Standardization – It’s Not Just for Reporting Anymore!

June 1, 2010 at 3:23 pm Leave a comment

Via Digistan

While developing mTuitive OpNote, we’ve used the knowledge and experience of many physicians to help shape the form of our postoperative report. As we’ve noted elsewhere, there is no standard form for postoperative reports. There are suggestions and basic requirements put forth by Joint Commission (formerly JCAHO) and each specialty’s own association (like American Society of Breast Surgeons, etc.) usually has its own idea of what’s important to capture in the reports for procedures that fall under its purview. But while debate about and progress in creating standardization for postoperative reports, there are other aspects of Health IT generating their own sets of standards.

This article from American Medical News discusses that, as more medical facilities adopt Health IT solutions, it’s becoming increasingly important to create a standardized schedule for maintenance and upkeep. Depending on the facility, the type of care given and the amount of patients treated, this standard could be revised accordingly – but it is a good starting point to begin a discussion on standardizing the type of care and oversight that Health IT companies will provide to their users. For example, with OpNote, one area that we’ll be working closely with our users is to analyze “financial and clinical performance.” As Pamela Lewis Dolan, the author of the piece, writes:

What it entails: Taking a measurement of how the system is affecting finances and clinical performance by comparing pre-implementation numbers with post-implementation measures. An analysis can run queries by demographics, diagnostic codes, labs, medications and vitals, or a combination of these, and on financial information.

Why it matters: Reviews will help a practice identify its return on investment for its system. The analysis will help the practice identify areas that need further improvement, and areas that an EMR already helped to improve. Reviews also will help a practice prove its case for bonuses or incentives under any insurance plan’s program encouraging information technology use, including meaningful use under Medicare and Medicaid.

What a physician has to do: If the physician is not doing the actual queries, he or she needs to be aware of the results. “If you’re not able to measure at all, you can’t improve,” said Chad Kerr, a health information technology consultant with Ingenix Consulting based in Eden Prairie, Minn.

OpNote allows users to turn formerly free text into structured data that can be mined for reports. Furthermore, we’ll be working with our users on creating the best way to capture this data and to develop a workflow for creating data reports or to generate the most common reports. It’s important that the users of all these new Health IT solutions feel not only like the tech company is still watching out for them, but also that the IT firm is listening to them. And by creating a standardized schedule of maintenance, updates and audits, these companies can go a long way to improving the efficiency of their own product as well as greatly increasing the efficiency of the medical facility.

Electronic signatures are another area of Health IT where standardization is beginning to coalesce. There are a myriad of different standards out there – with no one true universal standard being enforced by multiple agencies. Medicare has its own guidelines, as do some state governments (MA for example). American Health Information Management Association has done an excellent job of combing through all the requirements and standards that have been set up by various organizations and unifying them into one document highlighting best practices for Health IT companies and facilities to follow.

The authors do an excellent job of establishing and defining the common terms that are often used when discussing the issue of electronic signatures and security. Based on that foundation, the authors create a narrative that brings the reader through the various levels of security that IT companies should extend to medical facilities. And from there they discuss the myriad types of precautions facilities and their IT vendors should undertake when developing electronic signatures and passwords. The article covers many factors that all health facilities should consider when speaking with their prospective IT companies. And the post has relevant information that all IT companies should have already incorporated into their own product and workflow.

The AHIMA piece and a post from the blog InformIT both underscore that electronic signatures must incorporate the following three aspects:

  1. Message Integrity – that data brought in to the report and sent out from the report remains the same and isn’t changed.
  2. Non-repudiation – a user cannot state that s/he didn’t sign out a report where his/her signature is noted.
  3. User authentication – proof that the user that signed out is the actual person signing it out (i.e., username Doctor.Smith was signed out by Doctor Smith in real life, and not by someone else).

There are additional attributes that can be incorporated into the product’s electronic signature setup, but these are the most basic and should be adequate for the majority of a health facility’s needs. Once the user – usually a physician – has signed into the system, s/he should already be fairly secure from outside attacks and really only need to authenticate his/her identity for documentation (litigious) reasons.

It’s always daunting to break idiosyncratic routines down into standardized processes. How does one ensure that the solution is comprehensive enough that it encompasses all of the pertinent information? But, at the same time, how does one maintain that the solution is not be too expansive that it becomes a drain on the users’ workflows or detracts from the primary service the user provides (in this case, medicine)? It’s a hard balance that will take a lot of conversations and collaborations between the worlds of medicine and informational technology. By working together, these two industries can create streamlined processes that efficiently and expertly assist patients and enforce best practices all while remaining safe and secure.


Entry filed under: EMR, Standardization. Tags: , , , , , , , , , , , , , , , , , , , , .

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