Patient Safety is the result of practices and policies that healthcare organizations employ to protect patients from preventable harm. A National Health Record would help mitigate some main contributors to patient safety issues, such as medication errors, timely reporting of critical health events and data availability for care teams.

Medication Errors

According to Agency for Healthcare Research (AHRQ) and Quality’s Patient Safety Network (PSNET), “In a review of EHR safety and usability, investigators found that the switch from paper records to EHRs led to decreases in medication errors, improved guideline adherence, and (after initial implementation) enhanced safety attitudes and job satisfaction among physicians.”

In addition to the obvious benefit of having all information in one place, I am certain patients, especially the most vulnerable ones, would benefit greatly through reduction in medication errors. A standard Drug Utilization Review (DUR) could expand to every medication the patient is on instead of only the ones in the providers Electronic Health Record (EHR). The DUR looks at drug-to-drug contraindications, drug-to-disease or allergy complications, duplicative treatment, high or low dosage, as well as factoring in drug-age, drug-gender and drug-pregnancy precautions. If medical providers and pharmacists had a comprehensive list of medications prescribed to the patient, the value of the DUR would be exponentially greater than relying on the local EHR. All of this would contribute to improved treatment and reduced complication caused by the current localized electronic collection of data.

Critical Timely Knowledge of Events

Currently, managing the downstream effects of medical events, such as hospitalization, Emergency Department visits and readmission, are reliant on coordinated care between unrelated healthcare entities and self-reporting by the patient and family. As insurance consumers have moved toward PPO plans over coordinated HMO healthcare plans, the heavy burden for communicating medical events to a PCP and other providers rests with the patient. This puts the patient’s safety at considerable risk. The need for timely, clear and accurate communication of the incidents, the care given before, during and after, as well as the data that supports future treatment plan is critical to ensuring patients are not harmed by the care they are receiving.

Preventable Adverse Events are defined as: harm to a patient caused by the medical they receive, not from their actual condition, illness, injury or disease. Human error contributes to the prevalence of adverse events, but inadequate and timely data are critical to off-set the number of incidents. Again, the availability of a National Health Record would mitigate this costly, preventable danger within our healthcare system.

Care Team Support

Outside the day-to-day benefits of a National Health Record, there are long-term patient safety benefits related to clinical decision support. EHRs either have built-in clinical decision support or have the ability to buy plug-and-play modules. These packages provide care teams with best practices at a general level, but can also be personalized based on a patients’ medical history, medications, as well as the ability to incorporate family medical history, to take advantage of any genetic and genomics data that can strengthen the quality of their care. Having timely, comprehensive information alongside a personalized approach for a care team will support sound decisions, help avoid adverse events and help improve outcomes for patients.

Reducing preventable re-admissions is one area I think would benefit greatly from care teams having better clinical decision support. By assessing patients risk for readmission based on comprehensive patient data alongside best practice, the care team can proactively create discharge plans that focus on known issues that lead to readmission. The additional data that comes from external providers for an individual patient will bolster decisions provided from clinical decision support libraries. Simply put, the more information to feed into a decision support tool, the better the recommendations will be.

A Case Study in National Health Record

In 2016, Australia implemented My Health Record, the nation’s National Health Record. Some of the benefits they have experienced:

• Prevent adverse drug events, reduce medical errors, improve vaccination rates, better coordinate care and better inform treatment decisions
• Sustain a more efficient health system, through less time searching for patient data, reduction of avoidable hospitalizations, and reduced duplicated pathology tests and x-rays which inconveniences patients and increases the cost of healthcare
• Improve patient experience by putting the patient at the center of their healthcare, and keeping people out of hospital
• Provide greater access to healthcare for people living in rural and remote areas of Australia
• Protect the national digital health infrastructure and secure the personal health information of Australians

As mentioned in my previous blog, four major factors contribute to The Need for a National Health Record: collecting comprehensive information, supporting the role of patients as consumers, having the ability to care for our vulnerable populations and improving patient safety. In my opinion, our entire healthcare system and all who participate in it would quickly see the value on a financial, human and industry level. Australia has proven its worth, and has succeeded in showing that the value far outweighs any perceived risks and concerns.

