Nuts

1
Nuts Bolts of Data Sets/Electronic Records

• Margret Amatayakul
• Margret\A Consulting, LLC
• 2000 WEDI National Conference
• Atlanta, March 23, 2000
• 345-500 PM

2
Session Learning Objectives

• Understand the challenges faced by healthcare
  providers to better manage healthcare data
• Appreciate the current state of electronic health
  records (EHRs)
• Learn about current and potential HIPAA
  requirements for exchange of patient medical
  record information
• Discuss what WEDI can do to help the healthcare
  delivery system better utilize data

3

• Healthcare Data
• Background

4
What is healthcare data?

• According to HIPAA...
• Any information, whether oral or recorded in any
  form or medium, that
• is created or received by a health care provider,
  health plan, public health authority, employer,
  life insurer, school or university, or health
  care clearinghouse and
• relates to the past, present, or future physical
  or mental health or condition of an individual,
  the provision of health care to an individual, or
  the past, present, or future payment for the
  provision of health care to an individual
• It is individually identifiable when it
• identifies the individual or
• with respect to which there is the reasonable
  basis to believe that the information can be used
  to identify the individual

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What does that mean?

• Clinical information
• Patient demographics
• Health history and health status indicators
• Details of present illness or injury
• Orders for care and treatment
• Observations
• Results of diagnostic studies
• Records of medication administration and other
  procedures
• Conclusions about diagnoses/problems
• Plans for future care/patient instructions
• Administrative information
• Authorizations, consents, advanced directives
• Clinical guidelines, protocols, pathways
• Financial information
• Eligibility
• Claims

6
Industry Needs

• Consolidation requires sharing data

• Who owns what information?

• How will merged clinical
• financial data be protected?

• Competition demands
• more data

• Payers are employers
• providers

• How is confidentiality
• ensured w/multiple hats?

• Consumerism is growing

• How is access granted?

• Networks are more
• expansive

• How is data integrity
• ensured?

• Technology is
• heterogeneous

• How is security managed
• w/disparate mixed
• paper/electronic systems?

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What are the uses?

• Documents course of patients illness and
  treatment
• Safeguards confidential health information
• Communicates between caregivers and with patients
  
• Provides reminders for health services
• Supports users through alerts, problem solving,
  links to knowledge
• Assists in evaluating adequacy and
  appropriateness of care
• Substantiates claims for payment
• Protects legal interests of all concerned parties
• Provides case studies for education and data for
  research
• Contributes to public health surveillance,
  disease prevention, and health promotion

8
How well do we collect and use healthcare data?

• A patient died because information on allergy to
  anesthetic was not in hospitals standard format
  and missed when preparing patient for surgery
• A patients life was at risk when a change in
  status could not be communicated directly from
  the home care system to the hospital system
• A patient had a severe reaction to a medication
  when a nurse administered an incorrect dosage
  because the standard tablet size described in the
  formulary at the nursing unit was different than
  that used by the pharmacy
• A hospitals admitting office turned away
  patients because its system reported over 100
  occupancy, while the executive information system
  reported 80

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Yet,

• Automated smoking cessation reminders linked to
  every family members records reduced smoking
  prevalence in a region by 12 over 6 months
• Automatic display of charges for lab tests being
  ordered prompted physicians to choose less
  expensive tests, resulting in a cost savings of
  1M per year
• Computerized adverse drug event monitoring
  prevented 569 adverse drug events in a year that
  would have added 1,104 extra inpatient days

10

• Electronic
• Health Records

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What is it called?
CPR - EMR - CHR - CIS - PPR - AMRS - ABC - XYZ

• Some consider terms synonymous
• Some attempt to define a migration path with
  different terms
• Automated medical record - paper and electronic
  in parallel
• Computerized medical record - scanned documents
  eliminate paper
• Electronic medical record - electronic processing
  of data
• Electronic patient record - multiple settings
• Electronic health record - moves focus from just
  medical to health
• Computer-based patient record coined by Institute
  of Medicine - describes the vision
• Consumer health records
• Suffering same naming fate
• Some want to be distinguished
• Others want to be integrated

12
What is an EHR?
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It takes all these to build a house!

• Electronic health record is a system
  specifically designed to support users by
  providing accessibility to complete and accurate
  data, alerts, reminders, clinical decision
  support systems, links to medical knowledge, and
  other aids

14
Characteristics of EHR

• Encompasses a broader view of record than current
  today, moving from the notion of a location or
  device for keeping track of patient care events
  to a resource with much enhanced utility
• Provides longitudinal (i.e., lifelong) access to
  events that may have influenced a persons
  health. The CPR is a virtual core of a healthcare
  delivery system information infrastructure
• Supports patient care and improves quality,
  enhances productivity and reduces administrative
  costs, supports research, accommodates future
  health care technology developments, and ensures
  patient data confidentiality
• Merely automating the form, content, and
  procedures of current patient records will
  perpetuate their deficiencies and will be
  insufficient to meet emerging user needs

. . . Institute of Medicine
15

• Current State of
• EHRs

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Hospitals, in general . . .

