Live from AMIA iHealth: What Happens When Patients Upload Heart Rate Data Into the EHR? | David Raths | Healthcare Blogs Skip to content Skip to navigation

Live from AMIA iHealth: What Happens When Patients Upload Heart Rate Data Into the EHR?

May 4, 2017
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What should physicians do with flood of fitness tracker data?
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I have always been a proponent of the Open Notes movement and efforts to incorporate patient-generated data into clinical practice. But at AMIA’s iHealth 2017 Clinical Informatics Conference here in Philadelphia yesterday, I saw a great presentation about the challenges clinicians face trying to make sense of data submitted by patients’ wearable fitness tracker devices.

Joshua Pevnick, M.D., a hospitalist and assistant professor of medicine in the Cedars-Sinai Division of General Internal Medicine in Los Angeles, described what happened when Cedars-Sinai invited patients to upload personal fitness device data to the Cedars-Sinai Epic EHR through the patient portal.

Pevnick started by saying that the project came more from the IT side of Cedars-Sinai Health System and that what he was describing was clinicians’ response to the new data stream. “We did not realize all the challenges it would introduce,” he said.

Clearly the movement toward wearable fitness devices is growing rapidly. Pevnick noted that 1 in 5 Americans owns a wearable technology device. The Cedars-Sinai EHR is capable of ingesting data from wearables such as FitBit, Withings, Apple Health, and Google Fit. (The heart rate data he described was all coming from Apple Watches.)

In April 2015 Cedars-Sinai began allowing patients to use the portal to connect their devices. They were notified that clinicians might not have time to review the data. “It is pretty easy to do,” Pevnick said. But of the 80,000 patients who are users of the portal, only 450 signed up in the first month to share data from wearables. Apple Watch support was added in May 2015. It checks heart rate every 10 minutes and can be set to do it even more frequently. Google Fit and glucometer support was added in March 2017. Some patients were submitting their daily step count from their FitBit.

Cedars-Sinai researchers sometimes offer subjects wearables as part of research studies, and that data is going into the EHR now, too. The number of participants has grown from 450 to 2,800 today.

One question clinicians had revolved around patient demographics. Were they young and healthy or older and sicker? Having heart rate data on young and healthy people is much less valuable than having it available on older and sicker people. “As a general internist, I need the old and sick people to adopt it if it is going to be of a lot of value to me,” he said.

Of the initial 450 patients, it turned out that they were predominantly young, white and male, although they did have higher than average body mass indexes, he noted. When they studied the data, neither medical conditions nor health spending seemed to predict adoption.

With the heart rate data, one of the first thing clinicians noted was that the application they have available to view the data is not optimized for seeing so many data points. “It is good for an inpatient setting, but for thousands of data points, not so good,” Pevnick said.

Then the clinicians came to the real cultural problem. They started seeing abnormal heart rate data. “I am used to ordering a test and following up,” he said. But all of a sudden physicians had patients entering data that showed very low and very high heart rates. “It is not a test I ordered,” he said.

Is it a device error? (These are not FDA-approved devices, and could be sending bad data.) Manual data entry error? (They had one glucose reading of negative 11!) Normal variants? Or is it cardiac pathology? All of a sudden, there is a 70-year-old with a heart rate of over 210 in the EHR, and it is not a test any clinician ordered. They had to decide what to do about those cases.

It made them ask the question: whose responsibility is it to monitor this regular feed of data? The patient? The physician?  “We decided to look into it further,” said Pevnick, who reiterated that the interfaces are not designed to see so many data points. “There is not a good way to review it.”

They studied the outliers in heart rate —less than 40 and greater than 200. They had the de-identified data reviewed by a group of clinical informaticists, including a cardiologist. Where concern warranted it, they did a chart review. If there was something in the chart, they contacted the cardiologist or the primary care doctor.

In six concerning cases, chart review did not suggest device error. Three cases corroborated the personal fitness device data, but had already been recognized. (One person had already died from an infection.) The fitness device data may have offered earlier detection, but did not improve these patients’ outcomes.

Pevnick noted that the use of patient-generated data in EHRs is only going to increase, and it is important for health systems to decide who is responsible for abnormal values. Medicine has always been physician-centric, but there will be more opportunity for patients to push data in, he added.

Pevnick said there has been some physician pushback against being held responsible for signals in fitness tracker data, and others are probably unaware the data is even there.

If the data is going to be used, it needs to be made easier for clinicians to access. “What processing can we automate?” he asked. “We need algorithms to screen out worrisome data and we need ways to visualize data to make it more digestible.”








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Who Isn’t Using Patient Portals? New Study Sheds Light on Portal Use

December 12, 2018
by Heather Landi, Associate Editor
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About two-thirds of adult patients did not use an online patient portal in 2017, and research indicates vulnerable and disadvantaged patients are less likely to use these technology tools, according to a study published in the November issue of Health Affairs.

