Digital Medicine Not Fulfilling Promises

The electronic medical record and the digitization of the health care system is entering more main stream media and coverage as evidenced by the article in Business week - "The Dubious Promise of Digital Medicine". As they put it the companies are:

in a stimulus-fueled frenzy, are piling into the business

Neal Patterson from Cerner is quoted likening this to the

19th century land rush that opened his native Oklahoma to homesteaders

If that analogy is correct then much of the activity is individuals and companies tuned to their favorite radio station WIFM...What's in it For Me? There are some interesting quotes including the suggestion from GE that they will "Leapfrog the competition" by not only replacing paper but "guiding doctors to the best, least-costly treatment". Now this is an interesting concept tied to Evidence Based Medicine (EBM) that has been around for centuries dating back even to Greece but has more recently attracted attention given the greater availability of data and the tools to process it. But as the piece highlights this rare consensus in Washington conceals the

checkered history of computerized medical files and (is) drowning out legitimate questions about their effectiveness. Cerner, based in Kansas City, Mo., and other industry leaders are pushing expensive systems with serious shortcomings, some doctors say. The high cost and questionable quality of products currently on the market are important reasons why barely 1 in 50 hospitals has a comprehensive electronic records system, according to a study published in March in the New England Journal of Medicine. Only 17% of physicians use any type of electronic records

In fact the 17% probably over states the actual usage as other reports suggest that while 17% of clinicians have purchased these systems there is a further gap in actual use bringing this down to a lower 7-9% in actual use.

In fact as David Kibbe points out

"Most big health IT projects have been clear disasters. This [digital push] is a microcosm for health-care reform....Will the narrow special interests win out over the public good?"

And nowhere has the challenge and in particular the failures been more apparent than in the UK's National Health Service (NHS) that has spent billions on the NPfIT program but has little to show for it.

But the attraction of large sums of money are hard to avoid, especially in the current economic climate and Allscripts CEO Glen Tullman like many, but perhaps with better access given his established relationship with President Obama, are vying for their share of the cash. McKesson have a slew of lobbyists to push their agenda and "building on existing technologies". Epic inevitably promotes the one system from one vendor with the corresponding price tag.

But implementation of these systems remains a challenge and the paper from 2005 in the Journal of the American Medical Association: Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors (abstract here - full article requires subscription) linked errors not to fatigue but to the order entry system. Many subsequent studies support this and even suggest that once the error is introduced these systems have a tremendous effect on perpetuating and proliferating these errors into more health records. The most recent article from the New England Journal of Medicine hammers home the point on the adoption of these systems - "Use of Electronic Records in US Hospitals" (it's available here in full as a pdf) and reports that 1.5% of hospitals have a comprehensive EMR!

So where is this all going - uphill but with multiple interested and vested parties pushing. Part of the push has to come from the users and making these systems intuitive and easy to navigate should be a basic requirement. Requiring days or weeks of training suggests design problems in my mind. Creating interfaces that engineers like does not necessarily translate into a busy clinical setting. Usability, data capture methods and tools and above all workflow optimization that fits into our current future clinical practice will be critical. Just implementing the technology never delivered the value and it has been this historical method that we must recover from and show a smarter more user friendly system.

Anyone should be able to navigate and use an EHR, clinical knowledge resources and these healthcare systems but using them for greatest effect will require more understanding on the part of our current clinicians and support from the plethora of ancillary services and staff who contribute to the functioning healthcare delivery system. To borrow from one of my favorite innovative and error free industries - the airline industry: It is the whole team from design, construction, build, maintenance and ongoing support of airlines that makes the captain do a fantastic job. Take Capt Sully Sullenberger - his actions were truly awe inspiring but without everything around him doing what it was supposed to do and all the hours of training and support he received the outcome might have been very different. As a true hero and consummate professional while accepting praise he has been quick to credit others.

Healthcare is similar and in the old adage - "there is no I in team". We must all do our part in enabling the delivery of high quality healthcare - EMR's and Healthcare IT is one part of that which we do need to get right.

Rally in Support of Those Imprisoned for Expression

Freedom of Speech - One of Our Great Liberties. I join others who are part of the blog rally for bloggers that are dying - it started here for Roxana Saberi - the NPR reporter incarcerated in Tehran.

