March 13, 2017Quiz
Privacy and Security, are still important issues connected with Electronic Health Records (EHR). EHRs allow providers to use information more effectively to improve the quality and efficiency of your care, but EHRs do not change the privacy protections or security safeguards that apply to health information. EHRs Personal Health Records (PHR) are electronic versions of the 1) ___ charts in doctor's or other health care provider's offices. An EHR may include one's medical history, notes, and other information about one's health including symptoms, diagnoses, medications, lab results, vital signs, immunizations, and reports from diagnostic tests such as x-rays. The information in EHRs can be shared with other organizations if the computer systems are set up to talk to each other. Information in these records should only be shared for purposes authorized by law or by individuals. There are privacy rights whether information is stored as a paper record or stored in an electronic form. The same federal laws that already protect health information also apply to information in EHRs.
As health care providers begin to use EHRs and set up ways to securely share health information with other providers, it will make it easier for everyone to work together to make sure that one gets the care they need. For example: Information about medications will be available in EHRs so that health care providers don't perscribe another 2) ___ that might be harmful. EHR systems are backed up like most computer systems, so health information can be retrieved in the vent of a computer shutdown. EHRs can also be available in an emergency. If one is involved in an accident and are non-verbal, a hospital could retrieve personal information so decisions about emergency care can be faster and more informed. Doctors using EHRs may find it easier or faster to track lab results and share progress with patients. If doctors' systems can share information, one doctor can see test results from another 3) ___, so the test doesn't always have to be repeated. Especially with x-rays and certain lab tests, this means one is at less risk from radiation and other side effects. When tests are not repeated unnecessarily, it also means care costs less.
Most of us feel that our health information is private and should be protected. The federal government put in place the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule to ensure one has rights over one's own health information, no matter what form it is in. The government also created the HIPAA Security Rule to require specific protections to safeguard electronic health information. A few possible measures that can be built in to EHR systems may include: "Access control" tools like passwords and PIN numbers, to help limit access to authorized individuals. Encrypting stored information means health information cannot be read or understood except by those using a system that can decrypt it with a "key." An audit trail feature, which records who accessed information, what changes were made and when. Finally, federal law requires doctors, hospitals, and other health care providers to notify patients of any breach. The law also requires the health care provider to notify the Secretary of Health and Human Services if a breach affects more than 500 residents of a state or jurisdiction. In that case, the health care provider must also notify media outlets serving the state or jurisdiction. This requirement helps patients know if something has gone wrong with the protection of their information and helps keep providers accountable for EHR protection.
How can electronic health records (EHR) and regulations be designed to positively affect doctors' practices? The meaningful use program has been successful in forcing the adoption of EHRs but they weren't ready for prime time, said AMA President Steven J. Stack, MD, recently, during a town hall meeting on EHRs at the Swedish Medical Center in Seattle. This is the third AMA town hall on EHRs and was co-hosted by the Washington State Medical Association (WSMA). The focus of this special session was: What is wrong with current EHRs and how they could be designed to benefit physicians in practice. Earlier this month Centers for Medicare & Medicaid Services Acting Administrator Andy Slavitt said the agency is changing its culture to focus more on listening to physician needs and will implement better policy in place of the meaningful use program when the new streamlined Medicare reporting program is created. With this statement, there's never been a better time to speak up and offer constructive solutions to regulatory missteps that have stolen time from physicians that they would rather have spent with patients.
Taking control: Regulations should not hinder care of 4) ___.
As it did in Boston and Atlanta last year, the physician voice resounded through Seattle during Tuesday night's town hall, emphasizing that EHR design should be focused on usability and interoperability and the physician voice must be heard. "Administrative burdens are strangling medical practice and creating unnecessary and costly inefficiencies in health care delivery while adding stress to physicians and their teams," said WSMA president Ray Hsiao, MD, kicking off the discussion. "It can make a cynic out of the happiest people and can lead to discouragement, professional dissatisfaction and burnout, and even drive 5) ___ to leave the profession. We cannot let that happen." Regulations force physicians to do "a lot of busy work that has nothing to do with the quality of care we provide," said Jane Fellner, MD, a primary care physician at the University of Washington School of Medicine. "It needs to stop."
How we can make EHRs more functional in practice
Speaking to what they really need from these tools to help them in their practices, many physicians offered solutions and suggestions for how 6) ___ should work for the end-users who depend on them daily. Interoperability proved top of mind as the current EHRs struggle to communicate. "My EHR does not necessarily have the tools to interoperate well with other EHRs," Dr. Fellner said. "But within the universe of the other medical centers who use the same software - it is magic. I can import an entire record from Florida in 20 seconds." If all EHRs could talk to each other in this way, it would have a very positive effect on the way physicians treat patients nationally, she said. "It has revolutionized the care I provide." Another focus for improvement during the discussion was the need for more data usage focused on population health to show physicians how their patients' health compares to national trends. "What we don't see is our information going in to create this big picture that we can then [see] in real time," said Reena Koshy, MD, a family physician in Seattle. This capability is currently available but not to everyone using EHRs. Dr. Koshy said it would be very helpful if national patient data coordination were available to all practices. Thomas Payne, MD, medical director of information technology services at the University of Washington School of Medicine and board chair of the American Medical Informatics Association, said he uses his EHR in every patient visit. "We need to address documentation because that is the source of a lot of unnecessary new time that [we] spend," he said. "Natural language processing is a great example. As we speak, as we are this evening we can use that same capability to communicate in the medical record and be able to record what kinds of care people have received." "When you're searching for billing 7) ___, you have to type it exactly correct or it boots it out," said Carrie Horwitch, MD, a primary care physician in Seattle. She suggested physicians could work much more efficiently if EHRs had the same kind of spell-check and search option drop-down menus as Internet search engines.
