or preparing food.
• Concomitant alcohol-based handrub and soap use is not recommended.
• Soap and water hand-washing technique includes using a towel to turn off the faucet, thorough drying of hands, and single towel use.
• Acceptable forms of soap are liquid, bar, leaf, or powdered.
• Bar soap racks should allow drainage to ensure that the soap dries.
• Alcohol-based handrub technique includes applying palmful amount of handrub, covering all surfaces, and rubbing hands until dry.
• Surgical hand hygiene recommendations include removal of jewelry, no brushes, and use of either antimicrobial soap or alcohol-based handrub according to the maker's recommendations.
• Selection of hand hygiene agents should consider input from HCWs, interaction with other products or gloves, risk for contamination, accessibility and proper functioning of dispensers, approval of dispensers for flammable materials, and cost comparisons.
• Soap or alcohol-based handrub should not be added to partially empty soap dispensers.
• Skin care irritation in HCWs can be avoided by providing educational programs, alternative hand hygiene products for those with allergies or adverse reactions to standard products, and hand moisturizers to reduce irritant contact dermatitis.
• Glove use does not replace the need for handrub or handwashing.
• Gloves should be used if contact with potentially infectious body fluids, mucous membranes, or nonintact skin is anticipated.
• Gloves should be removed or changed after each patient or after contact with a contaminated body site.
• Artificial nails or extenders should not be used, and the length of natural nail tips should be less than 0.5 cm.
• Educational and motivational programs for HCWs should focus on behavior; be multimodal; include senior executive support; educate about the advantages and disadvantages of various hand hygiene methods; monitor adherence and provide performance feedback; and encourage partnership between patients, families, and HCWs.
• Healthcare administrators should provide and monitor safe, continuous water supply; provide alcohol-based handrub at the point of patient care; prioritize compliance; provide leadership, administrative support, and financial resources; ensure training; implement a multidisciplinary, multifaceted, and multimodal program to improve adherence; and adhere to national safety guidelines and local legal requirements.
• National governments should prioritize adherence; consider funded, coordinated implementation and monitoring; support strengthening of infection control in healthcare settings; promote community hand hygiene; and encourage use of hand hygiene as a quality indicator in healthcare settings.

Clinical Implications

• The WHO guidelines recommend handwashing with soap and water for visibly dirty hands, hands visibly soiled with body fluids, after toilet use, exposure to potential spore-forming pathogens, and if alcohol-based handrub is not available in other situations.
• The WHO guidelines recommend alcohol-based handrub before and after touching patients; before handling invasive devices; after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; between touching contaminated body site and another body site; after contact with inanimate surfaces and objects; and after removing gloves.

http://cme.medscape.com/viewarticle/702403?src=cmenews

Report: Climate Change Threatens Health

A newly released report identifies climate change as the biggest global health threat of the 21st century.

If nothing is done, global warming could affect the health of billions of people throughout the world, with the poor suffering most, according to the report from the University College London and The Lancet.

Deaths from heat waves, malaria, and other vector-borne diseases (diseases transmitted by sources such as mosquitoes or ticks) are projected to rise as global temperatures increase. But the report identifies food and water shortages and increasingly violent weather events as the biggest climate-change-related threats to human health.

Pediatrician Anthony Costello, MD, who chaired the commission that issued the report, says there is new evidence that climate change is occurring faster than many experts had anticipated.

He tells WebMD that recent findings on greenhouse gas emissions, global temperature changes, sea level rise, ocean acidification, and extreme climatic events suggest that climate forecasts made in 2007 by an international panel evaluating climate change may be optimistic.

"The forecasts made by the world climate scientists a few years ago are starting to look too conservative," he says.

Climate Change and Health

Costello points out that since records began to be kept a century and a half ago, 12 of the warmest years on record have occurred within the last 13 years.

He adds that the health effects of climate change are already being seen and will increasingly be felt as temperatures rise.

According to the report:

• Rising temperatures will affect the spread and transmission rates of vector-borne and rodent-borne diseases like malaria, dengue fever, Lyme disease, hantavirus, tick-borne encephalitis, and a host of other diseases. According to one model, there will be as many as 320 million additional cases of malaria in 2080. And 6 billion people will be at risk for dengue fever, compared to 3.5 billion today.
• As ocean temperatures rise and more intense seasonal weather events occur as a result, cholera outbreaks may increase.
• Climate change is projected to make existing food shortages worse. According to one study, half of the world's population could face severe food shortages by the end of the century due to rising temperatures. And hunger, illness, and death due to malnutrition will worsen in Africa and other underdeveloped regions that are already hardest hit by food shortages.
• Diarrhea and other diseases spread by lack of access to clean water are expected to increase. Average annual rainfall is forecast to decrease in some regions and increase in others, meaning that droughts and floods are likely to become more frequent and intense.
• Hurricanes, heat waves, flash floods, and other natural events are expected to increase in number and intensity as global temperatures rise. And rapid urbanization leading to inadequate housing, particularly in developing nations, will expose more people to the effects of these extreme weather events.

Costello says the health community is only now beginning to understand the widespread implications of global temperature change on human health.

"We definitely need more research into this," he says. "Health professionals have come late to the climate change debate."

He points out that the poorest 1 billion people on the planet use just 3% of its resources, but these are the people whose health will suffer most from climate change.

The report calls for the formation of an international coalition to study the health implications of global climate change.

"We've got about five years to get this sorted out," Costello says. "It is going to be very difficult and there will be huge political pressure not to do it. But if we don't make changes it could be catastrophic."

Source : http://www.medscape.com/viewarticle/702832?src=mp&spon=34&uac=133298AG

Women More Stricken by Health Care Costs

Medical bills and other health insurance issues may prompt more women than men to skip health care visits, a new report shows.

The report comes from the Commonwealth Fund, a private foundation focused on the health care system. Data came from a 2007 Commonwealth Fund survey on health insurance.

The report states that 70% of U.S. women younger than 65 reported at least one of these problems in 2007:

* No health insurance or underinsurance
* Medical bill or debt problems
* Cost-related problem accessing needed care

A smaller percentage, 60%, of men younger than 65 reported those same problems in 2007.

Women were also more likely than men to report not getting preventive health care services -- such as a cancer screening -- because of the cost of those services.

"This analysis finds that even before the economy entered recession, growing numbers of adults were going without adequate health insurance, having medical bill problems, and avoiding or delaying care because of the cost," the report states. "Because women require more health care services than men, and have lower average incomes, they are exposed to a higher health care cost burden."

Although women (and men) with low incomes don't have room for major medical costs, the report also shows that medical bills and medical debt are piling up for people with high incomes -- especially women.

"Even in households earning $60,000 per year or more, significantly more women than men had medical bill problems," the report states.

The report is based on data from 2,616 U.S. adults 19 and older who took part in a 2007 Commonwealth Fund survey on health insurance. That survey has a margin of error of two percentage points.

Source : http://www.medscape.com/viewarticle/702664?src=mp&spon=34&uac=133298AG

Choosing an EMR

Introduction

Someone once told me that selecting an electronic medical record (EMR) is like selecting a wife: Unless you make a really lousy choice, you will be happier than before. However, it is a huge deal to divorce your EMR and wed another, so you had better make the right choice the first time. However, a quick look at the over 400 different EMR software vendors can easily overwhelm anyone interested in selecting a system.

