The Risk Solutions Magazine Summer 2013 - MMIC Group · 2013-08-27 · 9 Brink is published four...

The Health IT Issue

The Risk Solutions Magazine Summer 2013

WhaT’S nexT In paTIenTSafeTy

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Brink is published four times a year by MMIC. Headquartered in Minneapolis, Minn., MMIC is the largest policyholder-owned medical liability insurance company in the Midwest. We serve the entire health care community, including large hospitals and health care systems, physician practices, and outpatient and long-term care facilities. By improving patient safety and physician well-being, offering risk financing and reducing risks associated with information technology, we provide peace of mind so clients can focus on delivering health care.

To contact the editor, please email [email protected].

©2013 MMIC Group, Inc. All rights reserved. Reproduction in whole or in part without permission is prohibited. BRINK is a trademark of MMIC Group, Inc.

I’d like to extend a heartfelt welcome to our expanded Brink readership — policyholders in Utah, Wyoming, Montana and Idaho. These states are now part of our geographic footprint as we welcome UMIA Insurance, Inc. (UMIA) to our MMIC family. Our acquisition was effective June 28, and we look forward to working closely with our new colleagues to provide new products and services, along with the outstanding service you are accustomed to from UMIA.

Our goal is to provide as seamless a transition as possible. UMIA policyholders won’t notice a change in the way they connect with UMIA. UMIA will continue to maintain its brand and presence in its markets. We will introduce UMIA’s new board of directors shortly, and UMIA’s current board will continue to serve in an advisory capacity to make sure policyholder interests are represented.

In addition, MMIC will work with UMIA staff to introduce new product and service offerings to clients, resulting in enhanced coverage and new ways to serve patients even more safely and effectively. These value-added services include the following:

/ Robust patient safety and risk management services, including physician well-being programs, twice-monthly and on-demand risk management webinars, and a rich risk solutions website

/ Available coverage for clinics, hospitals, large health systems, and outpatient and long-term care facilities

/ Cyber Solutions® coverage and HIPAA security consulting services

/ A suite of health IT products and consulting services, including NextGen® Ambulatory EHR and PointClickCare® EHR for long-term care facilities

/ Publications such as this risk solutions magazine that offer practical ways to improve patient safety

We are always thinking ahead to find new and better ways to protect our policyholders through risk financing, improving patient safety and reducing risks associated with information technology. That’s because our goal is to provide peace of mind for our clients, both existing and new, so they can focus on delivering health care in a challenging era of health care reform, increasing regulation and a growing patient base.

This issue of Brink focuses on the intersection of medicine and technology, and on technology’s ever-evolving influence on the way the health care community delivers patient care. We hope you find the insights, information and resources on these pages useful in your day-to-day practice.

On behalf of MMIC, thank you for your business and for joining forces with us to provide the best health care possible for patients and long-term care residents.

My best,Bill McDonough, President and CEO, MMIC

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DeparTmenTS

4 mmIC news Summer 2013

8 Book review: Be present, Be SilentInsights from an empathic physician.

30 Claim review: Working in the Shadowshow communication shortcuts contributed to a patient’s permanent injury.

34 The Last Word

10Brave new WorldThe master plan for health IT.

15Side effectsEHR: Unintended consequences.

16pulling the plugDecommission your legacy IT with care.

17Let GoLeaving paper behind.

20Trouble DownstreamTest management.

24Harnessing the power of your eHr

26patient portalIf you build it, will they come?

28are You Your Greatest Security risk?

33etc.Health IT facts and stats.

Managing health IT

Brink / Summer 2013 / 3

THe Ink IS DrY!MMIC finalized a transaction with the UMIA Insurance, Inc. (UMIA) on June 28. As a result, UMIA became a wholly owned subsidiary of MMIC. The Utah-based company will continue to have a base of operations in Salt Lake City and will maintain its brand. As a result of the acquisition, MMIC adds four additional states to its existing territory and nearly 3,000 new policyholders, while UMIA strengthens its patient safety and risk management services, breadth of coverage and health IT services.

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MN

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UMIA MMIC

mmIC parTnerS WITH CrICO STraTeGIeS

MMIC recently signed a three-year agreement with CRICO Strategies. The two companies will become data partners through the purchase of CRICO’s Comprehensive Risk Intelligence Service and membership in its Comparative Benchmark System. The depth and breadth of CRICO’s data — 30 years’ worth — will be invaluable in evaluating trends and reducing risk.

Julie Stafford, MMIC’s senior vice president of Business Development, says the collaboration will benefit both organizations. “We are poised to take our patient safety and risk management services to a new level, and we know that the symbiotic relationship with CRICO, and its track record of using data to improve patient safety, is essential to our work.”

According to CRICO, clinically coded and analyzed data provide tools for health care leaders to support different conversations, actions and outcomes. Says Bob DeVore, president of CRICO Strategies, “We partner with organizations that share our long-term holistic vision and believe that a critical step toward improving systems

and practices starts with understanding the current state, validating variation and learning from each other. The bedrock of this work is deeply analyzed, clinically relevant claims data.”

Explains Richard Corder, assistant vice president for CRICO Strategies, “While our insured members are different, we found common ground with MMIC. We both want to learn from past mistakes, identify areas of emerging risk, and develop systems and strategies based on data that lead to better outcomes and safer care.”

CRICO StRategIeS IS a dIvISIOn

Of the RISk ManageMent

fOundatIOn Of haRvaRd

MedICal InStItutIOnS, InC., a

CRICO COMpany. eStablIShed

In 1998, StRategIeS extendS

CRICO’S patIent Safety MISSIOn

thROugh bROad dISSeMInatIOn Of

pROduCtS and SeRvICeS deSIgned

tO ReduCe MedICal eRRORS and

MalpRaCtICe expOSuRe.

www.RMfStRategIeS.COM

DAtA pArtnershIp estAblIsheD wIth hArvArD-bAseD CoMpAny.

mmIC WInS TOp WOrkpLaCeS aWarDFor the third time, the Minneapolis Star Tribune has named MMIC one of the Top Workplaces in Minnesota in the category of medium-sized organizations.

Companies are selected for the award based on employee responses to survey questions pertaining to the culture, resources, leadership, strategic direction and benefits at the company. Recognizing the importance of a healthy culture to all levels of the organization, MMIC exemplifies its stated values and goals:

/ Always listen to and be inspired by our employees, customers and partners

/ Operate with integrity and moral courage in our quest to provide value and exceptional customer service

The acquisition of UMIa extends MMIC’s reach into the West.

/ Remain agile to meet the needs of a rapidly changing environment

/ Model stewardship in the communities we serve

/ Be humble

/ Maintain a performance-based culture

/ Strive for constant improvement

/ Continually learn and develop

/ Ensure that ‘we’ takes precedence over ‘me’

/ Portray an ownership spirit and positive, can-do attitude

/ Have fun working hard; maintain a work-life balance and state of well-being

4 / Brink / Summer 2013 Brink / Summer 2013 / 5

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sUMMer

2013

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SepTeMbeR

DeAlIng wIth the UnIntenDeD ConseqUenCes of ehrsspeaker: Dean f. sittig, ph.D.

Dean Sittig and his colleagues have identified nine major categories of unintended adverse consequences (UACs) associated with EHR use, many of which were introduced by clinical support features. Identifying and understanding the types and causes will enable health care organizations to better manage implementation and maintenance of future EHR projects.

Sittig is a professor at the School of biomedical Informatics, university of texas health Science Center at houston.

OCTObeR

An eIght-DIMensIon soCIoteChnICAl MoDel for sAfe AnD effeCtIve ehr IMpleMentAtIon AnD Usespeaker: Dean f. sittig, ph.D.

This presentation introduces an eight-dimensional model to address the sociotechnical challenges involved in design, development, implementation, use and evaluation of health information technology (health IT) within complex adaptive

health care systems. The eight dimensions are interdependent and inter-related concepts, and Sittig will illustrate how the model has been success-fully applied in real-world, complex, adaptive settings.

Based on: Sittig DF, Singh H. A new sociotechnical model for studying health information technology in complex adap-tive healthcare systems. Qual Saf Health Care. 2010 Oct;19 Suppl 3:i68-74. doi: 10.1136/qshc.2010.042085.

nOveMbeR

A “reD flAgs” ApproACh to IDentIfyIng ehr-relAteD errorsspeaker: Dean f. sittig, ph.D.

Although EHRs have significant potential to improve patient safety, safety concerns have begun to emerge. Through research by the American Society for Healthcare Risk Management, the American Health Lawyers Association and Sittig’s previous work in EHR-related patient safety, common EHR-related safety concerns have been identified. Health care organizations that routinely conduct EHR-related surveillance activities using a “red flags” approach can significantly reduce the risks associated with EHR implementation and use.

Based on: Sittig DF, Singh H. A Red-Flag Based Approach to Risk Management of EHR-Related Safety Concerns. Journal of the American Society for Healthcare Risk Management.

WeBInarS On WeDneSDaYS

To register for a webinar, visit www.MMICgroup.com/risk-management/webinars. All webinars are presented from noon–1 p.m. CST and are available on demand at MMICgroup.com after the initial presentation.

JUne

heAlth CAre reforMthe Impact on Malpractice liabilityspeaker: paul greve

The health care delivery system is being transformed, and with the changes comes uncertainty. This webinar focuses on the many ways that the health care industry’s malpractice exposures will be affected by reform and will impact health care professional liability exposures in the future. We discuss both positive and negative implications for malpractice liability and review ways to proactively manage risks.

JUly

proteCtIng pAtIent InforMAtIonwill you be ready to attest “yes” for Meaningful use?speaker: trish lugtu

Protecting patient information may be the last core objective listed in the Medicare and Medicaid EHR Incentive Programs, but it isn’t too soon to get started. While eligible providers and hospitals need to conduct or review a security risk analysis by the end of the reporting period, they also need to implement updates and correct identified security deficiencies as part of a risk management plan.

lugtu is Research and development Manager, health Informatics, MMIC patient Safety Solutions.

