electronic + record = language in search of a vendor
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The commons refers to resources that are collectively owned. There are two tragedies that may befall a commons: The Tragedy of the Commons and The Tragedy of the Anticommons. Paraphrasing Michael Heller (Gridlock Economy): the tragedy of the commons is when too many people share a single resource, we tend to overuse it; and the tragedy of the anticommons is when too many people own a single resource, and anyone can block the use. Modifying this for healthcare, the tragedy of the healthcare anticommons is that too many people own portions of a patient’s health information (HI), and anyone at anytime can block a full rendering of the patient’s HI.
A patient’s HI might be charcterized by those that have an interest in the HI, including the patient. This interest extends beyond the mere information itself and its transactional value—to a property interest, or ownership. We’ve created a whole host of terms for the access, control, and ownership of health information: personal health record (PHR), electronic medical record (EMR), and electronic health record (EHR) to name the most common terms. Here EHR is broadly construed to include those directly involved in patient care (e.g., hospitals and nurses) and indirectly involved or third–parties (e.g., insurers or coders).
If a full rendering of a patient’s HI might be considered a unique resource, then an anticommons effects exists where any entity maintaining an interest in the patient’s HI fails to participate in a common real–time sharing of the patient’s HI.
Health Information Fragmentation by Interests (Anticommons)
A partial HI commons is created where participating interests create a common storage of HI available to all (authorized) at anytime. Health Information Exchanges (HIE) are a form of commons. Participation in this form of commons has two requirements (or barriers): a willingness to participate and the capability (interoperability) to participate.
Creating a Health Information Commons
The barriers that distinguish the commons from the anticommons might be eliminated where HI storage is a function of the commons and not of the participants. A change in storage positioning (perceptual ownership) creates full participation of all interests, full real–time rendering of applicable HI, and no need for interoperability or HIE (eliminated by design).
Building a Health Information Commons
If we create an HI commons (and by extension a commons of commons), all interests may be addressed and all participant experience a full informational rendering. Who benefits? We all do!
Experiencing a Health Information Commons
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Hattip FlowingData
This one is too funny, my ED is just south of a bread factory and we see lots of yeast infections… When I finish the swing shift I drive home with the smell of fresh bread baking.
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As Ranking Member of the Senate Committee on Finance, which has jurisdiction over the Medicare and Medicaid programs, I have a special responsibility to protect the health of the programs’ more than 100 million beneficiaries as well as the congressionally authorized tax dollars used to fund these programs. This includes ensuring the effective and efficient use of taxpayer money by the health care industry in implementing Health Information Technology (HIT), such as Computerized Physician Order Entry (CPOE) systems and Electronic Health Records (EHR).
In recent legislation, approximately $19 billion in taxpayer funds was appropriated to encourage development and implementation of HIT systems, which further emphasizes the importance of responsible use and thorough oversight. Over the past several months, however, I have been made increasingly aware of difficulties and challenges associated with HIT implementation. The reported problems appear to be associated with administrative complications in implementation, formatting and usability issues, and actual computer errors stemming from the programs themselves, as well as, interoperability between programs. For example, I have heard from health care providers regarding faulty software that produced incorrect medication dosages because it miscalculated body weights by interchanging kilograms and pounds.
In addition, I have heard from health care providers around the country that when they report such problems to their facilities and/or the product vendors, their concerns are sometimes ignored or dismissed. Some sources recount difficulties in approaching the HIT vendor with problems and the lack of venue to discuss these issues either with the vendor or peer organizations. Often this is attributed to alleged “gag orders” or non-disclosure clauses in the HIT contract that prohibit health care providers and their facilities from sharing information outside of their facilities regarding product defects and other HIT product-related concerns.
Some HIT products, I understand, are medical devices regulated by the Food and Drug Administration (FDA). Therefore, the manufacturers of these devices are required to meet specific reporting requirements, such as the reporting of adverse events to FDA’s Manufacturer and User Facility Experience database. However, for HIT products that may not fall under FDA regulation, there appears to be a lack of a national system for reporting product errors or failures and adverse events associated with the use of such products. Thus, problems with these products may go without remedy thereby inhibiting the ability of the health care professional to provide quality care and potentially impacting patient safety. Furthermore, contractual restrictions on the sharing of experiences and information related to specific vendor products limit a health care facility’s ability to make informed decisions about HIT adoption and implementation.
