Improving Health Information Management
One aspect of patient centered medical homes and also Accountable care organizations is adopting Health Information Management Technology. This system makes record keeping easier and it facilitates record sharing. It is important for doctors to subscribe to this technology because the quality of the care a patient receives is dependent on it. Many times as patients visit various doctors for different problems, they get medications for some pre existing conditions. The tendency for one doctor to prescribe one medication for, let’s say, blood pressure and another doctor to prescribe another pill for blood pressure amounts to low quality care across the medical spectrum. This lack of communication among physicians puts a patient’s safety at stake. Part of Affordable Care Act provides strong incentives and subsidies for doctors to update their record keeping technology. But advanced record keeping is not enough. Doctors, particularly primary care physicians must be open to reach out and communicate a patient’s issues with the specialist they recommend. Collaboration is a requirement of being part of an Accountable Care Organization.
What does Patient Centered Medical Treatment mean?
As the Patient Protection and Affordable Care Act (PPACA) continues to unroll, new medical models in practicing medicine are to be offered. Patient- Centered Medical Homes is one of those models. The core principle of Patient-Centered Medical Home Model requires doctors to trust a patient’s self-knowledge regarding his or her own condition and health.
Upon a mandate by PPACA by 2012 primary care physicians will switch from their current model of practice to Patient-Centered Medical Home Model.
Patient-centered care is basically shared decision-making that involves:
¨ A mature dialogue, in which an informed professional informs the patient about available choices.
¨ Both parties’ responsibility for sharing and listening.
¨ Informed prepared and proactive patients.
¨ When necessary or requested, Involvement of family and other caregivers in decision making.
How does one become a proactive patient?
Know what questions to ask. And persist at getting answers.
Know my doctor’s office policies regarding routine visits.
- Know how soon I can see the doctor if I get sick.
- Know office and insurance policies on cancellations.
- Know the different options of communicating with my doctor.
- Make sure my physicians are aware of each other and in touch.
- Inform my doctor of my mental health or substance abuse issues.
- Have an updated and complete personal health profile.
- Understand my diagnosis more fully.
- Seek resources that help me understand my diagnosis.
- Ask comprehensive questions regarding medication?
- Know long term and short term side effects of my medications.
- Follow medication direction precisely.
- Know if I need to follow up with my physician.
- Prepare for my tests.
- Know risks and benefits to my test.
- Know how accurate my test result will be.
- Make sure my other providers get the test results.
- Understand the reasons I need surgery.
- Ask about other treatment option.
- Ask for a second opinion.
A complete personal Health profile is an important element in getting the right diagnosis and treatment. I must make sure that these questions are answered and my physicians have access to it:
- · Emergency contact person and contact information.
- · Insurance card.
- · List of prescriptions and over the counter medications.
- · List of Vitamins and supplements.
- · List of allergies.
- · List of hospitalizations and reasons.
- · List of surgeries.
- · Conditions and diagnoses.
- · Family members’ major conditions.
- · List of other health care providers I see.
Make sure at the end of each visit I give my opinion of the service I received. Ask for a doctor visit checklist and make sure it includes the following items:
- · Arrive on time?
- · Make my needs clear?
- · Make follow-up appointment?
Did the doctor:
- · Spend enough time with me?
- · Give me a chance to ask questions?
- · Really listen to my questions?
- · Answer in terms I understood?
- · Show respect for me?
- · Make me feel comfortable?
- · Address the health problems I came with?
- · Did he address and respect physical and mental health needs?
- · Make appropriate referrals?
- · Update my medications?
These points come from “Being a Proactive Patient: A guide to person-centered care”. Copies are available at Consumer Health Coalition. Contact Sally Jo Snyder for further information at: 412 456-1877 X203.
Only with wider accessible knowledge will patient centered medicine be possible.
What is Enhanced Access?
According to Qualis Health Enhanced Access is one of the principles of Patient Centered Medical homes. And it means.
- Promote and expanded access by ensuring that established patients have 24/7 continuous access to their care teams via phone, e-mail or in-person visits.
- Provide scheduling options that are patient- and family-centered and accessible to all patients.
- Help patients attain and understand health insurance coverage.
The goal of this Concept is to ensure that patients and family members can get healthcare when and how they need it.