My previous post outlined the 5 challenges impacting care plans that are managed. In the final post of this series, I highlight a few specific scenarios and outline next steps for home health programs (HHP).

Hypertension

If hypertension is a targeted chronic condition, that state (e.g., California, New York, etc.) will want reports on participants’ improved blood pressure as evidence of successful interventions. Payers will either “require” that providers send blood pressure readings or include appropriate coding in the claim. This can be done by using CPT codes. CPT Category II codes in the claim 3074F, 3075F and 3077F identify systolic ranges, and 3078F, 3079F and 3080F represent diastolic ranges, which will reveal if a hypertensive patient has their blood pressure under control or could benefit from an HHP case manager’s intervention.

Obesity

For obesity, BMI will likely be the measure of success. It is unlikely that an inbound data file is coming from providers to payers that contains height, weight, and a BMI. In this case, payers either need to set up inbound data files to capture that data or “require” providers to use the ICD-10 coding that relays results (i.e., Z68 series).

Diabetes

Diabetes patient improvement is measured by a number of indicators. One is Hba1c results. Payers get the claim for the lab, but rarely get the results unless providers send claims containing CPT Category II codes 3044F (below 7), 3045F (8-9) or 3046F (above 9) for Hba1c results. To collect this information, payers have to create new channels of data exchange with lab vendors or providers to get lab results.

Mental Health

Integration of care around mental health and substance use disorder diagnoses are major focal points for many state’s Health Home Program. Many providers will do a basic depression screening, like a Patient Health Questionnaire (PHQ-9) or Pediatric Symptom Checklist (PSC-17), and will set up a follow-up plan based on the results. Both of these activities can be sent via data files or as a claim with the appropriate HCPCS code (i.e., activities complete: G8431 or G8510; activities not complete: G8432 or G8511).

What’s Next for HHP?

As CMS continues to require participation in programs to provide improved healthcare benefits to Medicaid members, the industry will see significant impacts on providers and payers, as well as members.

The Health Home Program’s focus on coordinating care for Medicaid patients with the highest need has introduced some new challenges for payers. The need for well-planned, effective improvements in health information technology, as well as communication between providers and payers for HHP, will be far reaching. It will enable payers and providers to collaborate on other initiatives and will be well worth the investment of time and resources.

This guide provides an overview of the Health Home Programs and presents five common challenges payers will face when creating a successful program. To learn more, you can click here or submit the form below.

Previously, I analyzed the major players in the HHP. This post outlines the 5 challenges impacting managed care plans.

Naturally, measuring the success of the Health Home Program is critical. Each state’s Health Home Authority has designed quality measures, as well as reports for utilization and operations of the program. But some of the requirements laid out by states could pose real data-related challenges for payers. To prove HHP is successful, data that is not typically collected by payers may be required. These elements factor into communications, eligibility, risk determination, and reporting.

Here are 5 key data and reporting elements that will challenge participating payers.

1. Timely Data

Under HHP, managed care plans are responsible for timely and structured communication between the plan and its providers. This may require inbound and outbound data flows that will need to be incorporated into data warehouses, reporting layers, and operational systems. For example, if a patient went to the emergency room (ER) or was admitted to the hospital, the provider caring for her under HHP should be alerted.

While some of this information is available through claims, there is often a lack of timeliness in reporting due to claim lag, which diminishes the effectiveness of an intervention. Payers need to find creative ways, in this example, to identify and communicate ER visits and in-patient admissions to providers in order to be more effective and timely. One solution is using pre-authorizations to notify providers of possible in-patient stays. Another is creating a communication channel between commonly used emergency departments and acute care hospitals to alert payers and providers of HHP member activity.

2. Collecting New Data Elements

If a state’s reporting requires data elements that are specific to HHP – such as the number of people having health action plans created, or the number of case managers available for each HHP network provider – payers have to implement new data flows with the providers in their network. The implementation and operations of these new processes contribute to improved outcomes, but also have a cost in time and resources.

3. Mental Health Data Access

The main tenet of HHP is a “whole person” approach, which in many cases includes behavioral health services. In some states, mental health services for Medicaid recipients are provided by county- or state-run providers, and are essentially carved out from the payer. To facilitate the coordination of care, payers have to open up a data exchange from the county/state and ensure that HHP case managers have access to it and incorporate that data for holistic care.

