Tag: EMR

Your Health Information: Where do you want it?

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My extreme concern about data protection and privacy have made me wonder how effective the drive to electronic medical records (EMRs) will be, particularly in the behavioral health arena. My clearest recollections from the first day of my psychology internship at a community mental health center are all of the instructions related to protecting patient privacy. As a mental health software vendor, I have continued to have this strong drive to protect the data of any patient. Finally, HIPAA and HITECH have caught up with the concerns of those of us trained to put patient privacy protection ahead of most other concerns.

The rush to EMRs that can share information with one another (interoperability) has as its goal diminished costs and increased quality of health care. The need to keep that information secure and private is usually dealt with almost as a side issue. I have often heard statements like these: “Why, of course the data will be protected. Why are you so worried about keeping data private? Sharing it with other providers is much more important than privacy. Some compromises will need to be made . . . ”

The American Medical Association, in their discussion of patient confidentiality, briefly indicate their concerns about EMRs.

Electronic health information systems allow increased access and tranmission [sic] to health data.  Physicians in integrated delivery systems or networks now have access to the confidential information of all the patients within their system or network. Confidential information also is disseminated through clinical repositories and shared databases. Sharing this information allows patients to be treated more efficiently and safely. The challenge for physicians is to utilize this technology, while honoring and respecting patient confidentiality.

Sharing confidential information among treating professionals is only one aspect of this issue. Now we must consider to the issue of sharing the electronic data with the patient.  

According to John Fully on nextgov, patients want access to the information stored in the electronic records about them maintained by their physicians. 93% of patients have rarely or never asked their physicians for electronic copies of their data, but 70% say it is very important to them that doctors and hospitals provide those electronic records. 60% of patients and over half of physicians say sharing information from EMRs with patients will be a crucial measure of how successful health care reform and provision of stimulus dollars has been.

One potential method for sharing those electronic records is the Personal Health Record (PHR). After all, having an electronic copy of the physician’s record but having no way to store or to access it will not be a very beneficial state. As a result, provider organizations, payers, and even Medicare have begun to connect EMRs, claim histories, and PHRs as an effective way of tracking your health.

Even so, patients are hesitant.

. . . while the products use some of the same technology that banks use to secure financial data, some patients remain wary of putting health information online. Only about 4% of the online population uses Internet-based PHRs, according to Elizabeth W. Boehm, a principal analyst at Forrester Research Inc. in Cambridge, Mass. Many people don’t see the need, Ms. Boehm says, while others are nervous about putting confidential health information online.

That figure is telling. It is not that only 4% of patients use a PHR . . . only 4% of the online pupulation uses one . . . only 4% of the people who use the Internet all the time utilize an online PHR.

I have registered for the PHR used by my insurer. The Privacy policy says all the right things. I have entered some information into it, but I am still hesitant to put everything there. The conventional wisdom is that these programs are secure. I’ll give you an example of why I am slow to completely adopt.

About 18 months ago, I noticed that one of my mother’s physician claims was rejected by her Medicare supplemental plan. When I looked at the EOB more carefully, I noticed that it had been filed on my insurance plan rather than on my mother’s Medicare supplement plan. Since we both have the same insurer, I telephoned, explained what had obviously happened and was assured that it would be corrected. When I checked my PHR today prior to writing this blog, I found that claim still sitting in my record.

I have never been a patient of the physician who filed the claim, so I know he did not file the claim with my insurance information. I am thirty years younger than my mother and my first name does not come close to hers. But the same last name and address resulted in this confusion that has not yet been corrected. I cannot help but wonder what other two bits of information might result in the confusion of something important in my file and that of some stranger. Since this payer automatically adds claim information to the PHR, their system now sees me as the patient of a cardiologist . . . something I have not yet become. I wonder what other data confusions I have in store.

What is your take on PHRs? How do you see them affecting the behavioral health community? Please enter your comments below.

Bullying, Privacy, Decency: Where do we stand?

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This morning I saw a friend’s Facebook link to Kathleen Parker’s Washington Post column, With Tyler Clementi’s Death, Let’s Try Friending Decency. On Friday, I had seen an email from the Unitarian Universalist Association, Church of the Larger Fellowship, pointing me to a blog post by the senior minister, Rev. Meg Riley entitled How Can We Create a World Where All Young People Feel Safe? Each of these authors focuses on a different aspect of the tragic death by suicide of an 18-year-old. Parker focuses on the obscene invasion of privacy of this gay young man; Riley focuses on bullying of lesbian/gay/bisexual/transgender (LGBT) young people and on others seen as ‘different’.

