Electronic Health Record's Could Help Identify Which Patients Most Need ICU Resources

A national shortage of critical care physicians and beds means difficult decisions for healthcare professionals: how to determine which of the sickest patients are most in need of access to the intensive care unit.
What if patients’ electronic health records could help a physician determine ICU admission by reliably calculating which patient had the highest risk of death?

Emerging health technologies – including reliable methods to rate the severity of a patient’s condition – may provide powerful tools to efficiently use scarce and costly health resources, says a team of University of Michigan Health System researchers in the New England Journal of Medicine.

“The lack of critical care beds can be frustrating and scary when you have a patient who you think would benefit from critical care, but who can’t be accommodated quickly. Electronic health records – which provide us with rich, reliable clinical data – are untapped tools that may help us efficiently use valuable critical care resources,” says hospitalist and lead author Lena M. Chen, M.D., M.S., assistant professor in internal medicine at the University of Michigan and an investigator at the Center for Clinical Management Research(CCMR), VA Ann Arbor Healthcare System.

The UMHS and VA study referenced in the article finds that patients’ severity of illness is not always strongly associated with their likelihood of being admitted to the ICU, challenging the notion that limited and expensive critical care is reserved for the sickest patients. ICU admissions for non-cardiac patients closely reflected severity of illness (i.e., sicker patients were more likely to go to the ICU), but ICU admissions for cardiac patients did not, the study found. While the reasons for this are unclear, authors note that the ICU’s explicit role is to provide care for the sickest patients, not to respond to temporary staffing issues or unavailable recovery rooms.

A few integrated health care systems such as the Veterans Affairs (VA) Healthcare System and Kaiser Permanente Northern California have already tapped into the ability of electronic health records to generate reliable estimates of the risk of dying within 30 days for every patient on admission. This type of data could determine for instance whether a patient had a 3 percent chance or 80 percent chance of dying within the next month. Calculations are based on real-time data of laboratory results, demographics, coexisting conditions and vital signs. Authors note that this existing technology may be used to help assess ICU admissions.

“We are not suggesting this calculation be used alone in making these decisions but it’s another tool that may – with more research – eventually help physicians making difficult triage decisions. It may potentially help address our critical care shortage too,” says Chen, who is also a member of theU-M Institute for Healthcare Policy and Innovation. ICUs were opened decades ago to care for the sickest patients using the newest technology. Today, critical care in the U.S. costs more than $80 billion a year. With an aging population and growing demand for critical care, the shortage of ICU resources has become a major healthcare issue.

There are other benefits for healthcare institutions that explore the role of health information technology in ICU care. The Medicare and Medicaid EHR Incentive Programs provide financial incentives for providers who show that they are “meaningfully using” electronic health records to improve patient care.

“There are serious incentives for hospitals to use electronic health records in a meaningful way and it’s important to identify aspirational goals for health IT now, “ Chen says. “We may not have the abilities to achieve all of these goals today, but it’s important to put them in place to support a longer term vision of how health IT might transform patient care.”

Additional authors: Anne Sales, Ph.D., R.N., and Timothy P. Hofer, M.D. of the VA Center for Clinical Management Research and U-M. Edward H. Kennedy, M.S., formerly of the VA Center for Clinical Management Research is now a graduate student at University of Pennsylvania.

Funding: Chen is supported by a Career Development Grant Award (K08HS020671) from the Agency for Healthcare Research and Quality. This material is the result of work supported with resources of VA Health Services Research and Development Center for Clinical Management Research, VA Ann Arbor Healthcare System.

Disclosure: None

Reference: “Use of Health IT for Higher-Value Critical Care,” Jan.30, The New England Journal of Medicine, DOI: 10.1056/NEJMp1213273.

HIPAA Omnibus Rule

The Office for Civil Rights (“OCR”) of the Department of Health and Human Services has released the overdue, and much anticipated, omnibus final rule modifying the HIPAA Privacy, Security, Breach and Enforcement Rules. "Much has changed in healthcare since HIPAA was enacted over 15 years ago," HHS Secretary Kathleen Sebelius said in a statement. "The new rule will help protect patient privacy and safeguard patients' health information in an ever expanding digital age."