American taxpayers and health care facilities across the country will be investing substantially in the HIT industry, and it is important that their monies are appropriately spent on effective and interoperable HIT systems. In October 2009, I wrote to ten major HIT companies regarding similar issues and concerns. The purpose of today’s letter is to gather information from hospitals regarding their perspective and experiences with HIT. Accordingly, I would appreciate your response to the following questions and requests for information regarding the HIT products being implemented at your facility and any issues or concerns that have been raised by your health care providers. Unless otherwise noted, the requests cover the period of January 1, 2007 through December 31, 2009. In responding to this letter, please repeat the enumerated question and follow with the appropriate response and documentation.
- Please describe in detail your facility’s process for identifying HIT products for purchase and choosing an HIT vendor(s).
- What is the personnel structure of those involved in the purchase?
- To what extent do physicians and other health care providers within your facility provide input regarding the specific HIT items to be implemented within your facility?
- Who or what department within your facility is responsible for making HIT purchase decisions?
- Three of the companies that I wrote to in October 2009 informed me that they do not manufacture HIT software or hardware, but instead assist their health care clients, such as hospitals, with the implementation and management of HIT systems. To what extent do you contract with such entities to assist with the purchase, implementation and/or management of HIT products in your facility?
- Please describe the training process implemented in your facility to familiarize employees with new technology systems.
- How does your facility budget for HIT training?
- What are the vendors’ roles in helping your facility train in the use of their products?
- Does your facility have any policies or processes governing the reporting of problems or concerns by your health care employees related to the HIT products or systems implemented in your facility? If so, please provide a description of the policies or processes. If not, please explain why not.
- When patient care and/or safety problems related to HIT systems arise, how are these problems reported within the facility and what is the process or mechanism for addressing them?
- Are these problems also reported to the HIT vendor, and if so, what is the process for reporting them?
- If patient care and/or safety problems related to HIT systems are not routinely reported to the HIT vendors, please explain how your facility decides which problems or issues are reported to a vendor and/or addressed by a vendor and which problems are addressed internally by the facility.
- Please describe in detail any system your facility has in place to document, track, catalogue, and maintain complaints, concerns or issues related to HIT products that may directly or indirectly involve or impact the delivery of care or patient safety.
- Please provide a list of HIT problems or complaints that have been identified by or reported to your facility since January 2008 that directly or indirectly impacted patient safety or the delivery of care, including any complications or adverse events that have occurred as a result of HIT product design and/or usability. Please describe whether and how each of those problems or complaints was resolved and whether these issues have resulted in a change in policy to prevent the problem in the future.
- Does your facility have policies regarding the discussion of problems in your HIT systems with other health care facilities or with government officials or any individuals or entities outside your facility? If so, please describe those policies. To what extent are these policies driven by contractual agreements with the HIT vendors, and to what extent do they stem from internal processes? Please provide examples of contracts with HIT vendors that include non-disclosure clauses.
- Some of the HIT vendors stated specifically in their responses to me that they do not include language that would hold them harmless for failures of their products or for the company’s own negligence or recklessness. However, they may include provisions that spell out the vendor’s and the health care client’s respective legal responsibilities and obligations in the use of the product. For example, one vendor stated that it is accountable for the performance of its product as long as the client uses the product appropriately. Another vendor stated that it is not liable when harm or loss results from the client’s use of the product in diagnosing andor treating patients.
- Do any of the HIT vendors include language in their contracts with your facility that could be considered “hold harmless” provisions, i.e., the transferring of liability associated with the services or products provided to your facility, or otherwise limit their liability? If so, please provide a copy of sample contracts containing such provisions.
- What is the relationship between your facility and any HIT vendors?
