Health Informatics in the Real World
1. What are EHRs and EMRs? How do they compare and differ?
As quoted in (Braunstein, Lesson 3 – Health Informatics in the Real World : EHR – 4. EHR vs. EMR, 2017), “EMRs – Electronic Medical Records are the digital records of a patient as recorded by one or more of their providers.” (Garrett, 2011) mentions that EMRs are designed to be used for internal use by one practice and cannot be transferred easily, i.e. to transfer patient’s record from one’s Primary Care Physician to Specialist may require taking a print-out and mailing them.
Regarding EHR, (Braunstein, Lesson 3 – Health Informatics in the Real World : EHR – 4. EHR vs. EMR, 2017) quotes that “EHR – Electronic Health Record is a complete comprehensive record of a patient’s health.” According to (Garrett, 2011), EHRs are designed to collect and share information with all healthcare sources and they can be accessed by all the stakeholders involved in the patient care including patient’s themselves.
2. In detail, define the ONC. How does ONC impact healthcare vendors and EHRs?
According to (About ONC, 2017), Office of the National Coordinator for Health Information Technology(ONC) facilitates the adoption of health informatics by health system and oversees the implementation and use of health information technology and electronic exchange of health information. (Braunstein, Lesson 3 – Health Informatics in the Real World: EHRs – 5. Health IT Certification, 2017) mentions that ONC administers the HIT Certification Program and “The program defines technical requirements for health IT and process by which commercial systems may become and remain certified.”
According to (CMS, An Introduction to the Medicare EHR Incentive program for Eligible Professionals), EHR incentive Program provides incentive payments for healthcare providers to use EHR technology to improve patient care and to qualify to receive incentives, healthcare providers must use certified EHRs that is administered by ONC.
Figure reprinted from (About the ONC Health IT Certification Program, 2017)
3. What is Meaningful Use?
(Meaningful Use, 2017) describes Meaningful Use as a program that defines the use of certified EHR technology in a meaningful manner which ensures that the certified EHR technology provides electronic exchange of health information to improve quality of health care.
As discussed in (Meaningful Use, 2017), Meaningful Use addresses following priorities as well:
· Improving quality, safety, efficiency, and reducing health disparities
· Engage patients and families in their health
· Improve care coordination
· Improve population and public health
· Ensure adequate privacy and security protection for personal health information
Under the Medicare EHR Incentive Program administrated by Centers of Medicare & Medicaid Services (CMS), health providers are eligible to receive EHR incentive payment if they can show “meaning use” of their EHRs as per the specific objectives laid by Meaningful Use program. (CMS, An Introduction to the Medicare EHR Incentive program for Eligible Professionals) . As per (Meaningful Use, 2017), these objectives were defined in three stages as follows:
· Stage 1 – Rules relating to meaningful use in the context of objectives and measures and standards, implementation and vocabulary respectively were finalized.
· Stage 2 – New public health objectives for Eligible Professionals were added
· Stage 3 – In this stage, rules specifying requirements for Eligible Professionals and Eligible Hospitals to qualify for EHR incentives were finalized.
4. Should patients be the aggregation point for all or any of their health data? Why or why not?
Giving access to patients of their health care record is desirable to engage patient in their own health care. This promotes trust between health care provider and patient, enable better decision making, patient becomes more aware of his/her own health and is likely to communicate its symptoms better to the health care provider. However, I think that patient should not be sole aggregation point for all their health data. Being sole aggregation point would mean patient will have to manage, securely share, and maintain their health data. Often these tasks require understanding of medical terminologies, proficient use of computer technology. Also, sharing data could also require adhering to data standards, using encryption techniques (as in HIE), and authentication of the receiver etc. With varying education levels, not every patient will possess required skills to perform these activities. Therefore, enabling patients to take care of their own health record would need large scale education programs. Also, not all patients would be healthy enough to manage or perform these activities.
Having said that, patients can actively participate in maintaining their health record. For example, they could be given a task of updating their symptoms, noting down any side effects of the drug etc. A study conducted for an interface for parents of children with attention-deficit hyperactivity/disorder (Sox, et al., 2010) concluded that given a good user interfaced personal health application, data entry can be performed by parents having even low levels of health literacy. Hence, it is beneficial to actively engage patients, but they cannot be sole aggregation point of all their records.