Every EMR software program has its strengths and weaknesses. The perfect EMR does not exist and never will. Even those organizations that have built their own EMR still have long lists of new enhancements and features that they wish had been included in their EMR. In selecting an EMR, it is important to match an EMR's strengths with a clinic's needs. Even more important is to acknowledge an EMR's weaknesses. Then, ask yourself whether your clinic can handle those weaknesses and how your clinic will deal with them.

Most doctors don't have time to go through hundreds of EMR companies. The best thing that these doctors can do is to narrow the list of EMR companies to a small set of successful EMR companies. There are many stories of doctors falling in love with the EMR selection process and making it almost like a second job. However, there are more stories of people being overwhelmed by long lists of EMR companies that, after a while, get very confusing. By focusing on a few EMR companies with successful track records, you can avoid being overwhelmed in the process of selecting an EMR. Remember that you can always add other EMR programs to your list if you do not find a good match on your first try.

Whittling the List

The question then remains of how you should go about narrowing your choice of EMR companies. Working with a well-informed EMR consultant is one good method that can save hundreds of hours of research. Consultants are often already familiar with hundreds of EMR companies and are adept at ruling out EMR companies that will not fit a particular situation. Just be careful to find qualified consultants who have a broad understanding of the industry. It is also a good idea to ask the consultant about any conflicts of interest that might exist. Find out whether there is a reason they might suggest one EMR company over another so that you can account for any possible biases.

The Internet is also a great place to research and narrow your list of EMR companies. A number of Web sites have EMR selection tools that provide a list of qualified EMR vendors according to answers you provide to a questionnaire. However, you have to be careful to ensure that the Web site you use is credible, unbiased, and active. Many EMR selection Web sites and forums look professional at first, but upon further review are full of outdated, incomplete, or biased information that will leave you misinformed. Many may also find participating in an active discussion forum intimidating at first, but they benefit from the wealth of information provided by actual users of EMR software.

Those looking for an EMR also like to turn to various medical organizations, such as the professional academies and boards, to help them identify appropriate EMR companies. Although I don't have extensive experience in this area, the few EMR lists that I have seen from these organizations are incomplete and often do not present the wide variety of choices that exist. Furthermore, products endorsed by the Certification Commission for Healthcare Information Technology (CCHIT) or recommended in other rating systems should really be taken with a grain of salt; most certifications and ratings systems don't measure usability. Such ratings systems also do not allow you to gauge an EMR's probability of working well in your office; for example, most do not identify valuable information, such as the rate of successful vs failed implementations.

Pricing and Cost

One of the most important factors in narrowing your list of EMRs is the associated cost. A common misperception is that EMRs cost tens of thousands of dollars to implement. For clinics with multiple doctors, EMR companies that structure fees this way may be a viable option because partners can divide the large up-front costs. However, small practices can't share the large lump-sum payment the way in which a bigger practice can. This doesn't mean that small practices or solo doctors don't have other options available to them.

Many EMR companies have created innovative pricing plans that make EMR software available to small practices and solo doctors. For example, some EMR companies have no up-front fee, but charge monthly per provider; it is as if the doctor were renting the EMR system. At least 1 software vendor charges on a per-visit basis. Both of these pricing models avoid huge up-front fees and attempt to match the way a practice generates revenue.

One word of caution about many of the "free" EMR software programs in the market today: Be careful assuming that a free EMR doesn't mean you won't need to spend money. Most users of "free" EMR software still require a certain amount of custom work to satisfy their practice's unique needs. Plus, these EMR programs don't have the enterprise level support of other EMR vendors. This usually requires more technical know-how on the part of a doctor wanting to implement a free EMR and may require future expense to be able to support the program in the long term.

Those considering developing their own EMR should realize that this is an enormous task. I know of a number of doctors who have done this and absolutely love it. The problem is that while developing their own EMR, it is like they are working 2 jobs: doctor and programmer. Even after many years, a homegrown EMR still has trouble comparing to the powerful features of current EMR software. Remember that most EMR software includes charting, prescribing, ordering, and diagnosing, along with hundreds of other idiosyncrasies -- not a small project that you can just pay someone to do over a weekend.

More Considerations

After creating a manageable list of potential EMR companies, you will need to find a way to compare the feature sets offered in each tool. A simple method of comparison is to create an Excel file with a list of features down the left side and a list of EMR companies across the top. An Internet search will also find Excel files such as this already built, which can be used as a good starting point. Once you have the file, fill in the details of each software company as you participate in an online or live demo of the EMR software product (Figure).

Source : http://www.medscape.com/viewarticle/571849

Demystifying Computer Networks for Small Practices: Investing in Your Practice

Introduction

Small practices are becoming increasingly reliant on computer applications, such as practice management systems and electronic health record (EHR) systems, making them frequent topics of discussion for family physicians. Amid these technology discussions, however, physicians often fail to consider the computer networks on which these applications run. Planning and maintaining a computer network in a practice requires a number of important considerations. Failing to adequately account for these can result in an improperly functioning network with potentially serious consequences, such as security violations. This article will review the major decisions you must make to ensure that your computer network is an asset and not a liability to your practice.

If you're just getting started, you will likely need to hire a technology consultant to perform the actual network implementation. Make sure the consultant is aware of the special requirements of a medical practice and holds certifications such as Cisco Certified Internet Expert or Juniper Networks Certified Internet Expert. You should also ask for references or seek recommendations from your colleagues who have been through this process and can offer advice from their experiences.

Wired vs. Wireless

Both wired and wireless networks come with their own set of pros and cons. Wired networks are generally easier to implement and maintain. They also tend to be faster, more reliable and able to transmit greater amounts of data than wireless networks. The obvious disadvantage of wired networks is that they require you to pull cable to outlets throughout your office at every site where you wish to place a computer. This may be easy or difficult depending on the layout of your building. (Consult with a computer cabling installer early in your network planning to determine the amount of work involved.)

Wireless networks eliminate the need to pull cable to each computer location and allow you to use mobile computing devices. Many physicians find the mobility of a laptop or tablet PC to be an enormous workflow advantage. You can carry a device wherever needed in the practice and maintain a network connection. Wireless networks also eliminate the need to place a computer in each exam room. This reduces the security risk and damage risk posed by patients left alone in the exam room with a computer.

But wireless networks can create significant challenges:

Access Points

Deployment of a wireless network involves the placement of base stations with antennas, also called access points, which connect to a wired network. Small offices may require only a single access point, but most practices will require access points throughout the office. Effective placement of the access points is a combination of art and science, and it will help you avoid interference.

Interference

If your practice is in a building with, or simply near, other offices with wireless networks, there can be interference. With the rapid deployment of wireless local area networks, this is an increasingly common occurrence. One means of avoiding interference is to select a non-overlapping channel, which is a configuration option on the access point.

Interference can also be caused by other wireless devices, such as certain types of cordless phones. If you get interference from another device, it may help to change the position of either the device or the access point. You can also change the channel used for wireless transmission.

The physical layout of a building and the materials used in its construction can also cause interference. Inside doors with glass can have some effect on the signal, while double-glazed windows, concrete and brick allow only a small amount of the signal through. Large amounts of metal or water, such as a refrigerator or even a fish tank, will completely block a wireless signal. In these cases, you can install additional access points, adjust the antenna orientation, add a wireless repeater or add a signal booster. Of course, the stronger the signal, the greater the possibility that someone else will be able to pick it up.

