Saturday, May 12, 2012

Weekly Overseas Health IT Links - 12th May, 2012.

Note: Each link is followed by a title and few paragraphs. For the full article click on the link above title of the article. Note also that full access to some links may require site registration or subscription payment.
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Top 6 tips for e-patients

By Diana Manos, Senior Editor
Created 05/04/2012
BOSTON – Gone are the days when patients can afford to be passive about their healthcare, says Nancy Finn, author of the new book e-Patients Live Longer: The Complete Guide to Managing Health Care Using Technology.
“The ‘e’ in e-patient stands for empowered, engaged and educated,” says Finn, a Boston-based medical consultant who works with medical institutions on the development and implementation of digital communications. She has also written a book for doctors titled Digital Communication in a Medical Practice.
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HHS moves to mathematical modeling for research, intervention evaluation

By kterry
Created May 4 2012 - 11:31am
The Department of Health and Human Services (HHS) has decided to use a new method of mathematical modeling to research, analyze and evaluate the effects of specific healthcare interventions.  
Under a new contract with San Francisco-based Archimedes Inc., all HHS agencies will have access to the web-based Archimedes Healthcare Simulator (ARCHes). Among the agencies involved are the Centers for Medicare and Medicaid Services, the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, the National Heart, Lung & Blood Institute, and the Food & Drug Administration.
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6 must-haves for effective customer support in health IT

By Michelle McNickle, Web Content Producer
Created 05/03/2012
There's no denying that customer service is a key driver of success in any business. And when it comes to health IT, strong customer support is that much more important to successfully implement tools aimed at improving patient care and reducing costs.
Sonal Patel, vice president of client services at Corepoint Health and Cathy Wickern, system analyst at Washington-based Highline Medical Center, outline six must-haves for effective customer support in health IT.
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E-health technologies spreading in developing nations

By kterry
Created May 4 2012 - 12:22pm
The use of e-health technologies, including mobile health, is spreading rapidly in low- and medium-income countries around the world, according to a new report [1] from the World Health Organization (WHO). In part, this is because the use of mobile phones and computers is growing in these developing nations, the report said. But less than a quarter of the surveyed health programs used e-health technologies, and their reliance on private donors -- which provided nearly half of their financing -- is one factor limiting their expansion, the WHO report said.
The data on which the report is based comes from the Center for Health Market Innovations (CHMI), which has been collecting information on public and private programs likely to improve health in developing countries since 2007.  Due to the unreliability of government data, the WHO report focuses exclusively on private-sector programs.
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UCLA targets malaria with online gaming

By Mike Miliard, Managing Editor
Created 05/03/2012
LOS ANGELES – UCLA researchers have created a crowd-sourced online gaming system in which players distinguish malaria-infected red blood cells from healthy ones by viewing digital images obtained from microscopes. 
Working on the assumption that large groups of public non-experts can be trained to recognize infectious diseases with the accuracy of trained pathologists, researchers from the UCLA Henry Samueli School of Engineering and Applied Science and the David Geffen School of Medicine at UCLA developed the online game, which is being billed as a new front for telepathology.
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EHR Success All in the Details

APR 30, 2012
There's always something. Whether it's a pasture of COWs (computers on wheels) gathering dust, dead spots in your Wi-Fi coverage, or clinicians who want an unmanageable amount of customization, no EHR effort is without glitches. The eight providers below are doing about as well with EHRs as anyone-they are collecting meaningful use dollars, have reached Stage 7 on the HIMSS Analytics EHR adoption model, or have won a HIMSS Davies award for their implementations.
Health Data Management asked CIOs and other technology leaders to share their experience: what they wish they had known when they began, what they would do differently, what they still struggle with.
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Big Data, Big Biology, and the ‘Tipping Point’ in Quantified Health: Takeaways from Xconomy’s On-the-Record Dinner

Bruce V. Bigelow  4/26/12
Two of the biggest trends in technology innovation are converging—and as they come together, there is a chance to accomplish something rare in San Diego. Something exponential.
One of these forces is “big data,” the ever-increasing capabilities of computers and analytic software to move from gigabytes to terabytes, petabytes, and beyond. The other is “big biology,” which encompasses a breathtaking array of fundamental breakthroughs in DNA sequencing, molecular diagnostics, genome biology, proteomics, and other “omics” technologies.
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8 Social Media Tips for Physicians

