Parking on a busy street in New York City can often be overwhelming, just by the sheer number of parking signs posted on the same corner. NO STOPPING MON-FRI 7 AM – 7 PM; ALTERNATE SIDE PARKING IN EFFECT; COMMERCIAL VEHICLES ONLY; SNOW EMERGENCY ROUTE; the list goes on and on.
“I don’t have time for this—parking shouldn’t be so difficult,” you tell yourself as you hurriedly pull up to the curb. You attempt to read all the signs, but you’re quickly losing patience.
So you park your car in the next available spot you see and return three hours later; and although you thought you followed all of the posted instructions, you come back to a $115 parking ticket on your windshield. It seems that, distracted by the other parking signs, you overlooked an equally important instruction—MAX TWO HOUR PARKING.
Like parking signs on a city street, clinical alerts are often overwhelming. However, while electronic health records (EHRs) have utilized clinical alert systems to improve overall patient safety, prescribers are often bombarded with so many messages that, for time’s sake, they become conditioned to override them all. This ‘conditioning’ is known as alert fatigue, and it presents one of the most harmful obstacles to patient safety.
Sometimes it’s an important reminder: maybe the patient has a peanut allergy; or maybe an underlying condition such as diabetes. These things should be considered while writing orders. However, if a prescriber is provided regularly with information that does not apply to the diagnosis at hand, he or she risks developing alert fatigue; even though, under different circumstances, these same reminders could alert to something far more important, necessary, or even life-threatening.
Orders, in particular medication orders, are subject to close scrutiny for appropriate doses, precautions for age and gender, patient medical history, interactions with other drugs, and potential allergic reactions, to name a few. However, with alerts range from rather insignificant to potentially life threatening, clinicians have difficultly discerning between the two.
If a doctor receives the alert “MALE PATIENTS AT HIGHER RISK FOR HIGH BLOOD PRESSURE” when treating a female patient, for example, he may become conditioned to overriding these alerts due to their inconsistency. However, if one physician orders epinephrine and disregards an alert detailing an earlier MAOI administration, the result could be deadly.
When do these ‘alerts’ stop being helpful, and start deterring us from our initial responsibility? Sometimes, we become so confused by the amount of instructions, that we forget basic directions like stop and go.
Facility environments are in a perpetual state of change, with formulary lists constantly being updated. Only under certain preconditions are drugs to be administered, and never under others. That’s why, for safety’s sake, decision support systems and clinical alerts must be able to manage, process, and communicate patient data both intelligently and efficiently. Systems must be fine-tuned to present physicians with only the warnings that are applicable to their specific patients.
That’s why Meta has been working to combat alert fatigue for nearly twenty-five years. After witnessing the potential danger of disregarding clinical alerts, we developed a system that can be customized by end-user decision makers during implementation to work with clinicians.
That’s why MetaCare™:
Alerts to therapy changes on a real-time basis, based on real-time clinician input—to ensure the user knows why the alert has occurred, and how to resolve it;
Prompts for documentation before and after administration, and requires justification reporting to override any and all clinical alerts;
Utilizes our IntelliMed™ rules-based guidelines module, to provide users with comprehensive and customizable evidence-based rule sets, tailored to each unique care setting;
Has employed a team of highly-educated and highly-qualified clinicians for nearly twenty-five years—to constantly enhance the functionality of each alert module with recent and relevant healthcare knowledge.
Not only can specific modules be controlled by severity and turned on or off, but they can also be tailored based on the mandates of the facility environment, and the type of clinicians using the system. The net result is a system that provides the most applicable content possible, so that when clinicians are presented with clinical alerts, they are always deemed significant.
The further we progress into the age of digital healthcare, the more information there will be to consider during evaluation. Susceptibility to alert fatigue will only grow unless EHRs can conform to an ever-changing healthcare environment.
But if software developers are pro-active and constantly vigilant, they can create their EHRs to be efficient and universally improve the quality of care.
Are you ready to make a change, and make a difference?
Adapt, Transform, Improve.™
“Why do I need to immunize my child? I mean those diseases are so rare. And those side effects??? Who wants their child to get those? No thank you, not for my baby!”
So begins another summer of weekend picnics, good food, laughs and questions from the party goers on the subject of healthcare. The questioning usually begins within minutes of them finding out that I worked in medical university hospitals for twenty-five years as a clinical pharmacist (I live in rural upstate NY, and am the closest thing to a free medical consultation—for both humans and animals—within 10 miles). Soon, others started chiming in about how dangerous vaccinations were, and asked what I thought of the matter.