Security

Security is a major consideration for wireless networks. Wireless computers and access points broadcast their radio signals beyond the boundaries of your building, so you will need encryption in your wireless network to protect the privacy of your patients' health information. Various levels of encryption are available, and your choice will depend on several factors, such as how much you can afford to spend and how concerned you are about hackers attempting to access your network. The simplest way to encrypt your wireless network is to enable encryption on your access points. Modern access points will provide a variety of settings; you'll want to use the strongest you have available that is supported by your computer system.

Other simple measures will significantly improve the security on your wireless network. These involve changing the default settings listed below. To make these changes, you will typically use a Web browser to connect to the access point, authenticate yourself and then change the settings through the browser. Usually the vendor will provide instructions for changing the settings.

1. Service Set Identifier (SSID). Changing the default SSID (e.g., "linksys") to a name your staff members will recognize helps ensure that users connect to the proper network.

2. Internet Protocol (IP) Address and Subnetwork. Your Internet service provider, which we will discuss shortly, will provide you with a range of IP addresses. These are the only public addresses you should use. There are private address ranges reserved for internal use. These can be used freely inside any private network; however, to connect to the outside world, these addresses need to be translated by the border router to your public addresses. Using the proper IP address will make it less likely that users will find out the specific make and model of your access point. This will make it more difficult for hackers to break into your system.

3. Account Name and Password. Assigning new account names and passwords is a critical security measure. If you fail to change the account name and password, anyone who successfully connects can change the configuration.

4. SSID Broadcast. The SSID broadcast is what allows your network to show up in a wireless computer user's list of possible networks to select. This feature is usually turned on by default. Disabling the SSID broadcast means that a typical user has to know the network's name in order to connect to it.

5. Media Access Control (MAC) Address Filtering. Enabling this feature ensures that only specific computer systems can connect to your network. It can be a challenge to maintain, though, as you have to add an entry every time you bring a new computer into the network.

Network Security

Network security involves physical, technical and administrative safeguards, all of which are important.

Physical Safeguards

These are safeguards that defend your network from physical contact by unauthorized persons. To physically secure your network hardware, keep it in a locked room or closet accessible only to authorized persons. Repair and maintenance persons should be properly credentialed, and all parties should sign a Health Insurance Portability and Accountability Act (HIPAA) Business Associate Agreement. Computer screens should be positioned so that unauthorized persons cannot easily view them.

Technical Safeguards

A properly sized and configured firewall is a critical protection between your office network and the outside world. A basic guideline for firewall configuration is to permit network access only to known addresses and required services, and to deny all others.

Unique log-in names and strong passwords should be required for all network users. Strong passwords consist of at least eight characters, are alphanumeric and are not the log-in name or a word from the dictionary in any language. Network access should be given only to those individuals who need it to perform their duties, and even they should have access only to specific applications. Network users should lock their workstation if leaving for more than a very short period of time. The auto-logoff feature should be enabled on all computers so that a workstation inadvertently not locked will lock itself after a chosen period of time. Select the time-out interval based on your assessment of risk.

If you have a Web server, the default access via hypertext transfer protocol (HTTP) is not encrypted. If sensitive material can be exchanged on the Web site, encryption is required. To provide encryption, you must allow only secure access to the site. Any requests that are not secure should be forwarded to the secure server's address. Your consultant should be able to help you with this process.

For extra protection, if you have a Web site that provides an e-mail address for others to contact you, list the e-mail address in a way that makes it difficult for other computers to read. For example, replace "@" with "at" and "." with "dot." This would change "physician@provider.com" to "physician at provider dot com." Spambots continually search the Internet for e-mail addresses to add to unsolicited bulk e-mail mailing lists, better known as spam. Some spam can contain viruses that will damage your computer. Educate staff on identifying and deleting suspicious-appearing e-mail attachments.

Administrative Safeguards

You will need to create network security policies and procedures and hold all users accountable to them. Most computer security experts agree that the weakest link in the security chain is the system's users, and busy physicians are often the worst offenders. Physicians must set a good example for staff. Clear written policies about security breaches must be in place, including how you will notify those whose personal information has been exposed and what disciplinary actions will be imposed on those who committed the violation.

Writing down or sharing passwords is the most common breach and should be strongly discouraged. Staff accessing information they have no legitimate need to access is another common violation. You will also need to decide whether to allow network users to install software on their computers, either downloaded from the Internet or uploaded from CDs. Such software may introduce security weaknesses or other malicious programs into your computers and network. This includes benign appearing software, such as screen savers and games. Instant messaging is another Internet application that can invite malicious content into your network.

Finally, your office should have policies about the appropriate use of the network. Your network is a valuable and limited resource. Non-business uses can have a significant impact on network performance. Listening to Internet audio, watching streaming video and downloading large files of any kind can choke your Internet connection. Web surfing and using work e-mail for personal purposes consume employee time more than network resources, but you should still have policies about accessing inappropriate Web content and inappropriate e-mail content.

Investing in Your Practice

A computer network is the central nervous system for your practice. As such, it should be designed to meet your current demands and anticipate the need for growth as the use of computers in medical practices increases. It should also be equipped with ample security protection. With help from a qualified network specialist, you can successfully navigate the complexities that small practices face. It will be well worth the investment.

Source : http://www.medscape.com/viewarticle/570373

More Doctors Writing Prescriptions Electronically

National incentives for e-prescribing have started to make an impact, according to a report released on Wednesday.

An estimated 17 percent of office-based prescribers now send prescriptions electronically to pharmacies, according to the report by Surescripts, which operates the largest U.S. electronic prescribing network.

That compares with 12 percent at the end of 2008 and 6 percent at the end of 2007, Surescripts said.

"In the past two years, the United States has gone from 19,000 to 103,000 prescribers routing prescriptions electronically," Harry Totonis, president and chief executive of Surescripts, said in a statement.

Totonis said the growth this year shows "clear evidence that the steps taken by policymakers, prescribers, payers, pharmacies and others are having a positive impact."

Starting in 2012, providers who do not use e-prescribing may suffer penalties under the new rules for Medicare.

A report released last month by the Pharmaceutical Care Management Association (PCMA) projected that as many as 75 percent of doctors will move to e-prescribing within 5 years.

PCMA projects that e-prescribing will save the U.S. government $22 billion over the next decade, more than covering the $19 billion in spending in the stimulus bill.

By the end of 2008, approximately 76 percent of community pharmacies and six of the largest mail-order pharmacies were able to handle electronic prescriptions.

Surescripts said the number of prescriptions routed electronically more than doubled to 68 million last year but still accounted for only a small fraction of the 4.4 billion prescriptions written annually in the U.S.

Source : http://www.medscape.com/viewarticle/701786

Clinicians Override Most Medication Alerts

Because clinicians override most current medication safety alerts generated by electronic prescribing systems, these warnings may be insufficient to protect patient safety, according to the results of a retrospective analysis in the February 9 issue of Archives of Internal Medicine.

"Electronic prescribing clearly will improve medication safety, but its full benefit will not be realized without the development and integration of high-quality decision support systems to help clinicians better manage medication safety alerts," senior author, Saul Weingart, MD, PhD, vice president for patient safety at Dana-Farber and an internist at Beth Israel Deaconess Medical Center (BIDMC) in Boston, Massachusetts, said in a news release. "We need to find a way to help clinicians to separate the proverbial wheat from the chaff. Until then, electronic prescribing systems stand to fall far short of their promise to enhance patient safety and to generate greater efficiencies and cost savings."

