HIT Shrink

#HCLDR Oct 14: Patient Centered Medical Home (PCMH) and Behavioral Health Integration

noreply@blogger.com (Anonymous) — Sat, 11 Oct 2014 12:09:00 -0400

On Tuesday, October 14, 2014 (8:30-9:30 pm Eastern), the Healthcare Leaders (#HCLDR) group will hold this chat on Twitter. You can follow the live stream of the chat on Tuesday on Tweetchat using this link (for your local time, click here).

Healthcare in the United States has become so splintered and chaotic that most people would agree that our "system" is broken. People with chronic conditions, such as may wind up having five or more practitioners -- primary care, cardiology, endocrinology, psychiatry, neurology, etc -- and the communication among them all is often not coordinated. This system of care is centered around each practitioner, not around the patient who must go to five different places to get care, not to mention different places for labs, tests, and medications.

The patient-centered medical home, or PCMH, is designed to be centered around the patient. This is typically a single place in which one can get much or all of their care. It is open during late hours and weekends to reduce the reliance on expensive emergency departments. You can get same-day appointments and don't need to wait weeks to see your doctor. There are over 8000 PCMHs around the country, and each carry recognition or certification for meeting standards that all PCMHs must follow.

One of the challenges for people who have mental health and/or substance abuse problems has been the even more chaotic manner that insurance companies have handled these "behavioral health" conditions. It is common for people to have a different "carve-out" insurance company that pays for these services, with different lists of mental health practitioners, different co-pays, and different rules. The two different payers often don't coordinate, nor do the primary care people communicate well with the mental health people. It's a mess.

PCMHs take a different approach to behavioral healthcare, taking responsibility for coordinating the care, making appointments, and ensuring the different practitioners communicate with each other. In fact, the latest 2014 standards from the National Council for Quality Assurance (NCQA), which has a rigorous formal recognition program for PCMHs, has added additional standards for behavioral health. Among them:

The practice has a process for informing patients/families about the role of the medical home and gives patients/families materials that contain information on the scope of services available within the practice including how behavioral health needs are addressed.
To understand the health risks and information needs of patients/families, the practice collects and regularly updates a comprehensive health assessment that includes:

Mental health/substance use history of patient and family.

Depression screening for adults and adolescents using a standardized tool.

The practice implements clinical decision support (e.g., point-of-care reminders) following evidence-based guidelines for a mental health or substance use disorder.
The practice establishes a systematic process and criteria for identifying patients who may benefit from care management, including consideration of behavioral health conditions.
The practice maintains agreements with behavioral healthcare providers.
The practice integrates behavioral healthcare providers within the practice site.

NCQA also has a program that evaluates vendors having solutions that help practices meet these standards. This Vendor Prevalidation Program has approved one behavioral health solution for PCMHs. The company, M3 Information, has a software solution called M3Clinician that makes it easy for a PCMH practice to conduct multidimensional screening for depression, bipolar disorder, anxiety disorders, post-traumatic stress disorder (PTSD), drug and alcohol abuse, using evidence-based guidelines and clinical decision support for primary care providers managing milder forms of behavioral health conditions that do not require a specialist referral. Their consumer app, WhatsMyM3, provides an advanced self-management tool to people with behavioral health conditions. [Note: Dr. Daviss is the Chief Medical Information Officer for M3 Information.]

The #HCLDR questions for Tuesday's chat are:

T1: Patient centered medical home #PCMH is WHOLE person care around pt needs. What's PATIENT-CENTERED CARE mean to you?

T2: What can a #PCMH or any physician/nurse do to broach the subject of #behavioralhealth with a patient?

T3: How should #brainhealth/#behavioralhealth be measured/monitored in #primarycare/#PCMH care over time?

T4: What can we do to encourage orgs to be more like #PCMH (patient-centered) to incorporate #behavioralhealth?

FEB CHAT

Why is it important to integrate behavioral health into primary care settings?
Go to the #HCLDR chat from February titled, "Behavioral Health Integration and Hospital Readmissions," to read the content that reviews the avoidable costs (financial, quality, and personal) associated with the status quo. DrDaviss has additional resources from that chat on his HITshrink blog. The questions from the February chat were:

T1: With shortage of #BHealth resources, what impacts do you see in your settings?
T2: What can help PCPs better integrate #BHealth into their practice?
T3: What can help to address impact of #BHealth on chronic health conditions?

JUL CHAT
Also, check out Dr Ann Becker-Shutte's double-header chat from July titled, "Psychologists, Behavioral Health and Primary Care – Oh My!," with more great information and discussion. This was a special two-hour chat with people from #HCLDR and #InnoPsy joining together to respond to these eight questions:

T1: Making lifestyle/healthy changes is hard. What tactics worked for you? How did you stay motivated?
T2: If you could change one or two behaviors in healthcare to reduce costs what would they be?
T3: What type of support (peer/clinical/admin/gov’t) or tech would have helped to make the T1 or T2 changes?
T4: As a patient, would you be open to support for behavior change/lifestyle coaching via your primary care physician’s office?
T5: What would make patients more comfortable with receiving help/support for +ve lifestyle changes via primary care office?
T6: How do we start to shift health care culture to integrate behavioral health and physical health?
T7: What kinds of training would help all health care providers collaborate more effectively?
T8: How can we foster more collaboration between Psychologists & other behavioral health pros & primary care providers?

RESOURCES

Reasons for integrating behavioral health and primary care for patient-centered medical homes. Patient Centered Primary Care Collaborative (PCPCC), 2014.
Behavioral health resources from the PCPCC (reimbursement for depression & alcohol; slide deck)
Patient-centered medical home implementation effects on emergency room utilization: a case study. Hosp Top 92:59, 2014.
Mental health, substance abuse, and health behavior services in patient-centered medical homes. J Am Board Fam Med 27:637, 2014.
Joint principles: Integrating behavioral health care into the patient-centered medical home. Fam Syst Health 32:154, 2014.

#HCLDR Healthcare Leaders Tweet Chat on Behavioral Health Integration and Hospital Readmissions - Feb 18, 2014

noreply@blogger.com (Anonymous) — Fri, 14 Feb 2014 14:21:00 -0500

Twitter has been a great medium for having discussions, or chats, about various healthcare topics. The original "tweet chat" is #HCSM or HealthCare & Social Media, which is still on Sunday evenings at 9pm ET.

One of the increasingly influential healthcare tweet chats is #HCLDR, Tuesday nights at 8:30 ET, which typically has a hundred or so participants, many of them being patients, hospital executives, physicians, nurses, and others involved in various aspects of quality standards, business, compliance, and related aspects of today's healthcare industry. #HCLDR is passionately and expertly organized by Lisa Fields (@practicalwisdom) and Colin Hung (@colin_hung). Each chat starts with introductions, then three topic questions are asked, each followed by about 15 minutes of discussion. Everyone gets a last word at the end. Each chat must have the #HCLDR hashtag in it to show up in the discussion, which people either use the native Twitter site or app for, or other tools. I tend to prefer tweetchat.com, which will automatically refresh the screen to see new tweets, and it ensures you don't forget to add the hashtag.

Each week's tweet chat is documented on their Wordpress blog. Last week's chat was a very current topic regarding the increasing complex trade-offs between privacy and access to healthcare.

Lisa and Colin have asked me to be the guest host for next week's chat on Tue, Feb 18, 8:30-9:30pm ET. The topic will be about Behavioral Health Integration, and will touch on the impact of comorbid mental health and substance use disorders (referred to in the collective as behavioral health) on hospital readmissions.

To whet people's appetite and guide the focus, I've included an image below that shows the relative risk of hospitalization for several medical conditions for four groups of patients (this is 2011 Maryland Medicaid data):

patients without any comorbid behavioral health condition
patients with a comorbid mental health condition
patients with a comorbid substance abuse condition (drug and/or alcohol abuse or dependence)
patients who are comorbid for both a mental health AND a substance use disorder

(CELL-SEPT refers to cellulitis and septicemia; CHF is congestive heart failure; RESP//// refers to four respiratory conditions: asthma, COPD, bronchitis, pneumonia; and DM refers to diabetes)

I initially began with the following Topic questions:

T1: How can #BehavioralHealth (BH) be better integrated within primary health care?
T2: What are the barriers to addressing the impact of #BehavioralHealth on chronic health conditions?
T3: How can primary care improve screening for BH conditions that impact chronic conditions?

But after talking with Lisa on a Google Hangout yesterday, we thought it might be useful to have people suggest their own topic questions before we finalize them.

So, please send a tweet over the weekend about what you want to ask. Include my name (@hitshrink) and also the #hcldr hashtag. I will update this post over the weekend and finalize it on Monday.

***UPDATE 2/16/2014 17:38 ET***
Great discussion on Twitter #HCLDR...
@StorkBrian: Access to Behavioral Health Services is Sorely Lacking in Most Communities
@TeamMDrs: most primary care visits have their basis in a bh issue
>> @MeganRanney: true for ER visits too
>> @PracticalWisdom: We must change ~ some w/Beh/Health housed in ER ~ #noroomintheinn Not enough $ for Rehab
@TeamMDrs: the impact of depression on physical well being is profound and well studied
@StorkBrian: Behavioral Health is a Demanding Specialty Providers Need Support & Appropriate Compensation
@ProfAmyE: Integration of MH svcs in Pri.care is key. Paradigm shift for how this works required!
@PracticalWisdom: How many re-Admits every day b/c We left out Behavior Health.Huge #'s I say!
>> @PerronServices: Why? How?
>> @HITshrink: If pt too depr to take care of diabetes -> more admits
@ProfAmyE: Health promotion is about healthy behavior. This is what BH does best!
@StuartMarcusMD: R we seeing more violent pts in ED's & med/surg admits? Feels like it. Best practices needed
@TomVargheseJr: Standards for good surveillance & feedback systems? What are consensus best practices?
@MeganRanney: How to integrate #behavioralhealth into day-to-day clinical practice (constraints of time & access)
@MeganRanney: And many w/behav health issues have no other source of care #emergencymedicine

***UPDATE 2/17/2014 09:22 ET***
After fine-tuning the Topic questions, based on above tweets over the weekend, here are the final questions for Tuesday night's #HCLDR tweet chat (using the shorter #bhealth for #behavioralhealth):

T1: With shortage of #BHealth resources, what impacts do you see in your settings? #HCLDR
T2: What can help PCPs better integrate #BHealth into their practice? #HCLDR
T3: What can help to address impact of #BHealth on chronic health conditions? #HCLDR

***UPDATE 2/17/2014 12:50 ET***

Below are some resources that are relevant to the discussion, including links and slides (slide images are linked to underlying source when possible, so click on them to go to Pubmed or wherever).

WSJ 2014 Jan 16 - Shortage of mental health professional blamed on Obamacare

University of Washington's AIMS Center (Advancing Integrated Mental Health Solutions) offers free training for their collaborative care model.

M3 Clinician is an NCQA-recognized screening and clinical decision support tool that helps PCPs identify and manage patients with depression, bipolar, PTSD, anxiety, and substance use disorders. Patient version is WhatsMyM3.com. [Disclaimer: Dr Daviss is CMIO for M3 Information.]

Shameless plug for our book [Kindle], from the Shrink Rap docs.

Psychiatrists have lowest EHR adoption rate of all specialties

noreply@blogger.com (Anonymous) — Sat, 16 Nov 2013 13:53:00 -0500

Yikes! I've been silent here for close to a year. This is what happens when you get used to the appeal of short-form blogging (twitter). But you can only say so much in 140 characters.

Anyway, I tweeted yesterday about the low rate of electronic health record (EHR) adoption among psychiatrists (7%) and @ShellyVAdams asked for a link; so here is a bit more detail. Jonathan Wolfe has a piece in Psych News coming out next week with more details.

The HITECH Act's funding for EHR adoption for eligible providers does not cover most mental health professionals (eg, social workers, psychologists, counselors, community mental health centers (CMHCs), etc), other than psychiatrists and some nurse practitioners. Because many psychiatrists practice in CMHCs, it is not surprising that the rate is lower.