U.S. taxpayers have poured $30 billion into funding electronic records systems in hospitals and doctors' offices since 2009. But most of those systems still can't talk to each other, which makes transfer of medical information tough. Technology entrepreneur Jonathan Bush says he was recently watching a patient move from a hospital to a nursing home. The patient's information was in an electronic medical record, or EMR. And getting the patient's records from the hospital to the nursing home, Bush says, wasn't exactly drag and drop. "These two guys then type - I kid you not - the printout from the brand new EMR into their EMR, so that their fax server can fax it to the bloody nursing home," Bush says. "We should be working off the same set of standards," says Dr. Karen DeSalvo, coordinator for information technology, Department of Health and 8) ___ Services. In an era when most industries easily share big, complicated, digital files, health care still leans hard on paper printouts and fax machines. The American taxpayer has funded the installation of electronic records systems in hospitals and doctors' offices - to the tune of $30 billion since 2009. While those systems are supposed to make health care better and more efficient, most of them can't talk to each other. Bush lays a lot of blame for that at the feet of this federal financing. "I called it the ?Cash for Clunkers' bill," he says. "It gave $30 billion to buy the very pre-internet systems that all of the doctors and hospitals had already looked at and rejected," he says. "And the vendors of those systems were about to die. And then they got put on life support by this bill that pays you billions of dollars, and didn't get you any coordination of information!" Bush's assessment is colored by the fact that the company he runs - AthenaHealth - is cloud-based, and stresses easily sharing electronic health records. The firm also got a lot of the federal cash. Dr. Robert Wachter, with the University of California, San Francisco, says sure - in hindsight, the government could have mandated that stimulus money be spent only on software that made sharing information easy. But, he says, "I think the right call was to get the systems in. Then to toggle to, OK, now you have a computer, now you're using it, you're working out some of the kinks. The next thing we need to do is to be sure all these systems 9) ___ to each other." Right now, the ability of the systems to converse is at about a 2 or 3 on a scale of 0 to 10, Wachter and Bush agree. Wachter is about to publish The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age, a book that assesses the value of information technology in health care. Up until now, he says, there has actually been a financial dis-incentive for doctors and hospitals to share information. For example, if a doctor doesn't have a patient's record immediately available, the doctor may order a test that has already been done - and can bill for that test. Keeping EMRs from talking to each other also makes it easier to keep patients from taking their medical records - and their business - to a competing doctor. It's time for that to change, says Dr. Karen DeSalvo, the federal government's health IT coordinator.
The billions of dollars a year the government pays to doctors, hospitals and other institutions for patients enrolled in Medicare is a pretty good motivator. Already, 10) ___ is starting to increase pay to doctors and hospitals that work together to streamline care and avoid duplicative tests, and to penalize those that don't. Winning the new payments and avoiding the penalties increasingly require proving that all of a patient's doctors, no matter where they are, are working together. That requires using good electronic records that can seamlessly move from one system to the next. Wachter says that consumers are now demanding better health information technology, too - "because we're all used to our app stores and we know how magical it can be when core IT platforms invite in a number of apps." "So I think," he says, "that even the vendors and healthcare delivery organizations that have been fighting interoperability recognize it's the future." He says a lot of IT companies are now eager come up with software that meets the demands of the health care industry and consumers. About a dollar of every $6 in the U.S. economy is spent on health care. A new IT boom in that sector means there are billions of dollars to be made.
The effort to change meaningful use and fix EHRs
Early last year, the Medicare Access and CHIP Reauthorization Act of 2015 repealed the sustainable growth rate formula and called for the new Merit-Based Incentive Payment System (MIPS), which is intended to sunset the three existing reporting programs and streamline them into a single program. The AMA and 100 state and specialty medical associations recently submitted 10 principles to guide the foundation of the MIPS, and the AMA provided detailed comments (log in) as part of its ongoing efforts on this issue and submitted a detailed framework for what needs to change. The AMA and MedStar Health's National Center for Human Factors in Healthcare last year developed an EHR User-Centered Design Evaluation Framework to compare the design and testing processes for optimizing EHR usability. Visit BreakTheRedTape.org, the AMA's grassroots campaign to advocate for ways to solve medicine's regulatory and legislative challenges.
Sources: NPR's reporting partnership with Montana Public Radio and Kaiser Health News; www.hhs.gov/ocr/privacy/
ANSWERS: 1) paper; 2) medicine; 3) doctor; 4) patients; 5) physicians; 6) EHRs; 7) codes; 8) Human; 9) talk; 10) Medicare