Accelerating Adoption of Healthcare IT

EHR Initiative - Is it a Monkey on the Back

2010-03-03T10:11:00.001-05:00

In an interesting post by Evan Steele in his EMR Straight Talk blog: "Government EHR Teetering on the Backs of Physicians" talked about the recent HIT Policy committee response to the CMS proposed Meaningful Use regulations and the disconnect between the regulatory requirements and the practicalities of introducing these technologies into the complex clinical environment.

All this was nicely summarized in this graphic

As Evan points out

The government continues to ignore the fundamental problem that has discouraged EHR adoption in the past, particularly for high-volume, community-based specialists—and that is the EHR products themselves. The government has created an unstable program, basing it on unproven, difficult-to-use, traditional EHRs, and then has imposed additional layers of complexity on top of these products.

Demanding direct data entry by the provider into a Computerized Physician Order Entry System (CPOE) is a sure fire way to limit adoption. Did we learn nothing from the Cedars-Sinai failed CPOE implementation back in 2003

Cedars-Sinai failed despite having a very strong track record and deep experience in informatics, strong leadership, and substantial resources. There were several reasons for this failure: many decision-support mechanisms were introduced at the outset, especially for drug-drug interactions; with the way the application was set up, alerts could not be overridden; and it was hard to achieve buy-in from the very large number of providers using the system (Ornstein C. Hospital heeds doctors, suspends use of software: Cedars-Sinai physicians entered prescriptions and other orders in it, but called it unsafe. Los Angeles Times, January 22, 2003: B1)

So despite deep experience they failed and had to suspend use of the system. Meanwhile we see the government meaningful use objectives mandate CPOE from the start. The impact on physicians is likely to be negative and the impact on the vendors and their products will likely create more challenges:

First, EHR vendors will have to rush to modify their products to meet HHS certification requirements, resulting in even more cumbersome EHR products. Then, over the next five years, they will have to constantly hustle to keep up with the continuously evolving meaningful use criteria, as well as implementing the Y2K-like conversion from ICD-9 to ICD-10. In the technology world, rushing development efforts to meet unrealistically aggressive timeframes typically results in unusable and clumsy software. Unfortunately for physicians, the government will expect them to use these more complex EHRs to meet onerous meaningful use requirements that become increasingly stringent from 2011 to 2013 and 2015.

Building on existing processes and systems and in particular clinical practice that collects information as a natural part of the clinical interaction with patients would seem to be a much more constructive approach that would garner support all round. The narrative has been the mainstay of clinical practice and to date the most efficient way of capturing that narrative has been dictation. Facilitating and including the narrative dictation and building on it to satisfy the data needs of EHR's and even CPOE systems is the bridge between these two opposing views and the Healthstory Initiative creates an open and widely accepted infrastructure of standardized implementation guides for the common note types. The project members have been submitting commentary on the Meaningful use specifications and continue to push for the inclusion of narrative in the specifications.

EHR's should be in our future but on terms we can accept and will work in the complex and demanding clinical environment - that requires inclusion of narrative in meaningful use and sensible standards that focus on flexibility and adaptability of technology to meet the needs of clinicians.

Data Input Is Difficult

2010-02-24T12:00:00.003-05:00

A recent survey by the Texas Medical Association (TMA) (one page summary here -pdf and the survey results here - doc) shows an increase in the number of people reporting use of an EMR(43% in 2009 up from 33% in 2007). There is also a continued trend of physicians expecting to implement an EMR that is being helped by the Health Information Technology for Economic and Clinical Health (HITECH) Act with 59% of respondents looking to qualify for these incentive payments.

But it is the likes and dislikes of existing users that makes for interesting reading. 76% of respondents like electronic charting which I interpret to be the accessing the clinical data in digital form, the ability to process and manipulate and re-purpose in different formats. And features clinicians don't like..........

data input difficult or time consuming

Shock horror - clinicians don't like being data entry clerks (I can't see my patient's because I am at the Screen Entering Data and Doctor Please look at me not Your EMR). None of this is surprising and this remains the most significant barrier to adoption of EMR's in the busy and complex clinical setting. Designing a brilliant user interface to capture clinicians input into discreet fields may suit the needs of the data driven EMR but it falls well short of the clinical needs and in particular the physicians need for information. Physicians are pushing the federal Health and Human Service department to include the narrative as part of the proposed regulations for electronic health records and rightly so. As the eWeek article "Doctors Say Narrative Missing from Proposed EHR Regulations" stated:

No matter how good [EHR records] are, you'll never get the flavored nuance of the patient's [situation] if you don't have an unstructured note," said Dr. Steven Schiff, the medical director and service chief of cardiology at Orange Coast Memorial Medical Center, in Fountain Valley, Calif

The comparison between a template generated note:

The occurrence was one hour prior to arrival. The course of pain is constant. Location of pain: Head leg. Location of bleeding: None. Location of laceration: None. The degree of headache is mild. The other degree of pain is moderate. The degree of bleeding is negative. Mitigating factor is negative. Immobilization no backboard in place and no cervical collar in place. Fall description tripped. Intoxication: No alcohol intoxication. Location accident occurred was home

and the narrative created by a physician:

The patient is a 74-year-old female who presents with a complaint of fall, 74-year-old female presents with complaint of neck pain, headache. She states that she had mechanical fall at home where she tripped and fell downstairs, approximately 9 steps and landed on her back. She complained of shortness of breath right after the event. She noted that she had pain in her left ankle and left knee. She is not sure whether she had loss of consciousness and the patient further complains of the pain in the right wrist

makes this point with 97% of the survey saying they prefer the human generated note. It's unlikely that that any EMR system will pass the Turing Test anytime soon!

Patients too will start to insist on getting the full Health Story as Steven Schiff points out in his article on in the Huffington Post "Have you Thought About Your Health Story?". As patients increasingly become partners int eh care process rather than the traditional bystander information will need to be transferred between the patient and the clinicians and computer template generated notes are not going to work. There's a good reason that the:

written patient medical record had its birth in the 19th century and as such, has remained almost entirely unchanged for well more than 100 years. During this time, literally everything else in medical care has evolved

It was a very effective means of communication and has served the healthcare providers well but the transition from paper to electronic remains a major issue and the importance of the narrative in the progress note is essential:

From the outset, we need to agree on the critical importance of such notes. It is necessary to tell a patients story, and to assess the significance of that history. At this time, it simply is unrealistic to think that all healthcare givers will develop the typing skills needed to function adequately in this environment. At best, it will require a full generation of doctors, nurses, technicians, and therapists to come and go before that is as ubiquitous a skill as handwriting is now. It is clear to me that the answer to many of the physician challenges that surround electronic medical record adoption and full patient utilization of these records lies in the use of voice recognition software

Electronic health records coupled with voice recognition technology allows me to document in the chart while I am seeing the patient. The note is often created with the active participation of patients and family members; and is then finished at the end of the patient encounter and is faxed to the referring doctor. Additionally, a copy is printed out at the checkout desk and handed to the patient as they leave the office. The notes are error-free for the most part, and are immediately available in the chart. There is no reading, correcting, signing, and mailing to be done. Most importantly, the notes can be highly descriptive, capturing not only the raw facts, but the nuanced details that are unique to that patient.

You're unique; your health record should be too

Right on! EMR's need speech has an integral part of capturing clinical data. Turning that into shareable information that can be accessed and consumed by the data centric EMR is the function of the Healthstory Project that sets out an open Clinical Documentation Architecture (CDA) standard for Common Document Types. Tied to speech understanding and you bridge the divide and overcome the 50% of physicians surveyed who say they dislike the EMR because:

"Data input difficult or time consuming"

The pieces are all in place - we just need to put them together intelligently into the existing workflow and healthcare process.

What are you doing to capture or collect patient clinical documentation. Do you use voice or templates. What do you love or hate about your clinical system?

Patient Unfriendly Environments

2010-01-26T10:05:00.000-05:00

Bridget Duffy is the "Chief Experience Officer" for the Cleveland Clinic and gave a presentation at the first "Gel" conference looking at the patient experience from a personal standpoint when she broke a leg and as she described "became invisible". You can see the presentation here (it is 25 minutes long but worth the time from a provider perspective as well as the patient perspective)

Bridget Duffy at Gel Health 2009 from Gel Conference on Vimeo.

And if that does not work click this link here. Fascinating insight that I can only echo from recent experiences that start long before any interaction with the hospital. Dealing with insurance coverage is an excruciatingly painful experience. When I called my local, friendly and most importantly the pediatric orthopedist who I knew and knew my family I discovered he no longer accepted . There a whole side bar here on why he would stop accepting an insurance but who wants to bet that it has something to do with the pain and agony his office has in getting reimbursed for care and the rates he is forced to accept with those patients.

So now the patient choice is to pay "out of network" or find another provider who you don't know and does not know you (and unless you are religious about collecting your medical records and imaging studies won't have the slightest idea of your medical history). Electing to save money means navigating through the the voice navigation system designed in hell for your insurance company to reach a human being to ask who in the nearby area takes their insurance. Does this feel like rolling the dice in Vegas to anyone else? I spend more time researching the hard drive upgrade for my PC than I have and can spend on where to go for my care. Imagine if you were buying a hard drive but although you liked the Geek Squad at Best Buy could not go there because they did not take your credit card - frustrating. But then again perhaps Best Buy would not want your business if when you bought the hard drive worth $100 but your credit card company actually only paid them $35....

Back to the orthopedic referral - now you have to call the office and spend 15 minutes redialing as the number is constantly engaged! I thought that problem had disappeared along with my Vinyl records! Finally you get through and must finish strong persuading the receptionist that you do need an appointment today. Not unreasonable having placed your 11 year old patient in a painful holding pattern over the weekend because you knew that marching off to the local ER was a gargantuan waste of time and resources and nothing would be done over the weekend anyway. This step alone saved the insurance company hundreds of unnecessary dollars of spending but will never be taken account of.

Does any of this seem broken to you - it does to me and as Dr Duffy explains some of these things are not difficult to fix. If the first things I heard when I attended a medical facility was concern for me and how I appeared to them vs the typical first interaction that is composed of data and financial gathering I'd already feel better treated.

What insurance do you have
or
What is your Patient ID

Hello.....!
Sadly few facilities are likely to find the money or resources to allocate to a CEO (that's a Chief Experience Officer) for their facility or being able to run a Code Lavender that delivers Spiritual Care, Counseling, and arrange of other holistic type support services to departments and staff alike but you can bet that they all need one. There are few I have visited that have the slightest inkling of the challenge patients face every day dealing with their organization. To be clear this is not so much an individual criticism as an institutional one.

Ask yourself this question

Can you facility pass the Mother Test: can you drop your mother at the door of your hospital and leave her there for a few days and know that she has been treated with compassion, care and understanding and will emerge happy and contented at the end of it

If you can answer yes - please tell use where this is so we can direct people to this facility. If the answer is no what can you do to fix this and what would make you feel comfortable with a facility that it would pass your mother test?

Ready or Not Electronic Health Records are Coming

2010-01-05T16:45:00.003-05:00

The games afoot or as they say in England "Game on".....healthcare standards are published (actually the Notice of Proposed Rule Making NPRM - which can be found here) and supplemented by an article posted by David Blumenthal "Launching HITECH" posted by the New England Journal of Medicine.

As before there are multiple stages that include incentives linked to each of the stages but if we focus on Stage 1 that starts in 2011. This includes electronically capturing health information, clinical decision support for disease and medication management, clinical quality measures all tied with protection and securing of the information (don't forget liability for security breaches is now much further reaching). The investment is made (numbers vary but range from $14 - 27 Billion). To receive incentives providers must use their electronic medical records to improve the overall quality of healthcare delivered by demonstrating achievement of a series of objectives. These include (this is not an exhaustive list but captures the main elements):

Entering orders, medications etc in CPOE
Maintaining problem lists in ICD9-CM or Snomed-CT coding
Maintain active medication list and electronic prescribing
Recording vital signs, smoking status
Receive and display lab results encoded with LOINC codes
Generate patient lists based on specific conditions and generate patient reminders
Provide patients with electronic copy and electronic access to their record and discharge instructions
Generate a clinical summary for each visit
Exchange clinical data with other providers
Protect the information, encrypt it and record disclosures

There are others but these are broad categories and groups and represent a major push to genuine electronic medical records that are digital, contain useful data and are shareable between systems. Certification (as currently provided by CCHIT based on their existing criteria and what we know to date about the requirements for meaningful use) has 11 products certified for 2011 - list here. This is a work in progress and expect to see many more and probably other certification bodies.

The overall tenet of this initiative is summarized by Dr Blumenthal in his article:

...so as to reward the meaningful use of qualified,certified EHRs — an innovative and powerful concept. Byfocusing on the effective use of EHRs with certain capabilities,the HITECH Act makes clear that the adoption of records is nota sufficient purpose: it is the use of EHRs to achieve healthand efficiency goals that matters.

There are other strands/programs that are designed to address the obstacles to adoption - summarized in this chart from the NEJM article:

Behind the scenes the health information exchanges that allow for the easy sharing of clinical data between systems, clinical users and patients will be essential.

This is a broad set of criteria and for many clinical practices a long way from where they are now. The shape of this program is clear - sign up and participate now and receive additional funding/payment or wait and be punished later if you do not implement. There remain many challenges not least of all the products and expertise required to roll these technologies out but to me the message is clear - this train is leaving and failing to get on board will will cost you more in the future.

In the first instance we have an opportunity top provide input to the NPRM - the link for this can be found on the main page of the HHS HealthIT page here or the actual system here. Have you managed to wade through the 600+ pages or found a great summary of the content highlighting key aspects - share the knowledge, leave a comment with your thoughts and/or links and help everyone get up to speed with this material and provide input to the rule by the end of February 2010.

Time with the Doctor

2009-12-01T10:34:00.001-05:00

Scientific American publish an article titled "Are Doctors getting slower or are patients getting sicker" that was based on a paper written and published in the Archives of Internal Medicine: Primary Care Visit Duration and Quality: Does Good Care Take Longer? Chen et al. Arch Intern Med.2009; 169: 1866-1872. (unfortunately subscription required). Apparently people are going to the doctor's office more often and for longer visits than 9 years ago. Whether this is because we need more medical attention or because there are more treatments available, the end result is the same as it is for imaging and radiology. Fewer resources spread over more work. In radiology the explosion of images (imagine the effect of single slice CT to 64 and more slices CT exams) has created less time to review per image for the number of radiologists available.

In medicine in general, if we the patient are consuming more time with more visits and for longer consultations - assuming the number of clinicians stays constant this should result in a decline in time per consultation. This represents a challenge in achieving the goals of modern healthcare

Two of the most pressing goals for the U.S. health care system are to deliver higher-quality care and to lower costs

Since most studies suggest that better care is linked to time spent with the clinicians - especially in complex cases. It turns out according to this study that

(they) found no evidence for the commonly held belief that physicians are spending less time with their patients or that quality of care has diminished

Time spent had increased from 18 minutes per consultation to 20.8 minutes. The investigators discount clinicians inefficiency as the reason for the increase:

Although it is possible that physicians are becoming less efficient over time, it is far more likely that visit duration has increased because it takes more resources or time to care for an older and sicker population

And while I think the complexity has increased in care delivery I think it is far more likely a combination of both (complexity of care and inefficiencies in the clinical care system) contributing to increase in time necessary to spend with the patient. Unfortunately much of this inefficiency is the new clinical systems and the complexity of capturing the information that has added significantly to the time required. No doubt we will see more studies that segment the time in more detail. In fact in some results published in this article in the Healthcare Ledger (Medical Transcription Relevance in the EHR Age - warning pdf) a study suggested that documentation time had quadrupled adding more than 110 minutes per day!

There is consensus on the value of clinical systems and digital information in particular the opportunity of providing more useful data at the time of the doctor-patient interaction. But it was clear from recent discussions that there is a divide in the way in which doctors and clinical staff should interact with these systems to capture and record information. There are those who view additional resources appropriate for assisting (Moving Transcription Back into the Hospital). And there are those that see a need for a change in approach and style to adapt to this process and incorporate into the doctor-patient interview. My own personal experiences support both answers. In some instances the interaction with the clinical system forces a change in the way doctors interact with patients and the process, work flow, methods and materials suit a new way of working. But in a recent experience at a clinician specialist's office (in this case a pulmonologist) it was very clear watching the interaction and in particular the flexibility and dynamic nature of the paper based note taking that any imposition of a digital system would not only slow the consultation to a grinding halt but would reduce the information captured dramatically. This is not to suggest that there is not (or will not be) a solution to this problem but the "standard" digital note capture system would be hopeless in this setting and be quickly rejected.

The comments to the article demonstrate some of the strong feelings - those of doctors overwhelmed with administrivia

Patients are NOT sicker and Doctors are slower, but only because of the inordinate amount of documentation required. My office note 40 years ago might have been: Sore throat-----Penicillin. We all knew what a sore throat was and that Penicillin was prescribed. In contrast Today's visit must include all vital signs, past history, a history of the presenting complaint, history of allergy, plus a rather extended physical exam, otherwise we do not get paid by the insurance companies or the Government. I used to see 50 or more patients a day and see them very well. Now, with all the rules I"m lucky to see 30 and am exhausted after doing so.
Dr. Michel Hirsch, FP, FAAFP (1967-present)
Donaldsonville, LA.

and the patients who feel they are getting less at a higher cost

I must live on another planet. Nurses have always performed all of the routine stuff like vital signs etc. I am 54 years old and have type 1 diabetes. I have never had a doctor spend more than 10 minutes with me, ever. It's usually 5 minutes and $70.

Both are right - doctors are required to do more in less time and patients are getting less. I like many others buy the vision of electronic medical records but perhaps not exactly as they exist today. The current large scale implementations and clinical systems struggle to account for the variations in specialties and their needs and while there is some element of best of breed approach many shy from this concept given the historical challenges of integration and intelligent sharing of information between systems from different providers. Things have improved - Healthstory (using HL7 CDA) as an example of an open standard that allows sharing of clinical data. This is a journey not a destination....and if there is a destination Ill bet that will be constantly changing! The challenge in the coming months and years will be guiding the beleaguered, over worked and underpaid clinicians through the maze of systems, their features and functions and helping them adapt their technology to their practice and vice versa.

How important is the digital record and if given the choice of doctors with and without what would you choose. For the practicing physicians that has an electronic medical record - is it a good or bad experience. For doctors still working in the paper world - can you see this changing or are your needs met currently and cannot be sustained in any of the digital models you've seen?