Carrie Vaughan, for HealthLeaders Media , May 3, 2012

This article appears in the April 2012 issue of Healthcare Marketing Advisor.
1.       Develop a social media policy. This is true for all institutions no matter their size—even a small mom-and-pop clinical ­practice with one provider needs to have a social media policy. Remember, your employees will be on social media, and unless you have policy for behavior, you can't define how they are going to engage, says Mayo Clinic's Farris K. Timimi, MD. The AMA offers a set of guidelines.
2.    Be clear that the thoughts and views expressed are yours and not the hospital's or group practice's.
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Reclassifying EHRs as medical devices would come at a cost

By mdhirsch
Created May 3 2012 - 10:21am
Just two weeks ago, I expressed concern that a cyber attack on unprotected medical devices can infect the electronic health records [1] to which they are connected, causing the EHR to malfunction and the data to become corrupted.
But is blogger-physician Westby G. Fisher, M.D.--aka, Dr. Wes--correct when he suggests [2] that EHRs themselves should be seen as medical devices?
He states in his blog post that EHRs, like other man-made medical devices, are not perfect. He notes that they're full of documentation problems, they can spew useless and "potentially lethal" information and that updates are "routinely deployed without real-world real-life testing."
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Mitigating PHI danger in the cloud

By Rick Kam, President and co-founder ID Experts
For all of its benefits, cloud computing poses very real dangers to covered entities responsible for safeguarding protected health information (PHI).
The cloud model, which the IT industry has been embracing for its up-front cost savings and efficiencies for years now, is more recently being recognized by the healthcare realm for its potential to serve as an ideal infrastructure for Health Information Exchange (HIE) — a main component of the Electronic Health Records (EHR) meaningful use initiatives. What’s more, the cloud can provide easy, affordable access to the latest medical applications, such as e-prescribing or leading-edge diagnostic tools.
All of which could contribute to the strong growth of cloud computing in healthcare, according to CompTIA research. But PHI security dangers lurk in the cloud. Here’s a look at how to mitigate some of those.
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Consumer Advocate Slams AHA Position on Patient Access

MAY 2, 2012 4:41pm ET
The American Hospital Association has come under heavy criticism from an influential consumer advocate for its position on a proposed Stage 2 meaningful use provision to give patients electronic access to their health information within 36 hours of discharge.
In a blog posting, Christine Bechtel, vice president of the National Partnership for Women & Families and a member of the HIT Policy Committee that advises federal officials, writes that the AHA “has little interest in advancing meaningful use criteria that would result in tangible benefits to patients.”
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Report: Pricing, technology to blame for high U.S. healthcare costs

By sjackson
Created May 3 2012 - 11:43am
High prices and technology costs are what are driving skyrocketing healthcare costs in the U.S., not high utilization rates, according to a new report [1] from the Commonwealth Fund.
One major factor is the over-use of expensive testing, imaging and other technologies--compared to other countries like Norway, Japan and Germany, the report states. The U.S. uses far more MRIs, CT scans, PET scans and mammograms.
What's more, those tests are far more expensive in the U.S. than in other countries. For example, an MRI costs about $1,080 in the U.S., versus $299 in France and $599 in Germany, the report reveals.
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U.S. needs better way to track drug safety - study

Tue, May 1 2012
* IOM says risks of certain drugs become apparent over years
* Says FDA should monitor safety through drug 'lifecycle'
* Says FDA should create public document for drug risks
* FDA says supports transparency, concerned about costs
WASHINGTON, May 1 (Reuters) - The U.S. Food and Drug Administration should review drugs on a regular basis for as long as they are on the market in order to catch any new safety issues, according to a report from an independent research body.
The Institute of Medicine, which often advises the government on scientific matters, said the FDA should then create a comprehensive, publicly available document that reflects risks that crop up throughout the "lifecycle" of the drug.
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Report: Baby Boomers Will be Integral to mHealth

May 2, 2012
A new report from the Cambridge, Mass.-based research and consulting firm, Fuld & Company, has concluded that those looking to gain share in the growing mobile health (mHealth) market will have to find partners to cater to the affluent Baby Boomer generation and their caregivers.
Fuld & Company held a contest, with teams from Dartmouth's Tuck School, MIT Sloan, Northwestern Kellogg School, and Yale School of Management, which stress tested the wireless health strategies of Bosch Healthcare, GE Healthcare, start-up software company Independa, and Medtronic.
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Thursday, May 03, 2012