JUly

MAkIng MeAnIngfUl Use froM MeAnIngfUl Usespeaker: Chris tashjian, M.D.

Dr. Tashjian discusses how he and his clinic have used the information derived from the Meaningful Use standards to transform their practice. By managing data, they were able to transform their practice from reactive to proactive in treating chronic disease.

Chris tashjian, M.d., is a specialist in family medicine practicing in rural ellsworth, wis.

aUGUST

shAreD DeCIsIon-MAkIngspeaker: larry Morrissey, M.D.The medical issues patients face are complex. Making good quality decisions requires an

understanding of both medical evidence and patient prefer-ences and values. Research shows that there are clear gaps in the decision-making process that can be addressed to enhance the experience of both patients and providers.

larry Morrissey is a board-certified pediatrician. he is a nationally recognized leader with the foundation for Informed Medical decision Making, where his research study, “assessing effectiveness of decision Support in primary Care,” focused on a team approach with shared decision making, enhancing patient centered care, patient satisfaction and health care delivery. Morrissey practices at the Stillwater Medical group Main Campus.

aUGUST

peer revIew In the ClInICspeaker: David M. glaser

Most physicians are familiar with the peer review process. This process is often performed at the hospital, rather than the clinic level. But in most states, clinics can establish a peer review process that enjoys the same protection as a hospital peer review committee. This session will discuss the basics of starting a peer review process and describe some of the benefits and potential challenges of a peer review program.

glaser is an attorney and shareholder in fredrikson & byron’s health law group and helped establish its health Care fraud & Compliance group.

Save THe DaTe!Plan now to attend the annual MMIC NextGen® EHR User Group Meeting this fall. Meeting admission is free for MMIC’s NextGen customers.EVENT: NextGen EHR User Group MeetingDATE: October 2, 2013PLACE: Crowne Plaza – Plymouth3131 Campus DrivePlymouth, MN 55441

mmIC OfferS rISk SeLf-aSSeSSmenT TOOLS OnLIneBy proactively identifying your risks, you can employ strate-gies to prevent or mitigate risk before a patient is injured or the organization suffers a financial risk. MMIC’s online self-assessment tools provide a convenient way to identify potential risk in your organization.

Online assessment tools are available for the following organizations:

/ Clinics

/ Hospitals

/ Long-term care organizations

/ Clinic EHR*

/ Cyber risk*

* Formerly part of the Health IT Scorecard, which was piloted in 2012 in a limited release

After you complete the online assessment, a report is gener-ated outlining the identified

risks and recommendations for improvement. The assess-ment report includes:

/ Total score

/ Weighted scores in each assessment category

/ Practical, helpful recommendations for improvement

/ Metrics comparing your scores to those of other organizations that have taken the assessment

Your risk assessment score serves as a benchmark for the amount of risk your organiza-tion has exposed. By acting on the recommendations, you can lower your risk exposure. The assessment score page can be bookmarked or printed. You can retake the assessment multiple times and track performance improvement over time.


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MMIC news

If a book’s dog-eared pages are any indication of my passion for it, then my copy of Kitchen Table Wisdom is a testament to just how much I value it. More than that, I have never been so moved or changed by a book.

A board-certified pediatrician on the faculty of Stanford Medical School, Rachel Naomi Remen, M.D., was well on her way to becoming one of Stanford’s first female department chairs. Then she took stock of her life — not her parents’ life or anyone else’s life — and made a career-changing, life-altering move. She is now a clinical professor of Family and Community Medicine at the University of California, San Francisco, and she is pursuing her life’s work and passion: counseling patients

suffering from cancer. Remen has struggled with Crohn’s syndrome for more than 40 years, which gives her unique empathy.

In Kitchen Table Wisdom, Remen writes about the professional distance that is a

byproduct of medical school training and the barrier it creates between physicians and their patients. While she knew how to treat patients from her medical training, she learned how to heal by listening to stories from patients and her physician colleagues. These stories are inspirational, humbling and true.

I have two favorite excerpts from the book. The first is this: “[L]ife in the U.S. is diminished by judgment far more frequently than by disease. Our own self-judgment or the judgment of other people can stifle our life force, its spontaneity and natural expression. Judgment does not only take the form of criticism. Approval is also a form of judgment. When we approve of people, we sit in judgment as surely as when we criticize them. Positive judgment hurts less acutely than criticism. But it is judgment all the same, and we are harmed by it in far more subtle ways.”

I also love this passage about wholeness: “Reclaiming ourselves usually means coming to recognize and accept that we have in us both sides of everything. We are capable of fear and courage, generosity and selfishness, vulnerability

and strength. These things don’t cancel each other out but offer us a full range of power and response to life. Life is as complex as we are. Sometimes our vulnerability is our strength, our fear develops our courage, and our woundedness is the road to our integrity.” The underlying message here is that we are enough.

A final takeaway from Kitchen Table Wisdom is the value of simply being present, in every sense of the word. I once learned that active listening requires affirming both your understanding and interest. Even offering your own anecdotes to patients demonstrates interest. But certain ways of responding do just the opposite. They can change the focus from a story about the person who confided in you to your story instead. This germ of truth has caused me to take stock of my own “active listening.” We are all works in progress, and I am continuing to work at being simply present, and silent.

bIll MCDonoUghpresident and CeO, MMIC

be present, be sIlentInsights from an empathic physician.

reMen wrItes AboUt the professIonAl DIstAnCe thAt Is A byproDUCt of MeDICAl sChool trAInIng AnD the bArrIer It CreAtes between physICIAns AnD theIr pAtIents. For many, information technology for the health care

industry is currently a mixed bag, somewhere between muddle and miracle. When its full potential is realized, organizations will be able to deliver better health care than ever before. Until then, with federal mandates driving rapid adoption of health IT, risks abound. In this issue of Brink, we examine how to keep your patients safe as technology progresses from today into tomorrow.

MANAGING heAlth It


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book revIew

ManaGInG HeaLTH IT

LLately, it seems that every interlude in health care leads to dialogue about health information technology (health IT). This isn’t surprising. Many major initiatives — such as the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, HIPAA/HITECH, ICD-10 and Health Information Exchange (HIE) — all depend heavily on health IT. Nonetheless, because so many organizations are at early stages of technology adoption, the discourse about health IT tends to normalize to the lowest common denominator, focusing on the daily struggles of learning how to work side-by-side with technology whose neophyte work flows are less than perfect. The course of these conversations makes it easy for anyone to lose sight of the power behind the stories captured within health IT’s data, and understandably so.

What are we trying to achieve with health IT? It’s certainly not technology for the sake of technology. It’s about transforming the system so that we can intelligently improve care for individuals and populations, while simultaneously reducing cost and waste in health care.

Essentially, the vision for health IT shares a common goal with clinicians and those who support them: to empower better health and better health care.

So whether you’re dealing with the challenges of EHR adoption or have already attested for Meaningful Use, remember that your trials and tribulations are temporary. Stay the course, engage in the nation’s vision for health IT, and embrace data-driven health care.

by trish lugtu

Understanding the master plan for health IT — and how improved patient care is at its core.

10 / Brink / Summer 2013

Of course, this strategic plan cannot succeed without public confidence in the technology used to process patient health information. Because of the critical nature of public acceptance, strategies for privacy, security and safety of health IT dominate Goal 3.

The first two strategies are rooted in HIPAA, HITECH and the recent omnibus legislation that protects the confidentiality, integrity and availability of health information; informs individuals of their rights; and increases transparency regarding the uses of protected health information. When information can be disseminated exponentially through the Internet and social media, the public’s concerns around privacy are elevated, and breach enforcement is on the rise.

The third strategy focuses on the safety and effectiveness of health IT. The Institute of Medicine (IOM) is conducting formal studies of health IT patient safety concerns, while the Agency for Healthcare Research and Quality (AHRQ) supports research grants and contracts to develop best practices. Through collaboration between AHRQ, the U.S. Food and Drug Administration and the ONC, systems for standardized reporting of health IT-related events are being developed so that organizations such as MMIC can leverage the information to help manage the new electronic risks.

This goal centers on promoting patient engagement through the use of health IT. Just as data-driven medicine helps clinicians make better decisions, consumers with access to their health data are more empowered to manage their own health. Goal 4 strategies include accelerating electronic access to health information for patients and their caregivers, as well as integrating patient-generated health information and consumer health IT with clinical applications to support patient-centered care.

Portals and other websites dedicated to patient engagement focus on:

/ Self-management and activation

/ Honoring patient preferences and shared decision-making

/ Patient health outcomes

/ Community resources coordination and connection

The final goal of the Federal Health Information Technology Strategic Plan is perhaps the most elusive. In fact, its performance measure is marked as TBD (to be determined) and its data source is unknown. Goal 5’s strategy is to lead the creation of a learning health system to support quality, research, and public and population health. It also aims to broaden the capacity of health IT through innovation and research.

It’s one way of stating that the authors don’t know yet where new technology will lead, but they’re open and committed to pursuing innovation.

The health IT initiatives unfolding across the country are happening by grand orchestrated design. We’re now in the third year of the Office of the National Coordinator for Health Information Technology’s (ONC’s) Federal Health Information Technology Strategic Plan 2011–2015

1.

Its mission is simply stated: To improve health and health care for all Americans through the use of information and technology. All the interdependencies within the regulatory environment around health care are addressed within this one plan. The details behind the objectives and strategies for each goal can be found within the document’s 80 pages, and each shapes the vision to come.

Most health care organizations are just beginning to adopt technology through CMS EHR Incentive Programs. As stated in the plan, the widespread adoption of technology will eventually create a tipping point, and the Meaningful Use of EHRs will become ubiquitous across the nation.

