The issue of Patient Safety with EHRs

Optimal use of Electronic Health Records is expected to bring in fundamental and revolutionary changes in the healthcare industry. Its adaptation has already resulted in enhanced patient care and coordination. Things are only expected to get better moving forward. However, it is very important to understand that Health IT is like a tool which needs to be used properly to derive the real benefits – that there are also possibilities of negative unintended consequences also, leading at times to adverse events if not used in the right way. Keeping this in perspective, guidance has been issued to enable healthcare personnel recognize clinical mishaps or unsafe conditions arising out of an electronic health records as and when they occur. Most of such incidents don’t otherwise get reported since the concerned clinicians and risk managers don’t see the role of health IT in those adverse events. Some of the common causes of such adverse events related to EHR or Health IT, in broad terms, are because of

• system interface issues
• wrong data input
• wrong record retrieval
• software functionality
• configuration issues

To conclude that the adverse results are specific to EHRs only and will not occur otherwise will not be apt. Even if one were using papers, the likelihood of such occurrences still exists. Identifying the source is critical here as with EHRs, errors can have a cascading effect very fast with erroneous data getting auto populated into related fields.

It has been widely accepted that if health IT errors are unaddressed; they will act as huge lag factors in improving the overall patient care. Hence, efforts are being put at various levels to combat it. Since EHRs have fundamentally altered how physicians interact with patients, its adoption amongst the existing group of physicians has not been a smooth one. Inadequate technical support and changing regulations have only added to the woes, so much so that time and again there are questions raised in the physician fraternity on its effectiveness. To ensure that the next generations of physicians do not join their predecessor in holding such prejudices, medical school curriculums are being changed so as to include the required training on EHR usage. The aim is to maximize the understanding and acceptance of EHRs right from the beginning. As long as they consider it as part and parcel of their job, there will always be an intent to find solutions to issues arising out of them and not question their existence at the first place. There are many ways to guard against IT-related incidents in healthcare setups. For e.g. some of steps which can be taken could be to

• have a good monitoring system

• support a culture where such incidents get reported the moment they are identified

• establish a Health IT patient safety priority list

Among EHRs, it has been noted that the ones used in emergency departments seem to be more prone to errors. Research done in this field has suggested that such a trend could be a fall-out of the unique characteristics prevalent in these departments. Some of those would be rapid turn overs, frequent care transitions, interruptions and variance in patient volumes. EHRs have not been robust enough in handling so many factors.

The governing bodies realized that in order to find a solution to this issue, it will have to finally boil down to clinicians having the ability to share their insights with system developers. Since it is they who observe problems first-hand, they are best placed to share inputs related to making the required improvements. Also, it was concluded that just encouraging the clinician fraternity to work without subsequent actions from the IT side will lead to no positive developments whatsoever. Taking this into account a set of principles was shared with the EHR vendor industry to act as guidelines, the focus of which are on the following:

• Patient safety

• Privacy and security

• Patient engagement

• General business practices

• Clinical and billing documentation

• Interoperability and data portability

Besides the above, there are also implementation guidelines which have been shared with the vendor community. They have also been quite receptive to the guidelines and view this as a very important step taken so as to knit together stakeholders determined to improve the healthcare delivery system.

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Major factors affecting healthcare as it evolves

The true importance of Health IT will be understood only when people start looking upon it as something beyond just electronic health records. Only then, will Practices understand the relevance and the need to invest and build up the required infrastructure to support its implementation. At the same time, a lot is left desired in terms of the pace and manner in which its adoption is being rolled out. Standards seem to be in a constant state of flux followed by emphasis on technologies whose benefits in a true sense have not been realized universally. This has compelled comments from eminent groups expressing concern over unintended consequences and additional costs for physicians. Infact, surveys done have clearly started indicating that it takes time to bring about changes in the infrastructure of a health system to support the Health IT efforts and to deploy the tools – that to expect results to start showing immediately is a tall order.