Health Systems Spending Billions To Prepare for the 'Last War'

Health care IT departments have focused much of their attention on the $19 billion portion of the stimulus package allocated for the meaningful use of electronic health records. While this is logical given the available money, it is paying for health IT systems that are optimized for the "do more, bill more" model of reimbursement. However, that model is rapidly being replaced by a focus on value and outcomes -- a 180 degree shift.
On the one hand, it's hard to argue against modernizing health care systems. Thousands of lives are saved as a result of this modernization (e.g., avoiding deadly prescription errors). On the other hand, most companies benefiting from the stimulus package have two significant shortcomings that will need to be addressed for health systems to thrive in the new environment they are facing.
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6 reasons to manage and archive your social media

By Michelle McNickle, Web Content Producer
Created 05/01/2012
Social media's use in healthcare is without a doubt growing. But as organizations learn how to leverage these tools, a recent whitepaper by Osterman Research makes clear organizations also need have plans in place to both manage and archive their social media use. 
The report describes six reasons organizations should consider managing and archiving their social media.
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Health 2.0 to showcase 10 'hottest' startups

By Bernie Monegain, Editor
Created 05/02/2012
BOSTON – Health 2.0 will unveil 10 of what it bills as "the hottest new companies in healthcare technology" at the Launch! session during Health 2.0 Spring Fling Matchpoint in Boston, May 14-15.
Since its introduction in 2008, Launch! has given more than 55 new and innovative companies a platform for debuting new technologies. Launch! has introduced companies such as Unity Medical, Remedy Ventures, TheCarrot, Univita, Basis and the WSJ's 2010 top startup company, Castlight Health.
Each of the 10 companies will present at Launch! in a series of rapid-fire, back-to-back, four-minute demos. The audience will determine which company gets invited to demo on the main stage during the 6th Annual Health 2.0 Fall Conference in San Francisco.
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Epic win at Cambridge

27 April 2012   Rebecca Todd
Epic has won the Cambridge University Hospitals NHS Foundation Trust and Papworth Hospital NHS Foundation Trust joint electronic patient record procurement, eHealth Insider can exclusively reveal.
Cambridge and Papworth will be the first UK reference sites for the US software supplier, which is known to have heavily invested in the high-profile bid.
The trusts selected Epic ahead of Cerner and Allscripts in what is seen by many as one of the most important NHS IT procurements in recent years.
A Cambridge University Hospitals statement provided to EHI this morning says: “Epic has a successful track record of delivering software products designed with patients and clinicians in mind at academic healthcare centres in the US and Europe.”
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Processed EHR text can be used to develop CDS tools

By danb
Created May 2 2012 - 1:27pm
Free text in electronic health records, with the help of natural language processing (NLP) technology, can be used to create accurate clinical decision support (CDS) tools, according to a study [1] published this week in the Journal of the American Medical Informatics Association.
Researchers from the Mayo Clinic set out to develop a CDS system for cervical cancer screening geared specifically toward identifying patients with abnormal Papanicolaou (Pap) reports. According to the study's authors, providers often don't follow proper protocol for cervical cancer screenings; they believed that the use of CDS would help providers in their screening efforts.
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Facebook now matching organ donors, patients

By danb
Created May 2 2012 - 2:07pm
In search of a new organ? It could be just as easy as logging onto Facebook, according to an iHealthBeat post.
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IT exception to cutback in hospital capital spending

By Bernie Monegain, Editor
Created 05/01/2012
CHARLOTTE, NC – Spending on information technology is the one exception to a marked slowdown in capital spending by hospitals, according to a new survey from the Premier healthcare alliance. Premier pins the slowdown on legislative and economic uncertainty.
Premier’s spring 2012 “Economic Outlook” survey projects continued focus on health IT requirements; insights from industry experts on reform and improving patient care while reducing costs.
“The nation’s current debt concerns and looming reductions in reimbursement have, for the most part, slowed hospital spending and increased demand for greater value,” said Premier chief operating officer Mike Alkire. “The one exception is HIT, where hospitals are placing a great deal of fiscal and operational focus."
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5 reasons to use forensics