If you are unfamiliar with the events, this CBS News report will give you a four-minute overview. To make it short . . . Roommate 1 and his friend decide to publicly out his gay Roommate 2. Roommate 1 sets up webcam in their shared dormitory room, records and then, with the help of friend, publishes online Roommate 2 making out with his male date. Roommate 2 is so humiliated that he announces his suicide on Facebook and jumps to his death from the George Washington bridge. Tyler Clementi’s suicide was the fourth widely reported death by suicide of an LGBT teenager in the past few months.

Roommate 1 and his friend have been charged with invasion of privacy. It is yet to be decided whether they will also be charged with a hate crime.

Both Kathleen Parker and Meg Riley conclude that all of us must assess our own behavior and determine how we can behave differently to preclude such events in the future. Parker’s solution would be accomplished by the community of ‘decent’ folks refusing to tolerate invasions of privacy. . . our own or that of anyone else. Riley’s focus is on bullying of lesbian and gay kids and argues that we must ‘stand on the side of love’ refusing to allow people to be victimized because they are different from most of us in any way.

Reading these articles and viewing the news report on these sad events inevitably makes me think about our current rush to electronic medical records (EMRs) in the world of behavioral health care and chemical dependency treatment. How will be assure the protection of the privacy of the vulnerable populations we treat? Will we put them even more at risk by how we handle the records of their treatment?

I am reminded of a conversation with a customer several years ago. They were in the process of implementing their second try at an EMR. They were working on issues of security and access to data, and were attempting to make decisions about how to handle employees who read the treatment records of clients they have no business viewing. One of their experiences was with a staff person reading the record of a neighbor; another was a family member viewing a cousin’s record.

Of course, these breaches of privacy could almost as easily occur in a paper record world. Pulling a file off a shelf or out of a file drawer is not much harder than calling the record up on the computer. The paper record probably takes a bit more effort and sneaking around than just logging into the EMR that sits on the organization’s network and taking a quick look at what is entered there. Cases in California two years ago emphasized this; medical and nursing staff who had a right to view hospital records did not seem to hesitate at viewing the records of celebrities in their hospital for treatment, whether involved in their care or not. 2009 laws in California increased reporting requirements if inappropriate access of records is discovered. Last year’s HITECH requirements also focus this issue.

It seems to me that the more important issue is how we address the matters of human curiosity and discomfort with others . . . whether celebrities or LGBT clients. How do we create a culture of respect for other people and their right to keep their own information private? Where do we draw the line in our own lives? Do we gossip and tease and reveal secrets shared with us? Or do we empathize and protect and defend those in our lives who are different?

Please share your comments below.

OpenNotes Project: Where does mental health fit in?

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On Monday of this week, Seth asked me if I had a topic for my current blog. As I had none at hand, he pointed me to last week’s episode of the podcast/NPR show, Science Friday. Seth is a regular subscriber to this series and I listen when I find the time. That effort is always rewarded by fascinating discussions of current science issues. For the science professional, wanna-be-scientist or interested layperson, this show is a ready source of truly valuable information.

On Friday, July 30, 2010 the discussion topic was a medical records project called OpenNotes. With the advent of electronic medical records (EMRs) and patient portals into the medical records system, it is only reasonable to begin to consider the nature of the records that physicians keep on their patients. The OpenNotes project is an attempt to allow some 25,000 patients direct access to what 100 participating primary care physicians write in their notes after seeing them.

The project will study the experiences of both the physicians and patients, the impact on work flow of such note taking/sharing, the possible increase in communications between patient and physician, and the reactions of both sets of participants to their experiences. The details of the study are published in an Annals of Internal Medicine article, Open Notes: Doctors and Patients Signing On.

The Science Friday discussion included concerns about sharing sensitive information with the patient and the ability of the patient to understand and process the information included in the note. It has especially been argued that the mental health patient might be too fragile to be exposed to the psychotherapist’s or the psychiatrist’s true evaluation of their status as stated in the progress note.

On the other hand, Concurrent (Collaborative) Documentation has been touted by some community behavioral health specialists as an essential tool for increasing both quality and efficiency of client interactions while simultaneously increasing client buy-in to the treatment plan. The New York State Office of Mental Health writes:

It has been suggested that Concurrent Collaborative Progress Notes were the ‘way to go’. What about uninterrupted direct face to face contact as the best way to achieve high rates of engagement and retention in our clinics?

