Welcome to EMR and HIPAA

Recently I’ve been reading a fair amount about the movement that many are calling Health 2.0. I think the most simple description of Health 2.0 is applying many of the Web 2.0 concepts to health care. My question is whether EMR fits into Health 2.0. My personal feeling is that most of them don’t. Most Web 2.0 projects are consumer facing projects that allow people to interact, collaborate and participate in the process. EMR software is more about facilitating a doctor’s charting.

Certainly you could make a good case that a patient portal or EHR is more Health 2.0. In fact, that really seems to cut to the heart of Health 2.0. Creating a powerful interface between doctors and patients so that patients are a part of the process. However, I think that most EMR in their current state don’t benefit from this type of interaction.

Of course, this begs the question of whether an EMR should have this type of interaction. My short answer is that it should, but until the payment systems catch up with the technology that creates these interactions we won’t see broad Health 2.0 application to EMR software.

Think about how wonderful the ability to send a discharge summary by email to a patient straight from your EMR. I think it’s pretty easy to see the tremendous benefits of this type of communication. Send the patient information to one place they probably visit every day and where they can read and process the information away from the hustle and bustle of the clinic. Certainly many doctors have been doing this with little pamphlets or handout sheets with clinical information. Unfortunately, too many of these sheets never get read. Certainly that same thing could happen with an email, but at least the next generation of patients are going to want this information in their email box.

Of course, the problem with sending this information in an email is that email is not secure. Email encryption hasn’t taken hold fast enough to make it encrypted. Is a user’s email box really a secure location where they want their health information? I personally don’t have a problem with it, but I would expect that many people wouldn’t want their health information in their email any more than their regular mailbox. Either way, without the encryption it wouldn’t be difficult for someone to sniff out what’s being sent in an Email containing for example a patient’s discharge. It would be going across the internet in basically plain text.

This situation actually happened in Austrailia a little while back in an article I read called “Unsecured email sparks dispute.” I know I wouldn’t be happy if a clinic just decided to send these unsecured emails. Not so much because I was personally worried about my information being lost. I personally have nothing to hide (yet anyway). However, I would feel uncomfortable patronizing an organization that would deal so flippantly with my information.

I’m sure that someone will chime in that this is the whole purpose of a Patient Portal or EHR interface that allows people a secure method to receive and send protected health information. This is all well and good, but from what I’ve seen this usually requires the doctor’s EMR company to support this type of interaction. Plus, even more serious of an issue is that you’re giving your patients one more login and password that they’ll need to remember. Certainly not a deal breaker, but one more inconvenience for our users and the staff that have to support our users when they forget their password. Unfortunately, I think that this is the future of secured messaging, but I can always hope that there’s something better that we’re just missing.

We should also realize that this isn’t going to get any easier. In fact, I think we can reasonably say that this is going to get harder and harder. Don’t be surprised if soon some patient would like their health information somehow incorporated into some site like Facebook. It’s really only a matter of time until some developer creates a health interface into Facebook.

It might not make sense to most people, but the next generation of patients are going to grow up living and breathing their online life in some sort of social network (Facebook is just one example of these). They are very comfortable with transparency and will be interested in being able to track and compare health information with other people. Not to mention interact in a social network with other people who have similar conditions. It seems like this isn’t a question of if, but when this type of interaction will happen.

Even if you think that health information on a social network like Facebook is far fetched, we are already seeing health information propagating to the web in Microsoft’s HealthVault and Google Health. Is this going to be ok? Will it become as synonymous as online banking has become to the banking world? It’s not that far of a stretch to think that Google Health could easily be tied into Google’s OpenSocial platform which would allow a patient’s health information to do all sorts of cool things.

The convergence of Health Care and IT is going to be really interesting. It’s taken health care a while to get going with IT, but I think almost everyone agrees that IT could do amazing things to better the health care a person receives.

Today I was preparing a proposal to have my work send me to the HIMSS 08 conference. As part of that proposal I used the list of Keynote Speakers as a little justification as to why this conference would be incredibly interesting and useful for my job.