Click on the image below to go to the original source (page 38):

FYI: The average for solo practice physicians in 2012 is about 30%.

Public Comment by Feb 4: ONC Health IT Safety Plan

noreply@blogger.com (Anonymous) — Sun, 30 Dec 2012 16:00:00 -0500

ONC recently released its Health IT Patient Safety Action and Surveillance Plan for public comments, which are due by Feb 4, 2013. Comments can be sent to ONC.Policy@hhs.gov.

The report can be found HERE, as well as a brief Fact Sheet. The report is related to the IOM's 2011 recommendations from Health IT & Patient Safety: Building Safer Systems for Better Care.

Highlights

Patient safety objectives

Use health IT to make care safer
Continuously improve the safety of health IT

Increase the quantity and quality of data and knowledge about health IT safety

Make it easier for clinicians to report patient safety events and risks using EHR technology.
Engage health IT developers to embrace their shared responsibility for patient safety and promote reporting of patient safety events and risks.
Provide support to Patient Safety Organizations (PSOs) to identify, aggregate, and analyze health IT safety event and hazard reports.
Incorporate health IT safety in post-market surveillance of certified EHR technology through ONC-Authorized Certification Bodies (ONC-ACBs).
Align CMS health and safety standards with the safety of health IT, and train surveyors.
Collect data on health IT safety events through the Quality & Safety Review System (QSRS).
Monitor health IT adverse event reports to the Manufacturer and User Facility Device Experience (MAUDE) database.

Target resources and corrective actions to improve health IT safety and patient safety

Use Meaningful Use of EHR technology to improve patient safety.
Incorporate safety into certification criteria for health IT products.
Support research and development of testing, user tools, and best practices related to health IT safety and its safe use.
Incorporate health IT safety into medical education and training for all health care providers.
Investigate and take corrective action, when necessary, to address serious adverse events or unsafe conditions involving EHR technology.

Promote a culture of safety related to health IT

Develop health IT safety priority areas, measures, and targets.
Publish a report on a strategy and recommendations for an appropriate, risk-based regulatory framework for health IT.
Establish an ONC Safety Program to coordinate the implementation the Health IT Safety Plan.
Encourage state governments to incorporate health IT into their patient safety oversight programs.
Encourage private sector leadership and shared responsibility for health IT patient safety.

HIMSS mHealth Summit 2012 in DC

noreply@blogger.com (Anonymous) — Sat, 1 Dec 2012 03:26:00 -0500

I'm looking forward to the mHealth Summit in DC on Monday, Dec 3. I've not been to this conference before, but mobile health apps and and the use of mobile devices in the service of health care delivery and education has become such a game changer that one ignores this space with great peril.

A quick search of the mhealthsummit.org site for the terms behavioral or mental or psychiatry or psychology gets 75 hits! While a lot of these terms are in the bios for speakers and such, this is still quite a bit when compared to other medical specialty terms, such as cardiology (6), surgery (5), neurology (2), dermatology (3), and radiology (5). Granted, psychiatry only gets you 4 hits compared with 23 for psychology and 50 for behavioral, but considering all of these terms provides a lot more hits compared to other specialty areas. Even the term mental appears in 24 hits. Why is that that behavioral health is so represented?

I expect it is because the speakers and topics in the mhealth area will reflect three major components of healthcare:

patients currently coalesce around disease interests, especially those conditions that lend themselves to peer support
providers who treat or speak about these disease interests will naturally follow
healthcare costs: because mhealth is likely to be most disruptive in the disease areas that are most costly, it makes sense that these areas will be more heavily represented at this conference. Example: 2011 Maryland Medicaid data shows that people with chronic medical problems are admitted 8-15 times more often if they have comorbid mental health and substance abuse diagnoses. 8-15 times!! (data available on request)

AHRQ listed the top 10 most expensive conditions (2008 data). Here they are with the mean annual expenditures (averaged for men & women combined) and the number of hits on the mhealthsummit.org website.

Cancer $4678... 515 hits (cancer|oncology)
Heart disease $4043... 510 hits (heart|cardiac|cardiovascular)
Diabetes $2173... 505 hits (diabetes)
Trauma $2555... 4 hits (trauma)
Back problems $1973... 4 hits (pain; not easy to search)
Mental disorders $1857... 75 hits (behavioral|psychiatry|psychology|mental)
Osteoarthritis $1648... 4 hits (arthritis)
COPD/Asthma $1284... 15 hits (copd|asthma)
Hyperlipidemia $871... 0 hits (hyperlipidemia|hypercholesterolemia|cholesterol)
Hypertension $858... 4 hits (hypertension|"blood pressure")

Okay, so this is hardly a scientific study, right? In fact, it is a bit silly. But it backs my point that for chronic conditions where people seek out management and coping tools and supportive communities, mhealth buzz is circling these conditions. I can see why trauma might not have much here as it is more of an acute problem, albeit with chronic sequelae. I am surprised to see very few mentions of pain. HIV is not in the top 10 but has 502 hits.

Diving deeper into the mental health stuff, there are a few mentions of depression, anxiety, addiction and PTSD, but nothing on bipolar disorder (people often don't think of bipolar disorder even though it can be more costly than diabetes). There is an interesting talk on Tuesday evening at 5pm called "Open mHealth - Integrating mHealth Apps & Devices to Enable Better Health:"

"Imagine a world where a person with Post Traumatic Stress Disorder (PTSD) is able to share with their clinician--in real-time--their mood, behavior and medication data so they can collaboratively get to a richer, data-driven view of how they’re improving between clinical visits."

I won't be able to make it to that one, unfortunately, but if you attend, please tweet or blog or comment here about it. (thanks!)

Maryland Medicaid: Behavioral health problems predict skyrocketing medical hospitalizations

noreply@blogger.com (Anonymous) — Sun, 14 Oct 2012 11:00:00 -0400

Earlier this summer the Maryland Department of Health and Mental Hygiene released four years of aggregated data on Maryland Medicaid patients and some measures of health care utilization, such as hospitalizations. The data can be found here (look at the July 11 meeting materials called Data Book). This is in the context of Maryland's attempts to integrate mental health, addictions, and somatic health (see Crazy Busy for more details).

The data show hospital admissions for the top 25 conditions -- such as stroke, diabetes, pneumonia, etc -- and further break up these data into four groups of people:

people who also have a mental health disorder
people who also have a substance use disorder
people who have both a mental health and a substance use disorder
people who have neither of these conditions (ie, just a somatic disorder, like asthma or diabetes)

Taking this data and analyzing it in more detail led to some amazing discoveries that are buried in the data tables. For example, in 2011, adult patients in Maryland Medicaid's HealthChoice program who had co-occurring mental health (MH) and substance use (SU) disorders were admitted to hospitals 800-1500% more often than those without these co-occurring conditions -- hospitalized 8-15 times more often for things like pneumonia, asthma, diabetes, epilepsy, and cellulitis.

That is worth saying one more time:

Patients with both mental health and substance use disorders were hospitalized 8-15 times more often for things like pneumonia, asthma, diabetes, epilepsy, and cellulitis.

Here is a graph demonstrating this amazing connection. People with co-occurring mental health problems were admitted 2-4 times more often for these 6 types of medical conditions, and people with co-occurring substance use problems were admitted 4-7 times more often. This is based on claims data submitted to Medicaid and analyzed by the Hilltop Institute. The data are normalized such those without mental health or addiction comorbidity have a relative risk of 1 for hospitalization

The six conditions are the primary diagnoses as indicated by the Medicaid data: epilepsy; HIV-related illness; cellulitis/septicemia; congestive heart failure; respiratory conditions (bronchitis, pneumonia, asthma, and COPD); and diabetes mellitis.

It's no wonder there is data that people with chronic mental health conditions treated in the public health system die 25 years earlier.

If there was ever a reason to better integrate mental health care, addiction treatment, and primary care, this is it.

Crazy busy

noreply@blogger.com (Anonymous) — Sun, 19 Aug 2012 02:52:00 -0400

So I noticed it's been 4 months since I last posted on HIT Shrink. Lots of things going on. I've had a few people ask me about what I've been working on, so thought I'd put it up here... if only for me to keep track of, including all the links to these areas.

Epic Implementation
After about 15 months of planning, meeting, coding, optimizing, and preparing, we went live on Epic a week ago. We had Cerner before that, and a homegrown CIS before that. The initial CIS was mostly labs, rads, and dictations as I recall. With Cerner PowerChart and FirstNet, we added nursing documentation, MAR, and some clinical documentation, though we had a hybrid system that included a paper chart for all non-dictated physician documentation (mostly progress notes, as H&Ps, consults, and DC summaries were dictated) and paper physician orders. A handful of small, contained areas (Peds, OB, Psych, ED) did do CPOE, but expanding that to the rest of the hospital, and our many community-based physicians, was untenable.

Now we have (mostly) abandoned paper documentation, with all physician documentation being done by either phone dictation, templates (using Notes and/or Notewriter plus/minus partial dictation), or Dragon. We are piloting Dragon Enterprise with a small number of physicians, otherwise they are using their own licenses. Still having network connectivity problems with wireless devices, especially BYODs -- particularly those of the Apple persuasion. And ironing out printing issues.

Overall, the switch has gone amazingly well. I attribute this to excellent executive support, mandatory classroom (not online) physician training (8-12 hours), extensive clinician involvement in the build, and heavy at-the-elbow support.
Maryland's Behavioral Health Integration
In 2011 we kicked off an effort to combine the Department of Health and Mental Hygiene's two administrations -- Mental Hygiene Administration and Alcohol and Drug Abuse Administration -- into an integrated administration which is expected to be called the Behavioral Health Administration. The Joint Chairman's Report lays out much of the rationale, as well as the challenges. Health Secretary Joshua Sharfstein MD MPH, previously Baltimore City commissioner, then a stint at FDA, has led an admirably open, transparent, stakeholder-rich effort to shape this integration effort.

The past 3 months have been heavy with 2-to-3-hour long Workgroup meetings. I've been attending many of these meetings (maybe a third to a half), representing the Maryland Psychiatric Society. The main points I've been making mostly revolve around ensuring mental health parity and integration of primary care. Besides the large overall Workgroup, there have been four, more focused, workgroups (links have meeting agenda, minutes, resource documents). Their charges are as follows:

Systems Linkage:
Purpose: To make a recommendation on those factors that should be present to promote "integration." For example, should there be a shared electronic health record among all providers within an MCO? What factors indicate “integrated” care, and what factors indicate “collaborative” care?
State/Local and Non-Medicaid Workgroup: Purpose: To make a recommendation on what services/financing should be left outside a “Medicaid” integrated care model to accommodate non-Medicaid eligible populations, or non-Medicaid-eligible services. This Workgroup will also make a recommendation on the roles that state and local government should perform depending on which services/financing are left outside of the Medicaid financing model, as well as how to support and interface with selected model.
Evaluation and Data WorkgroupPurpose: To determine what data is available and relevant to the ultimate recommendation on the model, and to make a recommendation on potential measures to evaluate any selected model.
Chronic Health Homes Workgroup

Purpose: To make a recommendation on a new “Health Home” service under the Affordable Care Act, and make a recommendation on how the new service could be developed to support any integration model. For example, this workgroup would help define the service; define the population eligible for the service; and define the provider qualifications to deliver the service.

Maryland Health Benefit Exchange
Maryland is among the earliest states to respond to the ACA's requirement of health insurance exchanges that include qualified health plans (QHPs) which must include a minimum set of essential health benefits (EHBs). This process has been unfolding extremely quickly over the past three months, with several meetings per week across all the advisory committees, as well as the governing Board. I've served on the Plan Management Advisory Committee, which has completed its work and submitted a Summary to the Board and to the legislature. Over 200 pages of public comments have been submitted to the Board, which met last week. Ensuring that there are requirements to demonstrate Parity compliance, as well as adequate provider network standards, has been the main focus of mental health advocates.

