Transcript Health Information...

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Transcript

Health Information Technology

1. Welcome to the lecture on Health Information Technology. This is a lecture companion to Jonas &

Kovner’s Health Care Delivery in the United States, Chapter 16, “Health Information Technology.”

2. The presentation objectives include:

Describe the benefits of health information technology

Relate the trends in electronic health record (EHR) adoption

Review the basics of U.S. healthcare billing

Understand how laws, HITECH, HIPAA, and ACA, impact HIT in the U.S.

3. To start off, let me orient you to what I mean about health information technology. HIT is any of the

technology innovations that improve coordination of care, communications between patients and

providers or between providers, and efficiencies of care delivery. The key concept of HIT is the

exchange of health information.

Much of the benefit of HIT lies in the improved coordination of care through information continuity.

According to your text, information continuity means that “patients’ clinically relevant information is

available to all providers at the point of care and to patients through electronic health records (EHR)

systems.” The EHR should be available across settings and providers.

Communications is improved through technology such as telemedicine (also known as telehealth).

Telemedicine is most effective when there is an exchange of information between the patient and

providers. For example, sharing data on glucose levels for diabetics. Also, imagine how a group of

providers could exchange the results of the diagnostic tests and discuss its implications via the

internet. Next, I will present examples on how HIT improves access, quality, costs and patient-

centeredness.

4. Access to care is improved by health information technology. Telehealth is a promising, yet

unproven, technology that connects providers and patients via the internet. It has shown success in

providing access for rural patients. According to the Weiner et al. (2013), “if health information

technologies were to be fully implemented in 30 percent of community-based physicians’ offices,

HIT could help address regional shortages of physicians, by allowing 12% of care to be delivered

remotely or asynchronously—that is, through visits conducted in separate locations and at different

points in time.” In addition, according to Ekeland (2010), the use of advice nurses enables direct

access to care and the ability to triage the cases. Electronic health records enable the nurses to

access the patient health information and share information with other providers.

Furthermore, access to care is improved when doctors or hospitals enable patient access to

electronic health records to view clinical notes, laboratory results, doctor’s appointments, and more.

These systems are often called “web portals.” Patient records and results can be securely shared

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among the primary care physician, hospital emergency departments, and specialists, avoiding gaps

in information (Nazi et al., 2013). Furthermore, these systems enable patients to schedule

appointments, retrieve test results and home care instructions, request services, make payments,

and communicate with the physician’s office

Finally, EHR data can be encrypted and stored on health smart card. Some national health systems,

such as Taiwan and Germany, use smart cards to communicate drug allergy history, prescriptions,

accumulated medical expenditure records, and insurance related matters, such as the amount of

cost-sharing required by the cardholder (Liu et al., 2006). This technology has yet to take hold in the

United States.

5. Health information technologies that can improve the quality of care. First, providing tools for

managing patient information is an example of HIT efforts aimed improving quality. The obvious

example is electronic health records. EHR allows exchange of patient information across provider

sites – between PCP and specialist or between hospital and laboratories, for example. This is not

easily done with paper-based systems.

Next, biofeedback is the process of retrieving data from a patient’s body and sending it to providers

automatically. Wearable computers, such as the Smart Shirt developed at the Georgia Institute of

Technology, allows monitoring of heart rate, electrocardiogram (ECG), respiration, temperature, or

other vital functions.

Also, HIT has improved quality of care by promoting adherence to current clinical guidelines and

protocols (Wu et al., 2006). This is done from at least two perspectives. First, from a patient’s

perspective, computerized reminders can improve medication adherence. You can imagine a mobile

solution helping to solve the forgetfulness problem. The other is from the provider perspective. So-

called clinical decision support systems are utilized within the larger EHR system to guide a provider

to practice evidence-based medicine. Imagine triggered alerts based on the patient’s needs, such as

“did you order a hemoglobin A1c test for this diabetic patient?” Or more sophisticated guidelines

such as providing alternatives for treatment based on recent scientific studies.

Also, HIT has been found to reduce medication errors by computerizing prescription ordering to

reduce interpretation errors, improve adverse drug interactions, and prevent drug allergy problems,

according to Cutler & Everett (2010). I will present more details on the pharmacy functions of EHRs

later in this lecture.

