• Hospitals
  • A portal doesn’t improve US hospital outcomes

    As the internet and web have spread across healthcare, portals have been seen as an essential link between patients and clinical teams. It seems they don’t make any difference to hospital outcomes. A study at Mayo Clinic Hospital, Jacksonville, published in the Journal of the American Medical Informatics Association (JAMIA), found the 30-day re-admissions, inpatient mortality and 30-day mortality rates were virtually the same for hospital patients who used portals without prompting and those who didn’t have accounts to use them. The 30-day rates were adjusted for Lengths of Stay (LOS).

    Interpreting the results needs to incorporate the limitations of the portal. It has no specific features for communication between patients and healthcare teams. It only includes admission notes, operative notes, consultations and laboratory studies in real time. Daily progress notes can’t be viewed, and there’s a 72-hour delay in viewing radiology and pathology reports. There’s no educational material about patient-specific diseases and processes.

    Patients with portal accounts seem to drop their access on admission. About 44% of patients who had a portal account when they were admitted, but fewer than half, about 21%, accessed it when they were inpatients. Other studies have found similar results, such as 34% and 23%. For tertiary services, the rates were 25% and 16%.

     of registered users accessed their account.22 The lack of features designed specifically for inpatient use was previously emphasised in a systematic review.14 Consequently, several medical centres designed hospital-specific applications aimed at improving the use and usability of inpatient portals.23–25 In a realistic review, Roberts indicated that patient participation with inpatient health information technology (including patient portals) can be augmented by interactive learning focused on information sharing, self-assessment and feedback, tailored education, user-centred design, and user support. Outpatients with severe diseases use portals more frequently. 

    Patients who access portals have better outcomes for some chronic conditions such as: 

    ·             Diabetes, with lower haemoglobin (HbA1c) after 6 months

    ·             Hypertension, with improved blood pressure control at 12 months)

    ·             Depression management, with increased medication adherence

    ·             Preventative care, such as up-to-date immunisations and mammograms. 

    Portals can have benefits. African health systems need to be explicit about what their portals can achieve and ensure that these are maximised.

  • eHealth for consultations can reduce hospital waiting times

    It’s inevitable that appointments with hospital specialists have waiting times. eHealth that provides online consultations can reduce them. A report in the New England Journal of Medicine (NEJM) Catalyst says NYC Health + Hospitals, an integrated healthcare system of hospitals, neighbourhood health centres, long-term care, nursing homes, and home care, has built an eConsult services that improves access to specialty care and reduces patients’ waiting times.

    It offers fast review of clinic referrals for specialists to provide clinical guidance to some referring providers. The initial pilot found 30% of referrals were either appropriate for management by the referring provider or needed extra work before patients were seen by specialists. Transforming these clinical and working practices has three lessons that Africa’s health systems can consider for their eHealth strategies and plans: 

    1.     Learn the unique needs and limitations of health systems’ referral processes so eConsult’s aligned specific needs

    2.     Specialty clinics must prepare for an appropriate eConsult workflow by designating a specialist reviewer who can triage each referral and allocate resources for patient communications and scheduling

    3.     Specialty providers must collaborate on the best care plan each patient and set clear expectations on communications and shared management. 

    The greatest waiting time reduction was a pilot clinics third next available appointments dropping from 37 days to eight days in the first six months, about an 80% improvement. Achieving an equivalent for Africa’s health systems can improve productivity and liberate some of their overstretched healthcare resources for redeployment to other patients, and minimise costly journeys for patients and save them time.

    Los Angeles County Department of Health Services provides acute and rehabilitative services with 19 integrated health centres. Fierce Healthcare has reported that its eConsult service achieved similar benefits. About 25% of patients resolve their health issues without visiting specialists.

  • India’s NH adds another eHealth centre to its services

    Remote communities are challenging for all health systems. Solutions can rest with high level operators, not just community services.

    Narayana Health Group (NH), a successful healthcare provider in India, runs several prestigious facilities and services in and around West Bengal. They include Rabindranath Tagore International Institute of Cardiac Science in Mukundapur, Kolkata and Narayana Superspeciality Hospital in Guwahati and another in Howrah. It’s not surprising that it’s launched its fourth eHealth Centre in West Bengal at Tikiapara in Howrah. A report in the Echo of India says the initiative’s in association with Rebecca Belilious Charitable Dispensary, a Samaritan Help Mission project. The goal’s to make primary healthcare and diagnostic facilities accessible to people living in Howrah’s remote communities where access to quality healthcare, specialist consultations and diagnoses aren’t available.

