Posts of Home

EMR Enough for Care Coordination?

2012-03-28T13:29:17.617Z

The Journal of the American Board of Family Medicine published in its March-April 2012 issue a mixed method study on care coordination. The authors concluded:

" We demonstrate that the difficulties inherent in collaborative care are independent of the patient population being cared for. Regardless of the patient population and sector of health care, developing collaborative relationships and learning to work collaboratively is difficult and takes time. What many of these teams need is ongoing support and education about how to make these collaborative care practices work."

The real value of this care coordination initiative was that coordination tasks were transferred from family physicians (FP) to nurse practitioners (NP). This transfer and time-savings to FPs took place once trust was established among members of the team. The authors point out that the contributions of various actors were not expected (e.g., pharmacist and NPs).

Interestingly, the EMR contributed little to care coordination. The EMR had been in place for four years but the electronic "To Do" note did not offer a means of adjusting care plans (scanned into system) so current information was not available. Taken together (roles of team members and impact of EMR), this suggests that future EMR/EHR designs should be more chart-based (i.e., coordination artifact) rather than role-based as currently done.

Source:

Legault, F., Humbert, J., Amos, S., Hogg, W., Ward, N., Dahrouge, S. & Ziebell, L. (2012) 'Difficulties Encountered in Collaborative Care: Logistics Trumps Desire', The Journal of the American Board of Family Medicine, Vol. 25, No. 2, pp. 168-176.

1st Fill Adherence Reduces Costs?

2012-02-23T15:59:33.654Z

The blogsphere is abuzz about Surescripts February 1 press release announcing increased adherence with e-prescribing. The study does not appear to be publicly available so my impressions from press release may not accurately reflect the study. That said my initial impressions are that the term "costs" used loosely. Cost to whom should be asked? One should also ask if e-prescribing is the only way to improve adherence?

Surescripts relies upon the Roebuck et al (2011) study which estimated that adherence for four vascular conditions reduced medical spending by the ratios cited by Surescripts (3 to 10 times less). We will need to see what kind of medications have increased first fill adherence in the Surescripts study. These ratios are based on vascular diseases and Fischer et al (2010) reported adherence less than 30% for chronic diseases even though the overall adherence was 78% (similar to Surescripts study).

The Roebuck et al study also says "one should not necessarily expect to see immediate reductions in medical costs from improved medication adherence. This is a particularly salient point for insurers with short time horizons." Can improvements in first fill adherence rates be generalized to continued adherence, especially if costs to patient becomes an issue?

The Roebuck et al (2011) study summarized its study: "Our findings indicate that programs to improve medication adherence are worth consideration by insurers, government payers, and patients, as long as intervention costs do not exceed the estimated health care cost savings." What is the cost of e-prescribing? Why has the elimination of patient co-payments for chronic medications, known to increase adherence, been lost in the discussion? See Sipkoff (2004) which includes quoting Mark Fendrick that "We believe that some people should indeed get their drugs for free, and for a small class of people, should even be paid to take them".

It seems e-prescribing just shuffles the costs around to different categories that may or may not be included in a "cost" number. Higher adherence means more medication costs to the patient to save payers the cost of hospitalization. E-prescribing means medical practices and pharmacies pay for the cost of systems and transaction fees to increase adherence so that payers avoid the cost of hospitalizations.

Given that Surescripts press release is claiming the benefit ratio from chronic vascular diseases, one must ask if payers paying the co-pay of an at-risk population might be cheaper than the billions already spent on e-prescribing. I hope someone does the math.

Sources:

Fischer, M, Stedman, M, Lii, J, Vogeli, C, Shrank, W, Brookhart, M & Weissman, J 2010, 'Primary Medication Non-Adherence: Analysis of 195,930 Electronic Prescriptions', Journal of General Internal Medicine, Vol. 25, no. 4, pp. 284-90.

Roebuck, MC, Liberman, JN, Gemmill-Toyama, M & Brennan, TA 2011, 'Medication Adherence Leads to Lower Health Care Use and Costs Despite Increased Drug Spending', Health Affairs, Vol. 30, no. 1, pp. 91-9.

Sipkoff, M 2004, Not So Much of a Reach: Let Sick Pay Less for Drugs, October, January 18, 2007, .

Systems-oriented Clinical Informatics Mini-Track - AMCIS 2012

2011-12-26T18:28:40.110Z

Mini-Track Cochairs: Nelson King and Sweta Sneha

Healthcare information technology (HIT) is shaping the future of healthcare whether by mandate or the desire of healthcare organizations to improve the quality of patient care. The push is towards integrated HIT which arguably mirrors the push over the past 20 years to move from silos of automation to enterprise systems. This mini-track seeks papers that take a systems view towards clinical informatics.

Clinical informatics brings together clinical workflow and business strategies of a healthcare organization through timely and accurate exchanges of information. Healthcare organizations and the information they exchange are becoming increasingly complex necessitating fresh methodological and theoretical approaches on the part of researchers. Submissions with a systems orientation and clearly articulated context of use that showcase inter-disciplinary thought are trademarks of papers published in this area. The boundaries of the system should be defined and the interplay within and external to the system should be described.