Healthcare has an industry has been experiencing significant changes across all the major dimensions, namely; regulatory, technological, medical and market. This has compelled the leaders of the industries to come together and collaborate so as to define the best ways of adapting to the changes. Of all the important ones some which stand out for the impact that they make have been shared below:

• More engagement and control for Patients: They are going to be more informed about the what’s and how’s of any treatment process that they undergo. On the insurance front, the availability of exchanges will allow then to make better buying decisions based on their need. Use of mHealth will help them to administer self-monitoring technologies. With general awareness of better living habits going up, they will be more involved in managing their health.

• Overhaul of Care-Settings: There will be a major shift of care delivery to homes and communities. Technological advancements will make it possible for patients to stay connected with their providers remotely and avoid unnecessary visits. In addition to that, informed and engaged patients will be better equipped to self-manage a lot of things, courtesy availability of data through electronic health records, smartphones etc.

• Move towards to Pay-for-Performance Billing: Every dollar spent will have to be justified in terms of the treatment offered. Quality, Outcome and finally Satisfaction will slowly become the mandatory deliverable for all providers. New methods of payments are expected to evolve to bring about more risk-sharing and accountability. The models are likely to become more team-based with Non-physicians providers expected to play an important role.

• Consolidation of stakeholders: Independent hospitals and stand-alone practitioners are going to find it tough to sustain the operations. With the focus shifting towards better efficiency, lowering costs and improving quality, all concerned stakeholders i.e. payers, hospitals, pharmaceutical suppliers etc. will see consolidation as means of sustenance.

This will result in a better integrated approach to delivery of care for physicians the most important shift would be that in the payment model. From affecting the financial status of the present breed of physicians in the short term, it would have a defining long-term effect on the career decisions of many interested to join the profession.

Many physicians today receive payments on a fee-for-service basis which provides no incentive for delivering high quality of expertise and which ironically would result in reducing the number of visits and thus the services they offer the patients. However, the changes taking place currently have altered the dynamics altogether. With an emphasis on lowering cost and improving quality, physicians are going to be put on a budget and expected to offer the best of outcome and care within it .Be it capitation and shared savings, withholds and rick pools, pay for performance or bundled payments the emphasis of payment models will be entirely towards risk sharing. All this just adds to the headache for the fraternity already bogged down by the burden of having to adapt to the technical interventions. The last thing that they want now is their profession not rewarding them financially enough.

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What will be the future of Physician-Owned Practices?

The Healthcare Landscape is in the process of undergoing a major change courtesy reforms which have either been brought in or are scheduled in the near future. These reforms are expected to pose huge challenges for providers as they grapple with ICD-10 coding standards, payment and reimbursement reforms, new healthcare models like Accountable Care Organizations etc. They are expected to also make huge investments in meaningfully adopting EHRs or face penalty. All this is taking a toll on the revenue stream. Physicians who are otherwise expected to focus on providing care to their patients in the best possible way are now required to devout a considerable amount of their valuable time in understanding the mandates and adapting to them. Does it mean the moving forward we are unlikely to come across independents physicians? Well, the Federal push to adopt Health IT has kind of compelled many physicians to join hospitals or similar such setups in order to ensure exemption from the additional burden to investing in IT and having to keep up the multitude of technological and regulatory requirements .

The financial and administrative strain on these private practices has resulted in physicians actively looking out for opportunities for affiliation. The move seems quite logical also; to let existing setups deal with all matters not directly related to patient care while the physicians can channelize your energies into it. As early as 2005, the percentage of physician–owned practices was at 66% but has reduced considerably to 33% by 2013. Also, the new physicians entering the industry do not seem too keen to own an independent practice; concerned mainly by the administrative hassles involved in holding one and the resultant squeeze in the profitability levels. For the hospitals also, acquiring Physicians goes a long way in ensuring an increase in the cash flow. At the end of the day hospitals are business entities which have to operate profitably to serve their patients better and also in a larger sense project the industry as lucrative to young people looking at taking up the medical profession. Since adoption of IT mandates has increased the financial pressure on the independent establishments, long term sustainability efforts seem to be channelized towards their affiliation to hospitals.