To accelerate adoption, the government has created various programs and resources — such as the EHR Incentive Program and Regional Extension Centers (RECs) — to proliferate best practices, and grants for educational programs to increase the health IT workforce.

Goal 1 strategies:

/ Facilitate information exchange, Meaningful Use and managed transitions of care

/ Support business models such as Accountable Care Organizations and medical homes

/ Enable health IT adoption and information exchange for public health organizations and populations with unique needs, such as the use of immunization registries and collaboration for underserved communities

Even the Affordable Care Act is not immune to technology directives. In fact, health IT is instrumental to the infrastructure needed to manage population health efficiently. Objectives within this strategy include support for more sophisticated uses of EHRs and other health IT to:

/ Improve health system performance and efficiency

/ Better manage care and population health through EHR-generated reporting measures

/ Enable reform of payment structures, clinical practices and population health management

/ Support new approaches to the use of health IT in research, public and population health, and national health security

1 2 3 4 5A METHOD TO THE MADNESS

GOAL: ACHIEVE ADOPTION AND INFORMATION ExCHANGE THROUGH MEANINGFUL USE OF HEALTH IT

GOAL: IMPROVE CARE, IMPROVE POPULATION HEALTH, AND REDUCE HEALTH CARE COSTS THROUGH THE USE OF HEALTH IT

GOAL: INSPIRE CONFIDENCE AND TRUST IN HEALTH IT

GOAL: EMPOWER INDIVIDUALS WITH HEALTH IT TO IMPROVE THEIR HEALTH AND THE HEALTH CARE SYSTEM

GOAL: ACHIEVE RAPID LEARNING AND TECHNOLOGICAL ADVANCEMENT


While the benefits of implementing EHRs — such as greater efficiency, increased quality of care and improved patient safety — are powerful and well-documented, approaching the transition without anticipating and planning for roadblocks may leave you vulnerable to unintended consequences. These pitfalls may result in decreased provider acceptance, increased cost, failed implementation and even harm to patients.

For example, work flow changes can create new work, add complexity or slow the speed of documentation for a clinician. A work flow such as computerized physician order entry (CPOE) can reduce the number of clinicians in the ordering process. This may eliminate the manual checks that a nurse may have done previously. If not implemented with optimal thresholds, the process can create alert fatigue, causing providers to override the most critical drug interaction notifications.

A lack of defined processes can also cause unintended consequences. For example, without a process to notify an assigned clinician or clerk of a task documented within an EHR, a requested follow-up might be overlooked.

New types of risks are also appearing in EHR documentation. For example, some busy providers seeking efficiency may resort to workaround behaviors when faced with complicated work flows. They may bypass templates in favor of documenting free-text

notes, inadvertently causing conflict with generated template documentation.

An EHR’s convenient copy function can also create problems. If not used sparingly and specifically, copy functions can perpetuate old errors that may exist in previous records.

Another risky behavior is relying on the default values in an EHR template and changing them only when the actual values differ. For example, during a review of a system, all indicators may default to normal. But leaving the defaults intact implies that each factor was analyzed and a conscious choice made to assign it a value. This puts the integrity and validity of the record in question and raises the risk for charges of fraud.

Of course, the human factor also creates unintended consequences. Frustrated clinicians can resist implementation and put up roadblocks. Efforts can also be derailed by managers who mistakenly assume their support staff has adequate computer skills to implement electronic work flows.

Learning from othersRegardless of whether you are new to EHRs or if you’ve already implemented, you have opportunities to leverage best practices and the lessons learned by other organizations. One resource to consider is your local Regional Extension Center (REC). The Office of the National Coordinator for Health Information Technology (ONC) has funded 62 centers nationwide to help providers through the process of adopting, evaluating and implementing

EHRs. Other groups such as Health Information Management Systems Society (HIMSS) and the Agency for Healthcare Research and Quality (AHRQ) have also published best practices around EHRs.

Understand and identifyWhere do unintended consequences come from? Remember that an EHR is a sociotechnical system — a system of complex interactions between people and technology in the workplace. The organizational performance of such a system depends on the management of interactions, encompassing social and human behavior, technical knowledge, and procedure. Unintended consequences arise when any of these factors are not managed properly.

Once you understand what the unintended consequences may be, assign responsibility for tracking a process in an issues log. Include a description, details of the discovery, impact and causation of the issue, along with tracking and remediation tasks. A comprehensive

view of prioritized issues will help organize efforts for managing them.

Assess, remediate and monitorFollow standard practices for managing your EHR risks. Leverage root cause analysis to concisely define the issue and potential risk. Use the root cause analysis to develop and communicate a remediation plan for the improved process or work flow, including metrics defining success. Throughout the process, keep communications open with your users and solicit continual feedback, adjusting where appropriate. Following a standard process will help to systematically manage the risks of unintended consequences.

For the ONC’s “Guide to Reducing Unintended

Consequences of Electronic Health Records,” please visit its website, www.healthit.gov/unintended-consequences.

Trish LugTu, B.s., CPhiMs, ChP, ChssResearch and Development Manager, Health Informatics, MMIC Patient Safety Solutions Trish.Lugtu@ MMICgroup.com

ReferencesJones SS, Koppel R, Ridgely MS, Palen TE, Wu S, Harrison MI. Guide to Reducing Unintended Consequences of Electronic Health Records. Prepared by RAND Corporation under Contract No. HHSA290200600017I, Task Order #5. Agency for Healthcare Research and Quality (AHRQ). Rockville, MD. August, 2011.

ManaGInG HeaLTH IT

LIVING THE VISIONWhen all these strategies have been implemented, we will find the nation in a state of transformed health care. Organizations and agencies will have an enhanced ability to study care delivery and payment systems. Patients will be empowered with increased transparency. Outcomes will be improved for care, efficiency and population health.

Until then, we may find ourselves in an uncomfortable state of transition. But remember, as with all change, the challenges will also pass.

Technology doesn’t sit still and continues to improve. So pay attention to the conversations around you, and look for opportunities to support each other.

Finally, focus on the vision — for yourself, for your peers, for clinicians and support staff because in the end, the knowledge that data brings will empower and benefit all of us: providers and patients alike.

trIsh lUgtU, b.s., CphIMs, Chp, ChssResearch and development Manager, health Informatics, MMIC patient Safety Solutions [email protected]

references1. Office of the National Coordinator for Health Information Technology (ONC). Federal Health Information Technology Strategic Plan 2011–2015. www.healthit.gov/policy-researchers-implementers/health-it-strategic-planning. Accessed May 1, 2013.

2. HIMSS 2012 Davies Enterprise Award. The Mount Sinai Medical Center. How the Preventable Admission Care Team (PACT) Used IT to Expand Program. apps.himss.org/davies/docs/2012_CaseStudies/mountSinai/InnovationPACT.pdf. Accessed May 21, 2013.

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LEVERAGING HEALTH IT TO REDUCE PATIENT READMISSIONS The Mount Sinai Medical Center (MSMC) in New York won the Health Information Management Systems Society (HIMSS) 2012 Davies Enterprise Award for their work leveraging health IT to reduce patient readmissions. In fact, their program was so successful that they were able to reduce 30-day patient readmissions by 56 percent. And while their stated goal had only been to impact the 30-day mark, their program sustained lower readmission rates for the 60- and 90-day marks as well.

MSMC was able to achieve this success by analyzing data collected within their EHR over the previous year. They identified risk factors contributing to readmissions, such as comorbidities and demographic information, and were able to come up with a simple algorithm in order to assign a corresponding risk score.

Once MSMC identifies the risk factors, it incorporates this information into the work flow as an actionable event in order to identify high-risk patients immediately. Upon patient intake, the risk score is calculated in real time, which appropriately triggers patient enrollment into their Preventable Admissions Care Team (PACT) initiative, a best practices program led by social workers that coordinates care for five weeks after discharge. This includes intensive phone follow-up and home visits to evaluate home safety, environmental hazards, family involvement, medication compliance, and diet and nutrition.

MSMC’s innovative use of EHR data and its integration into the work flow ensures that every at-risk patient is identified and receives the post-discharge care that reduces his or her chances of readmission.


avoid unintended consequences by planning, assessing and monitoring your electronic health record (ehR).

sIDe effeCts

follow your retention policies and make records available for authorized requests? If you are not converting all data to your new system, how will you make legacy data acces-sible as needed for the duration of those retention require-ments? Remember to assess your policies against the record retention laws set in your state.

IntegrityIf you are converting data, how will you

ensure accuracy of the data through the conversion process? Don’t turn off your legacy system until you’ve thoroughly verified conversion results, and remember to document your process.

not just for eHrsThe designated record set includes both medical and billing records of patients used for access and amendment under the HIPAA Privacy Rule. Records may include enrollment, payment and claims adjudication. Have you analyzed the impact of decommissioning system data

For Chris Tashjian, M.D., a specialist in family medicine practicing in rural Ellsworth, Wis., successfully introducing an electronic health record (EHR) into any medical practice is about thinking broadly.

“If all you’re trying to do is move paper records onto your computer, you’re going to be miserable,” he says. “It’s the worst of both worlds. You’ll lose access to some of the shortcuts you developed in the paper world, and you won’t harness the possibilities of the electronic world.”

Staying focused on possibilities comes easily to Tashjian, who implemented an EHR two years ago with his organization’s 20 doctors in three locations.

ManaGInG HeaLTH IT

by lynn welch

Starting out with an ehR? leave paper behind and focus on the possibilities.

Meaningful Use incentives have motivated hundreds of software vendors to rush to market to compete for a piece of the health care pie — ready or not. The influx of electronic health record (EHR) systems with varying levels of maturity and cost has created an overwhelming number of options for a market of inexperienced buyers. Complicating matters, providers often choose to pull practice management along in the conversion wake.