Concurrent documentation does not require the clinician to take notes during a session or to detach themselves from the recipient. Rather it is advised that at the end of the session, a brief review of the session takes place and the recipient and clinician collaboratively record the progress note. This process supports the delivery of person centered services and often provides the clinician with important feedback about the recipient’s perspective and information obtained from the session.

The process of creating this record concurrent with the meeting and collaboratively with the client is the epitome of an open record. While the OpenNotes project does not go quite this far, it certainly opens the door in this direction. Since the patient owns the record, it seems only fair that they should have easy access to that record and even participate in its creation.

My background as a Feminist Therapist has long given me a strong leaning in this direction. In the view of Feminist Therapy, the treating professional is a consultant having special expertise who is hired by the client to assist them in solving their “problem”. This is certainly also the case in the medical office. The physician has expertise the patient is seeking in their efforts to treat illness and to live healthier lives. This collaborative relationship is more a meeting of equals working together for the patient’s benefit than a dictation of treatment by an authority-figure intent on successful treatment and risk management.

What do you think about opening progress notes to your patients and consumers of service? How would that change the work done by the provider of services? How do you imagine it would change the experience of the consumer?

Please share your comments below.

Information Overload: TMI

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Almost two months passed between my post last week and the last one before that. The combination of family illnesses followed by vacation and recovery from travel put me in a position of being so far behind in the reading I usually do that I could not possibly catch up. My personal inclination was to duck my head and try to ignore the overwhelming sea of information.

I found myself strongly empathizing with practitioners, administrators, and behavioral health care personnel of all stripes who spend their days trying to provide quality mental health services to their patients…and then spend their nights worrying about what has occurred that day that might get in the way of or assist them in doing their job, but not having the time or the energy to pursue that information. Certainly, the information is readily available on the Internet, but who has time.

There have been numerous discussions of the effects of too much information (TMI) on our functioning. In July, 2008 Nicholas Carr wrote an article in The Atlantic called Is Google Making Us Stupid? This year he has written a book length exposition of that subject called The Shallows: What the Internet is Doing to Our Brain. His thesis is that our brains are literally being changed by the way the Internet is organized. He posits that jumping from one place to another by way of hyperlinks results in shallow pursuit of topics rather than the in-depth exploration of a subject allowed by books. In my brief exploration about his book, I found an extremely articulate review and commentary by Venkatesh Rao who mentioned and hyperlinked to the blog of Jason Kottke, a writer whose name I had heard but had never read. I have demonstrated for you an example of Carr’s thesis. I got distracted from obtaining support for my original thought by the way the Internet presents information and by the ease of pursuing that linked information.

Back to my original thought…here I am adding one more place where there is a bit more information for you to take a look at…or not. You might find this a convenient place to check for information about behavioral health care and its place in the world-at-large, or you might drop in occasionally just to see if there is anything that interests you.

For those of you checking in for something interesting, here are a couple of tidbits.

  1. ONC (Office of the National Coordinator for Health Information Technology) has published a final rule in which it establishes a temporary certification program for electronic health records as required under HITECH. As reported by Healthcare & Technology blog, this rule should allow progress toward approval of certifying organizations for EMR products.
  2. iHealthBeat reports on release of final rules for “Meaningful Use”. Many observers believe that the easing of requirements for the meaningful use of an electronic health record required to receive stimulus funds made available under HITECH will make it easier for eligible providers to receive funds. Other observers believe that even the easing of the standards will not make it simple for stimulus funds to be acquired, even for those who have already purchased and implemented EMRs.

It appears that life gets more complicated all the time, even if we have information. Since I do believe that knowledge is power, I will keep trying to pass some of what I come across on to you. Thanks for reading. Please let us know what you are thinking about. Just enter your comments below.

Behavioral Health EMR Systems Learn to Cooperate: A sneak peek at interoperability

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I am on my way back from two and a half days in Phoenix where approximately 40 SATVA (Software and Technology Vendor Association) member representatives, EMR users, and industry IT experts met to find a way for behavioral healthcare providers to exchange patient information using the electronic Continuity of Care Document (CCD). The CCD is the mechanism specified by current healthcare IT initiatives for the communication of critical patient information between providers. Ideally a care provider could rapidly get up to speed on a patient’s status by requesting and receiving a CCD from another care provider already familiar with the patient.