5. Describe the challenges around PHRs?
(Tang, Ash, Bates, Overhage, & Sands, 2006) quote The Markle Foundation’s Connecting for Health collaborative as defining PHR as:
“An electronic application through which individuals can access, manage and share their health information, and that of others for whom they are authorized, in a private, secure, and confidential environment.” (Tang, Ash, Bates, Overhage, & Sands, 2006)
Some of the key challenges in adopting PHRs are:
Getting data to patients – To make data available to patients from all the sources or providers, require PHR systems to interoperate with other system throughout the entire health information environment. The lack of ubiquitous EHR usage presents greatest concern for integrated PHR adoption. (Tang, Ash, Bates, Overhage, & Sands, 2006)
Privacy concerns – Another major concern in adoption of PHR is authentication of both patients and health provider. Providers must be cautious of any legal implication while sharing patient’s health data in interoperability architecture. This makes it important to enable providers to identify patient’s identity without compromising patient’s privacy. (Tang, Ash, Bates, Overhage, & Sands, 2006)
Patient engagement – For PHRs to be useful, it is essential for patient to understand the importance of maintaining and coordinating health-related documentation and activities with health care providers. Also, for PHRs to have meaningful use to patients, they must be educated on medical terminologies and PHR workflows. (Tang, Ash, Bates, Overhage, & Sands, 2006)
Usability – In order to be useful to the patient, PHR systems should be easy to use and its cost of adoption should justify its perceived value. Technology that can achieve these goals is still evolving. (Tang, Ash, Bates, Overhage, & Sands, 2006)
6. Explain the Blue Button on FHIR Project and how the idea was formulated?
According (CMS, Blue Button API: Improving Medicare Beneficiary Access to Their Health Information, 2017), Blue Button’s vision is
“Enhance CMS’ current Blue Button service to provide developer-friendly, standards-based data API that enables beneficiaries to connect their Medicare claims data to the applications, services, and research programs they trust”
Blue button originated at the Veteran’s Administration as an icon on their patient portal to provide beneficiaries a secure way to electronically download their own medical record. Since then Blue Button has spread beyond VA to other government agencies. Since 2012, ONC has been entrusted the responsibility of enhancing its technical standards and encouraging its broader use. (HealthIT.gov, 2016) Now, NATE and Blue Button on FHIR team at the CMS are working to establish a trust mechanism for consumer-facing applications that wish to access beneficiary data via APIs. (CMS Blue Button on FHIR Pilot Project, n.d.)
7. How does Interoperability and Meaningful Use relate?
(Leaders, 2016) CMS’ updated rule for Stage 2 and final rule for Stage 3 of Meaningful Use aims to establish interoperable health IT between the health providers. This clearly emphasizes the importance of interoperability for successful implementation of Meaningful Use program. With the widespread usage of EHRs as part of EHR and Meaningful Use program, interoperability has become important to enable the seamless transfer of records to all healthcare providers to improve the patient care. According to ONC report to Congress on December 2015, there are significant barriers to achieve interoperability in healthcare including lack of universal standards for EHR adoption, privacy challenges, coordination among providers for smooth data transfer, etc.
Therefore, though Meaningful Use has been adopted widely, interoperability challenges hinder providers to meet requirements for Stage 2 & Stage 3 of the Meaningful Use program.
8. What is the Health Information Exchange? How does Privacy, Security and Trust relate to the Health Information Exchange?
According to (Health Information Exchange (HIE), 2014), Health Information Exchange(HIE) enables healthcare professionals to securely access and transfer patient’s records electronically. Chief aim of HIE is to improve speed, quality and cost of data transfer which in turn would improve decision making. There are currently three forms of health information exchange Directed Exchange, Query-based Exchange, Consumer Mediated Exchange. (Health Information Exchange (HIE), 2014). HIE also strives to achieve privacy, security and trust as follows –
Privacy – As explained by (Braunstein, Lesson 5 – Health Informatics in the Real World Today: HIE – Privacy, 2017), HIE enables transfer of protected health information for Treatment, payment or health care operations (TPO). In this, patient is required to sign a document authorizing a health care provider to use their data for TPO activities. These activities include sharing data when patient is referred from one health care provider to other, using data for payments and claim purposes, using data for research purposes or for improving quality of health care, etc. Furthermore, the process called de-identification allows data to be used for research purposes by skipping certain fields that can reveal patient’s identification.
Security – To provide security, HIE relies on cryptographic processes defined by Public Key Infrastructure(PKI) to share information between stakeholders of the patient care. While explaining the process of encryption in lecture (Braunstein, Lesson 5 – Health Informatics in the Real World Today: HIE – 9. Security, 2017), Dr. Braunstein explains that the PKI uses a pair of public and private keys to encrypt the data. These keys are tied to the identity of sender and receiver.
