Electronic Health Record Systems: Epic, Cerner, McKesson

If we were to base our analysis on Modern Healthcare’s findings, the industry’s “leading weekly publication on healthcare business and policy news, research and information,” then Cerner and Epic are the leaders in the current EHR market. Which of the two is better will depend on the setup of the health organization. Modern Healthcare says if it is a complete EHR system, then Epic is the better choice. However, for modular EHR system, Cerner is the leader in the market, according to Modern Healtcare’s review using Centers for Medicare & Medicaid Services (CMS) data from 2011 to early 2014, which ihealthbeat.org published just last month (May 5, 2014), in an article posted by entitled “Epic, Cerner Top Vendors for Hospital Meaningful Use Incentives.”  (CALIFORNIA HEALTHCARE FOUNDATION, 2014).

In the same article, ihealthbeat.org says Epic users received almost 20 percent of Medicare payments for those who have implemented a complete EHR system, while Cerner ranked first with almost 26% for modular EHR system users in the four-year period. But since facilities run by independent medical practitioners use of a variety of EMRs on their respective practices, ihealthbeat.org says then Cerner may be considered as the nation’s Number 1 choice for an EHR system, apparently because independent medical practitioners don't want to spend a ton of money in a hospital that has an EHR system where they only serve as independent admitters.

As far as the other leading software McKesson is concerned, meanwhile, a website appropriately named ehr-software.findthebest.com found it very much inferior compared to Epic in Practice Size, Platforms, Feature EHR/EMR and Practice Management categories (ehr-software, 2014). Apparently, McKesson’s “fault” was having two systems initially – Horizon and Paragon – until it decided to make the latter their sole platform for its EHR system. In the same ihealthbeat.org article, McKesson ranked fourth in the modular EHR category, and was even behind Meditech, which, consistently placed second behind Epic and Cerner in both complete and modular HER categories, therefore, another software that has penetrated the market with effective results.

While stiff competitors Epic and Cerner CCIT (Certification Commission for Health Information Technology) certified, McKesson is certified by Drummond Group. Both CCHIT and Drummond Group are ONC Authorized Testing and Certification Bodies assigned by the Office of the National Coordinator for Health IT. Although CCHIT has been around since 2006, Drummond is a trusted organization and serves the Fortune 500 companies. According to HealthIT.gov, Cerner's product's classification is Modular, while both Epic and McKesson have complete and modular EHR systems. Epic has among its meaningful use capabilities an integrated speech recognition system; telemedicine and guided medication reconciliation, barcoding, documentation reminders and apps for viewing test results, appointments and refills. Cerner also has CPOE, document imaging, medical devices for alerts, RxStation, smart pump integration, automated messaging, etc. McKesson also makes use of CPOE, has E-prescribing, automated diagnostic order entry, etc.

To break it down further, healthsystemCIO says Epic (was) the “only truly integrated and highly functional practice and hospital EMR” (Ciotti, 2011). The author, Vince Ciotti, said Cerner is probably “more functional on the hospital side” owing to the fact that the makers of Cerner – Judy & Co. – was a decade ahead of their competitors. This analysis, even though published back in April 2011, may still run true today because of the obvious fact that healthcare providers are still months – some maybe years – away from being fully EHR-ready amid a looming deadline for those providing care to Medicare and Medicaid patients.

Another online publication specializing in EHR, EHR Intelligence, says that Epic is an “intelligent choice” in the sense that clinicians are easily convinced to buy and adopt the product despite its hefty price. To give us an idea how much Epic could cost a hospital – much to the chagrin I’m sure of many a stakeholder – the 600+-bed Main Medical Center in Portland, Maine, was said to have spent a staggering $200 million in its Epic electronic health record implementation. (Miliard, 2013). It is worthy to note, however, that Healthcare IT News also states in the same article that despite the huge sum, the Epic EHR system was still problematic, and that Main Medical Center may spend more to iron whatever kinks the system is affecting the facility.

Speaking of costs, Open Health News says Duke University will pay $700 million for its health system. $700 million?! (Maduro, 2013). On a smaller scale, Open Health News reported that a 48-bed Bartlett Regional Hospital in Juneau, Alaska with a 12-bed Adult Behavioral Health Facility and a 16-bed Chemical Dependency Recovery Center ran into some financial problem after spending $7.37 million, plus an annual maintenance fee of $1.55 million. (No wonder, the EHR system implementation has been pushed up to the last days as provided in the new law.)

Tons of EMR softwares on the market

The beauty of a capitalist society like the U.S. is, is that anyone can compete in the open market. The same thing goes in the EMR industry, where more than a hundred software titles are available on the market depending on which ones are applicable to one's particular practice. According to EMR comparisons and reviews site Softwareadvice.com, the most popular EMRs, didn’t include the expensive Epic nor Cerner systems. Understandably because these softwares are for individual and small medical practices. The same site said the Top Ten are:  MediTouch, Benchmark Systems, Kareo, 2014 Waiting Room Solutions, Office Practicum, Medios HER, NueMD, Centricity, ChiroTouch and Electronic Medical Assistant by Modernizing Medicine. Other softwares also in the market are ECLIPSE, which is mostly tailored to physical therapists, ACOM Health RAPID for chiropractors, while Qualifacts CareLogic Enterprise is “designed specifically for mental and behavioral healthcare organizations.” (McCormack, 2014)

Of these software companies, Centricity is an interesting because it was created by General Electric, which – not only do they manufacture home appliances – produce jet engines. In my humble opinion, Centricity may be a potential software developer that can compete against Cerner and Epic if they so chooses with its billions from GE. Another common name in the top EHR software developers in the market is ADP with its AdvancedMD EHR and Practice Management Software. ADP of course is among the leading automated payroll maintenance organizations that thousands of companies subscribe to as it takes care of all money matters in employee payrolls, including tax deductions, Social Security contributions and other taxes.