    NH’s initiative includes telemedicine and cloud services. These help to overcome connectivity, electrical supplies and sourcing medical team challenges of rural areas. These are longstanding challenges caused by a lack of medical resources and poor infrastructure. The eHealth Centre will overcome these because it relies on self-sustained infrastructure and robust healthcare services using remote access through cloud technology.

    There are NH lessons for Africa’s health systems. Integrating eHealth as part of health system expansion may offer better opportunities that stand-alone eHealth programmes. eHealth is, after all, one of healthcare’s resources.

  • Four apps for ER doctors

    Emergency Rooms (ER) are busy. mHealth that eases workload and makes ER doctors’ working lives better are worth it. In Med Page Today, Dr Iltifat Husain has identified four that help.

    GoodRx for Doctors, described by Dr Husain as “fantastic … for helping your patients be compliant with their prescriptions,” it included a bookmark to find medications prescribed frequently but may be unaffordable for patients. An equivalent for Africa’s health systems would be well received by communities.

    OrthoFlow was developed by UK orthopaedic surgeons and doctors working in Accident and Emergency. Dr Husain says it’s “A great fracture management app that essentially puts an orthopedic surgeon in your pocket.” It helps with fracture management and understanding essential features of fractures, such as how much displacement needs changed management.

    STD Tx Guide, developed by the US Center for Disease Control and Prevention (CDC) provides alternative antibiotic regimes for patients allergic to penicillin (PCN). The app was updated recently to include new guidelines.

    Gout Diagnosis avoids tapping red or painful joints. Dr Joshua Steinberg took a validated study on gout diagnosis and created an app. He’s a bit of an appthusisast. They’re all available from iTunes.

    Africa’s mHealth plans could include investment programmes in ER services. These would have to be in parallel with investment in mHealth for citizens and communities.

  • Four ways hospitals should respond to data breaches

    A quick and simple set of steps to guide a data breach are in a slideshow in Health Data Management. The overall goals are to plan to minimise damage and react constructively. It suggests that the day after, hospitals should react, respond, transform and sustain. Advice is don’t report a breach until you understand where it’s from, what its goal was and which part of the infrastructure was compromised.

    The four steps include:

    React: understand what happened and collect and preserve evidence, detect a stop further damage and look for previous, unidentified attacksRespond: deal with security gaps and concerns and add new, effective defencesImprove: develop organisation’s cyber-security priority, attitude and behaviour  and redefine securitySustain: monitor constantly and support a dedicated security team led by a Chief Information Security Officer.

    It’s a simple checklist that CEOs and managers in Africa’s hospital and other health services can keep in their draw labelled What to do in the Event of a Security Breach.

  • South Africa introduces electronic bed management system

    A number of hospitals in the Steve Biko Academic Cluster in Tshwane, Gauteng, South Africa have reduced patient waiting times by at least two hours using a new Electronic Bed Management System (eBMS). It was introduced by the provisional Department of Health as part of their healthcare modernisation initiative. Gauteng hospitals manage an average of 27.7 million patients annually, and often experience bed shortages. To address this, the department piloted eBMS at Steve Biko Academic Hospital earlier this year, says an article in allAfrica.

    The eBMS allows medical staff to identify the location of available beds, so improve patient movement and management. Using innovative cloud-based technology, eBMS hospital staff can view current bed availability in their hospital on large display screens or over the Internet on their mobile device or PC. 

    The pilot phase was successful, so a decision was made to roll it out across the cluster., and hospital staff and management have commended eBMS. Hospital personnel use the information to make both long and short term decisions that have led shorter patient waiting times and better ward and staff utilisation. 

    "Management is using eBMS to make reallocation decisions about ward beds. We have split not frequently used wards to move beds to a ward that is always busy. Having had the system in place since early January, Kalafong has already seen a two hour reduction in their casualty waiting times," said Dr Htwe, clinical manager at Kalafong Hospital. "We are so excited about being able to view available beds across the cluster. This increases transparency which helps us improve patient care," added Dr Htwe.

    The Gauteng Emergency Medical Services uses eBMS too, including when transporting patients to hospitals. It leads to better coordination of it services.

    MEC for Health, Ms Qedani Mahlangu said introducing BMS was part of initiatives by the Department to use technology to improve healthcare. She anticipates that eBMSwill be fully implemented across the province by the end of 2016.