The Universal Declaration of Human Rights states, "Everyone has the right to freedom of opinion and expression; this right includes freedom to hold opinions without interference, and impart information and ideas through any media regardless of frontiers."

Journalist Roxana Saberi has been incarcerated in Tehran's Evin Prison, where she is spending her birthday on a hunger strike. Around the world, people continue to face similar violations of their rights to freedom of expression, free speech, and a free press. Let's show the international community that we won't be silenced by intimidation and tyranny - that we won't stop believing in and fighting for these rights.

Freedom of the press is not a luxury. It lies at the heart of making this world healthier and more just. People without a voice and without a clear line of sight into the things that would threaten or corrupt their societies cannot hope for equitable growth and meaningful change.

A group of bloggers is holding a blog rally in support of journalists, bloggers, students, and writers who have dared to express their thoughts freely and have been imprisoned, abused, or killed.

Please consider "wearing" a blue ribbon online this week on your blogs, websites, and facebook / myspace / twitter pages, and invite others to do the same. Get the discussion going, and keep it going!

Interoperability and Data Entry - There are Solutions

This piece on the Syleum blog analyzing data and effective communication on "The Data Model that Nearly Killed me" makes for interesting reading

During the last week of January 2009 a faulty electronic, networked, health information data model nearly killed me despite its vaunted status as a component of two state-of-the-art, health information systems at two of the world’s most advanced medical facilities.

It does not come as a surprise given the complexity of medical information and the exponential growth in that data that keeping all this information correct, connected and up to date. In fact there was a veritable uproar created with the this posting by ePatinetDave - Imagine someone had been managing your data, and then you looked" (also this post). Not surprising to those of us who have looked at our own data for the last several years, myself included but quite shocking to most folks who for that period of time have been entrusting their data to others expecting it to contain accurate and appropriate content.

The sharing of information across systems just doesn't exist and I've talked about his before (here, here and here) and it's frustrating as hell to everyone involved. The patient ends up repeating information multiple times

The nurse who escorts me into urgent care asks me for my doctor’s name. I tell her my allergist’s name. The nurse argues that she wants to know the name of my primary care physician. Of course, that information is in my electronic medical record that she can readily access. The nurse next requests me to relate my medical history - which information is available in the electronic record. Next, an attending physician asks for my doctor’s name, no, not my allergist, my internist, and please relate my medical history. Never mind that (a) I provided this information to the nurse only moments ago, (b) I can barely breath, (c) I have horrible pain in my lungs, (d) I have a high fever, and (e) the requested data already is in my electronic health record.

In fact this is all in one office let alone sharing between offices....! This goes on with multiple interactions being documented next in the Allergists offices, then in the ambulance and then in the ER

I was in ER for 20 hours before being admitted to the intensive care unit (ICU) where I spent another 28 hours. Throughout my stay, I was hooked to network attached monitors that incessantly sounded alarms to which no one responded. I was asked 11 times to repeat my medical history, medication, and allergies to as many different medical professionals. I was seen by seven doctors each of whom asked me similar questions. Five doctors were never to be seen again. All doctors mumbled something about putting their findings into the hospital’s electronic records system - most did not according to ICU nurses. No one read my allergist’s detailed report about my condition and health history.

Then some heroic efforts to enter and capture this in electronic form

One heroic medical professional, the first nurse I met in ICU, worked to create a consistent record of my condition, allergies, and medications in the hospital’s electronic health information system. She spent over one hour searching for previously entered data, correcting errors, and moving or reentering data.

The review is a damning indictment of "the system" and it matters not which one it is

Medical personnel at urgent care and the hospital who interacted with me all used a version of the same electronic health information system (the “system”). It became clear that everyone was fighting that system. Indeed, they wasted between 40% and 60% of their time making the system do something useful for them. The system kept everyone from fulfilling their duties - the health information system did not help medical professionals perform their duties.

Fixing the underlying data model and the systems that we use to interact with these systems must be on the critical path. Spending millions of stimulus dollars on systems that "wasted between 40 - 60% of clinician time" is not going to fix the problem. Unfortunately fixing the data model is a challenging problem as this is a moving target in medicine. But fixing the capture of this information is not - there are time related challenges but existing infrastructure - dictation and transcription used in conjunction with technology: speech understanding, CDA and the healthstory interchange format and most importantly knowledge based workers: medical editors can help facilitate this process and at least relieve the burden of data entry from the time pressured clinical staff who want to (and used to) focus on the patient and their care rather than on the system and data capture.