Now, weather a flood of softwares will mean a reduction in price remains to be seen. The fact remains that with so many softwares in the market even for individual practice use may, however, negate the ideal vision of having an electronic health record system that can be read, translated and analyzed by the majority, if not all, health providers. In the end, what good will these do if a patient in critical condition will have to wait before they can be admitted and provided with medical care if the software used to collect their medical record is foreign in an emergency room or that the hospital uses a different system? Fortunately, while being a student, I have been presented with these actual problems medical organizations now face. Hopefully, by the time I am confronted with this reality and come up with the most feasible, cost-effective, practical but a more universally-accepted system. I guess there is merit to the phrase “socialized healthcare” after all.­­­

Bibliography

CALIFORNIA HEALTHCARE FOUNDATION. (2014, My 5). Epic, Cerner Top Vendors for Hospital Meaningful Use Incentives. ihealthbeat.org .
Ciotti, V. (2011, April 12). Health System CIO. Retrieved June 5, 2014, from healthsystemcio.com: http://healthsystemcio.com/2011/04/12/breaking-down-an-epic-versus-cerner-selection/
ehr-software. (2014). Find the Best. Retrieved June 5, 2014, from ehr-software.findthebest.com: http://ehr-software.findthebest.com/compare/70-408/Epic-Care-Ambulatory-EMR-vs-McKesson-Practice-Choice
Maduro, P. G. (2013, July 3). EHR Systems & Cost Transparency in the Healthcare Industry.
McCormack, M. (2014, June 6). Compare Electronic Health Record Software. Software Advice (Softwareadvice.com). Miliard, M. (2013, December 27). Healthcare IT News.

Why is There a Delay in the Implementation of ICD-10 Coding System

Since 2005, there have been proposals to implement The International Classification of Diseases, 10th Revision (ICD-10) coding system. However, for the 17th time, a Sustainable Growth Rate (SGR) patch fix − SGR is the "flawed" Medicare physician payment system that rewards doctors for the number of services rendered to patients rather than providing quality healthcare care − was approved by Congress to delay a cut in Medicare reimbursements, as it finds a way to eventually repeal SGR. Though totally unrelated to ICD-10 (SGR is totally a whole different animal) there was a provision in the latest patch fix that delayed the implementation of ICD-10 for another year (Kyle Murphy, 2014). Although, many in the established medical associations seem to express their dissatisfaction with the further delay of ICD-10, there may be a hidden but a more realistic reason why Congress, who are lawmakers and are no way medical experts except maybe for a few, had to delay its implementation. The silent majority – the actual medical practitioners who toil in their clinics tending to their patients while maintaining to operate a business (waiting times at clinics could be more than two hours!) – seems not prepared at all in implementing the ICD-10 Code.

Contrasting Views on the ICD-10 Delay

According to Dr. Kyle Murphy, who wrote the article “Senate passes one-year SGR patch, ICD-10 delay bill” as posted in the EHR Intelligence website, he said “It is still unclear how delaying the ICD-10 compliance deadline became part of Section 212 of this latest SGR fix. What is clear (however) is the lack of support for the delay by provider associations.” (Kyle Murphy, 2014). The same sentiment was expressed by the American Medical Association through President Ardis Dee Hoven, MD, who, Healtcare IT News Editor Tom Sullivan says in his article “AMA explains silence on ICD-10 delay” (April 1, 2014) that AMA “did not support the bill” which Hoven described as “a fiscally irresponsible pattern of congressional procrastination that has perpetuated Medicare’s fatally flawed sustainable growth rate formula.” (Sullivan, 2014). The same frustration has been vented after a poll by the American Health Information Management Association (AHIMA) during a recent summit on ICD-10 showed that 88 percent of the respondents were “disappointed by the ICD-10 delay” since almost half (42%) has already spent more than $1 million on its implementation. (Stratton, 2014).

A week later, however, on May 1, 2014, the same AHIMA group then “applauded” the announcement by the Centers for Medicare & Medicaid Services (CMS) of the “expected interim final rule with an Oct. 1, 2015 implementation date for ICD-10-CMS/PCS (AHIMA, 2014),” making it appear that the delay may be necessary after all. AHIMA even stated in the same announcement on its website as it urged “our members to ‘stay the course’ of preparing for implementation.” Note the word “preparing.” AHIMA also said, “We particularly want to reach out to the physician community and are prepared to field support training for small physician practices proposed by CMS.” Therefore, it seems clear that “small physician practices” are still preparing or about to train their staff, if not themselves, in adopting to ICD-10. A closer look at the preparations include AHIMA advises, telling practitioners to allot 6-9 months to “become an expert in applying ICD-10-CM codes” and to “practice using the codes each week before going live.” They are also being urged to identify a “physician champion” within their practice to be the ICD-10-CM resource person who office employees will rely upon, which means one doctor in the practice may have to set aside his medical duties in order to concentrate on learning and becoming an expert in ICD-10 code alone. (AHIMA, 2012). Although this advice was released in 2012, the recent action in Congress and that latest pronouncement by AHIMA on May 1, 2014 may portray a solid basis for the delay.