Inspite of all these developments, there are quite a number of physicians who still want to operate in an independent manner. To make it a reality they need to have an upgraded and integrated software revenue cycle management, practice management and electronic health records. This was revealed by a survey which was conducted amongst Practices which are Meaningful Stage 1 attested. This is where cloud based EHRs and RCMs have innovated and come up with solutions that meet all regulatory requirements. Cloud Based EMR requires a user to pay a subscription fees rather than purchase it. The fees generally need to be paid on a monthly basis. Users, i.e. physicians in this case, are not required to make any investment on associated hardware and software. It is reckoned as cloud because the storing of data is done across a network of data storage centers and not in any one particular location.

The major reasons for physicians to want to adopt this model, so as to enable them to have an independent existence, are:

• They do not have to bother about meeting the HIPPA regulation

• The onus to meet Meaningful Use also lies with Vendor

• The model offers exceptional flexibility for Physicians on the move

• There is High focus on data security and protection

• It is highly cost effective

There are also some drawbacks of using Cloud based EHRs. The major ones are:

• High dependence on vendors for data backups and security

• Setup likely to suffer if the vendor closes down

If a physician is looking at the possibility of entering into a long-term relationship with a vendor, then it would be cost effective to buy the software. However, in the given circumstances when a lot of consolidation is taking place in the EHR marketplace, licensing is a better option. Physicians looking for getting software developed can hire developers from healthcare software development companies in India who can help build clinical and EHR/EMR software projects within allocated budgets and time schedules.

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How is mHealth metamorphosing Healthcare delivery?

Various researches have indicated the various benefits which implementation of mHealth is to bring forth in the healthcare industry. Although there is an inclination to quantify the benefits in monetary terms, the real focus should be on identifying the major changes in healthcare delivery which mHealth is going to bring about. The accuracy of monetary benefits is always going to be debatable but not the tangible benefits drawn from mHealth adoption. Of the many benefits predicted two areas which are going to see some real changes are remote patient monitoring and chronic disease management. In the event of the first, it will result in patients spending less time in hospitals and in outpatient visits. What has been really exciting is to have mHealth hardware getting directly linked to companion apps.

However, mHealth is expected to grow more so as Smartphone-based rather than being delivered through bespoke devices. As far as chronic disease management is concerned, from addressing high healthcare costs, inequality of care and medicinal waste, mHealth can actually bring about some serious positive change in lifestyle. Plus, it allows patients in some capacity to manage their health independently. For a chronic disease like diabetes, triggered mainly by incorrect lifestyle, mHealth can prove a really meaningful contribution in managing it well. For e.g. patients can use the proven apps to adhere to treatment regimes. Physicians can use make use of Patient portals to communicate directly with patients and provide information on disease management. All these and many more channels can be used to get patients to manage their blood glucose levels and reduce instances of emergency room visits and readmissions. Studies done have also indicated that with the younger lot, who unfortunately suffer from the disease, there are apps specially designed which use pictures and text messages which engage them to improve their compliance to care process at home. Also, it helps to get responses to queries from physicians in quick time. The texting program has seems to be gaining in popularity with text reminders ensuring better adherence.

Overall, these are early stages for adoption of mHealth apps. Most of the ones available currently do not have a high degree of sophistication, and are underutilized. However, it is laying the foundation for the next level of innovation to follow where the apps developed will be more suited to the changing healthcare landscape. Since a lot of changes related to healthcare IT are scheduled in the next few years, with some mandated by the federal government, the mobiles apps in the future will have to take into account the regulatory compliances to pervade into the lives of all stakeholders in the industry. The mHealth market is entirely in sync with the smartphone application market. Hence, the adoption is sure to pick from developed countries before it moves to others. In absolute terms, mHealth will see a exponential adoption since the number of people using smartphones and tablets is expected to be in billions in the next 5 years. That is also the time when it is expected to have entered the commercialization phase. But between then and now some major changes will also have to be done. For instance the regulations will have to be modified and defined in clear terms and the solutions have to handle more complex situations. The changes currently taking place in the operational models in the industry will create a an environment conducive to mHealth adoption. One of the studies done to identify the trends which will shape the market for mHealth had the following points to share