Finally, implementation of HIT, specifically electronic health records in hospitals, may be associated

with increased patient satisfaction, according to Kazley et al. (2013). However, another interesting

study by Kasmi (2013) showed that while EHR can improve the relationships between patient and

provider in some ways, it can exacerbate communication challenges of some the physicians. That is,

if the provider had a propensity to avoid eye contact or to miss for non-verbal cues of their patients,

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then EHRs make this problem even worse. They suggest training could help. I imagine that seminar

telling the providers, “Stop staring at your computer and talk to your patient!”

6. There are health information technology innovations that enable efficiencies in the practice of

medicine. Two categories of HIT-derived efficiencies include provider time improvements and

decrease in unnecessary health service utilization (Wu et al., 2006). An example of improvement of

physician productivity is a decision support tool that helps a provider streamline their workflow

associated with ordering and getting results from diagnostic tests. You can imagine the decrease in

office visits when a patient could get the results of a test in a web portal, instead of having to go into

the doctor’s office.

Next, HIT can improve disease management and case management for managed care organizations.

Disease management programs “identify people with a potential or active chronic disease then to

attempt to modify their behavior with educational materials intended to reduce the patient’s need

for costly acute care interventions” (Hillestad, 2005). HIT enables identification of patients, such as

diabetics, and stratification of patients based on severity, such as controlled or uncontrolled

diabetes, in order to create targeted DM interventions. Case management is a little different than

disease management. Typically, case management targets high-cost patients and provides to them

intensive coordination services, often by a nurse. HIT helps identify the costliest patients using

claims data.

Also, predictive-modeling algorithms can identify patients that may need services. For example,

computer logic can route out individuals that are likely to be re-admitted to the hospital. Care

management staff can reach out to prevent them from going back to the hospital. Finally,

organizations improve efficiency and resources management is something that we will talk about

later in this lecture. Specifically, I will present how the use of HIT can make the “revenue cycle” for

healthcare organizations more efficient.

7. In previous lectures, I talked about patient-centeredness as healthcare that is based with an

orientation toward the whole person. Patient-centeredness requires partnering with patients and

their families to understand and respect each patient’s unique needs, culture, values, and

preferences. Electronic health records are a foundational component of a more patient-centered

health care system (Krist et al., 2011).

For example, comprehensive EHRs should allow patients’ access to their clinical records through the

system. Also, EHR can enable individualized care such as helping the physician avoid any allergies, or

being alerted to any new medications the patient is taking. Also, based on logical combinations of

age, race, gender, and diagnoses, an EHR could present recommendations for treatment, education

materials, and support groups to both providers and patients.

Also, to show respect, it is critical that all EHR access remain secure and private. There are both

hardware and software solutions to protecting the privacy of patient information. The biggest risk to

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security and privacy to date is human behavior. People take home CDs with data on thousands of

patients; they carry laptops and thumb drives out of the office. Typically, these are people who want

to work at home on a data set, with no malicious intent, or forget that the records are on their

laptops. But then, the laptop is lost, the car is stolen with the disks inside, and so on. For this reason,

strict personnel policies and standards are as essential as technical safeguards. A law known as

HIPAA covers these requirements, and I present more on this law in a later slide in this lecture.

EHRs can also store advance directives. Advance directives are legal documents that tell providers

your wishes regarding end-of-life care, if you are not able to communicate your preferences, if

you’re in a coma, for example. A working Health Information Exchange should allow hospitals to

access these documents electronically.

8. In this next section, I will present information on the adoption of electronic health records in the

United States. Specifically, I will describe EHR adoption trends for physicians and hospitals. Then, I

will present some of the barriers to adoption. Finally, I will talk about an important U.S. law that

encouraged adoption of EHR that you should be aware of.

9. This chart is from CDC. As you can see the adoption of EHR in physicians’ offices has increased

impressively in the last ten years or so. According to the CDC, “in 2011, 57% of office-based

physicians used electronic health record (EHR) systems, with use by state ranging from 40% in

Louisiana to 84% in North Dakota.” According to Simborg et al (2013), by 2018 there will be “near

universal EHR adoption.”

10. Similarly, hospitals’ adoption of EHR has grown rapidly, according to a survey by DesRoches et al.

(2013). Nonetheless, less than half of hospitals had at least basic EHRs in 2012. Yikes!

11. What are the primary concerns regarding physician EHR adoption? According to the survey by CDW

Healthcare, the most common response to why they weren’t adopting EHR was the cost. In my

opinion, many of the other reasons could be categorized as “a big adjustment to how we work.”

12. The HITECH ACT, cleverly spelled with the first letter of Health Information Technology for Economic

and Clinical Health, was a part of the American Recovery and Reinvestment Act of 2009. If you recall,

ARRA was the major legislation called the “stimulus” that was designed to rescue our free-falling

economy.