Moving Transcription Back Into the Hospital

2009-11-12T13:12:00.000-05:00

What's old is new again......A recent article in USA Today (High-tech 'scribes' help transfer medical records into electronic form) highlighted the latest innovation in healthcare documentation - "High-Tech Scribes" who help "transfer medical records into electronic form. Is it just me or does that sound like something that is already going on in the electronic documentation industry with medical transcription and editing for the last 20+ years?

The challenge of capturing clinical documentation in digital format have remained the same and the continued struggle of adoption is highlighted by the poor adoption rate of electronic medical record systems

Today, only 1.5% of hospitals have a "comprehensive" electronic health record, and 8% have a basic version, according to Jha's March study in The New England Journal of Medicine. Most hospitals are intimidated by the cost, which can range from $20 million to $200 million.

Pretty poor given how long the industry has been working on this and despite the length of time still no clear exchange format or standard to facilitate the sharing of information

because there are no common standards for these records, doctors who do implement electronic charts may not be able to share them with a hospital across the street

But the value of digitizing medicine and implementing these systems has been clearly established and the terrifying level of errors that do occur as detailed in the landmark "To Err is Human - Building a Safer Health System" published in 2001 and many follow on reports and studies including he 2005 Health Affairs study that reported:

The country could eliminate 200,000 drug mistakes and save $1 billion a year if doctors in all hospitals entered their orders on computers

Despite these drivers we are still languishing in single digits of adoption and continue to struggle to roll out healthcare technology that effectively improves quality and safety without crushing efficiency and effectiveness of clinicians. So the University of Virginia Doctors elected to employ "scribes" to document the clinical encounter and these individuals such as:

Leiner, 22, a University of Virginia graduate who plans to apply to medical school

Who follow the doctors around and capture the clinical interaction on laptops. The consensus appears to be this will not catch on although a recent debate on the AMDIS list server offered some differing opinions that included some potential to reduce mistakes given the second set of eyes reviewing the documentation and the capture of the information real time with the patient. There is complexity in this approach made worse with gender conflicts (female patient and male scribe for example) but this approach appears to represent a modification of the current documentation process that uses dictation and transcription and perhaps offers some potential to free up clinicians to interact with patients rather than focusing on the clinical documentation and the electronic health record.

Moving the medical editor out of the bowels of the hospital just formalizes one of the well known methodologies in many transcription departments that attempts to link doctors to the same transcriptionists so they learn to "work together" (albeit remotely). This would make the bond stronger, the connection greater and the opportunity for error reduction using a trained and qualified "scribe" to document with the clinician. The medical editor is qualified, experienced and a highly knowledgeable resource that is currently disconnected from the clinical process.

Technology just becomes a facilitator in this process with speech understanding and speech recognition providing tools that can be used by one or both of the documentation team. The electronic medical record becomes integral to the documentation process. And although the real time aspects of alerts, evidence based medicine and the application of real time clinical knowledge to the interaction is still once removed from the physician the real time team documentation can provide direct access to the clinician through a combined approach to the capture and recording of the patient encounter.

How would you feel about a scribe being part of the clinician patient interaction - as the patient, as the clinicians or as the scribe?

Is Speech Recognition Ready for Prime Time - You Bet

2009-11-05T13:33:00.000-05:00

In a posting on the American Medical News site titled: Is Speech Recognition Ready for Prime Time - You Bet Pamela Dolan refers to the history of speech recognition and how the technology was cited as one of the best things to hit healthcare - 10 years ago. In fact in 2005 I wrote an article for Health Management Technology Magazine (now available for purchase through Amazon): "Is Speech Recognition the Holy Grail":

Speech recognition technology has been lauded as the best thing to happen to healthcare technology since the advent of the computer, but is it really the Holy Grail? Speech recognition has the potential to overcome one of the most significant barriers to implementing a fully computerized medical record: direct capture of physician notes. Industry estimates from physicians and chief information officers at hospitals suggest that 50 percent of physicians will utilize speech recognition within five years. Coupled with this is the growing demand for medical transcriptionists, which is projected to grow faster than the average of all occupations through 2010

In pulling up the original article from my archive it made for interesting reading and while there were still problems with the technology in 2005 it had reached a tipping point and the summary at the end was pretty much on the money:

Speech recognition is good technology, but it is neither a panacea nor the Holy Grail. Speech recognition has been two years away for the last 10 years, but we may be approaching the Grail — finally.

Developments over the last several years have incrementally improved speech recognition systems to the point that some have intelligent speech interpretation—extracting the meaning, not just the literal translation of words—and producing high-quality documents with minimal human intervention. Further integration and embedding speech recognition with mainstream EMR solutions will allow for expedited capture of documentation as part of the clinical care process, offering clinicians a choice of methods to document creation. The last significant development in speech recognition technology was the recognition of continuous speech. The next big leap in this technology will be the merger of NLP and CSR to create natural language understanding. This development will take the technology to the next level and will offer a realistic opportunity to make speech recognition the de facto method of data capture for the medical community. The question is, When?

As the article from the American Medical News says:

"It (speech recognition) wasn't ready for prime time," Dr. Garber pointed out. "Now it is. No question"

But I disagree on the impediment to EMR usage that is linked ot the lack of discreet data. This is true with old style speech recognition - the process of converting the spoken word into text

The problem is when you talk into it, the data is not discrete ... it's still like a Word document

but not for speech understanding which is the the merger speech recognition and natural language understanding - available today. Already in use in many sites and delivering data in Healthstory CDA4CDT format.

So to answer the question - Is Speech Recognition Ready for Prime Time: You Bet!

So are you using it, what are your experiences or would you rather be entering data using forms and computer screens?

I Can't See My Patients Because I'm At A Screen Entering Data

2009-10-29T14:31:00.003-04:00

As with so many services the world is getting flatter (per Thomas Friedman: The World is Flat - A Brief History of the Twenty-first Century) and medical services and in particular medical care is no exception. Everyone must run faster just to stay in place even the health care profession. We are seeing increasing interest and uptake of "Medical Tourism" (this term seems wrong to me - it reminds me of "Friendly Fire") and a recent posting on the Wharton Site on Health Economics: Bangkok's Bumrungrad Hospital: Expanding the Footprint of Offshore Health Care (Props to HISTalk). As with many of the offshore medical facility there are questions regarding safety and oversight (see this web site regarding Jim Goldberg's 23 year old son who died there and he is convinced there is a cover up and conspiracy).

That aside the interview with Mack Banner CEO of Bumrungrad makes for interesting reading especially when it comes to the implementation of their Electronic Medical Record system (in this case Microsoft's Amalga) and their move towards a totally digital hospital. This is interesting not least of all because Microsoft is exploring this vertical in another country and developing a solution that we will likely see being rolled out in this country once they have worked out all the issues and filled in feature/functionality gaps. But from a documentation standpoint as Kenneth Mays (the Hospital's Director of Marketing) points out:

We talk to our colleagues in the States and they're all facing the same challenge of getting doctors to enter things into computers. It's wonderful in theory. It makes your system more efficient. It makes it faster. It takes out a big source of errors. But it requires doctors to type in these things and it's not easy to get doctors to do that. It could also take something away from the doctor-patient interaction if the doctor has his head buried in a computer rather than looking at the patient and having a dialogue with the patient.... Hospitals, not just our hospital but I think hospitals everywhere, are facing this challenge.

This challenge is significant and one that remains unanswered in the limited roll out of EMR's. In fact a recent Washington Post article: "Electronic medical Records not seen as a cure-all" Alexi Msotrous makes the point that while everyone appears to agree that American Medicine needs to go digital (it is probably broader than that and I would suggest worldwide medicine needs to go Digital) the results are less than stellar and in some cases

suggest that computer systems can increase errors, add hours to doctors' workloads and compromise patient care

Yikes! The Senate Finance Committee has sent a letter to 10 major vendors demanding to know what steps have been taken to safe guard patient data - I expect the responses will be made public which should make for interesting reading. Meanwhile David Bluementhal rightly points out that

the critical question is whether, on balance, care is better than before and he (David Blumenthal) said. "I think the answer is yes"

I agree - we cannot continue the paper based record and we need data to feed these systems to make them useful. But to get this data in creates a data entry challenge that one physician said

I can't see my patients because I'm at a screen entering data

AND

his department found that physicians spent nearly five of every 10 hours on a computer, he said. "I sit down and log on to a computer 60 times every shift. Physician productivity and satisfaction have fallen off a cliff"

And my own daughter (as a patient) from her experience interacting with a physician office said "I wish the doctor would look at me as much as she looked at her computer" (See Doctor Please Look at Me not Your EMR).

The answer lies in using the current methodologies for capturing information - dictation, forms, and other tools that are blended to provide the easiest and most facile way to capture the data for clinicians. Making the data capture part of the clinical interaction without taking it over is essential. Clinicians talk faster than they can type - capturing that information and making this narrative tagged with semantically interoperable data that is usable by the EMR is possible today. Technology, standards and resources exist that allow for this today.

What would you rather be doing - typing at a screen or talking to your patients?

Cause and Effect - Unintended Consequences

2009-10-12T12:06:00.004-04:00

It was the story of the story of the Indiana Grandmother of Triplets whose picture ended up on the front page of her local newspaper titled "Drug Sweep" for the crime of buying two boxes Cold medication that got me thinking about the effect each of us has and fail to realize. She was arrested and prosecuted by the local Prosecutor (Nina Alexander) :

The public has the responsibility to know what is legal and what is not, and ignorance of the law is no excuse

whose inability to see past rules and regulations and direct transference of the problem directly to "the customer". As James Shott writes in Observations in his piece "Citizens deserve service from Lawmakers" the prosecutor clearly lost site of who precisely she was serving:

But does the public not also have a reasonable expectation that laws will be rational and bureaucrats will use common sense?

It would appear not in this case nor in this case. Working the other way was the surprise to the prison authorities in the United Kingdom who introduced anti bacterial hand gel pumps but quickly withdrew them when they discovered inmates were drinking the gel: "HM Prisons ban Anti Bacterial Hand Gel" - interesting they also mention the Royal Bournemouth Hospital was having the same problem and said:

it was one of many hospitals removing alcohol-based hand cleaning gel from reception areas in a bid to stop visitors drinking it

Who would have thought it!

But the same is true with money focused on healthcare reform already approved which according to Mark Leavitt from CCHIT and his presentation at AHIMA last week amounts to $36 Billion. As Kelly Mclendon from HIXPerts pointed out in his presentation this proposals are no longer proposals and the regulation went into effect September 23, 2009 (enforcement may be delayed but it's coming) with a series of focus areas:

Incentives Meaningful Use and Certified EHR's
Workforce Expansion
HIPAA - Privacy and Security
Data Exchange
Regional Centers (CER)

As quoted in the presentation - the Office of the National Coordinator (ONC) said on Meaningful use:

To some providers, particularly small or already stretched physician practices or small, rural hospitals, the path toward meaningful use may still seem arduous. To others, who would just prefer to stick with the "status quo," it may seem like an unwanted intrusion. We believe that the time has come for coordinated action. The price of inaction – in adverse events, lost patient lives, delayed or improper treatments, unnecessary procedures, excessive costs, and so on – is just too high, and will only get worse

This train has left and if you are left in any doubt as to the likelihood of the digitization of medicine is coming - ready or not. In the current documents for certification published on the CCHIT web site (warning pdf: Comprehensive Certification Handbook) a quick search of the for the following terms revealed the following number of hits:

Transcription - 0
Dictation - 0
Narrative - 1 ("Textual narratives must be present in each required section")

And the same in the Document (warning pdf: Meaningful Use Matrix Tagged for CCHIT Reference):

Transcription - 0
Dictation - 0
Narrative - 0

While this is neither scientific or conclusive it does represents the potential for unintended consequences. I wonder how many physicians can imagine their lives without Dictation, Transcription and Narrative. There are studies questioning the effects of technology on healthcare with the widespread implementation. Unfortunately subscription required for full articles - Journal of Biomedical Informatics: Qualitative studies to Improve Usability of EMR) - interference with worklfow as one of the posible challenges. More data continues to emerge that suggests that even for the oft cited "young" physician who grew up in an era awash with technology, computers keyboards still fail to transition easily to documentation using a keyboard and mouse once they enter a busy clinical practice overwhelmed with patients. As the Healthstory consortium states:

Approximately 1.2 billion clinical documents are produced in the United States each year. Dictated and transcribed documents make up around 60% of all clinical notes

With the looming regulations and incentives that currently take very little account of this enormous block of data. In fact in many instances have been promoting how they plan or propose to get rid of it, ostensibly to "save money" offers an opportunity to watch untended consequences grind the system to a halt. Anecdotal stories of physicians who are forced to spend more time on documentation for the purposes of clinical systems and in the case of the NPR story today: How the Modern Patient Drives up Health Costs that featured a tearful Dr Teresa Moore whose Keysville practice is overwhelmed with paperwork that finds her

stay(ing) at her office late into the night, trying to complete paperwork so that she is able to spend enough time with her patients during the day — enough time to explain why this test is probably not necessary, why that pill wouldn't be a good idea. And her children, she says, pay the price

In this story the focus is the additional burden of the educated patient questioning care, asking for alternatives or bringing in internet print outs and adverts. But the principles and issues remain the same - and as she says when asked if she preferred the old passive patient or the newer more demanding modern patient

But I do like an educated patient who's willing to read about their health issues. So I guess I'd like someone in the middle

Having others deal with the burdens of documentation (or in this case insurance that in her words: "Sometimes you have to request a form just to get the correct form — you do. You have to fill out a form stating the preauthorization form that you need") would help alleviate the strains placed on the clinical providers. But without involvement and participation of the providers of clinical documentation services we may be caught up in unintended consequences both from the perspective of the patient but also from an industry.

Be part of the solution and get involved - join Healthstory, get involved in Advocacy and provide input to the Rule Making and definition of Meaningful use.

I'm Henry The VIII I Am

2009-09-29T09:34:00.000-04:00

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

The Challenge of Integrating the EHR into Clinical Practice

2009-09-24T13:47:00.000-04:00

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

Student did not have their back to me during the exam.
Student adjusted the chair to be at eye level with me.
Student adjusted the screen so I could see it easily.
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

Student introduced him/herself before turning to computer.
Student introduced the computer into the triad.
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.
Student maintained good eye contact with me during the encounter.
Student alerted me verbally when turning attention from me to the computer.

Using the computer to teach/enhance the quality of care

Student showed me my vital signs.
Student graphed my vital signs or showed flowsheets or showed trends about my health.
Student asked if I’d like a copy of my data.
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?

Myths and Lies in Healthcare Debate

2009-09-17T10:07:00.003-04:00

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.

Agreement on Healthcare Reform

2009-09-08T16:32:00.006-04:00

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?

Information Overload in Healthcare

2009-08-31T14:18:00.003-04:00

Physicians are drinking from fire hoses that are fed by the expanding number of systems and information sources. Dealing with this information explosion was the subject of a recent posting by KevinMD on his blog titled "How a wealth of information takes attention away from the patient" (it was a reposting from Abraham Verghese blog originally called "A Theory of Attentivity"). Despite a prime time for working inpatient coverage as residents and senior residents reach the end of their training year and are better and more experienced it has as he describes it, gotten more challenging for the mountain of data that:

...exists on each patient. It’s a surprise every time, a feeling analogous to revisiting Bombay or Madras after years of being away and finding that a city you did not think could get more congested, has done just that

We add voluminous quantities of notes and data to a patient that represents the ever increasing haystack of patient data. IN fact as he quotes from a 1969 lecture:

What information consumes is rather obvious: it consumes the attention of its recipients

Or as he paraphrases TS Eliot with an excellent quote:

knowledge can get lost in information, just as wisdom can get lost in knowledge

Leading to a lack of attention to the patient. It's not just data as I highlighted in this post "Doctor Please Look at me not Your EMR" that stemmed from my daughter's visit to our local pediatricians office. While I understand the desire to push a "poverty of attention and agree that the computer should not rule the interaction as this hinders and in some cases destroys the clinical diagnostic process we do need to address this information problem.

The clinician interaction needs to be captured. Providing a point and click technology to capture that detailed process that he suggests to his student that demands:

getting as much as he can from listening to the patient, from sounding the body

Will never be captured in a drop down list or check box. This is the information in the narrative. But if we just load narrative it will provide little value as it just adds to the hay stack and clinicians will be relegated to turning pages of information in the eBook reader (better known as an EMR). For this information and knowledge to be useful it must be computer interpretable and usable by machines automatically. This is the strength that Healthstory format and structure brings. Allowing for the capture of the narrative but attaching codes and structure to that content that makes it useful.

The case is made - we need to keep the clinician patient interaction and preserve that content but it needs to be made useful. Filling in forms and selecting from drop down lists is not going to satisfy that need and worse may well limit the capture of rich detailed knowledge that is an essential part of that patient discovery process. Helping to bridge that gap is the Healthstory project that allows for both worlds to coexist happily.

Have you joined?

Standards and Interoperability

2009-08-18T17:52:00.002-04:00

It has been an interesting week of rhetoric and emotional outbursts for and against healthcare reform. In amongst the many articles I found this post from David Kibbe on the Healthcare Blog: Why Standards Matter - the True Meaning of Interoperability; a word that he believes that the American people are skeptical of.

You only have to take a quick visit to one of the personal health record systems Google Health or Microsoft HealthVault) to understand why when he says:

interoperability is a hugely important word in the context of today's ongoing debate about the use of EHR technology by physicians, hospitals, and patients too

It is not just an important work, it is an essential component of any future innovation in healthcare. At a recent meeting of the HIT committee several of the members acknowledged that

didn't really know" what interoperability means

Yikes! Frightening if the advisers don;'t have a good handle on what this should mean. He is right that there is complexity in a precise meaning of interoperability since there are many levels and the post contains some good descriptions on the various levels and elements of interoperability - for instance data, words, formats, layout etc. But as he rightly points out capturing medical information in PDF format does not make it truly interoperable and in the example h cites of loading his living will into Google Health this is simply an online version of the Amazon Kindle. Interesting and may be useful to have but not really interoperable.For it to be interoperable the information contained in the files should be in a standard format and the example here is XML (the underlying basis of web pages that you are reading this blog on). XML is an open standard and has a lot of flexibility (as we have seen with the advent of even more creative web pages and Web 2.0 type applications)

The essence here is the need for standards that are the industry and users of the information need to agree on the standard. We need to move past the VHS/BetaMax or BluRay/HDDVD debate and to a set of standards that everyone can use.