By systems, we mean a broader view than a singular focus on the efficacy of a feature or function within a specific HIT. An integrated system might be multi-function HIT like an EMR/EHR or a set of technologies that result in measurable outcomes. Such outcomes should reflect the interplay between functionality, workflow, information and strategy. Alternatively, the implications of infrastructure on HIT functionality and system use could be explored (e.g., e-infrastructures). The system might also be the interplay between social and technical aspects of an HIT.

Submissions that can be readily extended to a quality journal article will be considered for fast-tracking by the editors of Health Systems Journal (HSJ) coordinated by Nelson King (Clinical Systems Area Editor). Any invitation would be subject to the willingness of reviewers to continue through the HSJ submission process and an assessment that a solid extension of the work is feasible.

A complete description of the Systems-oriented Clinical Informatics Mini-Track is available on the AMCIS 2012 website.

E-prescribing Efficiency?

2011-11-22T19:44:20.757Z

E-prescribing is all about achieving efficiency to the practice and pharmacy to compensate for the cost of acquiring and implementing the technology. The just released Grossman et al (2011) study suggests there is some work to be done (excerpts follow):

New Prescriptions
"Pharmacies typically resolved transmission problems by calling physicians for verbal orders"

Refills
"Eight of these pharmacies lacked the functionality, and the rest chose not to use the feature, mainly to avoid Surescripts transaction fees"

"As one physician explained, ‘Sometimes the patient will call, the pharmacy will fax, and [send something via] Surescripts, all for the same patient, the same prescription, on the same day. That is cumbersome.’

'If they [don’t] respond, that’s where we run into problems. We fax the next day because we can’t send a duplicate request electronically.'

Mail order connectivity
"some practices ﬁrst tried electronic routing for new prescriptions or renewal responses, followed by faxing or printing the prescription if unsuccessful."

These workarounds to intended system usage are just for the logistics of sending prescription information.

These so-called digital e-scripts still require manual intervention: "Three prescription ﬁelds commonly required manual manipulation: medication name, quantity, and patient instructions". Dosing and quantity seem to be problematic according to the study. The e-prescriber must know all the variations of drug packaging at a particular pharmacy in order to reduce the risk of digitally transmitted information containing an error that must be corrected at the pharmacy. This issue represents the role changes that occur with the introduction of technology. There are others in (a hope to see published) article I have under review.

An informative study that speaks volumes to practices and pharmacies putting up with all these system design problems because overall e-prescribing is better. Just imagine if some thought had been made in advance to system design so these unintended consequences would not be a problem.

Center for Studying Health Systems Change provides access to this article by Transmitting and processing electronic prescriptions. (pdf) For the interview protocols appendix click here. (pdf)

Article Citation:
Grossman, J.M., Cross, D.A., Boukus, E.R. & Cohen, G.R. (2011) 'Transmitting and Processing Electronic Prescriptions: Experiences of Physician Practices and Pharmacies', Journal of the American Medical Informatics Association.

Social Media means convergence

2012-02-13T08:36:27.937Z

Social media may seem a bit off-topic from my usual focus on HCIT failure and effectiveness, but we need to be prepared whether we understand the phenomena of social media or not. I found this excerpt while preparing for my MBA-level Social Media Management Strategy course.

Here is an excerpt from 2012 Social Marketing & New Media Predictions compiled by Awareness.

“In the world of health care, the biggest social marketing development in 2012
is the convergence between the worlds of marketing and IT,” observes Pamela
Johnston of The Lahey Clinic. “These two distinct teams are learning from
and about each other in ways that will make us smarter, faster and more patient-centric
in the years to come. We need to combine our resources to reach patients
with relevant messages on the platforms they desire.”

I fear we are behind on the socio-organizational implications of social media technology on the way healthcare gets done.

Surprise! Formulary and Rx History Incomplete

2012-01-07T20:42:32.012Z

The Crosson et al (2012) study just published in The Journal of the American Board of Family Medicine reinforces what has been known for some time. E-prescribers continue having trust issues with electronic formulary checks and electronic medication histories. Why would an e-prescriber spend the time checking an unreliable e-formulary if the pharmacy must do so anyway for adjudication? How do you trust the completeness of a medication history (from claims database) when many filled prescriptions may not appear (e.g., paying cash for $4 generic at Target rather than $25 for same generic via insurance coverage). The authors point out pharmacy sales data might be a better alternative. Even if the information were available, there are issues with secondary use of pharmacy sales data that need to be addressed.

The premise of e-prescribing is that increasing the ease of information access enables collaboration in this inter-organizational network. Information integrity has been a known problem in inter-organizational environments as the importance of controlling integrity via the infrastructure has not been appreciated (Wilkin and Chenhall, 2010). There are no easy solutions but a meaningful dialogue must begin. The prescribers do want this information (Lapane et al, 2011).

