Using EHRs to eliminate rather than create health disparities for LGBTQ people: Landmark decision by U.S. DHHS

Via: Landmark Decision By Dept. of Health and Human Services Will Reduce Health Disparities Experienced By LGBT People | Fenway Focus (@FenwayHealth)

The finality in the way the rule is written reminds me of the R v North West Lancashire Health Authority Decision in 1999: “Appeals dismissed. Permission to to appeal to House of Lords Refused.”

That decision quashed forever the UK’s National Health Service policy of not covering transition-related care for its transgender or gender non-conforming residents.

When I visited Charing Cross, the world’s longest running gender identity clinic, in London in 2013, all of the medical records had to be managed on paper because their EHR systems were incapable of managing gender identity successfully and within policy.

This decision is pretty big one too, for the U.S. Health System, and one that might ultimately help our colleagues in the NHS as well.

The new rules released October 6 by the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator of Health Information Technology (ONC) will require EHR systems certified under Stage 3 of Meaningful Use to allow users to record, change, and access structured data on sexual orientation and gender identity.

And here’s what the final rule says:

We thank commenters for their feedback. Given this feedback, the clinical relevance of capturing SO/GI, and the readiness of the values and vocabulary codes for representing this information in a structured way, we require that Health IT Modules enable a user to record, change, and access SO/GI to be certified to the 2015 Edition “demographics” certification criterion. By doing so, SO/GI is now included in the 2015 Edition Base EHR definition. The 2015 Edition Base EHR definition is part of the CEHRT definition under the EHR Incentive Programs. Therefore, providers participating in the EHR Incentive Programs will need to have certified health IT with the capability to capture SO/GI to meet the CEHRT definition in 2018 and subsequent years.

I was at the convening mentioned in the Fenway Article and wrote about it in this blog post: Sexual Orientation and Gender Identity Data in EHRs, convening at Fenway Health, it matters to all patients, where we took this lovely photograph:

Sexual Orientation and Gender Identity Collection in EHRs Convening at Fenway Health 57914
Sexual Orientation and Gender Identity Collection in EHRs Convening at Fenway Health 57914 (View on Flickr.com)

Even though I was there, I am not responsible for making this happen. There’s the Do Ask, Do Tell Project Team, supported by the Robert Wood Johnson Foundation (@RWJF). I’m thinking Kellan Baker (@KellanEBaker), Harvey Makadon, MD (@HMakadon), Sean Cahill, PhD. And many others (please add their names in the comments) who deserve your thanks.

Even though I didn’t make this happen, I and millions of other people are the beneficiaries. This work will create a world where electronic health record systems work for us, to eliminate rather than create disparities. Thank you!

Doctors, EHRs, and the Patient relationship on the Kojo Nnamdi Show, Washington, DC USA

It is the decade of the patient, when the local (Washington, DC) affiliate (@Wamu885) hosts a conversation about how electronic health records are affecting the relationship between patients and physicians (You, Your Doctor And A Computer: How Technology Impacts Personal Health Care | The Kojo Nnamdi Show).

There was a time when I would come to Washington, DC, and other physicians would say things to me like, “isn’t a patient e-mailing their doctor kind of like spam?”

I was joined by 3 (superstar) physicians:

  • William Yasnoff, MD, PhD, Managing Partner at National Health Information Infrastructure (NHII) Advisors; CEO and President at Health Record Banking Alliance
  • Nareesa A. Mohammed-Rajput, MD, Internal Medicine Physician and Physician Lead for Electronic Medical Records, Johns Hopkins Healthcare
  • Alice L. Fuisz, MD, Internal Medicine Physician, Washington Internist Group (DC); Governor, American College of Physicians, DC Chapter

as Nareesa Mohammed-Rajput, MD (@nmohamme) aptly stated, “across the spectrum from health care.” And guess what, we all want to perform well for our patients, which in 2013 includes using the best technology. The art, which is what the show was about, is making it work for our patients. The comments of the listeners confirmed that there’s optimism, and also some work to do.