The investigators reviewed 233,537 medication safety alerts generated by 2872 clinicians in Massachusetts, New Jersey, and Pennsylvania who used a common electronic prescribing system from January 1, 2006, through September 30, 2006. Multivariate techniques helped to determine factors associated with alert acceptance.

Alerts were generated by 6.6% of electronic prescription attempts; most of these (61.6%) were high-severity interactions. Overall, clinicians accepted 23.0% of allergy alerts and 9.2% of drug interaction alerts. Clinicians accepted 10.4% of high-severity, 7.3% of moderate-severity, and 7.1% of low-severity interaction alerts (P < .001 for high-severity vs moderate- and low-severity interaction alerts).

Depending on the classes of interacting drugs, clinicians accepted 2.2% to 43.1% of high-severity interaction alerts. Clinicians of different specialties did not differ in alert acceptance, according to the results of multivariable analyses (P =.16). If the patient had previously received the medication for which an alert was posted, clinicians were less likely to accept the drug interaction alert (odds ratio, 0.03; 95% confidence interval, 0.03 – 0.03).

Limitations of this study included analysis of prescriptions written using only 1 electronic prescribing system; inference about an alert's utility based on the clinician's decision to accept or override an alert; assumption that a clinician's decision to override an alert was based on sound clinical judgment, without verification from the medical record; and inability to examine several patient and clinician characteristics, such as patient comorbidities and clinician familiarity, with the use of electronic medical records.

"The sheer volume of alerts generated by electronic prescribing systems stands to limit the safety benefits," said first author Thomas Isaac, MD, MBA, MPH, from BIDMC and Dana-Farber. "Too many alerts are generated for unlikely events, which could lead to alert fatigue. Better decision support programs will generate more pertinent alerts, making electronic prescribing more effective and safer."

Source : http://www.medscape.com/viewarticle/588151

Electronic Prescribing With Formulary Decision Support May Help Reduce Costs

Electronic prescribing with formulary decision support to prescribe medications was effective in reducing costs, according to the results of a study reported in the December 8/22 issue of Archives of Internal Medicine.

"Electronic prescribing (e-prescribing) with formulary decision support (FDS) prompts prescribers to prescribe lower-cost medications and may help contain health care costs," write Michael A. Fischer, MD, MS, from the Harvard Medical School in Boston, Massachusetts, and colleagues. "In April 2004, 2 large Massachusetts insurers began providing an e-prescribing system with FDS to community-based practices."

The investigators conducted a prepost study with concurrent controls using 18 months of administrative data from October 1, 2003, to March 31, 2005, to compare the change in the proportion of prescriptions for 3 formulary tiers before and after e-prescribing began. From these data, they developed multivariate longitudinal models to estimate the specific effect of e-prescribing, after adjustment for baseline differences between intervention and control prescribers. Using average medication costs by formulary tier, the investigators estimated potential savings.

During the study period, more than 1.5 million patients filled 17.4 million prescriptions. E-prescribing was associated with a 3.3% increase (95% confidence interval, 2.7% – 4.0%) in tier 1 prescribing, and the proportion of brand-name prescriptions for tiers 2 and 3 decreased correspondingly in multivariate models that controlled for baseline differences between prescribers and for changes over time.

In the intervention group, e-prescriptions accounted for 20% of filled prescriptions, a rate that could result in savings of $845,000 per 100,000 patients, based on average costs for private insurers. These savings could increase even further with higher levels of e-prescribing use.

"Clinicians using e-prescribing with FDS were significantly more likely to prescribe tier 1 medications, and the potential financial savings were substantial," the study authors write. "Widespread use of e-prescribing systems with FDS could result in reduced spending on medications."

Study limitations include preliminary economic calculations, lack of generalizability to other states and settings, observational design, lack of randomization, and possible residual selection bias.

"Our results suggest that there are important economic gains achievable through the broader use of e-prescribing with FDS but that merely providing e-prescribing systems to clinicians will not necessarily achieve those savings," the study authors conclude. "Rather, prescribers need to adopt the e-prescribing systems fully for these gains to be realized. Making those changes represents an important goal for physicians, insurers, and all those with a stake in the cost of prescription medications."

Source : http://www.medscape.com/viewarticle/584946

Beyond EHRs: How Technology Can Help You Treat Chronic Illness

Introduction

More than 133 million Americans currently live with a chronic condition.[1]The incidence of chronic illness is accelerating as the baby boom generation ages and young Americans become increasingly sedentary. Case in point: The number of individuals with diabetes in the United States is expected to double to more than 48 million by the year 2050.[2]

The numbers are staggering and perhaps overwhelming for primary care physicians. That's understandable because, in its present form, the U.S. health care system is largely ineffective in the management of chronic illness.[3] Several medical schools have responded by developing curricula emphasizing chronic disease management, but shortages of family physicians and other primary care specialists are expected to continue as fewer medical students enter these fields. This greater demand and diminished supply further support the need for new models of care delivery. Seven to 10 minutes is the norm for a typical follow-up office visit, but even if we could cut that time in half and doublepatient volume, we would not begin to address the growing supply and demand problem. Simply put, we are losing the capacity battle.

All hope is not lost, however. This article discusses how technology can help family physicians not only keep up with the needs of their chronically ill patients but also increase the quality of their care.

Staying Connected With Your Patients

Through initiatives such as the AAFP's 2007 Annual Clinical Focus on the management of chronic illness, family physicians have been introduced to the chronic care model. It outlines the critical elements needed for health systems and individual physicians to improve the health of the chronically ill.^[4]

The chronic care model focuses on a proactive medical team that follows up with its patients as well as empowered patients who are active in and educated about their own treatment. A big part of this can be accomplished by using technology to transform health care delivery. This concept, referred to as "connected health," has emerged from the need tomaximize health care resources in the face of growing demand, combined with the diffusion of communication technologies into the U.S. health care system.

Our vision of connected health emphasizes two core elements: self-care and remote care. Self-care can lessen demand, and remote care can increase supply.

Self-care is a vital component of chronic disease management. It involves giving patients the feedback, motivation and education they need to manage their conditions on a day-to-day basis. It can also encourage healthy behaviors in those at risk for chronic illness. In bothcases, tools that give patients ongoing feedback on their health can accelerate and support positive lifestyle changes.

Remote care involves monitoring, diagnosing and communicating with patients at a distance. It goes a step further than basic patient-physician messaging and uses sensors to capture quantitative data. This can facilitate higher quality care. It can also lead to greater efficiency for a multidisciplinary medical team if the data is reported through a centralized mechanism.

Real-life Examples

Several large health systems have positioned themselves to take a leading role in health care transformation and the integration of connected health services. One is Partners HealthCare's Center for Connected Health (CCH) in Boston. CCH has introduced several initiatives that demonstrate the value of technology-enabled, patient-centered care. Formore information, see its Web site at http://www.connected-health.org/programs.aspx.

In one CCH program, more than 325 heart failure patients are monitored remotely through the collection of vital signs, including heart rate, blood pressure and weight, using simple devices in the patient's home. The information is sent daily to a home health nurse, who canidentify early warning signs, notify the patient's primary care physician and intervene to avert potential health crises.