CROSSON J C, SCHUETH A J, ISAACSON N and BELL D S (2012) Early adopters of electronic prescribing struggle to make meaningful use of formulary checks and medication history documentation. The Journal of the American Board of Family Medicine 25(1), 24-32.

LAPANE K L, WARING M E, DUBÉ C E and SCHNEIDER K L (2011) E-prescribing and patient safety: Results from a mixed method study. The American Journal of Pharmacy Benefits 3(2), e24-e34.

WILKIN C L and CHENHALL R H (2010) A review of IT governance: A taxonomy to inform accounting information systems. Journal of Information Systems 24(2), 107-146.

Only 14% Patient Harm Events Captured

2012-01-10T10:55:42.608Z

HHS has published Hospital Incident Reporting Systems Do Not Capture Most Patient Harm that only 14 percent of patient harm events experienced by Medicare beneficiaries are captured.

The major highlights from a survey of 189 hospitals:

Hospital staff did not report 86 percent of events to incident reporting systems, partly because of staff misperceptions about what constitutes patient harm
Nurses most often reported events, typically identified through the regular course of care; 28 of the 40 reported events led to investigations and 5 led to policy changes
Hospital accreditors reported that in evaluating hospital safety practices, they focus on how event information is used rather than how it is collected.

A great systems topic to explore how these silos can be put together and submit your findings to the Clinical Informatics area of the systems-oriented Health Systems.

Handoffs More than Information Transfer

2011-11-09T06:32:45.531Z

Patient handoffs in hospitals involve more than information transfer. There is also a handoff of responsibility and control along with resilience that is embodied in the handoff routine according to a new article:

Hilligoss, B. & Cohen, M.D. (2011) 'Hospital Handoffs as Multifunctional Situated Routines: Implications for Researchers and Administrators', In: J.D. Blair & M.D. Fottler (eds.), Biennial Review of Health Care Management, (pp. 91-132), Emerald Group, Vol. 11.

The authors note that standardization (e.g., EMR/EHR) is the most common approach to improve handoffs but "introduce new sources of error (e-iatrogenesis) and eliminate established error-catching capabilities." It is a very careful literature review that characterizes the handoff on two dimensions: multi-functionality and situatedness. A thought provoking piece that probably can be applied to other handoff routines like e-prescribing, hospital discharge, and ambulatory care coordination.

Physician EMR Productivity Revisited

2011-11-03T08:34:41.913Z

A study by Dr. Bhargava (2011) at UC Davis was the focus of several articles at the end of 2010:

EHRs have varying effects on productivity: UC Davis study and EMR not boosting productivity? It could be a mismatch between system and specialty. The study concluded that specialty made a difference which makes sense that the inherent processes in an EMR can’t be completely generic but reflect some model of work.

His office just sent me the SSRN link to their EMR and Physician Productivity study.

When there is a fit, productivity does seem to increase after six months (Cheriff et al. 2010). In addition to EHR fit, one should also look at the related literature. Reardon and Davidson (2007) point to the learning capacity especially in small physician practices. Productivity is important because patients have more confidence in their physician the more time is spent (Wood et al. 2009).

Bhargava, HK & Mishra, A 2011, Electronic Medical Records and Physician Productivity: Evidence from Panel Data Analysis, <http://ssrn.com/abstract=1952287>.

Cheriff, AD, Kapur, AG, Qiu, M & Cole, CL 2010, 'Physician Productivity and the Ambulatory Ehr in a Large Academic Multi-Specialty Physician Group', International Journal of Medical Informatics, Vol. 79, no. 7, pp. 492-500.

Reardon, JL & Davidson, E 2007, 'An Organizational Learning Perspective on the Assimilation of Electronic Medical Records among Small Physician Practices', European Journal of Information Systems, Vol. 16, no. 6, pp. 681–94.

Wood, GC, Spahr, R, Gerdes, J, Daar, ZS, Hutchison, R & Stewart, WF 2009, 'Patient Satisfaction and Physician Productivity: Complementary or Mutually Exclusive?' American Journal of Medical Quality, Vol. 24, no. 6, pp. 498-504.

Required fields on e-scripts?

2011-07-12T15:13:36.865Z

The JAMIA paper that concluded e-prescribing had no impact on error rates (see post: e-Rx: Same Error Rates?) has evoked a response statement from Surescripts and the authors. Those of us citing this study are to note that the term e-prescribing as used in the study "does not accurately reflect the way the terms are used today and should be avoided". The e-scripts (from 2008) analyzed in the JAMIA paper were sent by fax or printed out. Note that Surescripts is consistent with the definition but in the 2007 National Progress Report they put it in the fine print (footnote 1). The pioneers of e-prescribing/EMR systems had to efax because there wasn't connectivity (sometimes the EMR - sometimes the pharmacy) - but the escript certainly was computer generated.

While greatly improved now, e-prescribing in the study era forced most pharmacies to dual screen the e-script with the entry form since the pharmacy systems had not incorporated the functionality or pharmacies had not upgraded. So I see the results as being historically valid.