As I looked over the list I was impressed to see that Eric Schmidt is doing a keynote at HIMSS. Then it dawned on me that HIMSS would be the perfect place to announce Google’s launch into the healthcare industry with Google Health. We know it’s coming or why else would they have put up a Google Health beta page and then taken it down.

Anyone have any inside information that this is the case? If it is, then I’m even more interested in being there to hear the announcement.

If I’m able to make it, then I’ll have plenty to do. I’ll have some great meet ups with many people from the EMR Update forums. I’m sure there will be a meet up of Healthcare IT bloggers like there has been at past HIMSS conferences. I can’t find the link now, but I’m sure I’ll find it if I go. I’ll also be certain to catch up with Naveen and the team at DoctorsPartner. I also told Nick from EMR Update that I’d bring my eee with its built in video camera and make sure to capture some interviews with some people. That would be pretty fun.

Anyone else planning to go to the HIMSS conference?

UPDATE: Neil Versel blogged the following info about Eric Schmidt at HIMSS

As for Google, CEO Eric Schmidt is delivering a keynote at next week’s HIMSS conference, and actually is holding a 30-minute press conference afterwards. The Internet search giant also is throwing a cocktail party next Tuesday, with the theme, “Home is Where the Heart Is.” The invite says, “Come meet the health team at Google and learn more about what we’re working on.” About all I expect to learn from the secretive company is who actually works for Google (I know a couple of people already) and whether the bartender can mix a dry vodka martini.

Today I saw an article on TechCrunch that talked about how Google Blogscoped found a Google Health login page (UPDATE: The Google Health Beta Landing Page has been taken down) for the hopefully soon to be released Google Health. Of course, there isn’t really anything all that special about the login page. It looks just like almost all the other Google login pages. However, the Google Health page did include the following information:

With Google Health, you can:

* Build online health profiles that belong to you
* Download medical records from doctors and pharmacies
* Get personalized health guidance and relevant news
* Find qualified doctors and connect to time-saving services
* Share selected information with family or caregivers

Too bad none of the other links work, but it does give some interesting information about what Google Health will be like. The part that is most concerning to me is downloading medical records from doctors and pharmacies. How are they going to do that? The answer is that they aren’t really going to do it. There are going to be a handful of the thousands and thousands of doctors and pharmacies that will be able to work with Google Health.

I hope that Google Health does the right thing and integrates with something like CCR since it is already beginning to be established in many Electronic Medical Record software programs. That would be a huge boon to CCR, but it would also open up an entire set of doctors that could support upload to Google Health. This could definitely be a nice differentiator from Microsoft Health Vault which can’t do this either (unless it’s been added since I looked).

If Google Health decides to create their own standard for a clinic to be able to upload to Google Health they are crazy. Doctors have almost no motivation to support Google’s standard for uploading medical records. I’m not sure many EMR companies will support it either. I can see a few of them do it as a PR move, but I’d be very surprised if many of them bit on this. Doctors don’t buy EMR software because their patients can get their record out easier. It just doesn’t make business sense for EMRs or doctors to really do any sort of uploading like this to Google Health.

Of course the good thing for this all is that having another big player like Google interested in helping the healthcare system with some Health 2.0 solutions is great by me.

You can see my previous coverage of Google Health and also the Google Health Co-op.

Update: Here’s a screen shot of what Google Health could look like.

Update 2: What CEO of Google Eric Schmidt said about Google Health at HIMSS08.

As I pointed out in my previous post on patients filling out forms electronically, it is absolutely essential that your EMR software supports a robust set of preferences for determining which forms a patient should fill out.

Let’s take three example forms to illustrate most of the needed options: HIPAA privacy form, Health History form, Consent for Pap Smear. All of these forms need to be filled out in different intervals.

HIPAA Privacy Form
I think that in most cases, the HIPAA privacy form is something that just has to be filled out one time. Once I’ve filled it out, then I don’t want to have to ever see that form again. What does this mean for the EMR self check in kiosk? That means the computer has to check my account and know if that form has been filled out already or not. Easy enough right. I check in for my appointment, the EMR checks to see if I’ve filled out a privacy form and presents the form to me if one doesn’t exist. No sweat…or is it.