Another CCH initiative uses cell phone technology and a "smart" pill bottle to detect whether a patient has taken his or her scheduled medication. If the bottle is not opened at the right time, it sends a signal to a small light in the patient's home that glows red to remind him or her to take the medication. If the patient has opened the bottle and taken the medication on schedule, the light glows green.

A third CCH program is attempting to help hundreds of employees at a major Massachusetts company manage their high blood pressure through an Internet-based wellness program. It is hoped that this program will interest employers in connected health as a way to increase access and reduce health care cost. The impact of this program is still being evaluated, butearly results are encouraging.

The Enabling Technologies

Here is a rundown of the technologies that are being used in the CCH programs and that family physicians might soon use to track their physicians' conditions remotely:

Sensors

From off-the-shelf blood pressure cuffs to wireless oximeters to implantable glucose monitors, the sensor industry is exploding with accurate, cost-effective tools to capture, store and transmit physiologic parameters.

Communicators

Data from patients, including physiologic markers and information regarding their disease severity, clinical state and functional status, must be aggregated and communicated to providers, and then displayed back to patients to encourage self-care. The technologies for achieving this include hand-held computers, desktop computers, mobile phones and even television.

Networks

While practices can choose from a variety of network technologies, including telephone, pager, Internet, wireless, cable and cellular, the leading trend is to use a single high-speed wireless Internet platform.

Storage/Processing/Databases

Robust, secure storage and computing power are both important parts of the technology mix. This includes sophisticated programs that use algorithms to identify important data points and trends, making some care decisions automatically in the background and presenting other cases to the appropriate clinician for action.

Presentation

For the clinician, this means the information transmitted to and from the patient must be integrated into an electronic health record (EHR) format for review, decision making and action. For the patient, this means the information must be presented in a clear and meaningful way that is easy to use and promotes self-care.

Personal Health Records

While just beginning to emerge, personal health records (PHRs) will increasingly be available to patients who wish to collect, store and share their personal health data. WebMD and Revolution Health are among a growing number of companies that offer secure, online PHRs. In the near future, other companies will offer personal health information with search capability, Web services that deliver personalized guideline recommendations and customizeddelivery of medication information, including discount pricing and drug-drug interaction warnings.

Addressing Common Concerns

As with any disruption to the status quo, the use of connected health tools will not be embraced without first addressing some common concerns for physicians.

First, it should be noted that there have been no liability claims filed by patients to date that involve allegations of negligence relating to the use of connected health technologies. Connected health maximizes patient information, education and participation, and it enables informed patient decision making. As such, it's likely that an informedpatient, involved in decision making about his or her own health, will be much less likely to use legal recourse as a solution to a bad outcome.

Similarly, compliance with the Health Insurance Portability and Accountability Act (HIPAA) doesn't create insurmountable barriers to implementing connected health programs. Relatively simple measures can be taken to ensure the privacy of patient data even as it is transmitted electronically.

Concerns that online communication will reduce office visits (and thereby reduce income) are understandable but have not been borne out in early experiences. Once in place, electronic communication decreases the demand for certain types of office visits (e.g., low-level, follow-up visits), but it minimizes interruptions from phone calls and creates more capacity for high-level visits or for a larger panel of patients.^[5]

Finally, many physicians worry about the costs of implementing these new technologies. While practices will need to invest in new technologies and teach their staff members how to use them, we are convinced that these costs will not outweigh the benefits of connected health technologies. In fact, they may usher in new models of reimbursement. In some states, several health plans are already reimbursing physicians for e-mail consultations through commercial portals such as RelayHealth.

Ultimately, physicians who have incorporated technology into their practices will fare better as the health care marketplace increasingly pays more for quality. It will be easier for these practices to take a population-based view of their patient panels, improve decision making and meet performance targets.

Connected health technologies can also enable more efficient use of resources, resulting in higher quality care at a lower cost. This is in part due to the ability to move patients to lower cost environments. Care once delivered in the hospital can be delivered in the home, and care once delivered in the physician's office can be delivered to the patient's desktop. Such an improvement in system performance means providing the right care, atthe right time and in the right place.

A Vision for the Future

The impending burden of chronic disease will further tax the U.S. health care system and will require new models of care delivery. Connected health strategies provide for improved access, quality and efficiency by encouraging increased self-care and enabling remote care of patients. The defining feature of connected health is to offer quality care where the patient is, when the patient needs it. Interactive patient-provider online communications, remote lifestyle feedback and home monitoring of patients with chronic diseases lie at the center of this vision.

Source : http://www.medscape.com/viewarticle/578919

The Government Push for Electronic Medical Records

The economic stimulus plan currently being considered by Congress allocates $20 billion to health information technology such as electronic medical records (EMRs). Recent postings on Medscape Physician Connect (MPC), a physicians-only discussion board, offer frank opinions about the utility of EMRs in clinical practice -- opinions that are decidedly mixed.

"EMR is the worst thing that has happened to me professionally in over 25 years of practice. My care of patients is impeded and the quality of my care is worse as a direct effect of the introduction of EMR," says a MPC contributor who championed the installation of an EMR system for his physician group.

"I absolutely love our EMR," says a nephrologist. "It has improved the quality of our practice immensely. I spent a lot of time customizing for our practice, but it was worth it. Everything is point and click. To improve care and cost, all patients need a Web-based collection of medical records that include hospitalization, lab reports, x-rays, as well as office notes. That would be the ultimate care."

Physicians who are dissatisfied with EMR systems cite loss of productivity, the negative impact on patient care, and high maintenance requirements. Physicians who have embraced EMRs cite the increased efficiency the systems have brought to their practices. EMRs tend to get high marks from subspecialists and low marks from primary care physicians.

Some of the MPC physicians least satisfied with their EMR systems are those practicing at large healthcare companies or medical centers. "My hospital solicited medical staff support for EMR," says one MPC contributor. "After implementation, administration took over and now EMR is solely for the benefit of medical records as a storage device. To hell with the medical and nursing staffs. RNs are input clerics rather than beside nurses."

"The very few efficiencies were all on the administrative side," says a regional medical director who helped bring an EMR system to a nationwide healthcare company. "A good sales pitch with nice graphics and testimonials sell it, then the clinical staff is left to suffer."

"EMRs need to address work flows and clinical efficiencies and not seek to provide administrative support," says a general practice physician. "Unfortunately, the administrators are the ones with the time and energy. The rest of us are seeing patients."

In smaller practices, issues of EMR maintenance and support infringe upon patient care. "In my clinic," says a family medicine physician, "provider meetings are completely dominated by EMR issues and problems. There is virtually never time left for discussing topics pertinent to improving patient care."

In speaking about their day-to-day experience with EMRs, primary care physicians complain that entering patient information is cumbersome and time consuming, often because of a template-based system that does not reflect the patient encounter.

"The assumption of the EMR is that you already know the diagnosis when the patient arrives." says an MPC contributor. "This may be better for specialty care, but in primary care, patients come in with fatigue, rash, insomnia, diarrhea, and cough. It's difficult to enter all this until after the visit."

An internist who describes herself as "tech savvy" says that her system's scripted entries for patient information are inadequate. "If you free-text, it is much more time consuming. And we are discouraged from free-texting by our administration because it doesn't trigger adequate billing codes. Not only has it reduced my time with patients, it has added an extra 2 to 3 hours of work each night from home."
The Choice of Systems

"My advice to practitioners," says one MPC contributor, "is wait for a decent EMR that produces useful notes that accurately describe a patient encounter in a way that helps a clinician."