Telling the Full Story

For the Record magazine did an excellent front page cover story on the Health Story project "Telling the Full Story". With less than 3% of the typical patient record composed of direct clinician input and somewhere in the region of 60% of clinical data coming from transcribed documents we need to find a way to capture and utilize this information to feed the data hungry EMR.

The Healthstory project represents that leap across the chasm. The opportunity to bridge the divide between the human readable and essential detailed free form narrative and the data elements necessary to drive the the EMR systems and automated tools available today but struggling to work as they sit starved of discreet structured, encoded clinically actionable data. As part of this initiative is the recognition that transcription and medical editors are a value added service bringing extensive knowledge, skills and data analysis skills to bear on the over burden documentation industry. As Liora Alschuler points out:

for a number of years, the “narrative” has been the EMR’s enemy, a relationship that the Health Story Project aims to reverse. “If you look at even the most sophisticated IT environments in healthcare, they still need this because their EMR does not eliminate the narrative form,”

Changing this perception of the narrative as the enemy and embracing the rich capacity of expression possible in narrative language is an essential first step. With the inclusion of narrative not just alongside but linked to the structured encoded clinical data creates meaningful clinical documents "that handle structured data and natural language narratives with equal ease". Providing both the computer and the clinicians with information suited to their needs.

“Data is structured to support rich links between clinical documents and electronic health records. That makes it easy to share information across provider and computer system boundaries while still retaining the essential human-readable, detailed narrative in one document.”

There was also other recent coverage including this piece in the JAHIMA April edition (pdf copy here or online here). If you don't know what it is or what is means to your organization you should.

If you are going to be at the MTIA conference this week - come along and find out more on Thursday April 23 at 7:30 - 8:15 (warning pdf). If not take the time to review the standards the "Shovel Ready" nature of the project, the benefits and the membership options)

The project has momentum and participation and needs your support. We should all be insisting on receiving the full story. If not

• press 1 to fill in all your information again at yet another clinical office,
• press 2 if you are fed up filling in forms and complete them half heartedly despite the fact that information is critical background to help your clinician make diagnostic and decision
• press 3 to have your blood work and x-rays redone since the information is not available to the one of multiple clinicians you visit each year
• Press 4 To skip a question since it does not have an suitable answer in the list of choices
• Press 5 To hear these choices, again and again and again

I know I want the full story and have been collecting mine for years.....are you?

Physicians Morphing into Data Entry Clerks

There is something wrong with the general positioning of technology in healthcare especially when you consider it relative to other industries. In no other industry do the most highly paid, skilled knowledgeable workers become data entry clerks. You don't find technology vendors working on optimizing the stock tracking systems to allow the CEO of Merrill Lynch to enter stock data in his financial tracking program.........

So, why oh why in healthcare do we spend enormous amounts of energy finding ways to make doctors more efficient in capturing data and entering that information into electronic medical records systems?

Philips Dowd, a former clinical associate professor of medicine at Brown University and an internist and hematologist suggests that these systems are not ready for prime time. The iHealthBeat site features a review of an opinion piece written by Dr Dowd for the Providence Journal: "Physician Says EHR Systems Turn Doctors Into 'Clerk-Typists" that places EHR's "where cell phones were at in the 1980s: primitive, proprietary and expensive".

Wrapped up in this piece are two major issues:

• Capturing the data
• Communicating the data

The capturing of data represents an ongoing challenge and the data hungry EHR's need to be fed. In fact much of the drive towards electronic records is being fanned by insurers who see this as a path to

reduce their billing costs and increase control over denials and prescription services

But as he rightly points out

patients found the [EHR] disrupted what had been a fluid, meaningful dialogue....the system offered little assistance and increased the time required to complete and record a patient visit

The process of interacting with a patient is an integral part of the clinical decision making and diagnostic process. Questions, answer and observation (dramatized to an extreme but not widely removed from reality in the clever series House on TV). Electronic systems have yet to facilitate this process and disrupt was has been meaningful and important element of patient clinical interaction. Dowd's summary brings this point home:

I see the [EHR] as the final stage in the forced metamorphism of physicians from thoughtful professionals to clerk-typists from the Katherine Gibbs School of Medicine

This is true and I heard in a recent discussion with a physician that his clinical interaction and the questions he asks has been changed as a result of the implementation of a structured EHR and data entry systems. With experience using the system he discovered that anything that was not covered in the "standard" replies available in the system cost him much more time......inevitably in a time pressured world he found himself not asking questions fearing a non-standard response from his patient and requiring a complex and time consuming additional data entry. The change from the widely used open ended questions to closed simple yes/no interactions is not likely to elicit more information or add greater value to the diagnostic clinical history taking.

Facilitating this data entry and voice enabling the capture of structured meaningful clinical documents cannot come fast enough. Technology can and already does automate some of this using Speech Understanding which understands words and their underlying context and meaning and output structured and meaningful clinical documents in Clinical Document architecture (CDA) format - or put another way The Full Healthstory that encompasses both the detailed narrative alongside the structured and encoded clinically actionable data necessary to drive the EHR and decision support systems. In addition the delivery of these structured documents are already available from many of the medical transcription service organizations (MTSO) who capture and produce CDA Healthstory documents. The Medical Transcriptionist is the knowledge based worker here to support and enable the clinicians to capture the information quickly, accurately and effectively. Right now many customers elect to receive text or word output but the rich meta data is available and health systems, doctors offices and physician practices should be asking for the Full Healthstory form their MTSO provider.

The challenge of communicating the data Dr Dowd rightly pointed out what every patient knows through the nauseam of multiple form filling activity in clinical offices

My brand can't speak to your brand or group or hospital

There is no sharing of data and information is repeated, recaptured and fails to be shared effectively between clinical teams. Walk into any clinical office and the first thing they do is ask you to fill in YAPF (Yet Another Paper Form) that contains much of the data you know is in multiple systems around the various clinical offices they have visited (an average Heart Failure patient visits 23 different providers per year). You can bet they fill out 23 or more different forms!

Once again the CDA concept allows for easy adoption and sharing of the full Healthstory. The standard encompasses all the elements necessary for good patient care, administration, reporting and research and importantly includes the narrative. You can download the Healthstory Q1 business update here (warning ppt download) and you can find out more about joining here. Everyone, patients, clinicians, hospitals, insurers and healthcare facilities should all be insisting on the full Healthstory

Software as a Service Has Come of Age

Here's why......In the current economic downturn the interest in alternative methods of financing solutions has increased. I hear repeatedly that capital budgets are evaporating and facilities are looking for new an innovative ways to finance innovation.

Software as a Service delivers the technology and innovation but does so in a different way putting less strain on capital finance requirements and delivering more value for money in a shorter period of time. In fact Gartner wrote a paper some time back (TCO Comparison of PCs With Server-Based Computing - subscription required) that demonstrated that the savings when considering the Total Cost of Ownership (TCO) can amount to as much as 48% relative to comparable fat client software installations. So how do these advantages accrue

Upfront Costs are Lower
The upfront costs to get technology installed and implemented is always going to be lower. There is typically limited technical requirements since the majority of the heavy lifting is done in the service providers environment in their technology center. Providing a good broadband connection with as the require resilience is typically the main cost

The savings mount up since payment for expensive licensed software can all but disappear. Depending on the application imaging the often forgotten add on costs of Microsoft Office and other additional licenses required when you purchase and run a fully fledged system and this can be multiplied many times over for each of the access points required. The model essentially lease the software on a “pay-as-you-go” basis. Not only is this pricing model more economical, it’s easier to predict and manage, and affords simplified financial reporting: Rather than trying to predict the funds required to pay out large chunks of capital for upgrades or replacements the ongoing costs is very predictable and tied to usage. Some call this conversion of CapEx to OpEx and will become increasingly important int eh current credit restricted market and cash strapped facilities. It also makes for inexpensive start up to provide access to a large number of users does not require huge capital injection.

Reduced ongoing costs
Often forgotten in the overall assessment of typical local software purchase and installation is the ongoing maintenance – not restricted to a single “maintenance” fee which is in the order of 10 – 20% of the initial investment but also needs to include the other software upgrades to the systems, equipment replacement and the inevitable complexity of troubleshooting.

