A new report from the National Quality Forum reveals that 5 percent or more patients in the U.S are being incorrectly diagnosed.

Those diagnoses contribute to nearly 10 percent of deaths annually, and up to 17 percent of adverse hospital events, according to NQF, whose mission is to improve health and healthcare quality with defined measures.

National Academies of Sciences, Engineering, and Medicine (formerly called the Institute of Medicine), supports that approach for improving diagnoses, noting that the lack of effective measurement related to the diagnostic process and diagnostic outcomes is a major contributing factor.

The NQF’s deep dive into the topic found that most electronic health record systems lack the capacity to capture the evolving nature of the diagnostic process. The committee also recognized the need for interoperability among EHR systems throughout the diagnostic process to assist providers in arriving at an accurate and timely diagnosis.

[Also: Medical mistakes still kill 1,000 patients a day, Leapfrog says]

NQF convened a multi-stakeholder expert panel to develop a conceptual framework for measuring diagnostic quality and safety and to identify priorities for developing future measures. The review resulted in insights for seven areas of inquiry and improvement”

Patient Engagement: Engaging patients and using their knowledge of their own medical histories are critical aspects of the diagnostic process.

Impact of Electronic Health Records: Diagnostic quality and safety can be advanced significantly if electronic health records have the capacity to collect key information related to diagnosis and are interoperable within and across organizations.

Transitions of Care: Transitions of care and errors during care transitions (e.g., loss of information critical to patient care) can have a significant impact on diagnostic quality and safety.

Communication: Communication between the provider and the patient, and between providers – is a key issue in diagnostic quality and safety. When communicating with patients about their diagnoses, healthcare professionals should be sensitive to the patients’ health literacy and cultural needs or preferences.

Engagement with Medical Specialty Societies: Improving diagnostic quality and safety will require medical specialty societies to engage and provide guidance as diagnostic measures are developed, in particular for conditions that are frequently misdiagnosed or can lead to serious harm in the event of a diagnostic error.

Inter-professional Education and Credentialing: Diagnostic quality and safety should become an important component of professional education, and credentialing organizations should ensure that their reviews emphasize diagnostic quality and safety.

External Environment: Issues related to the external environment, such as the alignment of payment incentives to promote timely and correct diagnosis, are less amenable to quality measurement but will have a significant impact on diagnostic quality and safety.

The Office of the National Coordinator for Health IT’s plans to change the ONC Health IT Certification Program has sparked some important questions. Wouldn’t allowing vendors to now simply say they're in compliance, rather than prove it in an ONC-Authorized Testing Laboratory, pave the way for EHR vendors to essentially flout the rules? And what’s to prevent more certification problems such as the eClinicalWorks $155 million settlement?

Or as Andre Thenot tweeted Thursday, "ONC switches to pinky-swear instead of actual compliance testing. #whatcouldpossiblygowrong."

ONC switches to pinky-swear instead of actual compliance testing. #whatcouldpossiblygowrong#HealthIT#EHRhttps://t.co/BgFh63AY1d

— André Thénot (@athenot) September 21, 2017

But National Coordinator Donald Rucker, MD, said ONC wasn't sacrificing any of its regulatory oversight but was simply doing what it could to reduce the hoop-jumping required of vendors so they could better allocate their resources to more usable and interoperable products.

"What we're trying to do here is make things as smooth as possible in the regulatory process," Rucker said Thursday during a call with reporters. "We're not changing the certification requirements, per se. We're doing a little bit of streamlining on the process. So that will hopefully, in part, reduce vendors costs – and in a market economy over time some of those savings come down to providers."

With the new rules, compliance requirements remain the same as ever, according to ONC. But now, rather than vendors having to put in the work to demonstrate, for instance, a relatively simple functionality such as CPOE for medications to a test lab, they can simply affirm that their product does that task, while focusing more of their time and energy on innovation.

But didn't the eClinicalWorks case show that sometimes a verbal promise isn't good enough? And that sometimes more stringent testing – showing, not telling – is necessary?

Rucker doesn't think so.

"The reality is that these are very public products," he said. "They have user bases who immediately know if something is working or not working. If a CPOE doesn't go through, these things are known almost instantaneously. So the vast bulk of the oversight is provided by those using the product. This has to be looked at in the broader context of use. That's where the data was coming from in prior enforcement actions."

Actually, he said the eClinicalWorks case is "a perfect example that what we have in place in fact does work."

The discrepancies with eCW's products were first "noted by end-users," he said. That case was ultimately investigated further thanks to reactive surveillance – not the randomized surveillance that would be reduced as part of these new rules.

ONC still fully intends to take an aggressive approach to reactive surveillance. In fact, just this past month it updated its Health IT Feedback Form, making it easier and more intuitive for providers to approach the agency with complaints or concerns about their products.

"Our experience is that people will report if there are issues with their product," said Rucker.

He emphasized that all certification criteria are still in place and enforceable. And he said he didn't see much changing for ONC-Authorized Certification Bodies and ONC-Authorized Testing Laboratories.

The self-declarable criteria are all relatively basic functionalities, after all. Those that require conformance testing to interoperability standards are still being affirmed by ONC-ATLs.

"There are a lot of things that are still being tested," he said. And even for those criteria that are now self-declarable, "you still have to know how to solve the equation. It doesn't change what you have to learn."

In other words, even with the new rules, when a product is certified, the vendor is attesting that it does what it's supposed to do. If that's later found out not to be the case, either by an ACB or through subsequent reactive surveillance, ONC will take action – correcting where there is a non-conformity or even decertifying a given product.

The bulk of certified technologies "do exactly what is asked of them from the certification criteria," said Rucker. "Building medical software is a highly iterative process. And there are many inputs on this. Because these foundations tend to be so heavily used – minute in, minute out – things become obvious relatively rapidly."