I paused for a second, asking myself a very simple question: “Why immunize?” To me, the answer seemed so inherent, perhaps instinctual.
But I stayed calm, and responded even more simply. “We immunize children to prevent diseases that can cause misery, heartache and even death.”
“But those diseases are much rarer than the terrible side-effects of the shots,” she attempted to reassure me.
I tried to contain my frustration. “On the contrary! These diseases are rare because we have immunized a very large portion of the population. Many people are highly susceptible to contagious diseases and by not immunizing you risk not only your child’s health, but the health and safety of everyone around you.
“We eradicated small pox because we continued to immunize everybody until the disease was virtually eradicated. Literally millions of lives have been saved. We need to vaccinate as many people as we can. The phenomenon is commonly called ‘herd immunity’ and it protects us all.
“Without it we are all vulnerable to the spread of communicable disease—even diseases that have been rendered virtually non-existent would stage a dramatic comeback should we let down out guard. History teaches us that failure to administer mass immunizations is a recipe for disaster. We eradicated small pox because we continued to immunize and, it bears repeating, literally millions of lives have been saved.
“Now if we act as you suggest, and the movement of not immunizing children continues to grow, we know exactly what to expect. In the early 70’s, Japan immunized nearly 80% of infants for Pertussis, or whooping cough. When in 1974 only 393 cases were reported, the population and the health professionals became complacent; the vaccination rate for infants dropped to less than 10% by 1976. To their bewilderment, an epidemic swept the nation three years later with over 10,000 cases reported resulting in forty-one deaths. When the vaccination program was re-instituted, the number of cases dropped.
“Immunizations work to save lives. We really must keep vaccinating until a disease has been eliminated. We vaccinate to protect our future, and constant vigilance is necessary to protect your children and grandchildren.” Nearly out of breath, I ended my long-winded tirade.
“But my children and I moved from another county and lost those records. How am I supposed to know what happened 5 years ago? I don’t want my child to be vaccinated—and certainly not more so than is necessary—because I can’t remember which shots they received.”
“Well the side effects can be managed by staggering the shots and giving them individually instead of as a multi-component vacination,” I told her. “That may lessen the side effects; but that doesn’t mean you should avoid vaccinations altogether. You need to sit down and talk to your prescriber about that. Tell them your concerns and ask what they can do to lessen the chances of any complications.”
Afraid my message had not fully taken seed in my audience’s mind, I tried to take the argument a step further.
“States have established an immunization registry,” I added. “All immunizations, marked with time, date, lot number, expiration date, manufacturer, site of injection, signed consents, as well as who administered the vaccine, are now recorded. The best part is most EHR systems have the ability to capture and save that information for the patient’s life in real-time. This information can be accessed within minutes.”
“But who would need that information?” she asked.
“People like you, whose records got lost in a move, for example. You could have a complete and accurate record no matter where you received the shot, avoiding problems like the one you alluded to earlier. It’s comforting to know that this information is there if ever needed.
“Another advantage is that if a certain lot number has an issue (excessive side effects, etc.) the registry can be searched, and patients who received the vaccine can be notified and assessed. This could be a huge help if any issues do arise.
“Now when you get a vaccination, that information is sent directly to the state registry. Additionally, EHR systems keep a history of your vaccinations, and can display any missing vaccinations according to the CDC recommendations; and if the CDC changes their procedural schedule, the changes appear on your record to ensure that your provider has the best information possible to care for you and your family. This means you and your doctor don’t have to guess which vaccinations are needed.”
I ended the conversation by stressing the responsibility of every parent to make sure their children’s immunizations are up to date and the correct. However, with the help of an EHR system and immunization module, the health of future generations can be assured.
– Dr. Ted
Adapt, Transform, Improve.™
A week ago, more than one thousand nurses marched in the streets of downtown Halifax to protest what they feel are the negative consequences of recent legislation on patient care, calling into question the future of Canada’s healthcare system. To many, it appears that, as the dust begins to settle in the province of Nova Scotia, lawmakers and healthcare administrators remain intransigent to the pleas of those outspoken nurses, and the hundreds of millions of Canadian citizens they represent.
Though these nurses are calling for improvements in several fundamental areas of Canadian healthcare (national prescription drug plans, senior care, health and human resource plans, to name a few), the crux of their cries stems from one common agenda: federal funding. But the bigger problem, as many nurses and non-nurses alike have voiced, is rather the consistency of this funding.