And now, with the federal EHR incentive program in its third year, we are bearing witness to a growing number of EHR replacement sales due to unsatisfied providers and EHR vendors’ inability to meet increased certification criteria. In all cases, a certain amount of data transitions from one system to another. And once converted, the old systems are decommissioned.

Whichever scenario applies, consider the following factors before pulling the plug on any legacy system.

record retentionHave you analyzed the impact of your new system on your legal health record, i.e., your organization’s official record of health care services delivered for a patient? The legal health record is defined by organizational policy regarding what information may be released upon authorization. If you unplug your legacy system, will you still be able to

pUllIng the plUgas you transition to new technology, take care how you decommission your legacy IT.

ManaGInG HeaLTH IT

Designated record Set Legal Health record

Medical and billing records — including health plan information — used to make decisions about individuals

Officially declared record of health care services delivered by a provider

Used to clarify access and amendment standards in the HIPAA Privacy Rule

Maintained for regulatory and disclosure purposes

Defined in organizational policy and required by HIPAA Privacy Rule

Defined in organizational policy

Supports HIPAA right of access and amendment

Provides a record of health status and documentation of care for purposes of reimbursement, quality control, research and public health reporting

Facilitates the legal needs of the organization

on retention requirements for HIPAA, such as accounting of disclosures? What about Medicare and Medicaid retention requirements? Do you have any information requiring retention in support of Medicare or Medicaid inquiries or investigations? When decommissioning technology, be sure to consider all types of information that must be preserved.

Litigation holdsAre you under a litigation hold? If so, your organization could receive sanctions if you destroy data before or during litigation. Remember that your systems hold electronically stored information that may be subject to discovery. Be sure to consult with your attorney before decommissioning systems if any litigation is pending.

SecurityLastly, if you store data from your old system, remember that archived data must also be protected. Assess its administrative, physical and technical safeguards during risk analysis. If you are destroying data, remember to consult your security policies and procedures for data destruction and sanitation.

trIsh lUgtU, b.s., CphIMs, Chp, ChssResearch and development Manager, health Informatics, MMIC patient Safety Solutions [email protected]

whAt’s the DIfferenCe?

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of his patients have multiple chronic conditions and take several medications, “I can enter six to eight of them in the time it used to take me to write one or two by hand.” The EHR also alerts him to drug interactions. True, many pharmacies can perform similar checks, if the patient uses a single pharmacy. “But in the end, I’m responsible for that prescription.”

Concern for his patients is expressed in other activities he couldn’t do in a paper environment. Tashjian recounts how the U.S. Food and Drug Administration (FDA) issued an alert about possible interactions between a cholesterol medication and a high blood pressure medication. He was able to search his database to find patients who were taking both medications and adjust the dosages within the FDA’s recommendations.

LeTTInG GO Of THe famILIar HaS unexpeCTeD BenefITSIt helps that Tashjian can empathize with his fellow physicians. Once he convinced them that they weren’t trying to recreate paper records, he had to get them to leave behind the way they created paper records. “We’re married to our notes,” he admits. “Most of us write big, long notes.” And lots of those notes were being generated at the end of the day, adding hours to the physicians’ workdays. “Keeping records in the EHR is far more useful,” he says. “And we’re able to document the visit on the spot and send the patient home with a visit summary. That means, at five o’clock, we can go home.”

DeaLInG WITH reLuCTanT COnverTSTashjian has a simple response for dealing with those reluctant to use EHRs. “Help them!” he exclaims. “Find out what’s in their way.” In his case, some doctors were having a hard time with the logging-in process and remembering their passwords. Answer: “We installed fingerprint readers.” Problem solved, and that’s just one example of Tashjian’s bent for working around difficulties and tweaking systems to work for his practice’s users.

ImpOrTanCe Of preparaTIOnSeeing possibilities didn’t mean rushing into things for Tashjian. It took his group three years to decide on an EHR. “We couldn’t afford to get it wrong,” he explains, alluding to the high stakes involved for independent practices that don’t have the resources to cushion missteps.

Preparation is key. Tashjian gives much credit to the Wisconsin Health Information Technology Extension Center (WHITEC), his state’s federally designated Health IT Regional Extension Center, tasked with

providing outreach, education and technical assistance to clinics and hospitals wanting to implement and achieve Meaningful Use of EHRs.

“They really helped us map all of our processes. A lot of practices want to skip the preparation part,” Tashjian cautions, “but it’s really important. Every hour you spend in preparation saves 10 hours of headaches.”

ManaGInG HeaLTH IT

eleCtronIC DrUg presCrIbIng Is one of tAshjIAn’s fAvorIte Uses of the ehr. “I hAven’t seen A presCrIptIon pAD In two yeArs. AnD I Don’t wAnt to see one.”

Tashjian brought the same vigilance to the implementation process. As the group approached its go-live date for the full EHR, they called for a two-month moratorium on staff vacations. “And we overstaffed. We had three physicians doing the work of two so we wouldn’t have any backlog in accounts receivable. We couldn’t afford that, because in an independent practice like ours without deep pockets, the physicians are paid last, and that would have meant physicians not getting paid.”

Their careful planning worked. The rollout went smoothly, and the group was able to resume normal operations within two and a half weeks.

TakInG THe LOnG vIeWNot surprisingly, Tashjian sees a bright future for EHRs as a tool to improve quality, prevent illness and practice better medicine.

He’s the first to admit he couldn’t go back to paper. “I’m accustomed to having data at my fingertips. Any hour of the day or night.”

Tashjian is confident that improvements will continue apace. He notes that EHRs were originally developed as financial tools, to enhance billing. As the possibilities on the clinical side have emerged, improvements in their use by clinicians have followed. “I think the next thing we’ll see is the ‘Apple-ization’ of EHRs. I think usability will be the next breakthrough.”

That’s the beauty of technology, he says. “It gets better!”

lynn welChSr. Communications Consultant, MMIC Communications [email protected]

He credits a hobby of 25 years — building computers — for his appreciation of the iterative process of health information technology. As he stated after the practice’s first year on an EHR, “This year, we have new capabilities that we didn’t have last year. Next year will be even better. This was not the case in more than 20 years of using a paper record.”

From reactive to proactiveImplementing an EHR involves more than just changing work flows. It changes the whole way you approach medicine. “We’ve gone from being reactive — waiting for people to get sick and come in — to being proactive.” Now their physicians reach out to patients to make sure they’re getting the care they need to prevent illness. With their previous paper-based system, Tashjian thought they were doing a good job with blood pressure control by helping 70 percent of patients keep their blood pressure within recommended ranges. In an electronic environment, that figure has increased to 90 percent.

“We’re in rural Wisconsin,” Tashjian emphasizes, “but with the EHR, we can practice state-of-the-art medicine.”

Helping otHers see tHe ligHtIn the beginning, Tashjian sometimes had to help others outside his immediate practice see the possibilities of an EHR. He recalls a lab that was reluctant to provide him with discrete lab results — individual values that he could sort, manipulate and analyze. Rather, the company wanted to provide him with a static sheet with all the data on it — another case of simply imaging a paper record. “What good is that?” Tashjian sums up his response.

“I started looking for another lab,” he said, until the original company agreed to build an interface

that would provide Tashjian with information he could actually use to improve

patient care.

e-prescribingElectronic drug prescribing is one of Tashjian’s favorite uses of the EHR. “I haven’t seen a prescription pad in two years. And I don’t want to see one.”

“Choosing from a menu is much faster and safer,” he points out. And it ensures the prescription arrives at the pharmacy with all the information needed to fill it. And, since many


A gynecologist referred a 53-year-old woman to her family physician (FP) for a pre-operative exam and chest x-ray before surgery. A radiologist read the chest x-ray, noted an abnormality and recommended follow-up imaging. The report was sent to the FP’s office. The FP documented the history and physical exam and cleared the patient for surgery. There was no documentation in the medical record that the FP ever reviewed the radiology report, or that the patient was ever notified of the abnormality.

The patient continued to see the FP for routine and acute care over the next three years. During an unrelated hospitalization for a heart problem, a cardiologist ordered a chest x-ray and it showed a pulmonary nodule. The radiologist compared the previous chest film with the current one and reported that the nodule had increased in size, consistent with a malignancy. A surgeon removed an adenocarcinoma from the patient’s lung and referred her to an oncologist for chemotherapy and radiation treatments. She died six months later.

This case illustrates how unreliable test management can lead to problems downstream, especially missed or delayed diagnoses. Working in a paper medical record system, this FP did not take note of the abnormality identified on a routine chest x-ray. As a result, the opportunity was lost to diagnose this patient’s cancer in the early stages. Could an EHR’s automated test management system with provider alerts have made a difference?

Diagnostic error is the most frequent and expensive allegation made against primary care physicians (PCPs). In a recent review of 25 years of malpractice claim payments, researchers found that diagnostic errors — not surgical or medication errors — accounted for the largest portion of claims, the most severe patient injuries and the highest total payments.1 Many diagnostic errors occur because of unreliable test management systems. Studies reveal that 18 to 59 percent of test management errors result in adverse outcomes.2 In another study of closed malpractice claims, nearly half of all diagnostic errors involved inadequate follow-up.3 Researchers also found that physicians failed to report clinically significant abnormal test results to patients — or to document that they had informed them — in one out of every 14 cases of abnormal results.4

by lori atkinsonManaGInG HeaLTH IT

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Health IT and test managementA review of research focusing on test management in ambulatory care reveals two common themes. First, providers are unhappy with their methods to track and manage test results, and second, they believe health information technology (health IT) can help. However, recent studies demonstrate that even in practices using health IT, test management is still unreliable, with poor tracking and follow-up of abnormal test results.5,6 These findings highlight the significance of managing health IT’s sociotechnical aspects — the interaction between people and technology.