The aim here, said Rucker, is to "increase the operational efficiency of the vendors to the extent that we can. Because those (testing) costs are all eventually, sooner or later, borne by the providers purchasing the products."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

Stanford Children's Health and Lucile Packard Children's Hospital Stanford have been awarded the 2017 Enterprise Nicholas E. Davies Award of Excellence for outstanding achievement in using health information technology to improve patient outcomes.

HIMSS, the Healthcare Information and Management Systems Society, has given the award each year since 1994. It recognizes healthcare organizations' use of information technology to achieve better clinical and financial outcomes.

[Also: Best Hospital IT 2016: Lucile Packard Children's Hospital Stanford taps analytics to advance precision medicine and patient care]

"This is a significant milestone for Stanford Children's Health," Christopher G. Dawes, president and CEO of Packard Children's and Stanford Children's Health, said in a statement. The achievements were made possible through excellent partnerships with clinicians and by leveraging innovative health information technologies and data analytics, he added.

Led by CIO Ed Kopetsky and CMIO Natalie Pageler, MD, representatives from Stanford Children's Health's Information Services and Clinical Informatics teams presented case studies to HIMSS demonstrating the organization's use of technology to improve implementation strategies, workflow design, adherence to best practices and patient engagement. The case studies presented Stanford Children's Health's innovative use of technology in three areas: The prevention of nephrotoxic acute kidney injury in hospitalized children; safety interventions for medication administration; and improved care for patients with congenital heart disease through the Clinical Effectiveness program that uses a data-driven and data-transparent approach to securely collect information from EHRs.

Lucile Packard Children's Hospital Stanford and Stanford Children's Health will be recognized at the HIMSS18 Awards Gala on March 8, 2018, in Las Vegas.

Twitter: @Bernie_HITN
Email the writer: bernie.monegain@himssmedia.com

The treasure-trove of data available to clinicians and usable for making informed decisions is among the by-products of a healthcare organization achieving goals associated with an electronic health record deployment.

As per the Center for Medicare and Medicaid Services (CMS), this data serves as a technology platform to improve the quality, safety and efficiency of patient care, reduce health disparities, engage patients and family and improve care coordination as well as maintain privacy and security of patient health information. 

Healthcare organizations are realizing that a critical success factor to achieving the benefits associated with this newly acquired data is to have operational leadership fully engaged and committed to driving value from the data. Although gaining this engagement may seem simple in concept, creating the dynamic of engagement in multiple organizational areas can be quite challenging. 

From a Chief Information Officer's perspective, I've observed and been privy to some of these engagement challenges which include:

• Inexperience in having data available on which to base decisions.
• Lack of confidence in the validity of the data.
• Disagreement regarding data definitions.
• Concern regarding the outcomes of evidence-based decisions.

Regardless of the reason for initial hesitance, a significant investment is needed to acquire and make required data available to achieve the benefits associated with this investment, or any other technology investment for that matter. Uncovering the reasons behind unspoken assumptions or even healthy skepticism early on is a key component to understanding any potential barriers and allowing one to break through the resistance.

Consider a few options for engaging with operations and other organizational partners to capitalize on the benefits of this newly acquired data:

• Ensure you have a data governance committee that is empowered, meets regularly and has broad representation.
• Identify key health system performance metrics and agree upon the definition and calculation for each.
• Meet consistently with senior leadership to resolve ambiguity in data metrics.
• Educate operational leadership on the self-service tools available to mine data.
• Utilize use case scenarios to display the power of the data.
• Be prepared to provide ongoing support on a shoulder to shoulder basis.

For some, gaining comfort with data and learning to make informed decisions based upon the data will be a journey. As members of the information services community and stewards of this data, it is our responsibility to work collaboratively with operational leadership in order to drive maximum value from our health system's investment.

Achieving this value will enable the prescribed CMS benefits for our patients and community and also create a tighter bond between members of the information services organization and their operational counterparts.

Mike Restuccia is the CIO of Penn Medicine. 

Merck Manuals, an electronic medical reference firm, is integrating its provider reference and patient education content into the Allscripts electronic health records platforms: Allscripts Sunrise, Allscripts Professional EHR and Allscripts TouchWorks EHR.

The companies designed the integration to be seamless and simple, activated by an HL7-compliant “Infobutton.” As such, the materials are readily available to clinicians within the Allscripts EHR workflow. The Merck programs have automatically been authorized for all Allscripts clients. The client healthcare organizations just need to activate the programs and enroll their users to make use of the Merck content.

[Also: KLAS: 'Clock is ticking' for Allscripts to do right by McKesson Paragon customers]

“Partnering with Allscripts builds on our ongoing commitment to disseminate authoritative medical information through content-sharing arrangements with innovators in the healthcare sector,” said Michael Wisniewski, strategic partnership manager for Merck Manuals. “We are continuously looking to build relationships with leading companies and other influential organizations that will expand the reach of our health information resources, which we make available to our partners at no charge.”

The provider reference content contains current information on the symptoms, diagnosis and treatment options for hundreds of diseases. Clinicians can share this information written in a language specifically for patients. The patient education material can be electronically sent to patients through the Allscripts EHR platforms or printed out and handed to them.

[Also: Allscripts picks Vidyo to add telehealth features to patient portal]

Merck Manuals content for providers and patients is available in English, Spanish and eight additional languages.

Merck & Co. published the original Merck Manual for doctors and pharmacists in 1899. The book for professionals is currently in its 19th edition. The first edition of The Merck Manual of Medical Information developed specifically to address the need for understandable medical information among consumers was introduced in 1997. That book made The New York Times best-sellers list.

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com

Healthcare CIOs have what could be considered one of the most difficult tasks within an organization. Not only do they manage the IT teams and needs for the organization, they’re tasked with combatting a wide range of cybersecurity issues and patient-driven technology initiatives .