4. Social Determinants of Health Data

Data associated with social determinants of health (SDoH) play a critical role in identifying members with the highest risk. Payers should consider these factors in determining who will benefit most from additional services through HHP.

The challenge for both payers and providers is to collect and disseminate this information in a timely, effective, and secure fashion, while ensuring its value outweighs the cost. However, data elements related to SDoH – such as access to housing, level of personal safety and availability of healthy food – are generally not collected by payers, and are just starting to be collected by providers.

5. Clinical Outcomes Reporting

Some states have created reporting requirements that measure clinical outcomes. If the targeted condition requires clinical measurements or screenings, which are not typically included in medical claims, payers will have to set up new data interfaces into a care management or similar system, or encourage providers to use CPT Category II codes that have results embedded in them.

This guide provides an overview of the Health Home Program and presents five common challenges payers will face when creating a successful program. To learn more, you can click here or submit the form below.

Previously, I discussed what home health programs (HHP) are. In this blog I analyze the major players in the HHP.

State Authority & Participation

The Center for Medicare Services (CMS) oversees the Health Home Program, but each state has a Health Home Authority that creates and manages its HHP. States are required to follow the core principle of HHP and treat each participant under a “whole person” philosophy, but states can create a program that best fits its participants’ needs.

The Health Home Authority also has the freedom to decide which conditions are included, the criteria that is used to select providers, how payment will be managed, and what reports and metrics are to be included in the program. Thus, it has a significant impact on what data and reporting are required to support the program.

According to CMS, as of March 2019, 23 states and the District of Columbia have a total of 38 approved Medicaid Health Home models.

The Major Players

Managed Care Plans (i.e., payers) who have Medicaid members play a role in Health Home Programs. Payers define which providers can be part of their HHP network. Generally, providers will include primary care providers, community health centers, social workers, mental health practitioners, home health agencies, and possibly case managers that work for the managed care health plan. Not only do payers contract service providers to be part of their HHP network, but they are responsible for gathering and reporting clinical and operational data, communicating with providers about key events, and administering reimbursement to the HHP provider.

Providers are on the HHP front line since they choose who will be part of the delivery team. They decide what activities will be involved in outreach and enrollment of participants, coordinate medical and non-medical care, and provide support for the individual and family members.

This guide provides an overview of the Health Home Program and presents five common challenges payers will face when creating a successful program. To learn more, you can click here or submit the form below.

The Health Home Program (HHP) is creating new data challenges for managed care organizations in the form of an increased need for timely data, collecting new data elements, accessing mental health data, and gathering data around social determinants.

What is the Health Home Program?

The HHP is designed to offer coordinated services within and beyond Medicaid medical coverage. The program was introduced by The Affordable Care Act of 2010, Section 2703, for Medicaid recipients with chronic conditions. It covers conditions such as, but not limited to, hypertension, diabetes, obesity, serious mental illness, and substance use disorder.

Specifically, HHP is designed for people with Medicaid who:

• Have two or more chronic conditions
• Have one chronic condition and are at risk for a second
• Have one serious and persistent mental health condition

The goal of this expanded program is to connect participants to a wider range of family, community, and social services that will contribute to each participant’s well-being and improved health through increased access and education.

This guide provides an overview of the Health Home Program and presents five common challenges payers will face when creating a successful program. To learn more, you can click here or submit the form below.

In healthcare, which is more important privacy or safety? Are they mutually exclusive? In the leaps that we have made in cybersecurity in healthcare, can’t we have both? The main argument I hear against a National Health Record is people’s fear of a data breach. Contrary to that popular belief, one study, related to sharing data for clinical trials, reported that “less than a third are concerned that their data might be stolen or used for marketing purposes.” The article goes so far as to say that HIPAA and inconsistency of state and federal data sharing regulations are the main prohibitors to sharing data for research purposes. In my opinion, the same holds true for a National Health Record.

My interest and enthusiasm for a National Health Record started when my father was diagnosed with Frontal Lobe Dementia. Long before my sisters and I knew that his health was in peril, he was diligent about seeing his Primary Care Physician (PCP) for any and all ailments. As a creature of habit, he even carried an index card with his medications listed on it. As time went on, his brain deteriorated and he was given the diagnosis of Frontal Lobe Dementia. Naturally, his medical needs grew in complexity. Lacking access to any other information about his healthcare, I was thankful that we had that index card. After my sister was granted Healthcare Proxy, we found the card was outdated and offered little assistance as we started to manage a 68-year old’s elaborate medical care.