You can view the transcript here, or if you are more about the audio, you can listen to the broadcast here.

I also personally enjoy being in a room with other doctors who like taking pictures – they’re the ones that celebrate the human spirit 🙂

UC Davis Health asks LGBT patients to share info for tailored care

UC Davis Health asks LGBT patients to share info for tailored care – Business – The Sacramento Bee.

There’s a groundswell of concern in the medical community that lack of sexual orientation and gender identity information might be impacting care of lesbian, gay, bisexual and transgender patients.The UC Davis Health System responded to those concerns Thursday, saying it will become the first academic health system in the nation to incorporate that information as standard demographic elements within the electronic health records of its patients.

As I mentioned previously in this post (see: Now Reading: Electronic medical records and the transgender patient – to eliminate, not create, disparities | Ted Eytan, MD), there is work to be done to improve electronic health records’ abilities for vulnerable populations, including people who are trans. Nice to see UCDavis (@UCDavis) move ahead on this work.

For more information, you can access Ed Callihan, MD’s presentation to the Intitute of Medicine here.

Now Reading: Electronic medical records and the transgender patient – to eliminate, not create, disparities

WPATH recommends1—in concert with policy statements from the American Medical Association,2 the American Psychiatric Association,3 the American Psychological Association,4 the American College of Obstetricians and Gynecologists,5 and the Center of Excellence for Transgender Health at the University of California, San Francisco6—that the healthcare needs of transgender people should be openly and properly addressed, at the same level of quality and thoroughness as is afforded to any other person.

This just published paper (unfortunately behind a paywall, but(no longer behind a paywall, updated 8/11/14) you can access a summarized version at the transhealth.ucsf.edu website) explodes an inaccurate tenet within electronic health record systems – that a person’s sex and gender are tied together, and in turn fully inform a person’s medical destiny. This is not the case for a small percentage of patients.

It is recognized that the overwhelming majority of patients are not transgender, which has led to implementation of a binary male/female oriented system across multiple platforms such as EHR systems, billing and coding systems, and laboratory systems; however, this structure inhibits the collection of accurate medical information, and therefore such systems should be modified.

The paper describes a recommended two-step process to collect two pieces of information, gender identity and sex assigned at birth, that is already in use at the CDC. In addition, there are recommendations for recording preferred pronouns, common treatments and procedures, and status of a person’s transition and anatomy. In 2010 The Institute of Medicine recommended that gender identity be accurately collected in electronic health records and be part of meaningful use.

The Working Group producing the recommendations is EHR experienced and the ideas make sense in terms of what is doable in an electronic health record. The alternative today is not very healthful for this population – having to change the “sex” field back and forth to order necessary preventive exams, or to not have ready access to transition history or preferred pronouns in establishing a relationship.

As WPATH guidelines become followed more regularly and medically necessary services are covered and performed across health care (37 Universities and counting), the health of trans people will be more and more about ongoing preventive care, just like the population at large.

Why do this?

A recent non-peer reviewed report on transgender discrimination showed some 28% of respondents had experienced harassment in a clinic setting and that 2% had been subject to physical abuse.12

Electronic Health Records are for health, and should not codify or indirectly create misunderstanding in the clinical setting. The results can be devastating. Fortunately, health information technology can be used to eliminate disparities in health instead of creating them.

I love hearing about great things HIT “does” for people rather than what HIT “is,” don’t you? 🙂

Visit to a very paperless practice: Michael West, MD PhD – Washington Endocrine Clinic, Washington DC USA

I recently reconnected with Emily Peters (@PFPresscenter), who I asked “How is that Practice Fusion EHR doing?” (she’s the Senior Director of Communications).

I seem to associate Practice Fusion with San Francisco, where the company is based, but I realize that electronic health records, especially web based ones, know no bounds, so I asked if I could shadow in a practice local to me, in Washington, DC. And so I was connected to Michael West, MD, PhD, at The Washington Endocrine Clinic.

If I can walk to it, I’ll do it. So I did it.