Enhanced access refers to expanding patients’ and family members’ options for interacting with their healthcare team, including opportunities for in-person visits, after hours care, phone calls, e-mails, and other services. Enhanced access requires flexible appointment systems that can accommodate customized visit lengths, same day visits, scheduled follow-up and multiple provider visits.(Qualis Health)
The Enhanced Access Concept expects that a patient’s healthcare coverage is viewed as a shared responsibility to be addressed by the patient and an assigned member of the care team. (Qualis Health)
This kind of change is a stretch for physicians who are so difficult to reach through a phone call. The patient would have to make an appointment in some cases to have their simple questions answered. This of course is pretty much a dysfunction of a practice. How can a physician like that make the switch to be widely available to their established patients? Let’s hope that the incentives offered through the Quality Care Act to provide quality care will be enough to motivate such hard to reach doctors to become more available to their patients.
Health Literacy Is Closely Related to Literacy
About 10% of adults in Allegheny County do not have basic literacy levels. What happens to these adults when they get sick? What if for their treatment they have to follow complicated directions having to do with taking their medicine or other routine practices, for example taking care of a wound, or taking a home test like the diabetes test? Many of these individuals are not able to follow directions and make mistakes that either complicate their situation or put them in danger. Several studies done in urban settings show that many parents do not understand how to correctly measure over the counter liquid medications that help their children get better. And therefore they put their children in danger by overdosing or prolong their suffering by under dosing them.
Low health literacy is directly related to low literacy level. The solution to low health literacy is adult health literacy training. Already in Pittsburgh area Greater Pittsburgh Literacy Council works with medical students and doctors to help them understand the problem of illiteracy and try to adjust the way they talk to patients in ways that is more understandable to patients with literacy issues. Now Consumer Health Coalition is in the process of creating Adult Health Literacy workshops in communities where basic literacy is lowest in Allegheny County. If you have questions about this project or wish to contribute to furthering health literacy among adults in Pittsburgh please contact Beth Heeb at Consumer Health Coalition of Pittsburgh 412 456-1877 X204.
Patient Access to Health and Mental Health Records
Early this year the office of Civil Rights and the Department of Health and Human Services issued a significant penalty against Cignet Health of Prince George’s County, MD.. The penalty in the amount of $4.3 million dollars is the first of its kind to be issued against a health organization for violation of the HIPPA Privacy Rules.
The 45 CFR 164.524 rule of the HIPPA act requires that health care providers provide a patient with access and/or copy of their health information within 30 days (no later than 60 days) after the patient requests such information. About forty patients were denied this access by Cignet and hence the complaint, and the result the heavy penalty against cygnet.
This information is particularly significant for mental health patients. According to the laws regulating patient access to records, mental health patients are denied access to some aspects of their files such as the therapy notes. The possibility that mental health providers abuse this law by denying access altogether to a mental health patient exists. Even though some regulations limit mental health patient’s access to their records, it is still possible for patients under some circumstances to gain access to their files. It is necessary for mental health patients to know the laws regulating their access so they would not be abused by wrongful denial of access.
The following is the Pa code regulating patient access to their health records:
§ 5100.33. Patient’s access to records and control over release of records.
(a) When a client/patient, 14 years of age or older, understands the nature of documents to be released and the purpose of releasing them, he shall control release of his records. For a client who lacks this understanding, any person chosen by the patient may exercise this right if found by the director to be acting in the patient’s best interest. In the event that the client/patient is deceased, control over release of records may be exercised by the client’s/patient’s chosen executor, administrator or other personal representative of his estate, or, if there is no chosen personal representative, by a person otherwise empowered by court order to exercise control over the records. In the event that the client/patient is less than 14 years of age or has been adjudicated legally incompetent, control over release of the client’s/patient’s records may be exercised by a parent or guardian of the client/patient respectively.
(b) The term ‘‘access’’ when used in this section refers to physical examination of the record, but does not include nor imply physical possession of the records themselves or a copy thereof except as provided in this chapter.
(c) A person who has received or is receiving treatment may request access to his record, and shall be denied such access to limited portions of the record only:
(1) Upon documentation by the treatment team leader, it is determined by the director that disclosure of specific information concerning treatment will constitute a substantial detriment to the patient’s treatment.
(2) When disclosure of specific information will reveal the identity of persons or breach the trust or confidentiality of persons who have provided information upon an agreement to maintain their confidentiality.
(d) A patient may obtain access to his records through the facility, or in the case of those records kept by the county administrator, through the physician or mental health professional designated by the administrator. Any third parties who are granted access to records may discuss this information with the patient only insofar as necessary to represent the patient in legal proceedings or other matters for which records have been released. Discussion of records with patients should be part of the therapeutic process and is not to be undertaken by other than mental health professionals.