“We’re very concerned where the direction of our health system is going because of the lack of leadership we have at the federal level… The provinces need help… (and) our people… are going to suffer unless (Harper) changes his position on the funding.” — Linda Silas, President of Canadian Federation of Nurses Unions
@petergb51 — “Oh sure Ottawa Hospital. We can afford valets to park cars like a swanky hotel, but we can’t afford nurses to take care of the sick! Hmmm!!”
One of the largest obstacles, as Ms. Silas expresses, is the federal statute that healthcare funding be dictated regionally by population, and not based on need. All of this financial burden, placed locally on individual facilities, ultimately translates to an overall poorer quality of care, especially in less densely populated areas; and although many Canadians struggle daily with their healthcare, from drug shortages to resource allocation, many reason that something can be done.
This may have something to do with one of the most eye-opening campaigns to take hold in Canada, Choosing Wisely Canada (CWC). Modeled after the similarly-named American program, CWC aims to prevent unnecessary tests, treatments, and procedures to ensure both the effectiveness and quality of healthcare. Beyond its focus on the quality of care, the program also attempts to reduce the financial burden associated with these unnecessary, sometimes harmful procedures.
However, whereas the intentions of the program are undeniable, its shortcomings stem from its unwillingness to acknowledge the essential role HIT is destined to play. These systems, namely clinical EHRs, have the potential to eliminate wasteful procedures in the aim of fiscal responsibility, and avoid harmful interventions in regards to patient care. And yet, CWC’s omission of this important piece of the puzzle is troubling.
Indeed, Canada’s languid incorporation of preventative technology is troubling; but the unfortunate reality is that adoption has been dogged by setbacks outside of the control of the individual facilities most in need. As such, many software decision processes throughout Canada have either slowed or stopped entirely, further evidencing the precedence of the nurses’ protest in Halifax.
Just the other day, my colleague and I confronted this issue; we were unsure why, after months of meaningful conversation between us and several Canadian facilities, several decisions had come to a halt or been stalled. It seemed as if they had simultaneously reassessed the needs of their facilities, even though they had, until very recently, recognized EHR adoption as one of their highest priorities. Without an answer, we investigated further until one representative at one such facility was finally willing to disclose some vital, though sparse, information.
“Yes, it’s true. We were looking for something a while back,” the voice said from the other end of the phone, “but it’s now overseen by the province. All procurement has been put on hold until further notice.”
What is most troubling is that these facilities began searching independently for a reason: they didn’t just want the technology; they needed it. Hence the reason they began searching in the first place. But here they were, years after they actually began searching for a system, bound by government red tape.
But what do all of these things—the nurses in Halifax, the CWC program, and the Canadian government—have in common? Well, besides the fact that two seem to pull in the opposite direction of the other, one possible answer regards an expansion of resources made through investment—both in our clinicians, and in the technology they use.
Investment in healthcare information technology, particularly EHR systems, provides vital infrastructure to overcome many of the recent plights Canada faces in healthcare. Medication administration software, especially when integrated with bar-code scanning, data management capabilities, and electronic documentation, will help nurses to better carry out their integral role as care providers; order entry modules will help physicians to more efficiently manage patient populations avoid costly and harmful procedures; and pharmacy systems, like MetaCare Rx, will help to reduce wastefulness through wholesaler interfacing. Put simply, systems capable of managing patient data and the overall care environment will help all Canadians to Choose Wisely.
EHRs will ultimately help to overcome these difficulties, but not if corners are cut in the process. With all of the recent turmoil in Canadian healthcare, clinicians and lawmakers need to unite to ensure healthcare reaches its fullest level of efficacy, beginning with further investment in Canada’s nurses, pharmacists, doctors, and HIT infrastructure.
But if this truly is the path that Canadian healthcare must take, then more and more clinicians will need to pick up where the one thousand Halifax nurses left off. They must encourage investment in country’s future, and push for change.
Adapt, Transform, Improve.™
To say that HIMSS15 was a success would be an understatement. With over 1300 exhibitors, a 50% increase in attendance in just a few years ago, as well as over 38,000 professionals, clinicians, executives and vendors from around the world, the city of Chicago was overrun. Hotel rates soared while vacancies were nearly nonexistent, and every corner of the city from South Side to the Magnificent Mile was packed with innovation.
Our goal this year at HIMSS (after grabbing some authentic Chicago deep-dish pizza – Lou Malnati’s may have the best), was to learn about this year’s most important developments in HIS. To do this, we not only attended conferences and explored new exhibits, but we also met with our Meaningful Use partners to discuss new e-prescribing mandates, as well as secure messaging and issues regarding usability. After meeting with everyone, however, we came to understand that one thing was to be of paramount importance in the coming months:
Among the many changes anticipated as part of this new phase, e-prescribing will become mandatory; so we met with our e-prescribing partner to learn about their latest products and updates. This new objective is an important element to improving the quality of patient care, though it requires coordination between physicians, pharmacists, and IT professionals. Of all of the new Stage 3 developments at HIMSS15, this one in particular seemed to be of mounting importance to healthcare professionals.