Technologies such as online patient portals, which provide secure internet access to medical records and test results in addition to email communication with providers, can improve health care quality. And, evidence thus far shows that access to online portals increases patients’ engagement and adherence and may reduce unnecessary utilization and spending.

However, while the majority of adults in the United States believe that online access to personal health information is important, disparities in portal access exist.

“Findings from multiple studies that analyzed different population groups, including nationally representative samples, consistently show that members of racial and ethnic minority groups, older patients, and people of lower socioeconomic status are less likely than others to access an online portal,” the study authors wrote. The study was led by Denise Anthony, professor of health management and policy and sociology in the Department of Health Management and Policy, University of Michigan School of Public Health. Anthony and her co-authors also note that “inequities in access to new and beneficial technologies can exacerbate existing disparities in health.”

One national study, a March 2017 by the U.S. Government Accountability Office (GAO), found that only about 15 to 30 percent of patients who were offered access to a portal used it, with lower use among people living in rural and high-poverty areas.

“To identify appropriate levers that can be used to address inequities in online portal access, policy makers and providers must have a clear understanding of who is and is not accessing portals, as well as the reasons for not accessing them,” the study authors said.

For the study, titled “Who Isn’t Using Patient Portals and Why? Evidence and Implications from a National Sample of U.S. Adults,” researchers analyzed information about 2,325 insured respondents to the nationally representative 2017 Health Information National Trends survey to examine characteristics of patients who do not use portals and the reasons why they don’t them. By identifying who is not using portals and why, the researchers sought to uncover barriers and reduce disparities.

The study indicates that about two-thirds (63 percent) of insured adults with a health care visit in the previous 12 months reported not using an online patient portal. The research indicates that nonusers are more likely to be male and age 65 or older, have less than a college degree, not be employed, live in a rural location, be on Medicaid, and not have a regular provider.

These factors, along with race, were also related to whether a patient reported receiving an offer to use a portal.

Relative to females, males had significantly higher odds of not being offered access to and not using a portal, the study indicates. Members of racial minority groups (specifically, non-Hispanic blacks and non-Hispanics of other races—including Asian Americans, Native Americans, Native Hawaiians, and Pacific Islanders) had significantly greater odds of not being offered a portal. Among only those who were offered a portal, these groups reported rates of using a portal comparable to the rate of non-Hispanic whites.

The study also found that people with only a high school diploma or less were significantly less likely than those with college degrees to have been offered access to a portal. Patients with Medicaid insurance were significantly more likely to report not having been offered access to a portal and not using one, compared to people with other insurance.

Patients who lacked a regular provider were significantly more likely to report not having been offered access and not using a portal.

When evaluating reasons why people did not use a portal, the researchers did not find evidence of disparities in technological barriers. The reasons patients gave for not using portals included the desire to speak directly to providers and privacy concerns, both of which require recognition of the important role of provider communication and patient-provider relationships, the study authors note.

The study authors conclude that healthcare providers will need to address patients’ privacy and security concerns to enhance provider-patient communication.

“Reducing disparities in portal use will require that providers, particularly those serving vulnerable populations, communicate with all patients about portal use and have the capacity to discuss these technologies with patients,” the study authors wrote.

“Health care providers and plans can increase patients’ use of portals and narrow disparities in that use through direct communication about the benefits of portals, while also addressing patient-specific needs and concerns. Such interventions will require recognition that providers’ communication with patients takes time—an extremely scarce resource in clinical practice today,” the study authors concluded, while also noting that careful monitoring of who is and who is not using new technologies, and why, and designing technologies to address patients’ needs, will help ensure that such innovations do not exacerbate disparities but rather lead to improvements for all.

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AMIA, AHIMA Call for HIPAA Modernization to Support Patient Access

December 7, 2018
by Heather Landi, Associate Editor
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Modernization of the 22-year-old Health Insurance Portability and Accountability Act (HIPAA) would improve patients’ access to their health information and protect their health data in a burgeoning app ecosystem, according to two leading health IT industry groups.

During a briefing on Capitol Hill Wednesday, leaders with the American Medical Informatics Association (AMIA) and the American Health Information Management Association (AHIMA), health informatics and health information management experts discussing how federal policies are impacting patients’ ability to access and leverage their health data.

While other industries have advanced forward with digital technology and have improved individual’s access to information, and the ability to integrate and use information, such as booking travel and finding information about prices and products, healthcare has lagged. Healthcare has not been able to create a comparable patient-centric system, AMIA and AHIMA leaders attested.

“Congress has long prioritized patients’ right to access their data as a key lever to improve care, enable research, and empower patients to live healthy lifestyles,” AMIA president and CEO Douglas B. Fridsma, M.D., Ph.D., said in a statement. “But enacting these policies into regulations and translating these regulations to practice has proven more difficult than Congress imagined.”

