Tuesday, September 29, 2009

I'm Henry The VIII I Am

Henry VIII continues to be a fascinating case study and the focus of movies, books, songs (if you wonder about the title it comes from Herman's Hermits' Song of the Same name)

and recently ShowTime's series "The Tudors" which has certainly captured much of the intrigue if not all the historical accuracy. So what does this have to do with clinical documentation you may ask.

Henry VII is famous for his six wives but is also subject to substantial debate as to the cause of death. He died on 28 January 1547 after suffering through a bad fever. As was common at the time he was bled during his illness by the "physicians" of the day, and like so many cases this likely contributed to his death. But here we are 462 yeasr later and we continue to debate the cause of his death. There have been many suggested causes of his death:
  • Syphilis
  • Untreated type II diabetes
  • Obesity
  • Tuberculosis
  • An infection coupled with breathing problems
and probably the most commonly held view is that Henry VIII died of syphilis. A position promoted some 100 years ago but currently thought to be inaccurate. But the list of possible causes of death today would be a lot shorter had the method of data capture been an EMR. Imagine Henry's physician documenting the case - he would be presented with a list possible causes of death as known in 1547:

Tudor EMRCause of Death:
  • Consumption
  • Smallpox
  • Consumption with SmallPox
  • Other
But Henry's medical record was one of the best medical records of his time and included the following information (from Trivia Library):
At 22 he contracted smallpox..At 33 he had his first attack of malaria...At 35, after a serious jousting accident, ...develop chronic migraine headaches and the extraordinarily painful leg ulcers which eventually crippled him...at44, Henry suffered his worst jousting accident and lay unconscious for two hours....fits of blind anger ..acute insomnia, painful sore throats, and recurrent, agonizing headaches. ....became prematurely gray and abnormally obese; in one four-year period his waist measurement increased by an astounding 17 in., ....At 45 he developed a strange growth on the side of his nose...At 49 he probably became sterile or impotent...at age 55, he could hardly walk ...increasingly absentminded, ...his last eight days in bed, too weak even to lift a glass to his lips
But recent review of the notes suggest she may well have died from complications of Type II Diabetes. And it was the narrative that helped current researchers to come to that conclusion.

So unless we believe we know everything we need to know about healthcare, symptoms, signs and diseases then collecting the narrative is imperative to capture the maximum amount of information both now and in the future. If we loose the narrative we will be loosing information. Identifying data elements is important but these two worlds can live in harmony in Clinical Document Architecture Format (CDA) in the Healthstory Project that preserves the narrative but adds additional data elements.

If you want to hear more come listen to the presentation:

Clinical Narrative and Structured Data in the EHR: Venus and Mars Live in Harmony with CDA4CDT on Wednesday Oct 7th @ 11:15 in the Grapevine Ballroom D, Gaylord Texan, at the AHIMA Convention in Grapevine Texas. Hope to see you there

Thursday, September 24, 2009

The Challenge of Integrating the EHR into Clinical Practice

It probably comes as no surprise to read a recent report published on the "Society of Teachers of Family Medicine". In a their January 2009 "Family Medicine Journal - Vol 41, No 1": First Year Medical Students Can Demonstrate EHR Specific Communication Skills: A Control Group Study (abstract here - and full text here - pdf) they reviewed the teaching of medical students in relation to EHR specific interactions. Not surprisingly students that received communications and skills training for EHR usage performed better that the control group when judged on 10 EHR communication skills

That skills measured in this instance were divided up into 3 major categories - geography, Doctor/patient/EHR relationship and using the computer to teach and enhance care as follows:
  • Adjust the geography
  1. Student did not have their back to me during the exam.
  2. Student adjusted the chair to be at eye level with me.
  3. Student adjusted the screen so I could see it easily.
  4. Student moved close enough for me to read the screen to construct a triangle between student/patient/computer (Signals like “Can you read the screen OK?”)
  • Triad: doctor-patient-EHR relationship
  1. Student introduced him/herself before turning to computer.
  2. Student introduced the computer into the triad.
  3. Student visually shared EHR information on the screen during the exam to bring me into the triad, rather than keeping me outside of his/her computer work.
  4. Student maintained good eye contact with me during the encounter.
  5. Student alerted me verbally when turning attention from me to the computer.
  • Using the computer to teach/enhance the quality of care
  1. Student showed me my vital signs.
  2. Student graphed my vital signs or showed flowsheets or showed trends about my health.
  3. Student asked if I’d like a copy of my data.
  4. Student accessed other online patient education materials for me.