Of course, you can’t forget about the case where the government decides to change HIPAA laws and so now you have to change your HIPAA privacy forms. Let’s assume you change this form on January 1, 2007. This now means that your EMR self check in kiosk needs to now provide the new HIPAA privacy form to anyone who has not filled one out since January 1, 2007. Can this be done? Of course, and it really isn’t that hard. However, it’s an important difference that must be planned for.

Health History Form
How often do you make your patients fill out a health history form? Some may only do it once and then never ask again. If that’s the case, then you can see my comments above on HIPAA privacy form. In our clinic (and I think most others), a health history form should be filled out every year [Emphasis Added]. My clinicians tell me it’s just good practice to get the history if it’s been more than a year, because you never know what else might have happened to them or their family in that time. Is this really possible with a paper chart? Not very easily. However, with a computer it’s no problem.

When a patient checks in for the appointment, the EMR self check in kiosk checks the patient’s notes for the last time they filled out the form called “Health History.” If the form is more than a year old, then the patient is prompted to fill out a new health history form. Of course, we’ve previously set a preference that the Health History form should have be filled out every year. Again, it’s not rocket science, but an important difference from the HIPAA privacy form.

Consent for Pap Smear
This form is even more difficult. Unless of course your EMR is like ours and requires you to use specific appointment reasons when scheduling an appointment. When scheduling an appointment our front desk will choose appointment reasons like Pap Smear, Wart Removal, etc. This makes it easy for the EMR self check in kiosk to quickly check the reason for the patient visit and require patients to fill out forms like the Consent for Pap Smear.

A few other points of note:

Minors: I could easily see an EMR self check in kiosk determining a patient’s age and displaying special minor consent forms for those that are under 18. We’ve solved this problem using conditional questions on our forms which I think I’ll leave for a future post if people are interested. Minors is another good reason to capture the electronic signature as opposed to just using some sort of individually identified login for a signature.

The Unseen Procedure: Often you won’t know if a patient needs to fill out a consent for treatment form until after they’ve seen the doctor. This is obviously a problem since they can’t just fill this form out when they check in for their appointment. We’re still working through this problem, but we’re either going to go with scanning a paper form or possibly some sort of portable workstation with signature pad. I sure wish that UMPC’s were a little farther along. I’ll let you know how it turns out. This could also apply to forms like birth control and the unplanned pap smear.

One thing that’s important to understand is just because you could sign the form electronically doesn’t mean that it’s always beneficial. Does it really matter if you have your consent for treatment or HIPAA privacy form in your EMR immediately? It’s certainly nice, but it’s not like someone’s going to go looking for it in the EMR the next day to see what was done. The EMR notes contain the time sensitive information. As long as it’s eventually scanned into the EMR, then some forms can wait. Of course, don’t forget to weigh the cost of scanning to the cost of signing it electronically.

In the end, there are a bunch of business and operational decisions that are required to make using an EMR self check in kiosk work properly.

I’m still seriously considering my idea to create a clinical website wrapped in some sort of content management system. I think it’s a scalable idea that would only cost me the cost of designing a new skin/theme/look and feel for the clinic. Next week I’m going to try and make time to visit the doctor’s office that I think will fund the development of the product. Then, I’ll use that product to roll it out to other doctor’s offices.

While thinking about a clinical website for a doctor’s office I started wondering why a doctor might want a website for their clinic. Here’s just a few of the things off the top of my head.

• Market their clinic
• List their products and services
• Show staff information
• Show clinic hours
• Contact information for their clinic
• Link to their Patient Health Record (PHR)
• Provide clinic announcements
• List Health Education materials
• Promote their clinical research

I think the most powerful tool could be marketing their clinic. With the right combination of keywords and an integrated blog where you post local news items, you could find a lot of referrals. I think this could also be true for those doctors who like to sell elective procedures that have high profit margins.

Is there anything I’m missing about what a clinical website could offer a doctor’s office? I expect there are probably a number of them that I haven’t considered.

Today I ran across what I considered a very new term for me: Biofeedback Here’s a definition and description of biofeedback I found:

What is Biofeedback?