FierceHealthIT blog follows up the joint statement with the post Surescripts' reaction to e-prescribing study doesn't erase the need for improvement. One suggestion of the study was a "forcing function" to make fields required on e-scripts. If my experience yesterday was any indication, one must consider this function carefully. I was getting a medical history taken and many of my medications (or dosage) did not show up on the list. Therefore the clinician chose to omit the drug from the medication history because there was no means of inputting something not on the list.

The Surescripts statement also ignores the fact that e-iatrogenesis errors from computerized inputs can't be ignored.

eRx - Same Error Rates?

2011-07-01T17:40:32.217Z

JAMIA published online on June 29th the article "Errors associated with outpatient computerized prescribing systems" by Nanji et al. They report one in ten e-scripts have errors (depending upon application) similar to manual prescribing. They point out the "lack of comprehensive functionality and processes" that prevent meaningful use.

A related article in the June 14th online version (i.e., related to computerized processes) is titled "Handling anticipated exceptions in clinical care: investigating clinician use of ‘exit strategies’ in an electronic health records system". Clinicians need to 'exit' unwanted situations that are beyond problems associated with early system usage. These exceptions persist just as they do in e-commerce (e.g., abandoning shopping carts). Perhaps it is poor system design but more likely a lack of understanding of the variations encountered in practice.

E-prescribing impact on non-abbreviation errors

2011-05-28T18:56:37.268Z

"most physicians did not view the newer system as improving safety, despite more CDS features, and alert fatigue led to routine overriding of alerts" based on both survey and qualitative study of 17 physicians. That is the finding of "Transitioning Between Electronic Health Records: Effects on Ambulatory Prescribing Safety" just published in the Journal of General Internal Medicine. The transition from an older medication ordering system to a new CCHIT certified e-prescribing system was assessed by reviewing all prescriptions written by the observed physicians.

While no e-iatrogenesis errors were reported, the efficacy of e-prescribing is questioned in this study especially the alerts module. Given that "two thirds of respondents (n=10) reported that the speed in ordering and refilling medications was much worse or worse with the new system compared with the older system" one has to wonder what benefit e-prescribing is offering - perhaps it is more than an issue with alerts?

Unintended prescribing errors?

2011-05-24T14:52:15.295Z

A pre-publication paper by Redwood et al (2011) is available from BMC Medical Informatics and Decision Making Journal. The title is "Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents".

I've added the e-iatrogenesis errors they uncovered. These include the usual suspects:

User interface including pick list error or free-text input error
Distraction caused by alerts
Prescribing roles restrictions results in no treatment or unauthorized treatment

Two of the errors I haven't seen before. Apparently a user must be logged on to the system to "sign" that the medication has been given but a user can administer the medication without signing on.

Log-in/log-off status for "signing"
Treatment duplication attributed to "signing" versus "administering"

These "signing" errors require further attention. One of hospitals I've been studying has an old system (no GUI) so the authorization is just a passcode on the medication line. There isn't logging on/off. It is more like a digital paper chart where the nurse initials when administered. Something to consider.

AMCIS 2011 Healthcare IT Schedule

2011-05-24T05:44:59.962Z

The AMCIS 2011 Research Program has been published. You can find the schedule of presentation for the 10 mini-tracks of the Health Care IT track (Excel file).

The Organizational Design and Engineering mini-track has the following schedule:

Compliance check of health care process models	8/6	2:00 PM	Bögel, Stephan	Germany
From Health Decisions to Performance: The Network Effect	8/6	2:00 PM	Ben-Zvi, Tal	United States
Model-Supported Business Alignment of IT — Conceptual Foundations	8/6	2:00 PM	Juhrisch, Martin	Germany

My paper will be on Friday:

A Service Value Approach to the Micro-Organizational Networks of E-prescribing

8/5

10:30 AM

King, Nelson

Lebanon

Look forward to seeing everyone at AMCIS 2011 in Detroit.

MCIS 2011 CFP - Health Informatics

2011-03-08T06:06:42.279Z

6^thMediterranean Conference on Information Systems

IS: Crossroads of Technology, People, Organizations and Markets

Limassol, Cyprus - September 3-5, 2011

TRACK: Health Informatics

Track Chairs:

Luca Buccoliero, Bocconi University, Italy

Constantinos S. Pattichis, University of Cyprus, Cyprus

Healthcare is an important challenge facing all nations in the Mediterranean as well as across the world. Developed and developing nations alike are facing the challenge of controlling rising costs while at the same time increasing quality of care, patient safety, and access. Given the promise of Information systems to address these challenges, the healthcare industry has embarked towards a wide spectrum of automation (e.g., electronic medical/health records, computerized provider order entry, clinical decision support systems, telehealth applications, and more). The objective of the Healthcare track is to promote exchange of knowledge on the use of Information Systems for healthcare in the region and beyond. We welcome papers that examine the role of IS in addressing technical, economic, behavioral, strategic, organizational, and policy issues pertaining to healthcare. Submissions can focus on various diverse perspectives including providers (hospitals, physicians), policy makers (e.g., government), insurance companies, and patients. Theoretical, empirical, and policy-oriented contributions from a variety of theoretical and methodological perspectives are welcome.