Waiting may not be an option for much longer, however. One provision of the government stimulus plan would impose reduced payments on physicians who are not "meaningfully using" information technology. Whatever is meant by the provision's phrasing, one thing is clear: the push is on to go electronic. Physicians must learn how to make information technology work for them. One EMR expert says that it starts with the choice of systems. "Primary care practices should stay away from templates and stick to a new program by Praxis® [Infor-Med Medical Information Systems, Inc., Woodland Hills, California] that uses pattern recognition of similar cases as well as rare cases. It decreases the workload immensely. For specialty practices, I recommend templates, and Visionary™ Dream EHR [Visionary Medical Systems, Inc., Tampa, Florida] is excellent in being very user friendly," says an MPC contributor whose research in medical management focuses on EMR systems.

Another MPC contributor notes that the technologically adventurous can customize an EMR system by using open-source software. In open-source systems, he explains, the source code needed for programming is included in the software, making the program infinitely adaptable. "When you buy most proprietary software, you have to accept the functions that come with it, as designed by the developers. With open-source systems, you can modify the software to your heart's content."
Is a Choice of Systems Really a Choice?

For some physicians, however, EMR systems remain a nonissue, and the heavy government funding of healthcare information technologies is nothing more than a smokescreen obscuring the real issues in primary care.

"The government and the public are not able to deal with the real problems facing medical practice and the real solutions necessary to turn it around (ie, reasonable reimbursement rates, malpractice reform, regulation of the unscrupulous practices of the insurance industry)," says an otolaryngologist. He adds that once healthcare information technology is "fully implemented and solves nothing, we can start to talk about real reform and real answers."

Source : http://www.medscape.com/viewarticle/588354

Stimulus Package Could Convert More Physicians to EHRs

One hundred years ago, the federal government didn't write physicians a check for installing new-fangled telephones in their offices, and it didn't penalize them if they didn't.

Then again, it wasn't operating 2 budget-breaking healthcare programs called Medicare and Medicaid. So Washington didn't care how up to date or efficient physicians were.

In the 21st century, however, it's taking a carrot-and-stick approach with another technology called the electronic health record (EHR). The latest example is the American Recovery and Reinvestment Act (ARRA) that President Barack Obama signed in February. This $787 billion economic stimulus package sets aside at least $17 billion (some analysts put the figure higher) in incentive payments to physicians and hospitals that adopt EHRs, also called electronic medical records, or EMRs.

Lawmakers aren't in love with the technology for its own sake. They view a national network of EHRs as a means to improve the quality of care (no more illegible handwriting, for example) as well as dramatically lower Medicare and Medicaid costs (no more need to repeat a test because another physician's paper chart isn't handy). They're so gung-ho to digitize healthcare that they crafted ARRA to punish physicians who refuse the EHR carrot and persist with paper.

With ARRA, Washington would like to create a bandwagon for EHRs, and so would software vendors who spot a potential bonanza. One of them, eClinicalWorks, has partnered with Wal-Mart and Dell to offer a package deal of software, hardware, installation, training, and first-year support through Sam's Club stores nationwide, all with the purpose of helping physicians earn their incentive money.

Will a trip to Sam's speed up the conversion to EHRs, which have been around for 40 years? Only 17% of office-based physicians use some sort of EHR, according to a study that appeared in the July 3, 2008, issue of the New England Journal of Medicine. And only 4% have the kind of comprehensive EHR system promoted by the federal government, capable of sending prescriptions directly to a pharmacy's computer and providing "clinical decision support" — a drug-interaction alert, for example. The US Centers for Disease Control and Prevention put the overall EHR adoption rate at 38% in 2008, but it also reported that just 4% of physicians use comprehensive EHRs.

Hospitals are even less computerized. A study published online March 25, 2009, in the New England Journal of Medicine (by the same researchers who studied physician adoption rates) reported that just 1.5% of nonfederal hospitals have a comprehensive EHR system across all clinical units, while 7.6% have a basic system in at least 1 unit.

Incentives Come With Hoops Galore

One barrier to EHR adoption has been price. When software, installation, training, and support are tallied, a comprehensive system can easily cost more than $40,000 per physician over 5 years, and that's not counting hardware, according to Mark Anderson, a healthcare information technology consultant in Montgomery, Texas.

ARRA tries to lower the price barrier. You can receive up to $44,000 over 5 years under Medicare if you meet complicated qualifications for EHR use — more on those later. Working in a "health professional shortage area" entitles you to 10% more. But to receive the maximum $44,000, you must qualify as an EHR user beginning in either 2011 or 2012. Waiting until 2013 or 2014 reduces your bonus period — all payments cease after 2016 — and your total haul. If you get around to first qualifying in 2015, you receive nothing. So early birds get more of the worm.

Anyone who treats Medicare patients without an EHR by 2015 will see reimbursements decrease by 1% that year. The pay cut grows to 2% in 2016 and 3% in 2017 and every year afterwards. . If EHR adoption fails to hit the 75% mark by 2018, the Department of Health and Human Services (HHS) can boost the penalty to 4% that year and a maximum 5% in 2019 and beyond.

Incentives under Medicaid are more generous — up to $63,750 over 6 years, assuming you rely on the government program for at least 30% of your patients. If you're a pediatrician and Medicaid accounts for 20% to 30% of your volume, you can receive a maximum $42,500. The Medicaid incentive doesn't come with paper-chart penalties.

Physicians who have already implemented EHRs will still be eligible for either the Medicare and Medicaid incentives that go into effect in 2011, Robert Tennant, a senior policy advisor for the Medical Group Management Association (MGMA), told Medscape Medical News. You cannot receive incentives under both programs, however, so you must choose one.

To qualify for a check, your EHR system must be able to "talk" to systems from other vendors, and it must have advanced features such as clinical decision support. You also must demonstrate that you're a meaningful user of the technology — that is, you electronically prescribe, exchange data with other providers, and generate reports on how you perform on as yet unspecified "clinical quality measures." Such measures may resemble those in Medicare's Physician Quality Reporting Initiative (PQRI), such as the percentage of patients with diabetes who receive a yearly eye examination.

Finally, your EHR must also be certified. ARRA does not specify who will supply this stamp of approval, but the feds will likely choose the Certification Commission on Healthcare Information Technology (CCHIT), said Robert Tennant. He and other students of ARRA recommend that incentive-seeking physicians not only buy CCHIT-certified programs, but also contractually require vendors to meet all the standards that emerge as the law gets fleshed out.

While upfront financial support would have been ideal, the Medicare and Medicaid incentives will only be doled out after you've invested in an EHR, said Tennant. "This could act as a disincentive for EHR adoption, especially during the economic downturn." However, you may be able to get financing through state loan programs envisioned in ARRA. This money would come from $2 billion allocated to an HHS agency that promotes EHRs.

Physicians View Incentives With Hope, Skepticism, Scorn

The federal pressure to digitize has been building. Last year, Congress applied the carrot-and-stick technique to eprescribing in the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). Those who eprescribe in 2009 and in 2010 qualify for a 2% raise based on their total Medicare revenue. The bonus decreases to 1% in 2011 and 2012, to 0.5% in 2013, and then disappears (physicians who receive the EHR bonus cannot receive the eprescribing bonus).

MIPPA also imposes a 1% penalty on physicians who do not begin eprescribing by 2012. The penalty increases to 1.5% in 2013 and to 2% in 2014 and beyond.