By Michelle McNickle, Web Content Producer
Created 04/30/2012
With the prevalence of data breaches rising, the industry is slowly yet surely realizing they're no laughing matter. And with price tags circulating around the billions, more organizations are starting to take the steps necessary to protect themselves against a costly breach of sensitive information.
Yet, breaches remain common, and as best practices continue to develop around how to handle them, one tool is proving to be invaluable: forensics. 
"Oftentimes, organizations want to understand what happened and how did it happen, and the chain of evidence and information has to be preserved," said Mahmood Sher-Jan, vice president of product management at ID Experts. "To bridge that gap, whether it was an outside attack or an internal issue, is to begin the process of analyzing information to see the overall scope of the damage. That causes it to get kicked-off with a forensic analysis."
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Government's power to accelerate HIE formation is limited

By kterry
Created Apr 29 2012 - 1:06pm
Health information exchange must overcome several barriers before it becomes widespread, say health IT experts Julie Adler-Milstein and Ashish Jha in a new commentary [1] published last week in the Journal of the American Medical Association. The authors state that the obstacles to the effective exchange of clinical data are substantially greater than the challenge of getting most providers to adopt electronic health records.
Adler-Milstein and Jha list five barriers to data interchange; the first three of these, they contend, could be lowered through government intervention. The roadblocks include concerns among clinicians about the privacy and security of patient information in HIEs; the growing use of the Direct secure messaging protocol, which was developed by a public-private consortium including the Office of the National Coordinator for Health IT; and the exclusion of providers other than eligible professionals and hospitals from the Meaningful Use electronic health record incentive program.
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Tracking diseases using Google Maps and cell phones

Researchers at UCLA digitize rapid diagnostic tests to test for diseases such as HIV, malaria, and tuberculosis with less user error.
by Elizabeth Armstrong Moore April 27, 2012 9:59 AM PDT
Many of us have relied on rapid diagnostic tests at one time or another, whether it's testing for pregnancy, blood glucose levels, or strep throat.
But while dropping fluid samples on a small strip for near-instantaneous results is affordable and convenient, reading results using the human eye means there is the potential for, well, human error.
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Electronic-Records Goals Aren’t Met by 80% of U.S. Hospitals

By Alex Wayne on May 01, 2012
More than 80 percent of hospitals have yet to achieve the requirements for the first stage of a $14.6 billion U.S. program to encourage doctors to adopt electronic medical records, the industry’s largest trade group said.
The program is too ambitious and goals may not be met, Rick Pollack, executive vice president of the American Hospital Association, said yesterday in a 68-page letter to the Health and Human Services Department. He cited “the high bar set and market factors, such as accelerating costs and limited vendor capacity.”
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Chicken Scratches vs. Electronic Prescriptions

By RANDALL STROSS
AS e-mail and texting have become our favored means of written communication, handwriting has almost disappeared. Penmanship is becoming a modern form of hieroglyphics, intelligible only to literary scholars.
But one place where handwriting persists is on medical prescriptions, and that’s unfortunate. Sloppy writing or inappropriate directions can lead to what doctors delicately refer to as preventable A.D.E.’s, or adverse drug events. These can encompass minor but still avoidable problems, like rashes or diarrhea, and much more serious events like, well, death.
Studies show that errors are much less likely if a doctor clicks to select medications from an onscreen list and sends the prescription data via computer to the pharmacy. Rainu Kaushal, a professor of medical informatics at Weill Cornell Medical College, led a study published in 2010 in which she and four colleagues followed prescriptions issued by a sample of providers in outpatient settings in New York. (Providers included physicians, physician assistants and nurse practitioners.) Some were prescribing electronically for the first time, and some continued to use paper.
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Automation and the Healthcare Cost Curve

Philip Betbeze, for HealthLeaders Media , April 30, 2012

This article appears in the April 2012 issue of HealthLeaders magazine.
Automation, the use of labor-saving devices and information technology to reduce or eliminate the need for human labor, has yielded exponential savings in dozens of industries. But why is healthcare historically a slow adopter of potentially labor-saving, and thus cost-saving, techniques and technology? For one reason, there was no urgency. Productivity in healthcare, in the sense of wringing out incremental savings in labor, has lagged far behind the rest of business largely because competitive pressures present in other industries simply didn't exist in healthcare. But with margins being threatened as never before, many new contracts with commercial insurers depend at least partially on efficiency, meaning healthcare providers must improve labor utilization.