The other advisory committees include Navigator, Continuity of Care, Financing, and Exchange Implementation.
Maryland Health Information Exchange
The MHCC Policy Board continues to slog through its policy discussions. The current list of policies is in a .pdf document here. We've also been working on draft regulations for HIEs in Maryland. Initial public comments on these draft regulations are available on the HIE website.

Other things I've been working on include APA's Committee on Electronic Health Records, M3Clinician (a clinician portal for the M3 mental health screening tool), and mental health parity. This last thing includes working with folks in the Parity Implementation Coalition, testifying at a Congressional parity hearing, and even appearing on the Diane Rehm Show.

I'll try to post a bit more often here, but you can also keep an eye on Shrink Rap, Clinical Psychiatry News, and a new column on health IT to start soon in Psychiatric News.

Thank you for reading.

Stage 2 MU: Universal Depression Screening?

noreply@blogger.com (Anonymous) — Fri, 13 Apr 2012 16:20:00 -0400

In Clinical Psychiatry News yesterday, I wrote a column entitled, "Effect on Psychiatry of Stage 2 Meaningful Use," where I focused primarily on the proposal that all "meaningful EHR users" must collect and report 12 clinical quality measures or CQMs. This is not to be confused with the objectives that must also be achieved. Both the objectives and the measures have core items and menu items. The core ones are mandatory (unless one meets exclusion criteria) and the menu ones are selectives (eg, one must be chosen from a list of options).

In the column, I listed the proposed core CQMs (as listed in Table 6 of the Notice of Proposed Rule Making or NPRM) and focused particularly on one of the proposed CQMs, depression screening. Here is the proposed list for Stage 2:

receiving consultant reports
functional status assessments for patients with complex chronic conditions
controlled hypertension
medication reconciliation
use of high risk meds in the elderly
therapeutic drug monitoring
antithrombotic use in ischemic vascular disease
obesity screening and counseling in kids
tobacco use screening in adults
cholesterol screening in adults
depression screening for ages 12 and up

[For a refresher on Stage 1, this article should be helpful.]
CMS actually proposed two possible schemes for reporting these measures. One scheme -- called 1a -- is to select 12 measures from a larger list of 125 options in Table 8 of the NPRM, with at least one from each of 6 domains. The other -- called 1b -- is to report on all 11 of the Table 6 measures (listed above) and 1 from Table 8. The former scheme makes more sense for most specialists, especially psychiatrists, because it maintains flexibility and does not force us to report on things like cholesterol screening and antithrombotic use, both of which are most likely being addressed by a patient's PCP (primary care physician). If one instead reports CQMs via the Medicare Physician Quality Reporting System's EHR Reporting Option, then one can skip the above two schemes (at least, that's how I read it).

This Table 8 list of 125 clinical quality measures is the proposed list, not the final list that will likely be a subset of these based on public comments. Out of this long list, I list below those CQMs that seem to be most relevant to Psychiatry, while being sure to include at least one measure from each domain.

CLINICAL QUALITY MEASURE RELATED TO PSYCHIATRY	DOMAIN
Initiation & Engagement of Alcohol & Drug Treatment	Clinical Process/ Effectiveness
Medication Reconciliation	Patient Safety
Major Depression: Diagnostic Evaluation	Clinical Process/ Effectiveness
Major Depression: Suicide Risk Assessment	Clinical Process/ Effectiveness
Anti-depressant Medication Management	Clinical Process/ Effectiveness
ADHD: Follow-Up Care for Children Prescribed ADHD Medication	Clinical Process/ Effectiveness
Mood disorders: Appraisal drug & alcohol use	Clinical Process/ Effectiveness
Bipolar Disorder: Monitoring change in level-of-functioning	Clinical Process/ Effectiveness
Screening for Clinical Depression	Population/ Public Health
Documentation of Current Medications in the Medical Record	Patient Safety
Depression Remission at Six Months	Clinical Process/ Effectiveness
Depression Remission at Twelve Months	Clinical Process/ Effectiveness
Depression Utilization of the PHQ-9 Tool	Clinical Process/ Effectiveness
Child & Adolescent Major Depression: Suicide Risk Assessment	Patient Safety
Dementia: Staging of Dementia	Clinical Process/ Effectiveness
Dementia: Cognitive Assessment	Clinical Process/ Effectiveness
Dementia: Functional Status Assessment	Patient and Family Engagement
Dementia: Counseling Regarding Safety Concerns	Patient and Family Engagement
Dementia: Caregiver Education and Support	Patient and Family Engagement
Dementia: Counseling Regarding Risks of Driving	Patient Safety
Closing the referral loop: receipt of specialist report	Care Coordination
Adverse Drug Event Prevention: Therapeutic drug monitoring	Patient Safety

So, if the 1b proposal is chosen by CMS, psychiatrists will have to report on cholesterol and anticoagulants, however this will also result in near-universal depression screening. This would likely result in a lot more referrals to mental health specialists when patients are found to score positively on the screening tool (note that any standardized screening tool is acceptable, such as the BDI, GDS, PHQ-9, and M3), resulting in improvements in morbidity and reductions in costs associated with undiagnosed and untreated depression.

But, it is also likely to result in more PCPs, pediatricians, and OB-GYNs managing mild and moderate depression. Unless they also screen for bipolar disorder, a certain percent of these people -- who have undiagnosed bipolar disorder -- will be placed on antidepressants and be harmed from induction of mania, hypomania, or a mixed state by the antidepressant. If this 1b proposal is chosen, we will need to ensure that PCPs know how to screen for bipolar disorder, and that they are able to recognize mania or hypomania induced by an antidepressant.

If the 1a proposal is chosen, then providers will be able to pick and choose which of the Table 8 CQMs (at least one from each domain) is chosen. While this will be preferable because specialists won't have to report on measures that they rarely address, this path will NOT result in widespread screening of depression, as I expect providers will pick those measures that they already record in most patients currently.

I must say that I am torn between the two options, as I would like to have my cake and eat it, too.

Please comment on your thoughts about this. Also, let CMS know your thoughts by providing public comment prior to May 7 at this regulations.gov page.

Meaningful Use Attestation by Psychiatrists

noreply@blogger.com (Anonymous) — Fri, 24 Feb 2012 08:00:00 -0500

The ONC released a spreadsheet recently of all the eligible providers (Medicare and Medicaid) who attested to Stage 1 Meaningful Use (MU) of certified electronic health records (EHRs). I downloaded the results and did some pivot table magic to see which EHRs are being used by physicians identifying their specialty as "psychiatry."

There were 285 people who said they were compliant with Stage 1 MU. Interestingly, there were others who identified themselves in other ways. Three were "Community Mental Health Centers," even though HITECH specifically included them (but a doc there can attest, so I guess it's ok); they used Meditech and HCA. Five identified as "psychiatric" (Cerner, Design Clinicals, Siemens, and Wellsoft). And 16 as "psychiatric unit (Epic, Cerner, NextGen, McKesson, GE, HCA, Meditech, Midas+, Siemens). Here is data on the 285 identified as "psychiatry." If I get ambitious, I'll come back and hyperlink the names.

[edit 2/26: the links are in the Clinical Psychiatry News version of this article]

After discounting the large system products (eg, Epic, Cerner), you can get an idea about the EHR products being used in outpatient private practices.

Vendor Name	EHR Product Name	Total	% of all Psychiatrists
Epic Systems Corporation	EpicCare Ambulatory - Core EMR	129
	EpicCare Inpatient - Core EMR	2
Epic Systems Corporation Total		131	46.0%
Practice Fusion	Practice Fusion	22
Practice Fusion Total		22	7.7%
Cerner Corporation	Health Sentry	8
	Millennium Powerchart, Healthe Exchange, IQHealth, Health Sentry, Cerner Health	1
	Powerchart and Cerner Healthe	8
Cerner Corporation Total		17	6.0%
Allscripts	Allscripts ED	1
	Allscripts Enterprise E HR Modular	2
	Allscripts Enterprise EHR	2
	Allscripts ePrescribe	1
	Allscripts MyWay EHR	1
	Allscripts PeakPractice	1
	Allscripts Professional EHR	5
Allscripts Total		13	4.6%
Community Computer Service, Inc.	MEDENT	9
Community Computer Service, Inc. Total		9	3.2%
Valant Medical Solutions, Inc.	Valant Premium Psychiatric Suite	9
Valant Medical Solutions, Inc. Total		9	3.2%
DrFirst	Rcopia MU	8
DrFirst Total		8	2.8%
MedSeek, Inc.	eHealth ecoSystem	8
MedSeek, Inc. Total		8	2.8%
WellCentive	WellCentive Registry	8
WellCentive Total		8	2.8%
eClinicalWorks LLC	eClinicalWorks	6
eClinicalWorks LLC Total		6	2.1%
ICANotes, LLC	ICANotes EHR/EMR for Behavioral Health	6
ICANotes, LLC Total		6	2.1%
NextGen Healthcare	NextGen Ambulatory EHR	5
	NextGen Inpatient Clinicals	1
NextGen Healthcare Total		6	2.1%
McKesson	Medisoft Clinical	4
McKesson Total		4	1.4%
e-MDs, Inc.	e-MDs Solution Series	3
e-MDs, Inc. Total		3	1.1%
MedPlus, A Quest Diagnostics Company	Care360 EHR	3
MedPlus, A Quest Diagnostics Company Total		3	1.1%
UNI/CARE Systems, Inc	Pro-Filer(TM)	3
UNI/CARE Systems, Inc Total		3	1.1%
AmazingCharts.com, Inc.	Amazing Charts	2
AmazingCharts.com, Inc. Total		2	0.7%
Greenway Medical Technologies, Inc.	PrimeSuite	2
Greenway Medical Technologies, Inc. Total		2	0.7%
MedCPU Inc.	Meaningful Use Advisor	2
MedCPU Inc. Total		2	0.7%
Meditab Software, Inc.	IMS	2
Meditab Software, Inc. Total		2	0.7%
MTBC (Medical Transcription Billing Corporation)	MTBC-EHR	2
MTBC (Medical Transcription Billing Corporation) Total		2	0.7%
Nuesoft Technologies, Inc.	NueMD EHR	2
Nuesoft Technologies, Inc. Total		2	0.7%
Office Ally	EHR 24/7	2
Office Ally Total		2	0.7%
TheraManager LLC	MaestroMed	2
TheraManager LLC Total		2	0.7%
Waiting Room Solutions	2011 Waiting Room Solutions Web Based EHR and Practice Management System	2
Waiting Room Solutions Total		2	0.7%
ADP AdvancedMD	AdvancedMD EHR	1
ADP AdvancedMD Total		1	0.4%
athenahealth, Inc	athenaClinicals	1
athenahealth, Inc Total		1	0.4%
DrChrono.com Inc.	drchrono EHR	1
DrChrono.com Inc. Total		1	0.4%
GE Healthcare	Centricity EMR	1
GE Healthcare Total		1	0.4%
HealthFusion	MediTouch EHR	1
HealthFusion Total		1	0.4%
Henry Schein Medical Systems	MicroMD EMR	1
Henry Schein Medical Systems Total		1	0.4%
Ingenix	Ingenix CareTracker	1
Ingenix Total		1	0.4%
IOS Health Systems	Medios	1
IOS Health Systems Total		1	0.4%
iSALUS Healthcare	OfficeEMR	1
iSALUS Healthcare Total		1	0.4%
Medical Informatics Engineering	WebChart EHR	1
Medical Informatics Engineering Total		1	0.4%
SuiteMed	Intelligent Medical Software (IMS)	1
SuiteMed Total		1	0.4%
Grand Total		285

Hmm, the numbers are cut off. I placed this here in a Google Doc so you can see all the data.

Health Insurance Exchange Regs: Mental Health Coverage and 45 CFR Parts 155-156

noreply@blogger.com (Anonymous) — Tue, 12 Jul 2011 08:00:00 -0400

The NPRM for the Health Insurance Exchanges portion (45 CFR Part 155 & 45 CFR Part 156) of the Affordable Care Act came out yesterday (thanks for the tip-off, +David Harlow). I quickly scanned it for specific mentions of standards related to mental health coverage. See below for relevant sections. (I'll look at Part 153 later.)

