Prior to the pandemic, Rush University Medical Center in Chicago, Illinois, had been using Adobe Media Server integrated with its Epic electronic health record for telehealth video visits. The technology was thoroughly tested both onsite and offsite, with employees working from home, and had a high connection-failure rate of about 30%.

THE PROBLEM

Rush was relying on the patient’s home Internet connection to be good enough to connect, and five to six years ago it was common that home Internet was not good enough to stream content, even in the big city environs of Chicago. Unfortunately, there was very little troubleshooting staff could do once they realized that a patient’s Internet was not high-speed, and that led to many awkward calls between the IT helpdesk and patients.

Another barrier: Adobe Media Server relied on Flash player to be installed on a patient’s web browser, which was a fairly common plug-in for older PCs using standard browsers. But the world was moving to new browsers like Chrome and mobile applications and tablets, and Flash was no longer a standard.

“Not only did the patient need it installed, it also needed to be the right version, and Flash was so finicky that it would not auto-update; sometimes it needed to be uninstalled and reinstalled to take,” explained Marisa Truesdell, information systems manager at Rush University Medical Center. “Moving to telehealth technology from Vidyo was like night and day compared to the amount of patient technical issues and calls we received with Adobe Media Server.”

"Assemble a tenacious cross-functional team and get moving or you will be left behind. They should consist of the Ninja-Warrior-Salesperson-Writer-Conciliator-Researcher-Tech Geek variety."

Marisa Truesdell, Rush University Medical Center

Rush’s current connection failure rate is below 10% and Rush, like many other healthcare organizations, has defaulted to mobile-first workflows, which ensure a certain technology spec is met on the patient’s side, making the workflow much simpler for IT to support and the patient to connect, she added.

PROPOSAL

The Vidyo Connect workflow resolved the problems. The new platform allows for Rush’s bandwidth to provide extra buffering if the patient’s Internet speed is not quite up to snuff. It also does not require the patient to download anything extra, and they can be on any mobile device and most browsers to connect to telemedicine visits.

“Troubleshooting the workflow for visits using Vidyo Connect now can be done by a layperson – typically a medical assistant virtually rooming the patient for their video visit – instead of an IT telemedicine expert,” Truesdell said. “This was essential for the ability to scale our telemedicine platform.”

MARKETPLACE

There are many vendors of telemedicine technology and services on the health IT market today. Healthcare IT News recently compiled a comprehensive list of these vendors with detailed descriptions. To read this special report, click here.

MEETING THE CHALLENGE

About the fifth week of the pandemic in the United States, the state of Illinois shut down except for essential services. What did this mean to a large, academic healthcare institution? All non-emergent surgeries and all nonurgent appointments were cancelled. Rush had a staff typically used to seeing approximately 50,000 patients per month that was now asking to be redeployed to do other work so its members wouldn't be furloughed.

“There was only one practical option: Rapid implementation of HIPAA-compliant telemedicine workflows,” Truesdell said. “The workflows we implemented at first were four standard flows that we made available immediately and trained physicians on over the course of a few weeks: New Patient Scheduled Telephone, Return Patient Scheduled Telephone, New Patient Video and Return Patient Video.”

On the patient’s end, they would receive custom appointment reminder texts via Rush’s texting vendor, Mutare, at seven days, three days and one day prior to their scheduled virtual visit, reminding them to electronically check in and log in to join the video visit 10 minutes prior to its start.

Every day, medical assistants monitor the schedule for upcoming telemedicine visits. If there is a video visit coming up and the patient has joined, a medical assistant jumps on to gather normal rooming documentation and greet the patient.

If the patient has not joined, Truesdell’s team developed custom ad hoc text message buttons that medical assistants can press in specific situations to remind the patient what to do next in order to connect to their visit and to provide troubleshooting documentation.

“For physicians, medical assistants and other supportive providers like interpreters, they can see if the patient is connected right from their Epic EHR schedule via a grey camera icon that turns green when the patient is connected,” Truesdell explained.