In a 2010 analysis of PCP workload volume, providers received a mean of 57.5 EHR-generated abnormal test result alerts per day.7 Providers with untimely response, defined as two or more alerts without follow-up after four weeks, received 28 percent more alerts daily. In response to their burden, 46 percent of providers used one of two workaround strategies: the use of handwritten reminders, or the use of another electronic reminder to manage their abnormal test follow-up. Most of these providers were unaware of the alert management feature capabilities of their EHR systems. Alert management features can help providers decide which alerts to address first by prioritizing them with sorting and notification features.

In another study, researchers found that 10 percent of test result alerts were not acknowledged by the provider and failure to follow up still existed in 6.8 percent of cases at 30 days.8 Even when

providers acknowledged the pop-up alert, there was still a lack of patient follow-up. The study authors concluded that automated alerts don’t necessarily result in timely follow-up of abnormal results. They suggested accompanying an alert with a separate pop-up window where doctors can select potential action options, such as:

/ Nurse call patient

/ Schedule follow-up appointment

/ Order consultation

/ Order follow-up test

/ No further action required

In a similar 2011 study, providers reported the biggest barrier to managing test results was the large number of other EHR alerts they receive in conjunction with abnormal test result alerts.9 The researchers identified a significant lack of proficiency by providers in EHR alert management features. They suggested a useful multidimensional approach for improvement including:

/ Improving display and tracking processes for critical alerts in the EHR

/ Redesigning clinical work flow

/ Streamlining policies and procedures related to test result notification

Researchers Sittig and Singh set out to understand the complexities involved with electronic communication of test results, and to develop solutions.10,11 They introduced an eight-dimensional model specifically designed to address the sociotechnical challenges

involved in the design, development, implementation, use and evaluation of health IT within complex adaptive health care systems. They suggested that patient safety solutions must take into account the social environment as well as the technology. In organizations with EHRs, they identified lack of clear policies and improper assignment of responsibility as key reasons for failure to follow up on abnormal test results.

Increasing reliabilityReliable test management in ambulatory care is a complex process with multiple steps and accountabilities:

1. Timely receipt of results

2. Timely review of results

3. Timely notification of results to the patient

4. Timely follow-up care

A breakdown in any of these steps can lead to diagnostic error or patient injury.

Research identifies two important factors affecting the reliability of test management:

1. Safety culture, defined as leadership focus and communication around quality and safety, teamwork and the presence of appropriate policies and procedures

2. Health IT, defined as the presence of an EHR, the use of a system interface between practice and testing facilities, the use of technology to communicate with patients, and the presence of forcing functions

Untimely follow-up of abnormal test results occurs even in clinics using health IT. Reasons include:

/ Information overload from too many alerts, leading to “alert fatigue”

/ Increased physician workload

/ Running behind schedule

/ Lack of evidence-based standard processes, enabling individual physicians to vary their processes based on personal preference

/ Inadequate enforcement of clinic policies outlining the accepted test management process

/ Lack of leadership and unsafe culture

/ Failure to audit medical records and run system reports to evaluate test management processes, leading to a lack of data to engage providers in performance improvement

Technology alone is not the answer. Investing money, time and effort to integrate health IT into a practice does not necessarily result in reliable test management and improved patient safety. Instead, focus on strategies to address the sociotechnical issues — a culture of safety, intuitive health IT, standardized processes and enforced policies.

patient safety recommendations

/ Simplify and standardize test management processes throughout the clinic

/ Outline and define each step of the process

/ Identify roles and accountabilities for each step of the process

/ Define acceptable timeframes for responding to test results

/ Appropriately delegate test management tasks to non-physician personnel

/ Implement a written test management policy and procedure

/ Establish a backup plan in case of absence of the ordering provider

/ Educate and train staff on standard work flow, processes and policies

/ Evaluate test management process by auditing medical records and alert logs

Communication and teamwork

/ Maintain a respectful work environment by endorsing and enforcing a zero-tolerance policy for disruptive behavior

/ Schedule regular team meetings to discuss patient safety successes and failures

/ Employ standardized communication tools and processes such as SBAR — situation, background, assessment and recommendation — and team huddles

/ Communicate all test results to patients — normal and abnormal — in words patients can understand

/ Do not use a “no news is good news” policy

/ Educate patients on your process for communicating results

/ Re-evaluate your clinic’s culture; more is involved than just communication and teamwork — culture provides a foundation for communication and collaboration

Health information technology

/ Use computer provider order entry to place all test orders for tracking

/ Ensure reliable interface with lab and imaging systems

/ Evaluate system alert sensitivity and usability

/ Work with developers to design intuitive, meaningful alert pop-ups and response options

/ Audit and analyze provider response to alerts

/ Educate and train providers and staff on test management system features and capabilities

/ Utilize patient portals for communication of test results

lorI AtkInson, r.n., bsn, CphrM Manager, education MMIC patient Safety Solutions [email protected]

references1. Saber Tehrani AS, Lee H, Mathews SC, et al. 25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank. BMJ Quality & Safety. Published Online First: 22 April 2013, doi: 10.1136/bmjqs-2012-001550.

2. Hickner J, Graham DG, Elder NC, et al. Testing process errors and their harms and consequences reported from family medicine practices: a study of the American Academy of Family Physicians National Research Network. Quality and Safety in Health Care. 2008;17:194-200.

3. Ghandi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnosis in the ambulatory setting: a study of closed malpractice claims. Annals of Internal Medicine. 2006;145(7):488-496.

4. Casalino LP, Dunham D, Chin MH, et al. Frequency of failure to inform patients of clinically significant outpatient test results. Archives of Internal Medicine. 2009;169(12):1123-9.

5. Elder NC, McEwen TR, Flach JM, Gallimore JJ. Management of test results in family medicine offices. Annals of Family Medicine. 2009;7(4):343-351.

6. Elder NC, McEwen TR, Flach JM, Gallimore JJ, Pallerla H. The management of test results in family medicine offices: Does an electronic medical record make a difference? Annals of Family Medicine. 2010;42(5):327-33.

7. Hysong SJ, Sawhney MK, Wilson L, et al. Provider management strategies of abnormal test result alerts: a cognitive task analysis. Journal of the American Medical Informatics Association. 2010;17:71-77.

8. Singh H, Thomas E, Sittig D, Wilson L, et al. Notification of abnormal lab test results in electronic medical records: Do any safety concerns remain? American Journal of Medicine. 2010;123(3):238-244.

9. Hysong SJ, Sawhney MK, Wilson L, et al. Understanding the management of electronic test result notifications in the outpatient setting. BMC Medical Informatics and Decision Making. 2011;11:22

10. Sittig DF, Singh H. A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Quality and Safety in Health Care. 2010;19(Suppl 3):i68-74.

11. Sittig DF, Singh H. Improving test result follow-up through electronic health records requires more than just an alert. Journal of General Internal Medicine. 2012. Published online July 12, 2012.

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consider these questions and how you would answer them for your practice:

/ Does your EHR meet your needs and goals?

/ Do work flow processes need to be re-evaluated?

/ Is additional training required?

/ Are you capturing the required data elements needed for internal clinical priorities, as well as for reportable quality measures?

/ Do staff roles and responsibilities need adjustments?

/ Is the technology in the appropriate locations?

/ Is the technology reliable?

/ Is the technology “fast enough?”

/ Is additional hardware needed?

Addressing the answers to these questions and making other sweeping improvements may be best accomplished with the help of experts. You’ll likely find that a small investment in expertise will make a significant improvement in your system’s effectiveness.

what you can do with some assistance1. get An optIMIzAtIon AssessMent

Make a small, short-term investment in an optimization assessment, which can identify conflicts between your work flow and EHR, problems with application design, usability issues and other obstacles. For specific issues, you can often get the help you need from the software manufacturer or an online user group. For ongoing support, consider a service contract with a local IT provider. MMIC Health IT may also be able to assist. Call us at 877.838.6869.

2. leverAge the DAtA

The information collected by your EHR should be used to further improve your clinic’s

processes and the quality of care. If you lack the time or know-how to analyze the data and identify opportunities, consider contracting with an experienced consultant. A modest investment can result in an EHR that not only helps your practice operate more smoothly and accurately, but can also improve patient outcomes.

3. lAUnCh A ContInUoUs qUAlIty IMproveMent InItIAtIve

An EHR is not a “set it and forget it” system. To get the most from it, implement a continuous process improvement cycle. The federal government provides a primer to help you get started.2

4. tAke ADvAntAge of free resoUrCes

A Health IT Regional Extension Center (REC)3 is an organiza-tion funded by the HITECH Act specifically to assist health care providers with their EHR technology. One such REC is StratisHealth in Minnesota, which, in addition to other ser-vices and resources, provides a best practices framework to help clinics select, plan, imple-ment and optimize their EHR.4

There are many other sources of reliable free information — such as HIMSS5 and the Office of the National Coordinator for Health Information Technology6 — all geared toward helping you implement and improve your system.

Your EHR is far more than an electronic alternative to paper records. When you maximize its potential, you’ll have a clearer understanding of your patients’ health, so you can make better decisions for their care. That’s powerful technology.

Devon thoMAs treADwellCommunications Consultant to MMIC

references1. www.healthit.gov/providers-professionals/ehr-implementation-steps/step-6-continue-quality-improvement

2. www.healthit.gov/sites/default/files/tools/nlc_continuousqualityimprove-mentprimer.pdf

3. www.healthit.gov/providers-professionals/regional-extension-centers-recs#listing

4. www.stratishealth.org/expertise/healthit/clinics/clinictoolkit.html

5. www.himss.org/resourcelibrary/TopicList.aspx?MetaDataID=543&navItemNumber=13263

6. www.healthit.gov/providers- professionals/ehr-implementation-steps

With the rampant technological innovations of the past decades, the transition from paper-based charts to electronic health records (EHRs) was inevitable. What you might not have expected, however, is the need for new business skills in order to get the most out of this new technology.