First impressions: it does encourage specific considerations for folks with mental illnesses and other disabilities be addressed, but I am so far (just based on the above) unimpressed with provisions ensuring parity for this population -- a population that was heavily marginalized and discriminated against during the managed care cycle from the 80s and 90s. I did not find a single reference to the Mental Health Parity Act (45 CFR Part 146), either. It also mentions the need for accurate provider directories, which are notoriously inaccurate in behavioral health. It encourages input about how to hold Exchanges accountable for accuracy, including indicating whether providers are accepting new patients.

[pg 30] According to section 1311(d)(6) of the Affordable Care Act, Exchanges are required to consult with certain groups of stakeholders as they establish their programs and throughout ongoing operations. We propose that the Exchange consult on an ongoing basis with key stakeholders, including:
a. Educated health care consumers who are enrollees in QHPs; “educated” is the term used in Section 1311(d)(6)(A) of the Affordable Care Act to describe consumers who must be consulted. We recommend that Exchanges include in these consultations individuals with disabilities;
b. Individuals and entities with experience in facilitating enrollment in health coverage;
c. Advocates for enrolling hard-to-reach populations, which includes individuals with a mental health or substance abuse disorder. We also encourage Exchanges to include advocates for individuals with disabilities and those who need culturally and linguistically appropriate services;

[pg 44] In paragraph (e), we propose that the Exchange conduct outreach and education activities to educate consumers about the Exchange and to encourage participation, separate from the implementation of a Navigator program described in §155.210. Exchanges should aim to maximize enrollment of eligible individuals into QHPs to increase QHP participation and competition which in turn increases consumer choice and purchasing clout. This will also reduce the number of individuals without health insurance coverage. We encourage Exchanges to conduct outreach broadly as well as in ways that are accessible to people with disabilities,
individuals with low literacy, and those with limited English proficiency. In addition, we encourage Exchanges to target specific groups including hard to reach populations and populations that experience health disparities due to low literacy, race, color, national origin, or disability, including mental illnesses and substance use disorders.

[pg 186] §155.130 Stakeholder consultation.
The Exchange must regularly consult on an ongoing basis with the following
stakeholders:
(a) Educated health care consumers who are enrollees in QHPs;
(b) Individuals and entities with experience in facilitating enrollment in health coverage;
(c) Advocates for enrolling hard to reach populations, which include individuals with a mental health or substance abuse disorder;
(d) Small businesses and self-employed individuals;
(e) State Medicaid and CHIP agencies;
(f) Federally-recognized Tribes, as defined in the Federally Recognized Indian Tribe List Act of 1994, 25 USC §479a, that are located within such Exchange’s geographic area;
(g) Public health experts;
(h) Health care providers;
(i) Large employers;
(j) Health insurance issuers; and
(k) Agents and brokers.

[pg 202] §155.430 Termination of coverage.
...
(c) Termination of coverage tracking and approval. The Exchange must –
(1) Establish mandatory procedures for issuers of QHPs to maintain records of termination of coverage;
(2) Track number of coverage terminations and submit that information to HHS on a monthly basis;
(3) Establish standards for termination of coverage that require issuers of QHPs to provide reasonable accommodations to individuals with mental or cognitive conditions, including mental and substance use disorders, Alzheimer’s disease, and developmental disabilities before terminating coverage for such individuals; and
(4) Retain records in order to facilitate audit functions.

Risks & Benefits of HIE's: "Sensitive" Health Information

noreply@blogger.com (Anonymous) — Tue, 5 Jul 2011 23:09:00 -0400

[cross-posted from Shrink Rap]

I participate in a committee that establishes policies for our state's health information exchange (HIE). The HIE is the electronic infrastructure that permits hospitals, physician groups, labs, imaging companies, pharmacies, and others to share information about patients. The idea behind the sharing is to make it easier for your primary care doctor to share your health data (ideally, with your permission) with your cardiologist and your dermatologist. The potential benefits to this sharing include:

quicker exchange of information than with faxing or mailing
less likely for papers to get misfiled or lost (eg, think Hurricane Katrina)
better tracking of who accessed what information
less duplication of tests ("I know you had a CAT scan at the other hospital last week but I can't wait for the results to be sent to me so I'm getting another one.")
improved coordination of care
fewer medical errors due to more information available
decreased liability due to sharing of important information with other providers

The potential risks include:

decreased privacy due to potential for data breach, identity theft
loss of data due to technical problems (viruses, hardware failure, etc)
failure to secure data due to inadequate authentication, authorization, encryption, etc
more errors in health record due to automated data collection processes
increased liability due to sharing of sensitive information with other providers

I wanted to talk briefly about this notion of "sensitive health information." Our committee has spent many hours discussing what this might mean and how to define it. One view is that all health information should be treated as "sensitive," while another is that only certain categories of health information, such as mental illness, substance abuse, HIV status, domestic violence, abortion history, and genetic data, should be treated with additional safeguards against inadvertent access or disclosure. This latter viewpoint promotes the stigma about mental illness that we have been trying to erase. It wasn't so long ago that epilepsy and cancer might have been on this list. My viewpoint is that patients should be the one to decide which elements of their health information should be treated with extra precautions and which should be considered routine.

This was ultimately agreed upon by the other committee members, but it still didn't help us much because the technology for patients to review their health information and mark which bits should be tagged as sensitive is not yet built into nearly any of the electronic health record products or the HIE systems. There is no standard for doing so nor is there even any agreement about how or whether it should be done. Groups like healthdatarights.org and speakflower.org have promoted these ideals, but we are not much closer to achieving them.

Anyway, I discussed this topic in my Shrink Rap News blog post this week over on Clinical Psychiatry News. Read more about it over there. If you are a psychiatrist, log in or register on CPN and join the discussion (my mistake -- other professionals and also consumers are allowed to register over there).

AMIA 2010: Sunday

noreply@blogger.com (Anonymous) — Mon, 15 Nov 2010 19:00:00 -0500

My first AMIA meeting and I'm finding it filled with all sorts of goodies. There's lots of tweeting going on, too. (Go to TweetChat with hashtag #AMIA2010 to keep up.)

I typed some notes and thought I'd put them here (1) so I can find them again easy and (2) some folks may find them useful (thought maybe somewhat cryptic). (The odd formatting is from OmniOutliner; I've given up on fixing the font colors--the red means nothing--and the bullets don't line up right.)

▼ AMIA 2010 Susan Dentzer, Editor Health Affairs

2010.11.14

▼ "Golden Age" of PPACA (?)

• compared Greek myth of Ae____ to Obama

▼ Open up goldmine of data to public

• CHDI website www.hhs.gov—open

• use data to shape community responses to childhood obesity... Children's Optimal Health

▼ [] l/u Health Affairs 2010 Nov 29:2047

• rapid-cycle improvement of medical home care @Geisnger

• reductions in risk-adjusted chronically ill hospital admission and readmission rates

▼ Three Aims

• 1. Better Health

• 2. Better health care

• 3. Better value

▼ IOM study on variations

• look at var in HC spending, pt diversity, MD decisions on what care to give and evidence

▼ Shared decision making by pts

• ACA provision

• even informed pts don't exercise their options well

• preference-sensitive care

▼ Quotations

• Quotes by George Carlin, Churchill on American People

• Quote by Jerry Garcia re Somebody has to do something and it is pathetic that it must be us

▼ Informatics Issues in HIEs

20101114 Rob Kolodner, Session chair

▼ Development and use of a Medication history Service Associated with a health information exchange: Architecture and Preliminary findings

M. Frisse, Vanderbilt Center for Better Health; L. Tang; A. Belsito, M. Overhage, Regenstrief Institute

• Memphis HIE in use 4.5 yrs... still a pilot going to full force

• 48% had full med hx; getting retail pharmacies online made a big different

• 36% pt not located

• $4 generics good for pts, bad for accurate HIE data

▼ Emergency Medical Services: the frontier in health information exchange

JT Finnell, M. Overhage, Regenstrief Institute

• Project: push HIE data out to EMS staff in 2 counties in Indiana (Siren by Medusa), using ruggedized tablet PC

• Uses LN, FN DOB Gender, can add zip and SSN optional

• Pushes back a pdf with a bunch of data: med list, allergies, DNR status, NOK notification, PMH

• Started at 15% requests to 26% of field pts seen

• 14% of medics never used

• connectivity a problem

• 41% medics nearly always queried system

• 66% said data was important for providing care

• "truth serum" effect (we can look it up if you don't tell us the truth)

• Value with heavy utilizers and pts "found down"

▼ Private Medical Record Linkage with Approximate Matching

E. Durham, Y. Xue; M. Kantarcioglu; B. Malin, Vanderbilt University

• Vanderbilt -- Emory: Flaw in current model for sharing de-identified data

• If pts don't match, they can be overcounted

• prob with fragmented data (spelling, missing data, etc)

• Private Record Matching can improve this using a hash function to maintain privacy but compare individuals

• Steps:

• blocking (toss out some)

• field comparison

• similarity function measures degree of similarity using a comparison vector and into a record pair similarity score

• draw a line where scores above a number are considered a match

• record pair comparison and classification

• Fellegi-Sunter probability vectors: uses log function of an agreement weight and a disagreement weight for each field (eg, FN, LN, MOB)

• Sum the similarity scores across all fields

• Used a data corrupter function to mess up experimental data to see if they get rematched

• looked at accuracy vs runtime

• Main thing they did was to use approximate matching rather than binary matching, leading to increase in accurate matches

• Note: they used a centralized approach but hope to extend ot decentralized model.

▼ Continuity of Care Document (CCD) enables Delivery of Medication histories to the Primary Care Clinician

L. Simonaitis, A. Belsito, G. Cravens, C. Shen, J. Over- hage, Regenstrief Institute

• Used INPC (Indiana)... x1995, 6M pts, 3B data items

• Workflow

• pt to front desk... ADT clinic trigger sends CCD request

• printer prints med hx (CCD)

• MD reviews meds

• CCD is generated, pulling in data from SureScripts and MA, and put rx codes from dif stds in same CCD

• Results: used in 1 clinic over 9 docs and 4500 pts

• 90% of cases took less than 2 min

• med hx helped doc discover drugs they didn't know pt taking, controlled rx overuse, and med underuse

• docs usually did not show med hx to pts

• no change to MD workflow

• accommodates paper-based clinic

• [] XSLT transformation of CCD data very promising

IOM to Address Safety of EHRs

noreply@blogger.com (Anonymous) — Sat, 2 Oct 2010 14:25:00 -0400

Scot Silverstein from the Health Care Renewal blog posted about IOM's recently announced contract with ONC to "identify best policies and practices for improving healthcare safety when using electronic health records."

"Perhaps these studies should have been initiated, say, ten years ago, or at least before the beneficence of health IT and its capacity to revolutionize medicine was openly promoted by the past and current Administrations (the current one going so far as to institutionalize penalties for non adopters)?"

The IOM consensus study, entitled "Patient Safety and Health Information Technology," will be conducted by NAS staffers Samantha Chao, Joi Washington, and Erin Wilhelm:

"The IOM will review the available evidence and the experience from the field on how the use of health information technology (HIT) affects the safety of patient care and make recommendations on how public and private actors can maximize the safety of HIT-assisted health care services. The IOM's final report will be both comprehensive and specific in terms of recommended options and opportunities for public and private interventions that may improve the safety of care that incorporates the use EHRs and other forms of HIT."

While I agree that this effort should have been done long ago, I am glad to see it being addressed. There is much polarization about whether EHRs are the best thing since sliced bread or the worst thing to hit medicine since managed care. Perhaps this IOM study will address both the pros and cons of EHRs from a provider's perspective (though I don't think any of the study staff are providers). Health care providers need to have a voice that can be heard by the vendors and governments when we find that given instances of EHR usability are inefficient or unsafe, and maybe this study will recommendations to address this current gap.