At this point standards have not been agreed and there are still some competing standards but XML does seem to be an underlying technology format of choice and is in use Healthstory. Based on Clinical Document Architecture (CDA) that uses XML this format allows for the capture of free form narrative linked to encoded content such that the Diabetes in the note can be identified by a computer systems as ICD9 Code of 255.0 - Diabetes Mellitus). Already some systems will import medical information encoded using XML type standards and this is likely to increase. As you think about your health record you should be looking for providers and technology that will export your information in a meaningful format that can be reused in other systems and applications. Start looking for your records in interoperable format - and insist on the full story not just extracts or sub sets of the data.

More is Not Better

2009-08-06T09:07:00.002-04:00

It is customary to believe that more is better. Higher availability and more access = better care...right? Wrong! A recent interaction at the pediatricians office amplified the point and the influence that the patient can have. In a case of extended week long general malaise some level of investigation and therapy was warranted and we agreed on some basic blood work. But in the conversation with the pediatrician she explained that many of her patients were insisting on "Lyme Titre's" based on local reporting of "huge increases in Lyme disease". Nationally the incidence runs around 0.04% and is considered "rare". I could have insisted but logically it made no sense - there had been no possible instance of exposure to risk factors (tick bites) so what would that test bring. But my choice was clearly not the norm.

It is this excess utilization driven by the system that is detailed in in Atul Gawande article penned a another insightful piece in the New Yorker that shreds the notion that we are getting better care just based on higher access. "The Cost Conundrum" is the talk of the town and rightly so.

In his tale of two cites - 800 miles apart in Texas the data available on healthcare costs and results shows that McAllen, Texas is spending approximately twice the cost (~ $15,000 per enrollee). Currently Medicare income per capita is $12,000....! In El Paso - some 800 miles away the costs are half as much running at around $7,504 per enrollee. Similar mix of demographics and public health statistics.

His discussions with local residents and providers was revealing in the wide variation of possible causes:

McAllen is providing unusually good care (it's not)
Better technology availability (it's not)
More doctors (no difference)
The service is better
Malpractice is a bigger problem (not based on the recent Texas law capping malpractice claims)

In Fact on the quality metrics published by Medicare:

Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse, on average, than El Paso’s.

Not only is the cost troubling but the outcomes show that the population is not getting value for their expenditure. As is so often the case if you follow the money" the answer becomes evident. Our system incentivise use not results. As the cardiologists put it when asked about a hypothetical patient with chest pain that goes away and has no associated family history or other clinical indicators to suggest heart disease...

“Oh, she’s definitely getting a cath,” the internist said, laughing grimly.

And for many patients this would be a great outcome. They got the test they needed and ruled out heart disease. Not so for the sub group who are unfortunate to suffer complications some minor and transient and some major and permanent (you can get a good overview of the procedure and complications here):

The1-2% of people who get major complications from the procedure, the 0.08% who die from the procedure, the 0.03% who have a myocardial infarction precipitated by the procedure, the 0.06% who have a devastating stroke or the 0.62% or 0.06% depending on the approach Hospital Acquired Infection, the 1% who have an allergic reaction to one of the many agents used, the 1% who may go on to develop renal dysfunction....still feeling good about the investigation?

In McAllen the analysis of the Medicare data revealed some troubling variation compared to El Paso:

Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits.

As Atul Gawande put it:

The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.

The good news is that just having the technology does not necessarily translate into over use. The Mayo clinic in Rochester has some of the highest levels of technological availability but one of the lower rates of Medicare spending (in the lowest 15% of the country at $6,688).

At the core of this story is data - the lack of insight and availability of data was troubling:

It was a depressing conversation—not because I thought the executives were being evasive but because they weren’t being evasive. The data on McAllen’s costs were clearly new to them. They were defending McAllen reflexively. But they really didn’t know the big picture of what was happening.

The most expensive piece of equipment in the hospital is a doctor's pen. But this tool has been heavily influenced by knowledge and availability of best practices. Where best practices are well defined there is close alignment in the clinical choices. Where the science is unclear the variations arise from high levels of investigation (in areas of low cost healthcare delivery) to low levels and conservative treatment (in areas of low cost healthcare delivery). Overall the intent is not to over charge or provide more care but the underlying drivers change behavior for clinicians who try to cope with a complex and overwhelming system that they have little training to deal with.

To borrow form the Six Sigma and Deming's "Plan-Do-Check-Act" Cycle Six Sigma attacks problems with DMAIC

Define high-level project goals and the current process.
Measure key aspects of the current process and collect relevant data.
Analyze the data to verify cause-and-effect relationships. Determine what the relationships are, and attempt to ensure that all factors have been considered.
Improve or optimize the process based upon data analysis using techniques like Design of experiments.
Control to ensure that any deviations from target are corrected before they result in defects. Set up pilot runs to establish process capability, move on to production, set up control mechanisms and continuously monitor the process.

Rinse lather and repeat. Critical to this process is developing measures and collecting the data to measure. But healthcare has lived in a wilderness of data both clinical and financial. Everything about the current system is focused on increasing volume in part to offset the decreasing levels of reimbursement. Creating systems like the Mayo that deliver care where "the needs of the patient come first" is at the core of the changes necessary. What is interesting is that most here would love access to the Mayo care but in the political battlefield the concepts and ideas are tainted as rationing and limits to our supposedly great service.

Everyone likes to bash the NHS in the United Kingdom and roll out the legion of complainers who list the reasons why the system is not working while failing to acknowledge the integrated care and access helps deliver better care. While the NHS may not be the perfect system it does encompass elements that we should learn from. I know which care I'd prefer to receive - that of the Mayo style; balanced and high quality. I avoid the McAllen experience where possible recognizing that the "MD" at the end of my name can influence the clinical interaction positively or negatively. I can invariable force the investigation or test if I choose to but I elect to be far more conservative in my approach for me and my family. As I did with the Lyme Titre and do repeatedly - I remain conservative bucking the trend.

Do you? Would you have insisted on the Lyme Titre or just accepted it when it was mentioned simply because you had heard about Lyme disease, were worried and your physician had mentioned it? More is not always better. What's your experience?

Risk Assessment in Healthcare

2009-07-31T06:03:00.000-04:00

Bruce Schneier posted an article in his newsletter "Why People Don't Understand Risks" that referred to a piece in the Minneapolis Star on Infant Death and their front page headline "Co-sleeping kills about 20 infants each year" (btw this case is more complex than this headline suggests as there are drugs and alcohol involved - babies have slept with their parents and in their parents beds for hundreds of years and without drugs and alcohol represents the a normal safe way for those that like this idea). As he points out - the article is useless since it provides not context or additional information to draw any kind of

The only problem is that there's no additional information with which to make sense of the statistic.

As was made clear with this cartoon:

the science of extrapolation is not quite that simple

The context is of course the usual for the media - shock value and attention grabbing headlines - in this case the tragic case of an infant death from smothering in their sleep. But nowhere so we see details of

How many infants don't die each year?
How many infants die each year in separate beds?
Is the death rate for co-sleepers greater or less than the death rate for separate-bed sleepers?

And the media is only trotting after the marketing machines in some companies - the latest instance of marketing taking over was featured in this piece on USA Today on Tanning Facilities and needless to say disputed by the "The Sunbed Association" disputes this and says:

"there is no proven link between the responsible use of sunbeds and skin cancer"

Well not according to the latest research published that sunbeds cause melanoma. Well proven links that the more sun or UV you expose your sun to the higher the risk of skin cancer.

And there lies the challenge in assessing risk. Filtering information requires some deep insight and sifting through the veritable tsunamis of available sources which represents a significant challenge for the every day user. The issue of Sudden Infant Death (SIDS) is very emotive and reminds me of the major change promoted some years back that had a big impact on incidence - place the baby on their back not on their front. "Back to Sleep" was the campaign back in 1994

So as you approach the headlines and marketing of technological advances take it with a pinch of salt, ask for all the data. Use the web and resources to research your decision in the same way you would do when you make a major purchase. As we discovered recently in our household - not all ear piercing is created equal.... the Ear Piercing Gun and the mall option at Clare's maybe no a good choice. Item no 3 in this search revealed the problems associated with the Ear Piercing Gun.

What are your experiences. How do you filter information - share your tips and tricks

Three Body Problem - Transcription Productivity and Speech Understanding

2009-07-20T12:07:00.006-04:00

As an official Space Aficionado who "Applied to Ride" in an attempt to get a spot on a Russian rocket into space in the 80's and was beaten to that spot by the scientist from "Mars" - the confectionery maker I can't resist finding a link between current Apollo 11 memories and healthcare and clinical documentation........

The moon shot was a triumph in so many areas - the science alone was complex, challenging and with the level of computer sophistication at the time even more incredible for its success. Bear in mind that the Lunar Lander had a computer that had the same power as a wristwatch today (actually it was probably less). It is clear from this insightful Op-ed piece in the NY Times - "One Giant Leap to Nowhere" that much of the drive and success of the moon shot was less about the technology and more about the vision of one individual. Wernher von Braun was the philosopher who created the vision and orchestrated the various components into place to successfully place a man on the moon and return him safely to earth. The original drive was more military than scientific despite the fact that any possible attack from space remains challenging by virtue of the "three body problem".

Clinical documentation needs to solve an equally complex three body problem of Medical Editors, productivity and Speech Understanding. There are clear benefits to be had from implementing technology but these benefits accrue not just from the technology but from addressing all the elements. Imposing requirements on physicians on the way they dictate (pronunciation, terms, punctuation etc), on what they use to dictate (audio quality is a big contributor to ability of a speech understanding technology) and even simple workflow improvements that remove the necessity to dictate patient information or repeat information that is already captured and can included automatically are all key elements that can contribute to successfully using technology to improve efficiency. That said I would advocate some variations including less demand on changing physician behavior and having the technology adapt to the physician rather than the other way around - but not all technology is capable of this smarter approach.

In fact Jay Vance in his Blog The XY Files in an MT World talked about these points in a recent posting "Transitioning to Speech Recognition Editing". As he points out there is more than just technology at play. As he rightly points out:

This leaves the impression that 100% of the permanent physicians' dictations are being successfully recognized by the system....I've never seen this level of successful implementation, ever

And the point is well taken there is more at work here than just technology. The medical editor remains a key resource in this equation and part of the three body problem. But just applying technology won't make medical editors more efficient and more productive and importantly better compensated. Addressing the productivity gains and educating not just the clinicians but the editors and management is essential.

I'd add an additional element to this equation one I believe is essential to clinical documentation companies and specialists in this field.... this is not just documentation this is clinical knowledge and information. Generating "reports" or blobs of text be they in RTF, PDF, DOC, or TXT format is not solving the problem or addressing the needs of the sector. Clinical documentation specialists should be using their human intelligence and knowledge to generate "Meaningful Clinical Documents". We require vision and drive towards the creation of clinically actionable data from the documentation industry. We have the necessary infrastructure to help achieve that - I've talked extensively about Healthstory and the importance of preserving the narrative while making the information contained semantically interoperable or computer interpretable for consumption in our increasingly digitized world of medicine. The industry needs to rally around generating useful information not plain old text.

In many respects I think the industry needs the philosopher visionary who can, like Wernher von Braun, articulate the reason why transcription remains an essential component of healthcare delivery and not a dieing industry. His response to the frequently raised question of space exploration and why we Robots were not the solution to space exploration:

there is no computerized explorer in the world with more than a tiny fraction of the power of a chemical analog computer known as the human brain

Has much in common with healthcare, medicine and in particular the process of documenting and capturing clinical information where I would say:

There is no computerized system in the world with more than a tiny fraction of the power of a chemical analog computer known as the human brain, that can replace the knowledge workers in healthcare

Are you that resource and can you be part of that vision or even lead that vision. This is a rallying cry for Clinical Documentation to shoot for Mars and generate Meaningful Clinical Documents that contain the complete Healthstory.

Self Service Medicine

2009-07-14T13:25:00.010-04:00

No doubt the title will raise a few eyebrows but there is a growing trend of self service in many other industries as detailed in this posting last month by Tim Egan at the NY Times - The Self Service City and also in this posting by David Strom - Surviving the Self Service Internet. In each of these pieces the authors describe the slow erosion of personal service in favor of automated systems and technologies. In almost all cases this is not for the benefit of the consumer but for the benefit of the service provider. In the case of cameras "it turned out to be a revenue-generator" and the local government "took to it with a vengeance":

Who needs a human being when you can write ten times as many tickets without overtime pay?

But in fact as Tim points out

Numerous studies have found that robo-cams make intersections less safe. People panic knowing the camera is on them, trying to beat the recording click of their license plate. In Alexandria, Va., one study found that accidents increased 43 percent at intersections where cameras were used to enforce red lights.

But you won't find easy links to those studies as the governments have found a new way to tax the citizens thinly disguised in the name of safety. In fact this is subject to a concerted effort in my home state to combat the rising tide of cameras (you can find out more here)

And the story has been repeated with frightening frequency from the original trail blazer of ATM cash machines to check in desks at air lines. How about the local little league baseball match, even professional games umpired by cameras. Perhaps that is good news for healthcare as the industry is certainly currently in the face-to-face contact world. But there are moves to change this - this the latest in self service healthcare in the PBS piece - Bill of Health: Self Service Medicine. The concept is still in its infancy and centered around capturing registration and basic details but we are seeing the idea moving into the healthcare realm. It is hard to assess this and there are of course concerns expressed over the safety of such an enterprise since no "professional" will have reviewed or checked the information and diagnostic process. Equally the application of a good data base could actually apply more information to a consultation given the limited capacity of the human mind to recall all relevant information. In fact in a recent posting on online symptom checkers that took a look at a few of the same tools being offered in a self service world. No question there are challenges but some of the tools I have seen show great promise and even the potential to bring more data analysis to each and every consultation. Today your success and treatment choices are very much driven by the first touch. This is well demonstrated in oncology where your the likelihood of your treatment being surgical is much higher if the first person you see is a surgical oncologists. Similarly for radiation (radiation oncologist) and chemotherapy (medical oncologist) - yet we know that there are some clear benefits to the correct sequencing of treatments for best possible outcomes with minimal side effects

So is self service medicine a good or bad thing......I'm going with good. But for it to be effective patients need to have complete detailed health records that they own and have full and ready access to. Part of that ownership includes the need to provide useful translation of complex terms into more readily understood information that can be read, understood and processed by automated clinical tools. In other words patients need the full healthstory that they can read and feed into these systems.

Imagine the circumstance where you have an incidental finding on a routine x-ray that is ignored because it does not fall in the typical patient profile for the clinicians specialty that you are visiting. But feeding that information into an online personal health record provides additional background and alerts that make you a better more informed patient that can discuss the findings and determine the best next steps in conjunction with a clinician.

There are challenges of privacy, insurance and even excess investigation but like your airline flight.... wouldn't you rather know why the aircraft is sitting on the ground or should the pilot just assume that he knows best and keeping you informed is unnecessary until such time as he is certain on the reason and the possible outcome. I know which one I prefer - full and complete disclosure. Unpleasant news is always hard to take but prevention is a key element to successful treatment and outcomes and without full disclosure getting to that early diagnosis is will be that much harder and take longer.

Do you have personal experiences good or bad. Do you agree - online checkers or self service medicine is good - or perhaps you disagree and you think this should be stopped at all costs. Let me know

Meaningful Use and the Missing Ultrasound

2009-07-07T19:31:00.002-04:00

Imagine you show up for a follow up appointment with your physician to review the Ultrasound you had done 10 days ago. An ultrasound that was performed in the same hospital system as the one you are visiting that you fully expect to be available for your physician to review with you - but when you arrive they have no information, report or even knowledge of the study every being performed.....well you don't have to imagine this at all as I would bet it is happening on a routine basis in many facilities.

So it was for a recent visit in our family. Fortunately I had insisted on a digital copy of the Ultrasound delivered on a CD in DICOM format. A quick visit to download a free DICOM Viewer - in this case OsiriX and a potentially wasted visit turned into productive experience. But were it not for the standard of DICOM making these images available easily, and my mission of collecting all medical records personally it would have been a very different story. In my mind the facility woud not have passed the first hurdle of meaningful use - no one involved in care was getting meaningful use of the imaging study or the information from that exam.

Which brings me to the the HITECH act and Meaningful Use standard. Health and Human Services convened hearings on Meaningful use in April this year and issued a set of recommendations that were open to public comment up to June 26, 2009. It is an important question because the incentive funds are linked to implementation that fulfills "Meaningful Use". Naturally everyone is scrambling to determine if their product/solution will meet the requirements and for those on the purchasing or user side wanting to know what Meaningful Use means to them. The Association of Medical Directors of Information Systems (AMDIS) submitted their combined response - the result of discussion that took place at the cleverly nabbed domain www.meaningfuluse.org. The AMDIS response can be found here (pdf). AMDIS promotes Meaningful use based on broad high level themes that include

Meaningful use should be from the patient’s eyes and in particular make the information available to them
Clarification of the requirements to receive funding - what must be met to receive payouts
Focus on data capture and sharing
Defer reporting requirements of quality measures on the basis that this will become a natural byproduct of implementing systems that capture this information appropriately
Defer requirements for CPOE implementation as this represents a huge technical and administrative challenge
Support the criteria with certification of systems that ensure they can talk to other systems - sharing of the data

Great additions to the debate and ones that include a common theme of the patient and importantly easy access to their own records and clinical information.

Not surprisingly the common theme of shareability of information is also evident in the Healthstory response which can be found here (Word Document). Healthstory focused on:

Incentives to make information sharing a core component of any system and process
Make the information shared available in "meaningful" form that includes structure and consistency
Include additional codification of the data that makes it useful to both humans and electronic healthcare systems
Create incentives for reporting of quality measures

The common thread is the ready sharing of information for the Personal Health Record. As presented in an organization chart that I remember from years back at ground breaking and innovative facility Health Care International Hospital (HCI) in Glasgow Scotland the patient is the king and appears at the top of the organization chart. So while the comment period has closed your ability to look for meaningful use and getting the full healthstory has not. Insist on receiving your information in usable form - it may save you and your physician a lot of time.

Have you had similar experiences - did you get your medical record in usable form or did you meet with full blown resistance. Let me know the good and the bad.

