AMIA 2010: Sunday

My first AMIA meeting and I'm finding it filled with all sorts of goodies. There's lots of tweeting going on, too. (Go to TweetChat with hashtag #AMIA2010 to keep up.)

I typed some notes and thought I'd put them here (1) so I can find them again easy and (2) some folks may find them useful (thought maybe somewhat cryptic). (The odd formatting is from OmniOutliner; I've given up on fixing the font colors--the red means nothing--and the bullets don't line up right.)

▼ AMIA 2010 Susan Dentzer, Editor Health Affairs

2010.11.14

▼ "Golden Age" of PPACA (?)

• compared Greek myth of Ae____ to Obama

▼ Open up goldmine of data to public

• CHDI website www.hhs.gov—open

• use data to shape community responses to childhood obesity... Children's Optimal Health

▼ [] l/u Health Affairs 2010 Nov 29:2047

• rapid-cycle improvement of medical home care @Geisnger

• reductions in risk-adjusted chronically ill hospital admission and readmission rates

▼ Three Aims

• 1. Better Health

• 2. Better health care

• 3. Better value

▼ IOM study on variations

• look at var in HC spending, pt diversity, MD decisions on what care to give and evidence

▼ Shared decision making by pts

• ACA provision

• even informed pts don't exercise their options well

• preference-sensitive care

▼ Quotations

• Quotes by George Carlin, Churchill on American People

• Quote by Jerry Garcia re Somebody has to do something and it is pathetic that it must be us

---

▼ Informatics Issues in HIEs

20101114 Rob Kolodner, Session chair

▼ Development and use of a Medication history Service Associated with a health information exchange: Architecture and Preliminary findings

M. Frisse, Vanderbilt Center for Better Health; L. Tang; A. Belsito, M. Overhage, Regenstrief Institute

• Memphis HIE in use 4.5 yrs... still a pilot going to full force

• 48% had full med hx; getting retail pharmacies online made a big different

• 36% pt not located

• $4 generics good for pts, bad for accurate HIE data

---

▼ Emergency Medical Services: the frontier in health information exchange

JT Finnell, M. Overhage, Regenstrief Institute

• Project: push HIE data out to EMS staff in 2 counties in Indiana (Siren by Medusa), using ruggedized tablet PC

• Uses LN, FN DOB Gender, can add zip and SSN optional

• Pushes back a pdf with a bunch of data: med list, allergies, DNR status, NOK notification, PMH

• Started at 15% requests to 26% of field pts seen

• 14% of medics never used

• connectivity a problem

• 41% medics nearly always queried system

• 66% said data was important for providing care

• "truth serum" effect (we can look it up if you don't tell us the truth)

• Value with heavy utilizers and pts "found down"

---

▼ Private Medical Record Linkage with Approximate Matching

E. Durham, Y. Xue; M. Kantarcioglu; B. Malin, Vanderbilt University

• Vanderbilt -- Emory: Flaw in current model for sharing de-identified data

• If pts don't match, they can be overcounted

• prob with fragmented data (spelling, missing data, etc)

• Private Record Matching can improve this using a hash function to maintain privacy but compare individuals

• Steps:

• blocking (toss out some)

• field comparison

• similarity function measures degree of similarity using a comparison vector and into a record pair similarity score

• draw a line where scores above a number are considered a match

• record pair comparison and classification

• Fellegi-Sunter probability vectors: uses log function of an agreement weight and a disagreement weight for each field (eg, FN, LN, MOB)

• Sum the similarity scores across all fields

• Used a data corrupter function to mess up experimental data to see if they get rematched

• looked at accuracy vs runtime

• Main thing they did was to use approximate matching rather than binary matching, leading to increase in accurate matches

• Note: they used a centralized approach but hope to extend ot decentralized model.

---

▼ Continuity of Care Document (CCD) enables Delivery of Medication histories to the Primary Care Clinician

L. Simonaitis, A. Belsito, G. Cravens, C. Shen, J. Over- hage, Regenstrief Institute

• Used INPC (Indiana)... x1995, 6M pts, 3B data items

• Workflow

• pt to front desk... ADT clinic trigger sends CCD request

• printer prints med hx (CCD)

• MD reviews meds

• CCD is generated, pulling in data from SureScripts and MA, and put rx codes from dif stds in same CCD

• Results: used in 1 clinic over 9 docs and 4500 pts

• 90% of cases took less than 2 min

• med hx helped doc discover drugs they didn't know pt taking, controlled rx overuse, and med underuse

• docs usually did not show med hx to pts

• no change to MD workflow

• accommodates paper-based clinic

• [] XSLT transformation of CCD data very promising

IOM to Address Safety of EHRs

Scot Silverstein from the Health Care Renewal blog posted about IOM's recently announced contract with ONC to "identify best policies and practices for improving healthcare safety when using electronic health records."

"Perhaps these studies should have been initiated, say, ten years ago, or at least before the beneficence of health IT and its capacity to revolutionize medicine was openly promoted by the past and current Administrations (the current one going so far as to institutionalize penalties for non adopters)?"