Choosing the right system, for example, requires a business analyst mindset to find the most compatible solution for your organization’s systems. Implementing a new EHR calls for project management skills as you integrate its use throughout a cross-functional staff. Managing sensitive data requires a working knowledge of IT security and governance. And to leverage that data for a measurable impact on patient health, you’ll delve into the world of data analytics.

Those are a lot of roles for any physician to fill. Keep in mind, though, that it’s the sociotechni-cal aspects — the way you and your staff interact with an EHR — that will largely determine the success you will achieve with it. That’s why it is so important to view your system as not simply a replacement for paper-based records, but as a presence that’s felt throughout your organization and work processes.

If you’re not yet tapping into the full power of your EHR, you should look into making adjust-ments in its use and how you utilize the data. Improvements can be conducted on a micro-level — adjustments you can make yourself — and on a macro-level, which may require some assistance. Here are a few things you can do right away.

what you can do yourself1. IDentIfy AnD eMpower yoUr teChnology ChAMpIons

If you have no internal IT depart-ment, use the natural talent and skills of your own staffers. Is there someone who gravitates toward technology and enjoys learning and problem solving? He or she can teach others a few tricks and timesavers, helping to reduce frustration and increase productivity.

2. Invest In trAInIng

Everyone who uses your EHR system should receive adequate training, whether in a group setting, through one-on-one guidance or by way of electronic tutorials.

3. shAre best prACtICes

If your organization has multiple departments, schedule a quarterly huddle between key users from different areas to share optimization ideas and cautionary tales.

4. explore yoUr ehr’s ADvAnCeD feAtUres

You may not be using some of the functionality that most directly improves patient care, such as physician alerts, reminder systems and performance tracking. One study1 showed that physicians who used the higher-level functions of EHRs demonstrated improvements in chronic disease management and preventive service delivery.

5. InsIst on ConsIstenCy

Avoid workarounds. Some EHR design constraints can be frustrating, but bypassing the system can endanger patients. Enter data directly into the EHR instead of writing it on a piece of scrap paper to enter later. Get rid of your Post-It® Notes. Avoid cutting and pasting progress notes, vital signs or other information. Respect alerts and warnings.

6. sUggest IMproveMents

Help improve your EHR technology by documenting any issues and reporting them to your IT department, vendor or the manufacturer. Getting the most from your EHR — really harnessing its power — requires continuous evaluation of your practice’s goals and improvement to your work flows. From a broad perspective,

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Delivering more patient-centered care, a goal established by the Institute of Medicine, requires:

/ Active engagement of patients as key participants in their care

/ Communication between the patient and the care team

/ Patient empowerment and control of their health information

/ Ready access to patient health information

Robust use of patient portals can contribute to all of these requirements, in addition to helping you fulfill Meaningful Use Stage 2 requirements. In addition, patient portals present significant opportunities to reduce staff time and costs spent documenting information and responding to phone calls.

For example, many portals enable patients to complete and submit health histories online prior to appointments. Portals with secure messaging capabilities enable patients to ask their physician a question in an online message. This avoids having the patient speaking to a receptionist, who then transfers them to a triage nurse, where they repeat the message, which the nurse then relays to the physician, who may return the patient’s call but get a voicemail message, leading to rounds of phone tag.

Finally, patient satisfaction is higher given these additional and more efficient ways of communicating their needs, requests and concerns.

Portals enable your patients do to many things online, depending on which functions you choose to implement. Among the most popular are:

/ Requesting or scheduling appointments

/ Requesting medication refills

/ Viewing personal health records

/ Accessing lab and other test results

/ Viewing statements and paying bills online

/ Completing health histories and other forms from the convenience of home, saving time during appointments and avoiding the need to repeatedly fill out paper forms

Changing habitsStudies have consistently shown that patients highly value access to their

medical records and want more effective ways of interacting with their care team. Despite all the benefits of a patient portal, however, changing the way they communicate can be difficult because it involves developing new habits. Fortunately, companies that offer portals are a rich source of advice, resources and creative ideas on how to encourage adoption (see sidebar).

One thing everyone agrees on: Promoting the patient portal is everyone’s responsibility. That’s because patients may be more or less receptive during different moments of an encounter.

Associated Eye Care in the Twin Cities metro region just launched its patient portal, part of its NextGen® product suite, in April of this year. The program already has 400 patients enrolled. Carrie Miller, Director of Health Information Management for the practice, notes the multiple approaches it has used. “We put a blurb on patient statements. We mention it in face-to-face conversations. We’re experimenting with scribes asking patients right in the exam room. And we just ordered buttons from NextGen that invite patients to ask us about the portal.”

She’s also worked to arm the front desk staff at each of the practice’s five locations with short, simple scripts they can follow to spark interest. “We created our own,” she notes, since the ones provided by the manufacturer were too long for the staff to feel comfortable using.

Everything you can do to make your team feel comfortable talking about the portal helps, says Miller. “It’s not like they’re asking patients to do something that’s not beneficial to them — they’re offering tools they’re going to love!”

Miller’s conclusion so far? While not everyone is immediately interested, “I think when they find something they need from us, like the ability to view records online, they’re more receptive. That’s a good time to invite them to sign up for the portal and submit a records release, and then we can put their records right on the portal for them.”

Focusing on the right services is also important. She notes that, with her patients, touting the ability to see their bill online isn’t that effective. “For one thing, it’s a bill,” she laughs. She’s had more success focusing on benefits, like the fact that “patients can contact us 24 hours a day and request chart notes any time.”

more convenient, more efficient interactionsConvenience is also a big draw for patients at St. Croix Orthopaedics, an MMIC client that has operated a patient portal for the last two years and currently has 5,000 patients enrolled.

“I think we started out with the most difficult function,” says Cindy DeSmith, NextGen Template Development Director at St. Croix Orthopaedics, referring to the ability for patients to complete and submit health history forms online. DeSmith’s broad skills in developing templates enabled her

to create a variety of materials, such as electronic medical release forms, knee surveys and HIPAA information summaries.

By providing that information online, the group was able to replace the new-patient packets they had formerly created and sent to patients, saving considerable time as well as the costs of assembling and mailing the materials.

As the group has expanded its use of the patient portal, they’ve discovered additional ways it enables them to practice more efficiently.

“There’s a lot less telephone tag now,” DeSmith notes of the portal’s secure messaging feature. “It creates a better work flow and a better use of time. The response has been very positive. Before, phone calls would have to be separately documented in the chart. Now, messages are embedded right in the record.”

Overall, she says the biggest benefit has been the ability of the portal to pull the patient-submitted electronic health history into the EHR. “That’s been a huge timesaver and very impactful,” she said. She encourages groups to take advantage of the much-improved templates that are available now and notes that there are very good user guides available on the NextGen website.

portal optionsMMIC currently offers two patient portals. As a reseller of the NextGen product suite, we offer the NextGen patient portal, which integrates with the NextGen product suite to enable real-time clinical and administrative work flow.

And we recently partnered with InteliChart®, a leading health care information technology provider, to offer InteliChart’s patient portal, a vendor-agnostic portal that can work with any EHR, creating more options for MMIC clients.

fOR MORe InfORMatIOn abOut patIent

pORtalS avaIlable thROugh MMIC health It,

Call 877.838.6869.

lynn M. welChSr. Communications Consultant, MMIC Communications

ManaGInG HeaLTH IT

If you build it, will they come?

how to promote your patient portal

/ Change on-hold music or your automated messaging system to introduce the patient portal

/ If your office has digital signage, post a message about the patient portal

/ If your office distributes an electronic or paper newsletter, highlight the patient portal for the next few months

/ When sending out your billing statements, put a message on the bottom of the statement letting clients know there is an easier way to pay online

/ Promote the patient portal to all of your office’s Facebook friends

/ Promote the patient portal to all of your office’s Twitter followers

/ If you have the ability to send a text to your patients, send this new offering as a text blast

/ Offer a drawing or incentive for the first 100 patients who enroll and log in

/ Have a random monthly drawing for anyone who is logging into their patient portal account

/ Brand office materials — e.g., pens, pads of paper, hand sanitizer — with information and benefits of the patient portal

/ Brand appointment reminder cards with information about the patient portal

(Courtesy of NextGen)by lynn M. welch


The belief in a right to patient privacy is almost as old as the medical profession itself. Early physicians in the fourth century B.C., following the teachings of Hippocrates, enshrined this value in the Hippocratic Oath: “Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.”

Respected through the centuries, this ancient ethic is now embodied in the mandates of HIPAA Privacy, which extends itself into the electronic age through HIPAA Security. Yet, while physicians originally built the strong foundation for patient privacy, many physicians today continue to display resistance to the security measures appropriate for protecting electronic privacy.

Securing protected health information (PHI), such as the PHI created, transmitted and maintained through electronic health records (EHRs), requires heightened awareness and diligence — not only to protect patient confidentiality, but also to protect your organization from steep penalties resulting from breach. The following sections describe how physicians can best support efforts to protect PHI.

Data on the movePHI physically on the move is greatly vulnerable to breach by theft or loss. Theft and loss of

PHI is the number one reason for breach in America, together comprising 65 percent of breaches that have impacted more than 21.4 million people since 2009.1

Pay attention to when and how you carry high volumes of patient information, whether paper or electronic — laptops, boxes of charts, data backups, thumb drives, patient schedules, reports and even smartphones — then make sure to implement appropriate safeguards. And also use common sense.

Treat PHI as a valuable possession and keep it out of sight, even when in a locked vehicle. Make a habit of storing PHI in your trunk before reaching your destination. Don’t leave your laptop bag unattended in an airport or other public area. And remember, if you use encryption and a

strong password for your electronic device, you may be protected by safe harbor in the event of breach.

enforce unique user IDs and Strong passwords

The second highest cause for breach is unauthorized access/disclosure (20 percent), and two very basic protections resisted by physicians which guard against unauthorized access/disclosure are the enforcement of unique user identifications (IDs) and the use of strong passwords. And the risk of sharing user IDs doesn’t stop with security.