Biofeedback is a learning process in which people are taught to improve their health and performance by observing signals generated by their own bodies. It is scientifically based and validated by studies and clinical practice. It is a highly effective way to control stress, realize true relaxation and help achieve important personal goals.

Fear, over-eating, smoking, anxiety and other problems are actually linked to, or aggravated by, stress. For some, stress is a stimulant to effective action, but for others it’s a barrier to self-fulfillment. The secret is knowing your reaction to stress, and using this new awareness as a springboard to a life in control. A life where you can release the powers of the mind for greater achievement and better health.

Biofeedback is the widely-used and medically-accepted technique for teaching us to control stress, achieve relaxation, and channel talents and energies toward realizing our full potential. Our home biofeedback devices make you aware of your unconscious “involuntary” physical reactions to stress – “feeding back” subtle changes in stress levels. You’ll be able to hear or see changes in your stress level!

Even more interesting was a list of biofeedback devices that you can purchase:

Skin resistance biofeedback (GSR Galvanic Skin Response) is a measure of how relaxed you are, which changes based on your overall mood and emotions.

A sensor is placed on your hand, you hear a tone that increases in pitch when your emotions or mood becomes more tense, and decreases when you are relaxing.

Muscle tension biofeedback measures how tight a particular muscle is. Relaxing your forehead can help reduce headaches, release jaw tension, and upper shoulder tightness. You wear a pair of headphones with a band containing sensors that goes across your forehead. When the muscles in your forehead let go, then the tone that you are listening to decreases.

Brainwave biofeedback measures the quality of your brainwaves. Improving the quality of your brainwaves helps people with learning and concentration, reduce mental clutter, reach deeper states of relaxation faster, and to improve the quality of sleep.

Two electrodes are placed on your scalp. Using a computer interface, you can see your brainwaves on the screen, which appear as wavy lines, much like ocean waves. When the waves are close together, it means that you are alert. When they are further apart (slower), that means you are relaxing into deeper states of alpha, or creative visualization (theta).

When you see irregular waves, the quality of that particular brainwave state is not very good. When the waves become smooth and regular, you are able to sustain focus within that particular brainwave state.

Heart Rate Variability biofeedback measures how your heart responds to emotional, mental, and physical stresses, and its ability to bounce back to a relaxed and better functioning state. It helps for general relaxation, and cardio vascular distress.

You wear a finger sensor, and a computer interface allows you to see your heart rhythms on the screen, which appear like ocean waves, or lines that move up and down. Irregular, ever-changing waves mean that things easily upset you, whereas smooth waves mean that you are able to stay calm in stressful situations.

Skin temperature biofeedback measures the amount of blood flow beneath the skin. The warmer the temperature, the greater the degree of relaxation in that area which improves circulation for healing.

I find the science of it all quite interesting. I’m interested in hearing people’s opinions on biofeedback. How is it accepted in the medical community? Would it be beneficial to have it integrated with an EMR system. Then, you could track a person’s change in stress level for example. I think this could be espescially intrigueing in a counseling center setting. Integrated with an EMR, I think if the biofeedback works you could get some really interesting data on how a client with stress in their life improves their stress level over time. Could be very interesting.

Can you believe that real doctors will answer your questions unpaid? The concept still kind of floors me, but when you look at their website you can see how it works. I’ve considered making a website like this before because I think I’m benefitted greatly by my access to doctors who I work with who can answer my detailed questions. My family doctor does his job, but when you get home you always have 2 or 3 more questions that you forgot to ask your primary care physician. This free service from OurHealthNetwork.com (http://www.OurHealthNetwork.com/) might just be the solution for many people interested in getting more information from an actual doctor.

Here’s a description of their service:

For millions of Americans who do not have health insurance, seeing a doctor is not an option. However one unique Web site allows visitors to ask its board-certified physicians questions - absolutely free. Since 1999 OurHealthNetwork.com (http://www.OurHealthNetwork.com) has provided the public with accurate and up-to-date information about a variety of medical conditions. This information includes causes, symptoms, and self-help treatments that are written in terms that the general public can understand

OurHealthNetwork.com is a “network” of specialty-trained physicans who have joined together to create Web sites that furnish information about each of their specialties. Each Web site covers a specialist’s field, and all of the information on the site is written and maintained by that physician.