The IOM consensus study, entitled "Patient Safety and Health Information Technology," will be conducted by NAS staffers Samantha Chao, Joi Washington, and Erin Wilhelm:

"The IOM will review the available evidence and the experience from the field on how the use of health information technology (HIT) affects the safety of patient care and make recommendations on how public and private actors can maximize the safety of HIT-assisted health care services. The IOM's final report will be both comprehensive and specific in terms of recommended options and opportunities for public and private interventions that may improve the safety of care that incorporates the use EHRs and other forms of HIT."

While I agree that this effort should have been done long ago, I am glad to see it being addressed. There is much polarization about whether EHRs are the best thing since sliced bread or the worst thing to hit medicine since managed care. Perhaps this IOM study will address both the pros and cons of EHRs from a provider's perspective (though I don't think any of the study staff are providers). Health care providers need to have a voice that can be heard by the vendors and governments when we find that given instances of EHR usability are inefficient or unsafe, and maybe this study will recommendations to address this current gap.

APA Annual Meeting in New Orleans 2010 #apanola2010

Lots of discussion about EHRs at this year's American Psychiatric Association meeting in New Orleans. Other topics of interest to me included TMS (transcranial magnetic stimulation for the treatment of depression), social media, and about the APA's role in helping its members adopt certified electronic health records.

Today at 11am the Committee on Electronic Health Records is presenting in Room 340 at the Convention Center: The Train Has Left the Station: National Incentives and Developments in Electronic Health Records.

Other IT talks were listed in John Luo's article, Your Annual Meeting IT Guide.

HIMSS EMR Adoption Model: 2009 Level 4 (CPOE) Only 14%

Hospitals in 2009 continued to have low CPOE adoption (Level 4), but they did manage to jump from 5.8% to 13.5% having CPOE (Computerized Provider Order Entry) from 2008 to 2009.

Looking at the HIMSS EMR Adoption Model trends, you can see how the 5000+ hospitals in the US are gradually moving up the electronic evolutionary ladder towards Level 7, which is full implementation of a completely interoperable, paperless, electronic medical record (note that HIMSS differentiates an "EMR" (within a single organization) from an "EHR", which it defines to specifically be a "subset of each care delivery organization's (CDO) EMR, ... owned by the patient and has patient input and access that spans episodes of care across multiple CDOs within a community, region, or state...").

As a reminder, here are the definitions of the levels (from HIMSS):

It'll be interesting to see how the HITECH Act's financial incentives accelerates adoption of the higher levels (4 and up). Looking at the cumulative adoption percentages below, I'd expect Level 4 to take off in the same way that Level 3 has over the past several years. But that is the hardest transition to achieve due to the dramatic changes in physician workflow required. This is easier to achieve in hospitals where the majority of the physicians are employed by the hospital; however, physicians at most hospitals (especially community hospitals) are not employed, so these hospitals have less fortitude in requiring them to enter their own orders.

Any guesses as to what the 2010 adoption numbers will be?

Snow Storm Good Advertisement for the Need for Telepsychiatry

Two feet of snow and Baltimore comes to a screeching halt. How to get the doctors to the hospital? This is where telepsychiatry can be very helpful. However, there are still so many impediments to using telemedicine (billing, liability, documentation, technical) that we are *still* unable to use it when we need it. Like today, where the hospital will have to send a 4x4 to pick up Dr Chandran to get him to the hospital.

A broader term for distance mental health services is Telemental Health services, or TMH. Proposed new regulations were released last week that would permit and regulate TMH under the public mental health system (aka Medicaid) in Maryland. Unfortunately, the way it is currently written would not permit me to "see" inpatients on our unit from home during a blizzard. Still, it is a step in the right direction.

For more info on TMH, check out the Maryland Telemental Health website.

This is a Job for Flower!

First post of 2010. Happy New Year, all! Oh, and enjoy reading the 500+ page Meaningful Use proposed rule [pdf] we got for New Years. More on that in a later post; in meantime, check out David Harlow's post on HealthBlawg.

Alan Viars (@aviars) wrote a post yesterday about his father's difficulties in getting access to his medical records when transferring from Hospital A to Hospital B. His father's POA had to essentially throw a fit just to get a copy of the records prior to open heart surgery at the receiving hospital, as they "don't normally do that." Oh, and his father learned that his EKG from a year ago showed evidence of a silent heart attack but no one ever told him.

Alan concludes:

Lessons for the Wise:

• When you have medical tests, YOU THE PATIENT, need to ask for the results. Get a copy. Make sure your physician has actually reviews your tests. Just because you didn’t hear anything, don’t assume everything is okay.
• If it’s possible, when you go to the hospital have someone by your side who cares about you and can advocate for you. If you’re lucky enough to have a nurse, physician, or other medically educated person to be your advocate, even better.
• Sadly, you may have to get angry in order to gain access to your medical records. Don’t let them tell you no. It’s YOUR data – all of it – and it’s your right to have a copy. Keep your own records.

This is a great example of what the Speak Flower movement is all about.

It's about getting access to your health information -- easily, quickly, automatically.

It's about allowing other authorized individuals or entities to access your health information -- easily, quickly, automatically.

It's about taking control of the health information that is yours -- easily, quickly, automatically.