Enhancing Diabetes Care with Health Information Technologies A Real-World Case Study

Health Information Technologies Margret K. Amatayakul, MBA, RHIA, CHPS, CPHIT, CPEHR, FHIMSS Real-World Case 11.1 A diabetic patient, John, moves to a new city and uses the Internet to select a local primary care physician (PCP), who is a generalist physician and will coordinate his overall care. He is able to select a PCP who appears to have strong outcomes in diabetes and positive patient satisfaction scores. John schedules an appointment via the physician’s website and is set up with a user ID and password to link the PCP with John’s PHR, which is a record he maintains himself by uploading copies of records from various providers he has seen over the years. This enables the PCP to view and retrieve pertinent information from other providers and information John has recorded about his diet, over-the-counter medications taken, and other information relating to compliance with his diabetic treatment regimen. John also asks his former hometown physician to send information to this new PCP. This physician does so using standard content and format specifications for exchanging referral information between providers. With the information supplied by the PHR and his former PCP, the new PCP’s EHR is prepopulated with a current problem list, recent laboratory results, and other data. Additionally, John’s medication history can be directly supplied to his new PCP’s EHR by the PCP linking to information available from John’s health plan. When John visits the new PCP, information from these various sources will be validated and updated. The new PCP is able to document all components of John’s visit at the time of the visit, including demonstrating medical necessity for lab work by applying ICD diagnosis codes and generating appropriate evaluation and management (E/M) codes for the level of service provided. The PCP decides to put John on a strict smoking-cessation program and exercise routine, with plans to adjust medications according to John’s vital signs and blood sugar levels, which will be monitored remotely through a medical device. All is going well until John has an accident at work that requires a visit to the emergency room, subsequent admission to the hospital, and outpatient physical therapy. All his providers, however, are members of a health information organization (HIO). As a result, each provider has immediate access to the specific information needed to treat John throughout his care and for which John has provided a consent directive enabling him to opt-in to the sharing of such information with all participants in the HIO. At the hospital, the physician providing care is able to reconcile all of John’s medications in accordance with the Joint Commission requirements and to select medications that have been screened against John’s known allergies. The hospital is also part of a health reform mechanism that ties reimbursement to quality metrics. This improves the quality of healthcare and reduces costs in an assigned population of patients. As a result, the hospital has access to John’s previous lab and x-ray results, so repeating these lab tests is not necessary—saving John time and potential health risks, and reducing overall costs. In selecting the physical therapy referral, the hospitalist has access to John’s health plan benefits information, so no time is wasted in arranging for physical therapy to begin. John’s PCP also continuously monitors the impact of the accident on John’s diabetes during Health Information Management Technology: An Applied Approach, 5e Workbook his hospitalization and makes appropriate adjustments. After John is discharged and in physical therapy, the health plan can monitor whether he is following the prescribed exercise routine and can notify the PCP to follow up if necessary. John can access tailored discharge instructions that superimpose his picture on the exercise instructions so that it is clear how to avoid further injury. In addition, each provider John encountered throughout this episode of care follows up with him on the smoking-cessation program he started with his PCP, motivating him to keep from smoking. Real-World Case Discussion Questions 1. What is the standard format in which John’s hometown physician can send referral information to his new PCP? 2. Why does John use a standalone personal health record (PHR) instead of one from his provider? 3. When John is hospitalized, what core EHR component enables medication allergy checking? Real-World Case 11.2 Rural Hospital is a 15-bed critical access hospital that has had a hospital information system (HIS) that provides typical administrative information systems services for a number of years. It also has had an LIS system from a different vendor. It does not have a full time pharmacist, so it has not had a pharmacy information system. Except for basic radiology procedures, it refers patients to a tertiary facility about 60 miles away and does not have a radiology information system. Broadband has not been financially accessible to the community. There are three primary care providers within a 30- mile radius of the hospital and none use an EHR. These physicians are predominantly those working off student loans or are on temporary visas for foreign physicians. Turnover is high. The hospital decided to acquire an EHR system when the MU program started. Believing its options were limited, it contracted with a vendor who catered to critical access hospitals. The vendor implemented a stage 1 certified EHR. The hospital subsequently found that because of its old and incompatible HIS, manual entry or re-entry of data was often required to register a patient into the EHR, to post discharges to the HIS, and such. Without a pharmacy information system, the physicians’ orders for medications had to be printed for the traveling pharmacist to use in stocking the medication cabinet for the nurses. The lack of other physician and nurse documentation not required in stage 1 resulted in the hospital printing all contents of the EHR to paper and continuing to file a paper chart. The result was significantly more time required to use the EHR system than with the paper chart alone. Finally, when stage 2 criteria for certification were released, the vendor struggled to respond and ultimately was sold to another company with no experience servicing small hospitals. Since incentives in the MU program were front loaded (the majority of the incentives were delivered for demonstrating meaningful use of stage 1) and the critical access hospital is presently reimbursed on a cost rather than fee-for-service basis (HealthIT.gov 2015), it made the 2 Health Information Management Technology: An Applied Approach, 5e Workbook decision to delay further deployment of health information systems. It wants to hire a health information management professional, contract for more comprehensive IT support, and engage physicians and community leaders in more thoroughly evaluating both health IT options and the state of reimbursement for critical access hospitals. It recognizes that whatever the future holds, it will need to move to a best-of-fit health IT environment, probably utilizing a SaaS provider through cloud computing, requiring affordable and reliable broadband services. HealthIT.gov. 2015. Benefits for Critical Access Hospitals and Other Small Rural Hospitals. http://www.healthit.gov/providers-professionals/benefits-critical-access-hospitals-and-other-smallrural-hospitals. Real-World Case Discussion Questions 1. 