Trust – As explained in lecture (Braunstein, Lesson 5 – Health Informatics in the Real World: HIE – 10. Trust, 2017), digital signature can be used to establish trust between sending and receiving entities. However, to verify if entity is what it claims to be, additional and sophisticated methods may be required.
About ONC. (2017, November 27). Retrieved from HealthIT.gov: https://www.healthit.gov/newsroom/about-onc
About the ONC Health IT Certification Program. (2017, September 26). Retrieved from https://www.healthit.gov/policy-researchers-implementers/about-onc-health-it-certification-program
Braunstein, M. (2017, August 16). HIT2 Lesson 2 5 Health IT Certification . Retrieved from https://classroom.udacity.com/courses/ud448/lessons/8969e504-12cd-4ae9-abf9-970416793866/concepts/7090570b-1b01-4286-a4c2-5fdef6786b1d
Braunstein, M. (2017, August 16). Lesson 3 – Health Informatics in the Real World : EHR – 4. EHR vs. EMR. Retrieved from Udacity: https://classroom.udacity.com/courses/ud448/lessons/8969e504-12cd-4ae9-abf9-970416793866/concepts/4023379a-2b2f-4bb6-be4a-1582e8263d71
Braunstein, M. (2017, August 16). Lesson 3 – Health Informatics in the Real World: EHRs – 5. Health IT Certification. Retrieved from Udacity: https://classroom.udacity.com/courses/ud448/lessons/8969e504-12cd-4ae9-abf9-970416793866/concepts/7090570b-1b01-4286-a4c2-5fdef6786b1d
Braunstein, M. (2017, August 26). Lesson 5 – Health Informatics in the Real World Today: HIE – 9. Security. Retrieved from Udacity: https://classroom.udacity.com/courses/ud448/lessons/dd600981-777e-41c5-bd42-3fce53425620/concepts/fc213582-cd41-4971-a10f-439bd85d4618
Braunstein, M. (2017, August 26). Lesson 5 – Health Informatics in the Real World Today: HIE – Privacy. Retrieved from Udacity: https://classroom.udacity.com/courses/ud448/lessons/dd600981-777e-41c5-bd42-3fce53425620/concepts/7f7cba8b-3b86-475b-b78b-c9a2a545f31b
Braunstein, M. (2017, August 26). Lesson 5 – Health Informatics in the Real World: HIE – 10. Trust. Retrieved from Udacity: https://classroom.udacity.com/courses/ud448/lessons/dd600981-777e-41c5-bd42-3fce53425620/concepts/6adfcaa2-b02f-4146-a837-3083f148b68b
CMS. (2017, September 29). Blue Button API: Improving Medicare Beneficiary Access to Their Health Information. Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/Blue-Button/index.html
CMS. (n.d.). An Introduction to the Medicare EHR Incentive program for Eligible Professionals. Retrieved from EHR Incentive Programs: https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/beginners_guide.pdf
CMS Blue Button on FHIR Pilot Project. (n.d.). Retrieved from NATE-trust.org: http://nate-trust.org/cms-blue-button-on-fhir-pilot-project/
Garrett, P. (2011, January 4). EMR vs EHR – What is the Difference? Retrieved from https://www.healthit.gov/buzz-blog/electronic-health-and-medical-records/emr-vs-ehr-difference/
Health Information Exchange (HIE). (2014, May 12). Retrieved from healthIT.gov: https://www.healthit.gov/providers-professionals/health-information-exchange/what-hie
HealthIT.gov. (2016, September 21). About Blue Button. Retrieved from https://www.healthit.gov/patients-families/blue-button/about-blue-button
Leaders, O. T. (2016, January 26). New Crossroads: Interoperability, Meaningful Use, Transformation, and Our Future. Retrieved from http://hitconsultant.net/2016/01/26/new-crossroads-interoperability-meaningful-use-transformation-and-our-future/
Meaningful Use. (2017, January 18). Retrieved from Centers of Disease Control and Prevention (CDC): https://www.cdc.gov/ehrmeaningfuluse/introduction.html
Sox, C., Gribbons, W., Loring, B., Mandl, K., Batista, R., & Porter, S. (2010). Patient-Centered Design of an Information Management Module for a Personally Controlled Health Record. J Med Internet Res, 12(3):e36.
Tang, P. C., Ash, J. S., Bates, D. W., Overhage, J. M., & Sands, D. Z. (2006). Personal Health Records: Definitions, Benefits, and Strategies for Overcoming Barriers to Adoption. Journal of the American Medical Informatics Association?: JAMIA, 13(2), 121-126. Retrieved from http://doi.org/10.1197/jamia.M2025