Not only does a user ID bind your identity to activities within an EHR, but the information is also subject to discovery during litigation. If you share user IDs or passwords, the integrity of your documentation for patient care may be challenged and declared inaccurate. So never share your user ID or password, and support strong password policies in your organization so they cannot be easily guessed.

Smartphones and Bring-Your-Own-Devices (BYODs)Adoption of mobile devices such as iPhones®, iPads®, BlackBerrys® and Android® devices is a fast-growing trend among health care providers. Smartphones are wonderfully convenient tools for communicating with staff and reviewing schedules, patient summaries, and other clinical references. And while they’ve infiltrated work life, they’ve become intrinsically intertwined in private life as well.

While allowing privately owned devices to be governed by organizational policy can feel vulnerable and invasive, it is still the HIPAA-covered entity’s obligation to create safeguards for PHI within its protection, regardless of whether PHI is accessed by a personally owned or organization-owned device. Be aware and plan accordingly for managing common risks associated with mobile devices.

/ Authentication — Authentication methods for mobile devices, especially unmanaged ones, are subject to user discretion, including the ability to disable PINs or passwords. In the absence of authentication, anyone in possession of the device can potentially access PHI stored within or access it through an app with saved credentials, such as email.

/ Encryption — Mobile devices are not encrypted by default. Even when screens are locked with a PIN or password, unencrypted PHI stored on the device is not protected by safe harbor and creates a high risk of breach if lost or stolen.

/ Wi-Fi Connections — Without the proper safeguards, Wi-Fi connections leave devices vulnerable to others also connected to the network. This is especially true of public Wi-Fi networks where cyber thieves may access data on your device without your knowledge.

/ Loss and Theft — Mobile devices are particularly vulnerable to loss and theft because of size and portability, but the benefit of convenience can outweigh the risks when they are managed appropriately.

/ Managing Mobile Risk — What’s a solid approach to managing risk surrounding mobile devices? Start with a written and enforceable policy that addresses both personally owned and entity-owned devices. Include guidelines such as acceptable use of devices, security procedures, reporting processes for loss or theft, and steps necessary to wipe confidential data before changing ownership. Consider technology controls such as remote wipe capabilities and location functions. Enforce use of PINs or passwords for screen locks, and encrypt as necessary.

empowering SecurityMany physician groups delegate the role of security to an operations staff member or IT resource, but they fail to empower him or her with the authority to develop, implement and enforce a security compliance program. Without proper authority, the individual assigned with security responsibility is in a no-win situation, and efforts to implement policies without enforceable sanctions will be defeated. Physicians must support and empower those given responsibility for

developing and implementing your security compliance program. Remember, building a culture of security starts from the top.

greg wIllIAMsSecurity Compliance Consultant, MMIC patient Safety Solutions [email protected]

references1. hhs.gov/ocr/privacy/hipaa/administrative/breachnotifi-cationrule/breachtool.html

2. hhs.gov/ocr/privacy/hipaa/understanding/coveredenti-ties/federalregisterbreachrfi.pdf

Are yoU yoUr greAtest seCUrIty rIsk?

ManaGInG HeaLTH IT

by greg williams

strengthening security Strengthening your organization’s security is easier than you might think. In the end, the goal of data security is to maintain its availability while protecting confidentiality and integrity. Following are some steps to strengthen your security program:

1. assign security responsibilityIdentify the owner responsible for driving development and implementation of your security program, clarify his or her accountabilities, and create an oversight structure between the compliance officer and the privacy and security officers. Make sure compliance management and policy writing are treated as skills that may need to be trained and developed.

2. Create written policies and proceduresUnderstand the regulations and develop the appropriate policies or procedures. Written documentation is a critical aspect of any security program.

3. Train your workforceAs soon as an aspect of your security program changes, train employees.

4. manage your risksStart with a baseline HIPAA security assessment and risk analysis of your current security controls. Remember to take HIPAA Privacy’s Minimum Necessary Requirements into consideration during the analysis.

Identify high-risk needs and start to manage them with a risk management plan. Gain access to technical resources as needed.

5. Be prepared for incidentsCreate a mechanism for anyone — employees, partners, vendors or patients — to report or raise awareness of incidents. And make sure to have a plan for responding. Make sure managers and compliance, privacy and security officers are trained in their responsibilities and know the steps to take.

6. Include security incidents in risk review practicesReview security incidents on a regular and periodic basis for the purpose of identifying and prioritizing trends requiring further risk management. If the review is done independently of the overall risk management or compliance review, make sure to create report escalation paths so that incidents determined as impacting risk management, compliance or both are reported to the appropriate parties.

If you follow a security program such as the one outlined above, you will empower yourself and your organization to identify and mitigate risks before they become liabilities. Developing a culture of security in your organization is essential to successfully managing security risks over time.


At approximately 2:30 a.m., another nurse documented the patient’s lower extremity muscle strength was 1/5 at midnight and 2 a.m. At 4:19 a.m., the first nurse documented absent strength in the patient’s right lower extremity and with left dorsiflexion and plantar flexion at 1/5. The nurse called the on-call resident and reported the absent strength in the right lower extremity. The on-call resident advised he would come to see the patient.

The on-call resident arrived at the hospital and examined the patient at 6 a.m. and noted considerable weakness in the muscles that controlled the feet and ankles, but intact muscle strength in the hip flexors, hip extensors, hamstrings, quadriceps and knees. Following his exam, the on-call resident sent a text message to the surgical resident documenting the physical exam of the patient and alerting the surgical resident to the decreased lower extremity muscle strength. The surgical resident advised the on-call resident that he would contact the orthopedic surgeon. The on-call resident did not document his exam in the patient’s medical record.

At 8 a.m., the orthopedic surgeon and surgical resident examined the patient and noted the loss of the patient’s muscle strength in both lower extremities and felt the most logical explanation was an epidural hematoma at the L3-L4 level. The surgeon took the patient emergently to the operating room for an evacuation of a suspected hematoma. Postoperatively, the orthopedic surgeon ordered an

how communication shortcuts contributed to a patient’s permanent injury.

workIng In the shADows

facts of CaseAn orthopedic surgeon examined a 50-year-old man with a history of previous back and neck surgeries for continuing low back and bilateral thigh pain. The surgeon and the patient discussed the options of non-operative care versus surgery consisting of an extension of his existing lumbar spinal fusion to L3-L4. The man elected to have surgery.

The orthopedic surgeon and a surgical resident performed an almost four-hour surgery that included the removal of the previous hardware, decompression at the L3-L4 level and extension of the posterior spinal fusion to include levels L3-L4. Although it was not documented in his written operative note, it was noted by the surgeon in his dictated

operative note (dictated and transcribed four months later) that the patient had extensive blood loss during surgery and, because of a concern for a dural tear, the surgeon did not place a drain.

The patient was admitted to the surgical floor at approximately 5 p.m. and the nurse noted the patient’s lower extremity strength was normal at 5/5. Four hours later at 9 p.m., the surgical resident sent an email to the on-call resident with the subject “Sign Out.” He used his Gmail account and sent it to the on-call resident’s Gmail account. The email contained a summary of patient names, room numbers and post-op information that the on-call resident would need to provide coverage for the weekend. There was no mention of the patient’s lengthy surgery, extensive blood loss or questionable dural tear. The on-call resident did not check his email that evening.

At 10 p.m., the nurse noted the patient’s lower extremity strength had changed. She documented that the right and left dorsiflexion and plantar flexion were 2/5, a significant weakness. The nurse did not phone the on-call resident right away, but rather rechecked the patient at 10:30 p.m. and documented that the patient’s strength bilaterally was 1-2/5. She called the on-call resident and reported the patient’s decreased muscle strength. The on-call resident later testified it was his understanding that only one leg had decreased movement and the severity of the decreased movement was minimal, not 1-2/5 as documented by the nurse in medical record. The on-call resident instructed the nurse to continue to observe the patient and to notify him if the weakness persisted or got worse. The on-call resident did not document this conversation.

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ACCorDIng to the joInt CoMMIssIon Center for trAnsforMIng heAlthCAre, An estIMAteD 80 perCent of serIoUs MeDICAl errors Involve breAkDowns In CoMMUnICAtIon At trAnsItIons of CAre.1

SpeCIaLTY aLLeGaTIOn rISk manaGemenT fOCuS

/ Orthopedic surgery / Delay in diagnosis and treatment of epidural hematomas resulting in permanent lower extremity neurologic damage

/ Breakdowns in communication at hand-off

/ Email and text message “shadow documentation”

MRI, which revealed another compression hematoma that extended in the dorsal epidural space to the L2-L3 level. The surgeon took the patient back to surgery that afternoon.

Following the two evacuation procedures, the patient went through extensive physical therapy at a rehabilitation center but was left with residual neurologic damage to both lower extremities. The patient filed a malpractice claim alleging a delay in diagnosis and treatment of the epidural hematomas, resulting in permanent lower extremity neurologic damage.

Disposition of CaseThe case was settled for more than $1.5 million.

patient Safety and risk management perspectiveThe experts who reviewed this case were unsupportive of the care and communication provided by the orthopedic surgeon, the surgical resident, the on-call resident and the second nurse who did not call regarding the patient’s continued and decreasing muscle weakness noted at

The experts were critical of the surgical resident’s incomplete and untimely hand-off email communication and lack of information about the complications during surgery. The experts felt that if the on-call resident had the information about the extensive blood loss during surgery and the reasoning for not placing a drain, he would have had a heightened awareness for neurologic complications beyond the normal decreased extremity movement expected following spinal surgery. They also questioned the ineffective process for hand-off communication. The on-call physician did not check his email until the next morning.