(e) The limitations in subsection (c) are applicable to parents, guardians, and others who may control access over records as described in subsection (a) except that the possibility of substantial detriment to the parent, guardian, or other person may also be considered.
(f) If a person wishes to enter a written reaction qualifying or rebutting information in their records which they believe to be erroneous or misleading, they shall have the right to prepare such statement for inclusion as part of their record. The patient’s written reaction shall accompany all released records.
(g) The director of the treatment team or the facility director may require that a mental health professional, who is a member of the treatment team, and who has reviewed the record in advance, be present when the patient or other person examines the record to aid in the interpretation of documents in the record. If the records pertain to a former patient, an appropriate mental health professional may be designated by the facility director.
(h) Access to pre-sentence reports, which may be part of the persons’ records, is governed Pa.R.Crim.P. No. 1404 (relating to disclosure of reports), and the patient may have access to these records only upon order of the sentencing judge. Any conditions of confidentiality imposed by the sentencing judge must be complied with. Similarly, parole and probation reports shall be released or access to them given only in accordance with 37 Pa. Code Part II (relating to Board of Probation and Parole).
(i) If a person is denied access to all or part of his record, this fact and the basis for the denial shall be noted in the person’s record.
(j) When records or information have been forwarded from one agency to another agency, the receiving agency may not refuse the client or patient access to the records received except in accordance with subsection (c). Records received from other agencies become part of the client/patient’s active record and are subject to the controls exercised over them by the client, patient, or those with authority over records as defined in § 5100.31 (relating to scope and policy).
This material has been drawn from the official Pennsylvania Code full text database.
Health Illiteracy Takes lives and It Costs Too
Health literacy is defined as the degree to which individuals have the capacity to obtain process and understand basic health information. According to the health literacy component of the National Assessment of Adult Literacy (NAAL), which took place in 2003, 36 percent of adults in the U.S. have below basic Health literacy levels. That is about 87 million people.
According to a study done at University of Connecticut in 2007 health illiteracy in the U.S is known to cost the health care system between $106 billion to $236 billion annually.
Annals of Family Medicine, an online journal, states that the problem of health illiteracy creates health disparities among those with efficient health literacy skills and those without efficient health literacy skills. One reason that many people do not have health literacy is that they don’t have healthcare insurance. Having healthcare insurance leads to people using health care services. Through experience many people will learn how to navigate the system and learn more of services that help them remain healthy. Some people may need more education initially.
Health literacy begins with knowing how to fill out health insurance forms. It is knowing how to communicating with health care providers and following basic instructions and medical advice. Fear embarrassment and a non-user-friendly health care system, language and cultural barriers on top of that are barriers to effective communication of those with low health literacy with health care providers.
Uninsured patients are less likely to use health care services and those who have it do not use it effectively hence ending up in hospital emergency rooms. Those with manageable diseases may not know when and how many times they may need a test, leading to complications or over testing which taxes the system.
Overall health literacy is significant in determining how individuals make choices about their health, including life style choices, how well they can search for best health care providers and for the best diagnostic services. Let’s face it, the biggest price some people pay for health illiteracy is death.
Not only do we need policies that help improve health literacy, but also we need grass roots organizations whose work is somehow related to health care concerns or education, to step in and take over where there are gaps in the health literacy education.
Health Care Reform and Health Disparities
Racial and ethnic health disparities in this nation’s health care system are responsible for people of color in the U.S being more likely to lack health insurance, receive lower quality care, suffer from worse health outcomes and die prematurely. The causes are either societal factors such as poverty, racism and unhealthy environments or health system factors like lack of health insurance, linguistic and cultural barriers, and limited access to health care facilities. According to a study by the Joint Center for Political and Economic Studies in Washington D.C, eliminating health disparities for minorities would have reduced direct medical care expenditures by $229.4 billion between 2003 and 2006.
The health reform legislation includes a number of provisions that will help reduce racial and ethnic disparities and move us closer to health equality. Families USA is a nonprofit advocacy group. In a report on their website titled Talking About Health Care Reform, a list of these provisions can be found:
Health Care Reform will increase access by:
- Creating exchanges in each state so small business and individuals can buy insurance in the private market.
- Provides subsidies to families and individuals who need assistance to participate in the exchange.
- Expand Medicaid eligibility for low income people.
Improve data collection
- Set more comprehensive standards for collecting data on health disparities.
- Coordinate analysis with Department of Health and Human Services.
Support community health centers
- Increase funding to community health centers.
- Provide grants for construction and renovation of community health centers over the next five years.
- Encourage other organizations to collaborate with community health centers to improve prevention and primary care services.