- HIT vendors that manufacture software, hardware and/or other products purchased by health care facilities have stated in their responses to me that they do not offer any financial incentives for purchasing their products, such as shares in the company or financial interests in a particular product. At least one vendor stated, however, that it does offer financial incentives in the form of discounts based on purchase size. Another vendor said that health care clients may receive royalty payments when the clients collaborate with the vendor to develop a product. What financial interest, if any, does your facility have in HIT vendors and/or their products?
- Do the vendors offer your facility and/or any of your health care providers any financial incentives for purchasing the vendors’ products? If so, please describe the types and value of the incentives.
- Did your staff, health care providers and/or facility receive any payments, product discounts, or other items of value from any vendor for discussing and/or promoting that vendor’s HIT products? If so, please list the different types of payments and discounts and their value.
I look forward to your cooperation and assistance on this important matter. Please provide your response to the questions and requests set forth in this letter by no later than February 16, 2010.
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Grassley asks hospitals about experiences with federal health information technology program
WASHINGTON—Senator Chuck Grassley has sent letters to 31 hospitals nationwide asking about their experiences in implementing the $19 billion federal health information technology program launched last year.
“Given the taxpayer investment and the investment of the health care system overall in the information technology industry, the more Congress and others overseeing implementation of this program dig into the problems and work to get them sorted out now, the better,” Grassley said. “Hospitals are on the front lines and their perspective will be very valuable in this effort, so I look forward to hearing what they have to say about expanded use of health care information technology.”
Grassley said that his survey of hospitals is based on concerns brought to his attention in recent months, including administrative complications, formatting and usability issues, errors and interoperability. Some health care providers have told him that software is producing incorrect medication dosages because it miscalculated body weights by interchanging kilograms and pounds, for example. And, some of those providers have expressed frustration about the response, or lack of, they get when they take those kinds of problems to the vendors or the hospital administration.
Last fall, Grassley wrote directly to major health information technology vendors regarding these kinds of issues and concerns. He is currently reviewing responses from the vendors who received a letter from him. The vendors are the Cerner Corporation, 3M Company, Allscripts, Cognizant Technology Solutions, Computer Sciences Corporation, Eclipsys, Epic Systems Corporation, McKesson Corporation, Perot Systems Corporation, and Philips Healthcare.
This week, Grassley sent his letter to the following hospitals: Banner Health, Brigham & Women’s Hospital Case Western Reserve University Hospital Health System, Catholic Healthcare West, Cedars Sinai Children’s National Medical Center, Geisinger Medical Center, Hackensack Hospital, HCA TriStar, Intermountain Healthcare, Indiana University Hospital, Jefferson Regional Medical Center, Kaiser Permanente System, Marshfield Clinic, Massachusetts General Hospital, Mayo Clinics, Memorial Hermann Healthcare System, Methodist Hospital of Indiana, North Shore-Long Island Jewish Health System, Palo Alto Medical Foundation, Rainbow Babies and Children’s Hospital, Saint Mary Mercy Hospital, Seattle Children’s Hospital, Stony Brook University Medical Center, Trinity Hospital System Tufts Medical Center, University of California San Francisco Medical Center, University of Pennsylvania Health System, University of Pittsburgh Medical Center, University of Virginia Medical Center, and Vanderbilt University Hospital.
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State adopts nation’s first health care access standards—Sacramento Business Journal
The rules require health maintenance organizations to ensure they have enough doctors and other providers to meet the following time frames:
- Triage or screening by telephone 24/7
- Wait times of no longer than 30 minutes for telephone triage
- A wait of no more than 10 minutes to speak to a HMO customer service representative during normal business hours
- 48 hours for urgent–care appointments that do not require prior authorization
- 96 hours for urgent–care appointments requiring prior authorization, including specialists
- 10 business days for non–urgent primary care appointments
- 15 business days for non–urgent appointments with specialists
- 10 business days for non–urgent appointments with a mental health provider, and
- 15 business days for non–urgent appointments for ancillary services like X–rays and lab tests.
- Dental HMOs must get patients in for urgent care within 72 hours for urgent care, 36 business days for non–urgent care and 40 business days for preventive care.