“Medical assistants set a dot on the schedule as well letting the physician know the patient is ready. All providers can join the visit the same way. We require two devices in order to perform telemedicine: 1) They should be at a workstation that has Epic hyperspace on it, so they can document during their visit like they would for an in-person visit, and 2) They need an iPad with Epic’s mobile physician application Canto.”

The physician can launch the video visit directly from their navigator in Epic and have the screen thrown to their iPad, which acts as their video camera as well. Generally, the call moves forward like any other video call, with the important exception that it is being launched from HIPAA-compliant platforms that are protected by encryption and the appropriate legal agreements with Rush’s vendors.

“Rush was able to leverage the energy generated from the crisis to completely roll out a HIPAA-compliant video platform, which was the right solution, instead of something that was potentially more convenient but not HIPAA-compliant that ultimately would need to be ripped and replaced,” Truesdell said.

RESULTS

Rush’s KPIs for telehealth are “beyond our wildest dreams,” Truesdell said, especially given Rush serves a state lacking payer parity. She points to two work streams. First, forward COVID-19 triage.

“When COVID-19 first hit, and Rush was working on setting up a command center and ED triage tent, our CMO Paul Casey had the brilliant idea to repurpose our on-demand video platform for forward COVID-19 triage,” Truesdell explained.

“Redeploying 183 outpatient physicians to cover the video lines, we set up our platform in a matter of days to be able to triage patients with COVID-19 symptoms, exposure and anxiety to the right level of care – be that the ED, a drive-through testing location, or just isolating at home at the guidance of a compassionate physician, directly from our My Rush app.”

At the end of the video visit, the patient automatically is sent a detailed clinical recommendation via the My Rush app and assigned appropriate educational videos to watch about their condition, in addition to any referrals or prescriptions being sent to their preferred pharmacy.

Thus far this year, Rush has completed 8,718 on demand video visits, which have approximately a 23-minute wait on average, 22% new-to-system patients, and a Net Promoter score on average of 89. Some 52% of these visits were for concern for coronavirus.

The second work stream Truesdell points to is scheduled video visits. Rush was able to greatly improve KPIs here.

“When outpatient clinics closed due to the pandemic, most staff were redeployed to deliver services via telemedicine,” she said. “Having staff that are immediately ready to engage with technology in this way was unprecedented. Our providers immediately took to the process and engaged with us to provide quick solutions and optimizations. This operational/IT collaboration resulted in patient care – virtually, where there would otherwise have been none.”

So far this year, Rush has performed 90,533 scheduled video visits with an average Net Promoter score of 80. Some 25% of these have been scheduled into same-day or next-day availability; 2% of these patients have been new to the system; and10% of them have been new to practice.

ADVICE FOR OTHERS

“First I would say that this is the future: Assemble a tenacious cross-functional team and get moving, or you will be left behind,” Truesdell advised. “They should consist of the Ninja-Warrior-Salesperson-Writer-Conciliator-Researcher-Tech Geek variety. Virtual care is not for the faint of heart, so you want to find a team that is resilient, creative and never takes ‘No’ for a final answer.”

Second, shop around, she cautioned. Telehealth is even more of a hot topic in the COVID-19 world, and video technology is now ubiquitous and getting cheaper by the day.

“Most vendors are not going to be able to offer much to distinguish themselves in today’s cutthroat market, except price,” she concluded. “All vendors are working on usability, so soon there will be no way to distinguish between them in that space either. The real missing link in virtual care is an all-in-one vendor that does it all and integrates it all seamlessly – e-visit to scheduling, to video visit, to remote monitoring, etc. This is where your ninja team comes in, and why we IT folk have job security … for now!”

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication.

Back in 2019, Healthcare IT News reported on a unique privacy case involving Google and the University of Chicago Medical Center– which had been named as defendants in a class action suit alleging that they'd failed to properly de-identify data used for machine learning research and predictive analytics projects.