For the most part, organized medicine is holding its nose at the penalties while it applauds the bonuses.

"People respond better to positive incentives," family physician Douglas Henley, MD, executive vice president and chief executive officer of the American Academy of Family Physicians (AAFP), told Medscape Medical News. "Fortunately, in the case of EHRs, the stick has been delayed well into the future, and the carrot is substantial."

Robert Tennant added that like MIPPA, the economic stimulus legislation contains a hardship clause that exempts physicians who might live in an area lacking high-speed Internet access.

Many physicians at the grassroots level, however, view the federal jump-start for EHRs with skepticism, if not outright hostility. For internist Audrey Corson, MD, in Bethesda, Maryland, there are too many unknowns. "Doctors will have to select an EHR without knowing what standards will be adopted, and if their vendor will survive," Dr. Corson pointed out.

Some clinicians bristle at the notion of having to buy CCHIT-certified programs, which generally cost far more than noncertified programs and have a reputation for being hard to use. "I can't afford a system that will slow me down," said family physician Frederic Porcase, MD, in Jacksonville, Florida.

Dr. Porcase also wonders whether the incentive payments will be as hit-or-miss as those under the PQRI program, which pays bonuses to physicians who report their performance on quality measures. In the program's first year, only 52% of participating physicians received bonuses, and most physicians found Medicare's reporting process cumbersome, according to an MGMA survey.

Still others worry that the billions in incentives could be ill-spent on EHR systems that right now cannot exchange data with each other or with personal health records controlled by patients. ARRA makes interoperability a requirement for qualifying EHRs, but the standards for interoperability have yet to be specified. Dr. Henley of the AAFP said nailing down that language is paramount.

"If all we do with this bill is to create islands of electronic data that can't be transferred," he said, "we haven't accomplished anything."

Source : http://www.medscape.com/viewarticle/590460?src=top10

Readers' and Author's Responses to "Clinicians Must Reinvent the Medical Record to Stimulate the Adoption of Electronic Medical Records"

To the Editor:

I totally dislike it that one of my doctors uses EMRs.^[1] I find it very annoying when his assistant puts me on "hold" while she finds something on the screen, or when she has to type in something. Then the doctor comes in and it is very much the same scenario. This is in comparison to my other doctor, who uses the "old-fashioned" method of writing his own notes while paying good attention to what I'm saying without breaking the stride of conversation. Before I moved, my doctor always took notes and after the exam was over he'd talk into a recorder from which a report was typed. So, in this case, one person listened, jotted notes, and spoke; another typed. In the former, two typed, had difficulty listening, and the patient (me) was very frustrated. There has to be a much better way than having computers in the exam room!

Dorothy Krystock
1dotbill@comcast.net

Reference

1. Lesselroth B. Clinicians must reinvent the medical record to stimulate the adoption of electronic medical records. Medscape J Med. 2008;10:45. Available at: http://www.medscape.com/viewarticle/570116 Accessed April 6, 2008.

Author's Response:

Many patients and providers lament that the introduction of information technology can disrupt workflow and interfere with the doctor-patient dialog. Nevertheless, there are opportunities for both parties to capitalize upon electronic health records to improve the quality of the clinic visit. The patient should recognize that immediate access to more robust health information and decision support can improve medical decision making and provider adherence to best practice behaviors. Many health records provide summary reports and print capabilities. Hence, patients might request reports of medication lists, forthcoming appointments, or preventative health logs before leaving clinic. Likewise, providers can use information technology to engage patients as collaborative partners in their healthcare. Many health records can plot laboratory data, display radiographic images, or show medication pictures. This type of multimedia information affords the provider the opportunity to educate and counsel patients in new ways.

Blake Lesselroth, MD, MBI
Assistant Professor of Medicine and Medical Informatics
Portland VA Medical Center
Portland, Oregon
blake.lesselroth@va.gov

---

To the Editor:

As a member of the research group that worked under the leadership of Dr. Lawrence Weed in the 1970's developing the Computerized Problem-Oriented Medical Information System (PROMIS), I view the current discussions about EHRs as well-intended yet often futile attempts to recreate the wheel.^[1]

PROMIS, a federally-funded prototype, not only enabled the efficient generation of a problem-oriented medical record with history, physical exam, problem lists, laboratory results, and progress notes in electronic form, it also furnished up-to-date medical information and guidance in the course of providing care, as well as the ability to audit care-giver performance and conduct population studies and research on large numbers of patients.

PROMIS was way ahead of its time in the 1970s both philosophically and technologically. It had the potential to revolutionize medical education and training and patient care but unfortunately was turned down both by medicine and the government.

Now, over 35 years later, its pioneering achievements continue to remain hidden as another generation tries to cope with the continuing challenges of the EHR. My recommendation to those who are really serious about solving the EHR problem is to investigate the specifics of the PROMIS project and contact Dr. Lawrence Weed for his enduring wisdom on this most important issue.

Brian J. Ellinoy, Pharm.D
Integrative Pharmacist Consultant
"Helping Empower You to Better Health"
rxbrian@yahoo.com

Reference

1. Lesselroth B. Clinicians must reinvent the medical record to stimulate the adoption of electronic medical records. Medscape J Med. 2008;10:45. Available at: http://www.medscape.com/viewarticle/570116 Accessed April 6, 2008.

Author's Response:

Dr. Weed's pioneering efforts in health records have had an indelible impact upon the evolution of health information management. And many informatics experts would agree that his work with PROMIS, a computerized version of the problem-oriented record, helped define the evolution of electronic record systems. However, it should be noted that Dr. Weed also recognized the importance of an "interconnected network for information exchange," arguing that healthcare informatics will only realize its potential to improve the standard of care when data are easily exchanged across a unified health information platform. Regional health information organizations, data standards, and technology breakthroughs are more likely to be cultivated in a collaborative environment than in provincial research silos. Already, the collective capabilities of massive online communities have produced such products as Wikipedia, Linux, and the Human Genome Project. Providers, technology specialists, and informaticists should strive to join these social networks in order to learn, teach, and spur innovation.

Blake Lesselroth, MD, MBI
Assistant Professor of Medicine and Medical Informatics
Portland VA Medical Center
Portland, Oregon
blake.lesselroth@va.gov

Source : http://www.medscape.com/viewarticle/572855

AAEM Young Physicians Section President's Message: The Value of EMRs in the ED

Yesterday, I had a patient brought in by ambulance with generalized weakness and dizziness. If not a favorite chief complaint, it certainly is a common one. You know this patient, you saw her as well. She was described by the nursing staff as a "terrible historian." Instead of correcting the nurse as to the proper definition of a historian, one who records history, I nodded and tried to get a story from this woman. Nevertheless, my open and closed ended queries were for naught. She was not in a talkative, telling mood. Unfortunately, she had never been to our department before, so my computer search was unhelpful. The paramedics had jotted down the name of some medications they found in her bathroom, but were otherwise unable to provide any information. The 911 caller´s identity was also a mystery. The patient was a little tachypneic and tachycardic. Auscultation revealed coarse breath sounds and a questionable holosystolic LLSB murmur. Also noted was trace edema about her ankles, occasional ecchymotic areas on her flank and upper extremities, and a non-focal, though certainly not normal neurological exam.