The rules provide some wiggle room. They allow waiting times for a particular appointment to be extended if the provider or person providing triage determines that a longer wait time will not have a detrimental effect on the patient. Health plans are required to monitor medical groups for compliance.
For already burdened primary and specialty care systems in California it is inconceivable that these standards will furnish the legislative intent. I can hear the calls now (already happening)—if you believe this is an emergency then just go to the ER. Here an emergency will be defined as any situation where the HMO can’t provide the access dictated by the standards. This is going to be a prime example of where the legislative intent will be unintended consequences.
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BTR: Doctor: Do You Speak “Flower”?, 1.26.10 0900 PST, hosted by @2healthguru
What is flower? At this time it’s an abstraction—a placeholder for several concepts centering on what would healthcare look like if…? And, more specifically what would personal health information (PHI) look like if…? A flower was chosen as the abstraction because it is easily and universally understood, regardless of language, anywhere in the world—a flower is a flower. Where a flower is flower carries the additional abstraction that there is a common ground—characterized by property and implementation. While a fluid and dynamic idea, this informed panel will provide both history and context for its genesis and diverse unfolding narrative. Join Dirk Stanley, MD, @dirkstanley, Tim Sturgil, MD, @symtym, and Steven Daviss, MD, @HITshrink, as we discuss Flower’s granularity and transformational potential to make sense of a complex and moving target: informatics, health care and the patient. For additional context and insights on “Speak Flower,” and the threaded discussion on Howard J Luks, MD, blog.
Several discussions are taking place on Google Wave, search on “Flower.”
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For me the core of Emergency Medicine is what we term the ABCs—airway, breathing, and circulation. Our mission is simply establish and maintain the ABCs, and you will maintain life. Of course most of Emergency Medicine does not involve the ABCs—in fact, quite the opposite, primary and chronic care consumes an ever increasing percentage of our ER time. But when you get a case of the ABCs—you remember why you chose this specialty.
All who practice Emergency Medicine have the type of cases they like and those they don’t. I’ve always been intriqued with angioedema—suddenness, insidiousness, progressiveness, and potential for life–threat. It’s the enemy you never underestimate and never turn your back on.
In the last month I’ve had 4 cases: 1 with enalapril, 2 with benzapril, and 1 idiopathic.
A few shifts ago, a 60 year old woman was triaged with the complaint: “something in my throat, for 20 minutes, making me gag.” She has hypertension, but knows none of the names of her medicines. She was started on a new medicine for blood pressure 2 weeks ago. She is on an insurance plan capitated to another health system in the area (common), and from experience getting a list of medicines will take at least 2 hours if successful at all (I’d put success at less than 25%, because it was prescribed in an office, not a hospital). She believe the new medicine is “benz–something.”
Health information is of value when there is time to obtain and review it. Unfortunately, this woman had little time. Oral examination showed palatal angioedema (area 1 on graphic infra). In the oral cavity angioedema may be likened to a plastic baggie filled partially with water—hanging in a drop–like manner to gravity’s pull. The droop in her right palatal arch (area 1) was about 50% down to the tip of the uvula at the initial examination. IV, cardiac monitor, and oxygen were all applied and medications were given.
Airway Anatomy
Modified for Illustration
The 5–minute re–examination showed the angioedema had extended to the tip of the uvula, causing it to droop and touch the back of the tongue (area 3). Time was up, she was moved to the resuscitation room and prep’d for orotracheal intubation. When she was all monitored–up, and with respiratory therapy in the room, she was roc’d (administered rocuronium) and given midazolam. At this point the angioedema had extended to the left palatal arch (area 2). Both affected palatal arches obscured the swollen uvula in an expanding tarp–like structure.
The pharynx may be divided into an oropharynx (mouth) and the nasopharynx (nasal passages leading to the back of our throats). What divides the two is the hard palate (separating the roof of the mouth from the floor of the nasal passages) and the soft palate (structures in Airway Anatomy graphic supra). When the soft palatal structures become sufficiently large (i.e., angioedema in this case) it acts like a flapper value blocking breathing through the nose, mouth, or potentially both (depending on head and body positioning).
