Last Spring, after attending an Institute of Medicine meeting on Childhood Obesity, I wrote about fronts and Heroes in the Health Attention War. Arguing that if we were going to do anything about long-term patient engagement around health and influencing healthy decisions, we had to start with habits and getting attention at an early age. Attention is the first step towards long-term behavior change.
At that time, I was happy to see the The Ad Council, who has been so successful in campaigns around littering and drunk driving, was working to get attention around childhood obesity to some specific communities. Advertising, after all, is all about directing attention, the necessary first step towards new behavior change. Meanwhile, some school districts were using the ideas behind behavioral economics to influence healthy food choices in schools, which continue to show success.
Today, I’m happy to report that something – or many things – have been working. Via the Robert Wood Johnson Foundation (RWJF) a JAMA Report “shows that that obesity prevalence among 2 to 5 year olds has dropped by approximately 40 percent in eight years.” This is truly outstanding progress. This is the most important age group to address as habits formed here can remain very hard to break later in life.
RWJF goes on to say “After decades of seemingly endless bad news about obesity, our collective efforts over the last several years show that we as a nation are finally moving in the right direction. Of course we can’t stop now.”
Also encouraging, they mention a report yesterday by “Let’s Move” declaring , “Nine out of ten schools across the country are certified to meet healthier lunch standards, and all schools with 40 percent of students qualifying for free or reduced-price lunch will soon be able to provide healthier, free meals to all of their students.”
Let’s continue to build on this progress, getting attention and enabling smarter choices around the problem that eventually became our nation’s health care crisis.
“Healthcare is influenced by where people live, learn, work and play, which has a huge influence on an individual’s overall health.” ~ Karen DeSalvo, MD, MPH, MSc
This year’s HIMSS Annual Conference and Exhibition saw Karen DeSalvo, the new National Coordinator for Health Information Technology, take the stage and it was clear we are entering a new era under her leadership. She recognizes that we are at a pivot point in the history of health IT and sees the need for everyone to take a breath and possibly find some better ways to reach some of our goals.
Speaking at a press event on Tuesday, one on one with me on Wednesday (video is below), during a Town Hall as well as a CCHIT led forum, then during her keynote on Thursday with CMS Administrator Marilyn Tavenner, and finally another press availability at the end of the conference, she laid out a broad vision of the current landscape and where we are heading as an industry.
On Tuesday DeSalvo explained some of her goals. One would be that every provider is using an EHR and health IT to capture, share and meaningfully use health information.
“That requires that there’s some floor that we set, that is raised, whether you’re a rural, small hospital, provider, payer, whatever you are,” she said. She also iterated a policy goal of using meaningful use as a driver to advance the healthcare marketplace. “It’s one thing to have an EHR,” she said. “We need to meaningfully use it, and push technology so that it is driving interoperability across the continuum and that it is improving outcomes.”
She also spoke of the critical importance of interoperability. “The reason I get excited about interoperability is because for it to work, for the doctor to show up in the ER and to know what medicine you’re allergic to, if you’re unconscious and need some help, there’s a lot of back work to see that everything comes together just at the right moment to save your life. That’s pretty exciting to me,” she said.
On Wednesday she joined former National Coordinators for a very interesting discussion on the birth and growth of the ONC. The only one missing was Dr. David Blumenthal, who headed the ONC during the passage of the HITECH Act and was instrumental in its creation.
“I’m sorry David Blumenthal isn’t here because he was advising (the Obama administration) but he was also advising Kerry when he ran against Bush,” said David Brailer, the first National Coordinator. “We spent the entire night trying to get two teams to back off of each other. We both agreed the next morning we made health IT bipartisan.”
The bipartisan nature of health IT was also important to Rob Kolodner during his tenure at ONC. “We didn’t want anyone to grab and control the core infrastructure. It was important to bring it in the room so that the solution didn’t favor one interest or the other.”