  • Analytics can make hospitals better

    As eHealth amasses more and more data, it should drive healthcare managers to use it to help to improve healthcare performance and patient outcomes. It’s not a simple step. Pyramids with data as a foundation build up with information, then knowledge, then may branch into wisdom or power, assuming the two may not be related. Robert Staughton Lynd, a sociologist and co-author of Middletown, had view on this. It was “Knowledge is power only if man knows what facts not to bother with.”

    Warren Strauss’s director of the Advanced Analytics and Health Research Resource Group at Battelle, an innovation company. He says many USA hospitals find it difficult to cut through the clutter of data required by the Centers for Medicare & Medicaid Services (CMS) and Centers for Disease Control and Prevention reporting to Agency for Healthcare Research and Quality (AHRQ) indicators.

    The challenge is how can hospitals use this data for initiatives that can improve and predict performance and improve patient outcomes? There are crucial goals for eHealth in Africa too. They determine many of eHealth’s benefits. His solution’s set out in Hospital Impact. It includes:

    Reviewing patterns in adverse events so hospitals can determine where they need to focus quality improvement efforts and track results of their efforts over time Don’t miss opportunities for improvement because hospitals have a long way to go to realise the full potential of data-driven improvement Present data that’s timely and in a format that’s usable for decision makers, a considerable challenge for many hospitals Make sure that quality information: Is easy to find, use and understand Provides actionable insights using effective analytics tools Offer time-to-value, so it’s as close to real time as possible It’s accessible and flexible Offers benchmarking and collaboration Is secure.

    Achieving these needs a combination of factors to be in place. They’re the right approach, resources and leadership in using analytics. It also needs rigour in selecting relevant data, an artistic skill identified Charles de Lint, a writer; “The best artists know what to leave out.”

  • What's needed for DRG's in South Africa's NHI?

    A critical theme in South Africa’s National Health Insurance initiative is changing the way that hospital services are financed. Switching to Diagnosis Related Groups (DRG) was part of the original Green Paper in 2011, and remains firmly in place in the updated version released in December 2015. It’s not a simple switch, and needs several building blocks to work effectively.

    It’s also a proven financing methodology. Many countries use DRGs, and have developed their bespoke versions. Originally designed as a quality assurance tool in the USA, DRGs were used by the Medicare Program to reimburse hospitals using prospective prices from 1983. It had 470 DRGs across 23 Major Diagnostic Categories (MDC), each of which can include both surgical and medical services. As combinations of WHO’s International Classification of Diseases (ICD), currently ICD-10, they initially didn’t reflect the severity or complexity of the conditions, and adjustments for these came later. There are now over 750 DRGs in use for 26 MDCs, depending on the version and country. Some DRG prices distinguish day case from inpatients. 

    About half the DRGs are medical, 47% for surgery in MDCs, plus 2% for pre-surgery and 1% for surgical cases not in MDCs and two DRGs for an invalid principal diagnosis and ungroupable workload. About 3% of DRGs aren’t in an MDC. It’s roughly a 50:50 split between medical and surgical cases.

    Prospective DRG prices are seen as a way to control healthcare costs. It requires hospitals to manage their unit costs and annual expenditure within these. So why’s it not that simple? DRGs don’t extend across all hospital activity and need time to catch up with new medical techniques. These can either have their own reimbursement rates, or take so long to set that they can be a brake on investment, a claim for a slow take up of telemedicine. A recent example’s the proposal in 2015 from the American Association of Hip and Knee Surgeons (AAHKS) to the Centers for Medicare & Medicaid Services (CMS) to modify or establish a new MS-DRG for total hip arthroplasty (THA) cases involving patients with hip fracture. For 2016, CMS has released DRG version 33, one a year since 1983, including eight changes to existing Medicare Severity (MS) DRGs.

    Since 1983, DRGs have almost gone global. As a proven reimbursement method, many countries have refined them to match their health systems. The UK and Ireland have Healthcare Related Groups (HRG). The Nordic countries have their NordDRG. These reflect health systems’ bespoke characteristics. This includes their different healthcare models and their specific cost structures. 

    Setting prices for DRGs often starts with existing unit costs. This needs a costing system with two main methodologies. One’s Total Absorption Costing (TAC) to allocate and apportion expenditure to unit costs. The others a variable and semi-variable costing methodology to identify expenditure changes arising from changes in workloads. Semi-variable costs are the most challenging to compile. Both methodologies rely on sound workload data and ICD 10 coding.

