Crisis on the Front Line of Health

The NY Times article today "Crisis of Care on the Front Line of Health" makes for interesting reading and also passes commentary on the often touted and argued issue of the uninsured. But the focus on primary care and specifically the comments

Finding doctors who know their patients well and who deliver informed
medical care with efficiency and empathy has become quite a challenge
in America

Feels harsh - I think what they mean is finding a physician who is still able to offer this level of service and survive mentally and financially is a challenge. The worrying trend is the declining number of medical students electing a career in internal medicine - given their debt load as they finally emerge from medical school it is inevitable that many will follow the money and choose specialties that are well compensated. Internal medicine specialists are:

the doctors who ask pertinent questions, about health and also
about life circumstances, and who listen carefully to how patients
answer.

But this process takes physician time and to maintain income means fitting more patients into the available clinic time. With the current anticipated average based on managed care reimbursement levels

"..you have only six to eight minutes per patient"

Which Dr. Byron M. Thomashow states "...you’re forced to concentrate on the acute problem and ignore all the
rest [of the conditions],”

So the idea that we can load up physicians with additional administrative burdens documenting in forms and finding items in lists seems counterintuitive. Whatever solution must take account of current workflow and existing efficient methods of data capture and incorporate those into the clinical process. Dictation is one of several methods in use today - as it stands it currently accounts for at least 60% of the input to the medical record. Capitalizing on this existing method and working this into the systems will add no additional time burden. By enabling the addition of meaningful clinical data with the free form narrative and storing this in one complete document in CDA format we satisfy the need for computer accessible information without burdening overstretched clinicians with additional processes

Transcription the WD-40 of Healthcare

WD-40 is renown as a solution for all sorts of problems (the list of 2000+ uses - pdf) - in a recent e-mail I received it was cited as follows:

You only need two tools in life WD-40 and duct tape. If it doesn't move and should use WD-40. If it shouldn't move and does use the Duct Tape

We have been hearing that transcription is the being replaced and will eventually disappear being replaced by direct data entry into Electronic Medical Records. But to borrow from a famous saying "the reports of the death of transcription have been greatly exaggerated". A fact hammered home in a recent presentation by L Gordon Moore, MD at the 2008 Scientific Assembly of American Academy of Family Physicians and reported in an article by Healthcare IT News "Beware of the EMR 'Ponzi' Scheme". Dr Moore did not mince his words:

When you put an EMR into a primary care practice, your life is hell for the next year

EMR's are essential to delivering high quality care. We need the support of technology to help deliver the highest possible quality of care. But the penetration of these solutions in the marketplace are a good indication that there are difficulties with these systems and implementations. On a a recent visit to an office with a newly installed EMR system I compared the experience to prior visits. The process of interacting with the screen (be it a tablet or desktop PC or some other mobile device) was very intrusive and difficult to manage while trying to interact with the patient. It is next to impossible to enter data on a screen while looking at the patient. So what I think Dr Moore is referring to is the difficulty of entering in clinical data to these systems - I bet he loves the ready access to all the patients clinical information but hates entering anything.

There are no easy answers and certainly not one answer to suit all situations but there is a reason that dictation by physicians and the transcription of this material has been an expanding industry that has insufficient resources to meet demand. The process works and has been the WD-40 for healthcare documentation for many years. The process has improved in efficiency moving from wax recording drums to digital recording systems and portable recording devices that include digital recording pens. We have added technology to speed up the transcription process counteracting the original design intention of the typewriter and the QWERTY Keyboard which was laid out in this format to separate out the most commonly used keys to slow typists down! Macros, auto correct, word expanders, speech recognition and most recently speech understanding. But through all these efficiencies the medical transcription or Clinical Documentation Specialist Knowledge Based worker remains a key contributor and an essential part of the process. They continue to be the WD-40 in the process of producing meaningful clinical documents to transmit clinical information to the ever growing participants of the healthcare team charged with taking care of patients. Clinicians will dictate their notes - its fast, efficient and cost effective when you consider the cost of the clinician. As Dr Leonard McCoy put it in Star Trek:



To grease the wheels of clinical communication, medical transcription and clinical documentation continues to evolve allowing for the free form narrative dictation but extracting the clinical data that the EMRs are hungry for. Fulfilling both needs requires the next generation of clinical documents using the HL7 CDA standard for Common Document Types (CDA4CDT). These documents support the flow of data from dictated clinical information to narrative documents and into structured, computer accessible records that EMRs can accept directly to support patient care with discreet clinical data.