2. Define the terms used in the critical access hospital’s description of its future needs. a. Best-of-fit b. SaaS provider c. Cloud computing Why does the critical access hospital need broadband connectivity? 3. What are some of the considerations this hospital must make when deciding on acquiring an EHR? Application Exercises Instructions: Answer the following questions. 1. For the rural hospital described in Real-World Case 11.2, describe the steps it should take to select a new vendor for its EHR, providing at least two examples for each of the steps. 2. A clinic with 10 physicians acquired an EHR and was able to achieve MU incentives for stage 1. It is struggling with stage 2 because several of the physicians do not like the system and use it minimally or not at all. Identify at least two steps that could be taken to help the physicians use the EHR more frequently and effectively. 3. The director of the HIM department and the director of patient accounting in a small hospital are working together to improve revenue cycle management and prepare to use business intelligence more effectively. For each of the areas where health IT systems and HIPAA transactions intersect, identify the specific applications that may be in place or are needed (one example is provided): Data Admitting diagnosis Health insurance plan Health IT Application(s) R-ADT or PMS PFS 3 HIPAA Transactions Eligibility verification Health Information Management Technology: An Applied Approach, 5e Problem list in POC documentation CPOE Workbook Prior authorization Review Quiz Instructions: For each item, complete the statement correctly or choose the most appropriate answer. 1. A radiology information system is which of the following? a. Core clinical component b. Hospital information system c. Source system d. Supporting infrastructure 2. When an EHR is integrated into the daily routine of clinicians it is said to be in what stage of existence? a. Adoption b. Implementation c. Meaningful use d. Optimization 3. Which of the following is a fundamental change in how medicine is practiced using health IT? a. Clinical decision support b. Clinical transformation c. EHR optimization d. Medical informatics 4. Which of the following is a program that assures there is documented approval for altering an application? a. Change control b. Configuration management c. System build d. System maintenance 5. What health information exchange is a sophisticated structure that enables both receipt of data and the ability to query an exchange for data? a. CONNECT b. Direct c. Microsoft Vault d. File Transfer Protocol 6. Infusion pumps and robotics are examples of which of the following? a. EHR systems b. Medical devices c. Smart peripherals 4 Health Information Management Technology: An Applied Approach, 5e d. Workbook Specialty clinical applications 7. What is interoperability? a. The ability to share health information with other health IT systems b. A form of health information exchange c. A process that integrates all health information into one database d. A system of technologies that work together to achieve a common purpose 8. Revenue cycle management is accomplished through use of which of the following systems? a. Eligibility verification system b. Form creation system c. Patient financial service system d. Registration-admission, discharge, transfer system 9. Structured data are which of the following? a. Able to be processed by a computer b. Images of data on a printout c. Organized according to a classification system d. Required for all parts of the EHR 10. Ideally, clinical documentation in an EHR should be performed _____________. a. At the point of care b. Before the patient is discharged from the hospital c. Via speech dictation when the clinician has completed examination of the patient d. Within one business day of collection 11. The source of drug-drug contraindication information in a computerized provider order entry system is ___________. a. Clinical decision support system b. Drug knowledge database c. Evidence-based medicine d. RxNorm 12. Which of the following is an example of clinical decision support? a. Authenticate a document b. Digital dictation system c. View lab results d. Workgroup tool 13. A standard vocabulary is used to achieve what type of interoperability? a. Process b. Semantic c. System d. Technical 14. A way to send secure messages over the Internet is which of the following? a. Cloud computing b. Digital imaging and communications network c. Virtual private network d. Web services architecture 5 Health Information Management Technology: An Applied Approach, 5e Workbook 15. In order to locate a patient via a health information exchange organization, there must be which of the following? a. Identity matching b. Identity management c. Record locator service d. Unique patient identifier 16. The systems development life cycle _________________________. a. Ensures all components for a system to achieve its value are in place b. Identifies when products or services need to be sunset or discontinued c. Helps organizations select appropriate software d. Relates applications to the technology needed to run them 17. A form of clinical decision support that guides a user in appropriate documentation is which of the following? a. Digital dictation b. Point of care documentation c. Reminder system d. Template 18. What is the combination of quality and cost of healthcare? a. Care process b. Risk c. System d. Value 19. True or false: Computerized provider order entry systems can be used to order narcotics. a. True b. False 20. True or false: A clinical data repository supports sophisticated data analytics. a. True b. False 21. True or false: An organization’s goals that are supported by health IT can be achieved more quickly and completely if monitoring results is performed. a. True b. False 22. True or false: A master patient index is used to locate where patients may have records within a health information exchange organization. a. True b. False 23. True or false: Medication reconciliation is very difficult to implement and often one of the last applications within the medication management set of systems. a. True b. False 24. True or false: The Logical Observations Identifiers Names and Codes (LOINC) vocabulary is used to encode laboratory orders and results 6 Health Information Management Technology: An Applied Approach, 5e a. b. 25. True False True or false: A portal is the same as a personal health record. a. True b. False 7 Workbook