Automation, either full or partial, of various jobs can be a productive tool for healthcare organizations looking to cut costs, and proven solutions and technology are enticing.

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Allscripts: Debacle or silver lining?

By Bernie Monegain, Editor
Created 04/30/2012
CHICAGO – After what turned out to be a sea-changing Q1 earnings meeting April 26, which saw the ejection of its board chairman and three other board members reportedly quitting in protest, Allscripts on Monday moved quickly to begin to right the ship, with the announcement of a new chairman.
Dennis Chookaszian, who has served on the Allscripts board since September 2010, will take the helm on the board of directors. He was formerly the chief executive and chairman of mPower Inc., a financial advice firm focused on the online management of 401(k) plans.
Some Allscripts customers say they are concerned about the recent chaos, but they believe Allscripts founder and CEO Glen Tullman will be able to move the firm forward.
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Walsall works with PatientShare

17 April 2012   Chris Thorne
Walsall Healthcare NHS Trust has implemented PatientShare, a web-based forum, to improve patient access to clinicians and give them a platform to share their experiences.
The trust is using the website to provide consistent and up-to-date written and video-based information on bariatric surgery, allowing patients to email directly any individual featuring in the videos.
Dr Andrew Hartland, medical lead for the bariatric services unit, told eHealth Insider the trust wanted to provide patients with “clear, accessible and consistent information.”
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Patients Know Best in US trial

25 April 2012   Rebecca Todd
A patient records access portal developed by a UK doctor is being used in a United States trial looking at whether giving patients access to their records saves on healthcare costs.
Dr Mohammad Al-Ubaydli, founder and chief executive of the patient-controlled records system Patients Know Best, spoke at the BCS Primary Health Info 2012 conference on Tuesday.
He said the patient record portal has been selected for a trial involving teaching hospitals in the US that has been set up to investigate how giving patients access to their own records can impact their use of healthcare.
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Leapfrog: CPOE detects more medication errors

By kterry
Created Apr 27 2012 - 3:43pm
There has been a major improvement in the ability of hospital computerized physician order (CPOE) systems to detect medication errors, according to the Leapfrog Group, a nonprofit organization that advocates for safety improvements in hospitals.
Two years ago, the Leapfrog announcement said, 214 hospitals used a web-based simulation tool to test the effectiveness of their CPOE systems in catching medication errors. Leapfrog found that, on average, the systems missed about half of routine medication mistakes and one-third of potentially fatal errors.
In another test conducted in 2011, 253 hospitals used the simulation tool to test CPOE. This time, they missed just slightly more than one-third of routine mistakes and 1 percent of errors that might have proved fatal.
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E-reminders improve med adherence in patients with chronic conditions

By mdhirsch
Created Apr 30 2012 - 11:52am
Sending electronic reminders to patients is a simple yet effective way to improve medication adherence of patients with chronic conditions, according to a new study [1] published in the Journal of the American Medical Informatics Association.
The researchers, from several institutions in the Netherlands, noted that one of the primary reasons that patients with chronic conditions have a hard time adhering to long term treatment is forgetfulness. While reminders may help, personal reminders from providers require an extensive time investment, while "reminder packaging" doesn't actively remind patients. The researchers hypothesized that electronic reminders may be a better option.
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E-prescribing growth not as slow as article portrays

By kterry
Created Apr 30 2012 - 5:01pm
The electronic routing of prescriptions from physician offices to pharmacies grew significantly from 2010 to 2011, to judge by the latest Surescripts data. According to an article [1] in the New York Times, a Surescripts report due out in May will show that 36 percent of U.S. prescriptions were transmitted electronically in 2011. By contrast, about 25 percent of all prescriptions were sent online in 2010.
Approximately 326 million prescriptions were routed electronically in 2010, according to Surescripts [2]. A straight comparison of that figure to the 3.54 billion retail prescriptions filled that year would indicate that the percentage prescribed online was only 11 percent. But a Surescripts spokesman told FierceHealthIT [3] that office-based physicians could have transmitted only 1.66 billion new prescriptions and renewals to pharmacies or mail-order houses. That number doesn't include prescriptions for controlled substances, which are about 13 percent of all prescriptions, and couldn't be sent online in many states in 2010.
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3 steps to EHR training for new staff members