Michael West, MD, PhD – click to enlarge

As the name of his practice implies, Michael is an endocrinologist and his practice has been open since 2009. Like so many physicians of his generation, he sought to enter practice without paper. He began with an electronic health record that was physically served within his practice, and then like so many humans in general, sought a system that didn’t require him to be a server technician at the same time he was building his professional career.

Three months in, then, he switched to an electronic health record that’s web-based. The advantage, especially for a physician building a practice, is to not have to worry about maintenance and upkeep of a software package, benefit from the improvements generated by a community of health care practitioners, and also to allow patients to access their data securely.

Michael has a good cadence to his use of the electronic health record. Information about the patients he’s seeing often comes from outside the practice, so it is scanned in or received electronically. What I thought was interesting is that much of the information comes in and goes out via secure electronic fax. In other words, there’s no machine printing out paper on Michael’s end but the protocol is the fax protocol.

Staff at the medical office then downloads the faxed PDFs, renames them, and uploads them to the correct patient file. (“As much as I wish this as an automatic process, we’re not there yet”) The good news is that the information is readable, the not as good news is that the information is not discrete data. There’s now direct lab interfaces to the system, which does populate the medical record.

The result is as the title of this post implies – this is a very paperless practice. I didn’t see much paper moving around, and the desk you see in the photograph pretty much looked like that during the entire session. To my eyes, the patients didn’t miss a beat, I didn’t hear complaints about the use of the electronic health record. In fact one patient said that they like to keep track of their lab values,  which prompted Michael to offer secure access to the information via the patient portal. Again, not a big deal, and this access is seen as a time saver. We’ve come a long way.

The electronic health record itself is steadily improving. I/we noticed there is some functionality that’s not present in this system that is present in other contemporary systems (yet). At the same time, there’s an ease of use and upkeep that’s extremely valuable in this situation.

I asked Michael about two things. First, the fact that this electronic health record is offered to physicians without cost, but with advertising. Second, about the sharing of lab result and pathology result information with patients. Here’s what he told me.

The ads are not really that bothersome.  They are in the periphery and so they don’t get in the way of me viewing the patient’s chart.  Regarding me being influenced to write prescriptions for those drugs, I generally have written those drugs even without being prompted by an advertisement in the EHR, and so I can’t say they have had much impact, if any, on my prescribing behavior.

and

Regarding patients accessing their lab results, I generally don’t release a specific set of results for viewing without meeting the patient in my office to discuss these in person first.  Pathology results are a different type of result.  Because this is unstructured data at the moment, I cannot release these to patients by using the personal health record (PHR).  Therefore they are either printed or emailed.  If emailing them, then the patient needs to request this and understand that most email is not HIPAA compliant.  If they understand that limitation and are comfortable with that, then I can email it to them.  I would never email patients a pathology report that was not clearly benign unless we had discussed this first in my office face-to-face.

Building a practice takes a lot of work, and I respect a physician who undertakes this challenge, especially today. To arrive at a state of good health, there needs to be enough patient volume and systems that allow people to feel well taken care of. On the particular day I shadowed Michael, he was seeing patients in follow-up, although he obviously does new consults and procedures. As a specialist, he also needs to be responsive to referring physicians, who expect to be notified about his findings in a professional and understandable way.

It’s good for physicians who make this practice choice (still the dominant form of medical practice today) to have the option to coordinate care using electronic health records. Also good to see a new generation of physicians embracing technology in our nation’s capital. Thanks again for having me, Michael, and Emily for the referral!

Why Dont More Hospitals Use Electronic Health Records? – Businessweek

Why Dont More Hospitals Use Electronic Health Records? – Businessweek.

When people in health care talk about the promise of digital medical records, they often point to Kaiser Permanente. The Epic system is integral to America’s largest nonprofit health maintenance organization. The Oakland-based operation’s doctors use it for everything from scheduling appointments to ordering lab results. Kaiser’s members seem to like it, too. They can log into the system, check their medical records, and correspond with doctors via Epic’s secure e-mail system

As of March, 2012, 1.2 million emails are being sent to physicians every month, as of May, 17 % of visits to kp.org are coming from mobile device, where people can get their test results, email their doctors, and make, view, cancel appointments.