Notably, the HITECH Final Rule does not address the May 2011 proposed accounting and access report rule. The four rules that combine to create the omnibus final rule include:

• Modifications to the HIPAA Privacy, Security, and Enforcement Rules mandated by the Health Information Technology for Economic and Clinical Health Act, and certain other modifications to improve the rules, which were issued as a proposed rule on July 14, 2010.
• Changes to the HIPAA Enforcement Rule to incorporate the increased and tiered civil money penalty structure provided by the HITECH Act, originally published as an interim final rule on Oct. 30, 2009.
• A final rule on Breach Notification for Unsecured Protected Health Information under the HITECH Act, which replaces the breach notification rule's "harm" threshold with a more objective standard and supplants an interim final rule published on Aug. 24, 2009.
• A final rule modifying the HIPAA Privacy Rule as required by the Genetic Information Nondiscrimination Act (GINA) to prohibit most health plans from using or disclosing genetic information for underwriting purposes, which was published as a proposed rule on Oct. 7, 2009.

“This final omnibus rule marks the most sweeping changes to the HIPAA Privacy and Security Rules since they were first implemented,” said HHS Office of Civil Rights Director Leon Rodriguez. “These changes not only greatly enhance a patient's privacy rights and protections, but also strengthen the ability of my office to vigorously enforce the HIPAA privacy and security protections, regardless of whether the information is being held by a health plan, a health care provider, or one of their business associates.”

On Wednesday January 23, 2013 at 2:00 pm Eastern Time I will join Deven McGraw and David Harlow for a Hangout where we will discuss the new HIPAA omnibus rules. These are two attorneys who are national experts on healthcare. David Harlow is a seasoned healthcare attorney and consultant recognized as an accomplished, innovative and resourceful thought leader in health care law, strategy and policy. Deven McGraw is the Director of the Health Privacy Project at the Center for Democracy and Technology (CDT). Deven has a strong background in healthcare policy. Prior to joining CDT, she was the Chief Operating Officer of the National Partnership for Women & Families, providing strategic direction and oversight for all of the organization's core program areas, including the promotion of initiatives to improve healthcare quality. You will be able to view the discussion live, ask questions, and also see the archived video afterward. It will be broadcast on Google Plus and the archive made available on YouTube.

As promised, here is the video from the Hangout :-)

2013 Health Matters Conference

The second annual conference, “Health Matters: Activating Wellness in Every Generation,” was held Tuesday, January 15. In addition to President Bill Clinton and his daughter, Chelsea, participants included Barbara Streisand, Noel Bairey Merz, M.D., Deepak Chopra, M.D., Humana Chairman of the Board Mike McCallister, PGA TOUR Commissioner Tim Finchem, Dr. David Satcher, former U.S. Surgeon General, and Dr. Donald Berwick, former administrator of the Centers for Medicare & Medicaid Services. 

In his keynote address President Clinton noted that the U.S. spends more than 17% of its gross national product on health care, far more than other wealthy countries, and yet we don’t manage to care for 100% of our people. Some of these costs are the result of obesity, diabetes and largely preventable chronic diseases, he said.

The video below contains the opening remarks from President Clinton, some framing comments from Dr. Don Berwick, as well as a fascinating discussion between the former President and Dr. Nancy Snyderman from NBC News. This is followed by an outstanding panel discussion on transforming our healthcare system.

Video: Welcome and Opening Remarks by President Bill Clinton



Health Transformation Panel

Framing Speaker: Dr. Donald M. Berwick, Former President & CEO, Institute for Healthcare Improvement; Former Administrator, Centers for Medicare & Medicaid Services
Panel
Moderator: Dr. Nancy Snyderman, Chief Medical Editor, NBC News
Dr. Kelvin Baggett, Senior Vice President and Chief Medical Officer, Tenet Healthcare Corporation
Dr. Donald M. Berwick, Former President & CEO, Institute for Healthcare Improvement; Former Administrator, Centers for Medicare & Medicaid Services
Michael McCallister, Chairman of the Board, Humana Inc.
Susan Siegel, Corporate Vice President GE; CEO, GE healthymagination
Dr. Peter Tippett, Chief Medical Officer, Vice President of Innovation, Verizon

A Man among Millions

If you do nothing else today, be sure to listen to this...



Ross Martin, MD President Founder and Fellow of the American College of Medical Informatimusicology (formerly of Deloitte) expressed this heartfelt word piece at the ONC Annual Symposium on December 11th, 2012. The words are posted HERE on Ross's personal blog.

HIT Men & Women of the Healthcare IT Industry

Folks are beginning to gear up for the HIMSS Annual Conference & Exhibition of 2013 to be held in New Orleans from March 3rd through the 7th. I will be there and plan to prime the pump with some posts before the event and also provide analysis from the keynotes, educational sessions and the exhibit hall. One cool thing for me this year is particpating in the H.I.T. Men and Women awards.