But Washington, DC, is often gridlocked, and even bipartisan efforts are difficult to get into law. It was only during a financial crisis and the trillion dollar stimulus that could really provide the funding to substantially move the needle on health IT adoption.
“It took an economic crash to create the opening for something that the groundwork had been laid for,” former National Coordinator Farzad Mostashari said. “The idea that we would get this opportunity was so unbelievable, literally unbelievable, and when the HITECH Act passed, it was a broad movement.”
Dr. DeSalvo, with only weeks in her current role, said, “I don’t have a low point yet.” She expressed optimism about her work saying that after her first HIT Policy meeting, “I got very excited about that because this is a community of vendors, purchases, providers, policy folks, who really want to get it right.”
The ONC has been focusing heavily on patient ID matching recently, including launching a collaborative initiative last fall.
During her keynote Thursday she emphasized interoperability and health data exchange saying, “We can do national healthcare exchange in three years.”
She also stressed the importance of meeting the challenge of patient matching to be sure that the right information about the right patient is being shared safely and securely. “This issue of patient matching and making sure that we get that right is very important,” she said. But she was very optimistic that we can get this done. “I know that this is possible. I have seen exchange in every part of our country.”
With regards to flexibility in stage 2 meaningful use and the challenges of many providers to meet the requirements in 2014, CMS Administrator Marilyn Tavenner announced that CMS will be “flexible” in granting providers “hardship exemptions on a case-by-case basis.”
“We have decided to permit flexibility in how hardship exemptions are granted in the 2014 reporting year,” Tavenner said.
Last December they announced they were extending Stage 2 of the HITECH Act EHR incentive program one year but that did not give any relief with providers who are struggling to meet the requirements in 2014, while simultaneously dealing with the ICD-10 conversion and a plethora of government mandates. Possible exemptions will be outlined in a forthcoming FAQ and will likely include vendors not being ready with their stage 2 technology.
The exemptions to deadlines will be granted for providers in situations where, “despite their best efforts, for reasons beyond their control, they can’t meet meaningful use Stage 2.” I predict there will be a LOT of providers that will need to take advantage of these hardship exemptions in order to avoid penalties.
Standing firm on the upcoming ICD-10 deadline, Tavenner said, “Now is not the time for us to start moving forward. Let’s face it, we’ve delayed this several times, and it’s time to move on.”
The switch from ICD-9 to ICD-10 means that the industry will have to change from about 14,000 codes to about 69,000 codes. I think the deadline for implementing the ICD-10 diagnostic coding set of October 1, 2014. is fairly well carved in stone. Since it had already been delayed one year, now it will not be delayed again.
At the press conference following the keynote, Dr. DeSalvo reiterated the hardship exemptions. Recognizing the call by a coalition of provider organizations to delay the timeline of the meaningful use incentive program and to offer providers more flexibility, she offered hope that these exemptions might stave off failure.
During my discussion with Dr. DeSalvo at HIMSS, she did a very good job of extemporaneously laying out the current landscape of health IT and a glimpse of the future. One of the things that I found compelling was the notion that we could eventually begin to pull in all those data that are outside of the traditional healthcare system that make up what are termed the “social determinants of health.”
She talked about the quantified self movement, patient-generated health information, and a move away from capturing data in the standard EHR to include all of these other data—including providers, patients, payers, and the entire healthcare ecosystem in the digital architecture. She paints an interesting picture of a future tech-enabled transformed health system.
Happy HIMSS to one and all! I say this because this week is HIMSS’ annual conference and exhibition, HIMSS14. The annual event is much like Christmas. People spend months preparing and looking forward to the big day, in this case big week. And when it gets here it’s a whirlwind of excitement over meeting up old friends, discovering new things and seeing some renowned and famous people. At Christmas it’s Santa. At HIMSS14 its Hilary Rodham Clinton. Also, like Christmas the week after the HIMSS conference is spent recouping from the excitement of the big event.