I first heard the term “continuity of care” in a healthcare seminar I took back in graduate school in the early ‘70s. It was an obvious, common sense concept that patients could receive better care at lower cost if providers were able to continue care already started by another provider, rather than starting over, duplicating care already rendered by the previous provider. Continuity of care requires that meaningful, usable information pass from provider to provider. Almost 30 years later, every patient in the US is familiar with the challenges of getting even simple demographic data, much less meaningful health records, transferred from one doctor to another. Well, the CCD might just be a solution to that problem.

Our meeting started with a demonstration of the creation of a CCD by the system of one SATVA member, and the display and subsequent import of that CCD by the system of another SATVA member. These are the exact capabilities that are mandated by 45 CFR, Part 170, HHS’s recently published Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology (Interim Final Rule).

Required or not, systems that are actually doing CCD interchange today are few and far between. To our knowledge, there are NO behavioral health EMR systems that do. Nevertheless, the technical proof of concept was convincingly demonstrated at our meeting — a valid CCD was created, and the generic medical information contained therein was displayed and “consumed” by another system.

In many respects, the technology is the easy part. The challenge that faced our group was to define a standardized way that behavioral health providers can represent their unique domain information within the CCD to allow accurate import by a receiving system. Think, for example, of the five-axis DSM diagnosis — something that exists only in our family of behavioral/mental health specialties. Ultimately, the DSM five axis profile turned out to be the focus of our group’s efforts.

The standard CCD contains sections for identifying information (technically called the Header section), Problems, Procedures, Family History, Social History, Payers, Advance Directives, Alerts, Medications, Immunizations, Medical Equipment, Vital Signs, Results, Encounters, Functional Status, and Plan of Care. A given CCD can contain one or more of these sections, in any order. In this context, the Problems section is normally intended to contain a list of diagnoses, but it is flexible enough to include other information including findings and observations, which means that “problems” in the behavioral health sense could be included when necessary to convey significant information that diagnosis alone could not.

One of the most important aspects of the CCD and related electronic documents is that they must rigidly adhere to standardized sets of coded descriptions that are included in the specification of these documents. For example, when diagnosis codes and descriptions are included in the Problems section, they must be either ICD-9 (until supplanted by ICD-10) or, better, the more universally used SNOMED-CT. The latter includes everything in the ICD, plus a great deal more, and is preferred. Before you get too worried, all the vendors present agreed that it would not be difficult to modify our products to take the sting out of SNOMED for you. Likewise, in Medications, drugs should be listed with their RxNorm codes, and in Results, labs should include LOINC codes. The use of these specific coding systems avoids ambiguity that could potentially result in misunderstandings and serious harm to patients.

The CCD is rendered in XML, a cousin of the HTML code that sits behind the content and presentation of the typical web page. As a result, the CCD can be displayed by any modern web browser. Without getting too technical, the CCD uses a related style sheet that determines the way the CCD data is displayed on screen. As a result, any CCD that you receive can easily be formatted to display in any way you like! Let’s say that you want the Alerts section (which contains important information such as allergies, adverse drug reactions, and perhaps such information as dangerousness) displayed in a bold red font in the top right corner of the page. You can modify your organization’s CCD style sheet to make it so. Thereafter, EVERY CCD you display will have the desired information in the desired font and position. It doesn’t matter who sends it. Compare that to searching through several inches of paper records that bear no resemblance to anything you do in your own organization. See what a breakthrough this would be? Below is the very same CCD, but displayed with two different style sheets. The fancier one is courtesy of Brett Marquard of Alschuler Associates, LLC.

Returning to the meeting, after considerable discussion the group determined that we could, in fact, communicate our beloved DSM axes within the existing CCD specification, with no need for extension or new templates (another component of the document specification). This conclusion was nothing short of huge! The fact that we can get what we need without having to go hat-in-hand to the standards bodies to plead for inclusion of something new means that implementation can go forward on a much faster schedule. Our goal now is much more modest – just an Implementation Guide that describes how and where to put our unique stuff.

If you are still with me, and are curious, we determined that Axes I, II, and III diagnoses will go into Problems, along with additional specific diagnostic criteria (as findings or observations) when necessary. Axis IV will go into Social History, and Axis V will, of course, go into Functional Status.

This initial core group of stakeholders expects to add supporters over the coming months, complete a well-tuned CCD Implementation Guide for Behavioral Healthcare Providers, and put it into use in the field. In the meantime we will move forward, with the expectation of obtaining official adoption by the relevant standards bodies.