The suit's plaintiff, Daniel Dinerstein, who was a patient at UChicago in 2015, alleged that, while Google and UCMC claimed the medical records used were de-identified, such a claim was "misleading."

Given that the data provided to Google by the university "included detailed datestamps and copious free-text notes," he alleged, the tech giant's expertise in data mining and artificial intelligence made it "uniquely able to determine the identity of almost every medical record the university released."

On September 4, Judge Rebecca R. Pallmeyer of the U.S. District Court for the Northern District of Illinois granted the University of Chicago and Google's motions to dismiss the suit.

"Plaintiff suggests that the risk of re-identification was in fact substantial because of the information Google already possesses about individuals through the other services it provides," Pallmeyer writes in her decision.

"Specifically, the amended complaint refers to Google as 'one of the largest and most comprehensive data mining companies in the world, drawing data from thousands of sources and compiling information about individuals’ personal traits (gender, age, sexuality, race), personal habits, purchases, and associations.' Google has 'create[d] detailed profiles of millions of Americans,' including public and nonpublic information, and 'possess[es] detailed geolocation information that it can use to pinpoint and match exactly when certain people entered and visited the University’s hospital,' according to the amended complaint," she explained.

"In fact, for a user of Google applications like Mr. Dinerstein, Google can track the specific University hospital buildings or departments he visited and the time of his visits. Plaintiff alleges that the combination of such geolocation information and the EHRs, which include the date and time of hospital services, 'creates a perfect formulation of data points for Google to identify who the patients in those records really are.' The amended complaint does not allege, however, that Google has in fact used its extensive data to re-identify any EHRs."

De-identification, re-identification

The use of de-identified data has been common for years, of course. But so have challenges around keeping it that way. As far back as 2010, the Office of the National Coordinator for Health IT was studying how to manage the privacy risks presented by health information that had been stripped of personal identifiers – the potential for "re-identification."

The contours of this University of Chicago case are similar in some respects to the so-called "Project Nightingale" initiative between Google and Ascension, which got lots of mainstream media attention this past November, amid concerns over how the Mountain View, California, company was using patient data to help inform its design of new AI and machine learning software for Ascension.

In many respects, the collaboration "is not unlike arrangements that happen every day in America between hospitals and other covered entities and contractors performing services on their behalf," Deven McGraw, former deputy director for health information privacy at the HHS Office for Civil Rights and now chief regulatory officer at health data startup Ciitizen, said at the time. "Many hospitals have hundreds of business associates, all with extensive access to PHI.

But Google isn't just any vendor, McGraw acknowledged. It "has access to so much other data about individuals," she said, and therefore understood concerns that "it may not be possible for data to be truly de-identified in their hands, given all of the data to which they have access."

As long as Google "fulfills its privacy and security obligations under HIPAA with regard to the protected health information provided by Ascension, there is no HIPAA issue on the face of things," added healthcare attorney Matthew Fisher, partner at Westborough, Massachusetts-based Mirick, O'Connell, DeMallie & Lougee. "However, given the enormous amount of data held by Google, a maybe not so academic question exists of whether data can be de-identified when in Google’s possession."

DeWitt Hospital is a critical access hospital in DeWitt, Arkansas. It provides emergency and outpatient services for rural Southeastern Arkansas. The hospital is equipped with a radiology department, a laboratory department, a respiratory department and an emergency room. It also operates a nursing home attached to the hospital, the Ferguson Rural Health Clinic, and the local ambulance and paramedic services.

THE PROBLEM

When Brian Miller joined DeWitt Hospital as CEO in January 2019, the hospital’s existing EHR from CPSI was sunsetting and the facility had nine months to find a replacement. Miller and staff knew they needed a system that was light on maintenance, updates and support; was able to adjust to different workflows and care levels; and was supported by a team willing to be a partner to the hospital, rather than just another vendor.

