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Saturday, December 22, 2012

December 22nd updates

Been difficult to even think about blogging this week in the wake of Newtown CT. But, here goes. First,

 The harrowing evacuation of hundreds of patients made headlines nationwide. The disruption of regular medical care for tens of thousands of outpatients was a clinical nightmare that is finally easing. And the education of hundreds of medical students and residents is being patched back together.

All academic medical centers, however, rest on a tripod — patient care, education andresearch.The effect of the hurricane on the third leg of that tripod — research — has gotten the least attention, partly because rescuing cell cultures just isn’t as dramatic as carrying an I.C.U. patient on a ventilator down flights of stairs in the dark.

But, of course, there is an incontrovertible link between those cell cultures and that patient. For every medication that a patient takes, someone researched the basic chemistry of the drug, someone designed the clinical trial to test its efficacy, and of course a volunteer stepped forward to be the first to take the pill.

Scientific research has engineered the impressive advancements of medical treatment, and every patient is a beneficiary.

When the hospitals were hit by Hurricane Sandy, hundreds of experiments were obliterated by the loss of power. Precious biological samples carefully frozen over years were destroyed. Temperature-sensitive reagents and equipment were ruined. Medications and records for patients in clinical trials were rendered inaccessible. And sadly, many laboratory mice and rats perished (though 600 cages of animals were rescued during the night by staff members who used crowbars on inaccessible doors and carried the cages out through holes cut in the ceiling).

...scientists can’t just walk in to a new space with a lab coat and a notebook; they need centrifuges, deep-freezes, lab animals, electron microscopes, incubators, autoclaves, gamma counters, PET scanners. They come with graduate students, lab techs, post-docs and collaborating investigators. For clinical researchers, there are also the patients enrolled in their clinical trials, with their medications and voluminous records...

...researchers felt a sense of loss, not just in time, money, momentum, samples and grants, but of a part of their lives. Some senior scientists lost decades of archived samples. Others lost irreplaceable mice with genetic mutations for studying how coronary plaques resolve, the role of inflammation in lymphoma and the development of neural networks. At the other end of the spectrum were post-docs whose nascent careers were suddenly up in the air. Some were in tears.

The logistical efforts to relocate and reignite such a vast research enterprise are staggeringly complicated. But the administration has cataloged each person’s research needs to match them with available space elsewhere, and hundreds of researchers have successfully rekindled their investigations despite the prodigious challenges.

For many patients, the thrum of research within a medical center is invisible. But it is an integral — and very human — part of a hospital. When a hurricane disrupts research, it is a loss that resonates well beyond the laboratories.
Danielle Ofri, an associate professor at New York University School of Medicine, is the editor of the Bellevue Literary Review and the author, most recently, of “Medicine in Translation: Journeys With My Patients.”

Wow. This falls under "Risk Assessment / Disaster Recovery / Business Continuity," does it not? I have to confess, I don't have a clue as to the standardization, security, and calamity response aspects of clinical research data systems (can you say "heterogeneity"?). But, I will certainly get one, ASAP. Will likely find a lot of spreadsheets and custom internal database apps written by IT departments specifically for what the PIs want.

HIT across the past decade seems to have been overwhelmingly focused, necessarily, on a mix of its antecedent revenue cycle management priority (billing -- more about that shortly) and, more recently, mid-office functionality -- the care delivery "clinical data" EHR piece. The big obsession going forward from this period will be on HIE, Health Information Exchange.

But, how about, well, "CRIT"?

Ceritified, secure, cloud-based, scalable, end-user configurable?

And relatively disaster-proof.

It would seem to me that entities such as the SAS Institute could be all over this. Not to mention the Open Source movement.


...Now that it is so easy to write a very detailed H&P, it must be tempting to bill every encounter at the maximum level. However, this may come back to bite those who try it. Medicare has been known to audit hospital charts and office records. They have profiles of what the distribution of the various levels of care should be.

Also, there are only so many hours in a day. Let’s say you are working a 12-hour shift and bill for eight 75 minute H&Ps and ten 25 minute subsequent visits. That’s 600 + 250 = 850 minutes or over 14 hours. If you are audited, you will have some explaining to do...
I've been around Medicare work on and off for nearly 20 years. During my first tenure with HealthInsight back in the early 1990's, "upcoding" was a frequent topic of conversation. The term had a slightly negative connotation. Experienced and adroit coders were astute in the fine art of spinning claims codes in ways that at once maximized the revenue and minimized the potential for audit red flags.

Then, during the mid-2000's, under the 8th and 9th Scope QIO contracts and its REC-precursor "DOQ-IT" initiative, EMR-programmed "upcoding" was spun as a legitimate tool for increasing revenue "on the up and up."

I recall thinking at the time "there will be pushback on this eventually."

That time is here (and it's been in the news lately).

Every system now has to have an always-on HIPAA-compliant audit log database within its RDBMS schema. e.g.,

Below, from the HHS OCR Audit Protocol:

Technical Safeguards

Access Control
. A covered entity must implement technical policies and procedures that allow only authorized persons to access electronic protected health information (e-PHI).

Audit Controls. A covered entity must implement hardware, software, and/or procedural mechanisms to record and examine access and other activity in information systems that contain or use e-PHI.

Integrity Controls
. A covered entity must implement policies and procedures to ensure that e-PHI is not improperly altered or destroyed. Electronic measures must be put in place to confirm that e-PHI has not been improperly altered or destroyed.

Transmission Security. A covered entity must implement technical security measures that guard against unauthorized access to e-PHI that is being transmitted over an electronic network.
I've said it before, I'll say it again. The audit log is a "workflow record." Any data miner worth her salt can determine who did what to which patient's protected health information, when -- right down to the second. Couple that with savvy claims analysts, well, goes to Skeptical Scalpel's point.