This is what an EHR does for patients, in addition to what it does for nurses and doctors.

Video of Booz Allen Hamilton’s Electronic Health Records 2.0 | Expert Voices

Electronic Health Records 2.0 | Expert Voices Speaker Series.

I was honored to be on this panel with Peter Basch, MD, L. Gordon Moore, MD, and Peter Levin (moderated by Susan Penfield – I am a fan!) where I happily pronounced that this will be the decade of the patient when it comes to EHRs (why not?). I don’t know about the expert part, but I feel good about the patient part. Video is below, enjoy

Now Reading: About today’s Health Affairs study, HIT, EHRs, and impact on test ordering

This study, being released to the public at the exact same time of this blog post, should generate healthy discussion about whether health information technology, fully implemented, is going to deliver on one of the biggest promises made: reduced ordering of unnecessary tests.

This paper should be read carefully. It is very well done AND it does not answer that exact question – it wasn’t intended to, read on.

It answers the question about the era of electronic access to test results and images by physicians and what that has done to ordering of lab and imaging tests across a national sample of office visits. It is not focused on a single type of organization, it uses a nationally recognized survey tool (NAMCS) and is written by nationally recognized authors, from a pretty good journal :).

I got to speak with lead author, Danny McCormick, MD, about his motivation to do the study and to see if I understood the implications correctly. Danny’s currently a physician at Cambridge Health Alliance (who I so enjoyed visiting previously), on the faculty of Harvard Medical School.  He related his experience seeing the predictions of cost savings by the now-infamous RAND study in 2005 while he was serving under Sen. Edward Kennedy in Washington, DC, on an RWJF Fellowship. I remember that study, too, and its rosy predictions.

Danny wondered if test ordering might stay the same (and not decrease as predicted by RAND), and not only found that they stayed the same, but they increased proportionally for patient visits at practices where electronic test results and images were available.

Exhibit 2: A different odds ratio for visits in integrated care/HMO practices. Courtesy of Health Affairs.

Integrated care and Community Health Center care bucks the trend toward more tests

I asked him about a finding of interest to me, which is that in the models there are some exceptions, most notably for visits that occurred in the “HMO Office” setting, where there was statistically significantly LESS ordering of imaging compared to private medical offices.  Same is true for visits that occurred in Community Health Centers. Again, care must be taken in interpretation – across visits in all places, 40 – 45% greater likelihood that imaging tests were ordered when results/images were available electronically, I am showing the part of the model that compares different practice settings within that overall result.

To the left is the part of the table, Exhibit 2, that shows this difference (reproduction of just this part permitted by Health Affairs). I recommend reviewing this table, and also Exhibit 3 in the same article, which shows the same analyses of just MRI, CT, and PET, where the HMO Office and Community Health Center visits do not show any difference from their private office peers.

Excerpt of NAMCS survey tool, from CDC website

The reason I equate the “HMO Office” category with “Integrated care” is because of the way the NAMCS survey is designed. If you look at it, this is clearly the category for physicians practicing at Kaiser Permanente – it says Kaiser Permanente right there on the survey.

Danny cautioned me, appropriately, that the numbers of visits in this setting were small compared to the other settings (paralleling the number of such visits in the United States). The statistical significance holds, but since this is a big picture study, we don’t know what’s going on in this setting compared to others, exactly, just that there’s less association with test ordering.

Lots of caveats

Here’s my list, feel free to add yours in the comments:

  • This is based on electronic access to test results not EHR use. Therefore it doesn’t really test education/alerts/prompts (aka “clinical decision support”)
  • This is based on 2008 data, which is an eternity in EHR terms – even if an EHR was in place, it’s unlikely it had good decision support and would have modulated physician ordering habits
  • If an EHR was present in the practice, it didn’t significantly alter the results (they did this analysis too).
  • We don’t know that more tests are a bad thing in all of these cases. For example, these systems may alert physicians to order preventive tests, like mammograms (see great example below). In the area of advanced imaging, there is a common problem of follow-up exams not being done. It’s possible that seeing the results of the last test that said,  “need follow-up exam,” would cause necessary care to be performed.