There are no real surprises to discover training an education can help improve the use of the EHR in the clinical setting but it was the feedback from the medical students that was interesting:
Medical students have expressed concerns about their ability to integrate the EHR into patient encounters. In a 2007 study, Rouf and colleagues reported that of 33 third-year medical students conducting electronic ambulatory encounters, only 64% were satisfied or very satisfied with doctor-patient communication when using an EHR.6 Further, only 24% thought the EHR improved their ability to establish rapport with patients, and only 21% believed that their patients liked them using the EHR. In addition, 48% of students reported they spent less time looking at the patient because of the EHR, and 34% reported spending less time talking to the patient.
So while a large number were satisfied with the doctor-patient communication when using the EHR they recognized that only 21% of patients liked them using the EHR. (the patient feedback directly would have been more useful). The 21% is not statistically significant since it is hearsay of the medical students not the patient but if my own personal family experience is anything to go by (Doctor please look at me not your EMR) then this may well underestimating patient dissatisfaction.

In fact I suspect patients are much like doctors in that they like the output and the improvement in communication and availability of information that comes with the EHR but like doctors hate the process of capturing this information and how this detracts from the patient-clinician interaction.. Solving this conundrum would push the adoption of these tools well past tipping point and into common use in every clinical setting. The dream of automating this task was captured in a still famous video from Hewlett Packard in the early 1990's "Imagine". Those that saw this were caught by the ease of interaction and the simplicity of sharing data. As the patient was wheeled into the Emergency Room the Emergency Medical Technician and nurse are documenting the vitals, history and related clinical findings directly into the EMR into the relevant fields - not with a keyboard and mouse but with their voice. Key data was identified and linked to the EHR database allowing the clinician to access the information and pull up related studies.

While we may not be quite there yet voice enabling the interaction still represents the most efficient method for capturing information. Capturing text has been possible for some time easily but the transition to structured clinical data is occurring now. The narrative is captured in its entirety (more on this next week) and within this narrative key data elements are identified and tagged and held in Healthstory format ready to be passed into structured data fields of the EHR.

Are you getting the full story?

Thursday, September 17, 2009

Myths and Lies in Healthcare Debate

The British Medical Journal published a letter to Senator Kerry that was from more than 100 National Health Service (NHS) health service professionals and patients that addresses some of the criticism leveled at the UK's NHS service. Titled "Setting the Record Straight about the NHS" it is worth reading in its entirety. I'm not here to suggest that we need the NHS in the US but having experienced the service as both a provider and consumer I can attest to the high level of service and the feelings of security that arise from a true catch all service that does not require the production of your money for service.

My own personal experience, coming from the fortunate position of having health insurance and good personal health and a family with few medical problems is a fear of approaching any medical facility or health care provider. It remains a mystery, much like the single sock in my dresser that never finds its pair, what the charge will be I end up paying. The idea of health insurance, given the extraordinary amount of money deducted from my pay each month would be that accessing care would cost me little over and above what I already pay in premiums. But this is almost never the case. Following the billing process and managing Explanation of Benefit statements, insurance, medical savings accounts and all the other associated tasks is almost a full time activity and is always a fight. In the tax system you need to reach a minimum outgoing of 7.5% of your Adjusted Gross Income (AGI). That might seem like a lot but each year I am often close and frequently pass this hurdle to be able to deduct anything in excess of the 7.5% of my AGI. This by the way is over and above my insurance premiums. And I consider myself lucky. I wonder how my British friends and colleagues would perceive this state of affairs. At any point in time when I do dig into the details or end up chasing a payment that has not been made I have to organize conference calls to get the insurance agent and the providers billing office on one call to agree what is missing and who needs to fix it. The Providers office does not see it as their problem - hence every time you enter their office they demand you sign a document saying you are responsible for all the costs and as a courtesy they will attempt to bill insurance on your behalf. The insurers for their part fails to deal with the provider except with your forcing the issue and any payments go through their Delay Department that seems designed to make life as difficult for everyone involved as possible. Recently I made a tactical error and agreed to pay the whole cost up front to the provider to get a discount. Suddenly the billing office had no incentive to follow up the billing to get me my insurance payment and the insurance company would not accept any "bill" or claim form me - it had to come from the provider. Heaven forbid I had a serious condition or required extended treatment or clinical visits?

So is this system working for you - I doubt it. But maybe if you started in a system where this was the norm you might not sense that this is an additional unnecessary burden and stress. For all the faults and challenges in the NHS I never feared walking into a physician office for care, treatment or preventative healthcare and screening - never!

Health insurance i nothing more than a commercial operation designed to manage the flow of money with an extra set of mouths to feed adding what some estimates put at 10 - 30% of total cost of healthcare. Is this value for money. While we are at lets crush one misconception here - dental insurance is not insurance. It's does not provide even the most basic of coverage adn the out of pocket expenses are huge even for the most basic of dental care.