Strengthen the Federal Office of Minority Health
- Reauthorize the Federal Office of Minority Health (FOMH) with accountability to Secretary of Health and Human Services.
- Authorize a Deputy Assistant Secretary for Minority Health
- Establish offices of Minority Health within the following departments of Health and Human Services agencies: Centers for Disease Control and Prevention, Health Resources and Services Administration, Substance Abuse and Mental Health Services Administration, Agency for Healthcare Research and Quality, Food and Drug Administration, and the Centers for Medicare and Medicaid Services.
Increase workforce diversity
- Create a permanent advisory to monitor the diversity of healthcare workforce and provide recommendations to improve it.
- Increase funding and scholarships for disadvantaged students focusing on institutions with a track record for training individuals from minority communities.
Focus on prevention, public health and social determinants of health
- Establish community transformation grants to promote community based prevention initiatives aimed at addressing chronic disease and reducing disparities.
- Develop a national prevention and wellness strategy, including an investment fund to promote prevention and public health.
- Provide grants for areas with diverse community representation that seek to work together to address health disparities.
- Promote health impact assessments as a tool for analyzing the effect of the built environment on health outcomes.
Reauthorize the Indian Health Care Improvement Act
- Set goals to address the health needs of Native American country and eliminating health disparities.
- Attract and increase the number of Native American health care professionals who serve the Indian Health Service and tribal health programs.
- Allow Indian Health Service to develop and carry out a plan for implementing innovative mechanisms for addressing the backlog of health facility upkeep needs.
- Revise laws to modernize health care delivery in Indian Health Care System.
In addition, the National Conference on State Legislatures reports that maternal and child health provision provides$1.5 billion over five years for the Maternal, Infant and Early Childhood Home Visiting Program. Regardless of whether a state plans to apply for this grant, each state must complete a needs assessment to identify at-risk communities to receive any Title V Maternal and Child Health Block Grant funds for FY 2011. Home visiting programs provide patient-centered support and education to individuals which cam improve health literacy and ultimately improve health outcomes.
Insurance regulation mandates that beginning in 2014 the ACA prevents insurance companies from denying insurance coverage to people who have pre-existing conditions or charging higher premiums to those individuals. It also prohibits higher premiums based on gender and determining insurance rates and coverage according race and ethnicity. Since minorities are disproportionately affected by chronic conditions including, diabetes, heart disease, and cancer this will be a significant factor in obtaining health insurance coverage.
The combination of these factors promises a focused attention on issue of health disparities experienced by minorities in this country. The broad scope of these reforms will influence policy in effective ways and give advocates of health equity a framework for their activities. One item that needs advocacy for example is that like the Native Americans, African Americans or Latin Americans could benefit from specific attention paid to their set of problems by creating offices that deal exclusively with their issues in the health care system. The more focused we are on each minority group the more accurate our data will be and the more targeted our solutions will become.
Health Disparities Debated
In England health disparities are looked upon from a socio economic standpoint. In hospitals when data is collected it is the occupation of patients which is asked and not their race or ethnicity.
In United States the issue is mainly looked upon from a race and ethnicity point of view. However there is a school of thought that says if health care quality in general improves, then disparities will disappear.
What this view point lacks in understanding is the various subtleties of why a patient experiences disparities. Among the Latin American population for example, the question of language, and not having access to health care because of immigration status are what cause disparities. Among the African American patients, a tension between the physician and the patient which stems from prejudices on part of some physicians and mistrust on part of patients are the issues. Among the rural poor, not having access to health care providers is the issue. Across all groups low health literacy is caused by low literacy rates is a major factor in health disparities.
Among academicians who study health disparities there is a reluctance to mention race as a factor. They believe genes, as related to one’s ancestral geographic origins, are culprit in health disparities. This is related to the attempt in academic circles to portray race as a social construct and not being substantiated by any sort of biological evidence. A phenomena known as intergenerational transfer of health is also known to occur so that nutritional environmental and stress factors affect the health of future generations. Also structural issues relating to redistributive justice is stated as a factor with this group.
However as we define the issues causing health disparities, we must be mindful that the issue of race is real for some groups identifiable by factors that separate them from the majority of people. Call these factors race or ancestral geographic origin we must come up with policies that meet the needs of populations who are suffering most from health disparities. Which ever way we define these groups we need to come up with clear cut goals with clear timeframes and methods of measuring progress. African Americans who day in and day out experience subtleties of racism know best how we should define this issue. A physician whose judgment is clouded by prejudice, does not think of ancestral origins of his patients. He looks at the patient and thinks he is black. Prejudice takes a direct approach to create disparities; therefore it should be faced directly. Even though academicians mean well by not talking about race, they show insensitivity toward issues that make African Americans so sensitive about exactly the issue of race. African Americans do not believe that color blindness, which is what the academicians aim for, is a solution to their racial problems. They believe acknowledgement that there are racial issues and compensating for them is the solution.