For Lisa Stump, the CIO of Yale-New Haven Hospital in Connecticut, a top-ranking metro hospital, what makes the job simpler is keeping the patient top of mind, as well as leveraging her clinical background.

“My personal philosophy is that our patients are our true north, and we are privileged to serve them,” said Stump. “The solutions we bring -- and we need to bring them proactively, sometimes leading the business -- need to enhance care and support the clinicians who deliver that care.”

“My background is as a clinician and in operations… and [I’ve] worked to establish and maintain IT’s connection with our operational colleagues,” she added. “We’re often the glue or the people connecting the dots across the organization because of the unique enterprise-wide view that we have: IT is everywhere.”

An Epic EHR rollout

This mission was most apparent in her first role at Yale-New Haven: Vice President and Epic Project Director. In 2010, Stump was tasked with leading the $300 million, multi-year implementation of Epic’s clinical and revenue cycle applications for the hospital system, affiliated physicians offices and the Yale School of Medicine faculty practices.

In a sector marred by many bumpy EHR installs, Yale-New Haven proved successful.

The project was transformational for the replaced the health system and the school of medicine’s disparate EHRs with a single, unified EMR and revenue cycle platform, explained Stump. And as the health system continues to grow, the platform extends with it.

The key to Yale-New Haven’s success? The dedicated team made up of key leaders from the health system’s hospitals and university, and the community, as it was crucial to learn from the experiences of others.

“We hand-selected these individuals based on their capabilities and motivation for the task at hand,” said Stump.

The project plan included input from Yale-New Haven’s doctors, nurses and employees, which Stump said was key to the process. Further, Stump said unnecessary variations in practice were also eliminated during the Epic implementation, as the organization committed to standardized workflows and content.

Throughout the project, Yale-New Haven recommitted to putting patients first and to holding each other accountable -- from clinicians to business owners.

“We lived to our scope, our timeline, and our budget, bringing the project in on time and under budget and achieving HIMSS Stage 7 status,” said Stump.

Patient-driven projects in focus

Patient needs are the driving force behind all Yale-New Haven strategies, which include population health initiatives, patient engagement, telehealth, genomics and even AI.

Yale-New Haven’s population health initiatives aim to lower care costs by zeroing-in on high-risk patients. To Stump, big data and analytics support clinicians in better understanding the needs of these populations and identifying care gaps.

The tools also provide insight into where stakeholders can increase value and monitor how interventions impact the patient population.

“We’re also focusing on patient engagement in the form of telehealth, education and outreach, access and research opportunities as a holistic approach to population health and care delivery,” said Stump. “Genomics, and pharmacogenomics as a sub-specialty, are also part of our strategy to enhance therapeutic outcomes and avoid adverse effects, both of which are key parts of the value equation.”

The health system is also leveraging AI in its predictive analytics projects, to fuel advancements in research, diagnosis and treatment.

“AI is a very interesting field right now and I believe will have profound impact on care,” said Stump.

“We’re actively deploying technologies and features in and with our patient portal to enhance patient engagement and improve the consumer experience,” she added. “Self-service features give patients and consumers more access and more convenience.”

Tackling physician burnout

For the coming year, Stump said Yale-New Haven is focusing on enhancing physician efficiency and well-being in response to physician burnout. The health system is currently deploying technologies to ease some provider burden.

First, the health system will launch MobileHeartbeat-Cure, a secure app for text communication and alerts, which integrates with the EHR to reduce communication delays and secure texts.

Yale New-Haven will also launch Imprivata Tap and Go to eliminate “redundant typing of usernames and passwords.” The single sign-on authentication tool lets physicians wave a badge over a reader to automatically log into virtual desktops.

And to reduce documentation times, the health system is launching two voice recognition projects.

The first leverages M*Modal Fluency Direct to capture the physician’s voice and record data discretely to reduce documentation and note-taking. The other, Virtual Scribes, provides the physician with a scribe via remote connection to assist with chart navigation, documentation, notes and pending some orders.

“We’re seeing significant time savings for our doctors as a result of these technologies, aimed at changing the fundamental paradigm for how we expect doctors to interact with the computer,” said Stump.

At its core, Stump said the health system is continuing to work with Epic to streamline documentation and improve user-friendly tools while making the data and decision support as meaningful as possible.

“Our top challenges are to bring ongoing value to the organization in the face of funding challenges in the health system market,” she said. “Maintaining a highly engaged and talented workforce is a key priority in addressing that challenge.”

Twitter: @JessieFDavis
Email the writer: jessica.davis@himssmedia.com

Hospitals and health systems trying to survive and thrive under value-based reimbursement realize that optimal clinical documentation is key to ensuring quality care and optimizing revenue cycle management.

Giving good feedback to physicians as they chart their care every day, helping them to log their diagnoses and treatments with accuracy, specificity and completeness is an essential skill for the era of accountable care.

Clinical documentation improvement specialists are trained to have a firm grasp the clinical details of high-quality care and to be able to spot gaps in electronic health record charting. Technology – natural language processing, machine learning – can help in big ways, but good CDI also definitely depends on good person-to-person communication and collaboration.

And it can lead to big clinical and financial benefits. Consider the $72.5 million in increased reimbursements enjoyed by Florida Hospital, for instance, thanks to a CDI program that also improved its case mix index, reduced mortality rates and led to greater physician engagement.

More and more hospitals are getting better at CDI, said Denise Johnson, vice president of HIM integrated services at nThrive -- the company that emerged from the merger of MedAssets and Precyse -- but there are still plenty of tips and tricks for doing it better.

There's been a shift recently, as health systems focus more on value-based care, to think differently and documentation, said Johnson, focusing "not just on reimbursement and looking for complications and comorbid conditions, but really looking at it more holistically in terms of an enterprise perspective, expanding into the outpatient space."

Risk-adjusted contracts are causing health systems to place a premium on how chronic conditions are also captured, for example, she said. "That's another challenge that CDI is facing – how to embrace that and how to structure it in such a way that there's that balance."