My dad (and my sisters and I) could have benefited immensely from having access to his medications, labs, diagnoses, procedures, as well as all of his doctors, hospital and emergency room visit data. I cannot imagine how his care would have been improved if we could also share that information with any provider treating him.

In my opinion, my father’s case showcases the value of having a National Health Record, which is rooted in four major factors. In this blog, I will cover the first three:

1. Comprehensive Information
2. Patients as Consumers
3. Caring for our Vulnerable Populations

In my next blog in September 2019, I will cover:

4. Patient Safety

Comprehensive Information: Physicians Providing Best Care and Advice

The bottom line is: more information equals better decisions, in any situation. Providers struggle with the current segmented, “unmanaged” care system, and patients are overburdened and stressed having to know what is relevant to their current medical needs and remembering to share all of the pertinent details with each provider.

In our current fee-for-service healthcare model, physicians are not able to or incentivized to provide “the best care”. I have asked my own practitioners about their challenges. They have equated it to a “garage sale jigsaw puzzle”. They have to rely on the patient to describe the finished picture, but they are lacking the physical pieces to complete that puzzle. Given the time-constraints and pressures that physician groups face on a daily basis, they are rarely able to get that comprehensive picture and/or follow up with the patient’s other providers.

Ironically, they often will refer the patient to a specialist when, with a little more data at their fingertips, the patient could have been treated by them. A National Health Record could allow practitioners to care for their patients in the current visit or limit the number of referrals and follow ups. A reduced number of follow ups could also give the practitioner more time with each patient, subsequently improving each patient’s experience and health.

Patients as Consumers:  Member-Driven Healthcare

With the prevalence of high-dollar deductible health plans, members have to assume the role of consumer as well as patient. This can be overwhelming for most people. We need information, education and tools to manage our healthcare options, costs and coordination of communication. A National Health Record would allow members to be able to collect, view and selectively share data with whoever they want.

We have also moved to a culture of choice, which leads to our information being stored at every provider we have seen. That information is helpful to each practitioner; it would be exponentially useful if each had a comprehensive view of all of it.

Caring for our Vulnerable Populations

The most vulnerable patients with complex medical situations utilize healthcare at the highest rate. Critically-ill patients and our elderly will find themselves seeing a variety of specialists in addition to a PCP. And they tend to have multiple, potentially conflicting, medical concerns.

Given the complexity of patients in critical care situations, they are likely to not be able to report thorough medical histories and provide accurate prescription lists. They are likely to be under considerable stress, have financial worries, are trying to balance their medical needs with some semblance of a “normal” life. Many times they are also taking medications that alters their ability to think clearly, concentrate or communicate.

At a time when people are living longer due to medical and health-related discoveries, we are also bound by the complications caused by the same advances. People are living longer, but the human body and mind still has the same biology. As we age, we deteriorate, and our healthcare needs become more frequent, complicated and dispersed. As our minds age, we couple the need for medical attention with the decrease in the ability to remember the pertinent details of our health.

Someone could be coordinating these patients’ care through case management or under a managed-care physician practice. But in a time when healthcare providers are typically over-scheduled and under-staffed, it is not likely that they could achieve the level of thoroughness that a National Health Record could provide. It would alleviate the stress of a patient having to know and communicate “everything”, and would give providers a more comprehensive picture to use when treating their patients.

Better Than an Index Card

As I contemplate what I can do to further the fight for a National Health Record, I wish I had kept my Dad’s index card. It reminds me that there are simple ways to empower patients, as well as showing there is a lot of room for improvement for engaging them using technology. Although there are many competing ideas and interests in the debate around a National Health Record, I think the value of a comprehensive, sharable medical record far outweighs any perceived risks and concerns.

The Mystery

I have worked in Healthcare Informatics long before it was called Healthcare Informatics, and this year was the first time I heard the term “IMO”.  While working on a data warehousing project the client asked if their Epic instance was storing Intelligent Medical Objects (IMO) codes.