As discussed in class, the ICD-10 coding system is “much more detailed and specific” compared to ICD-9. Even AHIMA stated that “payors cannot pay claims fairly using ICD-9-CM since the classification system does not accurately reflect current technology and medical treatment” (AHIMA, 2014). Personally, I have seen and used the ICD-9 book for a short medical billing course that I took, but last week’s brief immersion to ICD-10 was a eye-opener in the sense that it seems ICD-10 is much more user-friendly.

Delay May Be A Political Move vs. Obamacare; Economic Reasons and Feasibility

Personally, the action by Congress may be more of politics because of fears that the Obamacare law will ruin the entire health industry, giving less priority to the implementation of ICD-10. The Republican Party has said time and again that the law will fail because employers can’t afford it, and that a socialized healthcare program is anti-business that will affect the insurance companies big time. Their attention is more attuned to repealing it. For sure, their constituents have also voiced their concerns on shifting to ICD-10 system at a time when they are still recovering  because many lost their jobs during the Great Recession and lost their health insurance while also dealing with the fact that the same Obamacare law requires them to upgrade their operations to “Meaningful Use” because of EHR or else lose their Medicare and Medicaid patients in the near future.

In another Healthcare IT News article: “ICD-10 delay upsets prepared vendors”, this time by Contributing Writer John Andres (May 1, 2014), he  writes that “While there is really no way of knowing how many providers are in a position to make the ICD-10 conversion” he also said that Mike Lovett, the executive vice president and general manager of software provider NextGen Healthcare “acknowledges that some providers are behind in gearing up for the ICD-10 shift.” Andres also writes in the same article that although they too were dismayed by the delay, Athena Health said “It is alarmingly clear that healthcare is operating in an environment where there is no penalty for not being able to keep pace with necessary steps and deadlines” as expressed by its Executive Vice President and COO Ed Park – a clear indication, or an admission if you will, that many in the health industry are lackadaisical in facing the challenges of redirecting their focus on a new but much more improved coding system. Andres concludes that “there is no doubt that others will appreciate the extra time” – my own Downey-based doctor friend included, who professes that he himself doesn’t even have a computer in his clinic – as stated by MedAssets COO Mike Nolte, whose company supplies both labor and management expertise. Nolte, Andres writes, said it clearly when Nolte said that “A one-year delay provides welcome breathing room for some organizations coping with ongoing financial pressures…including  − as I have suspected − complying with provisions of the Affordable Care Act and attestation for Stage 2 meaningful use” − as I’ve also stated − (Andres, 2014).

Bibliography

AHIMA. (2012). American Health Information Management Association. Retrieved May 15, 2014, from www.ahima.org: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049471.hcsp?dDocName=bok1_049471#Champion
AHIMA. (2014, May 1). American Health Information Management Association. Retrieved May 15, 2014, from www.ahima.org: http://www.ahima.org/topics/icd10
Andres, J. (2014, May 1). Healthcare IT News. Retrieved May 16, 2014, from www.healthcareitnews.com: http://www.healthcareitnews.com/news/icd-10-delay-upsets-prepared-vendors
Kyle Murphy, P. (2014, March 31). Senate passes one-year SGR patch, ICD-10 delay bill. EHR Intelligence .
Stratton, B. (2014, April 25). www.ahima.org, Online Press Release in PDF. Retrieved May 16, 2014, from American Health Information Management Association: http://www.ahima.org/~/media/AHIMA/Files/PR/N140425%20ICD-10%20Summit%20FINAL.ashx
Sullivan, T. (2014, April 1). AMA explains silence on ICD-10 delay. (T. Sullivan, Ed.) Healthcare IT News .

Need for Electronic Health Record as Response to Tragic Hurricane Katrina

For a person who was born in a tropical country and grew up experiencing some 20 typhoons a year (Haiyan, Washi and Ketsana are some of the destructive to have hit Asia), not to mention writing tragic stories while delivering relief goods to far flung areas when I was as a reporter for a daily newspaper, Katrina to me was a very upsetting event because America was supposed to easily cope with such a crisis.  Besides, isn’t the US of A that’s been helping the Philippines and other calamity-stricken countries in times like this?  

The days beginning August 29, 2005 could be one of America's worst, if not the worst, chapters in its modern history on natural disasters, not only because the deluge was unheard of but because of the racially-charged politics involved, personal hygiene of unimaginable proportions (because it happened in the US) and the time that it took the Bush administration to provide help to those affected.  And who could be far worse victims than the impoverished people of New Orleans, who could barely afford to live decently before and when Katrina hit. In an article entitled "Health Care In New Orleans Before And After Hurricane Katrina" published by the Maryland-based Health Affairs, it said that when the hurricane came “New Orleans had a largely poor and African American population with one of the nation’s highest uninsurance rates, and many relied on the Charity Hospital system for care” (Robin Rudowitz, 2014). 

Which brings to mind the very divisive issue of a government-run program like Obamacare to provide quality healthcare to everyone as opposed to letting private companies run the industry…as should be in a capitalist society.  But when it comes to US veterans or if it concerns those who are serving the country, hardly is there an argument on the full use of government resources. Providentially, the Hurricane Katrina tragedy may have proven that a nationally-coordinated plan – whether its healthcare or disaster response – works in a very efficient way. 