Examples of topics include but are not limited to:

Adoption, implementation, use, and impact of Electronic health record systems (EHR, EMR, EPJ) in the region
Clinical decision support systems (CDSS) and real-time analytics: lessons learned in the region
Adoption, implementation, use, and impact of Computerized Provider Order Entry Systems
Adoption, implementation, and use of telemedicine for improved access to healthcare
Adoption, Implementation, and Use of Healthcare IT by hospitals, clinics, and physicians in the region
Automating provider workflow in multi-language settings, difficult political, economic, or social environments
IT-enabled mechanisms that provide greater access to and models for healthcare delivery in the region
Successful regional standards, policies, and practices
Role of IS in addressing coordination issues among providers, physicians, laboratories, and insurers
Assessing the role, impact, and methods of using IS for detecting and preventing clinical errors
Impact of IT adoption and use on healthcare efficiency, cost, and quality
Use of IT (electronic communities, etc) in clinical trials
Computer based simulation and modeling for healthcare treatment, training, and optimization
Models, methodologies, and standards for various types of healthcare IT

Conference Submissions

The conference invites paper, panel, and workshop submissions on a broad range of IS themes relevant to IS research and education. Submissions with a focus on policy and practice in the Mediterranean region are especially welcome.

Articles should be submitted electronically as pdf files via EasyChair: https://www.easychair.org/account/signin.cgi?conf=mcis2011

When submitting, authors should indicate the track for which they wish their paper to be considered. Submissions will be subjected to peer review.

Authors are advised to format their papers in conformity to the structuring guidelines described in the MCIS_template_2011 which is posted on the conference website, under the tab “Submissions.”

Types of contributions, in English, via the EasyChair Submission System:

· Full research papers (7–12 pages)

· Extended abstracts and short research-in-progress papers (3–7 pages)

· Research and Teaching Case studies(7–12 pages)

· Panel proposals (2–3 pages)

Important Due Dates

- Deadline for submissions: May 2^nd, 2011

- Notification of acceptance: June 15^th, 2011

- Camera-ready versions: July 1^st, 2011

Proceedings

Conference Proceedings will be published online. The proceedings will be listed in major citation databases such as EBSCO, ABI Inform, etc.

For more information on the conference, please visit

http://www.mcis2011.org/

PCAST - Another XML Variant?

2011-01-28T15:16:12.471Z

The President's Council of Advisors on Science and Technology (PCAST) released "Realizing the Full Potential of Health Information Technology to Improve Healthcare for Americans: The Path Forward" on December 8, 2010. The report calls for "tagged data elements" rather than metadata tag at the document level. The report argues that patient's may wish to reveal only certain parts of their medical record.

My first thoughts - Facebook users can't seem to set their privacy settings correctly or even aware of them. Facebook users are the same patients targeted in this report. I agree privacy is critically important (e.g., why do some patients buy certain drugs for cash) but can the patient really protect themselves from entities that might use the information against them?

I'm pointing you to a post on The Health Care Blog by Vince Kuraitis titled "PCAST HIT Report Becomes a Political Piñata" which summarizes early comments by various organizations primarily on technical aspects of the standard.

EMR Costs Underestimated

2011-01-28T14:38:09.034Z

Information Week in the article Health Systems Underestimate EMR Costs reports on an Accenture study "Secrets of Success on the EMR Journey to Meaningful Use: Leading Hospital CIOs Reveal Key Lessons Learned".

Accenture found:

1 EMR must be a strategic initiative.

2 Implentation time and costs double the estimate

3 IT operating costs spike (80%) during transition

4 Shortage of qualified health IT professionals

5 Nearly 50% increase in IT staff

6. Create culture for adoption

These huge increase in costs are considered a financial failure even if the clinical implementation proceeds smoothly. These findings sound oddly enough like outcomes of the typical ERP implementation.

Google Stack

2011-01-19T19:46:00.963Z

Joining the medical lexicon is a new phrase called Google Stack which represents the output from Googling one's symptoms.

A Time Magazine Googling Symptoms Helps Patients and Doctors column by an MD - Zachary Meisl (19Jan2011) is getting a lot of attention. However, Googling symptoms has been a topic for quite some time. The blog All Scrubbed Up had a post over four years ago titled "A Medical view on "Googling your symptoms"... This is the earliest reference that I found though I admit it was not an exhaustive Google search.

I'm guilty of it myself even playing back sound clips of my son's cough thinking it was whooping cough. The Time article seems to think its a good thing. At least the patient is trying to be involved in their own care. Maybe this leads to greater medication adherence. There is also a downside of which I've had personal experience but I won't go there.

Going to self-diagnosis is a slippery slope but patients are Googling so maybe we should help them. Perhaps Google can give MD's special IDs that allow them to tag reliable sites - a folksonomy of worthwhile medical sites.