The experts were also critical of the on-call resident for not obtaining specific information from the nurse about the patient’s level of lower extremity weakness. The on-call resident testified that he did not recall the nurse telling him about the level of weakness the patient was experiencing, except that he felt the patient’s symptoms were consistent with just having spinal surgery. He

Breakdowns in Communication at Hand-offAccording to the Joint Commission Center for Transforming Healthcare, an estimated 80 percent of serious medical errors involve breakdowns in communication at transitions of care1. Using ineffective and nonstandard communication methods is an identified root cause of patient injury during hand-offs. Studies of communication failures at hand-off identify two major categories of failure: content omissions, identified as the failure to communicate critical information needed to care for a patient, either verbally or in writing; and failure-prone communication processes, such as illegible, unclear or untimely communication.2

Electronic communication of hand-off information is one identified solution and can be an efficient method if the process is standardized and education of providers occurs. An electronic hand-off system integrated into an electronic health record can improve legibility and potentially reduce content omissions through the

midnight and 2 a.m. They were critical of the lack

of information in the orthopedic surgeon’s written operative report about the extensive blood loss, his reasoning for not placing a drain, and the fact that his dictated operative note (done four months following the surgery) contained this information.

testified that had he known the lower extremity strength was a 1-2/5, he would have come in to examine the patient immediately after the first call. However, he failed to document the conversations, and the nurse contemporaneously documented both of the calls and the resident’s response.

use of mandatory, standard fields. Computer prompts to update information and interfacing with existing patient data can also improve hand-off communication. Hand-off policies and procedures should outline appropriate electronic communication methods, response expectations, information to be included in the

by lori atkinson


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ClAIM revIew

hand-off communication, and appropriate documentation in the patient medical record.

email and Text message Shadow DocumentationAccording to estimates, between 57 percent and 70 percent of physicians use text messaging to share information with other providers. Text messaging and email communication offer fast, efficient and convenient methods to communicate about patients and schedules. However, there are several major concerns — privacy and security risks, lack of medical record

documentation and the resultant “shadow” documentation existing on a mobile device or email server.

Smartphone text messages about patients can be a potential privacy and security risk. Smartphones are susceptible to theft or loss, and texts may be viewed by an unauthorized person. Many provider organizations do not use secure messaging or secure email applications, and they don’t require password protection on mobile devices. A brief from the American Health Information Management Association — HIPAA Compliance for Clinician

Texting 5 — addresses texting between clinicians and offers suggestions on how to ensure safer texting practices as part of your organization’s privacy and security compliance program.

A text or email message between providers may be used to provide information only — such as cross coverage or hand-off details — but may also be used for treatment decisions. Problems arise when the communication resides only on the smartphone or in email. Experts report most emails and text messages about patient care never make it into the patient’s medical

record, leaving the electronic communication as only a “shadow” document of care and not the legal medical record. In this case, the on-call physician’s smartphone was taken from him and a forensic examination of the text messages was done to investigate the nature and timing of the text messages. The email accounts of both residents were reviewed for details of the sign-off communication. The sign-off email and text messages were the only record of communication between the surgical resident and the on-call resident, and the only record of the on-call resident’s physical exam of the patient.

lorI AtkInson, r.n., bsn, CphrMManager, Education MMIC Patient Safety Solutions [email protected]

references1. Joint Commission Center for Transforming Healthcare. Hand-off Communications. www.centerfortrans-forminghealthcare.org/projects/detail.aspx?Project=1. Accessed May 1, 2013.

2. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005; 14:401—407.

3. Academy of Pediatrics. More pediatric hospitalists using text messaging to com-municate. ScienceDaily. www.sciencedaily.com/releases/2012/10/121021102818.htm. Accessed May 1, 2013.

4. TigerText. Physician and hospital texting is on the rise. Press release October 12, 2011. www.tigertext.com/physician-texting-on-rise. Accessed May 1, 2013.

5. American Health Information Management Association (AHIMA). HIPAA compliance for clinician texting. library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049460.hcsp?dDocName=bok1_049460. Accessed May 1, 2013

6. AHIMA. Mobile device security (updated). Journal of AHIMA. 83, no.4 (April 2012): 50-55. Available from AHIMA. Accessed May 1, 2013.

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/ Standardize the hand-off communication process and use checklists or templates so complete information is provided to the on-coming provider in a timely manner

/ Allow an opportunity or method for questions and clarification at hand-off transitions

/ Utilize a standard communication method such as SBAR — situation, background, assessment, recommendation — to foster complete information transfer between nurses and providers

/ Educate and train providers and staff on standard communication processes, methods and tools

/ Document all examinations, treatments and care in the patient medical record immediately after care is provided, because the longer the time between care and documentation, the more likely the documentation will be incomplete, inaccurate and suspect after an adverse outcome

/ Document all phone and electronic communications used in clinical decision-making in the patient medical record

/ Implement policies and procedures outlining the appropriate use of secure email and text messaging about patients

rIsk MAnAgeMent tIps


AverAge Cost of DeAlIng wIth DAtA breAChes

Percentage of health care organizations that reported at least one data breach in the last two years.2

94%

Percentage of hospitals that have achieved Meaningful Use of their EHRs.3 90%

Percentage of eligible professionals who have received incentive payments for demonstrating Meaningful Use.3

50%

ManaGInG HeaLTH IT

$2,400,000

1. www.americantelemed.org; 2. ponemon Third annual benchmark Study on patient privacy & data Security, dec. 2012; 3. healthcare Informatics, May 22, 2013

according to a study released in the Journal of Medical Internet Research, there was a big cost savings when low-risk newborn infants were tracked through a website instead of using traditional care, including a return visit to the hospital within 48 hours of discharge.1Tr

ack

ing

Bab

ies

Lost or Stolen electronic Devicesare the primary cause of most privacy breaches.2

2

fUll of pArADoxes,so I am humbly going to admit a personal one. I am a “late adopter” when it comes to using electronic health records (EHRs). My emergency medicine partners would eagerly nod in agreement if asked to affirm this fact. And now, in my role as chief medical officer at MMIC, I am advocating that we physicians enthusiastically engage in designing, using, modifying and leveraging the EHR to improve patient care and mitigate risk. How can these seemingly contradictory stances exist within one practitioner?

First, I have a long history of resisting computer technology when it comes to patient care. I remember being asked to “put your orders in the computer” by a nurse who was standing right in front of me and responding, “What’s wrong with the old way of communicating — ya know, talking?” But I also remember asking for one medication with a specific dose, only to find out that another drug or dose was administered. With time, I came to appreciate the value of writing down or entering orders. And I learned over time that what I thought I communicated wasn’t necessarily what was understood. That said, I have also witnessed an adverse event that occurred because of hitting the wrong key on an order entry for a high-risk medication, so I am aware of the risks EHRs may inadvertently create.

Second, I have worried about the computer being interposed between my patients and me. Many people report experiences in health care these days where they felt their nurse or doctor spent most of the visit entering data into a computer rather than speaking face-to-face with them. Some patients even report the absence of a physical exam! As much as I value checklists for procedures — for ensuring that the necessary steps are performed in the proper sequence — I find them more problematic in other contexts, such as when important questions about psychosocial issues or symptoms may be asked mechanically for

the sake of completing a list, but the answers are not responded to with compassion and further inquiry. Those concerns are real, but now I will admit that I can’t imagine not having online clinical decision-making tools available to me when I am seeing patients. So, while I worry about the improper use of EHRs, I also recognize their current and growing value.

Third, I think we all know that the rapidity with which technology is being urged on health care providers may be creating safety problems of its own. EHRs are still relatively new, and we need to spend time and attention thinking about the best ways to develop them. Patient safety is a big concern with the use of EHRs, and it’s something about which we as providers need to be vigilant and involved.

That’s a main reason we at MMIC are advocating greater physician engagement in EHRs. Who better than our policyholders to press for EHR development efforts proceeding in directions that help us provide more consistent, efficient, safe, up-to-date care? The potential is there. But, as with all works in progress, achieving that potential requires that we be heartily engaged in the process, vigorous in our critiques, and generous with our ideas for improvement.

Another reason for our enthusiasm about increasing utilization of EHRs is the opportunity to use the wealth of data they generate to deepen our understanding of practices that promote or threaten patient safety. To this end, we are partnering with Harvard/CRICO in its claim data sharing project, Comparative Benchmarking Service, so we can analyze our claim data more effectively.

We believe the intersection of technology and patient safety is such an important topic that we have dedicated a special committee of our board of directors to explore advances in this area. The members of the committee, all practicing physicians, are uniquely able to evaluate emerging technologies from both clinical and potential malpractice perspectives. Their first-hand understanding of the challenges and risks of using technology in practice settings provides a bracing reality check and opens our eyes to opportunities we can pursue that benefit all of our policyholders.

If you have ideas you would like to share or want to learn more about our work in this area, please contact me at [email protected].

lAUrIe C. DrIll-MellUM, M.D., Mphvice president, Chief Medical Officer, MMIC [email protected].

n

Tex

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/ How better communication leads to better outcomes

/ Disclosure and apology: Moving from “deny and defend” to “I’m sorry and here’s what happened”

/ Avoiding burnout by building resiliency

/ Are your patients confident in managing their own health care?

/ Why transitions in care pose such a high risk

fAll IssUe:

the Communication edition

LIFE IS

34 / Brink / Summer 2013

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the lAst worD

The delivery room should be the happiest area of the hospital. But practicing obstetrics is risky, and mistakes involving infants can be especially heartbreaking. In this issue of Brink, we examine some of the risks involved in OB and offer strategies to reduce them.

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For many, information technology for the health care industry is currently a mixed bag, somewhere between muddle and miracle. When its full potential is realized, organizations will be able to deliver better health care than ever before. Until then, with federal mandates driving rapid adoption of health IT, risks abound. In this issue of Brink, we examine how to keep your patients safe as technology progresses from today into tomorrow.

feAtUre seCtIon:

Managing health It

The Risk Solutions Magazine Summer 2013 - MMIC Group · 2013-08-27 · 9 Brink is published four...

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