An important priority to keep in mind, she said, is to manage the burden on doctors.

"The challenge always has been documentation and the competing priorities for physicians," said Johnson. "They have lots of individuals approaching them, around documentation and CDI. What we're seeing too is they're also being queried for information from the coding team still. Then there are the quality metrics that the quality group is focusing in on. And you've got case management also looking at them from a documentation standpoint. In some ways, it feels like they're getting it from all sides.

"So I think one of the challenges organizations are facing today is really how to pull all of that together in a collaborative way in order to maintain that physician engagement without all of the alert and query fatigue that they experience," she said.

So what are the keys to getting physicians on board with CDI, communicating its importance without badgering them into annoyance?

"One of the things we've found that has been really successful is physicians love data," said Johnson. "One of the things we have seen really allowing us to engage with physicians has been giving them their data through our analytics."

For example, "we have the ability to get detailed information for them around their queries, their query response rates – but also comparatively for them to their peer group," she said. "We have the ability, as we're rounding on the floors, to have those conversations – pulling up their data, showing them their trends for the last month, the types of queries they've had and identifying the ways in which we can help them so we don't continue to query them. Because ultimately, that's our goal."

Another opportunity is to collaborate with the clinical informatics team to spotlight ways in which certain necessary documentation elements can be built into their EMR templates, said Johnson. "That's another area we can explore to really engage the clinical team. Whether it's a physician or a physician extender, we have seen that that's been pretty successful in engaging them."

Alerts – real-time notifications to either the clinician or the CDI team, depending on the technology, are another useful tool, when used judiciously, to help make sure "you're getting it right the first time," she said.

"And then the last piece I would highlight is around analytics – leveraging the technology to get robust data back to the physicians to track trends and then to collaborate on the back end, if we're seeing denials, with the denials team so you can close that loop."

But what to measure?

Good analytics depends on good data, of course, and the metrics providers choose to focus on can go a long way toward ensuring a CDI initiative is optimal, said Johnson.

"Obviously we always measure query rates– how many queries are going out? And more importantly, the trends around this queries – what are the top queries you see month over month, are there patterns and trends?"

Even more important is also the response rate, she said. "It's one thing to send a lot of queries, but are you getting that physician response rate and that engagement?" Response time, from query initiation to response, is also important to measure.

Presuming they are responding, what are they saying? Another key metric is the concurrence, or physician agreement rate, said Johnson.

"If you're seeing a high level of disagreement, or non-response, what are the reasons for that? It's not always a physician issue. It could be a CDI education opportunity. Maybe the CDI team is not querying in such a way that the physicians are responding to them."

Production metrics for the CDI team – "how many reviews are they doing per day, for instance, so we can do the right staffing" – are also important as key performance indicators, she said.

"So is tracking and trending things around CC/MCC (complication and comorbidities/major complications and comorbidities) capture rate," said Johnson. "And case mix, obviously, is something all organizations measure. But not just overall case mix but really drilling down and looking at the overall case mix comparatively to the medical and the surgical. Month over month and year over year are you seeing patterns and trends?

"As we get close to Oct. 1," – when thousands of ICD-10 codes will be updated – "it's always important for organizations to take a look at the relative weight changes that will be happening," she added. "And to do that ahead of time so you can forecast."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

Healthcare IT security company Imprivata has partnered with Just Associates to position its Imprivata PatientSecure offering as the top patient ID and data integrity tool for healthcare organizations.

The partners say they will prevent misidentification by retroactively cleaning up patient data and proactively eliminating the creation of duplicate and overlaid medical records.

The average duplication rate in a healthcare organization’s medical records is between 8 and 12 percent, according to the American Health Information Management Association – AHIMA.

[Also: Regenstrief scientist extols open source tool for consolidating patient data from multiple medical records]

Duplicate medical records can result when a single patient has multiple records connected to them or when a single medical record has co-mingled data from multiple patients. To avoid future patient matching problems, Imprivata PatientSecure identifies patients at the source, creating a one-to-one link between a patient’s biometric and the patient’s unique electronic medical record.

With Just Associates, Imprivata executives say they can ensure the integrity and accuracy of patient data by utilizing comprehensive master patient index clean-up services that employ duplicate-detecting algorithms to analyze the data, and leverage an expert workforce and efficient workflow tools to identify and resolve duplicate records and overlays.

“Accurate, complete, and consistent data is necessary to properly identify patients at the point of care,” said Beth Just, CEO at Just Associates.

Imprivata PatientSecure, which employs palm-vein scanning, is directly embedded into self-service kiosks and admission, discharge, and transfer systems so healthcare organizations can easily and accurately identify patients.

 “Having a single solution for patient identity through medical record clean-up and patient matching optimization is critical to ensuring accurate patient identification throughout the care delivery process,” said Sean Kelly, MD, chief medical officer at Imprivata “

Twitter: @Bernie_HITN
Email the writer: bernie.monegain@himssmedia.com

While hospital CIOs have achieved solid returns on investments in outsourcing complex IT, they are also less satisfied with the vendors hosting those technology services, according to Black Book’s new outsourcing report. 

“The biggest surprise is that the EHR companies managed service divisions are scoring better than the standalone outsourcers,” said Doug Brown, managing partner at Black Book. “Cerner, Meditech, McKesson and Allscripts all ranked above 9.0 on a 10.0 scale.”

When it comes to ROI, among the 1,587 people Black Book polled — which includes 807 CIOs and IT leaders as well as 89 CFOs and finance executives — 91 percent of hospitals reported that they either already achieved a return or are within six months of doing so.

[Also: Black Book ranks top population health vendors] 

Eighty-four percent said that outsourcing IT reduces costs and increases efficiencies in ways that are transformative to their business, whether that is EHRs or other mission-critical applications, and 57 percent indicated that they do not view maintaining technology infrastructure as something they must do in-house.