APA Annual Meeting in New Orleans 2010 #apanola2010

noreply@blogger.com (Anonymous) — Tue, 25 May 2010 08:43:00 -0400

Lots of discussion about EHRs at this year's American Psychiatric Association meeting in New Orleans. Other topics of interest to me included TMS (transcranial magnetic stimulation for the treatment of depression), social media, and about the APA's role in helping its members adopt certified electronic health records.

Today at 11am the Committee on Electronic Health Records is presenting in Room 340 at the Convention Center: The Train Has Left the Station: National Incentives and Developments in Electronic Health Records.

Other IT talks were listed in John Luo's article, Your Annual Meeting IT Guide.

HIMSS EMR Adoption Model: 2009 Level 4 (CPOE) Only 14%

noreply@blogger.com (Anonymous) — Mon, 22 Mar 2010 08:00:00 -0400

Hospitals in 2009 continued to have low CPOE adoption (Level 4), but they did manage to jump from 5.8% to 13.5% having CPOE (Computerized Provider Order Entry) from 2008 to 2009.

Looking at the HIMSS EMR Adoption Model trends, you can see how the 5000+ hospitals in the US are gradually moving up the electronic evolutionary ladder towards Level 7, which is full implementation of a completely interoperable, paperless, electronic medical record (note that HIMSS differentiates an "EMR" (within a single organization) from an "EHR", which it defines to specifically be a "subset of each care delivery organization's (CDO) EMR, ... owned by the patient and has patient input and access that spans episodes of care across multiple CDOs within a community, region, or state...").

As a reminder, here are the definitions of the levels (from HIMSS):

It'll be interesting to see how the HITECH Act's financial incentives accelerates adoption of the higher levels (4 and up). Looking at the cumulative adoption percentages below, I'd expect Level 4 to take off in the same way that Level 3 has over the past several years. But that is the hardest transition to achieve due to the dramatic changes in physician workflow required. This is easier to achieve in hospitals where the majority of the physicians are employed by the hospital; however, physicians at most hospitals (especially community hospitals) are not employed, so these hospitals have less fortitude in requiring them to enter their own orders.

Any guesses as to what the 2010 adoption numbers will be?

Snow Storm Good Advertisement for the Need for Telepsychiatry

noreply@blogger.com (Anonymous) — Sat, 6 Feb 2010 07:46:00 -0500

Two feet of snow and Baltimore comes to a screeching halt. How to get the doctors to the hospital? This is where telepsychiatry can be very helpful. However, there are still so many impediments to using telemedicine (billing, liability, documentation, technical) that we are *still* unable to use it when we need it. Like today, where the hospital will have to send a 4x4 to pick up Dr Chandran to get him to the hospital.

A broader term for distance mental health services is Telemental Health services, or TMH. Proposed new regulations were released last week that would permit and regulate TMH under the public mental health system (aka Medicaid) in Maryland. Unfortunately, the way it is currently written would not permit me to "see" inpatients on our unit from home during a blizzard. Still, it is a step in the right direction.

For more info on TMH, check out the Maryland Telemental Health website.

This is a Job for Flower!

noreply@blogger.com (Anonymous) — Sun, 3 Jan 2010 23:00:00 -0500

First post of 2010. Happy New Year, all! Oh, and enjoy reading the 500+ page Meaningful Use proposed rule [pdf] we got for New Years. More on that in a later post; in meantime, check out David Harlow's post on HealthBlawg.

Alan Viars (@aviars) wrote a post yesterday about his father's difficulties in getting access to his medical records when transferring from Hospital A to Hospital B. His father's POA had to essentially throw a fit just to get a copy of the records prior to open heart surgery at the receiving hospital, as they "don't normally do that." Oh, and his father learned that his EKG from a year ago showed evidence of a silent heart attack but no one ever told him.

Alan concludes:

Lessons for the Wise:
When you have medical tests, YOU THE PATIENT, need to ask for the results. Get a copy. Make sure your physician has actually reviews your tests. Just because you didn’t hear anything, don’t assume everything is okay.
If it’s possible, when you go to the hospital have someone by your side who cares about you and can advocate for you. If you’re lucky enough to have a nurse, physician, or other medically educated person to be your advocate, even better.
Sadly, you may have to get angry in order to gain access to your medical records. Don’t let them tell you no. It’s YOUR data – all of it – and it’s your right to have a copy. Keep your own records.

This is a great example of what the Speak Flower movement is all about.

It's about getting access to your health information -- easily, quickly, automatically.

It's about allowing other authorized individuals or entities to access your health information -- easily, quickly, automatically.

It's about taking control of the health information that is yours -- easily, quickly, automatically.

Licensing One's Own Health Care Data

noreply@blogger.com (Anonymous) — Tue, 24 Nov 2009 08:00:00 -0500

Paul Roemer at HealthcareITstrategies asked about the difference between a patient owning vs accessing their health care data.

To which I replied:

Paul, I'd like to see a model considered where the patient owns the data, and licenses it out to others, such as doctors, hospitals, and insurance companies. One could then imagine a situation where that data (including their genetic info), owned and licensed by the patient, might have a value. The patient could then do the following:
be paid licensing fees for access to their data (from Google or other marketing companies; and from insurance companies and Pharma, who would benefit from knowing this info)
grant access for free to their providers, spouse, etc
pay others to access their data in order to gain some benefit, such as analytics
This would change the whole discussion about health care, privacy, and costs.

Think about the incredible shifts and changes in the marketplace if such a revolution developed.

Not only would there be this "power to the people" shift in mindset, it would also create a huge change in the average consumer's approach to their own health. It would encourage them to pay attention to their data, and thus their health, in a manner similar to how people pay attention to their savings and checking accounts. It might even result in a reduction in health care costs. It would certainly create a more fluid marketplace.

How do we get there? (add comments/ideas)

[Edit: Dec 13- I'm linking to some of the great prior posts and items noted by the commenters.]

HealthBlawg: David Harlow's interview with law professor Marc Rodwin about idea of public ownership of de-identified health data. [Jul 2009]
Marc Rodwin's JAMA article, "The Case for Public Ownership of Patient Data". [Jul 2009]
Silona Bonewald's post about mutual data ownership. [Jun 2009]
Leo Kish asks: What if all applications, caregivers and patients were connected online? [Nov 2009]
Gregg Masters (@2healthguru) posts "I Will License or Lease My Health Info to Providers". [Mar 2009]
Steve Holcombe's piece on granular information ownership. [Aug 2008]

Links to HIT and MU Resources

noreply@blogger.com (Anonymous) — Fri, 16 Oct 2009 12:42:00 -0400

Please add a comment for other links that should be included. Thanks.

Upcoming meetings & public comment . . .


FDA Hearing on Social Media	Nov 12-13	fdasm.com \| Federal Register notice (PUBLIC COMMENTS thru Feb 28) \| FDA Notice \| AGENDA \| Speakers \| Panelists \| transcript of 1996 mtg re internet
HIT Standards Comm	Thu Oct 29	Public testimony to better understand adoption and implementation issues, needs for enhanced implementation guidance, and identification of enablers that would accelerate interoperability such as new tools or filing standards gaps. We'll also conduct an online forum and accept written testimony. [per John Halamka]
HIT Policy Comm	Oct 27-28	MU relevance to Specialty providers (incl Psychiatry & Behavioral Health), small practices, and small hospitals. \| Agenda \| Webcast \| Oct 27 transcript

ARRA - HITECH Act | W&M summary | statute
Meaningful Use page (HHS)
Meaningful Use matrix (pdf)
Meaningful Use documents (HHS)
Summary of comments from non-physician providers and specialist physicians from June 2009 meeting (pdf)

HIT Policy Committee | meetings | past mtgs | recommendations
HIT Standards Committee | meetings | past mtgs | recommendations
HITSP
CCHIT
Ed Bennett's Hospital Social Media list (list of hospitals and their official blogs, Twitter names, and Facebook pages)

Twitter links . . .

#fdasm: FDA hearing on social media and web2.0 (Nov 12-13)
#hcsm: Health Care & Social Media chat, Sunday nights 9-10 ET
@ahier: Brian often is the first to post transcripts of the public meetings on his blog
#hitpol: Tweets related to HIT policy issues
#ehr: EHR-related tweets
#hchit: Health care HIT chat, Thursdays 1-2pm ET

HITPC Recommends Changes to HIT Certification Process: 10 Bullet Points

noreply@blogger.com (Anonymous) — Fri, 17 Jul 2009 09:00:00 -0400

The recommendations from the HITPC Certification & Adoption workgroup came out yesterday (see below).

Here are my ten take-home bullet points:

Certification should be solely focused on Meaningful Use, Privacy, Security, & Interoperability. Nothing extra.
The setting of criteria and testing of criteria satisfaction should be done by separate entities.
HHS establishes the certification criteria (not CCHIT).
NIST should oversee the testing to determine if products or orgs meet the criteria.
NIST can accredit orgs, such as CCHIT, to conduct the certification process.
Certification is required every 4 years (this seems too long?).
Slide 17 suggests a surveillance function, which might fill the 4-year gap with periodic monitoring, perhaps.
Open source is clearly accommodated.
CCHIT should keep doing what it is doing until further notice.
"Criteria on functions/features should be high level; however, criteria on interoperability should be more explicit." (Slide 15)

If ONC and HHS agree with all of this, after public comment, then CCHIT will likely become more of a testing org, rather than a standards-setting body.

This is a huge step forward in clarifying and advancing our national HIT undertaking. The Workgroup should be congratulated for this set of recommendations.

HITPC Recommends Changes to HIT Certification Process

View more presentations from sdaviss.

Lyrics: Beautiful Dreamer = Meaningful User

noreply@blogger.com (Anonymous) — Sat, 27 Jun 2009 09:41:00 -0400

A couple weeks ago I had the idea that the song "Beautiful Dreamer" had the same number of syllables as "Meaningful User," so started to rewrite the lyrics appropriately (I love doing stuff like that). But I guess my creative spark fizzled and only got the first verse done.

Here are the original lyrics:

Beautiful dreamer, wake unto me,

Starlight and dewdrops are waiting for thee;

Sounds of the rude world, heard in the day,

Lull'd by the moonlight have all pass'd away!

Beautiful dreamer, queen of my song,

List while I woo thee with soft melody;

Gone are the cares of life's busy throng,

Beautiful dreamer, awake unto me!

Beautiful dreamer, awake unto me!

Beautiful dreamer, out on the sea

Mermaids are chanting the wild lorelie;

Over the streamlet vapors are borne,

Waiting to fade at the bright coming morn.

Beautiful dreamer, beam on my heart,

E'en as the morn on the streamlet and sea;

Then will all clouds of sorrow depart,

Beautiful dreamer, awake unto me!

Beautiful dreamer, awake unto me!

Here's what I came up with so far...

Meaningful user, wake unto me,

Certifications are waiting for thee;

Sounds of our health care, falling away,

Lull'd by C-C-H-I-T saving the day!

Meaningful user, no one defines,

Stimulus money for healthcare IT;

Will it prevent us from losing our minds?

Meaningful user, awake unto me!

Meaningful user, awake unto me!

Please have a go at finishing it up in the comments. Thanks.

Meaningful Use: Official Draft Definition Released by HITSP

noreply@blogger.com (Anonymous) — Tue, 16 Jun 2009 16:30:00 -0400

The anticipated release of the draft definition of "meaningful use" (mentioned in ARRA but not defined) was released by the HITPC (Health IT Policy Committee) today. There is a public comment period ending June 26 (max 1000 characters). All public comments should be sent to MeaningfulUse@hhs.gov. The anouncement is on the HHS website.

The preamble describes the framework, while the matrix lays out the five policy priority areas and the target measures for each 2-year block (2011, 2013, 2015). The 5 areas are:

Improve quality, safety, efficiency, & reduce disparities 
Engage patients & families
Improve care coordination 
Improve population & public health 
Ensure privacy & security protections

Each area has associated Care Goals (eg, use evidence-based order sets and CPOE; provide transparency of data-sharing to patient), along with Objectives and Measures for each of the three 2-year blocks. Check out the Matrix for details (alternatively, just follow the white rabbit).