Quoted in volume 29 of Social Alternative, prominent epidemiologist Geoffrey Rose sums it up this way: “The primary determinants of disease are mainly social and economic, and also its remedies must be social and economic. Medicine and politics must not be kept apart.”
Race is a vital social issue such as health care and health disparities. and must be kept at the center of solutions.
What Can We Do to End Health Disparities
In April, 2004 the second meeting of the Federation Task Force on Disparities in Health Care was convened. With representation from over 35 state and specialty medical societies and other health professional organizations, the task force, chaired by the American Medical Association, in conjunction with the National Medical Association, reaffirmed its commitment to eliminating disparities in health care. The group elected to call themselves the Commission to End Health Care Disparities, focusing on physician leadership, quality, and system approaches to the elimination of disparities.
The AMA takes a very active role in eliminating health disparities. Some of the activities they are involved in consist of the following:
- The AMA has created a program on health disparities to coordinate many of the AMA’s activities in science, ethics, and medical education addressing the issue.
- The AMA has extensive AMA’s Principles of Medical Ethics, used to define ethical and professional behavior for physicians.
- The AMA is involved in ongoing efforts to increase the number of minority physicians so as to reflect the diversity of the US population.
- The AMA’s House of Delegates reaffirmed our commitment to minority health care by making the elimination of racial and ethnic health disparities an issue of high priority.
- The AMA is partnering with the AMA Foundation to help physicians become aware of and appropriately manage low health literacy among patients.
- Educating Physicians on Controversies in Health (EpoCH) is a series of brief informational Web streaming programs developed by the AMA targeting primary care physicians.
In the United States health disparities are looked upon from the angle of race and ethnicity. However understanding health disparities and health care disparities involves understanding historical, political, economic, social, cultural, and environmental conditions that have produced inequitable health status among numerous population groups in the U.S. Health Care disparities are related to socio-economic status, class, sexual orientation, gender identity, age geographic location, education, language spoken, literacy, disability and other factors. These factors are well studied in the context of social science. Well designed research which will gather data in each and every aspect mentioned will give us numbers of the people who are affected by disparities, the result of these disparities and the patterns in which these results influence people’s lives.
Some of the ways that health disparity works is in lack of promotion of health and availability of health care services, limited financial and social resources among minority communities, public safety and urban design issues, lack of culturally and linguistically competent providers, and others. Some of these problems are related to the structures through which health care is implemented, and some have to do with structural issues relating to our society in general. For example the way funding is issued to certain areas which suffer low socio-economic status.
Policy development at federal, state and local or organizational level is critical in working to end health care disparities. The Commission to End Health Care Disparities provides guidelines that provide a broad and unifying framework for policy analysis, development and implementation. It can be used at federal, state, local, and private organizational policymaking to address health care disparities.
The goal in creating and implementing policies should be to ultimately end all disparities in health care and health of all groups affected by disparities.
The commission to End Health Care Disparities offers these ten guiding principles to develop and implement policies to address health care disparities:
- Relationship-centered policies supportive of the delivery of patient-centered, family-focused, community-oriented, care to individuals throughout the life span,
- Culturally and linguistically appropriate strategies tailored to the unique needs of the diverse patient populations.
- Targeted policies focused on recognized and demonstrated gaps in access to health prevention, health care, safety, and quality in order to improve the health of racial/ethnic patient groups that are affected by these disparities.
- Data driven policies making use of qualitative and quantitative information to inform,
- Transparent, participatory and collaborative policies designed in open processes with the input of all key stakeholders and interested constituency groups
- Long and short term fixes are important but policies should aim at resolving underlying causes of disparities and should create structural and financial incentives to prevent the reemergence of disparities,
- Policies should be designed comprehensively because health care disparities result from a complex mix of social, cultural, economic, political, environmental and other factors.
- Judiciousness in the use of incentives and mandates could have a role in ending disparities, but policy-makers should favor incentives since mandates could cause backlash.
- Non partisanship and fiscally responsible policies.
- Monitoring and revising policies should track unintended consequences of policies so they can be revised.
Such guidelines in policymaking expect high ethical standards that should be the norm in health care professionals anyway.