It should also come as no surprise to readers of our blog that one buzzword was tossed around with particular frequency at HIMSS15: interoperability. Professionals at HIMSS15 advocated strongly for the adoption of more interoperable sound systems so as to encourage data sharing and security. Population Health Management was also proposed as one of the most pressing issues facing HIT along this same line of reasoning. It seems the ability to coordinate patient data with public health agencies is becoming an increasingly imperative standard of healthcare, likely due to national attention to the outbreak of Ebola in West Africa, and the Measles closer to home.
“We’ll take a look at what is coming in the industry–where we’ve come from and where we’re headed.” – JoAnn Klinedinst, V.P. of Professional Development
HIMSS15 also allowed us the opportunity to unveil a host of new developments to the healthcare sector on a grand scale. We exhibited our new website, products, and image, while demonstrating Meta’s latest updates and improvements through our recent partnerships with multi-facility and state-level organizations across the nation. We also met with various organizations to familiarize ourselves with the more challenging obstacles currently facing the industry, such as secure communications practices and patient medication therapy adherence.
But with uncertainty in regards to Stage 3 clouding much of the near future, HIMSS15 acted as an ideal opportunity for professionals to meet and discuss important issues in a collegial manner, and to learn from each other in the process. A lot is poised to happen in the coming year in regards to HIT and EHR adoption. We are certainly glad to have played a part in the year past, and are already looking forward to HIMSS16 in Las Vegas.
Meta Healthcare IT Solutions: Adapt. Transform. Improve.
On March 20, the CMS laid the groundwork for the next phase of EHR adoption, announcing its “Proposed Rule” for Stage 3 of the EHR incentives program. After various delays and set-backs, the new criteria focus in particular on the overall improvement of patient outcomes, and the interexchange of patient data. Stage 3 also designates many practical changes, such as the realignment of the reporting period with the calendar year.
As expected, however, the proposal was not met without criticism. While the plan seems straightforward as proposed by the CMS, it has not won favor with the majority of those most direct affected. In a survey orchestrated by QuantiaMD, 71 percent of physicians said with confidence that they would be able to successfully attest; but only 38 percent say the government did a fair job with the Stage 3 proposed rule.
This begs the question: why have the CMS and ONC not taken a more active role in engaging clinicians? They offer the opportunity to comment upon the proposed rule, but seem to bypass their considerations when drafting the actual proposal. What’s more is that the feedback period lasts only a little more than two months, and seems to be reserved for the smaller and less crucial details of the adoption plan. This dissent, if it remains unaddressed, will only cause problems further down the line.
The CMS has designated eight initial Meaningful Use objectives that must be met in order to attest during Stage 3, though a number of additions will likely be made as part of the final ruling. These points build upon the foundational elements of Stage1 and 2, but are also meant to provide a sense of direction of the overall plan moving forward. The comment period for Stage 3 ends May 29, 2015.
Included below is a brief guide to the CMS’ stage 3 proposal:
- Protect patient health information
Expanding upon earlier privacy rules, particularly the need to conduct a security risk analysis and address data security as part of Stage 2, this objective requires the creation of increased technical, administrative, and physical safeguards on patient information.Organizations are required to conduct a security risk analysis upon implementation and after each system upgrade, while any and all system deficiencies must be reported by the end of each calendar year. Providers must also conduct a security risk analysis at least once per year.
- Electronic prescribing
Authorized users must be able to generate and transmit prescriptions electronically, while eligible hospitals and CAHs are required to do likewise for permissible discharge prescriptions. Stage 3 also increases the number of discharge medications eligible for e-prescribing.As part of Stage 3, users are required to query 80 percent of all permissible prescriptions for a drug formulary, and transmit them electronically using a certified EHR. For eligible hospitals and CAHs, this number is set at 25 percent. Due to the success of this objective during the Stage 1 and Stage 2 reporting periods, the CMS showed confidence in raising the threshold for Stage 3. The new proposal has also removed the requirement on refills, mandating e-prescribing only for new and changed prescriptions.