In typical consultant fashion, I said I’d have to look into it.  Off to Google I went.

Naturally, the first hits were IMO’s website, Wikipedia plus an older news release about Epic integrating IMO with their EHR.  Curiously, IMO’s career posting page boasts that they need help to “continuously deliver our products and services to over 80% of US clinicians”.  MedAptus, one of IMO’s partners, says that “IMO’s terminology database is used by more than 2,500 hospitals and 350,000 physicians daily”. Why had I never heard of IMO?  Am I the only one?

Mission

So, who is IMO and what are their intentions?

Intelligent Medical Objects (IMO)’s website is very clear about what they do:

IMO is Clinical Interface Terminology

We bridge the gap between clinical language and complex coding systems.

Through a focus on the adoption and advancement of healthcare standards, accurate capture of clinical data at the point-of-contact, and timely management of semantic interoperability, IMO provides tools to healthcare organizations to support efficient billing, improved revenue cycle management, adoption of healthcare technology, and enhanced decision support, patient education and data analytics.  And in the end they aim to improve “global health”.

Definition

At the American Health Information Management Association (AHIMA) Clinical Vocabulary Mapping Methods Institute, Dr. Andrew Kanter, IMO’s Chief Medical Officer presented Vocabularies: Critical Software Infrastructure for Interoperability and Adoption Workshop, which focused on the keys to technology like IMO:  interoperability, ease-of-use and outsourced risk.

“In healthcare, interoperability is the ability of different information technology systems and software applications to communicate, to exchange data accurately, effectively, and consistently, and to use the information that has been exchanged.”

In healthcare we like to adopt a standard and then customize it to fit our providers, administrators and work flows.  There is a tug-of-war between understanding the wide-spread benefits of strict standards and the need to support the adoption of technology by end-users.

Even if we did agree to adopt a standard vocabulary, we still have too many to choose from.  In healthcare, there is no standard vocabulary for a specific use.  For example, we can use ICD or SNOMED for diagnosis codes; we use CPT, HCPCS, ICD or SNOMED for procedures; LOINCs and CPTs are used for labs; and medications may use NDC or RxNorm.

Getting staff to adopt and adapt to the ever-changing landscape of healthcare terminology is a big challenge.  Doctors are more likely to adopt technology if they can continue to think like doctors, and not like the billing department.

On the other hand, when all front and back end users of technology see a benefit, the mere fact that they will use it is a tremendous benefit.  One organization integrated clinical and financial coding, so each part of the organization could get what they needed into and out of the data.  Physicians in particular had positive experiences and replied to the experiment with:

“I spend less time searching for and/or documenting diagnoses/problems in [the EHR].”

“I can enter more meaningful clinical documentation (more closely describe the true clinical situation, or capture more detailed information).”

The final reward for users of technology like IMO is “Managing the Madness”.  Dr. Kanter points out that managing the vocabularies is difficult, time consuming and can come with a high risk and cost, if done incorrectly or not in a timely manner.

Products

IMO’s products provide users with an interface between user-friend front end and complicated vocabulary management in the back end.

Three products, Problem IT, Procedure IT , and Map IT lay the foundation for turning clinician and patient friendly terminology into billing, operational and administrative data, and vice versa.

Problem IT provides expressions that are more familiar to clinicians for choosing diagnosis codes for the encounter, problem list and past medical history.  Patients are also given information that they understand to better understand and manage their conditions.

Procedure IT also employs a user-friendly interface to allow clinicians to select relevant procedure codes using familiar terminology, and for patients to understand their patient health records while the tool translates the choices for billing and other code sets.

Map IT works behind the scenes to allow searches for key words or code sets, and link existing terminology maps to IMO content.

Partners

An article on crunchbase.com claims that Intelligent Medical Objects (IMO) is the “market leader in clinical interface terminology and a strategic partner with major content providers and EHR developers.”

IMO’s website list a wide range of partners.  They cover healthcare associations (eg. AHIMA, AMA), drug and clinical content providers (eg. Lexi-comp, Netsmart), healthcare revenue cycle, charge capture and management technologies (eg. MedAptus, CloudCare), and Electronic Health Record (EHR) software (eg. Epic, Cerner, AllScripts, Aprima, NextGen).

eClinicalWorks’s website states that “with IMO, eClinicalWorks users find the right terms quickly and easily, encouraging thorough and accurate documentation. Clinician terms are translated automatically into administrative codes for billing. Maps to reference vocabularies power intelligent searching, clinical decision support, and business intelligence tools.”