Despite Floods, Veterans Electronic Record Basically Intact

The floods that inundated New Orleans, other cities and neighboring states spared no one; homes and properties were submerged for days.  As discussed before, a lot of paper medical records were destroyed.  In today’s homework,  however, the “complete electronic clinical records” of US service veterans were immediately accessible. These were made possible by a rehosted VistA system and by the Consolidated Mail-Out Pharmacy – an automated prescription fulfillment system that processes outpatient prescriptions – although the latter was interrupted by the hurricane it remained online and was accessible. In fact, two weeks after the hurricane slammed the southern coast, “all of (veteran) patient data (from the affected states) was available nationwide within 7 hours (American Public Health Association, 2007).” Contrast this with the “non-VA evacuees” 200,000 of whom from the 1.3 million residents of New Orleans who had “chronic conditions needing ongoing management” but who in their “rush to evacuate, many left home without documents, medications, and other essentials (APHA: Katrina Evacuation, 2007)” Thus, in an article by Public Health Association, it said that “Responding clinicians were challenged with assessing unfamiliar and ill evacuees without the benefit of their medical charts (APHA: Katrina Evacuation, 2007).” Worse, it added, the consequences may still be affecting thousands of others but these could not be understandably monitored as people without records have spread to different places, meaning there were no succeeding statistics as to their current health status.  The article SUMMED UP the “stark contrast”: VA efforts to maintain appropriate and uninterrupted care were supported by nationwide  access to comprehensive electronic health records systems” as opposed to those who did not – who are the majority and were poor. (APHA: Katrina Evacuation, 2007).

Other facts:

After a month, or by the end of September, 2005, VA producers had accessed clinical data for 38%  of New Orleans VA patients;

Healthcare data were delivered to more than 2,300 users at more than 200 VA sites in 48 states and District of Columbia;

Before Katrina, New Orleans veterans had more than 75,000 prescriptions filled – right after Katrina, more than half or about 41,000 had their prescriptions immediately filled through a rehosted system;

Between August 29 and September 30, VistAWeb, a patient index and locator for veterans, logged 59,454 requests for Web pages containing clinical, etc. (VistAWeb, 2007).

Katrina Exposed Advantages and Need for Electronic Medical Record

Going back to my point, since Obamacare which provides for the “electronication” – for lack of a better word – of medical records, politics seem to be out-of-line when a national program for US servicemen and veterans are concerned.  While Republicans ironically oppose a national healthcare program, they are more than willing to extend assistance to the veterans, which as was shown in the Katrina experience, in a system whereby clinicians can access medical data of patients that turned out to be very much beneficial.  In an earlier class discussion on this topic, Katrina-affected children whose vaccination records were submitted to a nationalized system also proved its worth and is cost-effective, efficient, accurate, verifiable and obviously accessible.  In the case of veterans, who because of their age and injuries suffered from serving the country, accessibility to this important medical data was paramount or else their health conditions might have been largely compromised.  We all know that in disasters and tragedies such as the Hurricane Katrina event, as in any medical emergency, time is of the essence.  Not only are medical records important as to the health status of a person, especially a victim, they are now a requirement in employment, background checks, prevention of communicable diseases or epidemics, and most importantly, in research since demographics are very useful for this purpose. 

Urologist Neil Baum, MD, an assistant clinical professor at Tulane University School of Medical in New Orleans who quoted by Foxnews.com in an interview with WebMD, has said that “If the displaced patients left with their records in an electronic format, there would have been better continuity of care and fewer mistakes would be made.” After the storm, Baum who temporarily relocated to Austin, Texas, said he was able to treat his displaced, patients and “had access to some of my patients’ records over the Internet and that made communicating much easier.  I was able to get lab reports, X-rays and pathology reports and it made coordinating care in the patients’ new cities much easier.” Baum thus declared that “I am convinced now more than ever that patients should have portable access to medical records. (Mann, 2005)

A free enterprise is ideal and a market economy spurs development that create jobs.  However, just like the national defense, some sectors need to be nationalized like the healthcare system, in my opinion, for safety and security of all Americans, and for a quicker response in order to save one’s life.  In today’s world, where doctors can now diagnose a person halfway around the world through a smartphone or a tablet, it would be an irony if a child or an elderly in places like Katrina-affected areas will be left suffering, if not dying, because their medical record was lost to the flood. 

Bibliography

American Public Health Association. (2007, April). Use of Electronic Health Records in Disaster Response: The Experience of Department of. American Journal of Public Health , 6.

APHA: Katrina Evacuation. (2007). KATRINA AND THE EVACUATION OF NEW ORLEANS. American Journal of Public Health , 3.

Mann, D. (2005, September 23). Katrina Shows Need for Electronic Health Records, Online. (Fox News) Retrieved April 9, 2014, from www.foxnews.com: http://www.foxnews.com/story/2005/09/23/katrina-shows-need-for-electronic-health-records/

Robin Rudowitz, D. R. (2014). Health Care In New Orleans Before And After Hurricane Katrina.

VistAWeb. (2007, April). Use of Electronic Health Records in Disaster Response: The Experience of Department of. American Journal of Public Health , 4.

American Public Health Association. (2007, April). Use of Electronic Health Records in Disaster Response: The Experience of Department of. American Journal of Public Health , 6.

APHA: Katrina Evacuation. (2007). KATRINA AND THE EVACUATION OF NEW ORLEANS. American Journal of Public Health , 3.