Porter on Value in Health Care

2011-01-04T15:26:45.472Z

Michael Porter published a piece in the New England Journal of Medicine (make sure to get the two supplements) on defining value in healthcare. He defines value as "the health outcomes achieved per dollar spent." It is a patient-centered definition that "unites the interests of all actors in the system". He goes on to say "If value improves, patients,
payers, providers, and suppliers can all benefit while the economic sustainability of the health care system increases."

There are a number of assumptions that underlie this definition. First, equitable allocation of benefits among actors. Second, compensation for services can be tied to value creation. I look to e-prescribing to see how these assumptions work out in practice. The prescriber does more work at behest of the system. The pharmacy pays to receive an e-script that strips out any value that have might been generated (e.g., formulary or DDI check) before it is sent. Any increase (and with generic substitution in most states the improvement not clear) in generic usage accrues primarily to the pharmacy benefit manager (PBM) or payer. The infomediary (partially owned by PBMs) collects 21.5 cents per prescription (translation - hundreds of millions of dollars when fully adopted). It seems the service provider gets left out in the way US e-prescribing is implemented. Obviously value is more complex than this simple analysis. I'm currently reading up on value network analysis to see if there might be a way to operationalize the health care value proposition.

References:

Allee, V 2008, 'Value Network Analysis and Value Conversion of Tangible and Intangible Assets', Journal of Intellectual Capital, Vol. 9, no. 1, p. 5-24

King, N 2008, Overcoming Ambulatory E-Prescribing Adoption Challenges: Governments Shaping Innovation on Behalf of Individual Stakeholders, IBM Center for the Business of Government. Available at SSRN: http://ssrn.com/abstract=1334653.

King, N, Christie, T & Alami, KM 2007, 'Process Implications of E-Prescribing Information Integration Models: United States Versus a Middle East Approach', E-service Journal, Vol. 5, no. 3, pp. 15-38.

Lee, TH 2010, 'Putting the Value Framework to Work', New England Journal of Medicine, Vol. 363, no. 26, pp. 2481-3.

Porter, ME 2010, 'What Is Value in Health Care?' New England Journal of Medicine, Vol. 363, no. 26, pp. 2477-81.

Need for HIE?

2010-12-23T06:48:53.565Z

When looking at the business case for a health information exchange, the population that might benefit and the cost to provide such a benefit must be considered. How often does someone on a cross-country vacation get sick and need access to their medical records? After all, much of the population in the US has never left their city. The study by Bourgeois et al (2010) published in the Archives of Internal Medicine begin what they call "Quantifying Information Fragmentation".

The most striking observation: mental disorders (15.5%) and other psychoses (6.3%) accounted for 21.8% of repeat visits to more than 5 sites of care and these patients had much higher ED and hospitalization charges. If these findings in Massachusetts are indicative of nationwide trends, the data suggests prioritizing electronic record upkeeping and sharing for patients more likely to end up at different facilities.

Reference:

Bourgeois, FC, Olson, KL & Mandl, KD 2010, 'Patients Treated at Multiple Acute Health Care Facilities: Quantifying Information Fragmentation', Archives of Internal Medicine, Vol. 170, no. 22, pp. 1989-95.

Health Informatics @ MICS 2011 - CFP

2010-12-23T06:34:25.467Z

The 6th Mediterranean Conference on Information Systems call for papers includes a health informatics track.

The conference theme is "Information Systems: Crossroads of Technology, People, Organizations and Markets" to be held in Cyprus September 3-5, 2011.

Other tracks include:

Economics and Value of Information Systems • E-Services and Business
Process Management • E-commerce, E-business, E-Government
• Business Intelligence, Data Warehousing and Data Mining • Human
Behaviour and IT • Online Communities and Group Collaboration •
Organisational Theory, Strategy and Information Systems • Design
Science • Information Systems Security and Privacy • Mobile, Pervasive,
Ubiquitous IS • Cloud Computing • Sustainability and Green IT •
IS Applications for Culture and Tourism • Health Informatics • Graphics,
Visualization and Media • Interdisciplinary and Emerging IS •
Information Systems Policy and Practice in the Mediterranean Region
• Information Systems Curriculum, Education and Teaching Cases •
Research Themes • Panels

Submission Deadline is May 2nd, 2011.

IJODE Healthcare CFP

2010-12-14T19:36:30.065Z

Special Issue on Organizational Design and Engineering in Healthcare

The International Journal of Organisational Design and Engineering (IJODE) and its associated workshops (IWODE09, IWODE11) welcomes submissions for a special issue on Organizational Design and Engineering in Healthcare Information Technology.

See the call for paper details on the IJODE website. Deadline is June 15, 2011.