Lexi-Pro, a  leading provider of print and electronic medical references, formed the Lexi-Comp/IMO partnership.  It supports their main product, Medication Enhanced, by pulling “these two worlds together to enhance medical software with integrated prescription writing, automated drug-to-drug, drug-to-disease, drug-to-herb interaction checking and other computerized tools” to further advance patient safety practices utilizing data.

MedAptus, a software company specializing in charge capture and charge management, and patient assignment and care collaboration products, is also a partner with IMO.  MedAptus’s website lauds IMO: “IMO’s terminology database is used by more than 2,500 hospitals and 350,000 physicians daily, and this trusted terminology platform supports innovations by provider systems. IMO’s medical vocabulary and mapping products effectively capture clinical intent and help EHRs preserve and communicate this across the entire spectrum of care. This accelerates workflow and increases clinician utilization and satisfaction. “

Mystery Solved?

Many of us in Healthcare Informatics are all too familiar with standard vocabularies.  We also know the frustrations of converting one code set to another.  We have seen the challenges of EHR adoption and of forcing codes into disparate worlds.

Clinical interface terminology, like IMO, has applied a user-friendly, interoperable engine to encourage wider use of healthcare data and to add more power to its use across all areas in the industry.

In My Opinion Healthcare Informatics professionals would benefit from education on Intelligent Medical Objects (IMO) and similar technologies.  Understanding the connection between point-of-care clinical content and the stored values in the back end could help data analysts, business analysts, data modelers, as well as many other healthcare professionals, bridge the gap between the myriad of front and back end users of healthcare data.

What is your experience in this realm?  What other companies live in this space?  And where do analysts, developers, and consumers of healthcare data go to find out more?

What comes to mind when you hear the word “Odyssey?” Did you picture a journey filled with international discovery? Did you associate images of a quest filled with notable experiences? Or, did you think of OHDSI (pronounced “Odyssey”), the “multi-stakeholder, interdisciplinary collaborative that is striving to bring out the value of observational health data through large-scale analytics?” Researchers are coming together under the umbrella of Observational Health Data Sciences and Informatics (OHDSI) to use healthcare data for an international journey filled with notable discoveries.

Five fun facts about the quest:

1. OHDSI is a community of people with interests in healthcare who want to leverage large-scale analytics within a variety of research areas, such as comparing alternate treatment paths, personalized medicine, product safety, and overall quality improvement in healthcare. Their mission is propped up on innovation, reproducibility, community, collaboration, openness and beneficence.

2. OHDSI has created and supports Observational Medical Outcomes Partnership (OMOP), which is the Common Data Model (CDM) to standardize seemingly disparate databases. Its central coordinating center is at Columbia University, but is fueled by data from almost 100 organizations across dozens of countries, and covers more than 1.5 billion patients’ lives.

3. Observational Outcome Research leverages secondary electronic data to perform large-scale evidence-based longitudinal patient-level clinical studies. The data can come from Electronic Health Records (EHR), Enterprise Practice Management (EPM), billing and claims, general ledger, public health sources, biobanks inventories, and pharmaceutical sources.

4. Available data is typically not intended for Observational Outcome Research, but it can be transformed into a standardized, powerful warehouse of information. To achieve that purpose, OHDSI focused OMOP’s design on three areas of harmonization: a common format (i.e., the data model), a common representation of vocabularies (eg. acceptable terminologies and coding schemes), and the availability of analytic tools that have been created to use with the common format.

5. The CDM enables researchers across the world to be able to systematically identify specific cohorts, compare results, reproduce protocols using data, and investigate combinations of interventions and outcomes. Examples of current research using the OMOP model include: “large-scale modeling of patients with thyroid conditions,” “Oral tetracycline-class Antibiotic Use for Acne Therapy” and “Investigating Birth Month-Disease Risk Relationships Across the OHDSI Network.”

With the increasing amount of data available in the healthcare space and the multitude of research opportunities, OHDSI and OMOP are poised to be Sherpas into the future.