• Have automated patient registration, ancillary
  services (lab, x-ray, pharmacy), and order
  communication
• Have automated diagnostic study results, and some
  communicate these to physician office affiliates
• Some have automated patient care systems which
  are essentially nursing documentation systems
• Few have been successful in getting physicians to
  access results online, let alone do order entry
  or documentation
• A few are achieving some success with electronic
  authentication of transcribed dictation
• Most use paper systems, potentially with
  offline/retrospective database support, for care
  management
• Most manually abstract charts for most clinical
  studies
• Virtually all print and archive paper medical
  records
• Most batch and transmit claims in flat files

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Next steps for hospitals

• Keep ahead of new regulations, upgrades, and
  integrated delivery system requirements
• HCFA compliance
• Enterprise-wide master patient index
• Manage the paper flow better
• Digital dictation systems
• Document imaging systems
• Demonstrate value to nurses/address data capture
• Islands of information are still focus (e.g.,
  PACS)
• Physician office connectivity
• Consumerism
• Internet portals
• E-commerce
• Confidentiality and security concerns
• Communication concerns

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Ambulatory care is different . . .

• The ambulatory environment is mixed
• Some have virtually no automation
• Many have practice management systems that
  automate front desk functions
• Some have sophisticated electronic health record
  systems
• Ambulatory care is becoming more complex
• Next steps for physician offices
• Many are looking to acquire clinical systems
• Many are looking for more comprehensive systems

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Barriers to Adoption

• Cost
• Return on investment
• Incremental value of another system is difficult
  to quantify
• Threshold level of activity required to prove
  value
• Balanced Budget Act
• Confidentiality and security
• Timing
• Build upon legacy systems
• Adopt new technology
• Risk tolerance
• Historical level of expenditures low
• Systems arent really ready for prime time anyway

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Vendor Offerings

• Hospital market
• A few giants
• Fairly tightly integrated HIS
• Niche players for specialty areas
• All scrambling to adopt Internet technology
• Ambulatory market
• Many start ups
• A few solid companies
• Many different product offerings
• Major vendors
• Consolidating to compete
• Consolidating to address integrated delivery
  systems

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Different Environments . . .
one size doesnt fit all
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Vendor Decision Making
New Technology
Stable Vendor
Best of Breed
Full Suite
Acute
Ambulatory
Niche
Best of Fit
New Entrant
Established Technology
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Vendor Marketplace
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• Challenges in Managing
• Healthcare Data

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Why arent we further along?

• Computers are designed to crunch large volumes of
  numbers very quickly
• Healthcare data are narrative, contextual, and
  temporal
• To date, attempts to structure data - through
  data sets - have been unsatisfactory
• Data capture methods do not match clinician use
  of information
• Clinicians scan large volumes of data and
  integrate mentally
• In general, clinicians are mobile with respect to
  data entry
• Time is most important to clinicians
• No information system has yet felt like it was
  improving productivity, most take longer to
  document
• Clinicians have resisted decision support as the
  return on their investment for using systems
• Continued concern about privacy and
  confidentiality
• Concerns about availability and usability

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Data capture is biggest challenge

• Structured data required to produce useful
  information
• Most popular solutions do not produce structured
  data
• Dictation
• Document imaging
• Speech recognition
• Structured data entry now required for structured
  data
• Text processing still in its infancy
• Some intelligence being applied to structured
  data entry in the most sophisticated of systems
• Goal is to capture data
• once at the point of care,
• at the most granular, or precise level, and
• all information required for other purposes, such
  as reimbursement, public health, research,
  derived therefrom

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Data Quality Issues

• Erroneous data and variation in rigor of editing
• Missing data
• Lack of standardized data definitions
• Lack of uniformity in units of measure
• Use of nonstandard codes
• Modification of standard codes
• Limitations of current coding systems
• Lack of accountability mechanisms
• Inconsistent use
• Incomplete
• Inconsistent retention
• Limited protections for data integrity