However one word of caution on efficiencies that is best summarized by Dilbert - "...I have infinite capacity to do more work as long as you don't mind my quality approaches zero":

Medical Transcription the EMR and Speech Understanding

The Medical Records institute e-Newsletter from September contained an article by Claudia Tessier from the Medical records institute titled: "Medical Transcription and EMRs: Opportunity Lost?" that discussed the relationship between medical transcription and the electronic medical record (EMR). As the Claudia says:

...medical transcription offers a bridge to EMR adoption

But the idea that

the EMR offers the best opportunity yet to get rid of transcription and its concomitant headaches

Misses the opportunity for medical transcription and valuable data that is lost with the push towards the structured form based hunt and click style documentation. In a recent discussion with a clinician he lamented the loss of "the beauty and descriptive nature of medical language that has been used to describe medical conditions and image findings". Instead as he put it "we have turned detail rich clinical information into dumbed down fill in the blank cookie cutter reports" which do not reflect the richness of the information he wants to provide to his colleagues.

To date medical transcription is estimated to constitute 60% of the input into current EMR systems but that input is in the form of text blobs and not clinical data. The article goes on to suggest that:

...EMR vendors should ramp up their cooperation to create uniform integration. Let every one of the 300+ EMR systems allow dictation and let the market determine whether the related turnaround time, quality, costs, etc. (see below) are acceptable. Let users dictate on cell phones and dictation devices, or through laptops and tablets—whatever their preference.

Is spot on - the systems work and with better integration and more choices for input we open the doors to capturing input from our clinicians caring for patients and struggling to document for the benefit of communication with others members of the team as well as capturing sufficient information to be paid for the services they are delivering to their patients.

But this input is still not resolving the necessity to feed EMR's with clinical data which is essential for computer based systems to understand the information and be able to act on it. There are existing standards to hold and transmit this information including the Continuity of Care Record (CCR) which is "....working in collaboration with HL7 on the expression of ASTM's Continuity of Care Record content within HL7's CDA XML syntax and the seamless transformation of clinical and administrative data between the two standards.” - Rick Peters, MD

Transcription companies are already offering xml-based solutions that support structured output and the significant value this brings to EMR's is that this structured data has been checked and reviewed by medical transcriptionist/editor with expertise and knowledge to validate that content relative to the original dictation input of the clinician. More value from the validated data output from Medical transcription will make the transcription industry more of a partner and even more important in their contribution and ongoing role in the delivery of high quality healthcare.

So where does Speech Understanding come into all of this - unlike the traditional speech recognition technology which Hollywood conditioned us to expect far more comprehension on the part of the engine as captured in this classic clip from Star Trek IV - the voyage home where Montgomery Scott (Scotty) of the original series of Star Trek fame is trying to interact with a computer circa 1980.....

But his experience is typical of traditional speech recognition systems and a typical response either visually or verbally would be "Directions unclear - please repeat request"

Speech Understanding is the next generation of the technology, crossing the chasm between the need and desire of physician to dictate using all the richness and expressivity of language but that is recognized and understood and not only creates an accurate representation of the free form text but also produces a structured and encoded document. Structure is captured and stored in native CDA format and encoding is achieved using clinically relevant encoding systems such as RadLex for radiology, RxNorm for drugs, Universal Medical Language Systems (UMLS) and SnoMed for clinical terminology etc

You can have the best of both worlds and Medical Transcription will be around for years to come - albeit in a updated MTv2.0 form where the transcriptionist is a knowledge based worker proofing, editing and validating clinical data......so in the words of Spock: "Live Long and Prosper"

A Facebook Medical Record

What are we trying achieve with medical records....? Asides from the obligatory proof that the care was delivered (billing) and determining how much should be paid for the delivery of that care medical records are about sharing information between care givers. It has always been that way. Years back the number of care givers was lower and specialization less so the number of people needing accessing to the this information was lower. Now with the tsunami of medical information it is impossible for single care givers to deliver all the possible ranges of care and it takes a village team to deliver care.

And the latest explosion on online activity - one who's traffic can exceed that of Google and you tube is Facebook, which according to their own description

...is a social utility that connects people with friends and others who work, study and live around them. People use Facebook to keep up with friends, upload an unlimited number of photos, share links and videos, and learn more about the people they meet.

Now take this concept and adjust the wording.....

FaceBookHealthRecord is a social utility that connects patients with their care givers and others who provide diagnostic services, imaging, laboratory tests, results and pay for that care. Patients and clinical care givers use FaceBookHealthRecord to keep up with the status of their healthcare, their wellness and long term disease outlook as well as communicate quickly and effectively with specialists. All images, diagnostic study videos and diagnostic testing information can be uploaded and shared withe the clinical team allowing everyone to learn more about he care of that patient.