To get the most out of HIMSS14 (and Christmas) it’s a good idea to make a list and check it twice. Between the speakers, special sessions and exhibitors, there is a ton of information to be had at HIMSS14 and at times it can get overwhelming. In fact, just a few weeks ago Shane Damico wrote a post for HL7standards.com full of advice on how to make the most of HIMSS14 that I hope everyone read before attending.
What I’d like to do is to get feedback from HIMSS14 conference attendees on a few of the sessions I’ve listed below. You came, you saw, you conquered and now what do you plan to do with your new knowledge? How will you apply this information to nursing? What do you think it means for the nursing profession as a whole? So please comment here or tweet your musings to @healthstandards #HIMSS14. We want to know what you’re discovering!
Nursing Informatics Hot Topics Review
This interactive panel session was held Feb. 22 and covered up-and-coming innovations in the field of nursing informatics with a focus on quality. The goal of the session was to:
So what did those of you who attended learn? How will health IT facility quality measurement and improvement?
I think systems that allow nurses to collect and compare data and outcomes will have a huge effect on the type of care we provide. It’s real time evidence-based practice. I feel that in the past, we nurses have sometimes felt obligated to launch a quality improvement project and we run to the literature first to see what others have done. But by first analyzing your own data you can determine what you really need to work on at your facility. The numbers can help guide you as to what to improve so you can then focus on literature that will help solve your problem and present possible interventions.
What did you find most valuable about this session?
This session explores implementation of new care delivery models, how the profession must enable tomorrow’s leaders and the value of informatics principles in this transformation from a nurse executive’s perspective. Session objectives were to:
What are specific opportunities to show leadership at the executive level? From my perspective, because IT can be a process driver, it’s a chance to work with other nurse leaders and executives to develop and nurture new and efficient patient care workflows. It’s also an opportunity to make the bedside nurses’ jobs more efficient by developing a process and selecting a product to allow them to spend more time with the patient at the bedside.
What was your biggest a-ha! moment during this seminar?
This session was Feb. 26 and part of the TIGER Institute. It features a presentation of findings from two health IT patient engagement studies. The first study measured the impact of patient engagement tools (kiosks, portals, and mobile phones) on decision-making, adherence to care plans, and healthcare outcomes. The second study discusses the development and roll-out of a patient engagement portal to support interdisciplinary care teams in engaging patients.
Goals of the session are:
I’ve written about patient engagement recently in regards to OpenNotes and patient assertiveness so I’m interested to hear what you have learned during this session regarding patient engagement. What types of data show that more engaged patients help reduce costs? How can you get patients interested in and using portals and how does it benefit the clinicians?
The title of this poster presentation caught my eye because of the word Technostress. I was glad to see someone acknowledge that technology is often a source of stress among nurses. It’s a legitimate thing, not just nurses whining.
As the poster’s description says: “Nurses represent one population that has been pressured to utilize the EHR, has suffered stress during the process, and has been forced to adapt to the challenges inherent with multiple changes in workflow, often without any feedback into the activities that directly affected them. This research examined the effect of technostress creators and inhibitors on the perceived productivity of nurses.”
The objectives of the poster presentation:
I would love to hear some of the strategies visitors came away with and attend to apply back at their facilities. And does reducing technostress improve nurses use of EHR? Tell us what you think!
If you attended a session that isn’t on this list please share your experience with us here or at @HealthStandards #HIMSS14, or with me directly @Jen_NurseEditor.
I hope you enjoyed this year’s event and remember HIMSS15 is only 365 days away in my hometown of Chicago!
Healthcare interoperability is the “must have” for our care delivery system. The reasons why this is important are many, including:
Getting patient data into an electronic format was the first required step and Meaningful Use has been successful in driving this forward. The incentives have worked. The next step may be more challenging, but it shouldn’t be. What may be required is more innovative ways to empower health data exchanges and traditional models may need to be put aside.
In reviewing some of the key statistics in the infographic below, here are a few interesting points:
There are four imperatives to health information exchange, and we need to embrace each fully.