So, for example, under Improve Care Coordination, we have the following:

Care Goal
Exchange meaningful clinical information among professional health care team

2011 Objectives

(Goal is to electronically capture in coded format and to report health information and to use that information to track key clinical conditions)

Exchange key clinical information among providers of care (e.g., problems, medications, allergies, test results) [OP, IP]
Perform medication reconciliation at relevant encounters [OP, IP]

2011 Measures

Report 30-day readmission rate [IP]
% of encounters where med reconciliation was performed [OP, IP]
Implemented ability to exchange health information with external clinical entity (specifically labs, care summary and medication lists) [OP, IP]
% of transitions in care for which summary care record is shared (e.g., electronic, paper, eFax) [OP, IP]

2013 Objectives

(Goal is to guide and support care processes and care coordination)

Retrieve and act on electronic prescription fill data [OP, IP]
Produce and share an electronic summary care record for every transition in care (place of service, consults, discharge) [OP, IP]
Perform medication reconciliation at each transition of care from one health care setting to another [OP, IP]

2013 Measures

Additional public reports using NQF-endorsed HIT-enabled quality measures [OP, IP]
% of transitions where med reconciliation was performed [OP, IP]
% of encounters where fill data accessed [OP]
% of encounters where clinical information is shared with external clinical entities [OP, IP]

2015 Objectives

(Goal is to achieve and improve performance and support care processes and on key health system outcomes)

Access comprehensive patient data from all available sources

2015 Measures

Aggregated clinical summaries from multiple sources available to authorized users [OP, IP]
NQF-endorsed Care Coordination Measures (TBD)

There was a lot of discussion about moving some of the more distant objectives up sooner. This part of the discussion (before the lunch break) was tabled, and a plan to release a revised draft was described.

There was also quite a bit of Twitter discussion as well (see search.twitter).

If you'd like to read the transcript of the conference call, check out Brian Ahier's blog.

#hcsm: Jun 14: Legal Issues Around Use of Social Media in Health Care

noreply@blogger.com (Anonymous) — Sun, 14 Jun 2009 23:30:00 -0400

Whew! This one was a doozy. Instead of the usual 4-5 topics, there were 900 (well, it felt like that). This is my recap. Note: These are just my own personal notes from the Sunday night #hcsm chats on Twitter. It's what I found interesting or memorable or wanted to be able to easily refer back to.

We were treated to two "guest" tweeters, both health attorneys. From @healthsocmed :

-@danielg280 is Daniel Goldman

Dan is a graduate of UCLA and UVA law school, chair of Business Law group at Mayo Clinic and member of Mayo Clinic's brand management team. Practice in the areas of business law, copyright, trademark, telemedicine, privacy and internet. Biggest claim to fame is legal counsel for Mayo Clinic's Social Media efforts headed by @Leeaase

-@healthblawg is David Harlow

David’s legal and consulting practice includes advising health care providers of all shapes and sizes on a variety of business and regulatory issues, including HIPAA compliance, patient communications and more. Please contact him if you require such services.

Web http://www.harlowgroup.net

Blog http://healthblawg.typepad.com

The Disclaimers

*No legal advice will be offered during this chat event*

"No legal advice" means the attorneys will not address specific use cases (e.g. "at my hospital, we have this social media problem, what is your advice")

The attorneys will engage on general issues, concerns and legal topics related to the use of social media in healthcare

The tweets:

healthblawg Biggest areas of concern ppl have re healthcare SoMe is HIPAA and privacy law. Right area to be concerned abt. #hcsm 15 Jun 2009 from TweetChat

healthblawg Fed and state healthcare privacy laws interact and overlap; EU & other int'l law to think abt given global reach of www #hcsm 15 Jun 2009 from TweetChat

healthblawg Under HIPAA, 'covered entity' can't release PHI to 3rd party w/o pt consent. #hcsm 15 Jun 2009 from TweetChat

healthblawg Providers get consent up front by having pts sign notice of privacy practices (NPP); need to articulate planned use for PHI in NPP #hcsm 15 Jun 2009 from TweetChat

healthblawg State law can be stricter than HIPAA (recent NV and MA general privacy laws, focused on protection against ID theft) #hcsm 15 Jun 2009 from TweetChat

healthblawg Another area of concern: mandated reporting. St law often make providers mandated reporters of things like gunsht wnds, domestc violnc #hcsm 15 Jun 2009 from TweetChat

healthblawg I mention mandated reporting laws as example of how receiving info via SoMe may trigger obligations beyond obligs to pt #hcsm 15 Jun 2009 from TweetChat

healthblawg Mass. law, for example, applies to doc who is attending or treating pt w GSW http://bit.ly/qbHZz What does attending or treating mean? #hcsm 15 Jun 2009 from TweetChat

healthblawg When docs offer medical advice via tweets or other SoMe I'd say they are 'treating' #hcsm 15 Jun 2009 from TweetChat

healthblawg #hcsm But let's step back a mopment... IMHO, this is all a bit academic right now. The @susannahfox Pew/CHCF rpt, 'The Social LIfe of Health Information' released last week says only 6% of people want health info via SoMe http://bit.ly/lw72h Now, @edbennett says that will change, and I agree - change will come, and so we have the opportunity to plan, lay groundwork for these interactions, develop rules of the road for the future: like rewriting NPPs with SoMe in mind, for example.... Read More: http://is.gd/123pv 15 Jun 2009 from Twitlonger

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danielg280 Gd evning. Jst a remndr that I’m a civilian tonight. My opnions r my own, not my employer's. Also, this is gen'l info, not legal advc #hcsm 15 Jun 2009 from TweetChat

danielg280 Laws to be aware of: State licensure laws for docs and nurses: Center for telehealth and ehealth law: http://tinyurl.com/mqwsfn #hcsm 15 Jun 2009 from TweetChat

danielg280 Copyright law and fair use: Stanford Libraries C page: http://tinyurl.com/374b4 Disney C parody http://tinyurl.com/2mvjg2 #hcsm 15 Jun 2009 from TweetChat

danielg280 Defamation: Electronic Frontier Foundation Blogger’s legal guide: http://tinyurl.com/ah8rr9 #hcsm 15 Jun 2009 from TweetChat

danielg280 Trademark law: INTA trademark basics: http://tinyurl.com/bakgxb #hcsm 15 Jun 2009 from TweetChat

danielg280 Most medical practice acts are broad and cover any attempts to heal or diagnose, whatever the means #hcsm 15 Jun 2009 from TweetChat

danielg280 T 3.1, Generally this is fine, so long as its voluntary and the patient signs a hipaa compiant auth #hcsm 15 Jun 2009 from TweetChat

danielg280 Key is to make sure patient really understands what they're getting into. Don't want to have them surprised they're on network tv #hcsm 15 Jun 2009 from TweetChat

danielg280 Generally claims of "best" are puffing, and ok to say without support. #hcsm 15 Jun 2009 from TweetChat

danielg280 May not need an auth if only allowing a forum for them to do it. May need an auth of directly soliciting #hcsm 15 Jun 2009 from TweetChat

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NOTE: These tweets are not necessarily in order. QuoteURL is not consistent about that.

stephaniethum @healthblawg Does that mean language in NPP practices documents need to change to include SM references as a "planned" use? #hcsm 15 Jun 2009 from TweetChat in reply to healthblawg

dr_bob @healthblawg yes have to be careful about creating an online doctor-patient relationship #hcsm 15 Jun 2009 from TweetChat

drval @healthblawg But what constitutes medical advice? A direct suggestion to a specific person to change mgmt or DO something? #hcsm 15 Jun 2009 from web

ctsinclair @healthblawg What is the difference between medical advice and education about medical topics? Are there cases debating this? #hcsm 15 Jun 2009 from TweetChat

ShrinkRapRoy "advice"...it's all in what you say & how you say it. Need to speak in generalities and veer away from specific case.
#hcsm 15 Jun 2009 from TweetChat

craigstoltz "Advice" easy to spot/disclaim in "long" form online media. In a Tweet, hard to draw line between [actionable] advice & benign info #hcsm 15 Jun 2009 from TweetDeck

healthblawg @drval Sounds about right; so need to est MD-pt rel 1st IRL #hcsm 15 Jun 2009 from TweetChat in reply to drval

dr_bob @ctsinclair education is general, treatment is specific to the patient #hcsm 15 Jun 2009 from TweetChat

ctsinclair @dr_bob Yes but any education may be considered specific from the pt point of view and therefore become advice 15 Jun 2009 from twhirl in reply to dr_bob

healthblawg @stephaniethum Yes I think NPP's need to be updated to reflect SOMe use #hcsm 15 Jun 2009 from TweetDeck in reply to stephaniethum

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Fact or Myth

T1.1 Fact or Myth: Patients can disclose PHI, evaluate docs, payers, providers anywhere/anytime using social media. Providers not in control.

candacee116 Everyone owns their own story. If they wish to share on a soc/med site-they are giving permission
#hcsm 15 Jun 2009 from TweetChat

ctsinclair T1.1 I vote Fact. RE: Patients can disclose PHI, evaluate docs, payers, providers anywhere/anytime using social media. #hcsm 15 Jun 2009 from TweetChat

healthblawg T1.1 Pt can disclose own info; if provider sponsored forum important to have notice re lack of privacy #hcsm 15 Jun 2009 from TweetChat

patrickmann How can a doc truly a patient is who they say they are over SM? #hcsm 15 Jun 2009 from TweetChat

chrisboyer Re: T1 - i would like to agree with @ctsinclair - I would like for this to be ffact. #hcsm 15 Jun 2009 from TweetDeck

danielg280 1.1 Fact Patient controls own PHI and can disclose.Can also say what they want re docs, subj to limits of libel Must be opinion or tru #hcsm 15 Jun 2009 from TweetChat

dr_bob @patrickmann on SM nobody knows if you're a dog #hcsm 15 Jun 2009 from TweetChat

ahier anyone have real-life examples of pt testimonials on hospital blogs? #hcsm 15 Jun 2009 from TweetDeck

StevenBarley @irb123 For example: http://bit.ly/MRd89
#hcsm 15 Jun 2009 from TweetChat in reply to irb123

chrisboyer @MarksPhone I believe a patient can comment wherever they want, whenever they want on SM. That's they're right. #hcsm 15 Jun 2009 from TweetDeck in reply to MarksPhone

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T1.2 Fact or Myth: Providers should never follow, friend or reply to patients via social media, HIPAA absolutely forbids this.

ShrinkRapRoy RT @patrickmann How can a doc truly a patient is who they say they are over SM? [good point]
#hcsm 15 Jun 2009 from TweetChat in reply to patrickmann

danielg280 Spoofing is a concern on SM, which is why it's generally not a good idea for true treatment relationship without a way to validate id #hcsm 15 Jun 2009 from TweetChat

nickdawsonhc do patients have an expectation that they will be treated via SM? #hcsm 15 Jun 2009 from TweetChat

candacee116 Ithink you should not create a relationship separate from provider/patient on soc media such as FB or MS but reply on email to patient #hcsm 15 Jun 2009 from TweetChat

healthblawg T1.2 Best practice: advance consent; online or paper, should be part of std HIPAA NPP (notice of privacy practices) #hcsm 15 Jun 2009 from TweetChat

danielg280 Close to fact: Prvdr mst be mindful of pvcy obligations and HIPAA in all interactions. Evn Disclosing that someone is a pt is a prob #hcsm 15 Jun 2009 from TweetChat

nickdawsonhc I think most PTs understand that SM is like a cocktail party. Ask general questions, not seeking treatment. seems a moot point to me #hcsm 15 Jun 2009 from TweetChat

candacee116 If they are in rural area, this may be only means of health info communication-they may need Dr to friend them to establish connection #hcsm 15 Jun 2009 from TweetChat

macobgyn How is a patient asking me questions after hours via SM any different than the pt calling me through the office paging system?
#hcsm 15 Jun 2009 from TweetChat

ekivemark #hcsm Seems like we need an "I opt out of HIPAA" just like we have a "Do Not Call" Registry 15 Jun 2009 from TweetDeck

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T1.3 Fact or Myth: Employees have no right to use social media "on company time" for personal matters. Blocking access is ok.