The H.I.T.Men & Women awards are given to the who's who and game changers in HIT. The annual H.I.T.Men & Women Awards Reception is held at HIMSS and recognizes the men and women considered among the most influential throughout the HIT industry, as chosen by the readers of Healthcare IT News. Winners will be chosen from the three following categories:

• Enhancing Patient Care through IT
• Shapers and Influencers
• Innovators, Up and Coming

I am nominated for the "Enhancing Patient Care through IT" category. Voting is open until January 20, 2013 and you can read the bios and vote HERE. Here are my choices for each category:

Enhancing Patient Care through IT
Brian Ahier (ME)
Lynn R. Witherspoon,MD
Mark Hulse, RN

Shapers and Influencers
Joseph Kvedar, MD
Regina Benjamin, MD
John Halamka, MD

Innovators, Up and Coming
Paul Tang, MD
Clayton Nicholas
Wil Yu

It will be fun to celebrate the winners no matter what happens. This is an amazing group of individuals and I am honored to be included. Please be sure to register for the reception on Monday, March 4, 2013, 6:30 pm at the J.W. Marriott on 614 Canal Street in New Orleans. See you there :-)

Healthcare Impact of the "Fiscal Cliff" Deal

Members of the U.S. House of Representatives have voted by 257-167, with 172 Democratic votes and only 85 Republicans voting in favor, to approve the previously Senate-passed bill that will avert the so-called "fiscal cliff" of automatic tax increases and mandated spending cuts. Under the plan, taxes will increase for individuals making more than $400,000 a year and couples earning more than $450,000, as well as on investment profits and dividends, the first U.S. income tax increase in 20 years. The package will extend unemployment benefits for a year and boost taxes on large inheritances. It also allows payroll taxes to go back up to 6.2% this year from 4.2 percent in 2011 and 2012, amounting to a $1,000 tax increase for someone earning $50,000 a year. The "fiscal cliff" bill is the result of two days of marathon negotiations between the White House and Senate Republicans. It was passed in an unusual vote early on New Year's Day, 89-8. Senate Minority Leader Mitch McConnell said the compromise was an "imperfect agreement" that will keep tax hikes from affecting most Americans. There are significant effects on healthcare as part of this package.

The nonpartisan Congressional Budget Office released a report estimating that the Senate bill would add $329 billion to deficits in 2013 and $3.9 trillion to deficits over the next 10 years, relative to current law. The CBO analysis of the bill shows fiscal 2013 revenues would be $280 billion lower and spending $50 billion higher, resulting in a $330 billion deficit increase, for a total deficit of around $971 billion in 2013. The bill would apply another temporary SGR fix and block the scheduled 27% payment cuts to Medicare providers, and keep rates frozen at current levels for one year. A companion CBO report (PDF) entitled Detail on Estimated Budgetary Effects of Title VI (Medicare and Other Health Extensions) of H.R. 8, the American Taxpayer Relief Act of 2012, As passed by the Senate on January 1, 2013 gives the details of the impact to Medicare. Among the provisions affecting healthcare (hat tip to Matthew Taber) are:

• elimination of funding for Medicare Improvement Fund
• rebasing of State DSH allotments
• repeal of the CLASS program (part of the ACA)
• creates commission on Long Term Care
• ambulance add-on services
• extension of payments for low-volumne hospitals
• extension of MDH program
• extension Medicare Advantage special needs programs
• extension of medicare reasonable cost contracts
• extension of qualifying individual program
• extension of transitional medical assistance program
• extension of S-CHIP Express Lane
• extension of family-to family health information center
• extension of indian diabetes program
• coding adjustment for MS-DRGs
• revisions to Medicare ESRD bundled payments
• treatment of multiple service payment policies for therapy services
• payment for certain radiology services
• adjustment of equipment utilization rate for radiology 
• elimination of overpayment for diabetic supplies
• removes obstacles to collection of overpayments
• improves medicare advantage coding intensity adjustment

The bill rescinds all unobligated funds for a program in the health care law to help set up consumer-oriented nonprofit health plans. The bill will create a contingency fund of 10 percent of current unobligated funds to help co-op plans that have already been approved. Savings from this provision amount to $2.3 billion. Also under the bill, the Medicare Improvement Fund would be eliminated, saving $1.7 billion.

