Folks in the Rio Grande Valley are getting used to the idea of evacuations in case of weather-related disasters such as hurricanes, floods, etc.  The National Weather Service has shared maps and photos of what Brownsville might look like when the “big one” comes.  Hospitals would be flooded and patients would have to be moved inland.

What you might not know is that all participating Trauma Regional Advisory Council (TRAC V)  hospitals currently have access to Intermedix EMtrack. This proven technology has been in use for 3 years now in the RGV area and is used throughout state of Texas.  This software connects the emergency rooms of the hospitals so that they can transfer patients from one hospital to another without the loss of critical information.  

The software keeps track of the patient and the sending hospital, the next of kin, etc.  Users can not only track the patient’s demographic data, eye color and other identifying marks, but also any equipment that came with them during the transfer.

The RGV HIE is currently assessing a pilot project which would use the Intermedix EMtrack as a spring board for sharing patient information (ePHI) across hospitals as transfers occur.  Qualified healthcare providers in the receiving emergency room would be able to sign into a link between EMTrack and the sending hospital’s Electronic Health Record system to receive the needed information to continue safe treatment of the patient.

Thinking back to Hurricane Katrina and the people who were lost, wouldn’t it be nice if we could evacuate an entire healthcare facility safely, know where the patients went AND that their most critical patient information went with them?

A well-structured health information exchange (HIE) could save lives by enabling people and healthcare providers access to patient information – securely – whenever and wherever it’s needed.

If your practice or yourself as a physician would also like to benefit and receive the maximum incentive payment for eligible Medicaid and Medicare providers, please fill out the Statement of Interest two page form found on the link below.

RGV HIE Statement of Interest

This statement of interest does not represent a binding commitment; but you or your practice would be interested in utilizing the services of RGV HIE to support the vision for statewide health information exchange (HIE) in Texas. To get the maximum incentive payment, Medicaid and Medicare eligible providers and hospitals must make “meaningful use” of the EHR’s by exchanging clinical health data across secure networks.

Therefore, we are obligated to meet these criteria despite the fact that it may feel uncomfortable for many.

Cameron County, Texas, however briefly, was the epicenter of the US epidemic of the HINI influenza virus in April 2009.  Dr. Joseph McCormick, Regional Dean of the School of Public Health in Brownsville, TX and volunteers from the school and community were instrumental in helping the local health officers figure out who was affected, how the virus was spreading, and what might happen next.

Dr. McCormick and his colleagues have published an article outlining the lessons learned from their experience.   The conclusions reached by Dr. McCormick and his colleagues speak most eloquently to the point, so I quote below:

We believe that our report also confirms the importance of collaborations between different government agencies, community groups—in our instance, county and city health departments, a school of public health, the University of Texas-Brownsville, local schools, adult and child daycare facilities, hospitals, clinics, and county government—in establishing effective surveillance and response to the local epidemic. Influenza pandemics continue to be unpredictable and threatening; therefore, more thought needs to be given to developing preparations at the community level that more effectively connect local and national surveillance information. Simple surveillance systems using readily available data sources need to be in place at the community level with clear, uncomplicated instructions tailored to those who are in a position to take action, such as health officials, school districts, and daycare facility administrators. More efficient communication and flexibility to meet the challenges of a new pathogen outbreak and fewer elaborate formal requirements would allow a more flexible and timely response and maintain the confidence of the community.

[accessible online at: http://www.utb.edu/vpaa/csmt/chemenv/Documents/pubs/20MCCORMICK_WILSON_ETAL_2010_FLU_PREVENTION_BIOSECURITY.pdf]

Our HIE project will connect these entities and institutions together at a local level and make us much more prepared to identify and address the next epidemic if (when?!)  any county in the Rio Grande Valley again becomes the focal point.

So, I think I’ve finally figured out a couple of ways to spell HIPAA (Health Insurance Portability and Accountability Act) correctly. The easiest is that it isn’t like hippo – it doesn’t have 2 “p’s”.   The better way is that HIPAA is “patient-centered” – that is, it only has one “p” in the middle.