Declare Your Rights to YOUR Health Data

2009-06-25T08:26:00.006-04:00

A small group of individuals including Adam Bosworth, Jamie Heywood, David C. Kibbe, Gilles Frydman, Alan Greene, and Sarah Greene, began drafting the Declaration and reaching out to others for feedback and improvement. The refined Bill is available at this site and is summarized at the end of this posting A Declaration of Health Data Rights

A Declaration of Health Data Rights

In an era when technology is allowing personal health information to be more easily stored, updated, accessed and exchanged, the following rights should be self-evident and inalienable. We the people:

Have the right to our own health data
Have the right to know the source of each health data element
Have the right to take possession of a complete copy of our individual health data, without delay, at minimal or no cost; if data exist in computable form, they must be made available in that form
Have the right to share our health data with others as we see fit

These principles express basic human rights as well as essential elements of health care that is participatory, appropriate and in the interests of each patient. No law or policy should abridge these rights.

What a great concept founded on the same principles from a couple of hundred years ago as part of the formation history of this country. It is the end of the secret code and hidden meanings in patients notes (think GOMER, Turf, Bounce and many others). Something that was highlighted in the ground breaking book by Samuel Shem; "The House of God" that was released in 1978 and was one of the first to reveal some of the struggles in the medical field and coping mechanisms that included coded abbreviations describing patients in less than complimentary terms. But all of that is a good thing and the full sharing of notes and information with the rightful owner has some added value - things that are wrong can be corrected. e-PatinetDave generated a big swell of interest when he highlighted the junk that exists in your medical records as he started to review his own making the point that we must get our data, manage it and review it. In fact as I said before - we need to become our own Primary Care Physician. Dave deBronkhart needless to say is an early supporter and in his post on the declaration makes the point:

These rights are as inalienable as the right to life itself.
Whose life depends on the data's accuracy, its availability?
Whose data is it, anyway?

I could not agree more and am reminded of a discussion I had three times prior to the birth of each of my children. I had the privilege of delivering my kids but took no clinical responsibility. The hurdle and message I had to get through to the obstetrician (OBGYN here) and midwife was that there was possibly only one other person in the room with bigger vested interest in the successful outcome - that would be my wife. So they had to know and believe that I would not get in the way or hinder their ability to deliver care in the event that medical intervention was required. Fortunately in all three cases we had normal and successful deliveries but had that not been the case I was ready to step aside at a moments notice. The same principle applies to my medical record - I want it to be correct and am more likely to have the time and knowledge to review and correct any mistakes.

There is of course a fly in the ointment here - one of knowledge of terminology (something that technology and support infrastructure may help along with review in conjunction with experienced clinical professionals). BTW - I see an emerging role for a patient supporter who has additional knowledge and training to help with this. Interestingly the Medical Editor has much of the knowledge necessary to help process and understand this data and this might well become one of the future roles of these knowledge workers. But there is also the issue of pre-existing medical condition coverage and the general mess that exists in the US related to patients inability to get coverage when they have a conditions - and in some cases being "turfed" out of the insurance plan after they are diagnosed with a condition. This creates an incentive to lie about conditions and conceal diagnostic information. The answer here of course is to fix the insurance problem and create an all encompassing affordable insurance system that spreads risk across the whole population not just the healthy. There is no incentive in the United Kingdom's NHS system to conceal clinical data for fear of lack of coverage since the system treats all.

As someone put it on the site - you can bet that Steve Jobs insisted on getting his Medical Records in Digital form and in a form that he could review and transfer to other doctors. I bet he got it too. But this is about everyone else's rights and our need for easy access to our information.

Go endorse these rights here or add a tweet with the HashTag #myHealthData and become a fan of the FaceBook Page that is here

Proportional News Coverage - Skewing Health Perception

2009-06-23T15:05:00.004-04:00

Our perception of health and risk is all wrong and instantly accessible media is one of the key reasons. The recent coverage locally in the Washington area demonstrates the point well. A quick Google search of "Metro Crash" in the news reveals a total of 6,132 results (no doubt this will increase over time). A tragedy occurred on the Washington DC Metro when one train collided with one car riding up and over the other. There were several fatalities (9 at the time of writing this post) and a range of injuries from severe to minor. Coverage in the hour long evening news on the night of the tragedy could be summarized as follows:

Evening News Length: 60 Minutes
Advertisements Time: ~20 mins
Time dedicated to the Crash: 35 mins
Time dedicated to remaining news: ~5 mins

This disproportionate level of attention skews our perception of risk. Anyone watching the news last night would find themselves focusing on the safety of the Metro system. A quick search for statistics (interestingly the Wiki Page on the Washington DC Metro's Security and Safety had already been updated with details of the latest crash!) reveals a list of accidents but no suggestion of significant problems or challenges facing this system. In fact the overwhelming commentary suggests "The DC Metro has a very good safety record". When compared to data on Traffic Fatality Rates for DC:

Traffic's most recent data for 2007: 44 fatalities (US total fatalities 41,059)
DC Metro 15 (subject to change based on the most recent crash) over the last 20 years

Healthcare is the same and our perception of risk is skewed based on media coverage and our own personal experiences. If the news media gave proportional coverage based on risk and causes of death it might look something like this

Evening News Length: 60 Minutes
Advertisements Time: ~20 mins
Time dedicated to the Heart Failure and Cancer: 20 mins
Time dedicated to Cerebrovascular Disease: 4 mins
Time dedicated to remaining causes of death 6 mins

How can technology help - in this instance it appears not to be. The instant availability of news, our ability to blog and tweet the latest information and the way in which information can take on a life of its own (can anyone say ~~Swine Flu~~ H1N1). We need to filter information and it is the link to our clinician that helps provider that input and balance. Id be the first to encourage everyone to be their own primary care practitioner - in fact I said so last week but this has to be balanced with appropriate input from trained experienced professionals. There are a range of tools to help diagnose problems including some online symptom checkers and they have a place in the range of choices available to us. But this is not about replacing the education and experience of your clinical team. This is about supporting them with appropriate information.

In a recent discussion with a clinical colleague he was adamant that clinicians must use technology and clinical systems to be able to deliver better and safer care. I agree that technology must be used to help support the decision making - in fact I think it is as much about information as it is about technology. Technology just helps bring the information closer to the decision making point. This can be as simple as patients searching for information and bringing in printed material to the consultation (I know to some clinicians this is their nightmare but I remain convinced that there is no stronger more dedicated advocate for the successful outcome than the patient themselves).

But getting to this data and providing it not only in digital form but better yet in a form that can be consumed and processed by electronic systems takes this to the next level. Linking this information to the full Healthstory allows for some automated processing and relevance mark up that will help in filtering useful from distracting data.

Personal health management includes the capture of information and the intelligent sharing of this between the patient, the clinician and clinical systems. This is a team approach and the team will help balance the perception of risk. Finding balance is one of the keys to navigating through life. Have you found balance and if so how. What's your perception of coverage, risk and the media coverage distorting our perception of risk.

AHRQ Patient Videos - Become your Own Primary Care Provider

2009-06-16T07:02:00.000-04:00

In an interesting use of technology and social media AHRQ (Agency for Healthcare Research and Quality) have a series of public service announcements directed at patients encouraging them to ask more questions before during and after your medical appointment and in one case have a song and dance spot (wmv file) encouraging patient participation and asking questions:

DOCTOR (spoken): Any questions?
PATIENT (spoken): No.
DOCTOR: You know...
DOCTOR: (begins singing): We're not magicians, we can't read your mind!
BACKGROUND (singing): Read your mind!

Fun video - important points. Questions are the answer. As the AHRQ group puts it you play a critical role in improving your own healthcare and making wise medical decisions. As I heard recently in one presentation - we all need to become our own Primary Care Provider - managing our own healthcare and understanding the choices available to us. As was pointed out in one of the videos - we spend more time asking questions when we order food or buy a cell phone than we do when we go meet out doctor for a check up or clinical problem. No doubt some of this is time challenges faced in busy clinical practices and a degree of intimidation that persists in relation to patients and their relationship with their clinical provider.

Part of the process must include bringing information to the appointment and referring to it as well as extracting as much information both verbally but more importantly in electronic form from the clinical visit. Asking for a copy of your medical record should be a standard request - over time this may become a more electronic activity and even include requests that ask for the record to be sent digitally to your own Personal Health Record. But for now a paper print out is already an improvement and will allow a better understanding of the appointment. There is no better advocate for a successful outcome that you and your family members and oftentimes more time available for you to focus on doing the research on your own condition and understanding of the choices available if not the personal choice to be made. The AHRQ site gives some guidance on questions to ask here - extensive list and not all questions are necessary for all interactions but a good starting point. It's your health - start taking care of it and participating in the process actively not as passive observer.

Had good or bad experiences share them here - maybe your doctor actually volunteers your record and discussion or maybe your clinical office refuses to provide you with all your records. Whatever your experience I'd love to hear from you.

Documentation and Coding Burdens

2009-06-09T07:00:00.000-04:00

Medical economics published a great article "The Perfect Storm" and Peter Basch provided some additional commentary on this article and how the perfect storm should mean the end to E&M coding. As he points out prior to 1995 physicians were not paid for documentation but paid for services rendered. The main driver in recent years has been generating sufficient documentation to support the E&M Billing code.

Fear of failing a coding audit has made many senior physicians unlearn documentation skills developed over decades, regardless of whether they handwritten notes, dictate, or use an EHR.

The process of delivering care has been hijacked for the purposes of creating billing codes. In fact diagnostic coding systems can be traced back to King Henry VIII reign and the adoption of ICD coding in the early 1900's for morbidity and mortality. The codes were designed to track reasons for death and have been hijacked in attempt to fulfill a range of other purposes.

Multiple calls for scrapping what is an unfair burdensome system have occurred

In 2002, the Department of Health and Human Services convened a committee that concluded almost unanimously that the E&M system should be scrapped. Among its conclusions: The E&M system was not a fairer way of judging physician effort than the previous self-attestation method, it failed to add any new value, and it added an unreasonable burden to an already overburdened healthcare system

The Medicare Modernization Act of 2003 recommended to the Secretary of HHS that pilots of alternate payment systems be conducted

Unfortunately we remain locked into a process that adds little or no value to the process of caring for patients. There is an opportunity to focus on the value of clinical documentation to contain useful information that helps in the care and treatment of patients.

This is the right time for the Centers for Medicare & Medicaid Services to reissue its call for pilots of payment and documentation schema without E&M coding requirements. This is the right time for physicians to reject the shameful organizing metaphor of E&M coding—"it's not what you do, it's what you document"—and replace it with a renewed focus on what our patients deserve: better healthcare

He's right - for the longest time the call to documentation has been about the coding and billing. We have an opportunity to demonstrate the value of rich meaningful clinical documentation. Instead of asking our clinicians to be data entry clerks filling in forms for the purposes of coding use existing technology and solutions to allow for the capture of rich detailed clinical content that includes the narrative but is computer interpretable. It is possible today - we have technology, solutions and a whole industry of medical knowledge workers that delivers much of what is required already. We can create the additional information necessary to feed the data hungry EMR as part of that process and as a residual benefit this information can feed a new payment system focused on delivering high quality efficient healthcare

Doctor Please Look at Me not Your EMR

2009-06-02T07:22:00.015-04:00

A recent personal experience with a pediatric office that I have been attending with my children for the last 7 years provides some valuable insight into the effect of an electronic medical record on a typical busy general pediatric clinical practice.

A little history - this practice has been servicing patients in our area for many years. Currently there are 7 physicians on staff and they have regular hours and see patients 6 out of 7 days providing on call coverage at all other times. They are great, my kids like them and my wife and I both love the practice. I have been to the practice and watched the impact of the implementation of an Electronic Medical Record (EMR) over the last 18 months. I was there shortly after they went live with their new system and watched as the clinicians struggled with a large unwieldy tablet using a combination of tablet and keyboard entry that clearly was uncomfortable and difficult for a physician who in previous visit had been highly efficient with a pen and paper based record.

The most recent visit was simple physical examination immunization and paper work for participation in sports programs. What should have been a brief efficient visit was not but it was my 10 year old who pretty much summed up the experience

She (the doctor) spent more time looking at her computer than at me

Practical medicine is about body language, facial expressions and interpreting more than just what someone says. The picture below dates back some years to an implementation of an EMR I was involved with in 1993 - the patient in the bed is ignored by the 5 doctors focused on the EMR screen in the corner:

When you ask a patient if there anything else that's bothering them you don't just listen to the answer but look at their face and the way they behave. There are clear indication if this patient is going to drop some significant additional piece of information on you with the classical line, often delivered as the patient is standing up and reaching for the door know

Oh and by the way doc..."insert interesting/relevant piece of clinical data"....thought that might be relevant"

It's a well known phenomena - part of our general make up that prevents from arriving at the doctors office for a "routine visit" and when first asked if you have any problems opening with

Yes, I have been bleeding rectally for the last 3 days, it's fresh blood

We all dread sharing what in our heart of hearts we know is bad news even though most know that early detection, treatment and dealing with problems is a much better strategy than putting our head in the sand:

To be clear I am not leveling criticism at our physicians - they are doing the best with the hand they have been dealt. Their perception of the EMR has changed over the course of this implementation. Prior to the implementation (which predates the economic crisis and the current rush towards a set of incentives currently linked, albeit with poor clarity, to implementing an EMR) they were not excited by the prospect of imposition of technology. Their decision was driven by their lead physicians drive towards modernization and the belief that current paper based systems were failing them in delivering the best possible care. They reviewed the choices and selected based on their needs. During the implementation the sentiment was very clear - everyone was fed up with the additional overhead required to cope with the new system and the huge change required in their day to day work flow and clinical practice.

Now many months on things have settled down. In the words of one of their physicians - they love the ready access to all the information on their patients when they are seeing them. For the most part the presentation of patient data is helpful and easily navigated..........but the capturing of this information is a burden and interferes with the clinicians/patient relationship.

Clinicians need to look at their patients, they need to interact with their patients and technology should not interfere with this essential component of the diagnostic process. Computers can be part of that interaction but currently in the vast majority of implementations they are a distraction and interfere. As my 10 year old said

Why is the doctor more interested in her PC than in me?

In fact in a recent exchange the story is even more disturbing with the roll out of these EMR's. A clinicians recently shared with me that his clinical interaction had changed since the new EMR system had been implemented. Since the system presented him with a series of choices to questions he would ask questions designed to elicit responses that were featured in the list. If he thought a question might elicit a response that was not featured in the list of choices available he would avoid that question since documenting the response was a time costly exercise.

Dictation has long been tainted as a problem not a solution....but dictation has been the mainstay of capturing clinical information. We moved from hand written notes to dictation and transcription as the volume of information increased. It made sense because off loading the heavy lifting of creating a typed legible note was more efficiently done by someone who specialized in that process and was more cost effective than asking a clinicians to spend more time documenting and less time seeing patients.

Despite the bad rap dictation and transcription is the mainstay of clinical information today - 60% of the data we have on patients is generated by dictation and transcription. Of the remaining 40% the vast majority of this data comes from automated clinical systems including laboratory and imaging systems that generate data - not clinicians who currently generate somewhere in the region of 3-5% of this information input into EMR's today.

But to satisfy the informational needs of the EMR we need the clinical data. This is possible today and the technology is available to make the process of dictation and transcription not only more efficient and cost effective but generating the data necessary to fill the information void in the EMR's. Instead of just accepting the concept that physicians should become data entry clerks ask how you can use existing technology and services to allow doctors to focus on their patients not on an inanimate piece of technology

I'll leave it to my 10 year old to sum it up

I wish she (the doctor) would look at me not her computer

How have your experiences been in any recent visits to your doctors office. Do they have clinical systems and do they interfere with your relationship with your doctor(s)? Let me know - I'll publish any stories people are willing to share

HIT as a Catalyst to Healthcare Improvement

2009-05-22T11:27:00.001-04:00

The Center for American Progress - a think tank group dedicated to improving the US through policy and innovation) published a report: "A Historic Opportunity - Wedding the Health Information Technology to Care Delivery Innovation and Provider Payment Reform". You can download the executive summery here (pdf) or the full report here (pdf)

They make the point tat the American Recovery and Reinvestment Act’s HITECH $19 billion investment is not just about technology. In fact if this is the way the program is actioned:

failure is effectively guaranteed if the HITECH program embraces technology adoption for the sake of adoption. But if this new health IT investment program is wedded to a strong commitment to provider payment reform in forthcoming health care reform legislation and implemented specifically as an accelerator of health care delivery innovation and payment reform, then the investment program can help transform U.S. health care as we know it.

We know technology can contribute significantly to our lives. Everything from basic tools in our homes from cell phones to computer access that replaces the limited access to the Encyclopedia Britannica that we had some years back based on the sale to individual homes. This has been replaced for school children and households with access online to all this information in an instant.

Technology has had similar extended effects in healthcare that have seen revolutions in the diagnosis and treatment that previously were unimagined. But technology alone will not solve the underlying problems of our healthcare system and in the US we must change the payment model that currently incentivises everyone int he system to "do more". The system rewards for volume of service delivered and this is the underlying challenge faced by clinicians and facilities that continue to strive to maintain income when presented with the decreasing reimbursement per unit are forced to increase volume. This leads to the current circumstance where a consultation and patient interaction must be limited to minutes if the number of patients to be seen is to increase and the income stream to be maintained.

But seeing more patients for less time does not help manage chronic conditions, allow for a focus on prevention and chronic condition management that demands time and attention to detail. So as they suggest health care reform should include:

Proactive improvements in individual and population health status
Collaboration among health care providers necessary to accomplish these improvements
Achievement of efficiencies in care, such as the elimination of duplicate services, avoidable hospital readmissions, and unnecessary in-person visits

and should also include a change in the documentation and in particular coding requirements. As they rightly point out the current system of coding

so called evaluation-and-management, or E&M, coding of office visits—which drives extraordinary complexity into clinical documentation and EHR workflow—could be replaced by payment-and-documentation standards that are simpler and more focused on what is actually valuable for patient care.

The much used term "meaningful use" comes up again and the suggestion that this be focused on Health IT that actually helps improve care and accelerate payment reform. IN fact the suggestions include:

Tracking key patient-level clinical information in order to give health care providers clear visibility into the health status of their patient populations
Applying clinical decision support designed by health care providers to help improve adherence to evidence-based best practices
Executing electronic health care transactions (prescriptions, receipt of drug formulary information, eligibility checking, lab results, basic patient summary data exchange) with key stakeholders
Reporting a focused set of meaningful care outcomes and evidence-based process metrics (for example, the percentage of patients with hypertension whose blood pressure is under control), which will be required by virtually any conceivable new value-based payment regimes.