With that all said moving the existing healthcare system to a new format is not going to happen. The challenge of "Getting from There to Here" was eloquently detailed by Atul Gawande in his New Yorker piece. The NHS was established on July 5, 1948 but what is lost in the mists of time is the sequence of events to reach that point:
Instead, the N.H.S. was a pragmatic outgrowth of circumstances peculiar to Britain immediately after the Second World War. The single most important moment that determined what Britain’s health-care system would look like was not any policymaker’s meeting in 1945 but the country’s declaration of war on Germany, on September 3, 1939.
The sequence of events and war time necessity created "a national Emergency Medical Service to supplement the local services" which expanded to cover essential services necessary to the population remaining int he country and dispersed by the war time bombing of cities and the returning veterans injured in the line of duty. For many groups providing free care was a necessity of the "war effort" and engaging the private system to supplement the rapidly assembled government system was an obvious step. The system was expected to be temporary but status quo had been destroyed and not least of all because the population, despite the war, had seen an improvement in the health of the population.

The medical and social services had reduced infant and adult mortality rates. Even the dental care was better. By the end of 1944, when the wartime medical service began to demobilize, the country’s citizens did not want to see it go. The private hospitals didn’t, either; they had come to depend on those government payments.
So in 1945 the concept of the NHS was really nothing more than extension of what had been created through necessity of the war.
By 1945, when the National Health Service was proposed, it had become evident that a national system of health coverage was not only necessary but also largely already in place—with nationally run hospitals, salaried doctors, and free care for everyone. So, while the ideal of universal coverage was spurred by those horror stories, the particular system that emerged in Britain was not the product of socialist ideology or a deliberate policy process in which all the theoretical options were weighed. It was, instead, an almost conservative creation: a program that built on a tested, practical means of providing adequate health care for everyone, while protecting the existing services that people depended upon every day. No other major country has adopted the British system—not because it didn’t work but because other countries came to universalize health care under entirely different circumstances.
So whatever we end up with in the US it won't be an NHS. It might take some of the elements of the NHS and it will be based on our countries experience and system drivers. But within the discussion lets focus on facts rather than anecdotal stories and fears (as seen here in the Scientific American article on "Anecdotal Evidence undermining Scientific Results":
Thinking anecdotally comes naturally. Thinking Scientifically does not
So please start thinking scientifically and base discussion on science and facts and help move this reform forward.

Tuesday, September 8, 2009

Agreement on Healthcare Reform

The healthcare debate continues front and center with every last group weighing in on what needs to change, what needs to stay the same. In fact I'd be willing to bet that for every position in favor of change or status quo you can find the opposing view from another group.

But there are some core principles that I think some level of agreement:
  • Elimination of Waste
  • Improve Patient Care
  • Care for Everyone (Life sustaining not lifestyle sustaining)
  • No one should be bankrupt paying for Care
Based on a totally unscientific poll with friends and colleagues who represent from both sides of the aisle there was agreement with the above principles. No doubt the devil is in the detail but if we can agree on some basic principles and start with agreement rather than disagreement perhaps there is some hope for much needed reform of our healthcare.

Each of these issues is complex and as I wrote in my other blog on a recent incident involving abuse of services for a bee sting it may seem obvious in this case but the problems arise when you look at cases that are not so obvious. The level of waste is staggering - based on this report from Price Waterhouse Coopers:
more than half of the $2.1 trillion spent on healthcare every year is
This is spread across many areas and reasons why but as they point out in looking at one large facility - John Hopkins which is representative of the complexities facing the other 4,500 hospitals around the US:
About 700 different organizations, health plans, and employers pay the bills at Johns Hopkins Health System in Baltimore. Each one has different rules about what’s eligible for payment, how much to pay and when to pay....Reducing the redundancies could save the hospital more than $40 million annually, and that’s only “numbers we could identify if we could just get computers talking to each other”
This is basic stuff and these savings alone could go along way to help pay for some of the proposed reforms that, on principle, we agree are desirable such as care for all. In the words of one reporter in the UK: US Healthcare - the Biggest waste of Money in the World. I might not go that far but the idea we are getting any degree of value for money. What is interesting in the breakdown shown is the public/private split of payment

Interesting since in this view it would appear that the number in the US is skewed so high in excess cost because of the Private Costs. Maybe focusing on fixing the excess cost int eh private system might be a place to start on cutting waste.

I look forward to hearing the President's address and hope he can focus on the areas we agree on and set a framework that unites people to overhaul the system for the benefit of everyone.

What do you think - can you agree on the principles above or are these even subject to disagreement?