T1.4 Fact or Myth: Employers cannot regulate employee speech-employees can use personal PCs/phones, networks & *personal* social media accts

danielg280 t1.3 true No employee "rights" to do this. Employers can limit or allow as they see fit. dsnt mean it's a good idea #hcsm 15 Jun 2009 from TweetChat

candacee116 Employees deserve breaks can't they go on then? #hcsm 15 Jun 2009 from TweetChat

macobgyn RT @GraftFinder: I think we should start by referring to SM as "Communication" not "media" it portrays the wrong picture. #hcsm 15 Jun 2009 from TweetDeck

healthblawg T1.3 Agree w Dan. However: employee morale issue, and need to enlist employees as SoMe ambassadors now or later so why piss them off? #hcsm 15 Jun 2009 from TweetChat

ekivemark #hcsm T1.3 Employee personal use - If employers want to go there then they should accept not being able to contact off duty employees 15 Jun 2009 from TweetDeck

Aurora_Health @healthblawg employees as ambassadors has great value if directed w/in appr. guidelines #hcsm 15 Jun 2009 from Seesmic Desktop

ShrinkRapRoy T1.3 Agree, no RIGHT to use SM for personal use. But are what we doing here "personal" or "work-related"? Both? #hcsm 15 Jun 2009 from TweetChat

craigstoltz Re: Employee use of SM: Employers originally banned telephones for same reason, that they would kill productivity. Ditto web. Now SM. #hcsm 15 Jun 2009 from TweetDeck

bacigalupe @shrinkraproy @HealthSocMed are you making a distinction between exempt and non-exempt employees? Big difference #hcsm 15 Jun 2009 from web in reply to ShrinkRapRoy

ShrinkRapRoy @bacigalupe Great point! As an exempt employee, when am I ever really "off"?
#hcsm 15 Jun 2009 from TweetChat in reply to bacigalupe

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T1.5 Fact or Myth: Social media content published by employees on work or personal accounts is automatically the property of the employer

danielg280 Myth mostly but emplyers own stuff created "w/in the scope of emplymnt" #hcsm 15 Jun 2009 from TweetChat

patrickmann Big concern for corps is info leaking out through SM. Company is liable for employee actions. #hcsm 15 Jun 2009 from TweetChat

danielg280 thus, If it's your job to do it, could be owned by employer, even if personal acct or equipment. #hcsm 15 Jun 2009 from TweetChat

healthblawg T1.5 Classic work for hire rule; not unique to SoMe - Matter for contractual negotiation #hcsm 15 Jun 2009 from TweetChat

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2. Back to Law School Basics

T2.1 Are social media tools like Twitter, FcBk, YTb redefining what constitutes intellectual property?

ekivemark #hcsm Put the patient at the center -They choose/own/control/delegate - seems like it simplifies a lot of complexities in HC. 15 Jun 2009 from TweetDeck

danielg280 t2.1 Prob not. File sharing was bigr challenge and hasnt caused sea change yet #hcsm 15 Jun 2009 from TweetChat

ctsinclair T2.1 Oh yes. Check out some legal blogs for great posts on "Who owns your LinkedIn contacts?"
#hcsm 15 Jun 2009 from TweetChat

crgonzalez T2.1>> That's where I think your Terms of Use can help guide employees #hcsm 15 Jun 2009 from TweetChat

healthblawg T2.1 Old rules like "fair use" might not seem as fair when the "use" is so instant and widely disseminated; law always plays catch-up #hcsm 15 Jun 2009 from TweetChat

nickdawsonhc Great point--> @sarahzaenger T1.5 Myth. no one can 'own' social media-- it's just out there #hcsm 15 Jun 2009 from TweetChat

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T2.2 Can you copyright a "Tweet" or a "Wall Post" in Facebook? - http://www.canyoucopyrightatweet.com/

danielg280 t2.2 Prob too short to be copyrightable, plus (don't shoot me) not enough creativity per copyright law. #hcsm 15 Jun 2009 from TweetChat

jensmccabe @HealthSocMed #hcsm - can't copyright tweet yet. For IP, suggest this method: 1. creative commons info in profile, blog, facebook. 2. record 15 Jun 2009 from web in reply to HealthSocMed

healthblawg #hcsm T2.2 Twitter TOS says Twitter asserts no claim of copyright, belongs to ac... Read More: http://is.gd/124jz 15 Jun 2009 from Twitlonger

danielg280 The rare tweet that's pure creativity could be (eg haiku), most are not. Good article: http://www.canyoucopyrightatweet.com/ #hcsm 15 Jun 2009 from TweetChat

HealthSocMed @healthblawg and @danielg280 - Can I put a "c" with a circle next to my Tweets or Wall Posts? #hcsm (TS) 15 Jun 2009 from Tweetie

consultdoc RT@chrisboyer @drval This type of conversation would work great in Google Wave...#hcsm #hcsm 15 Jun 2009 from TweetChat

crgonzalez T2.2 Under the Commons, and even under Twitter's rules, a tweet belongs to the owner and can be RT'd w/ author's consent #hcsm 15 Jun 2009 from TweetChat

danielg280 @HealthSocMed You can put the circle C, but it won't affect whether you actually have a copyright #hcsm 15 Jun 2009 from TweetChat in reply to HealthSocMed

danielg280 Actually, you can't own ideas unless it's patentable (which is a very high standard) copr. protects only creative xpression, not ideas #hcsm 15 Jun 2009 from TweetChat

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3. Best Practices

T3.1 What are the issues with *encouraging* or soliciting patient testimonials on a hospital branded social media account?

ctsinclair T#: Had potential client worried about employees or patients saying" Dr. Smith is the BEST doctor!" #hcsm 15 Jun 2009 from TweetChat

danielg280 T 3.1, Generally this is fine, so long as its voluntary and the patient signs a hipaa compiant auth #hcsm 15 Jun 2009 from TweetChat

danielg280 Key is to make sure patient really understands what they're getting into. Don't want to have them surprised they're on network tv #hcsm 15 Jun 2009 from TweetChat

chrisboyer Re T3: why would HC providers attempt to encourage patients to participate on SM accounts? That's against what SM is all about! #hcsm 15 Jun 2009 from TweetDeck

danielg280 Generally claims of "best" are puffing, and ok to say without support. #hcsm 15 Jun 2009 from TweetChat

healthblawg 3.1 Has to be voluntary, authzn needed too #hcsm 15 Jun 2009 from TweetChat

stephaniethum @danielg280 So voluntary, unsolicited online pt testimonials are ok, but only if the person offering the testimonial signed a release? #hcsm 15 Jun 2009 from TweetChat in reply to danielg280

danielg280 May not need an auth if only allowing a forum for them to do it. May need an auth of directly soliciting #hcsm 15 Jun 2009 from TweetChat

EdBennett So it's OK if patient shares happy story on any other blog, but if they post to the hosiptal blog they need a signed release? #hcsm 15 Jun 2009 from TweetChat

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T3.2 Any special issues when a hospital doc tweets vs. hospital employee who is not a doc? Personal vs. corp branded Twitter acct matter?

consultdoc I have officially reached information saturation. I will enjoy reading the summary later. #hcsm 15 Jun 2009 from TweetChat

ekivemark @mkmackey #hcsm Cos have rules for communicating in co name.Most can be applied to SM as just another channel. Not sure more rules needed 15 Jun 2009 from TweetDeck in reply to mkmackey

EdBennett @jensmccabe "control" social media? That just makes me laugh. Only the old and clueless think that way. #hcsm 15 Jun 2009 from TweetChat in reply to jensmccabe

healthblawg #hcsm T3.2 Clinical communications not OK unless between clinician and establish... Read More: http://is.gd/124F6 15 Jun 2009 from Twitlonger

danielg280 t3.2 Docs and nurses generally can't practice med across state lines. Need to be esp. careful to not cross into pract med. #hcsm 15 Jun 2009 from TweetChat

coachkiki @HealthSocMed Perhaps personal accounts vs. work accounts - many gov. employees tweeting have "this is not work" or something on acct. #hcsm 15 Jun 2009 from TweetChat in reply to HealthSocMed

ahier RT @chukwumaonyeije: @drval @Dr_Bob #hcsm Yes. This would be great on BlogTalkRadio @2healthguru 15 Jun 2009 from TweetDeck

craigstoltz RT @HITshrink: Hmm, I haven't seen any ads: "Has this happened to you? Ur doc twittered ur surgery w/o consent?" 1-800-LAWYERS. #hcsm 15 Jun 2009 from TweetDeck

donshep @danielg280 That an interesting one T3.2 if a provider in MA recommends something to a "follower" in CA is that prohibited #hcsm 15 Jun 2009 from TweetChat in reply to danielg280

crgonzalez T3.2 There's the public expectation that what a doctor says can be construde as a medical opinion; not so with non-doc employee #hcsm 15 Jun 2009 from TweetChat

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T3.3 What are the rational boundaries for allowing posting of negative comments on hospital social media account? What's OK to approve, what's not? T3.3-1 Any legal scenario where blocking a negative comment would not be the best course of action?

healthblawg #hcsm T3.3 To me, less legal, more intestinal fortitude issue. In this case (ne... Read More: http://is.gd/124U2 15 Jun 2009 from Twitlonger

HealthSocMed @danielg280 and @healtblawg T3.3 What abt those pesky negative comments in social media toward providers, practitioners, payers? #hcsm (TS) 15 Jun 2009 from Tweetie

jensmccabe @HealthSocMed Allowing posting of critical comments required for improvement. Abusive/trolling take yer pick of best practice TOS. #hcsm 15 Jun 2009 from web in reply to HealthSocMed

danielg280 @HealthSocMed If from non-patient, can pursue for libel if untrue. If patient, Hipaa ties your hands in public forum #hcsm 15 Jun 2009 from TweetChat in reply to HealthSocMed

donshep T3.3 Negative comments are a way of life whether waiting room bitching or on SM not much different #hcsm 15 Jun 2009 from TweetChat

healthblawg T3.3 http://www.medicaljustice.com/ tries to get pts to agree in advance not to post negative rvws; I think that's inappropriate #hcsm 15 Jun 2009 from TweetChat

nickdawsonhc @danielg280 hands tied how? Can you respond Bank Of America style "can't answer here, but here is my number, call me... ?
#hcsm 15 Jun 2009 from TweetChat in reply to danielg280

donshep T3.3 Lawyers are dealing with the same issue aren't they negative comments in SM?
#hcsm 15 Jun 2009 from TweetChat

gocatallina What if patients want to videotape their entire hospital experience and put it on YouTube? What are there boundaries? #hcsm 15 Jun 2009 from web

ctsinclair @donshep Have been following legal sm circles but not seen much chatter about this. Lawyers have ethics guideline re: marketing self #hcsm 15 Jun 2009 from TweetChat in reply to donshep

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T3.4 What about targeted use of SocMedia tools by covered entities & employees toward specific racial, ethnic, gender communities offering treatment? T2.4-1 E.g. HIV/AIDS testing offers are very effective at dating web sites, esp when offer is made by a trusted member of community.

candacee116 @HealthSocMed this might be the best way to reach some vulnerable groups we would not see/hear from otherwise #hcsm 15 Jun 2009 from TweetChat in reply to HealthSocMed