Mann, D. (2005, September 23). Katrina Shows Need for Electronic Health Records, Online. (Fox News) Retrieved April 9, 2014, from www.foxnews.com: http://www.foxnews.com/story/2005/09/23/katrina-shows-need-for-electronic-health-records/

Robin Rudowitz, D. R. (2014). Health Care In New Orleans Before And After Hurricane Katrina.

VistAWeb. (2007, April). Use of Electronic Health Records in Disaster Response: The Experience of Department of. American Journal of Public Health , 4.

The Role of the Joint Commission in Providing Quality Healthcare

According to the American Hospital Association, there are 5,723 registered hospitals in the whole of United States, registered in the sense that these “hospitals that meet AHA’s criteria for registration as a hospital facility” (American Hospital Association, 2014). Out of these “registered” hospitals, the Joint Commission has more than “3,300 accredited hospitals, which is almost 60 percent of all registered hospitals in the nation (The Joint Commission, 2013).  While majority are reporting to the Joint Commission – membership is voluntary –, my initial observation was that although all Kaiser hospitals are apparently members, there were only two hospitals from the City of Los Angeles that were listed in the State of California.  The more popular hospitals USC (University of Southern California) Medical Center, Cedars Sinai, Children’s Hospital, and Good Samaritan were not listed, even the Huntington Memorial Hospital in Pasadena.  The latter hospitals of course don’t necessarily have to be “evaluated” as they exemplify the epitome of first rate world class medical institutions, known as pioneers and leaders and implementers of cutting edge technology in the field of medicine.  In San Gabriel Valley’s stretch of Alhambra, Monterey Park all the way to Rowland Heights, where doctors of Asian descent – doctors of Indian descent dominate the medical field – have based themselves, only one hospital in Rosemead is a member.

The reason I cited the top hospitals in Los Angeles is that they could be great contributors to The Joint Commission, and their models can be replicated by other institutions. They could also share their techniques and expertise to improve health care for all hospitals and other facilities in America, if not the whole world.  At any rate, from the Executive Report of the President of CEO of The Joint Commission, at least one third or 1,099 of the 3,300 accredited hospitals were reported to have improved their facilities in 2013, which is exemplary.  Moreover, The Joint Commission said “more than 200 core measure solutions have been posted by hospitals (in the Core Measure Solution Exchange ) that have dramatically improved and sustained their performance (The Joint Commission, 2013).” The Joint Commission was also proud to announce that more hospitals were “top performers” for 2013, while others “have reached or have nearly reached Top Performer distinction” that allowed President and CEO Mark R. Chassin to declare that “we are approaching a tipping point in hospital performance (The Joint Commission, 2013).”  Dr. Chassin added that more than 673 others are on their way to becoming top performers. The report said the 1,099 hospitals earned a grade of 95 percent or better across the board for core measures for heart attack care, heart failure care, pneumonia care, surgical care, children’s asthma care, inpatient psychiatric services, venous thromboembolism (VTE) care, stroke care, perinatal care, immunization, etc.

A closer look, however, may show a slow progress in the delivery of quality health care as The Joint Commission was founded way back in 1951. “Evaluating and accrediting more than 20,000 health care organizations and programs in the United States (History: The Joint Commission, 2014)” which is the main function of The Joint Commission, however seems to be a gargantuan task given the enormity of the industry and the costs involved in running a medical facility where patients are treated first before they get to pay.  The report also indicated that it was only in 2002 when member hospitals began providing core measures data to The Joint Commission, which raises more questions.  It is worthy to mention that while a some monitoring agencies rely on volunteered data from their members, The Joint Commission “worked closely with clinicians, health care providers, hospital associations, performance measurement experts, and health care consumers across the nation to identify the quality measures. This collaborative process identified measures that reflect the best ‘evidence-based’ treatments” for patients (The Joint Commission, 2013) and therefore allowing both healthcare workers and patients alike the freedom to provide information based on their own experiences. On the other hand, the improvement in the member’s performances show that The Joint Commission is policing their own members to keep the industry at a high level of standard.  Such methods also prevent the spread of disease and epidemics, including reducing infection incidents in hospital themselves (like the use of sanitizers).

Hospital Standards

While The Joint Commission incidentally requires payment for us to view their standards, the “comment on standard” page indicated the areas where these have been set: ambulatory health care, behavioral health care, critical access hospital, disease specific care, hospital, healthcare staffing services, laboratory, long term care, home care and office based surgery.  According to the Joint Commission, their standards “focus on important patient, individual, or resident care and organization functions that are essential to providing safe, high quality care (Standards: The Joint Commission, 2014).” To be more specific, The Joint Commission expected evidence-based treatments such giving aspirin at arrival for heart attack patients, giving antibiotics one hour before surgery, and providing a home management plan for children with asthma and transmitting continuing care plans for psychiatric patients for its members, etc.

Some of the Standards as listed require that the organization:

·         Manages safety and security risks

·         Manages risks related to hazardous materials and waste

·         Manages medical equipment risks

·         Inspects, tests, and maintains medical equipment

·         Manages its space during demolition, renovation, or new construction

·         Verifies staff qualifications

·         Staff participates in ongoing education and training

·         Safely administers medications

·         Provides for diagnostic testing

·         Plans the patient’s care

·         Collects data to monitor its performance

·         Compiles and analyzes data 

Comment:  While it’s worthy to note that The Joint Commission has set its own standards, there are healthcare accreditation organizations that may have a different set of standards.  Moreover, since members of The Joint Commission apparently come from their own organization that it’s supposed to monitor, there have been reports where the practice of advising hospitals when the inspections occur at their facility have been highly criticized, according to Wikipedia based on reports from the Washington Post and Boston Globe (Wikipedia, 2014).  Hopefully, these have been rectified or eliminated if not reduced.