“It also was really important for us that our new EHR would be interoperable and could connect to the statewide SHARE health information exchange,” Miller explained. “We often transfer patients to other hospitals, and their medical data needs to transfer with them. On top of that, a lot of our patients have chronic conditions and receive health services from multiple providers, and their data is fragmented across each provider they receive treatment from.”

It is absolutely essential to continuity of care that clinicians have easy access to their patients’ medical records, no matter where the patient is coming from or where they have been treated in the past. By connecting to the SHARE HIE, DeWitt staff could access a unified longitudinal patient record, allowing clinicians and others in the state to make more informed decisions and improve the quality of care, Miller said.

PROPOSAL

For an EHR, DeWitt decided on vendor Azalea Health. Azalea came in with a cloud-based system that minimized IT spend and lift, reduced the need for training and expensive consulting services, and offered an interoperable approach that enabled DeWitt to connect to the SHARE HIE, while also connecting its facilities, so it could easily share patient data across its own network, Miller explained.

“The idea was simple: Azalea would deliver a system that limited the amount of upfront and long-term spend, empowered our hospital staff to customize the solution based on their clinical workflow, and unlocked our data so that we could have a unified view of the patient regardless of the care setting,” he said.

The move to a cloud-based EHR platform required a big shift in mindset for DeWitt.

"We made the right decision to go with a cloud-based EHR that helped us pivot to meet new demands for testing and tracking."

Brian Miller, DeWitt Hospital

“We were coming from an on-premise system that demanded time and dollars to maintain,” Miller said. “The interface was old and workflows were static. The idea of a cloud-based solution that we could quickly integrate into our existing technology ecosystem with very little lift was something totally new for the organization. And it was an approach we very much needed.”

MARKETPLACE

There are many vendors with electronic health records systems on the health IT market today, including Allscripts, athenahealth, Cerner, eClinicalWorks, Epic, Greenway Health, HCS, Meditech and NextGen Healthcare.

MEETING THE CHALLENGE

Right as DeWitt was moving from the integration stage of the EHR implementation into the support stages, COVID-19 hit.

“We were forced to finish the implementation remotely,” Miller said. “But it’s gone smoothly. Azalea simplified the process and worked to ensure integration into our existing radiology and lab solutions. They worked across our groups, including nursing, registration and IT, to make sure everyone was aligned, informed and prepared on Day One. Azalea has been a very supportive and attentive partner, and we still meet with them twice a week.”

The EHR vendor also played a big role in connecting DeWitt to the SHARE HIE. DeWitt is part of the Arkansas Rural Health Partnership (ARHP), a network of 14 rural hospitals that pools resources to better meet the unique needs of patients in their rural communities. When the pandemic started, Arkansas Blue Cross Blue Shield came to ARHP and provided the funding to connect all the rural hospitals in the partnership to the SHARE program.

For DeWitt, Azalea was instrumental in facilitating its connection to the SHARE HIE. With the vendor’s help, DeWitt became one of the first providers in Southern Arkansas to be connected to the SHARE program.

“The SHARE program has led to more informed care transitions between DeWitt and other local community clinic providers,” Miller explained. “We use the exchange to share episodic admission/discharge/transfer data, discharge summaries, radiology reports, image narratives, laboratory results, prescribed medications and clinical procedures. Our clinic gets 24-hour daily reports on all our patients, and we get notified in real time when any patient has an ED or inpatient discharge or if they test positive for COVID-19.”

RESULTS

Azalea also has supported DeWitt in testing the community for COVID-19. As one of the only places in the area to get tested, DeWitt had a lot of people coming to the clinic to get tested. One day the hospital had more than 100 tests, and that went on for about two weeks.

“What draws a lot of people is that they can get their test results in 15 minutes at our clinic instead of waiting a week,” Miller said. “This appeals a lot to local businesses. When the business is open and one employee tests positive, they need to test everybody. They don’t want to have to shut down for a long time, so rapid results are ideal.”

Testing kits were reallocated by HHS in late July. DeWitt still is testing people who come into the hospital. But the removal of these tests means that DeWitt does not have the resources to help local businesses test their employees. It’s an added strain to an already stressful situation.