The interaction concept has been tested and reported on - Bob Wachter wrote an article just recently on this very concept "Creating a Facebook-like medical record" where he slams home the point on interoperability

In fact, today’s medical record virtually guarantees the silo-ization of care. Few physicians ever read nurses’ notes, even though all of us depend on the nurses to be our eyes and ears. And the situation iteratively worsens every day. Why would a nurse, realizing that no doctor ever reads her notes, even try to write them to be useful to physicians? And visa versa, obviously. Over the years, this divergence has been codified into ritual, calcified by templates, and hard wired through regulations whose original rationale no one can remember

Interestingly he points out that the spooks have gotten in on the concept with FaceBook-007 aka A-Space (I am guessing short for Analytical Space...?). Launch is set for Sep 22, 2008. UCSF back in 2003 launched a concept very much in line with the sharing of information amongst all the related parties (notably not the patient in this case) called Synopsis

As with all folklore associated with good concepts it was an rapid victim of its own success receiving requests for access, being copied and installed at other locations by users and even covered on a Web based M&M rounding on the Agency for Healthcare Research and Quality (AHRQ) site

There is work on these concepts underway and even some launches - if you live in New York you can sign up with HelloHealth from MyCA Health group who liked the approach taken by Jay Parkinson (the Hipster-MD from New York- pdf) who launched his own home made system with a similar ideal of sharing information digitally and providing easy, affordable access to patients some months ago. The NHS in the UK is getting in on the act with the "Individual Health Record" and covered in a recent article "Personal Healthcare Management" (subscription required) in my regular column in the British Journal of Healthcare Management.

There is even a Facebook application - MedCommons available today for a subscription plus monthly storage charges. Unfortunately much of what will be transferred in is likely to be scanned images and print outs. The introductory video even shows your physician office receiving access to your medical data and printing it out.....sigh! This will change but for now we are stuck with the legacy information

No doubt there will be detractors and there are bound to be issues and problems but overall you have to like the idea of sharing data on the quickly and effectively with the full clinical team. And there lies a key point.... the information must be be clinical data and should be tagged to a controlled medical vocabulary to make this information valuable for automatic machine processing. But lets not burden the clinicians with entering data in online forms but provide tools that capitalize on clinical documentation and the natural expressivity of language while still creating the structured data that can be used by these connected applications.

Doctors in the Typing Pool

An interesting blog from Westby Fisher on the failures of EMR systems that what it has turned our clinical staff into:

"...the world's most expensive typing pool has been born"

As he notes

Each morning, without fail, there's one or two individuals circling the computer terminals waiting for access to these electronic monetary portals, like children waiting to grab the last chair when the music stops.

That's true but I think the missing comparison here is how it used to be before the advent of the EMR's.....I can remember the same scene on the wards I worked on but instead of waiting for a seat in front of a computer it was waiting to get access to the "notes trolley" and the wait and frustration was no different and in many respects worse since there was only one record and therefore only one person could access it and enter data into the record. Much of this could be fixed with more accessibility, more computers or even better mobile access to the clinical data (here's one example combining the latest user friendly gadget with EMR access - you can see a video of this in action here:

But the issue of canned content being generated in large quantities with shortcut codes and pulling information from other sources to create a document is a problem. To create my note I can type
.id .pmh .psh .cmed .all .soc ....... you get the picture. These commands pulling data from other sources that add little to the actual clincal value of the document:

....demographics from the Central Registration.....four pages of Past Medical History...the original work was completed by the patient's poor primary care physician, neatly organized, but never to be updated again

.......page and a half of the current medications, their dose, prescribing physician, half of which come from self-generated 'CYA' hypoglycemia orders are also self-generated in the interest of 'safety'.....

......."Mother died of CA" automatically spits out previously entered by the hospitalist - bless their soul - so that billing to Medicare can go from Level 4 to Level 5 for the rest of the health care team

When clinical documentation really was clinical documentation and not just an automatic regurgitation of previous clinical notes captured by other people, the process of documenting was part of the clinicians analytical process. Entering the details was important as it afforded an opportunity to think about the patient, their history, symptoms, and signs and provided real input to the diagnostic process to arrive at a differential diagnosis and plan for the next steps. Clinicians are still trying to do this but all the while working to satisfy the documentation requirements so they can bill for their services

The rest is for Medicare and has been added repetitively and
identically by countless other individuals, all whom enter the same
content to assure achieving the maximum amount billed by law for their
services. Not that any of it is read, mind you, but it'd better be
there, lest the Medicare auditors descend on your facility.

Technology has helped kill the richness and detail of clinical documents and turned detail rich
reports into dumbed down "fill in the blank" cookie cutter reports that do not
reflect the richness of the information that physicians wants to provide to the colleagues.