And in each of these is the implied requirement to capture this information at the point of care which has been a significant challenge to date. I've said it before and I'll say it again - turning our clinicians into data entry clerks does not make sense. Whatever systems are put in place must allow for the capture of this information in way that does not interfere with the patient/clinicians interaction and includes the ability to capture the detail and the data to drive these activities of tracking, clinical decision support and evidence based metrics. There does not seem to be many technologies that can fulfill this at the time of care delivery and one that shines out constantly is that of speech and in particular speech understanding that is able to understand the meaning and generate meaningful clinical documents that can be used in these clinical systems to help deliver this higher quality care.

To this commentator, speech technology and in particular speech understanding must be a fundamental component of the success of healthcare IT as part of the HITECH investment act. What do you think - are we there yet?

Meaningful Use - Getting the Full Story

2009-05-14T14:55:00.000-04:00

There has been much activity relating to the term meaningful use cited in the health care reform proposals form the government that includes AMDIS that includes a new web site to encourage "meaningful" discussion (the website: http://meaningfuluse.org) and various others.

The Healthstory project is carrying the torch for the inclusion of narrative in a written response: Written Testimony Regarding “Meaningful Use” (Word document). Narrative and free expression has been under fire for some years as inefficient and requiring replacement with semantically interoperable information. But since the vast majority (by Gartners estimates 60%) of content is created using the traditional dictation and transcription methodology we fail to leverage this information by discounting it. Trying to force a behavior that is not natural and removes much of the value contained in the fine detail in our rich and expressive language is counter intuitive.

Meaningful use of the Certified Electronic Health Record (EHR) must encompass dictation for creation and exchange of standards-based clinical documentation. This comprehensive view of the EHR supports the immediate needs of front-line physicians and patients, is complementary with structured data, and lays the ground work for increasing EHR adoption and information reuse

Narrative documentation enhances clinical care and the use of free form narrative is essential to the delivery of high quality care ensuring that the care team get the full story and all the fine details necessary to contribute to high quality health care

The Healthstory format - CDA for CDT or Clinical Document Architecture for Common Document Types (CDA4CDT) uses HL7 Clinical Document Architecture (CDA) documents that are XML representations of familiar clinical documents designed for exchange, recognized by ISO, ANSI, NCVHS, CHI, HITSP, CCHIT.

Healthstory represents disruptive technology that has the greatest capacity to transform practice and deliver the benefits of standardization of dictated notes. This is an achievable step for providers that will inject massive amounts of important information into our fledgling networks, lower costs, and provide a clear pathway towards standardized computable data.

Get on board - join now and start insisting on getting the Full Story from your provider, hospital, vendor.....

Interoperability - Smorgasboard of Particpants

2009-05-14T09:34:00.001-04:00

Whew - if you want a visual representation of the challenges in the field of government this post in Ross Martin's blog which includes a brilliantly put together harmony you can watch here:

The blog features more details on Health Information Technology Standards Panel (HITSP), Certification Commission for Healthcare Information Technology (CCHIT) and AHIC which has become National eHealth Collaborative (NeHC)...phew what a collection of names and abbreviations. If you are looking for quick relief from the abbreviation nightmare - this site is useful.

Social Networking and Healthcare

2009-05-07T09:01:00.000-04:00

The network is buzzing with excitement over twitter and social networking and there are increasing numbers of guides, top ten lists and other material aimed at the new participants in the world of twitter. Ashton Kutcher is doing it, Oprah Winfrey is doing it (albeit in CAPITALS initially) - interestingly the race to 1 million followers was close but now Ashton is almost double.

For the Record recently featured an article titled: Healthcare All Atwitter Over Social Networking that looked at the range of social networking tools. Everything from You Tube, Facebook, twitter and blogging is being used by the University of Maryland Medical System (twitter, facebook, blog and youtube links). They attract around 700 people per day that watch videos and read their material - new members, existing patients and more awareness of the system are all good results that will translate into business and good will.

Although healthcare organizations must deal with a unique set of challenges when it comes to establishing and maintaining a presence on social networking sites, they should nonetheless be taking the steps to utilize these sites and tools to reach out to patients and consumers. It is also imperative to monitor what is being said about them by others in the social media space to protect their brands and reputations.

It reminds me a lot of the discussions i was having ten years ago about a web presence with similar resistance to the idea of publishing or spending resource on a web site. Here we are today and it is hard to imagine any facility without a web site (usefulness, design etc widely varied) that is for the most part the online store front. It is not unreasonable to suppose that Social networking is the next innovation in the online/digital world.

In healthcare here is clearly a concern relating to protected health information (PHI) but this is a low cost

"It’s a grand experiment and it may fail, but the cost of entry is so low. It’s not like we have to decide to spend a million dollars to participate on Facebook. It’s more like investing a percentage of an employee’s time to set up an account. Hospitals should be saying ‘We’re here and we’re ready to talk to you.’ … You can just post press releases, or you can become very chatty and friendly. You’ll find out what the best match is for your personality and the way you think of yourself.”

Go ahead take a dip....join me on Twitter (and ranked #27 in the list of top CMO's on twitter), Facebook, LinkedIn, My other Blog - Navigating Healthcare or Plaxo....amongst some of the places I can be found online

Digital Medicine Not Fulfilling Promises

2009-04-30T10:25:00.000-04:00

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

2009-04-30T10:00:00.000-04:00

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

2009-04-23T12:51:00.004-04:00

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

2009-04-20T11:29:00.003-04:00

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

2009-04-15T12:00:00.000-04:00

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

2009-04-04T23:14:00.004-04:00

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

Speech Recognition and MT Compensation

2009-03-24T15:00:00.000-04:00

Speech Recognition and its relationship to compensation took on a life of its own over at the MTChat message board in this thread titled MT Exchange: MTs and "Speech Wreck". There were strong words and a concerted attack on Julie Weight....Yikes! The confusion that ensued linking and even blaming a technology with poor business practices and in particular poor compensation models that appeared to be unfair missed the point.

But it was the posting by Jay Vance of XY Files in an MT World who posted a thoughtful response to some of the criticism being leveled at Speech Recognition in this posting "Is Speech Rec Wrecked" that even featured actual data (thanks for sharing this!) from a survey he conducted in 2006 of Speech Recognition editors. In fact the data presented was helpful in assessing the actual benefits (back in 2006 - a long time ago in technology terms!) that even then showed:

a total of 51% of respondents - saw an average increase in productivity of between 25% and 50%. This confirms the anecdotal information I had collected via informal conversations with MTs working as SR editors in a variety of situations on a variety of SRT platforms.

I don't think it is a stretch to assume that this must have gotten better and productivity has improved beyond this and for a greater proportion of editors. The survey included some review of compensation changes (there was a reduction in rate but hard to determine if this was a real reduction or represented a reduction in rate that was offset by increased productivity) and a final question on satisfaction with the technology:

31% said they were somewhat satisfied
26% said they were very satisfied. These two categories totaled 57%

Not great but better than average. Overall

there is a wide spectrum in terms of the impact of SRT on productivity, compensation, and overall satisfaction among MTs working as SR editors. Consequently, I don't believe there is enough objective evidence to conclude that speech recognition has proven to be a widespread disaster for the MT working class. As with any scenario involving people, technology, and money, mileage is going to vary widely. In my experience, there are simply too many factors that can influence productivity, compensation, and overall satisfaction with speech recognition technology to draw hard and fast conclusions about the impact SRT is having on working MTs on the whole.

And this was in part the point that Julie Weight was trying to make on the MTChat board - there are many factors and there is no use trying to stall the implementation of Speech technology - that trains has left, like outsourcing.

Both Jay and Julie make the point that this technology is in use and although I probably am a stronger advocate and believer in the Speech technology I think the overriding point here is that this can and should be a good thing for the industry. Reducing the labor intensive element of producing a report has to be a good thing....freeing up the medical editor to add value to the clinical information as part of the process of review, editing and validation.

Recognizing this is old data this gives us a good reason to update this information and there is a survey currently ongoing from MTIA that can be taken here and I would encourage you to participate. This is an extensive survey and needs input but if you don't have the time I put a 4 question survey here that. If you can spare the time please take the full survey, but if not I'd welcome hearing your responses.

Reinvestment is not Just About Technology

2009-03-16T09:37:00.000-04:00

There is lots of excitement or even frenzy over the wave of investment coming down the pipe towards healthcare technology but in this piece on the Huffington Post: Workforce Development Essential to Obama's Health Care IT Initiative Julian Alssid and Jonathan Leviss are quick to point out that there is an essential element that must be included - that of Human Capital. Healthcare is unique and transplanting technology from other industries is not a straightforward process

Hospitals are not banks, or insurance agencies, or hotels. Healthcare's unique workflows -- including many physicians and nurses sharing computers in a busy emergency room, the challenges of maintaining working hardware in an intensive care unit, and the vast realm of data accessed to care for a sick human being -- require novel technologies and processes that cannot be easily translated from other industries.

While I agree that some technologies have stalled many are being implemented and are delivering success today. Speech Recognition did suffer problems in noisy environments (that's why the early adopters of this technology are Radiologists who mostly work in quiet reading rooms). But newer Speech Understanding which is modelled on nature's success in speech understanding by not only using audio inputs but also getting information from the patent's previous history, demographics, prior reports and any other elements that will help in understanding what was said.

But that's not enough

Physicians, nurses, and other health care providers routinely learn new skills and adopt new technologies....What is missing, however, is a parallel training track for a sufficient workforce to develop, implement, manage, and support advanced information technologies in hospitals, doctors' offices, and other health care venues.

So providing the infrastructure is one thing but having the resources to support it is an essential part. This is especially true for the embattled medical transcription industry that has been fighting declining rates of pay as hospitals and healthcare providers continue to push for lower and lower line rates. All this is driven by the perception of the medical transcription is a cost, when in actual fact it is a value added service that frees up the clinical staff to focus on taking care of patients rather than the drudgery of data entry. There are lots of examples of systems trying to turn clinicians into data entry clerks and while there are instances where this methodology makes sense in many cases it does not. Technology will help (see above - Speech Understanding is moving speech into the 21st Century) but even with this technology there is still the requirement to provide support and expertise to facilitate the process of capturing information that is essential to the new age of data driven medicine. The Medical Transcriptionist is the knowledge worker who delivers the value add of helping turn clinical information into structured clinical data that includes the fine detail in the free form narrative that clinicians need and want to include while adding tagged structured data to deliver the full Healthstory for the patent's episode of care.

Computers Don't Have to Depersonalizes Medicine

2009-03-10T16:27:00.003-04:00

The NY Times article this week; The Computer Will See You Now written by a pediatric physician complains that the electronic medical record has depersonalized her interaction.

HISTalk commented on it in his morning update and highlighted the complaints:

using the computer in front of patients is intrusive
standard questions must be asked in order even when they clearly don’t apply
the doctor might swear in front of patients when the computer does something wrong
computers lose context because doctors can’t underline, write bigger, or otherwise highlight something important

And I would add that because it gets printed out and is held in a computer it appears to carry more weight/validity.

As the author says:

The benefits (of the EMR) may be real, but we should not sacrifice too much for them

And the end result for her is

In short, the computer depersonalizes medicine. It ignores nuances that we do not measure but clearly influence care

But the prescribed treatment of a hybrid using a tablet ignores most of the issues and concerns highlighted and forgets the relative difficulty of interacting with tablet or screen based technologies while facing and talking a patient. No doubt there are some circumstances where this does make sense but the key to success is the hybrid approach or blended model that does uses all the available methods and tools.

It is important to not turn our clinicians into data entry clerks and utilizing the finely honed and developed skills of the medical editor/transcriptionist to convert this audio into the data necessary to drive the EMR. Technology can assist and provide some efficiency to the process and specifically Speech Understanding can automate some of this process. But this method of capturing the voice is repeatedly dropped or forgotten in this discussion. There are circumstances where this technique may not apply (public forum in earshot of nosy eavesdroppers fro instance) but for circumstances where it does voice provides a ready and efficient method. Historically this created text that the EMR systems had difficulty using (they are essentially data driven repositories) but with the addition of tagged information that is linked to the narrative all held in the complete Healthstory we bridge the gap. Not only allowing for the inclusion of the fine detail that is essential and influences care but linked and part of this same material is tagged structured and encoded data that can feed the data hungry EMR.

Annoying Hard to Use Systems Won't Be Used

2009-03-03T10:56:00.005-05:00

It is no real surprise to find that criminals are getting a pass because the police in Queensland Australia don't want to waste time using an expensive "time-consuming data entry system" that takes hours for jobs that used to take an hour.

The QPRIME (Queensland Police Records and Information Management Exchange) is supposed to reduce the burden and improve efficiencies but due to the complexity of navigation, officers are:

reluctant to make arrests and they're showing a lot more discretion in the arrests they make because QPRIME is so convoluted to navigate....minor street offenses, some traffic offenses and minor property matters were going unchallenged

Naturally the Queensland Police Service are standing by their $100 Million investment with the tired and worn out mantra

....the benefits of the QPRIME system into the future far outweigh short-term disaffection by some officers

It's the same in healthcare and the EMR systems being pushed onto the busy clinician today. In some cases they rebel and refuse to be stuck in a system that forces inefficiencies but in many cases find themselves turned into data entry clerks. I've said it before and I'll say it again - why is it Healthcare is the only industry that tries to turn our most highly skilled knowledgeable resources into data entry clerks?

Stop the madness, allow clinicians to capture information without creating a burden of data entry. Clinical documentation is supposed to support clinical care and capturing it should not be a burden that prevents adoption of essential healthcare support technology like the EMR. There is a swathe of clinical documentation specialists who spend their lives offering highly skilled review and editing services that free up the clinician to focus on patient care. They are not just a cost - in fact they offer a value add service that has been delivering grammatically correct, well structured and presented clinical reports for many years. Allow clinicians to capture the full Healthstory that contains both these elements and satisfies the clinical need and computer’s insatiable demand for structured data.

Otherwise patients, like the criminals in Queensland, will find that their symptoms may go unchecked or noticed as clinicians are unable to do both data entry and deliver high quality care.

If you are a patient watching your clinician attempting the nigh impossible feat of paying attention to you and your clinical condition while juggling a laptop, tablet or some other computer based data entry system, do him and yourself a favor. Insist you want the full Healthstory and let him know he can deliver that with the help of his friendly clinical documentation specialist/knoweldge worker without him having to do hunt and click through endless screens. And if you do tell him, let me know what he says and leave a comment here.

From Dictation to Direct Computer Input

2009-02-26T16:18:00.001-05:00

I hosted a panel at the recent TEPR conference on "From Dictation to Direct Computer Input" that included presentations from Laura Bryan (MedEDocs Transcription) and Louis Cornacchia, MD, of (Doctations). I already posted my presentation on LinkedIn and in Google Docs but with the consent of my co-presenters I post the other presentations here

Laura Bryan, MedEDocs Transcription:
"Narrative Data in the EMR: Have Your Cake and Eat it Too"

Louis Cornacchia, MD, Doctations, Inc.
Doctations

Documentation at the Point of Care

and for completeness
Nick van Terheyden, MD
Dictation to Clinical Data: Automating the Production of Structured and

Healthstory - Providing Data to Healthcare Business Analytics

2009-02-25T15:27:00.003-05:00

A recent posting by Laura Madsen on the b-eye-network site titled "The Impact of the Obama Healthcare Agenda on Business Intelligence" reviews the stimulus package and its potential effect on Healthcare Business intelligence and Analytics. As she points out the package has said they intend to invest in

“invest in proven strategies to reduce preventable medical errors.” First and foremost is wider adoption of electronic medical records (EMR)

There is little doubt that EMR's can contribute to improving medical errors but as Laura rightly points out this impact is limited as

the disadvantage is that much of the data is textual and therefore more difficult to analyze

And promoting the advantages of the data base centric solution that demands specific answers and fills in fields does produce "quantifiable data for analysis" but is very limiting to the physician, but more importantly is turning our most highly paid. knowledgeable expert, the clinician into a data entry clerk - as I have said before and was quoted here you don't find the CEO of Merrill Lynch entering stock data....!

So how do we satisfy this need while not limiting clinicians to the small boxes and multiple choice hunt and peck nightmare yet still satisfy the need for structured data to provide some of the value for applying business analytics to this burgeoning pile of data.

The answer is already here with the Healthstory Project that provides the perfect container to capture and hold the full story of the clinicians patient interaction. Satisfying the needs of the clinicians to capture the fine detail of the interaction but also fulfilling the data requirements for EMR's and Business Analytic systems. Healthstory has already created and published four technical guidelines for the

Consultation Note
History and Physical
Operative Note
Diagnostic Imaging Reports

and unlocks the valuable data from narrative documents enrich the flow of data into the electronic health record and creating interoperable clinical document repositories. The coalition is growing and you should expect to see these specifications becoming part of any requirements for clinical systems and documentation providers to be able to comply and both receive and send Clinical Document Architecture for Common Document Types (CDA4CDT) documents. Time to get on board.

Patient Confidentiality and the Clinical Documentation

2009-02-24T10:45:00.003-05:00

Breaches in patient data by the clinical documentation industry shine an uncomfortable light on the industry and when stories surface (Slip puts Patient data on the Internet) of lapses in security relating to a transcription company they should be a wake up call to all the participants in the production of clinical documentation (read medical transcription companies, transcription editors, technology and infrastructure providers etc).

In this instance the patient was seen by Northeast Orthopedics in NY and they outsource their transcription to MRecord based on Raleigh NC who offer both technology and outsourced transcription solutions. Northeast Orthopedics rightly posts a letter on their web site (Letter to our Patients Regarding Patient Confidentiality) getting front of the issue, notifying their patients of the possible breach, apologizing and providing contact information for anyone who has a concern. But surprisingly there is no statement on the web MRecord web site regarding the security breach and while I could find some legal notices they were all about the protection of their solution and usage and nothing regarding the security breach......I suspect no plan in place for dealing with such an issue and a lock down the hatches mentality that often permeates when such mistakes happen.