Obviously, the differential for someone like this is broad. And more certainly, a "gramma-gram" will be ordered (CXR, ECG, CBC, Lytes, BUN/Cr, U/A, etc…). Most certainly when we diagnosis the pneumonia, renal failure, or whatever disease she harbors today, we will initiate therapy and dispo to the appropriate unit, including the possibility of a discharge home.

Murphy´s Law dictates that when something can go wrong, it will go wrong. Sure enough, she develops anaphylaxis from that aspirin or fluoroquinolone du jour. Or you cannot determine her primary care physician (PCP); therefore, you are spinning wheels trying to get her an inpatient bed. Or because you chose to ignore the next five patients brought in by triage, you got a hold of the paramedic supervisor, sent back the medics to provide you her medication vials and ultimately determined her PCP.

Fret not! Larry Page and Sergey Brin have entered the healthcare arena to help. Who are these two? These folks are Google´s founders. In May, Google, Inc. unveiled their version of the electronic medical record. This new site allows users to enter, update manually or automatically and remove one´s personal medical records. One can then chose with whom to share the information and even select what information each party may view. After care at the hospital, if desired, the medical center will upload your medical information into your account.

This is potentially a very powerful tool in the emergency department. Were we able to view this patient´s electronic medical record perhaps we could have avoided the allergic reaction or contacted her family and PCP. Perhaps we would have been able to glean valuable information from her recent office visit at the Cleveland Clinic. As borderline ADHD physicians, we cherish high yield information; this is one such opportunity to gain high yield information with minimal effort. Cynics will argue that other modalities have greater value; an example is the medical alert bracelet or microchip. No doubt any additional information, that doesn´t simply raise the volume of background noise, will benefit the overall care of the patient. That said, Google commands a lot of respect and has buckets of cash. This, along with a relative vacuum in the area of national medical records, perhaps sets Google up for success.

While it is unlikely that Google will revolutionize the way we gain access to health information, it certainly will contribute to the evolution. Perhaps city-dwelling technology worshipers will readily flock to this method, but it is doubtful that the majority of Americans will buy into this. At least not for a number of years, until the security and bugs have been vetted. Currently, I cannot imagine the majority of baby boomers feeling comfortable with the security of online records. But perhaps even less likely, are those younger workers whose hacked medical information might be considered embarrassing or even career damaging.

There are other challenges as to how emergency physicians and their patients could benefit from access to this information. This includes, though not limited to, knowing that information exists, how to gain access in an emergency and of course HIPPA and other legal concerns. Furthermore, major health systems will have to buy into this. Unless multiple hospital systems allow medical records to be uploaded, patients would have to be diligent at keeping the records current. At the time this is written, this capability is only available at The Cleveland Clinic, Beth Israel Deaconess and some well-known national pharmacies. That isn´t too shabby, considering its´ availibility is very recent.

Granted, this system would not have prevented the anaphylaxis in this case. At this time, an allergy bracelet would have been the best option. But in the future, I do believe that electronic medical records will be readily available and invaluable to the emergency physician. It is refreshing to see private enterprise continue this exploration. Google, Inc. has a tremendous amount of clout and capital and if used carefully and appropriately, Google Health records may be a wonderful adjunct.

Source : http://www.medscape.com/viewarticle/578473

Hidden Malpractice Dangers in EMRs

An estimated 85,000 medical lawsuits are filed annually, which include those against hospitals and individual physicians. One of the highly-touted benefits of electronic medical records (EMRs) is the potential to help prevent malpractice incidents and medical errors. By providing better documentation, automatically checking for medication errors and drug interactions, providing failsafe systems to track test results and follow-up with patients, EMRs can dramatically reduce the risk of malpractice.

While the benefits of EMRs are far greater than the cons, no road is without stumbling blocks. A physician who is not careful when using the EMR could increase his malpractice liability.

Some of the possible malpractice risks are shown below.

Too Much Information

Because EMRs allow physicians to document easily, paragraphs of information can be generated with a few keystrokes or even a checkmark. Doctors can describe a comprehensive examination in great detail using predesigned templates. Lists of negative findings can appear, neatly printed, with the push of a button.

This bevy of information may help the physician breeze through an insurance audit; however, all of this information can also create pitfalls.

Pages of repetitive documentation can be more time-consuming to review than brief, handwritten notes. When important information is embedded in paragraphs of boilerplate, it can easily be overlooked. The chance of missing critical data increases.

Overlooking important information is, of course, a significant cause of malpractice. A positive finding embedded in a string of negative findings can easily be missed. To avoid skipping over important information, positive findings must be documented in a way to enable the reader to find them quickly -- either by highlighting them or placing them in a separate section of the record.

Wrong Template Can Bollix Up the Chart

EMRs contain different templates for various types of specialists and types of visits. Templates are helpful for documenting repetitive acts. However, inadvertently using the wrong template can cause potential malpractice problems.

For example, when a neurologist reviewed his records of a neurologic examination of a 1-year-old boy, the neurologist, who had just converted to a new EMR system, recorded, among other findings, that the baby boy was oriented as to time, place, and person. Such a test cannot apply to small children. Needless to say, the neurologist used his template for a normal neurologic examination, without considering that some of the language wasn't suitable for a year-old child.

Fortunately the case did not evolve into a malpractice suit. Imagine the difficulty the neurologist would have had trying to defend himself from charges of documenting findings that were not medically possible to ascertain.

Changing the Standard of Care

Offices that don't adopt technology integrating clinical practice, documentation, and billing procedures may face malpractice exposure. Insurers, including Medicare, continue to ramp up their auditing activities. When a doctor's medical record documentation doesn't match CPT codes, demands for huge repayment follow.

Failure to incorporate EMR into a practice may, in the not-too-distant future, be considered a deviation from recognized standards. When an EMR could, arguably, have avoided an adverse result, trial lawyers will be arguing that physicians were obligated to use this new technology. Because EMR systems can catch medication errors and adverse drug interactions, track test results and patient follow-up, and make it far easier for a physician to access and review medical history, failure to embrace it could be problematic.

As the EMR technology becomes pervasive, failure to use it to avoid medical errors may also lead to malpractice claims. It will not be too long before EMR becomes the "standard of care."

Attention to the Patient

Some physicians who do not yet use an EMR have expressed concern that working with an EMR could divert their attention from patient signs and symptoms. They worry that this could potentially lead to a greater malpractice risk. Proper training and ease of use are essential elements of any successful EMR system. Doctors must be sure to have sufficient training and experience using the EMR before widespread implementation. During the initial implementation period, physicians should schedule additional time during office hours to address their use of the EMR, so that inattention and missed symptoms do not occur.

Conclusion

No doctor can ignore the growing pressures to start using an EMR. With the Obama administration avidly promoting healthcare information technology, and tens of thousands of dollars at stake in incentives and future penalties for doctors, more physicians will be implementing EMRs in the coming years. Under the recently passed American Recovery and Reinvestment Act, physicians who demonstrate meaningful use of EMR by 2011 will be eligible for full federal subsidies of up to $44,000. Failure to implement EMR by 2014 may also result in increased malpractice premiums and increased exposure to malpractice claims, as well as a reduction in Medicare reimbursement, beginning in 2015.

As with all other aspects of their practice, doctors need to be careful and vigilant when using an EMR. Although it's inviting to let templates do much of the heavy lifting, physicians need to be cognizant of the information contained within them, and to not blindly follow templates.

Source : http://www.medscape.com/viewarticle/589724?src=top10