HIT + Patient and Family Access + Leadership = SUCCESS

This is a helpful, well done study by a talented group of researchers.

I never banked on the predictions of the RAND researchers, because they did not include a key ingredient in the recipe – leadership. HIT + Leadership = success

The most important power of health information technology is what it does for patients and how it connects them to their health care. With an EHR, there’s an efficient way for patients and families to understand what’s going in their care and change the conversation from being recipients “in front of the counter” to understanding and helping to fix what’s behind the counter. It’s revolutionary in that regard.

With regard to leadership, I’ve shown Mary Gonzales’ story on here before, here’s a new one, from the Kaiser Permanente Care Stories Blog, about what happened when Dale Gordon went in for a swollen knee, a lab test was ordered, and his life was saved. This requires the use of technology, the leadership to make a difference in care using the tool, and the work to integrate it into a system at all points for our patients. So not more tests, not less tests, the right amount of tests, which is now possible – check it out:

#greenhealthcare part 4: Health Information Technology helps health care be green

This is part 4 in a series on health care and climate change, or “Prevention is the new health information technology,” based on my learning prior to ACPM2012. You can see all the posts here.

A goal of health information technology may be prevention, however, health information technology can support prevention by making health care more green. A very useful paper: Turley M, Porter C, Garrido T, et al. Use of electronic health records can improve the health care industry’s environmental footprint. Health affairs (Project Hope). 2011;30(5):938-46. was published in HealthAffairs last year which examines the ability of health IT to replace paper (in charts), water and toxic chemicals (in imaging), reduce energy use (transportation to office visits) and reduce waste (imaging plastics). In a comprehensive way, it also included energy use increases from computers, and waste increases from plastics used in personal computers.

And…the news is good, with a huge caveat. The carbon sequestration savings estimated nationally at 1.7 Megatons of CO2, or the amount of CO2 sequestered by 362,473 acres of pine or fir forests.

The caveat is that health information technology must reduce transportation of people to and from health care. If it does not, then the carbon savings becomes a carbon spend..

Therefore health information technology by itself is not enough. Leadership is required too. This is one of many areas where the conversation about climate change and health is a lot like the conversation about patient empowerment, and in this case, it’s about patient access to online records. The slides below the carbon saving calculation show what Kaiser Permanente has done. There are now 3.8 million members (59% of the eligible population) using kp.org, with steady use – almost 11 million messages sent by members from January – October, 2011. The slide below it puts it in focus around the experience – new medical offices are built:

  • Without medical records rooms
  • Without X-ray processing or file rooms
  • With smaller foot prints, and more importantly,
  • Less parking lots, the most toxic structure you can build

Expert Voices Broadcast : Electronic Health Records 2.0: What Does the Future Hold? (I’ll be there, Walking Gallery style)

Expert Voices Event Registration | Booz Allen Hamilton – As part of the work that brought together yesterday’s California Healthcare Publication on EHRs (See: Now Reading: What’s Ahead for EHRs: Experts Weigh in), Federal News Radio and presenting sponsor Booz Allen Hamilton will conduct a live webcast who’s title is the title of this post.

Click on the link above to register. The date is February 16, 2012, 10:00 – 11:30 am Eastern Time, and we’ll be live from Washington, DC.

Special treat is moderation by Susan Penfield, who I met during as part of her service on the board of HealthyWomen (whom I got to visit in 2010).

If I can walk to it, I’ll do it, I’m going to wear my Walking Gallery jacket, and as your special friend if there’s anything you think important that should be said in this discussion post in the comments.

I’m representing Kaiser Permanente so this is a bit of a balancing act, because in the end I’m really not the expert, the 3,745,000 people who use Kaiser Permanente’s personal health record and the 8,900,000 people who are cared for by 16,000 physicians and 43,000 RN’s using Kaiser Permanente’s electronic health record are.