• The main driver for the mHealth usage will be the penetration of Smartphones
• There will customized mHealth applications available for smartphones or tablets
• Most of the applications will be native
• There are likely to be niche stores for mHealth apps
• The commercialization phase will require better regulations to be in place
• The market will be driven by the buyers
• The traditional health distribution channels will start adopting mHealth apps
• Countries with high smartphone penetration and healthcare budgets will be the main benefactors
• The chronic diseases will draw special focus
• New business models will come into play

With the adoption rate for mHealth apps on the rise, healthcare software testing also starts assuming increasing importance. It becomes vital and hence imperative to use app testers to test the robustness and security of the apps before they are rolled out to the patients and users.

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Major hurdles to Healthcare IT adoption

The Healthcare industry is currently undergoing a metamorphosis which is unprecedented. All the efforts being put in to digitize data is expected to bring in significant changes to the manner in which care is provided. Health Information Technology for Economic and Clinical Health Act was enacted under the American Recovery and Reinvestment Act of 2009, has pushed for the adoption of electronic health records. This has resulted in efforts directed towards innovation in this industry. The intent is to move towards using more evidence-based tools in helping physicians provide better services to their patients. All this is finally expected to result in a smarter healthcare model. However, the entire story looks pretty promising till the issues at hand are considered. The biggest hurdle at this moment, which has the capacity to undermine the entire initiative, is the pace at which the adoption is taking place. The changes in approach which need to be brought in require acceptance and widespread use to ensure that the real benefits are passed on to the patients. Unfortunately there is a lot of inertia amongst physicians against adoption of information technology in their operations. Government is doing its bit by trying to enforce them, through incentives first and planned penalty later, to accept the change. But the real benefits can only be derived if there is a change of heart in the present generation of physicians and the various tools made available at their disposal are used to their fullest extent. The medical schools are doing their bit in making it mandatory for the students to use software tools and devices as part of their curriculum. This will automatically make it possible for them to extend it to their practices because of the familiarity which would have developed. The problem here is that such a phenomena will have a lag time. To ensure that the current population is not denied the benefits or is not made to wait for decade, it is the unwilling bunch of experienced practicing physicians who have to change.

In the current healthcare model the focus is on quantity. Physicians, to run their setups profitably, have to see a large number of patients on a daily basis. They are also badgered by the continual interference of payers who want to call the shots on how patients should be treated. All this has rendered the model effective and unyielding from both the physician as well as the patient perspective. Accountable care Organization is one of the new models which is taking shape as a consequence of these developments. This ties the provider payment to the quality of care and reduction of care cost for an identified population. They are responsible to the patients as well as the payer for the appropriateness, quality and efficiency of care that they provide. They are driven by 3 primary objectives:

• Improved Care

• Improved Health

• Lower per-capita Cost

However, setting up an ACO involves a considerable amount of startup cost and large annual expenses for maintenance. This is where implementation of info systems can be of tremendous benefit – both in terms of reducing the cost as well as improving the quality of care. It is effective IT solutions which can ensure that the physicians receive the best possible information at the right time to enable them to achieve their goals. All this can be done ensuring confidentiality of patient information throughout the processes. But implementation of IT has also had its fair share of challenges which are not completely removed yet. For e.g. an ACO generally has a large number of Primary Care physicians under its wing. each of the setups generally have their home grown EMRs which generally are seen to lack all the functionalities needed to make them comply with Meaningful Use mandates . On handling this issue the next one to surface is generally that of lack of interoperability. As more and more physicians start joining the group ensuring both the above factors is a must. Another issue which came to the forefront was the differing speed of communication at healthcare setups which indirectly affected how fast physicians driven by need could communicate. Clinical software development teams can help you build clinical and EHR/EMR software projects within allocated budgets and time schedules.

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