To overcome the objection of cost as a reason to not to implement EHR, the federal government

designated about $28 billion in HITECH to encourage EHR adoption. The systems must meet the

“meaningful use” standard in order to qualify for the incentives. I will explain this in the next slide.

Also, hospitals and physician practices that do not adopt the technology are subject to financial

penalties starting in 2015.

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Also, one of the main goals of HITECH was to develop systems interoperability so that all of the

systems could talk to each other. In other words, the EHR information must flow from one provider

organization to another.

Finally, HITECH also funded $564 million to state governments to lead the development of

technology infrastructure to move secure health information data among providers and between

providers and consumers. Once the health information exchanges are running, data can be collected

across the continuum of patient care allowing for informed medical decisions, and the promotion of

prevention and effectiveness. Prevention and effectiveness will come later when the exchanges are

ready for health service researchers to analyze the data that will be collected from the EHRs to look

at population health, and compare treatments to determine which is more effective Health

Information Exchanges (HIEs) will assist providers in sharing encrypted data (Blumenthal, 2010).

13. For providers to be eligible for incentives offered in HITECH, their EHRs must meet “meaningful use”

standards. There are certifying organizations that ensure that meaningful use is included in an EHR

system. The meaningful use components include:

EHR to be used in a meaningful manner (such as computerized physician order entry, able to

maintain list of patient allergies and active medications, and drug interaction check

capabilities)

EHR technology to be used for electronic exchange of health information to improve the

quality of health care

EHR technology to be used to submit clinical quality and other measures

14. Now I want to talk about electronic health records, also known as electronic medical records. To

explain EHR, I will show you a physician EHR system, discuss hospital EHR system functions, and give

you details about pharmacy functions of hospital EHRs.

15. The EHR is a form of technology that influences the patient–physician relationship, depending on

the type of program a physician uses. The most robust electronic medical record systems, such as

the screenshot from eClinicalWorks shown here, can prompt patients to schedule follow-up

appointments, have laboratory tests, obtain vaccinations, and so on.

16. This figure from DesRoches et al. (2013) show the percentage of hospitals that have implemented

specific functions of EHR systems in 2012. As you can see a vast majority collect smoking status,

patient vital signs, lab and prescription tracking. Over half had some decision support for key illness

types.

17. One of the most important improvements to quality and cost reduction is from computerized

physician order entry of prescriptions (CPOE). Medication errors are reduced from the system

warning providers about drug interactions or contraindications. In addition, systems can support the

provider in deciding which medication is appropriate for the patient. Finally, implementation of a

pharmacy bar code scanning system helps to reduce medication dispensing errors at large hospitals.

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According to Nanji et al. (2009), the idea with bar codes is that “they ensure that the correct

medications are dispensed to patient care units [by the pharmacist] and that they carry a bar code

for nurses to scan before administering the dose to a patient” [to confirm that it is the correct

patient and medication combination].

18. In this next section of the lecture, I will review some topics associated with billing and health

information technology. First, the revenue cycle management is a phrase that describes the

complete billing process for healthcare providers. Medical coding and billing are the details of how

providers get paid. The diagnosis and billing codes are what go in the electronic health records and

on the claims (the term for bills in healthcare) sent to healthcare payers.

19. Revenue cycle management is the business process of providing care, working with payers,

submitting claims, and collecting money. As you can see from this figure, it is quite complex, and

therefore, health information technology can greatly produce cost saving efficiencies. The figure

follows a patient from the point of scheduling and registration certification all the way around to

management of the hospital’s contracts with payers. The circles in blue identify the steps in the

revenue cycle where HIT is especially relevant. Note that the first blue circle on the left is

“encounter charge capture coding.” In essence, this is the step where the provider enters the

diagnosis of the patient and the services provided. Ideally, this is done in EHR. If electronic, the next

steps of medical record documentation, HIM coding, and claims submission can avoid paper

altogether. The final three blue circles deal with either accepting payment or dealing with rejections

by the payers. Effectively managing this process is very important for a hospital’s financial health.

20. This is physician office medical coding and billing process. It is less complex than the hospital

process, as there are less “mother-may-I” permissions needed with payers. Nonetheless, you can

see how EHR would make the process paperless. Note that Step #3 is the coding process done by

the physician or a coding specialist. I will present information about these codes in the next slide.