In a recent discussion with a busy radiologists he remarked that what the referring physician needs from him is "more detail". He wants to provide the referring physician
the clinical information they need to treat the patient giving them the confidence in the information they receive with a rich detailed report that speaks their language.

So as not to reach the destination for the future of medicine painted by Westby Fisher:

Will they (future doctors) actually process what is entered, or merely become
highly-efficient typists and plagiarists in the never-ending quest to
become more "efficient" health care providers?

we must provide the tools that allow for clinicians to document clinical information efficiently with the richness of medical language while still providing the computers and clinical systems with their bits and bytes of data that allows these tools to function and help support the clinicians in the delivery of clinical cared

Wired - Why Things Suck

Wired's magazine article earlier this year titled: The 33 Things that Make us Crazy
featured a section on Medical records

The review was spot on:

Most medical records are about as orderly as an ER on Saturday night. Because they're mainly confined to paper, they can't be easily transferred from one physician or hospital to another. And because they're not subject to any standards (or even legibility requirements), they're nearly impossible to compare and combine.

Harsh but true.....and the ongoing problem of getting everyone to cooperate and share information which is int he best interest of the patient but not necessarily in the best interest og the hospital, healthcare provider or even insurance company:

..because the software vendors selling electronic record-keeping systems are competing, their systems are proprietary and incompatible. Oddly, that's OK with many physicians. Another name for an all-knowing, all-seeing, all-compatible electronic system is database, and physicians don't want people mining theirs — not because of patient-privacy concerns, but because the info could be used for doctor-on-doctor performance stats. Plus, docs already hate filling out charts; you think they want to learn data entry?

The potential cure cited is the arrival of Microsoft and Google as knight's in shining armour - not sure I buy this but I do believe that the entry of large organizations intent on shaking things up is going to have a positive impact. But the key point of advice:

Pressure your docs into accepting a more transparent system.

Agreed - interoperability and the sharing of data is essential. We have been sharing information since the beginning of time. Before the advent of writing, stories were shared, drawings made on walls and information was shared round a camp fire. When new more reliable media arrived (the pen and paper) information sharing moved to this media. Now we have digital media and bits and bytes and we need to wean the industry off its dependence on paper which is no longer effective and start sharing information using standardized compatible formats that everyone can use.

EHRs and Data Collection

The latest issue of the Journal of American Medical Informatics Association features a case report titled:

Opportunities for Electronic Health Record Data to Support Business Functions in the Pharmaceutical Industry—A Case Study from Pfizer, Inc. - you can view an abstract here (you need a subscription to see the full article).

I am all in favor of data collection and firmly believe that we must move to a data rich model in healthcare to allow the use of technology to support all the complex interactions and activities associated with the delivery of care. But the capture and collection of data has to be linked to a value for the beleaguered physician who is more often than not the one tasked with the collection.

What I found interesting about this paper was the focus on pharmacy data – not surprising given the authors affiliation but this particular quote stuck out

“Drug Safety & Surveillance,” “Clinical Trial Recruitment,” and “Support Regulatory Approval” were the most oft-mentioned scenarios during the interviews (Table 2), in which the senior executives believed that EHR data would prove valuable.

Drug Safety and Surveillance is a genuine crowd pleaser but Clinical trial recruitment and Support Regulatory approval is not likely to feature in many clinicians minds who are facing a waiting room chocked full of patients. Then in the summary

While EHRs can clearly provide some support to the pharmaceutical industry for data re-use, an ongoing dialogue must continue among EHR companies, research based organizations, and the pharmaceutical industry to ensure that the data being captured, aggregated, and analyzed can produce the value necessary for all stakeholders.

The problem is while the Pharmaceutical industry can see great value in the data from the EHR's they do not (or cannot) provide resources to help capture it. Everyone is tuned to the same radio station – WIFM (What’s in it for me) and in the case of the beleaguered physician there is little if anything in capturing data to suit the Pharma companies that offers the physician anything in return….. so why should they focus or pay any attention to this need of Pharma companies.

Better to focus on the opportunities related to:

1. Improve quality of care
2. Provide support to the delivery of that care, and
3. Save the physician time
   

All this needs to occur while helping clinicians capture more complete information at the point of care. Doing so will support the above elements but from the business perspective will show capture the information to prove the physician is performing all the relevant tasks to allow them to bill effectively. To that point in For the Record Magazine: Getting in Tune — New Survey Spotlights the MT’s Role in Healthcare. The article reviews the results of the "2007 Survey of Medical Transcriptionists". The lead author Gary David, PhD, an associate professor of sociology at Bentley College reviews some of the studies findings

One of the quotes sums up the current state of affairs

“Doctors do not generate revenue; documents do"

Or put another way "If it's not Documented then it didn't happen" (one of many references to this)