Guest Editors:
Dr. Nelson King, American University of Beirut, Lebanon
Dr. Ronald Batenburg, Utrecht University, The Netherlands

The worldwide trend in healthcare has been to look to Healthcare Information Technology (HCIT) for a solution. Yet two recent reviews of the electronic health record (EHR) literature show that all is not well especially with respect to the alignment of organizational design and the engineered artifact. Niazkhani et al (2009, p. 546) concluded "When put in practice, the formal, predefined, stepwise, and role-based models of workflow underlying CPOE systems may show a fragile compatibility with the contingent, pragmatic, and co-constructive nature of workflow.” Two of the findings of Greenhalgh et al (2009, p. 767) were “while secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work is often made less efficient” and “the EPR may support, but will not drive, changes in the social order of the workplace”. In addition, Fontaine et al (2010) concluded from a systematic literature review in primary care that “The potential for HIE to reduce costs and improve the quality of health care in ambulatory primary care practices is well recognized but needs further empiric substantiation “.

Just as in enterprise resource planning (ERP) adoption, healthcare organizations (HCOs) expect HCIT to shape their organization design through the embedded workflow engineered most often from a mechanistic worldview. Oftentimes the contingencies and exceptions aren’t accounted for leaving the blame to fall upon the usual reasons for HCIT failure (e.g., poor implementation, lack of training, resistance). Organizational Design and Engineering (ODE) takes the position that the “either-or” mindset must be replaced with a more holistic view of designing the organization and artifact. The complex interplay between organization and engineering, oftentimes intangible, requires a multi-disciplinary approach to solve the challenge of the social and technological world of healthcare being inextricably linked to healthcare policy.

The special issue seeks contributions from the spectrum of disciplines that are involved directly in HCIT or broader healthcare fields that implicitly rely on HCIT (e.g., policies for care coordination). These contributions must have both the elements of organizational design and an engineered artifact regardless of research discipline. These might address theoretical, empirical and design-based studies on medical- technical infrastructures, tools and applications, health information behavior, or cost/benefits, policy, as well as social implications. HCIT’s are broadly defined to include technologies in clinical informatics, E-health, M-Health, consumer health, public health, and health policy.

Fontaine, P., Ross, S.E., Zink, T., and Schilling, L.M. 2010. "Systematic Review of Health Information Exchange in Primary Care Practices," J Am Board Fam Med (23:5), pp. 655-670.

Greenhalgh, T., Potts, H.W.W., Wong, G., Bark, P., and Swinglehurst, D. 2009. "Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method," Milbank Quarterly (87:4), pp. 729-788.

Niazkhani, Z., Pirnejad, H., Berg, M., and Aarts, J. 2009. "The Impact of Computerized Provider Order Entry Systems on Inpatient Clinical Workflow: A Literature Review," Journal of the American Medical Informatics Association (16:4), pp. 539-549.

All papers will be peer reviewed and should conform to IJODE publication standards. Methodological and theoretical pluralism (empirical or theoretical work, quantitative or qualitative research, design science, prototypes ...) is welcomed by IJODE

Group Practices On the Rise

2010-12-14T19:18:14.275Z

The National Ambulatory Medical Care Survey (NAMCS) summary results for 2007 were released in November. It is found on the Ambulatory Health Care Data page of the National Center for Health Statistics. The focus is on the 994,321 office visits.

I'm looking at the data from the perspective of e-prescribing adoption. While 42.7% of office visits continue to be solo/partner practices, it is a significant drop from results 10 years ago. Pratices with 6-10 physicians showed the greatest increase in office visits - moving from 12.1% to 17.7% of office visits. Generally the larger the practice the more likely an electronic health record has been adopted so this is good news.

For these office visits, there was an average of 2.26 "medication mentions". This isn't exactly prescriptions as it includes OTC, immunizations, and desensitizing agents. Around 10% of office visits involve 5 or more medications. Less than 1% of office visits are for adverse effects of medical, surgical care, or medications.

There are many other data categories that haven't been mentioned.

CFP AMCIS 2011 Healthcare Mini-Track ODE

2010-12-12T14:43:59.884Z

Organizational Design and Engineering in Healthcare IT

AMCIS 2011 Call for Papers - Healthcare Mini-Track

Two recent reviews of the electronic health record (EHR) literature show that all is not well especially with respect to the alignment of organizational design and the engineered artifact. Niazkhani et al (2009, p. 546) concluded "When put in practice, the formal, predefined, stepwise, and role-based models of workflow underlying CPOE systems may show a fragile compatibility with the contingent, pragmatic, and co-constructive nature of workflow.” Two of the findings of Greenhalgh et al (2009, p. 767) were “while secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work is often made less efficient” and “the EPR may support, but will not drive, changes in the social order of the workplace”. In addition, Fontaine et al (2010) concluded from a systematic literature review in primary care that “The potential for HIE to reduce costs and improve the quality of health care in ambulatory primary care practices is well recognized but needs further empiric substantiation “.