Like every advancement in the history of mankind it can have good and bad uses. The internet is no exception. I am sure most of us would find it hard to imagine our business and personal lives without the ready access to information. Those weighty tomes - Yellow Pages were relegated to the recycling bin in our house (after passing through a quick session on learning how to tear them in half) once we realized that searching the internet was faster and more relevant. But that same relevance and ease of searching provides instant access to everyone on for all sorts of information. In this instance it was a chance finding on the part of a relative searching for condolence messages for her deceased daughter.

So if your belief is that your security and confidentiality is fine in part because no one would be interested in the data your company deals with - think again. The internet is a great leveler - it only takes one person and that information can then be instantly available to everyone else on the internet. Google just makes that even easier with its constant searching and compiling of information on the internet.

In the medical documentation industry we are dealing with confidential data every day - imagine this was your data and treat it accordingly. Use this as a wake up call to review your security and data practices and take the time to prepare a PR Disaster plan with the expectation that you will never need it.

How is your security? Have you ever had a breach or seen a breach and if so what was your feeling about it?

Rating Doctors

2009-02-19T10:30:00.003-05:00

The blogs and twitters are alive with commentary both good and bad on the concept of rating doctors. It all seemed to be triggered by a NY Times article: Restaurants Brings Its Touch to Medicine that discussed briefly the concept of developing a ratings system for doctors.

Now the editors are asking people covered by one of the country’s largest commercial insurers to post reviews of their doctors and rate them in categories like trust and communication. As in other Zagat guides, the responses are summarized and presented as scores that, in this case, are edited by the insurance company WellPoint. They can be viewed only by WellPoint customers. The reviews are being introduced online to millions of WellPoint’s Blue Cross plan members across the country.

Many folks jumped in - I tweeted the article and Paul Levy Blogged the conundrum which generated a veritable avalanche of comments including my own both positive and negative. e-Patient Dave (I still have not received an answer to where he keeps his time machine to cram 33 hours into a 24 hour day!) weighed in

I don't know how it'll all shake out. Being publicly judged by others is challenging at first; I've come to accept that some people are crazy and there's no accountin' for tastes, let alone the variability of provider or reviewer having a bad day.

and the justifiable concerns (this from Lachlan Forrow MD FACP)

...but if we develop systems that make it easy for any unhappy patient to post for the world her/his unhappiness and name my name, that would be a serious threat to my morale, and while it might not make me actively avoid patients I thought might express their unhappiness (though it might) it would almost certainly have reduced my energy for actively seeking out “difficult patients” because I found the challenges and occasional rewards had satisfactions that outweighed the frustrations.

But I think anonymous said it best for me:

Ratings are coming: On the web nobody needs your permission or approval to set up a ratings system. If it seems unbiased, fair and rates the things people care about it will get traction.
Do you want to help steer the bus or get run over by it?

I agree and here is what I said

We have to start somewhere and adapt as we learn more about this concept
It is currently being done anyway and with little consistency or transparency
Like it or not much of the rating is about the overall experience, not so much the care or the doctor but the decor, cleanliness, friendliness & helpfulness of the staff, the quality of the food..... to quote a recent discussion with a specialist radiologists in cancer care "the value measurement has changed: it used to be measured based on whether you were carried out in a box or walked out, now we are so much better and more successful the measure of success is about everything else, food, decor, the linen"
Having seen some of the shocking comparisons of success/failure rates in different hospitals for the same conditions even taking account of a different case mix I would definitely want some indicator on quality/comparison to help make my choice for obtaining what I believe to be the best care for myself and my family.

So lets get over it and get the ball rolling - the beauty of rating systems is that the community is self policing and correcting. Outlandish claims that are out of sync with the majority are quickly identified and squashed and attempts to manipulate the system are discovered and exposed quickly.

Why Speech Recognition is no Longer Sufficient

2009-02-10T10:23:00.003-05:00

Speech recognition has been around for over 30 years and part of our consciousness since the mid 1960’s but it is only in the last 3-4 years that we have see the technology really start to deliver some value to the much beleaguered and over worked clinician. There are innumerable studies that demonstrate the savings linked to the efficiencies possible with faster report turnaround. Unfortunately producing more reports faster is not always the best answer and oftentimes this is simply making the patient information haystack larger. This tsunami of data is overwhelming even the best organized clinicians and many are struggling to keep up with this alongside the explosion of diagnostic and treatment choices. Keeping up with the medical knowledge is a full time job if anyone had the time – but they don’t.

Clinicians want to give great care - that's a universal maxim for the profession and anything that enables or facilitates this will be successful. But that's not what has been going on with speech recognition which has not only required a change in behavior to enunciate in special ways, dictate commands, speak slowly and add punctuation and in the ultimate punishment requiring the highly skilled and time pressured expert to review and correct poorly drafted content. The output is a blob of text that cannot be read or interpreted by the electronic medical record (EMR) since it is not machine readable.

Innovation in speech recognition was last made in 1993 when continuous speech recognition was rolled out. Since then the technology has stagnated and while allowing clinicians to type with their tongue has provided some efficiencies and improvements, speech recognition has failed to address the underlying challenges facing clinicians today. So now we have reached this point what’s next?

It is the capture of structured clinical data that can automatically feed the EMR that is the real goal. Achieving this requires an alternative approach to speech recognition, not just recognizing the words but actually understanding the meaning and context. Comprehending normal human speech is not a word recognition process but speech understanding process that takes as input not just the phonemes or parts of words but the complete context of a conversation including the intonation, the subject matter and relevant prior information which is all applied to the complete conversation. It is this process that enables humans to exhibit the “cocktail effect” which allows us to listen in to more than one conversation at a time even though we are not fully participating in either. The added knowledge allows for inferring of missed words and understanding the content allows us to complete the picture producing a fully understood interpretation of the speech. Speech understanding is the next frontier of innovation in clinical documentation.

This content can be stored as part of the full story - the Healthstory that contains the computer interpretable data AND the fine detail in the narrative that is the essence of clinical insight, judgment and essential to the transmission and flow of useful clinical information between all the team members delivering care in our multi disciplinary model.

Does the Information get Captured - Not even a Fraction of it

2009-02-06T18:02:00.004-05:00

In an HIT moment with Andy Kapit, the CEO of Coderyte Mr HISTalk explores the trouble with coding. There are some good insights into the challenges facing the clinicians in the system and several great quotes.

They down-code because they are afraid to get audited, afraid that the system will not be reasonable. They are afraid to stand out and afraid that the fact that their patients are ‘sicker’ means that their higher codes will make them stand out. They are afraid — period.

There is enough in the way of pressures without adding more burden to clinicians in worrying about audit's and the veritable army of folks and companies who are employed just to investigate and find discrepancies. Ironically they are probably using more sophisticated tools to identify poor coding than the doctors themselves are using to create the codes.
As Andy says it creates "adversarial culture not only reduces the morale of the physicians, it forces the data to be more flawed than it needs to be"....sigh...it's true it does, fear is not the answer. It's just like tax returns as described in a recent article in USA Today that suggested there will likely be an increase in tax cheating because of the high profile cases of folks who appear to have gotten away with it but:

Americans are among the most law-abiding taxpayers in the world, in part because the IRS uses computer matching programs that make it difficult to cheat, says Walter Pagano, a former IRS agent who is a partner at accounting firm Eisner.

But this is not clinicians cheating but a fundamentally flawed system cheating them through fear. As Andy said - talked about flawed....

Think about it — the most complex series of events most people endure in their lifetimes are reduced to three-, four- or five-digit codes

The heritage of these codes dates back to Henry VIII and the tabulation methodology used by Graunt to describe the 50 or so causes death that were the precursor to ICD coding system (this is from memory but the original article was in the Journal of Public Health: Public health, data standards, and vocabulary: crucial infrastructure for reliable public health surveillance. and I cannot find the copy of the article so if you have this please send it to me)

But it was this that really struck a cord

Physicians have these well-trained powers of observation and, with the full color of their narrative, describe what is wrong with us and what they are going to do about it. In that language are rich and complex concepts — some of which are negated, historical, related to a family member, or are equivocal because more information is needed. Does all of that valuable information get captured in the medical coding process? Not even a fraction of it. The information captured in the record accurately reflects the actual health of the patients. The information healthcare uses to evaluate the quality of care and outcomes is inaccurate — out of fear and is both measuring and rewarding the wrong things.

Excellent points indeed. To further complicate the issue the content is then dumped into text based files that contain a one dimensional view of detail.....so much better to start storing this information in a richer more suitable container to capture the full story.... The Healthstory: "Comprehensive electronic clinical records that tell a patient’s complete health story." Such information to include the rich complex concepts and whatever codes are necessary to make the information computer interpretable. It can also include the billing codes and other richer vocabularies including Snomed-CT, Radlex and even ICD-10 should that ever arrive.

The project needs more members, both those providing the capabilities and the information as well as those consuming or using the information. You can sign up here.

I'd love to hear feedback on the Healthstory project - good and bad. If you are not a member - why not?

Why Participating in Blogs is Important

2009-02-06T11:18:00.014-05:00

I had the privilege of meeting e-PatientDave at the TEPR conference this week. He was there to bring the patient's views to this conference - wow - that's a novel thought! Getting patient input at a conference on healthcare......this does not happen often enough. It was a commanding performance and one that should have been videoed and then youtubed but I think he has this in the plan based on what I read.

He has his own blog(s) e-PatientDave and is of course on twitter and is an advocate for the inclusion on the patient in the care process (whew - two eureka moments in a single post!). He made many compelling points, delivered an emotional and riveting diary of his incidental finding of an especially aggressive form of Renal Cell Carcinoma that he fought and won. He joined an impromptu tweetup at the evening reception and continued to engage throughout the conference. Much of what he does is on his own coin and time and done with the attitude that given the history every second is a bonus.

A post from last month on why he loves participating in blogs and healthcare is descriptive and a great study of the relevance of this media to our future.....if you are not involved in this media the world is going to pass you by. This post linked to Paul Levy's "Running a Hospital blog that is definitely leading the crowd in communication and openness. He had cited the news of the day on "Check Lists" - I talked about this last year in this post - Simple things save lives crediting Peter Pronovost and congratulating him on his recognition as a newly inducted fellowship. There was a great article in the New Yorker titled "The Checklist" that detailed the concepts and the amazing results

Social media power. Connecting and engaging everyone. If you aren't on board you should be. Do you agree or is this just more "stuff" to distract us form delivering care - you tell me.

There are so many ways to participate and here are some of mine (it's horses for courses - pick the media you like):

Twitter
Technorati
RSS Feed - Speech Understanding
RSS Feed - Navigating Healthcare
Linked-In
Plaxo
Facebook
Digg
del.icio.us
Follow me on Twitter
DM Reply on the Twitter

Jonathan Bush from Athena Health on Government Reforms

2009-01-26T12:12:00.004-05:00

Great interview on CNN Fast Money program with Jonathan Bush commenting on the investment and reforms and how this might impact his company.

He makes some salient points and in particular the focus on delivering data and focusing on data rather than paying to implement a bunch of "legacy systems" is the way to effect real change. Not using the money to "buy toys with it".

Athena Health helps clinicians get paid more money faster. They deal with the payment back end of health care. As opposed to building your own claim activity or use someone else who specializes like Visa does for retailers. So I guess Athena is the Visa of Health care. They offer Software Enabled Services rather than "shrink wrapped toys". In his word the key process starts with:

Step 1: Crap Removal

They claim to have one of the most sophisticated back ends in the business and they deal with 23,000lbs of paper for their customers each week! How they extract data from this is beyond me if this is coming in in paper form....

Follow this with a program not so much focused on the amount of investment but rather the execution that:

Pay for data and pay for results

Then stop using these legacy devices and start working towards capturing this as data as part of the process. Here he is singing my song and the need to capture the information in computer interpretable form (I have to believe that some portion of the 23,000 lbs of paper is being processed by an army of folks to digitize and extract data from it) and make this a requirement.

Once again Healthstory help satisfy this need allowing for the generation of the fine clinical narrative detail but complementing this with structured tagged data that can be used to process and show the health improvements and facilitate the flow of reimbursement for better results at higher rates.

David Brailer Weighs in on Health Information Technology

2009-01-16T18:38:00.007-05:00

David Brailer writes on the Healthaffairs site with guidance to the incoming President on key reforms to our health care systems. The pledge he refers to of $50 Billion does not appear to jive with the released "American Recovery Reinvestment Act of 2009" (pdf file) draft report that features $20 overall for healthcare + $4.1 billion for preventative health care but relative to the previous investments this is a significant program.

He highlights 4 key areas:

The chasm between the have and have not's - not of health care but of EMR's but rightly he says

We should not incent physicians and hospitals simply to purchase electronic records. We get no benefit when a physician or hospital buys an electronic record. What we should do is reward the use of these tools as part of a patient’s care. “Pay for use” can fund the conversion of the health care system to digital records and ensure that we get the life-saving and money saving benefits they promise

I agree - just buying these expensive systems and funding them seems a flawed strategy and we will just end up with a bunch of unused EMR systems.

Second - the need to build a workforce to enable the digitization of health care - 50,000 people by his reckoning, of people who understand both clinical medicine and information technology. Already in short supply and years in the making. This is right on the money (and I say that with a certain sense of pride since I fall very clearly into this category having made this transition long before this was even a career path or specialization). It is bridging this divide with clear understanding of the issue and challenges faced in practicing day to day clinical medicine that will facilitate acceptance and success.

Third - Information sharing, which is a core fundamental but remains a significant challenge by virtue of the proprietary and protectionist nature to the health care vendors to date. This challenge has thawed and there are many initiatives that will move the industry towards real sharing of data. I certainly want to take my complete "Healthstory" with me wherever I go having just completed the valueless paper based forms for the umpteenth time in my daughters physicians office. There are others but Healthstory represents the complete picture with flexibility to allow participation at a wide range of levels and different detail that makes the adoption more likely. Not forcing or mandating specific data or fields may seem like we loose the data but pragmatic approaches that drive adoption quickly will succeed where highly regimented and overly demanding standards tend to fail in complex environments. So here's my pitch to the incoming Obama administration - mandate the Healthstory standard for capture, exchange and sharing of clinical data. The resistance will be minimal and the standard will allow all stake holders to participate quickly and effectively. Granularity of information will increase over time as the value of this increasingly detailed data is demonstrated with real world use cases - market forces at work.

Fourth - freeing up the clinicians to use the technology and to get paid for digital consultation remotely and facilitating telemedicine. While you are at it I suggest resolving the challenges faced over the practice of medicine in different states as detailed here in the sad case of a Colorado Doctor being prosecuted by California.

Health care reform will happen...it has to happen and there is an explosion of suggestions and ideas, but the above four make a great start and I concur with David Brailer on their importance and value in making these reforms a resounding success but lets make sure that the interoperability is a fundamental part of the equation.

Plans to Computerize the US Healthcare Records

2009-01-12T11:30:00.003-05:00

CNN Money features an article today on the President-elect Obama's Digitizing the US Health Records System featuring the proposal to modernize the health care system by "making all health records standardized and electronic."

The plan calls for computerizing all records withing 5 years and is subject to much discussion in the various communities I participate in that is both positive (great investment and resources allocated to help fix a broken US healthcare system) to negative (are we just spending money on technology rather than spending money on
improving the outcomes and quality)

One observer put it this way:

this is a bit like watching a train wreck that is too late to stop

and more worryingly:

I don’t think that even a free EMR is attractive enough for most docs right now

One source cited came from information published by the AAFP (now restricted to members) that showed substantial variation in satisfaction with current implementations

....substantial variance in physician satisfaction with EMRs by product from “if I could get out I for zero cost I would” to “I’m not happy but my practice couldn’t live without it” to some actual satisfaction.....in large practices seldom rose above the “not happy, but …” level.

Current penetration and usage cited is at 8% of hospitals and 17% of physicians so there is a long way to go. Estimations for the price tag to achieve this range from $75 - 100 Billion. A Large percentage of any "bail out" that may or may not be approved but a small drop in the ocean of "$2 Trillion a year the industry spends" today.

But it is the usability that is required and ubiquitous access:

Doctors cannot spend hours and hours learning a new system," said Castillo. "It needs to be a ubiquitous, 'anytime, anywhere' solution that has easily accessible data in a simple-to-use Web-based application."

I agree but what is missing from this discussion is how to get this information into these systems. If we had a 100% adoption of EMR's today this would be an enormous mouth to feed with clinical data. It is no use implementing these systems if we don't have the data and the idea that clinicians will interact with the current technology, no matter how good it is with screens, feedback, menus and intuitive interfaces, is just not going to happen.

Providing the tools to capture the data naturally is going to be critical tot he success of these systems and there seems no better method that using voice. All our interactions are based on voice and capturing this as clinical data that can feed the data hungry EMR's. Speech recognition has gone some way to helping and automating this process but these older engines only output text which does not satiate the EMR's needs for structured and encoded clinically actionable data.

Ensuring that technology does not take over the practice of medicine and replace bedside skills is a major concern as detailed in this a New England Journal of Medicine article covered here where Dr Abraham Verghese says:

In short, bedside skills have plummeted in inverse proportion to the available technology. I truly believe that good bedside skills make residents more efficient," Verghese said. Doctors who rely on hands-on skills tend to order tests more judiciously, reducing the number of unnecessary and expensive trips to the radiology department.

To that point allowing for ready voice capture that generates the date required to make these clinical systems useful is essential and is precisely what speech Understanding does. Free form narrative that is converted into structured meaningful clinical documents that contain the full fine detail from the clinicians but also contains encoded structured data that is tagged against relevant controlled medical vocabularies including Snomed, RxNorm, RadLex, LOINC, ICD9 to name a few. All this can be output in CDA format for Common Document Types that has been defined and approved through the HL7 balloting process through the tremendous work being done by the Healthstory Project that creates one document that delivers multiple outputs for different purposes and retains complete and detailed clinical information. Due to the open nature and flexibility of the standard this format allows for ready adoption by multiple stake holders quickly creating immediate value to the participants by generating a flexible rich clinical document that provides useful output.

The conversation on Digital Health Records is going in the right direction and i think it is exciting but must include the capture of information and while speech understanding is not a panacea it is an essential contributor to the equation of making digital records work

Secretary Daschle First Steps

2009-01-09T08:41:00.003-05:00

Senator Tom Daschle formally launched into his new role (to be confirmed but seems likely) as the Secretary of Health and Human Services yesterday at the Committee on Health, Education, Labor and Pensions - presided over by Senator Edward Kennedy.