“What makes these sites unique is the fact that the doctors will answer questions that are submitted to them through their Web sites, free of charge,” said Dr. Lowell Weil, Jr., a medical director of OurHealthNetwork.com. “Of course the doctors cannot make diagnoses, but they can clarify an individual’s medical problem, answering that person’s specific questions. Our goal is to offer people in pain accurate medical information and peace of mind.” OurHealthNetwork.com’s doctors have personally responded to tens of thousands of questions every year since 1999. Another unique feature of OurHealthNetwork.com is the fact that it does not allow advertising on any of its sites. This permits its physicians to provide truly unbiased information. “We do not need to tailor our information to please ‘Corporate America,’” Dr. Weil, Jr. added. “Having no ads or pop-up windows helps to keep our Web sites from being cluttered, and allows for easy and hassle-free navigation.”

OurHealthNetwork.com finances its efforts by allowing visitors to purchase the exact same products its doctors recommend and use in their private practices. Visitors benefit from purchasing these products through the physician’s Web site because they get the correct medical-grade products that they need at discounted prices.

But Dr. Paul R. Kasdan, the network’s founder, emphasized that visitors do not need to purchase anything in order to use OurHealthNetwork.com’s informational services or to have their questions answered. “Purchasing products is just another convenience we offer the public.”

Millions of visitors from every U.S. state and more than 30 different countries around the world now turn to OurHealthNetwork.com every year. The specialty Web sites that are currently available include arthritis; the back; hand, wrist, and elbow; the knee; and the foot and ankle. According to Dr. Kasdan, “New specialty sites are added when we find a specialist who is dedicated to practicing medicine ‘the old fashion way’ - helping individuals in need and not worrying about a fee for their service.”

There website also seems like a good source of information for those doctors interested in linking their main website to other online medical resources. I personally took a look at the carpal tunnel syndrome page since I think I’m headed down that road since I spend so much time on the computer. Some good information.

I also wonder how many doctors should start doing something like this in their own web portal. Patients would love it. It could be integrated with your EMR and provide a great service to patients. Maybe OurHealthNetwork.com (http://www.OurHealthNetwork.com/) could provide an affiliate program to doctors who want to integrate OurHealthNetwork into their own patient portal. This would give doctors a funding mechanism for answering questions online while also increasing the knowledgebase of OurHealthNetwork.com (http://www.OurHealthNetwork.com/).

I’ve recently been working with a doctor who is starting a brand new office in May. He has asked for some help in selecting an EMR, choosing computer hardware and he even mentioned creating a website for his new clinic. You’ll be seeing the results of my labors posted in my EMR Implementation Ideas and EMR Features which has been transgressed since I started my EMR and HIPAA blog.

I’ve created a lot of different websites in the past. However, I wasn’t sure what I should include in a new clinical website. Sure, I could put the basic hours, contact us, about us information. I also know there are a lot of things that could be done with a patient health portal. However, that really depends on which EMR is chosen and not what I was asked to build.

I found a post that talks a little about what could be done with a clinical website:

A good website can be a great benefit to your practice and deserves consideration. Your practice’s website, if constructed carefully, can bring you operational efficiencies, financial gains and improvements in quality of care and documentation without the high cost and difficulty of transition that EMRs involve. If the physicians in your practice are technology-shy, starting with an interactive website can help them become comfortable with IT.

Many physicians have a limited idea of the value of a practice website. They think of it as a resource for information about the practice such as locations, physicians, services that you provide, and contact information. A website that contains this important information is a good start. By adding HIPAA-compliant interactive features that allow patients to communicate directly with your practice, you can do even more. Examples of such features are pre-registration pages that collect patient demographic information prior to a visit and verify insurance information prior to the appointment, features that allow existing patients to request appointments and/or prescription renewals, on-line bill paying, and provision of on-line advice to existing patients.

This definitely points to the need of a patient portal, but it looks like there is definitely some value in a clinical website. I think the thing that this post missed was a doctor’s blog on healthy living and links to other patient education that would be beneficial. I think this would definitely set you apart form other doctors in the area.