“AHIMA’s members are most aware of patient challenges in accessing their data as they operationalize the process for access across the healthcare landscape,” AHIMA CEO Wylecia Wiggs Harris, Ph.D. said. “The language in HIPAA complicates these efforts in an electronic world.”

AMIA and AHIMA recommend that policymakers modernize HIPAA by either establishing a new term, “Health Data Set,” which includes all clinical, biomedical, and claims data maintained by a Covered Entity or Business Associate, or by revising the existing HIPAA “Designated Record Set” definition and require Certified Health IT to provide the amended DRS to patients electronically in a way that enables them to use and reuse their data.

According to AMIA and AHIMA, a new definition for “Health Data Set” would support individual HIPAA right of access and guide the future development of ONC’s Certification Program so individuals could view, download, or transmit to a third party this information electronically and access this information via application programming interface. Alternatively, a revision of the current DRS definition would provide greater clarity and predictability for providers and patients.

The groups also noted that a growing number of mHealth and health social media applications that generate, store, and use health data require attention as part of a broader conversation regarding consumer data privacy.

Congress should “extend the HIPAA individual right of access and amendment to non-HIPAA Covered Entities that manage individual health data, such as mHealth and health social media applications, the two groups said. The goal is uniformity of data access policy, regardless of covered entity, business associate, or other commercial status, the group leaders said.

Beyond HIPAA, during the briefing Wednesday, panelists discussed the success of efforts to share clinical notes with patients during visits, including the successful OpenNotes initiative, and recommended that federal officials look for ways to encourage more providers to share notes with patients through federal policies, such as Medicare and Medicaid payment programs.

“More than two decades after Congress declared access a right guaranteed by law, patients continue to face barriers,” Thomas Payne, M.D., Medical Director, IT Services, UW Medicine, said in a statement. “We need a focused look at both the technical as well as social barriers.”

What’s more, AMIA and AHIMA recommended federal regulators clarify existing regulatory guidance related to third-party legal requests, such as those by attorneys that seek information without appropriate patient-direction.

“HIM professionals continue to struggle with the existing Office for Civil Rights guidance that enables third-party attorneys to request a patient’s PHI,” Harris stated. “We recognize there are necessary circumstances in which a patient has the right and need to direct their health information to an attorney. However, AHIMA members increasingly face instances in which an attorney forwards a request for PHI on behalf of the patient but lacks the information required to validate the identity of the patient. As a result, the HIM professional is challenged as to whether to treat it as an authorization or patient access request, which has HIPAA enforcement implications

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Health Systems Work with Epic on Electronic Patient-Reported Outcomes for Oncology

November 18, 2018
by David Raths, Contributing Editor
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With eSyM app, patients will provide feedback to their cancer care team via the EHR

Six U.S. healthcare systems are sharing a $9 million grant to research introducing electronic patient-reported outcomes (ePROs) into the routine practice of oncology providers to improve symptom management and to decrease hospitalizations.

The National Cancer Institute, in association with the Beau Biden Cancer Moonshot Initiative, recently announced the funding of the collaboration, the SIMPRO (Symptom Management IMplementation of Patient Reported Outcomes in Oncology) Research Center. The SIMPRO team will work with Epic, the EHR system used by all six participating institutions, which are New Hampshire-based Dartmouth-Hitchcock, Dana-Farber/Brigham and Women’s Cancer Center in Boston, Baptist Memorial Medical Center in Memphis, Lifespan Cancer Institute in Rhode Island, West Virginia University Cancer Institute, and Maine Medical Center in Portland.

SIMPRO will develop, implement, and evaluate an ePRO reporting and management system through an app called eSyM. Patients’ smart devices will enable a secure connection to their cancer care team via the EHR, and facilitate symptom tracking following cancer surgery or chemotherapy. The study will test whether monitoring the symptoms patients experience and providing coaching on how to manage them can decrease the need for hospitalizations and emergency room visits.

“The opportunity to partner directly with Epic and their resources, to build these tools into our electronic health record, means in the short-term the research is more likely to bear fruit “and in the long-term that successful strategies can be disseminated around the country.” said Dartmouth-Hitchcock Chief Health Information Officer Peter Solberg, M.D., in a prepared statement,

After development and pilot testing, eSyM will be fully integrated into the EHR at each participating center, allowing for direct communication and real-time updates for clinicians who will have access to a dashboard of patients’ symptoms to prioritize outreach efforts and coaching.

The SIMPRO investigators will conduct a randomized trial to evaluate implementation of eSyM from a patient, clinician and health system perspective. Across all study phases, the implementation, adoption, acceptance, and adaptation of the ePRO system will be critically evaluated to promote better delivery of cancer care.



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