Yet only seven of the 68 qualifying outsourcing vendors Black Book asked about are currently exceeding expectations and, what’s more, 39 percent of respondents answered that their outsourcing experience fell below expectations.

Black Book noted that 77 percent of the dissatisfaction came from working with vendors that bring limited healthcare experience to the table.

[Also: Healthcare's digital divide is getting bigger and other bad news from Black Book]

Do falling satisfaction rates suggest hospitals will outsource less in the future despite the earned ROI?

No. The research found that 58 percent of participants expect it to continue at current levels through 2019 — and 34 percent are planning to outsource more in that same time.

“Fifty-eight percent of healthcare organizations responding said that they expect their usage of IT outsourcing will continue at current levels through 2019, and 34 percent anticipate an increase in IT outsourcing over the next two years,” the firm added. 

Twitter: SullyHIT
Email the writer: tom.sullivan@himssmedia.com

The Pew Charitable Trusts on Friday called on Office of the National Coordinator for Health IT head Donald Rucker, MD, to focus on electronic health records safety particular to pediatric patients as it institutes a voluntary certification program.

“The use of EHRs has contributed to new, unanticipated safety concerns that were not present with paper-based records, and left some safety hazards unmitigated,” Pew wrote in the letter to Rucker. “Many of these safety challenges directly affect care for pediatric patients.”

Pew’s letter was cosigned by the American College Cardiology, American College of Physicians, American Medical Group Association, American Nurses Association, and Children’s Hospital Association.


While EHR vendors already have to prove that their products comply with certain ONC requirements, those neither apply to pediatric populations nor home in on functionality that the letter explained could cause medical errors.

That’s about to change. The 21st Century Cures Act, in fact, includes Section 4001, which requires ONC to establish voluntary certification criteria requirements specifically for pediatric EHRs by the end of 2018.

“Specifically, the criteria developed through this voluntary program should include provisions to detect potential safety concerns before EHR systems are installed and used, and after implementation to identify challenges associated with, for example, customization by a healthcare facility,” the letter said.  

Pew highlighted aspects relevant to pediatric patients including weight-based drug dosing, age-related determinations and tracking height, weight and other vital indicators as EHR functionality particularly susceptible to medical errors.

The letter also urged ONC to integrate existing into the voluntary certification program. The National Quality Forum, for instance, has guidance for evaluating safety, notably the Retract and Re-order measure to avoid drugs being prescribed to the wrong patient.

Another is the Leapfrog Group’s standard for CPOE that includes a test to alerts clinicians when at least 50 percent of common and serious errors arise, which ONC could hold up as an example.

And Pew suggested ONC use its own voluntary Safety Assurance Factors for Electronic Health Record Resilience (SAFER) Guides for evaluating, as well as resurrecting the National Council for Prescription Drug Programs SCRIPT that ONC proposed but did not previously include in the EHR certification requirements.

“As ONC implements provisions from the 21st Century Cures Act,” the letter stated, “we urge you to consider and incorporate improvements to safety — especially for pediatric patients.”

Twitter: SullyHIT
Email the writer: tom.sullivan@himssmedia.com

Black Book on Friday published its roster of the 50 most disruptive tech companies in healthcare.

From startups to household names — literally spanning athenahealth to ZeOmega — these are the companies that hospitals and payers rated highest in the firm’s indicators of positive client experiences. 

Black Book broke out the winners by categories including analytics, cybersecurity, HIM & coding, interoperability, mobile and telehealth as well as pop health and value-based care, among others.

The hottest realms for innovation and disruption?

“Lots of mobile product and services companies. Cybersecurity and blockchain. Interoperability tools between payers and providers,” said Doug Brown, managing partner of Black Book.

See the winners below: 

Twitter: SullyHIT
Email the writer: tom.sullivan@himssmedia.com

Since the last time we checked ONC’s Certified Health IT List, back in July, certification bodies have approved the 2015 edition of 29 more products.

Epic, Cerner, athenahealth, Allscripts, InterSystems, McKesson and others, in fact, have joined the list.

As of July 17, 2017, there were 86 vendors in compliance with the 2015 edition. As of today that has risen to 115.

See ONC’s list below:

Twitter: SullyHIT
Email the writer: tom.sullivan@himssmedia.com

Information security teams use many tools to protect patient data and now a Vanderbilt University researcher said it’s time to add a new tactic for detecting inappropriate access to medical information. 

“The industry needs to move beyond statistical anomaly detection – the count of accesses – and focus on the context of the access,” said Daniel Fabbri, assistant professor, biomedical informatics and computer science, at Vanderbilt University, and founder and CEO of Maize Analytics. “Moreover, there are tons of timing eccentricities to consider in healthcare that must be thought through. For example, a doctor sees a patient but does not write a note until 24 hours later.”

[Also: 10 stubborn cybersecurity myths, busted]

To begin with, it is important to understand the challenges of detecting inappropriate access to patient data in electronic health records systems. EHRs, for instance, generally have an open environment, which means employees can access any patient’s data after logging into the system. In practice, role-based access controls are limited.

“Further, employees are mostly well behaved,” Fabbri said. “Thus, occasional inappropriate accesses, snooping or identity theft, for example, are buried among normal treatment operations. Unlike other environments that treat a user as exclusively bad or good, in healthcare the user can be both good and bad on a single day.”

With these factors in mind, security approaches that look at the access login isolation, without clinical context, can only detect a few types of threats, and may even miss breaches, Fabbri explained.

[Also: Security giant McAfee to healthcare CIOs, CISOs: Know your enemy]

“First, because users have knowledge of the system, they can mimic standard workflows by clicking more to appear normal,” he said. “Second, EHR accesses are the observed effect of patient care, and to understand why those accesses occur, systems must incorporate clinical context surrounding an access in its prediction.”

Examples of that include appointments, labs, medications and others. 