Technically Speaking. By Pamela Lewis Dolan, amednews staff. Posted April 30, 2012.
Physician practices generally have a detailed training map that is laid out for all its doctors and staff as they implement an electronic health record system. But practices can’t lose the map once the system is up and running.
At some point, new physicians and employees will join the practice, and they will need the same level of system training everyone else received. “Organizations that are successful … have been careful not to shortchange their new employees,” said Jerrilyn Cowper, solutions manager for CTG Health Solutions, a health care technology consulting firm.
Small organizations don’t have the luxury — or the need — for full-time trainers like large organizations have. Therefore, the job will fall to either practice managers or “super users” within the practice. Super users — employees who generally have more extensive training than others and get others excited about the new system — are generally identified at the implementation stage.
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April 27, 2012

A Potential Passport for Care Coordination

Steven D. Freedman, M.D. is looking to improve communication between patients and physicians, not only during the office visit, but beyond it as well.  Freedman, chief of the Division of Translational Research at Beth Israel Deaconess Medical Center in Boston and a professor of Medicine at Harvard Medical School, started up the Passport to Trust foundation alongside Mark Aronson, M.D., to do just that and improve the overall patient-physician encounter.
“One of the problems and barriers in healthcare is that generally the office visit is a black box,” explains Freedman. “You may get a great doctor. You may get a not so great doctor. It’s a one-way communication where the doctor says to you, ‘Here’s the test that I recommend, why don’t you see me back in six weeks.’ They and their families generally are not informed partners in their care. And then we wonder why patients may not follow our recommendations.”
For improving in-visit interactions, Passport to Trust physicians created paper-based written summaries of the patient’s plan of action during the visit. The results, according to a study done by Passport to Trust, were successful, with 97 percent of the patients finding the written summary of the plan able to address their concerns. However, to get patient engagement and interaction ramped up in between visits, Freedman and those at Passport to Trust are looking to go digital with the initiative.
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Decision support and shared electronic data are 2 key IT tactics for ACOs

Posted By Dr. John D. Halamka On April 27, 2012 @ 1:26 pm
I recently presented a webinar outlining the the IT work ahead to support Accountable Care Organizations.
Here are the slides [2] that I used.
I recommended five priorities to create a foundation for care management and population health:
1. Universal adoption of EHRs – every clinician in an ACO needs to record data electronically, ideally using the same EHR vendor.   If not the same EHR, then using common pick lists/vocabularies enables data to be comparable across practices.   At BIDMC we created a model office workflow to ensure data is recorded by individuals with the same role at the same time in the same processes using the same value sets.
2. Healthcare Information Exchange – data should be shared among caregivers for care coordination and panel management.   Approaches can include viewing data in remote locations, pushing summaries between providers, or pulling summaries from multiple sites of care.   BIDMC has created novel approaches [3] to secure data sharing as well as participated in many federal and state HIE pilots.
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Monday, April 30, 2012

Driving Interoperable Health Data Exchange Under HITECH

Recent HITECH regulations -- including the Stage 2 meaningful use proposed rule and the proposed rule setting forth standards, implementation specifications and certification criteria for electronic health record systems -- chart the health care system's next steps on the path toward electronic health information exchange, or HIE. 
Background
HITECH included a number of programs designed to spur electronic HIE throughout the nation, including programs to develop necessary HIE infrastructure, identify common HIE standards and policies, and supply health care providers with incentive payments to adopt and meaningfully use EHR systems. The Affordable Care Act built on the foundation that HITECH laid by implementing new payment and care delivery approaches, such as bundled payment options and accountable care organizations, that recognize HIE as a critical enabler of broad transformations in health care.
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Enjoy!
David.

1 comment:

Anonymous said...

Some weeks ago I received an unsolicited package in the mail from the National Bowel Cancer Screening program. Then, a few days ago, I received a letter from them, quoting an ID number, stating "Our records show that you have not yet returned a completed faecal occult blood test (FOBT) for analysis", and wanting me to fill out an Opt-Off form if I do not intend to use the test.

Their website indicates that they have created a special purpose register of health records where they keep track of the results of this intervention.

If I did take part, would I be given access to my personal details on their register?

Most importantly, in my mind, is whether or not this Bowel Cancer screening register interacts with any of the (many) other registers of health records.