The national news has had a lot of information lately on breeches of HIPAA.  Everything from lost hard drives to Rep. Gabrielle Gifford has been in the news.  Some of the breeches have been huge – resulting in the notification of thousands of people.  Some have been brought by a single person.

We all recognize the “need to know” as the basis of HIPAA.  Anyone who is not part of the employee’s treatment team, and does not need the information for payment, health care operations, or other permissible purposes, simply doesn’t need to know.  I’m pretty sure that most of us understand the right of the patient to his or her privacy.

HHS.gov has collected stories about HIPAA to help folks understand the regulations.  The samples can be found here:  http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/index.html.  What struck me about the samples is that most of them happened during pretty routine stuff – publishing OR schedules, for example.  Several had to do with supervisors looking up the records of their employees without the need to know.

I didn’t find any that had to do with real patient care.  And there were no stories about emergencies, hurricanes, tornadoes, heart attacks, poisonings, flu outbreaks, etc.   There aren’t any stories about providers who really needed the information and didn’t get it.

For our HIE, we will need to carefully address both sides of the HIPAA story.   The purpose of our HIE is provide needed information about the patient to the provider at the point of care. We are committed to being patient-centered and will strive to always do what is best for the patient, while balancing privacy with the need to know.

Our policies will be created by one of our planning subcommittees on Data Sharing, Privacy, and Security in keeping with state regulations and HIE standards. If you are interested in HIPAA and patient privacy and security, please contact us by using the information in the ABOUT section of this blog.

I remember the first hospital I worked at had a rabbit hutch on the top of the building. The rabbits were used for pregnancy tests.  When the rabbits were no longer needed by the lab, the library used the hutch for storage of old journals. Today, in the age of home tests and instant results, no one even gets the old joke about the rabbit dying.

Information from laboratory testing supports about 70 % of clinical decision-making.   We know that.  Our providers always tell us to come back for the results of our tests.  Even then, many patients don’t go back, so the provider fails to follow-up on the results.  A study showed that even with abnormal results 7 of 100 were not communicated to the patient.*

A  2005 publication by Roy et. al. showed that nearly 40% of patients discharged from the hospital with lab results pending and that 9% of those required some action on the part of the provider*.  Another related study showed that up to a third (33%) of all physicians don’t even have a reliable system for ensuring that all ordered lab tests are reviewed.

What does this have to do with HIE?  The article by Roy concludes that better communication between inpatient and outpatient providers is needed.  That one goal of our HIE.  The communication of lab results is one of the three top priority elements for the state-funded HIE projects.  Making the results of lab tests visible to all members of the patient health care team means that they each have them available to guide decision-making at the point of care.

* Electronic Release of Clinical Laboratory Results: A Review of State and Federal Policy: http://www.chcf.org/publications/2010/01/electronic-release-of-clinical-laboratory-results-a-review-of-state-and-federal-policy#ixzz1MG7SczLl.

Patient Safety Concerns Arising from Test Results That Return after Hospital Discharge http://www.annals.org/content/143/2/121.short.

A project in Rome, Georgia plans to approach their HIE differently — through patient health records.  Other states have developed projects based on hospital, doctors, or other provider exchanges, but this one will be more customer-focused.  The original grant was made to the Georgia Cancer Coalition and the Georgia Department of Community Health. [1]

“The grant will be used to develop information technology that focuses on improving patient-provider communications and care coordination through the secure use of personal health records. The goal is to develop patient-centered technology and processes that will give patients access to, and a degree of control over, their health information as an essential, central partner on their healthcare team. This health information exchange will be developed by the healthcare providers in Rome (Floyd County), initially focusing on serving their cancer patients.”  [2]

The exchange initially will be available to cancer patients with complex diagnoses and treatments, people who now must navigate an obstacle course of specialist visits, lab tests, chemotherapy sessions and medications worse than anything on Wipe out (ABC).  The HIE will focus first on cancer patients but eventually include the chronically ill, as well as healthy people.

This is one of the HIE projects that we will be interested in watching over time. Because of their different approach, their use of technology and their development of policies may differ from other HIE’s that we are watching.   The headline for the news story was “Patient health records ready to go viral”.  I wish them all the best with that, but I wonder if patient health records will really catch on as they currently exist.  I don’t know many people who are so focused on their health that they are willing to take the time to write down notes from each medical encounter.  Cancer patients are certainly a great choice for a starting place because they are almost forced by the system to carry a notebook and keep their own notes.  For them, there is no other way.