ShrinkRapRoy My hosp is opening OB in Fall. An encouraging them to open up Tw/FB/Flickr. Those new moms wont like no access. #hcsm 15 Jun 2009 from TweetChat

jensmccabe There are Twitter conventions we can try to 'activate' groups without personal identifiers. #getupandmove. #don'tsmoke #hcsm 15 Jun 2009 from web

healthblawg #hcsm T3.4-1 HIV is a whole other story. Many/most states have pt privacy laws ... Read More: http://is.gd/12594 15 Jun 2009 from Twitlonger

sarahskiba #hcsm What protects patients from hackers or stalkers posing as their health care professionals? 15 Jun 2009 from TweetDeck

nickdawsonhc @shrinkraproy OB is our first/most interested service line as well #hcsm 15 Jun 2009 from TweetChat in reply to ShrinkRapRoy

donshep T3.4 I know the hospital I volenteer at is look to social media to keep in touch with gastric bypass/band patients
#hcsm 15 Jun 2009 from TweetChat

MarksPhone @HealthSocMed yes target specific demographic groups with objectives and strategies and outcomes. Use SM as one tactic #hcsm 15 Jun 2009 from TweetChat in reply to HealthSocMed

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T3.5 Is social media message traffic on a provider/employee acct using a provider network subject to HIPAA data capture/retention requirements?

healthblawg T3.5 HIPAA covers PHI. Social media should not include PHI except in ltd circumstances (w consent) #hcsm 15 Jun 2009 from TweetChat

macobgyn @shrinkraproy For the OB people Check out Macarthur OBGYN on Facebook and see what we are doing. #hcsm 15 Jun 2009 from TweetChat in reply to ShrinkRapRoy

leonpalmer Think anyone else would watch if we turned this tweetchat feed into a YouTube video? #hcsm 15 Jun 2009 from TweetChat

macobgyn @ShrinkRapRoy Here is our practices FB page #hcsm http://bit.ly/TGJ7y 15 Jun 2009 from TweetDeck in reply to ShrinkRapRoy

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T3.6 A patient (identifies self as a pt of specific hospital) makes a public comment about an inaccurate bill on a social media account. T3.6-1 Can the hospital respond in the same forum? Can the hospital respond with helpful details? T3.6.2 Can the hospital set the record straight if the patient representation is grossly inaccurate or misleading?

jensmccabe @HealthSocMed re: hospital setting record straight if patient account 'grossly inaccurate' exhibit A: Glenn Beck (bleck). No, counter. #hcsm 15 Jun 2009 from web in reply to HealthSocMed

HealthSocMed @danielg280 and @healthblawg T 3.6 - pt tweets about a bill, "too much", "not right", "outrageous" #hcsm (TS) 15 Jun 2009 from Tweetie

jensmccabe Slander, libel will somehow make their way into our precedents for rating/ranting using social media sites and tools methinks. #hcsm 15 Jun 2009 from web

stephaniethum @HealthSocMed T3.6.2 Interesting q b/c even if they *could* set the record straight, should they, publicly, for face-saving reasons? #hcsm 15 Jun 2009 from TweetChat in reply to HealthSocMed

danielg280 Provider can't respond publicly unless patient auths in writing. response almost always will entail the disclosure of PHI #hcsm 15 Jun 2009 from TweetChat

ahier #hcsm @HealthSocMed pts tweeting about bill needs to be immediately personally responded to (just like other business) 15 Jun 2009 from web

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T3.7 A 3rd party posts via Twitter, Facebook, MySpace: “My grandmother has been waiting in the ER for hours, sucks!” T3.7-1 Can the provider respond to these posts via social media since the patient did not initiate the posting? What if patient had posted instead?

healthblawg T3.6.2 Either without PHI, or w PHI if consent is given; can't assume/imply consent & w unhappy camper, not likely, so keep it generic #hcsm 15 Jun 2009 from TweetChat

nickdawsonhc We've addressed several complaints in comments in local paper's site. (was a top google hit for me). Asked concerned pts to call me #hcsm 15 Jun 2009 from TweetChat

Miz_Marie 50-60 people on chat- way too many comments to follow in one sitting but great topic/posts on Health care and Social Media #hcsm 15 Jun 2009 from web

candacee116 I say respond immediately to someone upset with you and take control to make it right-show you are aware and willing to fix problems #hcsm 15 Jun 2009 from TweetChat

ctsinclair RE T3.7 - if a family member intiated and named the provider,, the provider/org should be able to communicate back without ID of pt #hcsm 15 Jun 2009 from TweetChat

HITshrink @danielg280 "Provider can't respond publicly" [well, they could make a general comment about how they manage xyz situations. #hcsm 15 Jun 2009 from web

mneedham @HealthSocMed re: T3.7 “... waiting in the ER for hours... ” :: happens to us regularly - working on response protocol now. #hcsm 15 Jun 2009 from web

healthblawg #hcsm 3.7.1 1. Send a human being to the ER empowered to cut red tape and post a... Read More: http://is.gd/125yq 15 Jun 2009 from Twitlonger

danielg280 @HITshrink AGreed. That's the one way to do it. Still have to be careful not to disclose something patient specific #hcsm 15 Jun 2009 from TweetChat in reply to HITshrink

ekivemark @HealthSocMed #hcsm T3.6.2 This prob exists in many other industries. Don't get in a cat fight. Be reasonable. undetones will come through 15 Jun 2009 from TweetDeck in reply to HealthSocMed

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T3.8 A patient initiates a private email or public social media communication to a doctor/provider that is not solicited and contains PHI. T3.8-1 What's the best way to handle the private email or the public social media conversation?

mneedham @HealthSocMed re: T3.7 “... waiting in the ER for hours... ” :: response will involve personal delivery of flowers - not social media #hcsm 15 Jun 2009 from web

macobgyn @HealthSocMed T3.8-1 Great question. Should the provider not respond? #hcsm 15 Jun 2009 from TweetChat in reply to HealthSocMed

ctsinclair RT @donshep A good rule is to use your profile URL to have a FAQ about how you will interact on twitter. "Good tip" #hcsm 15 Jun 2009 from TweetChat

GraftFinder Explain the "openness" of the comm plateform in PLAIN language to the patients and have them sign that they understand risk/reward #hcsm 15 Jun 2009 from TweetChat

healthblawg T3.8 Email and other elec comm OK w est pts; "cold call" needs friendly but firm response instructing pt on how to est that rel #hcsm 15 Jun 2009 from TweetChat

chrisboyer Wish I could spend more time on #hcsm, but will have to check back on the transcript later. Will blog my thoughts: http://bit.ly/T7rfK 15 Jun 2009 from TweetDeck

patrickmann T3.8 I have always recommended our users remove any unwanted PHI information when replying to a patient via email. #hcsm 15 Jun 2009 from TweetChat

GraftFinder I would much rather talk to a Dr by email personally, unless I was very sick. #hcsm 15 Jun 2009 from TweetChat

danielg280 HIPAA actually does not mandate encrypted email. Doc can use regular email to correspond with patient and not violate law #hcsm 15 Jun 2009 from TweetChat

danielg280 Need to think thru whether it's a good idea: will email be attended if pt emails time sensitive, will info get into med record, etc #hcsm 15 Jun 2009 from TweetChat

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Wrap Up

HITshrink @StevenBarley So right ... this is a convo that must be reread later to digest, reflect. [will add to http://tr.im/ouuF #hcsm 15 Jun 2009 from web

HealthSocMed Big thanks to David Harlow and Daniel Goldman for their time tonight at #hcsm. Virtual applause/cheering! (TS) 15 Jun 2009 from Tweetie

HealthSocMed And many thx to all who participated in this experimental format. Obviously, lots of lessons learned. Thanks for your patience. #hcsm (TS) 15 Jun 2009 from Tweetie

danielg280 Thanks everyone for the lively chat. Lots of fun, tho what little hair I have is standing on end and I'm sweating. . . #hcsm 15 Jun 2009 from TweetChat

HITshrink @ekivemark Coveritlive used on my blog if you want some recap of tinight. http://bit.ly/Y101M [VERY COOL!] #hcsm 15 Jun 2009 from web

danamlewis if you have comments, suggestions, and/or ideas for a future #hcsm, please feel free to DM @danamlewis @healthsocmed or @tstitt 15 Jun 2009 from TweetDeck

healthblawg @patrickmann HIPAA and Son of HIPAA -- some of the questions raised by ARRA changes to law http://tinyurl.com/nvpd5j #hcsm 15 Jun 2009 from TweetChat in reply to patrickmann

healthblawg Thank you all - and I look forward to continuing the conversation here, there and everywhere #hcsm 15 Jun 2009 from TweetChat

otoole4info Look for transcript in the next 24 hrs I'll Tweet when it's complete! #hcsm 15 Jun 2009 from TweetChat

danamlewis wonderful volunteer @otoole4info is compiling a transcript, & i believe @klxmedia is providing some overviews (in addition to others) #hcsm 15 Jun 2009 from TweetDeck

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#hcsm: Apr 5 Topic 2: Will HC Orgs to use Social Media

noreply@blogger.com (Anonymous) — Sun, 19 Apr 2009 23:21:00 -0400

HealthSocMed TOPIC 2 - Will inviting people to join the conversation via SM work? Can HC orgs get people to sign up and use SM? #hcsm 06 Apr 2009 from web

ctsinclair Other HC Orgs: Hospices, Home Health, Nursing Homes, Pharmacies #hcsm 06 Apr 2009 from TweetChat

flipgonzo T2 - what defines the tipping point or critical mass that will make joining the SM convo valuable for 'people', whoever that is? #hcsm 06 Apr 2009 from TweetChat

jacquebrown T2 - Before we try to get more ppl to sign up, we need to figure out how to talk (and listen) to ppl who are already out there #hcsm 06 Apr 2009 from TweetChat

aloumeyer I think engaging employees, patients and their families is important for hospital use of SM. They're most likely to join vs. avg. Joe. #hcsm 06 Apr 2009 from TweetDeck

nickdawsonhc @DaphneLeigh if you look at raw numbers about 0.5-3% of a HC orgs market r likely 2 be on twitter are we waiting on them or vice versa #hcsm 06 Apr 2009 from TweetChat in reply to DaphneLeigh

EdBennett heard that Mayo Clinic is actively engaging its employees to become ambassadors on SM #hcsm 06 Apr 2009 from TweetChat

ctsinclair @dfolkens With such low barrier to entry for SM, HC Orgs 'think' it is easy to do and lack follow through IMHO #hcsm 06 Apr 2009 from TweetChat in reply to dfolkens

miketempleton @MeredithGould If they want to be successful in SM, they HAVE to commit to the follow through. If they don't, ppl won't be happy. #hcsm 06 Apr 2009 from TweetChat in reply to MeredithGould

EdBennett RT @tstitt SM programs in HC orgs have 1 or 2 personal champions who move fast, take calculated risks, no permission asked #hcsm 06 Apr 2009 from TweetChat

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Note: These are just my own personal notes from the Sunday night #hcsm chats on Twitter. It's what I found interesting or memorable or wanted to be able to easily refer back to.

#hcsm: Apr 5 Topic 1: Paid vs Earned Media Coverage

noreply@blogger.com (Anonymous) — Sun, 19 Apr 2009 20:33:00 -0400

nickdawsonhc @PediatricInc great question - does bought media have an air of being inauthentic simply b/c it can be purchased? #hcsm 06 Apr 2009 from TweetChat in reply to PediatricInc

tstitt @Doctor_V @DaphneLeigh With Google indexing everything, SM is like WOM on steroids but you never flush the SM steroids. #hcsm 06 Apr 2009 from TweetChat in reply to Doctor_V

flipgonzo @nickdawsonhc SM can have an air of inauthentic if the source is not transparent #hcsm 06 Apr 2009 from TweetChat in reply to nickdawsonhc

PhilBaumann T1 - Earned SM involves investment of Time into Trust. Paid media involves investment of Dollars into Interruption. #hcsm 06 Apr 2009 from TweetChat

chimoose I'm waiting for the "so what" in the social/earned media discussion. Have I missed the point? #hcsm 06 Apr 2009 from Tweetie

-- this quote was brought to you by quoteurl

Note: These are just my own personal notes from the Sunday night #hcsm chats on Twitter. It's what I found interesting or memorable or wanted to be able to easily refer back to.