“At its peak, the number of people coming in to get tested was more than double our normal patient volume,” Miller said. “With so many new people coming into our hospital, Azalea’s EHR has been a valuable tool for keeping track of new patients. Having this broader pool of patients in our records will be helpful for our recovery once we can ramp up elective procedures again.”

ADVICE FOR OTHERS

“The landscape has changed to the point where it’s difficult for smaller hospitals to stand alone and survive,” Miller remarked. “Larger hospitals have more access to funding and get better deals when purchasing equipment, but everything costs more for critical access hospitals. We’ve been fortunate enough to leverage our connection with Jefferson Regional Medical Center in Pine Bluff to use their buying power and save a lot of money on supplies.”

DeWitt is working to get the ARHP to a similar place, where the hospital can share resources between the 14 hospitals to secure grants, centralize staffing and acquire supplies at lower rates. Rural hospitals are in a tough place right now, and solidarity between hospitals might be the only way forward, Miller said.

It’s also important to understand the different kinds of solutions that are out there, the benefits and risks to each, and scalability to future demands, he added.

“We never would have anticipated COVID-19 and the resulting impact that it had on our hospital operations and data,” he concluded. “We made the right decision to go with a cloud-based EHR that helped us pivot to meet new demands for testing and tracking. And we have been fortunate to be part of the SHARE program, which is helping draw insights into the impact of COVID-19 on our community and the broader hospital network that serves Southeastern Arkansas.”

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication.

A woman living in Woodstock, New York, has filed suit against HealthAlliance Hospital and the information management vendor Ciox Health for allegedly declining to release her deceased husband's electronic health records in a non-paper format.

The lawyer for the plaintiff, Sherry Russell, said that HealthAlliance Hospital's Broadway campus (formerly known as Kingston Hospital) has repeatedly directed her to Ciox for the records, which in turn allegedly told her she will have to pay 75 cents a page for photocopied paper versions.

"The maximum charge for electronic medical records under federal law is $6.50," said Russell's lawyer, John Fisher, in an interview with Healthcare IT News. "But if they charge for the paper copy of the records, it could be thousands of dollars."  

According to a 2016 guidance from the U.S. Department of Health and Human Services, HIPAA-covered entities and business associates should either charge $6.50 to fulfill a record request or calculate fees based on the labor cost of doing so.

Earlier this year, the U.S. Department of Health and Human Services lifted that cap on fees when it comes to organizations charging third parties, such as law firms, when releasing copies of electronic records. The fee cap for patients, however, remains in place.  

Fisher says that Russell's alleged treatment is a violation of the HITECH Act, which – among other provisions – requires HIPAA-covered entities to provide patients with an electronic copy of their records.   

According to Fisher, after the death of Russell's husband, Charlie, in October 2019, she requested his electronic health records in order to file a separate malpractice lawsuit against the hospital. Without the records, said Fisher, Russell cannot identify the physician involved in her husband's care. Ciox said that it could not comment on pending litigation; the Westchester Medical Health Network, of which HealthAlliance is a part, said it did not comment on ongoing litigation.  

WHY IT MATTERS

According to Fisher, in March 2017, Charlie Russell underwent a chest X-ray as part of a routine procedure. That X-ray showed a mass in his lung, but as Fisher told Healthcare IT News, neither Russell nor his wife were informed of it.  

The next March, Fisher said, Russell went in for another chest X-ray. This time, doctors found a six-centimeter mass in his lung. Further imaging showed cancer in his brain and liver.

Sherry Russell believes her husband's cancer could have been treated sooner, had the mass been identified and communicated about in 2017. She is planning to file a medical malpractice lawsuit. The deadline to sue is September 14, said Fisher, but Russell is relying on the electronic health records for her case.   

Fisher said he has other clients with similar experiences at HealthAlliance concerning their records, and that clients whose cases qualify could join onto Russell's class-action suit filed this past week.  