21. Diagnosis codes. First, diagnosis codes are called International Statistical Classification of Diseases

and Related Health Problems (or ICD) codes. These are codes used to classify the disease or

condition that a patient has. The version used in the U.S. now is ICD-9, as implementation of the

newest version, ICD-10, has been delayed several times. There will be automated crosswalks from

ICD-9 to ICD-10 in EHR systems to help providers select the appropriate codes. For example, the ICD-

9 code for “extrinsic asthma, unspecified” is 493.00. The ICD-10 code for a similar diagnosis,

“predominantly allergic asthma” is J45.

Earlier in the semester, I told you that Medicare uses diagnosis codes to create inpatient payment

amounts. To prevent hospitals from billing for many different services, Medicare decided to pay the

hospitals the average cost of caring for patients with groups of certain diagnosis codes. For example,

all congestive heart failure related DRGs are paid the same thing under DRG 127. This way, the

hospital has to manage their costs in order to make a profit under a certain “diagnosis-related

group” or DRG prospective payment system.

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22. Now on to billing codes. In the provider office environment, claims are sent with Current Procedural

Terminology (CPT) codes. Created by the American Medical Association, the CPT code set identifies

the health services provided to the patient. For example, the CPT code for an initial examination and

management of a newborn baby would be 99460. Subsequent E&M visits by a physician for a

newborn would be coded as 99462. Of course, EHRs help the physician choose the delivered service

and the system knows the associated code.

There are other coding sets that are used for billing in U.S. healthcare, also. Healthcare Common

Procedure Coding System (HCPCS) is the coding set for products, supplies, and services not included

in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics,

and supplies (DMEPOS). Logical Observation Identifiers Names and Codes (LOINC) are used for

laboratory services. Finally, National Drug Code (NDC) are used for pharmaceuticals.

23. Students need to be familiar with the Health Insurance Portability and Affordability Act, 1996

(HIPAA) to understand health information technology in the U.S. While the first part of the act, the

portability portion, enables people to continue their health insurance after they leave a job that

offered health insurance, the second part covers rules around personal health information in

electronic form.

First, HIPAA set many needed standards for healthcare organizations in the U.S. to exchange health

information. For example, there is a set format for data files containing health plan enrollee

information (aka, 834). This standard makes the exchanges more efficient.

Protected health information (or PHI). PHI is any individually identifiable information that “relates to

the past, present, or future physical or mental health or condition of any individual, the provision of

health care to an individual, or the past, present, or future payment for the provision of health care

to an individual.” There are certain standards for de-identifying PHI that include removing name,

address, etc. from the data.

According to CMS, “the Privacy Rule establishes national standards to protect individuals’ medical

records and other personal health information and applies to health plans, health care

clearinghouses, and those health care providers that conduct certain health care transactions

electronically.” Essentially, the Privacy Rule applies to the right of the patient to control to whom

their protected health information is disclosed.

According to CMS, “the Security Rule requires appropriate administrative, physical and technical

safeguards to ensure the confidentiality, integrity, and security of electronic protected health

information.” In other words, the Security Rule governs the mechanisms by which the PHI is

protected, these are the technical safeguards.

24. The Affordable Care Act attempts to make additional inroads into EHR adoption by providing an

additional $19 billion in funding. These grants include the Health Center Controlled Network grants

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to Federally Qualified Health Centers in the U.S. As you may remember, FQHCs are important safety

net providers for uninsured and other vulnerable populations. Finally, probably the most noticeable

health information technology development from the ACA was the health insurance marketplace. I

present more on the exchange next.

25. Remember, the health insurance marketplaces are online shopping sites established by the

government so that people could shop for qualified health insurance plans. Also, these marketplaces

help consumers determine their eligibility for and facilitate enrollment in federal subsidies and

public programs.

There were three options for the development of the health insurance marketplaces in each state of

the U.S. First, the states could build and operate their own web marketplace. The states could also

build and operate an exchange in partnership with the federal government. Or the state could

default to a health insurance exchange run by the federal government, as Florida did.

Many of these online marketplaces, including the federally built site, struggled in the roll-out in late

2013 and early 2014. Problems with contractors led to escalating costs and missed deadlines.

Eventually, the bugs were worked out, and millions of people obtained health insurance through the

websites.

26. Here are some take-aways from this lecture:

HIT improves coordination of care through information continuity

HIT improves access, quality, costs and patient-centeredness

Although still lacking, EHR adoption has increased impressively recently

HIT improves healthcare billing process efficiency