Personal health records really haven’t gone viral, as evidenced by the recent announcement that Google will close Google Health as of Jan. 1, 2012.  If you want to look at a personal health record (PHR), you can still go to Microsoft HealthVault and take a look.

1. http://www.ajc.com/news/patient-health-care-records-1112756.html
2. http://www.georgia.gov/00/press/detail/0,2668,31446711_31673855_168758032,00.html

A few posts ago, we posed this question:

She said that if she couldn’t log on to the Internet anywhere she is and find out the current situation with her bank account, she would be frustrated and even angry.  She asked why she couldn’t do the same for her health information.

Yesterday, a very intelligent man from Washington, D.C. told me the answer!  Michael Glickman, our keynote speaker from the HIE symposium, visited us again yesterday to talk about standards.  Michael has a delightful sense of humor, “The one thing I like about standards,” he said, “is that there are so many to choose from.”

Eventually, someone in the room posed the banking question to Michael.  The requester asked what standards were used by banks and why all of the banks could communicate when it wasn’t being done in healthcare. I don’t want to misquote Michael, so I will just say that he has heard this one before.

Here is what I understood from Michael.  The banking system is set up to achieve 99.999% accuracy.  Thinking about billions of dollars, this could amount to thousands of dollars in losses, but not enough to pay for the cost of the increased accuracy.  If the banks are losing 5% and it doesn’t come out of your pocket, you probably won’t care much.  After all, they limit your liability to only $50.

On the other hand, if your health records were accurate to only 99.999% and over the billions of transactions, there would be a few thousand errors, there’s a good possibility that you would care.

Many years ago, I went to an emergency room for plantar fasciitis.  I left the ED on crutches because this is an issue with the arch/bottom surface of the foot.  When I got my insurance statement, it said I had genital warts.   Needless to say, I called the hospital.  They told me that the coder couldn’t find the code for plantar fasciitis, so she coded for plantar warts.  But the next person couldn’t find plantar warts, so she used genital warts.  It’s probably still on my medical record.

While this example is humorous, there are errors that could occur in medical records that could result in serious injury or even death.  Nothing but 100% will be good enough.  We can think about the banking analogy and what this network has done for our lives, but in healthcare, we have to achieve something even better!

In episode # 2907 of the Woodwright’s Shop, Roy Underhill takes viewers on a tour of a Steam-powered Sawmill.  You can watch it here: http://www.pbs.org/woodwrightsshop/video/2900/2907.html.  Go ahead, I’ll wait…..

What was fascinating about this was the interoperability.  The mill took the steam power from a piston and converted it many ways.  A belt mounted in a figure 8 could convert a wheel turning clockwise into one turning counter-clockwise.  A twist in another belt turned horizontal motion into vertical motion.  The different size and formation of gears could make wheels move slower or faster as needed. 

The IEEE Glossary defines interoperability as:  “the ability of two or more systems or components to exchange information and to use the information that has been exchanged.” (Wikipedia).  If you change the word information to “energy”, the steam engine certainly qualifies.  The energy is exchanged and is useful!

A sawmill is certainly meaningful use of steam.  The man who actually sawed the boards had a number of steps that he repeated each time to make sure the boards (outcome) were the right shape and size, but he was able to create a consistent product with good quality.

Some of the other characteristics of the sawmill, though, were the constant maintenance of the systems and, I suspect, a pretty fair number of breakdowns. One man with an oil can was working his way around the mechanical parts keeping them well greased while the sawmill was in operation.

What is the lesson to be learned about the interoperability of information systems?

• The designer must have a working knowledge of the desired outcome in order to get the system right.
• The entire workflow must be mapped out before construction in order to get the interfaces correct.
• The users must pay special attention to all of the moving parts.
• The designer can’t know just pistons.  He also needs to know belts, gears, and pulleys.
• Friction is always a problem.

If you can successfully address the above 5 guiding principles, you can make great progress toward interoperability of your IT systems.