“We are again at a time of great change. The doctors of medicine long have been revered like priests of old; scribes copied their words as a holy writ that the public could not easily access. Then came the electronic medical record. Now patients, doctors, nurses and scribes are trying to find their way in this new world. Each has a place in the system of care and scribes are walking a new path.” – Regina Holliday, “The Scribe”
I had a chance to talk with Dr. Luis Saldaña about the benefits of “medical scribes”, and how the role has evolved and exploded in the age of EHRs. Dr. Saldaña is an emergency physician whose group was among the first to use medical scribes – way before the introduction of the Electronic Health Record. Even in the paper world, scribes were found to increase efficiencies by 25 percent while improving the patient experience.
Today, medical scribes are a growing trend, and Dr. Saldaña is uniquely poised to speak to the value of medical scribes in our digital world. He also serves as chief medical information officer (CMIO) of Texas Health Resources, one of the largest faith-based, nonprofit health systems in the United States. In 2012, Dr. Saldaña co-authored HIMSS’ Book of the Year: “Improving Outcomes with Clinical Decision Support: An Implementer’s Guide.”
A medical scribe is a trained medical information manager who specializes in charting physician/patient encounters in real-time during medical exams. A scribe follows a physician through his or her work day and documents information in the Electronic Health Record so that the physician can focus on patient care.
Our group, which contracts with our hospital – and we staff all the THR hospitals, except maybe one or two – has used scribes for many, many years. One of the group’s owners came from a military background where corpsmen acted as scribes in the emergency department. He brought something similar to our emergency practice.
We started with our own scribes but that later morphed into a totally separate company, PhysAssist, with whom we contract today.
Scribes let me focus on the patient. I don’t see any other way than a third party being in the room to capture the patient’s voice. That is a narrative. The history of present illness is now a narrative.
It has a huge value to me. As a busy physician, you may have heard one thing, but the patient may have told you something in addition. Scribes capture all the elements, and that is key.
Even with voice recognition, you can’t capture the whole physician/patient encounter as well…I’d have to leave the room to dictate…or try to type and capture in the room which would be very awkward.
The process allows our physicians to be more productive and efficient because they can parallel task.
You need both. It allows us to focus and be more patient-centered. Am I meeting the patient’s needs? Have I given the proper discharge instructions for followup? Have I told the patient what they need to look for?
I’ve never once had a patient have an issue with it. I make sure to introduce the scribe. The patient sees that I am talking directly with them, and the scribe is capturing the information.
What bothers me is that people describe scribes as workarounds for EHR shortcomings, and for some people, that may be how they look at it.
But regardless of what setting you are in, you have to think about how the work is done, and how it can be done more efficiently and effectively.
Our vendor has been very good adopting to the workflow, so you can use a scribe or not. A vendor has to understand the workflow, that’s critical in any Electronic Health Record. As much as we like standardization, in different settings, there are different workflows. And in physicians’ offices, there are also different models of care. You have to be cognizant of all these various workflows, and be flexible to allow for those differences.
Because of the nature of parallel processing, scribes are a great fit in the emergency department. It’s not the same for a primary physician where adding a separate person to serve just as a scribe wouldn’t work. Again, you have to look at workflow, and maybe the role of the medical assistant on the team.
Our program is really like an apprenticeship. Almost all of our scribes are pre-med students. They commit to doing a year or two working all the shifts with us – nightshifts, weekends, holidays. We’re teaching them, and telling them what we’re thinking.
Many of the scribes end up working with us after medical school. They’re now emergency physicians or other physicians on staff. Every one of the scribes has told me that when they did their residency, they were far ahead of their colleagues in terms of understanding the patient encounter because they saw many, many patient encounters.
They were also ahead in understanding medical terminology and in decision-making skills.
It’s a reward to see these students come back as colleagues and peers.
Demand for scribes is growing 46 to 50 percent every year according to PhysAssist, which employed 35 scribes in 2008, and now has over 1400.