His passion was clear and he was articulate and knowledgeable talking of personal stories of bankruptcy and lack of insurance coverage that he had witnessed. You have to like his agility in dealing with his colleagues from both sides of the floor and certainly his rhetoric resonated with me.

The problems are large and the challenges great but facing up to the issue of uninsured, catastrophic health bankruptcy (covered here in the US vs UK nightmare experience) is a great place to start. He referred back to the health care reform from 1994 which I personally remember well as an observer from the other side of the pond when many thought the two systems from the UK and the US were moving towards each other but unlikely to meet in the middle. The prevailing view then was the US system was moving to a UK style model and the UK was moving towards a pay for service US style..... neither materialized.

On first blush there is much to commend and like about his style, understanding and intent. The system is broken - I think most would agree on that and needs fixing. The process must include all the stake holders involved but requires government involvement with great leadership.

As a note on a colleagues board says - "if you think you are leading and no one is following you then you are just taking a walk".... I'm following for now and watch this with renewed optimism

Integrating Knowledge bases into Training Environments

2009-01-08T11:37:00.002-05:00

Changing training is as much a part of the process of improving health care as is the implementation of technology. In many respects it can have more of an effect since influencing the upcoming generation of workers early, before they become set in the ways of the existing methods, will ease and promote transitions to new and more efficient tools and work process. This is a longer term strategy but one that will have a more persistent effect.

So the news that "Career Step" is integrating the BenchMark KB (Knowledge Base) into their training package for clinical documentation specialists bodes well for increased standardization and the provision of technical support tools to help with the process of verification of facts, clinical terminology, names of drugs and other elements of clinical documents.

The resulting output of trained clinical documentation knowledge workers (some 10,000 expected to be enrolled this coming year) will be fully fluent in using these resources and many others and be catapulted into the workforce equipped and more importantly experienced in using the latest tools for improved efficiency and accuracy of clinical documentation.

There is no doubt that new tools and technologies are going to change the way we practice and deliver health care. Providing access and incorporating this into training programs is a big step to moving our health care system forward along the path of improved, more efficient delivery of safer more cost effective medicine.

Debt is Bad for Healthcare

2008-12-31T15:29:00.003-05:00

Props to HISTalk in his latest column featuring the review by Greg Halls blog note on Healthcare Profit and Debt and how this has essentially mortgaged off assets that were owned but that asset was sold off to show a profit.....

The concept is best summarized by comparing this to the fire service:

Examine the notion of ‘capacity utilization.’ Without debt, excess capacity is not viewed as a problem. Consider the local fire department. Paid staff resides at stations 100% of the time, regardless of emergency conditions. 100% state of readiness. Imagine if the fire station had to pay a mortgage: it would then be forced to convert its unused (excess) capacity to a cost, and in turn focus on raising revenues to support its excess capacity. This is exactly the case with hospitals (and many other large U.S. businesses).

So for the fire department they would need to service that debt and might be encouraged to start a few fires, find a side line business of fire extinguishers and perhaps even spin off various pieces to show profit - perhaps privatizing the ladder (front and back to different organizations that specialize in being the best at ladder work at the front). If we do that we could even turn our fire fighters into independent contractors paying those that have Self Contained Breathing Apparatus (SCBA) training higher salaries.....who would then tend to group in higher density areas where they would have more work and higher pay as a result.....

You get the picture. So as Greg suggests any restructuring or stimulus package must attend to the debt load accrued as a result of the "pirated equity" squandered by a procession of "B-school grads, many of them who found their way into health care as their widget of choice". Wouldn't it be nice if we could try and reclaim some of that wealth that got paid out as big fat bonuses similar to the one paid to Peter Kraus of Merrill Lynch to buy his $37 Million dollar apartment.

Americans Pay More for Healthcare - But Why?

2008-12-26T13:16:00.004-05:00

The McKinsey report "Why Americans Pay more for health care" (free registration required for access to full report) provides useful insights into the spending patterns and some of the underlying reasons for the high cost of health care in the US

While the higher costs is expected in part due to the wealth of the country:

Across the world, richer countries generally spend a disproportionate share of their income on health care. In the language of economics, it is a “superior good.” Just as wealthier people might spend a larger proportion of their income to buy bigger homes or homes in better neighborhoods, wealthier countries tend to spend more on health care.

Despite taking account of this the US spends some $650 Billion more than might be inferred from its wealth. As for the where this spending goes

The research also pinpoints where that extra spending goes. Roughly two-thirds of it pays for outpatient care, including visits to physicians, same-day hospital treatment, and emergency-room care. The next-largest contributors to the extra spending are drugs and administration and insurance.

But do we receive value for money - not based on outcome measures as compared to other OECD countries where we lag in many areas (more here and here where the US ranked last in a group of 19 countries). The report looks at possible reasons for the additional costs including the possibility that a less healthy population would mean higher treatment costs........survey said no.

So where does this additional expenditure go? Two thirds of this goes to outpatient care and while the US is doing well by shifting care and cost from in patient treatment to outpatient (and the legacy of President Bush's community clinic outreach has been a positive component of that as detailed here) this has actually added to the cost of health care in the US because of much higher utilization. Unfortunately not only was the utilization up but so too was the cost visit in part due to increasing use of expensive diagnostic testing (CT and MRI's being major contributors). The system is structured in such a way as to incentivize this type of care with the delivery of more services offered that are more expensive.

After outpatient care the next highest contributor is pharmaceuticals and not because of increased usage of drugs but because the mix is of more expensive and and the higher cost of drugs in the US

the price of a statistically average pill is 118 percent higher than that of its OECD equivalents

Even taking account for the possible explanation that the US pays more for a "superior product" and the high prices that subsidize the R&D for the rest of the world this still does not explain the large differential

But none of these factors, by itself, can explain the gap between the price of drugs in the United States and the rest of the OECD. When we adjust for US wealth, we find that the country’s branded-drug prices should carry a premium of some 30 percent, not 77 percent for branded small-molecule drugs.

Finally administration and insurance costs are the third highest but although these costs are significantly higher than other countries, the good news it

.....we find that given the structure of the US system, its administrative costs are actually $19 billion less than expected, suggesting that payers have had some success in restraining costs

The possible solutions are wide and varied but must involve all the stakeholders. Despite the high spend the US continues to lag behind in the general health of the population and as such "reformers should therefore focus on the preventative efforts" which represent a potential big win. Community clinics as supported by President Bush's administration are one such effort. In addition the consumer must be more engaged and informed and this requires the sharing of health care information that is structured so as to provide real information and not just make the medical haystack bigger. Technology plays an important part in the sharing of data and the ability to structure and make it available quickly and in meaningful ways to allow decisions and choices to be made.

Speech Recognition no Panacea to Change Work Habit

2008-12-19T10:12:00.003-05:00

Study published at RSNA 2008 and reported on in Auntminnie: SR Technology no panacea for reporting work habit change (registration required) reviewed the implementation of speech recognition technology at University of North Carolina Hospitals in Chapel Hill. This was not a review of the effectiveness of Speech Recognition overall since:

It's a well-known fact that implementing speech recognition (SR) technology can revolutionize report turnaround time and dramatically enhance the workflow efficiency of radiology departments.

But the question for this study was "can it improve the work habits of individual radiologists?". Not surprisingly technology does not change work habits. Radiologists who were slow to report before the implementation of speech were slow to report after the implementation of speech. Installing technology that speeds up the overall process does not change reporting behavior. Rank order of turnaround times by radiologists did not change pre and post implementation

The learning point - using technology to change behavior tends not to be successful. Technology should adapt to individual behavior rather than trying to change the behavior. Providing tools and technology that does not require a change behavior is more likely to be successful. Often behavior has been refined over the course of time that is optimal for that individual and circumstance - change is not always better or more efficient.

Why Doctors Don't Like EMR's

2008-12-17T16:58:00.002-05:00

Mr HISTalk is on the money in his latest blog

Doctors, like 99% of people, want to be consumers of information, not creators of it

Doctors want to give great care - that's a universal maxim for the profession and anything that enables or facilitates this will be successful and will get used. But that's not what has been going on:

The model of forcing doctors to share their thoughts through manual electronic documentation is fatally flawed. There is no industry … none … where someone with the education and time value of a physician is expected to peck on a computer, especially in front of a client who’s only going to get seven minutes of time (I’ve never seen a CIO typing meeting minutes into a PC, yet they’re often the ones beefing about computer-avoiding doctors).

and my personal favorite part of this piece - philosophic johad:

....trying to force those small business owners to use computers based on some kind of naive philosophic jihad against the inefficiency of paper-based recordkeeping

He is right "speech recognition" (or better yet the newer and more relevant speech understanding) is ready for prime time.....

Gathering the data should not be the focus - it should be a natural by product of the interaction and speech can help in achieving this. The real value comes with driving clinical information to support to decision making allowing clinicians to focus on the healthcare process

Diagnostic Imaging Report Added to the Healthstory

2008-12-04T15:41:00.002-05:00

Interoperability is one step closer especially in radiology with the announcement of the approval of the implementation guide for Diagnostic Imaging that makes it possible to seamlessly share information between radiologists and other electronic health records. The story was reported in Health Imaging and IT Radiology reporting takes on a sharing approach:

The new implementation guide for diagnostic imaging reports will help
radiologists capture and share the whole report or patient story in an
industry-accepted, human- and machine-readable format that includes
both narrative and structured data, according to HL7. As a result,
high-quality diagnostic decision-making reports will be more easily
available to both referring clinicians and clinical systems.

This implementation guide along with the previous guides is available from The Health Story Project (formerly known as CDA4CDT).

This is great work and will of increasing significance as more guides are established and more participants join the project

Automating the Pull of Information from EHR's

2008-11-25T12:38:00.002-05:00

The Social Security Administration announced they wanted to set up a project to test the concept of pulling information automatically form EHR's to help them deal with the 2.5 million disability claims it receives each year

Currently the process cost ~ $500 million a year to retrieve paper copies of records and then process them. The initial request asked vendors, health providers and payers to suggest a process and referred to a trial currently in process using the Continuity of Care Record (CCR). The framing by SSA as:

a fully automated Personal Health Records prototype system

is a little misleading and submissions can come from all areas. If these records are produced by dictation and transcription (and given the high proportion of information that currently is it is a fair bet that most is) then the opportunity here is for the value to the information by creating these documents in CDA format to be made available to SSA for those records to allow them to process the information automatically.

Information on the request can be found here

This project could be a great demonstration vehicle to show the value of moving all documents into a CDA format making the information instantly more useful and available for processing.

Magical Thinking in Implementing Healthcare IT

2008-11-11T11:45:00.000-05:00

There was a great article published in the Health Affairs Journal by Carol Diamond from the Markle foundation - "Health Information technology: a few years of magical thinking" - abstract here the full text requires a subscription

The concept of magical thinking in this context was that implementers must resist the concept where this notion that

..isolated work on technology will transform our broken system...Another tempting and related notion suggests that a lack of technical standards is the main barrier to health IT adoption..

Given that as they state

...the literature on computerization, stretching back to the 1980s, is unambiguously clear on this point: computers are amplifiers. If you computerize an inefficient system, you will simply make it inefficient, faster. IT can contribute to improving care only when underlying system processes are transformed at the same time.

To be successful instead of joining the stampede of standard creations from the likes of Health Information Technology Standards Panel (HITSP) and the Certification Commission for Health Information Technology (CCHIT) which are increasing awareness in the public and helathcare industry but have not according to recent testimony by Sam Karp of the California HealthCare Foundation stated

"Not a single data element has been exchanged in real world health care systems using standards this process has developed or deployed."

The point being that standards are adopted and the process of standardization is incremental. The internet being a great case in point that was developed over severalyears and floated to users unfinished and lacking consistency to allow usr interaction and use to help refine and develop a standard that we all use on a daily basis

So taking this concept to the next level and looking at the 60% of healthcare notes that are simply free-form notes - providing simple easy access to essential parts of this information would be invaluable. And there lies the beauty of the of the CDA4CDT system allowign for the capture and sharing of this infomation wihtout the impostion of structure, coding or limitations of choices. Sections can be easily identified and shared in a meaningful way. At a high level in the first instance but in more detail as people explore and adopt this standard and actually use it. THis is a standard to use without the imposed and artifical limitations that normally accompany the typical narrow "ideal" standard that does not meet the test for real use and genuinely useful interoperability

User Design - Basic Principles

2008-11-05T13:33:00.003-05:00

The British National Health Service (NHS) has one one of the largest healthcare IT projects (National Programme for IT NPfIT) in the world rivaling size and complexity in almost any industry. It's no wonder given the size and complexity that there are problems but in some cases these are just plain simple mistakes and getting basic simple things wrongs does nothing to engender the support and confidence with the embattled clinical users

A Recent post from "Phil Hammond 'Medicine Balls' " Confusing for Health highlights the reasons why the NHS Care Record Service (CRS) implementation systems has been "indefinitely postponed". (I've copied the full post below in case this link fails or ceases to work) but it was item 9 that caught my attention.....

Users who select 'died in department' by mistake (which is default outcome if D is used to navigate drop down), do not receive a warning resulting in appropriate letters sent to the GP. For genuinely deceased patients, the code is mapped incorrectly and does not bring up fields to complete, to register patient dead on the spine.

(The spine in this context is the NHS network backbone)

In a cock-up worthy of the Colemenballs moniker the default value for patient outcome is "Died in Department"!! Someone, somewhere is not firing on all cylinders and there there is a chain of people who let this through into a live systems that are diagonally parked in a a parallel universe.

As Phil Hammond states

...you can only succeed by starting as simply as possible and then getting those who have to use the new system to help build it into something fit for purpose

Sage advice!

>>>>> Confusing for Health >>>>>
Original posting should be available here

The NHS Care Records Service (CRS) is a secure service that links patient information from different parts of the NHS electronically, so that authorised NHS staff and patients have the information they need to make care decisions.' So says the Connecting for Health website, but there isn't much sign of it up and running in the West Country. A computer literate consultant tells me that CRS has been 'indefinitely postponed' where he works because 'it cannot migrate data across the system into the correct coding slots which means there is no way for a hospital to record what work it actually carries out and be paid appropriately.'

Our new market driven NHS depends for its survival on the right money following the right patients. And then there's the extra cost not just of installing the new system but paying extra staff to run it properly. A document sent to me for the Royal Free hospital in London shows not just how many bugs still need ironing out in the CRS, but how we all need to learn a whole new language to communicate with each other.

'1. There are problems associated with the use of smart cards to log on, which takes 7 key strokes, resulting in a very long log-in time, as much as 10% of each hour. This discourages use of the system, and encourages staff to leave the card in place, which then prevents the identification of the user when requesting X-rays, bloods etc.

2. The GP letter is very poor quality and requests to change this via the RFC (Referral Facilitation Centre?) have not been implemented. The treatments and investigations form does not support the user in choosing clinically important tests or support HRG 4. The Inbox not emptying automatically leads to significant delays in the system.

3. Clinics must have DNA patients dealt with as DNA, otherwise 18 weeks reporting is a problem. Reporting for the four-hour target is clunky and can only be done in Explorer because of the delay in updating IM200. This still takes up to 2 hours to validate the performance each day, causing 40-50 breaches a day for first few weeks.

4. Data can be entered but may not be visible to other users, and is difficult to find the forms and summaries. Multiple issues raised with LPfIT and BT/Cerner since going live have not been resolved

5. Free text fields on the discharge letter only allow 750 characters, resulting in limited summaries and poor communication with GPs.

6. Excessive time taken for scanning, registering, creating pending admission and GP letter printing. Five extra A & C (administration and coding?) staff have needed to be employed.

7. Discharge time of patient is displayed rather than check-out time (i.e. time patient left department). This makes reviewing 4 hour breaches impossible, since discharge time may be as much as 24 hours after checkout time

8. Manchester Triage does not populate white board. (I've no idea what this means either).

9. Users who select 'died in department' by mistake (which is default outcome if D is used to navigate drop down), do not receive a warning resulting in appropriate letters sent to the GP. For genuinely deceased patients, the code is mapped incorrectly and does not bring up fields to complete, to register patient dead on the spine.

10. The system crashes 2 or 3 times a week.'

I think I only understand number 10 with absolute certainty, but the message is clear enough. Implementing large scale IT projects is unbelievably complex. And you can only succeed by starting as simply as possible and then getting those who have to use the new system to help build it into something fit for purpose (preferably without inventing a whole new geeky language). I'm generally an optimist but I'm not sure about this. How long before we have more coders than doctors? Or are we there already?

Healthcare CIO's Grappling with EMR Adoption

2008-11-03T15:07:00.003-05:00

SearchCIO online magazine ran an article on EMR adoption that made for interesting reading:

When patients, physicians and payers embrace the electronic health record (EHR), life will be different in pretty amazing ways.....For the first time, patients will be treated by a personal team of clinicians. When a new drug for hypertension comes on the market, all patients (not just Nobel laureates like James Watson) will be able to map their genotypes and phenotypes to that medication to determine if it's right for them. Hospitals will be held to the "perfect care" standard -- the elimination of all medical errors in instances of preventable harm.

Wow! But the problem is we are nowhere near the level of adoption necessary to achieve these kinds of advances and the barriers to adoption remain frustratingly present and challenging. Privacy, interoperability, liability issues and physician reimbursement are all main stays of resistance to the move towards wide scale adoption of the EMR. As expected there are some frightening stories to hammer home the point from an emergency room physician who estimated he treated 80,000 patients "with my own hands

...the thing that stuck out as he looked back on his career was how many times he was put in a position of "guessing over and over," "flying solo," in an information vacuum. In situations where people "die right in front of you," he said he often felt he was "one data element away" from stopping a patient from dying.

Needless to say there continues to be the naysayers who are convinced that physicians " know what they are doing; why do you want to tell them what to do" but in all this seem oblivious to the tsunami of knowledge rushing down the luge of clinical practice that is impossible to keep up with.

I agree with John Halamka

that the lives of primary care physicians -- snowed under by paperwork that does not require an M.D. but is required nonetheless, frustrated by prescribing a medication only to find out it's denied by the insurance company and terrified of making a mistake -- is sheer misery. He predicted they will welcome the help, and patients will be better off for it. As the system stands now, "all the medical students are becoming dermatologists," he said.