The legislation cuts $4.9 billion by changing the bundled payment given for end-stage renal disease services. An additional $300 million will come from cutting payment rates by 10 percent for non-emergency ambulance services used by patients with end-stage renal disease. There is also $1.8 billion projected to be saved by reducing reimbursement for multiple therapy procedures when performed on the same day.

The bill is a mixed bag in that it would require that hospitals pick up nearly half of the approximately $30 billion cost of stopping the 27% payment cut. The legislation will reduce hospital payments in two ways: number one, it will cut $10.5 billion from projected Medicare hospital payments over 10 years for inpatient or overnight care; number two, it will reduce Medicaid disproportionate share payments to hospitals by an additional $4.2 billion over the next decade.

Statements from stakeholders:

American Hospital Association

Federation of American Hospitals

National Association of Public Hospitals and Health Systems

Researchers Identify Ways to Improve Quality of Care Measurement from Electronic Health Records

Health care providers and hospitals are being offered up to $27 billion in federal financial incentives to use electronic health records (EHRs) in ways that demonstrably improve the quality of care. The incentives are based, in part, on the ability to electronically report clinical quality measures. By 2014, providers nationwide will be expected to document and report care electronically, and by 2015, they will face financial penalties if they don't meaningfully use EHRs.

A new, federally-funded study by Weill Cornell Medical College in the Jan. 15 issue of Annals of Internal Medicine demonstrates ways in which quality measurement from EHRs — which are primarily designed for documentation of clinical care for individual patients — can be improved. In a large cross-sectional study in New York state, researchers demonstrated that the accuracy of quality measures can vary widely. Electronic reporting, although generally accurate, can both underestimate and overestimate quality.

"This study reveals how challenging it is to measure quality in an electronic era. Many measures are accurate, but some need refinement," says the study's senior author, Dr. Rainu Kaushal, director of the Center for Healthcare Informatics Policy, chief of the Division of Quality and Medical Informatics and the Frances and John L. Loeb Professor of Medical Informatics at Weill Cornell.

"Getting electronic quality measurement right is critically important to ensure that we are accurately measuring and incentivizing high performance by physicians so that we ultimately deliver the highest possible quality of care. Many efforts to do this are underway across the country," continues Dr. Kaushal, also a professor of pediatrics, medicine, and public health at Weill Cornell and a pediatrician at the Komansky Center for Children's Health at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.

For this study, Weill Cornell researchers analyzed clinical data from the EHRs of one of the largest community health center networks in New York state. The research team examined the accuracy of electronic reporting for 12 quality measures, 11 of which are included in the federal government's set of measures for incentives. What they found was fairly good consistency for nine measures, but not for the other three.

"The variation in quality measurement that we found in a leading electronic health record system speaks to the need to test and iteratively refine traditional quality measures so that they are suited to the documentation patterns in EHRs," says the study's lead investigator, Dr. Lisa Kern, a general internist and associate director for research at the Center for Healthcare Informatics at Weill Cornell.

The automated reports generally performed well. However, they underestimated the percentage of patients receiving prescriptions for asthma and receiving vaccinations to protect from bacterial pneumonia. A third measure suggested that more patients with diabetes had cholesterol under control than actually did. The automated report said 57 percent of eligible diabetic patients had cholesterol controlled, while a manual check of the charts showed it was actually only 37 percent. Part of the problem is that physicians and nurses filling out the EHRs may be typing in information in a place that is not being captured by quality reporting algorithms.

"EHRs create the opportunity to measure and provide feedback to clinicians regarding quality performance in real time, thereby improving clinical practice," says Dr. Kern, who is also an associate professor of public health and medicine at Weill Cornell.

Dr. Kaushal adds, "EHRs are not just electronic versions of paper records but rather tools that enable transformation in the way care is delivered, documented, measured and improved. The federal meaningful use program will enable the deployment of these promising systems across the country, thereby enabling health care to enter the digital age."

This study was funded by the federal Agency for Healthcare Research and Quality and featured in an AHRQ exemplary video, entitled "Developing and Testing Quality Measures for Interoperable Electronic Health Records."

Principal Investigator: Rainu Kaushal (Grant No. R18 HS 017067)
The story features the four-part process that began in 2007 by Dr. Rainu Kaushal and her team to generate and test the reliability of prioritized quality measures from the ambulatory setting. Fifteen of these measures were subsequently included in Meaningful Use.

via Weill Cornell Medical College