- Clinical decision support
The CDS objective is divided into two sub-requirements: the first pertains to the implementation of five CDS interventions related to four or more clinical quality measures; the second requires technology to alert for drug-drug and drug-allergy interactions. Certain EHR systems, such as our MetaCare Enterprise EHR™, provide integrated drug monographs and databases to further the aims of this objective, in regards to drug administration alerts. This objective allows for some flexibility, as it provides EPs, eligible hospitals and CAHs with the freedom to determine which CDS tools would best suit their patients and their organization. The clinical quality measures provide evidence-based clinical decision support, and include the following:
- Problem list
- Medication list
- Medication allergy list
- Laboratory tests and values/results
- Vital signs.
- Computerized physician order entries
The new CPOE objective is divided into three sub-requirements: the first requires 80 percent of medication orders in a hospital setting or a CAH’s inpatient/emergency department to be recorded in a certified CPOE system; the second requires more than 60 percent of all lab orders to be be created using a CPOE; and the third requires that more than 60 percent of diagnostic images be ordered using a CPOE.Stage 3 broadens the authorization requirements for this objective, expanding slightly upon the requirements of stages 1 and 2. Whereas in the earlier stages only eligible providers were permitted to place orders electronically, Stage 3 opens the objective to any licensed healthcare professional or credentialed medical assistant. The CMS has also granted EPs the ability to authorize staff as they see fit to input orders electronically.
- Patient access
One of the largest undertakings of Stage 3 is the patient access initiative. This objective seeks to increase communication between physician and patients using web-based technology. Put simply, certified EHRs must allow for patients to view, download or transmit their health information online or on a separate application within 24 hours of its availability.The provider is only required to provide this access, however; the patients need not to utilize these methods for the provider to successfully attest. Patient access, as stated by the CMS, “should not require the provider to make extraordinary efforts to assist patients in use or access of information, but the provider must inform patients of these options and provide sufficient guidance so that all patients could leverage this access.”The objective is divided into three sub-requirements: first, more than 80 percent of all patients should be provided access to view, download or transmit health information within 24 hours of its availability; second, providers must provide more than 35 percent of their patients with specific educational materials, such as medical references, using clinically relevant information from the EHR.Stage 3 will increase percentage of patients given access to this information, and decrease the period of waiting between the patient’s visit and online access. The CMS, however, is also searching for alternatives due to the increased use of Application Program Interfaces (APIs) in medicine.
- Coordination of care through patient engagement
This objective is divided into three sub-requirements, the first of which pertains to a patient’s active engagement with an EHR system. More than 25 percent of all patients seen by an EP or discharged from an eligible hospital, CAH inpatient or emergency setting must be given access to and actively engage with the EHR system in place. EPs, hospitals and CAHs may choose to attest during an EHR reporting period either through the online patient portal or through an ONC-certified API.The second and third requirements are much vaguer, requiring EPs to send secure messages using their EHR to at least 35 percent of patients, and incorporate patient-generated data or data from a non-clinical setting for more than 15 percent of all unique patients. According to the CMS’ definition, “data from a non-clinical setting” includes care environments that do not utilize a certified EHR, with the exception of EPs, eligible hospitals and CAHs. This includes therapists, psychologists, home health providers, etc., as well as data generated by the patient. The CMS understands the broad nature of its definition in regards to this objective, and welcomes feedback on how to incorporate this data into clinical practice.
- Exchange of health information
EPs, eligible hospitals and CAHs must send a summary of care when moving or referring to another practice or hospital, and must receive the same document upon the first encounter with a new patient. This outside information must then be incorporated into their EHR.This objective is divided into three sub-requirements: first, more than 50 percent of referrals and transitions of treatment must use an EHR to provide an assigned summary of care record; second, more than 40 percent of referrals, transitions and new patient encounters must be incorporated into the provider’s EHR; third, clinical information reconciliation must be implemented for more than 80 percent of new patient encounters for the patient’s medications, allergies, and current problem list.The ONC has also issued a common clinical data set to bolster data exchange, which the CMS has included its Stage 3 proposal.
- Public health and clinical data registry reporting
This objective focuses on the growing field of Population Health Management (PHM), necessitating that users actively submit data to public health agencies or clinical data registries using their EHR. The focus in Stage 3 will shift from the “ongoing submission” stipulation of Stage 2 in favor of a principle of “active engagement.” This, the CMS believes, will more accurately reflect the desired state of communication between immediate care providers and public health officials.EPs, eligible hospitals or CAHs must also share public health information in three of the following six measures: immunization registry reporting, syndromic surveillance reporting, case reporting, public health registry reporting, clinical data registry reporting and electronic reportable lab result reporting. The objective also provides flexibility in regards to reporting periods and deadlines to simplify the transition into Stage 3 public health reporting.