Basing detection models solely on what is observed (in other words: accesses) instead of the root cause (treatment) limits a model’s ability to differentiate appropriate and inappropriate access, he added.

[Also: Why diverse cybersecurity teams are better at understanding threats, patient needs]

As such, it is important for healthcare CIOs and CISOs to consider the threats they are trying to detect when selecting models to identify inappropriate use. If they choose a statistical anomaly detection model that identifies users accessing more records than normal, then it cannot detect one-off inappropriate accesses, such as snooping on a friend’s record.

“Other statistical anomaly detection systems attempt to identify ‘normal’ access patterns, and then alert on outliers,” Fabbri said. “The major challenge here is defining what is normal given the extremely dynamic nature of patient care, consultation services and constantly rotating clinical staff.”

One well-defined way to capture normal or appropriate behavior is to understand the clinical or operational reason why an access occurs. If there is a reason for the user to access a patient’s record, then the access is likely appropriate.

The clinical context necessary to make such a decision is already stored in the EHR and can be leveraged to infer why most EHR accesses occur. Any that do not have a reason is suspicious.

“The importance of context-based methods is that they not only tell you if an access is good or bad, but also the reason why, with the evidence for the decision, thus providing transparency rather than a black box,” Fabbri explained.

As Fabbri mentioned earlier, timing eccentricities in healthcare can mess with cybersecurity protection. But there are steps healthcare provider organizations can take to alleviate that.

“Ideally, all inappropriate access to health data would be detected immediately, or even prevented before they can occur; however, blocking access in healthcare can risk patient safety if, for example, a physician is unable to access a patient’s allergies in an emergency and then orders a medication the patient is allergic to,” Fabbri said. “Thus, organizations often focus on quick detection such as real-time auditing.”

Real-time auditing works well for a small list of VIPs, but real-time auditing systems can be susceptible to higher false-positive rates because the clinical context needed to infer why accesses occur does not show up in the EHR until after the access, he added. 

“Near-real time auditing systems analyze accesses hours or a day later, thus utilizing additional context, which allows for more accurate detection,” Fabbri said. “Organizations must balance this trade-off between detection time and false-positives when developing their monitoring program.”

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com

Genomics and precision medicine are still seen primarily as the province of large academic medical centers with lots of resources, given that they require highly specialized knowledge and robust IT infrastructure.

But a new online toolkit from the National Human Genome Research Institute hopes to help nurses and clinicians working in smaller care settings start taking advantage of the promise of this new paradigm in treatment.

The Method for Introducing a New Competency Genomics website launched by NHGRI, a division of the National Institutes of Health, offers more than 100 resources for nursing leaders "at all levels of genomics competency," according to the group.

[Also: Precision medicine: Hype today but the promise is even bigger than we think]

Whether offering tips on basic genomic facts or exploring the practical implications of precision techniques for hospitals and health system, the MINC toolkit is meant as a "starting point for healthcare providers who want to promote genomic integration into practice to benefit their patients,” said Laura Lyman Rodriguez, director of the division of policy, communication and education at NHGRI.

It can help nursing leaders care for patients who are undergoing genomic testing and treatment and better prepare their workforce for fast-emerging clinical applications, she said.

Structured in a Q&A format, the toolkit lets users tailor their interventions according to what will work best for them in their particular clinical setting. Among the lessons it offers: assessing where to begin; how to design a genomics action plan; how to select interventions; how to overcome bottlenecks and challenges; how to assess whether new techniques are working and how to make them last.

The website also offers video testimonials from various healthcare professionals, offering lessons about how they overcame hurdles as they developed genomic competencies at their own organizations.

The emergence and maturity of precision medicine in recent years makes it the right time for a toolkit such as this, said Rodriguez.

[Also: Precision medicine is creeping up on healthcare, and it sure is exciting]

"We are in the midst of an inflection 'wave,'" she said. "Genomic medicine is already in broad use in fields such as oncology, while other areas of care are just beginning to implement genomic applications. Now is, therefore, an ideal moment for providers across the spectrum to think about how these advances might apply to their own patients, and begin to plan for how they will prepare to implement those applications."

Even if providers aren't yet quite sure how to put precision medicine into practice, she said, "there is the opportunity to learn by building upon the successes of others who have already begun the process. We hope that this kind of resource will help providers (and institutions) to jump-start their own activities and enhance their ability to efficiently move toward genomic medicine as a means to meet the needs of their patients."

[Also: Weill Cornell uses HL7 to help integrate structured genomic data into Epic EHR]

While world-class, resource-rich healthcare institutions – Mass General, Penn Medicine, Johns Hopkins, Mayo Clinic, UCLA, USSF – are still clearly at the forefront of genomics and translational medicine, Rodriguez said NHGRI is "working to help facilitate the dissemination of knowledge from large academic medical centers to smaller care settings, and settings in different environments, such as rural health care practices."


In fact, of its flagship research programs, the Implementing Genomics in Practice consortium, or IGNITE, is focused on just that, she said. "It includes partnerships between academic medical centers and diverse clinical care settings so methods for dissemination and sustainability of genomic medicine in clinical care can be studied and made available for others to utilize."

Still, "the timeframe for broad uptake in smaller care settings is a bit unpredictable, and I anticipate that it will occur at different rates for different types of care – just as is happening in academic medicine."

What are some basic best practices – do's and don'ts – for integrating genomics techniques into patient care?

While emphasizing that it's still an emerging discipline, and that strategies will "likely vary based on the type of setting and the type of care," Rodriguez noted that "we have seen to date that it is definitely useful to engage healthcare administrators, because they are critical in releasing time for practitioners to update their knowledge in genomics, and to provide openings in the Grand Rounds schedule or even dedicate time for a series on genomics within such local continuing education programs."

Those leaders are "also in important positions for incentivizing learning and application of new technologies by providers or across care systems."