I would not be trying to game the chart in pursuit of the upcoded claim anymore.


Yet another unscheduled CMS announcement, just in time for our year's-end lame duck Fiscal Cliff Follies. $9.322 billion paid to date? What's not to love?


Broke 100k. Nice. Not why I do this, but nice nonetheless.



Well, better late than never (pdf). Now that we've issued the 2014 Certification standards, let's study HIT safety some more.

Over a decade ago, the Institute of Medicine’s (IOM’s) report To Err is Human raised an alarm about the failure of healthcare to recognize and reduce the large number of avoidable medical errors harming patients. Health information technology (health IT), in particular electronic health records (EHRs) and health information exchange, create the potential to reduce medical errors. This potential is part of the reason for the creation of the Office of the National Coordinator for Health Information Technology (ONC), first by executive order in 2004 and then through the Health Information Technology for Economic and Clinical Health (HITECH) Act — passed as part of the American Recovery and Reinvestment Act of 2009. In addition to creating ONC, the HITECH Act also provided economic incentives for eligible providers to adopt and meaningfully use certified EHR technology.

The premise of these initiatives is that health IT, when fully integrated into health care delivery organizations, facilitates potentially enormous improvements in health care quality and safety as compared to paper records...

Just as health IT can create new opportunities to improve patient care and safety, it can also create new potentials for harm. For example, poor user interface design or unclear information displays can contribute to clinicians ordering medications not appropriate for their patients’ condition. Health IT will only fulfill its enormous potential to improve patient safety if the risks associated with its use are identified, if there is a coordinated effort to mitigate those risks, and if it is used to make care safer...


The California Health Care Foundation does consistently excellent work (pdf). to wit:

THE HEALTH INFORMATION TECHNOLOGY for Economic and Clinical Health (HITECH) Act, part of the 2009 American Recovery and Reinvestment Act (ARRA), set high expectations that federal investment in health information technology (HIT) would significantly improve health care delivery. Now, more than three years later, the high hopes that accompanied HITECH’s passage have given way to more sober realities.

On one hand, marked progress on the adoption of electronic health records (EHRs) among California’s providers has taken place. For example, 40% of office-based physicians in 2011 had a basic EHR, up from 21.8% in 2010. On the other hand, there is room for progress toward widespread use of electronic health information to improve the quality and efficiency of health care delivery.

This report examines HITECH’s history and impact in California and details how HITECH funds have been spent so far. It describes how market drivers and health reform policy have affected the health care environment and given cause for greater alignment among programs to support payment and delivery system redesign. The report was informed by an analysis of publicly available data and through interviews with industry leaders.

Specifically, the report looks at the three largest federally funded programs in California: the Medi-Cal EHR Incentive Program, regional extension centers (RECs), and health information exchange (HIE). It also looks at the state’s progress on telehealth, which was supported through a separate ARRA funding stream, because of its potential to improve health care delivery by expanding access to care and increasing efficiency...
A bracing read, at once candid and diplomatic.

Regarding RECs broadly, a couple of snips:
No federally funded technical support beyond Stage 1. 
Despite the federal government’s goal of getting 100,000 providers nationally to adopt and meaningfully use EHRs and providing implementation assistance to support them, ONC does not provide funding to help providers reach Stages 2 and 3 of meaningful use. This gap in technical assistance may challenge many providers as they attempt to meet increasingly difficult meaningful use requirements.

Develop sustainability plans. 
When considering REC program sustainability, it is helpful to understand the model upon which the program is based. The REC concept was inspired by the US Agricultural Cooperative Extension Program created to help farmers increase acreage and address labor shortages during World War I. The agricultural extension program still exists today, but its programs have shifted as community needs have changed over the decades. Similarly, RECs should be flexible to the changing needs of providers as they optimize their use of EHRs.

To build a long-term plan, RECs must be able to demonstrate the value of the technical assistance that they provide. Until they do, questions will remain as to whether it is worth expanding funding to RECs...
[1] I really tire of the Ag Extension analogy, and, [2] color me dubious on "sustainability." How many Ag Extensions were private market-sustainable after four years?

I see "consolidation" among and "talent flight" from RECs.

Point of accuracy: We're only funded for Stage 1 Year 1. One and Done, baby.

Lots more great stuff in the CHCF report. Check it out.


Federal Register: no HIPAA Omnibus Final Rule yet.

But, nice to know that the Feds are hard at work promulgating vital stuff like this:
Marketing Order Regulating the Handling of Spearmint Oil Produced in the Far West; Revision of the Salable Quantity and Allotment Percentage for Class 1 (Scotch) and Class 3 (Native) Spearmint Oil for the 2012-2013 Marketing Year

This rule revises the quantity of Class 1 (Scotch) and Class 3 (Native) spearmint oil that handlers may purchase from, or handle on behalf of, producers during the 2012-2013 marketing year under the Far West spearmint oil marketing order. This rule increases the Scotch spearmint oil salable quantity from 782,413 pounds to 2,622,115 pounds, and the allotment percentage from 38 percent to 128 percent. In addition, this rule increases the Native spearmint oil salable quantity from 1,162,473 pounds to 1,348,270 pounds, and the allotment percentage from 50 percent to 58 percent. The marketing order regulates the handling of spearmint oil produced in the Far West and is administered locally by the Spearmint Oil Administrative Committee (Committee). The Committee recommended this rule for the purpose of maintaining orderly marketing conditions in the Far West spearmint oil market.


More to come...

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