28
Data Comparability Issues

• Comparability of data is a huge issue
• Uniform data sets, definitions, and data
  dictionaries
• Arent uniform
• Contain limited volume of data
• Currently, only classifications are in use to
  encode data for processing
• Reference terminology is required to produce
  precise and accurate interpretation
• Relates terms to one another (set of
  relationships), and
• Qualifies terms (set of attributes)
• Relationships and attributes are represented in
  an information model
• Multiple terminologies need to be harmonized

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Interoperability Issues

• Disparate systems must communicate
• at a minimum at the functional level (messages
  transmitted)
• ideally at the semantic level (content is
  interpretable)
• Message format standards provide protocols to
  exchange data
• Current standards embed options
• Each implementation has to negotiate its own
  interface agreement, which is different from all
  others and costly
• Since there are no standard implementation
  guides, there can be no conformance testing
• Message format developers are beginning to
  address content, and creating a reference
  information model
• New technology may surpass need for current
  protocols
• Legacy systems will continue to require
  interoperability protocols for some time to come

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• Expectations for
• HIPAA

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Quick Overview of HIPAA

• Health Insurance Portability and Accountability
  Act of 1996 (PL 104-191)
• Provides
• Continuity of healthcare coverage
• Administrative Simplification
• Requires use of
• Standards for electronic transactions and code
  sets
• Unique health identifiers
• Security (and electronic signature) standards
• Privacy standards
• Uniform data standards for patient medical record
  information and the electronic exchange of such
  information
• Proposed rules for some standards have been
  published. No final rules have been published

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Potential Benefits of HIPAA

• Transaction standards
• (ASC X12N and NCPDP)
• Eliminate the need for multiple, proprietary
  systems
• Improve productivity
• Reduce cost of systems ownership
• Real time access to eligibility, referral, and
  coordination of benefits improves cash flow
• Real time claims submission improves cash flow
• Official coding guidelines eliminates dual coding
  systems
• Claims attachment standards will contribute to
  privacy protection
• Standardize some data elements

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Potential Benefits

• Identifiers
• (Federal Employer Identification Number)
• (HCFA National Provider Identifier)
• (Health Plan Identifier TBD)
• Reduce cost of systems ownership
• Reduce errors
• Improve productivity

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Potential Benefits

• Security standards
• (Administrative, physical and technical services
  and mechanisms)
• Establish baseline to standardize products
  thereby lowering total cost of systems ownership
• Reduce risk of wrongful disclosure, minimizing
  liability
• Reduce risks associated with data integrity
  problems, improving patient safety, improving
  productivity, and minimizing liability
• Promote adoption of lower cost Internet-derived
  technology that promotes connectivity to enhance
  availability of information, improving quality
  and cost of care
• Electronic signature standards
• Would ensure legal acceptance of electronic
  health information

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Benefits

• Privacy standards
• (Use, disclosure, individual rights)
• Reduce cost of processing of release of
  information forms for all but what should be a
  small number of requests
• Engage the consumer in responsibility for
  accuracy and potentially reduce misunderstandings
  and potential lawsuits
• Reduce risk of wrongful disclosure

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Potential Benefits

• Patient medical record information (PMRI)
  standards
• (Under study by National Committee on Vital and
  Health Statistics NCVHS)
• Interoperability standards (message format
  protocols that achieve full semantic
  interoperability)
• would lower total cost of ownership for systems
• custom interfaces would not have to be developed
• vendor development costs would be lower
• would promote adoption of more disparate systems
• would enhance data interpretability

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Potential Benefits - PMRI

• Comparability standards (vocabularies converged
  to a reference terminology)
• would support expanded capabilities of systems to
  provide decision support, outcome analysis and
  variance
• would improve quality of data for establishing
  best practices

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• Role for
• Industry Consortia

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How can WEDI help?

• Put pressure to bear on getting final rules
• Most providers will not adopt standards without
• Some vendors are recognizing value beyond another
  set of regulations
• It will take a long time for convergence of
  provider and vendor attitudes to achieve benefits
• Promote adoption of standards
• HIPAA standards are good business practice
• Transaction standards could easily be adopted
  without regulation
• An industry consortium could accept the role of
  identifier enumerator
• Proposed security standards require individual
  risk assessment and standards selection anyway

40
Help?

• Help ensure success
• Promote education
• Develop standard implementation guides
• Establish conformance testing
• Serve as a watchdog to standards efforts (ANSI
  HISB)
• Create incentives to achieve compliance
• More positive than enforcement
• Better data helps everyone

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• Discussion

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Contact

• Margret Amatayakul
• Margret\A Consulting, LLC
• 1817 Georgia Ct. 202 ? Schaumburg, IL 60193
• Tel. [phone] ? Fax. [phone]
• E-Mail Margretcpr_at_aol.com ? www.Margret-A.com