"We know firsthand that there are others" that have experienced problems obtaining their electronic health records, said Fisher.  

THE LARGER TREND  

The HIPAA Privacy Right Rule of Access guarantees patient access to physical or digital copies of healthcare records – and noncompliant health systems can face hefty fines. In 2019, Bayfront Health St. Petersburg had to pay the HHS Office of Civil Rights $85,000 and promise remediation after failing to give a pregnant woman timely access to her medical records.

Meanwhile, Ciox has been at the center of a number of lawsuits concerning the costs of electronic health records. In 2018, the company sued HHS over the $6.50 flat fee Fisher invoked, saying that it "bears no rational relationship to the actual costs associated with processing such requests."  

HHS, in turn, said that it couldn't actually enforce that flat fee against Ciox, because Ciox is a business associate, not a covered entity.

This lawsuit eventually led to the agency lifting the cap on fees for third-party organizations' requests for records.  

And last year, Ciox Health and the Wisconsin-based Aurora Health paid $35.4 million to settle a class-action lawsuit that accused the companies of overcharging for records requests.

Studies have shown other hospitals not complying with the HHS-recommended $6.50, with one reportedly charging more than $500 for a 200-page record.  

ON THE RECORD 

HealthAlliance, said Fisher, is "stonewalling our client and affecting her ability to bring a lawsuit."

Kat Jercich is senior editor of Healthcare IT News.
Twitter: @kjercich
Email: kjercich@himss.org
Healthcare IT News is a HIMSS Media publication.

The United Arab Emirates’ Dubai Health Authority (DHA) has become the first healthcare authority in the country to integrate Wolters Kluwer’s clinical decision support (CDS) resource, UpToDate with an electronic medical record (EMR), it has been announced.

In a statement released by the US-headquartered information services and solutions company, the UpToDate integration allows doctors, nurses and pharmacists from 18 DHA sites to access it via the authority’s Salama EMR to “make evidence-based clinical decisions for their patients and keep their medical knowledge up to date in a more seamless way.”

As well as being accredited by the DHA, UpToDate also enables clinicians to gain Continuing Medical Education (CME) credits while applying their learnings from searches during clinical practice.

THE LARGER CONTEXT

According to Wolters Kluwer, UpToDate – reportedly used by over 1.9 million clinicians around the world – is the “only clinical decision support resource associated with improved patient outcomes and hospital performance.” 

It continued in a statement: “Over 100 independent studies evidence the benefit to patients, clinical teams and healthcare systems in terms of improving length of stay, efficiency and patient outcomes, and reducing error rates and healthcare costs.”

In 2018, a study published in the International Journal of Medical Informatics found a “significant association” between use of UpToDate CDS and reduced diagnostic errors, with physicians using UpToDate encountering a “significantly lower rate of diagnostic errors compared with a control group without UpToDate”.

Denise Basow, managing director, president and CEO for Clinical Effectiveness at Wolters Kluwer – Health stated: “We are delighted to support DHA in their vision to provide world class healthcare across Dubai. 

“Providing evidence-based clinical decision support in the clinical workflow is critical for driving consistent, standardised and high-quality care throughout a patient’s care journey.”

ON THE RECORD

Meanwhile, on his part, Younis Kazim, Dubai Healthcare Corporation CEO of DHA said: “Patient Safety is DHA’s number one priority and our goal is to be at the forefront of healthcare innovation that delivers significant benefits to patients.

“Making UpToDate accessible through the Salama EMR will support busy clinicians at the point of care to drive consistently high-quality care, minimise errors and improve hospital efficiency. We are pleased to partner with Wolters Kluwer on this mission.”

DHA’s Medical Education and Research Department Director, Wadeia Sharief added: “As a resource for medical education and daily practices, UpToDate at the point of care for all DHA healthcare professionals can be accessed through the library platform and smart devices.

“Integrating UpToDate into Salama showed light after great efforts from the library and Salama team to obtain and gain return on investment in patient care.”