And what about IT? Where should hospitals be investing their resources to capitalize on the coming precision medicine wave?

"Rather than a focus on specific technologies for any group of providers, NHGRI has focused on developing and maintaining resources and tools in partnership with health professional organizations," said Rodriguez.

"NHGRI resources include tools such as the Genomics and Genetics Competency Center, or G2C2, which provides practice-based competencies mapped to a set of curated educational resources for five different provider disciplines, and the Global Genetics and Genomics Community, or G3C, a learning resource that provides a series of 15 interactive case-studies involving genomics," she said.

"We also convene the Inter-Society Coordinating Committee for Provider Education in Genomics, or ISCC, which brings together over 70 professional organizations and others working in clinical care to discuss needs and opportunities for professional education in genomics and ways to integrate this knowledge across teams and disciplines," said Rodriguez.

Irrespective of a hospital's organizational or technological maturity, it's critical to manage expectations as these fundamental changes in patient care gain traction, she said.

"One thing to avoid doing is to expect non-genetics healthcare practitioners to become geneticists," said Rodriguez. "Rather, we have learned from the community that providing the tools to make the usage of genomics clear and relevant to an individual's practice is the ideal way to encourage uptake of the information."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

After almost one year of consultation with hundreds of physicians, staff and patients, Alberta Health Services is poised to lay the groundwork for a system-wide EHR from Wisconsin-based Epic Systems.

AHS operates 400 facilities across the province, which is one Canada’s western provinces. The facilities include hospitals, clinics, continuing care facilities, mental health facilities and community health sites.

[Also: Mayo Clinic kicks off massive Epic EHR go-live]

Rather than referring to the technology as an EHR, Alberta Health Services executives refer to it as CIS, for Clinical Information Systems. AHS executives have named the CIS “Connect Care.” The initial work is expected to begin soon and continue over five years.

Today the health authority operates more than 1,300 information systems, many of which are badly outdated, unconnected and expensive to maintain.

Verna Yiu, AHS president and CEO noted on the website that the CIS would serve as a hub that can be accessed by both the care providers and the patients. On the provider side, the CIS would be accessible in all clinical care areas, including hospitals, ambulatory clinics and continuing care centers.

Patients will have access to their health information and appointment setting via Epic’s My Chart patient portal.

The AHS Provincial CIS will support Connect Care, an AHS-led initiative to transform healthcare delivery in the province.

“Healthcare providers will have consistent tools to use with patients and families, Barb Kathol, senior program officer for clinical information systems,” said in an interview with Yio, which is posted on the Connect Care website. “They will be able to see a consolidated problem list and understand the patient perspective. They’ll be able to have clinical knowledge support as they’re providing care and will also eventually have data about our health system that we don’t currently have.

AHS will have wireless services at all AHS facilities to enable site staff and physicians to wirelessly access the secure AHS network and to provide free wifi for patients and families.

Twitter: @Bernie_HITN
Email the writer: bernie.monegain@himssmedia.com

EHR giant Epic Systems will be receiving less than it expected in its trade secret lawsuit against Mumbai, India-based conglomerate Tata Consultancy Services.

In April 2016, a Wisconsin court jury awarded Epic $940 million in the case. But Epic subsequently asked a federal court to reduce the award to conform with state law.

Wisconsin law caps punitive damages at twice that of compensatory damages.

Earlier this year Epic asked a federal court to cut the $940 million a jury had awarded to $720 million in order for the company to comply the state law.

However, over the weekend, a U.S. jury went a step further and more than halved the original $940 million TCS would have had to pay to $420 million.

Epic filed a lawsuit against TCS in 2016 claiming that while TCS employees worked as consultants at a Kaiser Permanente hospital in Portland, Oregon, during an Epic EHR implementation they created a fake user account to take more than 6,000 documents that contained Epic development information.

TCS countered it had not misused or benefitted from the documents it had downloaded.

Twitter: @Bernie_HITN
Email the writer: bernie.monegain@himssmedia.com

CHICAGO -- Change is dominating the state of population health management in 2017. Whether it's large transformations, such as massive patient engagement initiatives and big investments in new population health IT platforms, or small shifts in clinical workflow and tweaks to EHR templates, the industry is in a state of flux.

It's an interesting fact, since healthcare has traditionally been "very resistant to change," said Cliff Frank, executive director of Somers Point, New Jersey-based Shore Quality Partners, speaking Monday at the HIMSS Pop Health Forum in Chicago. "We don't do change very well."

But though the shift has begun, it’s not exactly moving quickly. "We think we're changing really fast," said Frank. "The auto and technology industries would love to have five years to develop a new product, or 16 years to move to a new model of care."

[Also: Next wave of population health promises to broaden beyond the 1%]

But change is necessary to survive in this new reimbursement landscape, said Susan Hawkins, senior vice president of population health at Detroit's Henry Ford Health System.

"Value-based care is here to stay," said Hawkins. "It really doesn't matter what happens with repeal-and-replace." Whatever the political maneuverings on Capitol Hill, her job as a population health leader is to stay the course, charting new innovations toward greater access to higher-quality care for lower costs, she said.

In this new era, the key for providers and payers alike is to be agile enough to sense where changes are happening and adjust strategies accordingly, said Joel Gleason, global head of provider market at Cognizant Healthcare. A crucial example of that, he said, is to "tune our systems and models to focus on outcomes."

Another innovation he's seen more of lately is a more holistic approach to data aggregation and integration, with payers working to ensure that they and providers are seeing information – not just clinicals and financials, but increasingly sociodemographic and geographic data – "through a single pane of glass."
 
Similar efforts to ensure uniformity are are under way at Chicago's NorthShore University Health System, said Smita Patel, a neurology, integrative medicine and sleep disorders specialist at NorthShore Neurological Institute.

"We're creating a practice-based network, where all our providers use the same structured document" as they spend their days logging data into the EHR, she said. "We all have same forms, same measures."