Requirements for a hospital seeking accreditation by The Joint Commission:

·         As posted by the Joint Commission, any hospital wishing to be accredited by the agency must meet the following requirements:

·         Located in the U.S. or its territories

·         Must conduct its own assessments and improves services where needed subject to review by clinicians

·         Must identify its services

·         Must meet The Joint Commission standards

·         Must meet minimum parameters as required 

The Joint Commission-accredited hospitals near my area (Norwalk, California):

·         Kaiser in the cities of Downey, Anaheim

·         Presbyterian Intercommunity Hospital in Whittier

·         Garden Grove Hospital and Medical Center in Garden Grove

·         Miller's Children Hospital in Long Beach

·         The Huntington Beach Hospital in Hungtington Beach

·         Centinela Hospital Medical Center in Inglewood

·         La Palma Intercommunity Hospital in La Palma

·         Children's Hospital of Orange County in Orange

·         Providence Little Company of Mary Medical Center in Torrance

Bibliography

American Hospital Association. (2014, January). Fast Facts on US Hospitals. Retrieved April 1, 2014, from www.aha.org: http://www.aha.org/research/rc/stat-studies/fast-facts.shtml

History: The Joint Commission. (2014). History of The Joint Commission. Retrieved April 1, 2014, from www.jointcomission.org: http://www.jointcommission.org/about_us/history.aspx

Standards: The Joint Commission. (2014). Facts About Commission Standards. Retrieved April 1, 2014, from www.jointcommission.org: http://www.jointcommission.org/assets/1/6/Standards1.PDF

The Joint Commission. (2013). Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety . The Joint Commission.

Wikipedia. (2014, February 24). Joint Commission. Retrieved April 1, 2014, from Wikipedia: http://en.wikipedia.org/wiki/Joint_Commission

The “Unavoidable” Death of Esmin Green

Esmin Green was “Disregarded, Disrespected, Discarded”: Powerful words from a congresswoman from New York, Rep. Yvette Clark in her eulogy during the wake held for Esmin Green, an immigrant from Jamaica, who died while waiting for medical care at Kings County Hospital Center in New York (Clark, 2008). And I guess that answers the first question: If Esmin Green received quality health care. For documentary evidence, the City of New York’s Department of Investigation (DOI) made a thorough investigation and had submitted a report detailing the “Circumstances Surrounding the Death of Esmin Green” (Hearn, 2009) In that comprehensive report, DOI stated that Ms. Green was never medically examined during the times that she was supposed to be cared for, and despite an earlier order by a doctor, no examination, no EKG and no blood work were done on Ms. Green, who spent almost a day at the emergency room until her death on June 18, 2008.  

As to the first premise of the same question, however, it would seem that Ms. Green received “quality health care” as far as her old 2007 medical record was concerned (Hearn, 2009) and on that fateful day when Dr. Thomas Kowacz examined her and issued written orders. It was Dr. Kowacz who, the report said, diagnosed Ms. Green as “psychotic and schizophrenic” and who ordered Ms. Green to be “involuntarily admitted to KCHC’s Inpatient Service” and who made written orders that Ms. Green receive full medical examination, blood work and an EKG (Hearn, 2009).  Be that as it may, Ms. Green’s fate may have been sealed when the nurses failed to follow the Comprehensive Psychiatric Emergency Program (CPEP) protocol to include Ms. Green’s name in the 24-Hour Observation Sheet for an hourly observation (Hearn, 2009).

ER “Strong Documentation Standards”

As provided in the DOI report, the particular incident involving Ms. Green indicated a dismal and total failure to observe proper documentation at Kings County Hospital Center…for at least one patient in the person of victim Esmin Green.  It should be noted that Kings County Hospital Center had a “first rate” reputation, especially when dealing with patients suffering from gunshot  wounds, and was once named the first Level 1 Trauma Center in the U.S.” by the New York City Health and Hospitals Corporation (Wikipedia, 2013).  But in the June 18, 2008 incident, KCHC failed miserably, as shown by the “doctored” or falsified documents by nurses, and even by medical doctors who claimed to have “examined” Ms. Green but did not as shown by the video.  The cover up showed that although KCHC may be a top-rated trauma center, the indifference towards people needing medical care was very glaring.  For all we know, more may have also died as a result of the staff’s negligence and dereliction of duties.   Perhaps, because they were “psychotics and schizophrenics” and were unable to express themselves properly.  Unfortunately, from the names of the nurses, who I believe may be Filipinos like me, I am scared for my life.  I thought we are compassionate, caring and hard workers.  And even if Ms. Green was from Brooklyn, though Jamaican, and is an “inner city” I hope that race was not a factor in her death...but I doubt that.