Faster time to Deliver Solutions
In the standard purchase and own methodology setting up a new system involves many steps and is time consuming and costly. With professionally delivered services setting up a new system for a site is a rapid process. The SaaS capitalizes on the specialized staff who focus their energies on optimizing and scaling a system to ensure availability and delivery that is integrated into customer environments. With the solution ready scaling and delivering a new site can be extremely rapid getting sites up and running quickly benefiting from the solution and technology. Local staff focus on delivering service to their customers while the technology and the heavy lifting associated with getting it up and running is done by the SaaS vendor who has skills, staff and resources necessary to do so quickly and effectively
In addition given the push to roll out healthcare technology encompassed in the stimulus package showing benefit quickly will be essential to maintaining the momentum and flow of funds. Investing in large scale projects that have yearlong implementations and extended time frames before they can be installed and show any results will be less desirable and anything able to deliver quickly will be very attractive, especially when linked to low up front investment costs

Faster access to new technologies
In the rapidly changing world the risk of obsolescence is still high and being locked into a large up front investment that is obsolete before it even has time to be fully rolled out is an ever increasing risk. Not only does SaaS mean customers get faster access to new software and features but also provides customers rapid access to new and “trial” applications as they become available.

Enabling the Virtual Access
SaaS solutions are ideal for facilitating geographically distributed application needs and in cases of home access or remote accessing multiple sites this can be delivered quickly and cost effectively. Even in the case of local installations and sites access is often provided on thin client environments and this requires significant processor and server infrastructure for heavy weight solutions. In the SaaS model the processor power is shifted to distributed locations specialized in delivering power necessary for each application relying on broad band communications to link these environments.

Scalability
SaaS providers are engineered from the ground up to scale cost rapidly and effectively. Careful monitoring and management optimizes the resources to ensure availability of the solution and has built in capacity to meet unexpected spikes in needs without disproportionate investment requirements in technology infrastructure locally. SaaS also delivers built in geographic redundancy for an overall more reliable service performance than a traditional customer managed premises solution.

Better analytics and reporting
With the focus on delivering the service comes the inevitable requirement by SaaS vendors to monitor and optimize the application and the customer interactions with it. All this monitoring delivers a level of reporting capabilities that can provide detailed insights into customer habits and even performance that can be packaged into useful reports.

Better Management of Access
Hosted solutions also offer the ability to apply business rules across the whole center limiting access to specific times, locations and even intelligently routing work and information to those who are active based only on their availability. This is flexibility in delivering the solution and then linking the resources necessary to work with the application in the case of solutions that can be staffed outside of a facility

Improved customer satisfaction
All of the above elements combine to create a radically improved customer experience. By virtualizing the solution access is improved, new features are added quickly, problems prevented though intensive monitoring and maintenance and customers free up their resources to focus on their jobs rather than worrying about the applications

Guaranteed 24x7, 365, uptime
Fro many facilities it can be hard to relinquish control of precious IT assets to a third party. But rest assured today’s service based solutions have facilities fully-backed up and redundant and use state-of-the-art security to protect sensitive information. These service providers know that just one failure or breach could spell real problems for their business, so it’s in their own interest to protect your data.

For the same reasons today’s service providers have a vested interest in ensuring that their applications meet their customers’ needs: If the application performs poorly or turns out to be a bad fit for the customer’s business, the service provider loses a revenue opportunity. And because SaaS can be turned on and off just like a utility, it’s relatively easy for organizations to switch to another provider in a short amount of time. That gives the service providers all-the-more incentive to roll out tested, reliable applications that help companies meets their business goals. In fact SaaS providers are fighting for your business every day because if they don’t continue to deliver excellent service and improve their offering customers will stop using the solution and the SaaS provider will lose revenue and customers.

It took a while for SaaS to live up to its promise in no small part due to the challenges in the past with services and connectivity. But reliability of today’s platforms and the speed of today’s networks in particular have answered the remaining resistance points and it appears that SaaS is finally gaining serious traction.

So who's out there really (not standard software that has just been installed and hosted in a data center and called SaaS) offering SaaS in healthcare? How have your experiences been with SaaS? Let me know and post your thoughts