    Using TAC throws up a specific challenge for healthcare. Direct costs that can be allocated to specific patients are a small proportion of total costs, maybe less than 10%. This creates the risk of large skewed unit costs derived mainly from using formulae for apportionments. One way to minimise these inconsistencies it to create cost pools for the MDCs or specialties where direct costs can be increased significantly. Each MDC can have its own apportionments on to workloads. This minimises skewed results, but doesn’t avoid them, so comparisons between hospitals’ will still reveal some odd numbers.

    For South Africa’s switch to DRGs, some important activities are needed that apply lessons learned from other health systems. They include:

    Test the accuracy and completeness of hospital’s workload data, including duplication challenges as reported in eHNA, and minimising the workload assigned to DRGs for invalid principal diagnoses as discharge diagnoses and ungroupable workload Test hospitals’ ICD-10 readiness to avoid the USA’s unhappy experiences reported in eHNA Design the DRG grouper needed for reimbursement, including DRG choices for patients with more than one DRG for their hospital stay Set up reimbursement models for hospital services that don’t fit the DRG model Design and trial a national hospital costing methodology that reconciles workloads x unit costs to total expenditure Refine the costing methodology Run a parallel DRG financing model alongside the existing model to identify large swings Design an interim DRG financing model to minimise financial risks Estimate and monitor changes to hospital costs and the impact on total health service spending and finance.

    With the NHI’s fourteen-year development timescale, now’s the time to start these. An early start provides time to iron out data idiosyncrasies and will help to minimise risks, which are always prevalent when financing models change. eHNA’s looking forward to reviewing these soon.

  • ICD-10's resulted in lower productivity for US hospitals

    As African countries develop and apply their interoperability (IOp) plans, there’s a salutary lesson from USA hospital. A survey by Himagine Solutions, a coding company, says hospital productivity dropped after hospitals switched to WHO’s International Classification of Diseases and Related Health Problems Series 10 (ICD-10) the standard diagnostic tool for monitoring the incidence and prevalence of diseases and other health problems. It’s also an essential data source for Diagnosis Related Groups (DRG) and their derivatives.

    ICD-10’s a statistical tool requiring compliance with WHO’s definitions and rules. The data enables accurate, consistent and comprehensive capture of data for secondary purposes, including billing. It’s not designed for recording by clinicians at points of care. That’s Systematized Nomenclature of Medicine--Clinical Terms’ (SNOMED CT) role.

    Himagine’s survey and Benchmark Report says 75% of respondents predicted the adverse productivity impact from ICD-10 is more than 30%.

    Large hospitals, those with more than 250 beds, reported a productivity drop of 30 to 45% for inpatient services, and a 20 to 40% drop for outpatient services. Community hospitals, which have fewer than 250 beds, the inpatient productivity drop was 22 to 33%, and 35 to 40% for outpatients. 

    Large Hospitals (over 250 beds) are seeing a 30-45% reduction on the Inpatient side and a 20-40% reduction on the Outpatient side. When it comes to Community Hospitals (under 250 beds), the Inpatients reductions are much lower ranging in a productivity decline of 22-33% while the outpatient is higher on average hovering around 35-40%. Teaching hospitals reported an average 40% drop in inpatient productivity, with a 10 to 35% ranges for outpatients.

    It may be that part of the explanation may be an increased rejection of reimbursement claims due to incomplete supporting data, so a loss of income, rather than a productivity drop. Either way, it’s a considerable disruption to hospital’s operational and financial performance. Part of the solution may be better and more training for coders and billing teams and greater use of eHealth solutions. Another part is the low use of Computer Assisted Coding (CAC), about 56%. This could increase to 75% in a year’s time.

    As Africa’s health systems move their eHealth on and rely more on health insurance schemes, it’s important they don’t have a similar experience to the USA. eHealth can be disruptive. It’s a bad idea for hospitals to have strained productivity and income too.

  • PatientSource can fit Africa's hospitals

    A doctor working in England’s emergency services has developed a wide-ranging EHR that’s available for African countries. Dr Michael Brooks set up PatientSource. It has several modules developed by clinicians: 

    eCase notes ePrescribing eObservations Investigations as Computerised Physician Order Entry (CPOE) Patient administration eDischarge Diabetes management Bespoke specialty modules Community mHealth Interoperability (IOp) tools Auditing 

    These enable benefits of:

    Better responses to abnormal vital signs Improved patient safety Health workers’ time savings User friendly for nurses Better monitoring for patient outliers.

    PatientSource works on tablets, so clinicians can take their eHealth to bedsides. Because it’s built around doctors and nurses working with their patients, and it has several IOp tools, it can fit into most healthcare settings in different health systems. It offers an effective EHR option for Africa’s hospitals.