Just prior to intubation the woman’s angioedema had progressed sufficiently to threaten occlusion of both oro– and naso– air passages. Once the paralytics and sedating agents had taken effect, she was moved from a 90° position (sitting straight up) to a 45° position (placing the flapper valve midway between total occlusion of either airway). Her airway was instrumented with a large Miller blade (Tradecraft graphic infra, lower left). A 70 cm intubation stylet (infra, right) was used to place an 8.5mm endotracheal tube. Airway is secured, emergency is over, and admission is required— time span about 15 minutes.
Tradecraft
Several years ago I had 2 significant cases of angioedema involving the tongue. The first patient was taking captopril and primarily had anterior swelling of the tongue and couldn’t pull her tongue into the mouth. The second patient was taking moxifloxacin and had tongue and palatal involvement that rapidly progressed to obstruction. The patient was very obese with poor neck exposure and the cricothyroidotomy was not successful. Airway was established with the only digital intubation (fingers only) of my career.
Angioedema Not Requiring Advanced Airway Intervention
Angioedema Requiring Advanced Airway Intervention
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Columbia is a fictional city of 1.5 million in the fictional state of Jefferson. The greater Columbia catchment area has a population of 3 million. There are four integrated healthcare systems in Columbia. The healthcare systems are associated with ten hospitals, dozens of clinics and skilled nursing facilities, over one hundred pharmacies, over one thousand physicians, and several hundred ancillary services.
Columbia’s population utilize emergency services with an average incident rate of 0.35, consistent with the rest of the state and country. Thirty–five percent of the population goes to the ER every year, with 10% arriving by ambulance. The annual ER and EMS censuses are 1.05 million and 105,000 respectively. On any given day there are 2,877 ER visits and 288 ambulance transports—normalized to the minute there are 2 patients arriving in Columbia’s ERs every minute and 1 ambulance every 5 minutes.
Five years ago the healthcare systems realized there was a tremendous annual turnover of their patient populations. Although there are many causes that are believed to be factors in this turnover, the chief causes are the competitive nature of the healthcare systems amongst the major employers and the rise of unemployment in Columbia. A solution they implemented to deal with their changing patient populations was the creation of a health information federation (HIF).
Columbia’s HIF was founded on the premise that health information, like currency, must be freed up to flow where transactions occur. They defined transactions as any patient-provider interaction where patient–specific information (PSI) is exchanged. All PSI from all patients within Columbia, regardless of health entity affiliations, are marked up in an open standard convention so that all information is structured information (data). Once structured, the information is stored in a Columbia–wide database controlled by the patient and by authorized providers. Providers are broadly construed to include all actors that are involved in the patient–specific informational transaction: including physicians, nurses, hospital, payers, coders, etc. The Columbia–wide database is the source of and storage for all PSI in Columbia.
Columbia chose a system that provides for real–time (just–in–time, JIT) delivery of PSI, which is actuated by a presence communication protocol (PCP). The essence of the PCP is the formation of patient–specific provider groups. These are similar in a trivial sense to the authorization of friends within a social network. Columbia’s PCP generated groups are controlled by the patient and where membership is authorized based upon patient–specific needs. The PCP’s presence awareness is conducted by the active messaging, within Columbia’s HIF, of the availability to participate.
Columbia, via the HIF, has created a single instance of PSI for every patient within the Columbia catchment area with JIT availability. The single instance of PSI is activity added to in real–time at the point of service (POS) or point of transaction (POT). The providers in Columbia, because of the HIF, have realized substantial savings by eliminating the need for the multitude of provider–based record and storage systems. Because of the commonly structured data there are no expenses for interoperability or for health information exchanges. And every patient in Columbia has access to a single instance of their complete health information at any time.
A single patient–centric transaction within Columbia’s HIF:
Prehospital Transactions
Primary Resource Availability Polling
Secondary Resource Availability Polling
Hospital Transactions
POS/POT Additions to PSI
Meaningful Use Substantiation and Deindentification Uses
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