Clinic Was Responsible for Esmin Green’s Death

The mere fact that the hospital fired at least six of its staff, the DOI investigation showing cover up and for doctors to assert their Fifth Amendment to avoid self-incrimination clearly demonstrated the lack of proper hospital supervision in relation to their medical staff, and for this incident, even for their security personnel.  Which brings to mind this very obvious security measure: Video cameras are there for the security of safety of all people in the facility, which the security personnel ironically should be manning or at least be in charge of.  Not only are the medical staff perhaps criminally liable for Ms. Green’s death, the family of the victim has valid reasons to civilly charge the hospital and the City of New York (Fennell, 2008), as Ms. Green was a provider of six children, who may still be living today if not for the negligence  by the nurses, doctors and security personnel, some of whom as already mentioned lied and tried to cover up their misdeeds.  If we were to base our argument on Wikipedia’s article, which stated that the Kings County hospital has apparently “paid out more than 1/3 of all medical malpractice claims against the New York City Health and Hospitals Corporation (over $60 million)…has a very high amount of malpractice claims compared to other city hospitals (and) has been the most sued hospital of the city’s health care system” (Wikipedia, 2013), the more that the hospital is responsible for Ms. Green’s death, and perhaps for many others whose episodes were also fatal but not as controversial as Ms. Green’s death.

If EHR system were in place

For the purposes of our class, the death of Ms. Green could’ve have been avoided if only the medical staff at  Kings County Hospital Center were responsible enough to follow established  protocols, including monitoring and actually applying the ordered procedures, especially if aided by an electronic health record system that would’ve alerted the healthcare workers and even the security personnel.  As we’ve learned from our previous meetings, an electronic health record management would’ve begun as soon as when Ms. Green was picked up by the EMS personnel prior to arriving at the psychiatric emergency room of the KCHC.  From there, they would’ve known that since 2007, Ms. Green had been in and out of KCHC and was “diagnosed with psychosis and/or schizophrenia .” and was prescribed medications for these symptoms (Hearn, 2009).  Her records also indicated that Ms. Green was “non-compliant” with her medications in 2007 that could’ve alerted the staff on her behavior upon her arrival at the hospital on June 18, 2008. 

Moreover, Dr. Kowacz may have also found out Ms. Green’s wasn’t placed on the 24-Hour Observation Sheet even when she was deemed on the early morning of June 18, during the initial screening, that she was a “Priority 2-High Priority” patient (Hearn, 2009).  Regardless, Ms. Green’s fate seemed hopeless because she wasn’t monitored on an hourly basis and Dr. Kowacz’s written orders were not administered.  These incidents were aggravated by the fact that the assigned doctors later that day didn’t do the tasks that they were supposed to perform and by the insensitivity of the security personnel and other medical staff who could only manage to “nudge” Ms Green with their foot to find out how she was and did not perform CPR as required at that very moment (Associated Press, 2008). Again, for the purposes of this class, the monitoring alone could’ve saved Ms. Green’s life, which apparently all it needed was the administration of anticoagulation drugs to stop clots from forming (Associated Press, 2008). 

Bibliography

Associated Press. (2008, July 11). Esmin Green, who died on Brooklyn hospital floor, perished from sitting. Daily News .

Press, A. (Producer). (2008). Video Shows Woman Dying on NY Hospital Floor [Motion Picture]. USA: Associated Press.

ZYNCTV (Producer). (2008). Esmin Green Remembered (Woman left to die at Kings County Hospital) [Motion Picture]. USA: Youtube.

Fennell, A. (Producer), & Fennell, A. (Writer). (2008). Esmin Green Case [Motion Picture]. USA: NBC Universal/Comcast.

Hearn, C. R. (2009). DOI’s Investigation into the Circumstances Surrounding the Death of Esmin Green. New York: New York City Department of Investigation.

Wikipedia. (2013, October 29). Kings County Hospital Center. New York, New York, USA.

The Monetary and Other Benefits of Implementing Electronic Health Record

This article is centered on two items: One, an advertising from Dell Computers (http://www.dell.com/downloads/global/solutions/perot/electronic-health-record-implementation-costs-benefits.pdf?c=us&cs=RC968571&l=en&s=hea), which enumerates the benefits of transitioning to an Electronic Health Record system by citing the studies conducted by Washington DC’s Congressional Budget Office and by the Healthcare Information and Management Systems Society; and two, by the encyclopedia of medical professionals, the American Journal of Medicine (AJM http://www.amjmed.com/article/PIIS0002934303000573/fulltext.  From my own experience at Kaiser, where doctors and nurses make use of their Dell computers from the moment I check in for a  check-up, to the nurses’ station for vitals and by the attending physician who inputs his findings and the required medicines in the system, the use and benefits of EHR are very obvious: It saves time; reduces billing errors and redundancy of medical procedures and other costly errors; avoidance if not elimination of unnecessary lab tests; creates a better system of identifying what procedures to charge for reimbursements and applying them correctly; and most importantly, it lowers the cost of medicines and other costs for the patient. The end result, a win-win-win situation for the provider, the insurer and the patient.