For its part, Henry Ford Health has been changing its focus on recent years, said Hawkins, keeping close watch on three specific areas to drive improvement in population health management.

But homing in on complex chronic disease, the health system has been able to realize a 20 to 40 percent reduction in ER utilization, she said. That's encouraging, but it's still what she calls "low-hanging fruit."

More ambitiously, Henry Ford has been looking closely at medical variation – building protocols into its EHR that alert clinicians when to seek consultations from specialists, or order certain tests – and also at post-acute care, which has enabled reductions in lengths of stay in its skilled nursing facilities.

There have been changes on the technology side of the equation too, said Gleason. While there was something of a gold rush five or so years ago toward emerging population health tools, he sees the market maturing and thinks there's "going to continue to be a consolidation of unique standalone offerings."

More population health vendors will be working to offer "more offerings under one tent," as the need for "data liquidity and KPI-based usability" continues to increase, he said. APIs will be critical to connecting various components – analytics, care management and more – and serving up data where and when it's needed.

At Henry Ford, for instance, Hawkins said the health system has two different predictive analytics tools, with 10 percent overlap. "That's not going to help us," she said.

But other technologies are already bringing pop health returns. Henry Ford offers asynchronous e-visits through Epic's MyChart, for example. Patients can email providers and get back same-day responses with prescriptions, treatment recommendations and more.

Mobile visits, where patients are linked with physicians "in real-time on the phone," are another promising development. But "some insurers are paying for that, and some aren't," said Hawkins.

Mental health – psychiatric consults for certain patients right at the point of care – is another area Henry Ford is exploring, she said.

Addressing social determinants is a key part of any successful pop health program, she added, noting that Henry Ford is working with a company that's helping it identify a broader array of socioeconomic factors for patients – not just their ethnicity and the language they speak at home, but information about how stable their housing is and their access to reliable transportation.

"Those are all non-clinical in nature but they have a tremendous impact," said Hawkins.

By assessing those social factors, as well as the patient's motivation to change unhealthy habits – smoking cessation, for example – the health system can often then connect them to a community resource for help, she said.

"We're all playing in a bigger sandbox now," said Hawkins. "It's not just our four walls."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

Read our coverage of HIMSS Pop Health Forumin Chicago.
⇒ Experts on AI in healthcare: 'We need to be more realistic'

My mother is in her late 70’s and hasn’t been in the best health over the last 20 years. She’s a breast cancer survivor and has recently struggled with arthritis, diverticulitis and fibromyalgia. Keeping her mobile, out of pain and in good spirits is my primary focus. Recently my mom had a minor fall. The initial pain didn’t subside, so she went to her PCP.

After an X-ray didn’t reveal anything, she was sent to physical therapy. But the moves were too painful for my mom. The physical therapist prescribed steroids and rest and scheduled her to return a week later. But her discomfort finally led her to her to ask her PCP if she can see an orthopedic specialist and after near pleading, she underwent imaging that showed a shattered hip! She was going to need a hip replacement.

[Also: Read more #IHeartHITstories here]

In the interim, the pain medication catalyzed a bout of ischemic colitis that would need to be treated first – and a follow-up colonoscopy to make sure things were on the mend. Now we have a treatment plan for the next three months. A regime of antibiotics for the colitis, followed by a colonoscopy and finally the hip replacement.

My mom is now immobile and is crushed that she will not be able to actively participate in Thanksgiving and Christmas. I feel that this is a case where no one looked at my mom’s health holistically. There wasn’t a care coordinator – someone driving toward a healthy conclusion. And they didn’t listen to her initially – imagine sending someone to physical therapy when their hip is broken. And they’ve stolen two of her favorite holidays.

If this was diagnosed and addressed 2 months ago, it may have been a very different story. But that’s where health IT comes in, to improve the lives of our fellow humans. That should be the North Star. We must continue to challenge and refine the current models and attract fresh ideas, new energy, and most of all, the passion to take idea to solution to healthier lives.

Tamara StClaire is the chief operating officer at BaseHealth.

A new Health Affairs report on the state of interoperability in healthcare reveals scant progress in spite of what the authors of the report called “substantial efforts.”

The researchers looked at 2014 and 2015 data and found that 2014 national data suggested that hospital engagement with interoperability were at low levels.

They examined the 2015 data for national trends in engagement in four areas of interoperability: finding, sending, receiving and integrating electronic patient information from outside providers. They found small gains in 2015, with 29.7 percent of hospitals engaging in all four domains compared to 24.5 percent in 2014.

[Also: NQF says interoperability goes far beyond EHR-to-EHR data exchange]

Sending information showed an increase of 8.1 percent while receiving information showed an increase of 8.4 percent.

But there were no changes in integrating systems, however. Hospitals’ use of data for patient care from outside providers was low, with only 18.7 percent of hospitals reporting they “often” used these data.

“Our results reveal that hospitals’ progress toward interoperability is slow and that progress is focused on moving information between hospitals, not on ensuring usability of information in clinical decisions.”

The researchers concluded that in 2015, fewer than 30 percent of hospitals engaged in the four primary areas of interoperability, a slight increase over 2014. Engagement in one domain, integrating outside information, was stagnant.

“This is a concern because integration is critical to data usability, and lack of integration was found to be a top barrier to the use of outside data in clinical care,” the researchers wrote.

On a high note, researchers found that each of the four domains of interoperability was positively associated with the availability and use of outside clinical information and that nearly half of hospitals were “often” or “sometimes” using this information in the delivery of patient care, there is still much room for progress, they wrote.

However, they pointed to issues with integrating information into existing EHR systems. Clinical workflows were the most commonly cited barriers for hospitals that were not routinely using external information for patient care. It further underscores the need to shift the policy focus from transmitting information to information usability

Twitter: @Bernie_HITN
Email the writer: bernie.monegain@himssmedia.com