Just as in enterprise resource planning (ERP) adoption, healthcare organizations (HCOs) expect Healthcare Information Technology (HCIT) to shape their organization design through the embedded workflow engineered most often from a mechanistic worldview. Oftentimes the contingencies and exceptions aren’t accounted for leaving the blame to fall upon the usual reasons for HCIT failure (e.g., poor implementation, lack of training, resistance). Organizational Design and Engineering (ODE) takes the position that the “either-or” mindset must be replaced with a more holistic view of designing the organization and artifact. The complex interplay between organization and engineering, oftentimes intangible, requires a multi-disciplinary approach to solve the challenge of the social and technological world of healthcare being inextricably linked to healthcare policy.

The mini-track seeks contributions from the spectrum of disciplines that are involved in HCIT whose paper focus has both the elements of organizational design and an engineered artifact regardless of research or discipline orientation. These might address theoretical, empirical and design-based studies on medical-technical infrastructures, tools and applications, health information behavior, cost/benefits as well as social implications. HCIT’s are broadly defined to include technologies in clinical informatics, E-health, M-Health, consumer health, public health, and health policy.

Best papers will be fast-tracked to a special issue on HCIT with The International Journal of Organisational Design and Engineering (IJODE) due out in second half 2011. Contact the co-chairs if you have questions about submission and fit of your contribution with IJODE.

Mini-track Chairs: Nelson King and Ronald Batenburg

References:

Fontaine, P. Ross, S.E., Zink, T. Schilling, L.M. 2010. "Systematic Review of Health Information Exchange in Primary Care Practices", J Am Board Fam Med (23), pp. 655– 670

Niazkhani, Z., Pirnejad, H., Berg, M., and Aarts, J. 2009. "The Impact of Computerized Provider Order Entry Systems on Inpatient Clinical Workflow: A Literature Review," Journal of the American Medical Informatics Association (16:4), pp. 539-549.

NCHS Reports EMR/EHR Use Increasing

2010-12-11T07:16:12.666Z

The National Center for Health Statistics has just published Electronic Medical Record/Electronic Health Record Systems of Office-based Physicians: United States, 2009 and Preliminary 2010 State Estimates. The percentage of fully functional systems has increased by 45% but the overall use has increased only 5%. We will have to wait and see where the growth actually took place - upgrades of basic systems or new adopters.

Photo Credit: http://www.cdc.gov/nchs/data/hestat/emr_ehr_09/emr_ehr_09_fig1.png

The NAMCS Survey instrument Electronic Medical Records Supplement asks the question:

16. Does the reporting location use and electronic medical record (EMR) or electronic health record (EHR) system?
Allowed responses: Yes, all electronic; Yes, part paper and part electronic; No, Unknown

18. Please indicate whether the reporting location has each of the computerized capabilities listed below.
Allowed response: Yes; Yes, but turned off or not used, No, Unknown
[a list of features followed]

What I found interesting in the survey is a question on surrogate prescribers:

19. At the reporting location, if orders for prescriptions or lab tests are submitted electronically, who submits them? CHECK ALL THAT APPLY

I look forward to more details from the survey.

Prescribers Talking Costs

2010-12-09T16:01:12.285Z

An implicit assumption with e-prescribing is the prescriber being willing to take the time to make a formulary check. Even if the patient's formulary is available (chatter on internet suggests its not due to missing functionaility or incomplete data), the prescriber has to be willing to do something. Patients certainly want some feedback to combat rising prescription drug prices. Prescription abandonment has been a rising concern (see earlier post).

The Kaiser Family Foundation survey of 2006 reported half the doctors "frequently" talking with patients about out-of-pocket costs. This is a jump from the Alexander et al (2003) study reporting only 35% of physicians doing so (and patients saying only 15%). When they do talk costs the conversation averages nine seconds (Tarn et al, 2008).

Patient demographic seems to make a difference on the sensitivity of physicians to out of pocket costs. For every 10% increase in the number of privately insured patients, a physician was less likely to ask about cost (Patel et al, 2009)

Alexander, GC, Casalino, LP & Meltzer, DO 2003, 'Patient-Physician Communication About out-of-Pocket Costs', Journal of the American Medical Association, Vol. 290, no. 7, pp. 953-8.

2006, Prescription Drugs: Advertising, out-of-Pocket Costs, and Patient Safety from the Perspective of Doctors and Pharmacists, Kaiser Family Foundation.

Khan, S, Sylvester, R, Scott, D & Pitts, B 2008, 'Physicians’ Opinions About Responsibility for Patient out-of-Pocket Costs and Formulary Prescribing in Two Midwestern States', Journal of Managed Care Pharmacy, Vol. 14, no. 8, pp. 780-9.

Shrank, WH, Fox, SA, Kirk, A, Ettner, SL, Cantrell, CH, Glassman, P & Asch, SM 2006, 'The Effect of Pharmacy Benefit Design on Patient-Physician Communication About Costs', Journal of General Internal Medicine, Vol. 21, no. 4, pp. 334-9.

Tarn, DM, Paterniti, DA, Kravitz, RL, Heritage, J, Liu, H, Kim, S & Wenger, NS 2008, 'How Much Time Does It Take to Prescribe a New Medication?' Patient Education and Counseling, Vol. 72, no. 2, pp. 311-9.

See the page Talking Prescription (Rx) costs.