The AJM study says that by saving $5 (the average chart pull cost) on every patient and by reducing transcription costs, implementing an electronic health record system may result in more than $17,000 in extra revenues for the provider in any given year. Over a five-year period, the study states that the “estimated net benefit” of an EHR system is $86,400 for the provider, a third chunk of which comes from drug expenditure savings, while more than half comes “radiology utilization (17%), decreased billing errors (15%), and improvements in charge capture (15%):” (Consensus, 2003). While we are still recovering from the Greatest Recession, this amount of money far outweigh the cost of actually procuring the equipment needed for an EHR implementation and the training necessary to apply these capital that in the end may help stave off rising health care costs. The study says if all hospitals and all other health providers in the U.S. participate, the nation may save $80 billion from the burgeoning health care cost of about $2 trillion annually. (Dell Services, 2010)

Even for capitated health plans, where providers serve patients at fixed rates regardless of the number and types of care given, the savings is also an enormous $86,400 per provider. For some, this goes high to as much as $140,100, even if a provider serves a low number of capitated patients with high discounts (“the net benefit range was as low as $3000 per provider”) (Consensus, 2003).  The same AJM study also cites other revenues, such as “capturing of in-office procedures that were performed but not documented (Consensus, 2003)” and as Dell says, it helps “reduce the duplication of diagnostic tests ,” provides for better security and safety of patients caused by “illegible” prescriptions and medical orders, and “prevents harmful drug interactions.” (Dell Services, 2010). Although not a friend of the labor unions, the use of technology means enhanced workflow, less manpower means reduced human errors, thus less malpractice lawsuits. Besides, as technology advances, the world moves forward and soon all will be implementing an EHR system. Europe for sure is on its way, the U.S. has to catch up.

Capital Costs and Return on Investments (ROI)

In spite of earning the title as the leading country in computer technology, the U.S. sadly lags in the use of EHR compared to other developed countries.  The AJM study says only 7% of U.S. healthcare providers use the technology, a far cry from across the Atlantic where countries are 50-90 percent EHR capable.  Reasons cited could be that of U.S. providers’ hard-to-change habits, the most likely unknown expense involved in purchasing the hardware and software components, and the reality of reduced productivity in retraining the staff.  Worse, some may be worried about the painful decision of actually firing loyal employees who may be slow in adopting to the new EHR environment. While it may be easy for some to just procure and the equipment and train their staff, it may be difficult for bigger health organizations that the AJM study recognizes. There could a staggering amount in “system integration costs depending on the complexity of system interfaces, the change in workflow design and the realities of power outages” (Consensus, 2003) affecting operations, specifically in areas where storms have caused disruption to power, which may compromise the safety and health status of inpatients.  Not to mention that security breach has affected even the biggest companies in the U.S.  People may be able to get back their stolen money from credit card, but no one wants their medical record compromised.

The AJM says that when implemented (their study was based on one provider – Partners HealtCare  – however) transitioning to EHR is just a measly $1,600 in software costs; $6,600 in hardware (for three computers, a printer and network installation that’s good for at least three years); $3,400 more for redesigning work process; and at least $1,500 more for employing technical expertise and other maintenance costs (B. Middleton, 1998).  All told, costs may reach a total of about $11,200 in “revenue loss” in the first year – not a staggering amount considering the return on investment as cited by the AJM study, especially when all things considered, all the costs in purchasing the equipment and services would be paid for in just after a year of EHR implementation (B. Middleton, 1998).  According to AJM, “the most pessimistic savings…when the most pessimistic assumptions were made, the model showed a net cost of $2,300 per provider.” When the most optimistic assumptions were used, this analysis yielded a net benefit of $330,900 per provider. Moreover, the same study says, “Savings due to prevention of adverse drug events in the model did not include costs of malpractice settlements, injury to patients, or decreased quality of life for patients, so the actual savings may be higher.”  AJM also “underestimated future cost savings because the model did not account for the annual growth rate of expenditures, which may outpace inflation in some categories, such as in drug and radiology costs” (Consensus, 2003). Incidentally, dollar figures used in the AJM study were all based in 2002 .

The Dell ad, however, tells a different picture. It says that based on a study by the CBO, costs that may be incurred by physician groups may range from $25,000-$45,000 “per physician” in addition to $3,000-$9,000 more in operating licensing and maintenance costs – amounts that are considerably high. It adds that the CBO also found out that EHR implementation costs for hospitals averages to about “$14,500 per bed” while annual operating costs may reach as much as “$2,700 per bed per year.” Despite that, however, the Dell ad includes many benefits gained, and cites at least one facility – Cincinnati Children’s – where there has been “a 52 percent decrease in time spent on the medication cycle entering and receiving orders, shortening the care process for patients and staff,” along with more orders signed by physicians (down to 10% from a high of unsigned orders of 40%) that improves reimbursements; less verbal orders for controlled substances; and better compliance in assessing pain protocols.

Be that as it may, saving $80 billion from the biggest deficit-causing industry in the national budget, according to Dell, is a huge amount.  The federal government is the biggest payer of healthcare.  Hospitals and healthcare providers may be in the business of saving lives and taking care of people's health.  But any Dr. Tom, Dr. Dick and Dr. Harry will know that providing this type of service requires a great deal of money, investment and wise financial decision.

Bibliography

(n.d.).

B. Middleton, M. M. (1998). Table 1. Costs of Electronic Medical Record System Used in the Model (Per Provider in 2002 U.S. Dollars).

Consensus, E. P. (2003). A cost-benefit analysis of electronic medical records in primary care. The American Journal of Medicine , 114 (5), 397-403.

Dell Services. (2010). Electronic Health Record Implementation: Cost and Benefits. Retrieved March 6, 2014, from Dell Computer Services: http://www.dell.com/downloads/global/solutions/perot/electronic-health-record-implementation-costs-benefits.pdf?c=us&cs=RC968571&l=en&s=hea

Samuel J. Wang, M. B. (2002). Table 2. Annual Expenditures Per Provider (in 2002 U.S. Dollars) before Electronic Medical Record System Implementation and Expected Savings after Implementation. Boston: Department of Finance, Brigham and Women’s Hospital, Partners HealthCare System.