And it's easy to see why with the information overload with "medical literature published every month that is is more than a doctor could read in a year". Not to mention declining reimbursements and shattered dreams that litter the halls of our hallowed medical facilities. We need EMR's and EMRs need data to provide the decision support that an automated and optimized medical technology infrastructure can provide physicians in their daily practices. But all of this should not turn clinicians into data entry or data capture clerks - they are not good at this task and technology is available to facilitate this issue and provide clinicians with the tools to ease the burden and provide them with the necessary clinical decision support they want and need.

Healthcare Myths

2008-10-20T15:06:00.003-04:00

Great post from Arthur Garson at Chron.com titled "Setting the Health Care Record Straight" - where he addresses some of the prevalent myths associated with the problems in the US healthcare industry

The myths as detailed:
1) There's no money - there is it's just wasted (by everyone)

2) New Plan = Government Run Healthcare - no they are not but they are trying to provide more universal coverage.

On the issue of "free" healthcare this is not a simple problem/solution - see the experience in Hawaii whose experiment in offering "free" healthcare to low income families has been suspended as it ran out of money after 7 months.

3) You can't Change it (third rail in politics) - as another poster pointed out there is now sufficient interest/incentive to fix the problems not least of all driven by the economic problems.... American has been and will continue to be an innovator. As a good friend of mine Dr Bruce Merrifield shared with me recently in a paper on global warming and Integrated Patterns of Civilization "about 90% of all recorded scientific knowledge has been generated over just the most recent 30 years, a knowledge base that will likely double again in the next ten years".

I am an optimist like Dr Merrifield and take the view "The current explosion of learning and experimentation now extends to all fields of knowledge with consequences for the future that may be incalculable and certainly under appreciated"

I have no doubt we will find solutions to these issues and many others - our rate of innovation and knowledge sharing is increasing daily and the world is full of latent genius. We just need the incentive and I think recent difficulties and the level of focus are helping provide a spotlight to focus our minds and innovations on solving these issues.

NQF Issue Brief on Measuring Elements of Care

2008-10-16T16:41:00.003-04:00

The recently released issue brief from the National Quality Forum titled "Performance Measurement and Reporting at the Clinician Level" can be found here (pdf file) makes the case for clinicians reporting which like it or not is coming. While many resist and there are difficulties in comparing results in healthcare because of the many contributing variables to outcome it seems impossible for me to imagine the future without comparisons of quality by patients.

For heavens sake - I can compare the quality of a dishwasher, the performance of a store and customer service of a technology provider why should I not want or be able to compare the results of my hospital and clinical service provider.

It is important to remember a point I made before:

Millions of times each day, patients interact with the U.S. healthcare system. During these interactions, most patients receive the benefit of solid clinical judgment and technical expertise from their care providers and witness basic and state-of-the-art technology appropriately applied

And rightly they point out that

Current incentives encourage more care rather than the right amount of care

So the effort underway is to refine these measures to make them better and more helpful and specifically to address the charge of Apples to Oranges that we hear repeatedly when data is published showing poor quality in one institution over another. The current work seeks to address this:

Clinician-level measurement is undergoing refinement. The shortcomings of current measurements are driving concurrent efforts to more broadly define relevant, important, and measurable elements of condition-specific episodes of care and related accountability.

In the Charter they focus on the criteria and attributes that are desirable for measuring clinicians from a patient perspective:

Measures should be meaningful to consumers and reflect a diverse array of physician clinical activities.
Those being measured should be actively involved.
Measures and methodology should be transparent and valid.
Measures should be based on national standards to the greatest extent possible.

But to achieve this as they identify in their discussion paper (Rattray MC, Clinician Level Measurement and Improvement – Improving Reliability, Actionability, and Engagement, Washington, DC: National Quality Forum; 2008) and follow up discussions needs to:

Enrich clinical data. Accelerate efforts to capture relevant clinical data to augment administrative claims data.

To satisfy this need without weighing down the already over burdened clinician requires that this data is enriched as part of the clinical process and not by imposing new and difficult processes onto their current clinical activity. A recent example cited by one of my clinical colleagues had me truly surprised. In this implementation the new clinical system required the clinicians users to be shadowed 1 on 1 for 30 days to help them learn and use the system. If this is what is required there has to be something wrong with the approach and/or the system. Educators are told that if everyone fails their test on material they have delivered to their students then the chances are that there is a problem with the education method, format or delivery and not with 100% of the students. What is surprising to me is that a healthcare facility would consider the necessity to shadow clinicians for 30 days an acceptable aspect of any system..... and rest assured that the cost of this training must be an additional administrative burden on an already stretched healthcare system.

Enriching the clinical data is essential to our move to quality and getting maximum value from our stretched clinical dollars but we cannot capture and impose complex systems and requirements on clinicians to achieve this aim. Use existing processes, tools and resources that are already efficient and use technology to facilitate the enhancement and capture of this information. I am all in favor of new ways and technologies to be applied to healthcare and our lives in general but let's use what is in place and help improve efficiency without burdening the scarcest clinical resource we have - the clinical staff.

Maternity Care Makes up 25% of Admissions in the US

2008-10-09T19:21:00.004-04:00

Obstetric care makes up ~ 1 in 4 discharges from hospital. The Agency for Healthcare Research and Quality reports that admission for childbirth outnumber admissions for pneumonia, cancer and heart failure. Unfortunately for many their view of childbirth is summarized by this quote:

"A lot of people think pregnant women are an accident waiting to happen"

Yikes! Mothers have been having babies for many years - this kind of attitude is reminiscent of the "State of Fear" that is detailed in Michael Crichton's book of the same name. There are some trying to combat this and Rita Rubin's article in USA Today this week: Maternity-care failings can be remedied with cost-saving fixes features some good examples including Valerie King of the Oregon Health & Sciences University who makes an excellent point

"Fortunately, maternity care is a place where good care and good economics come together."

And given the numbers this is a great place to focus. The latest numbers show a big increase in costs with a jump from $79 Billion in 2005 to a $86 Billion in 2006. Of this, estimates are that $2.5 Billion of that cost is associated with unnecessary care (mostly intervention with Cesarean Sections). The latest report published by the Childbirth connection on Evidence-Based Maternity Care focuses on the unnecessary care being delivered and the over use of intervention which is best demonstrated by the Cesarean Section rate in the US which stands at 30% (in the UK the rate is 24% which is also higher that expected)

Key to dealing with this is clinical data so there is no need to repeat unnecessary tests and investigations and making this information readily available will help the clinical staff and making the capture of this information as facile as possible.

You can read more about this at my "Navigating Healthcare Blog" - here which talks about the UK experience and covers some personal guidelines for mothers and parents to consider as they look at care in this area.

EMR Adoption and PHRs

2008-10-06T23:16:00.002-04:00

Chilmark Research published a "PHR Market Report, Analysis and Trends" - the Executive Summary is available for free (with sharing of your details). In their blog commentary they make an relevant point

PHRs simply won’t go anywhere without data and arguably the best source of data is a physician EMR system. Unfortunately, the adoption of EMR is abysmal across the care continuum of providers sitting at somewhere around 15-20% depending on how you count it/who you believe.

And even if you believe the 15-20% penetration of this, the vast majority of the information in these systems comes from dictation and transcription and is stored as blobs of text. There is certainly some potential for the personal health records/systems to help drive the capture of more shareable data. There are problems of security and confidentiality but as they suggest I think the benefits will outweigh the risks in the near future, especially given the entry of Microsoft, Google, Intuit and Dossia (there is a piece of my British Heritage that feels this is not the best name choice - see here).

For both PHR's and EHR's to succeed the data has to be shareable.....easily. It has to be as easy as clicking on a link or plugging in a USB stick and selecting import. To see what this needs to look like you need look no further than Facebook which has rapid user adoption. Facebook has exploded onto the social networking scene by offering simple ways for sharing applications, data and tools between all the users.

The HL7 approved CDA format represents the way forward and the potential to bridge the divide between structured and unstructured content. CDA4CDT commenced the process in 2007 and has defined the formats for 4 document types so far and there are more to come. There are several presentations available here. With shareable formats data can be made available from PHRs to EHRs and vice versa. This will drive adoption in both systems.

Crisis on the Front Line of Health

2008-09-30T15:07:00.001-04:00

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

2008-09-23T09:47:00.011-04:00

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

2008-09-19T21:23:00.015-04:00

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

2008-09-17T09:54:00.006-04:00

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

2008-09-16T14:30:00.005-04:00

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

2008-09-10T17:06:00.003-04:00

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

2008-09-05T13:23:00.002-04:00

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:

Improve quality of care
Provide support to the delivery of that care, and
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)

Privacy of Information

2008-08-25T15:35:00.003-04:00

There's a fun video posted to the ACLU web site - it is worth watching as it raises some legitimate issues on the privacy of information and the consequences of the sharing and linking of that information. You can watch the video here

What is interesting about this video is how close we are already to this reality. Many private companies can already link existing public sources of data to create an extensive and fairly detailed profile of individuals, their buying habits, preferences etc. You only have to visit your local Jiffy Lube to see how quickly they can pull up all the details on your car and based on this offer the best "treatments" for the "health" of your car! In this case best is probably as much about your car as it is for selling you additional services. In the case of you supermarket shopping card this tracks your purchases in excruciating detail and there have been many instances of this data being used against the individual. In this particular instance it turns out the data used while correct proved to be a red herring and in the words of Bruce Schneier:

The moral of this story is that even the most innocent database can be used against a person in a criminal investigation turning their lives completely upside down.

Clearly today we already see data usage beyond what might be expected, and many would say beyond reasonable limits. But at the same time I think most patients would agree that any visit to a medical office is an extremely frustrating experience. Such visits require patient's to hand write all their data onto a paper form. Data that already exists in many other systems and often in the very system that it is destined to be entered into.

So where is the balance - I believe unfortunately that as Lord Acton said:

Power tends to corrupt, and absolute power corrupts absolutely. Great men are almost always bad men

I also firmly believe that the sharing of information is essential to the delivery of high quality care. So while it is clear to me that ready access to the complete medical record is the most helpful to clinicians there has to be some limitations to accessibility.

So how do we balance the need to share relevant medical information with the concern that the sharing of that information could be used against you. The answer is unclear and the issue complex but several groups are working towards this goal, trying to balance the need for information with the need to protect everyone from the inevitable abuse that comes with total access and power.

Some of the EMR companies have a "Break the Glass" approach to urgent access - providing emergency access to anyone with a corresponding oversight in all cases where they felt the need to break the glass and access all the patient's data. The Voluntary Universal Healthcare Identifier (VUHID) group has taken a slightly different approach by creating a voluntary identifier which allows the individual to control and manage access to their clinical information on an ongoing basis:

.....to enable error-free linkage of clinical information,
enhance the privacy of patient information, improve the quality of
medical care, reduce the rate of medical errors, decrease the incidence of healthcare-related identity theft, and help control healthcare costs.

There are others solutions and ideas and no doubt there will be more added as the systems and ideas develop - whatever we end up with it is clear this is complex area and will require continued debate, careful consideration and ongoing participation by all parties from the vendor community, through government all the way to the individual to ensure we come out with a solution that everyone can live with

EMR Adoption in Small Practices

2008-08-21T10:08:00.004-04:00

Why all the resistance and difficulty in getting EMR's adopted and in use across the board. Why is there not a queue along the street as there was for the Apple iPhone v1 and v2?

Is it the usability, the coolness, price point, ROI, design and features, overall complexity or just basic lack of time that prevents the adoption and take up of this technology.

In a recent posting on Mr HISTalk Jonathan Bush started a discussion on why getting small groups to use EMR's. The spirited discussion highlights some interestiung points including one of the reasons not to need an electronic medical record - in the words of one physician:

All I have to do is ask and someone will get me the information

It is hard to imagine a more frustrating experience for a patient let alone a doctor being asked the same question over and over again. Not to mention the implication that the physician has the time, full recall and insight into the patient's condition and possible risk factors to ask all the relevant and necessary questions to reach an accurate diagnosis. With the explosion of clinical data this seems an increasingly unlikely proposition. Far better to have the technology help guide that process, capture and store that information so that it can be reviewed quickly prior to and during the patient interaction. I am reasonably confident that I can review a chart (digital or otherwise) and garner more relevant clinical information in a shorter period of time than going through a question and answer session with a patient. I can pretty much guarantee that this is true if the information is presented in a consistent, structured format.

Cost pressures and the cost of implementing tied to the suitability seems more likey to create a barrier to suucessful adotpion. An attitude of:

We’ll take care of the aggravating stuff

Is more likely to engender success. Perhaps not lines down the street but certainly decrease resistance and increase the desire to use technology to help. There's a reason why we have appliances dotted around our house - most are there to make our lives easier. Some are those poor choice impulse buys that remain on the shelf but all the others do make life easier.

There is another big driver looming - the desire of individuals to have access to all their personal health records:

Consumers want access to their info online, hence PHR

There are those who consider this unimportant and even undesirable and there remains resistance to this concept of personalized
healthcare with
concerns ranging from confidentiality of information to patient’s inability to
understand complex medical diseases and the fear that a patient’s record may
become contaminated by inaccurate medical information if we allow patients to
enter and interact with their own medical record.

I fall clearly on the side of patient empowerment and providing more information and like many other areas I believe consumers want more access and more information. As Regina E. Herzlinger, the author of “Who Killed
Healthcare?” stated in a recent presentation that consumer driven healthcare with improved
access to information will follow the same course as we have seen with cars and
personal computer (PC). Consumers don’t need or even want to know all the
workings of a car or PC but ready access to performance, quality comparisons
and details on cars and PC's allows for intelligent choices and overall improvement of quality
and decrease in price by market pressures brought to bear by the informed
consumer. Healthcare needs to follow the same course and it is the consumer
that will be a key driver of this march towards electronic medical records, easier access and sharing of information and the resulting higher quality care

Getting Technology that Actually Works in Healthcare

2008-08-15T10:11:00.002-04:00

There is a article in the fox news site titled: Let's See Gadgets That Actually Work which talks about the frustrations of twenty years of dealing with technology and the fact we are still "fussing" with it.

My own experiences are best represented by one of my favorite people who remains firmly in the camp of "technology needs to be simple to use and does what I need it to do"...

A lot of this has to do with the simple fact that I don't enjoy playing
with machines. I just want them to do what I need them to do with
minimum fuss.

Much of this has to do with a disconnect between designers and users....Motorola had a break out product when they made these two groups the same in designing the original Razr. They gave their engineers carte blanch to build a phone to specifications they would want as users; the result was the Razr which was a smash hit and redefined mobile phones for many.

In a recent thread discussion on the AMDIS listserv one of the participants asked for help in preparing a presentation: "Can IT actually improve medicine without killing the physicians". One of the insightful responses made this exact point:

IT folks tend to work physically isolated from clinicians, but physically proximate to one another, where they reinforce each others' views (and misconceptions).

Exactly! The author suggested that one of the ways to combat this is bring IT folks into your practice, force them to be there during busy working periods and to experience everything you experience from the failures and successes of the technology you deal with. I couldn't agree more...and have made this very point in every company I have ever worked in. Engineers, designers, coders, product managers, and others needs to immerse themselves in the working clinical environment..... maybe instead of bring a child to work day we should have bring an engineer to work day!

At the end of the day - to use Jonathan Weber's words

I just want tools that work. And in that, I don't think I'm alone

I think he's right and this is true in healthcare with some variations in tolerance for the failure and difficulties in using the technology represented by the typical adoption curve

For technology to be successful and rapidly adopted we have to appeal to the larger cohort of users in the tail of the chart. That's the "early and late majority" and that boils down to ease of use and the functionality the tools offer. If the tool makes a clinicians life easier, speeds up a process or reduces the time to carry out a process or procedure then adoption will be faster....

So how about it..... bring an engineer or programmer to work with you next week. However just for the record I disagree with Jonathan on the iPhone. It is cool, it is useful and it is functional but as always YMMV

What to Believe in Todays Information Tsunami

2008-08-12T09:01:00.007-04:00

It is a confusing world we live in and making choices is becoming increasingly difficult
Today is a great example of the conflicting nature of information available for our own personal healthcare

Half of overweight adults may be heart-healthy, which includes statements such as

The first national estimate of its kind bolsters the argument that you can be hefty but still healthy, or at least healthier than has been believed.

and Obese people not always unhealthy

... 1/4 of people who were a healthy weight actually had health problems such as high blood pressure, low levels of good cholesterol and high levels of bad fats in the blood.

....over half of overweight adults and almost a third of obese adults did not have these problems.

Versus the long standing advice you can see here, and here, and here
and published articles such as this one published yesterday: Measures of Obesity and Cardiovascular Risk Among Men and Women from the American College of Cardiology that concludes:

This study adds to extensive prior findings, which associate adiposity, in particular abdominal adiposity, with increased risk for CVD

On the same day as news feeds such as CBS and the Times included Why elderly joggers just keep on running.The conclusions included:

California Couch potatoes might not like to hear it, but running regularly has long-term health benefits that last well into old age, according to a study.

Elderly joggers remained fit and active for longer than non-runners and were half as likely to die early, scientists at the University of California at Stanford found. They were also less likely to succumb to age-related illnesses, including heart disease, cancer and neurological disorders.

It's a complex world and making sense of all of this "information" is a significant challenge for everyone, users, patients and professionals alike. The key to helping sort through this data is providing ready access to latest validated research and pushing this data into the consciousness of the users and clinical professionals. Pushing means we need to comprehend the clinical findings, signs, symptoms and tie them back to our clinical databases. This will link the knowledge and information in these clinical databases and push out supporting information to the decision makers which includes the clinical professionals as well as patients themselves. Capturing clinical information as data is one of the first steps in this process - entering it as items on digital forms is one way but that process can be laborious and time consuming so providing alternatives that match current processes is helpful. Dictation of clinical documentation is a prime example that needs to update the way it captures this data and how we achieve this should reflect this growing need for data not text.

As we think about the future of documentation, the data content locked in our traditional documents must be set free to help our healthcare providers and patients start to make sense of the conflicting information feeding in to our clinical decision making

Oh..... and for what it's worth; exercise good and obesity bad.

The Medical Transcriptionist - Knowledge Based Workers Setting Clinical Data Free

2008-08-09T10:31:00.015-04:00

Sitting in the Medical Transcription Industry Association Board meeting recently the group spent some time discussing the future of the industry and the changes we need to demonstrate the key value that our members and their organizations bring to the healthcare setting.

The Medical Transcription Industry is transforming and will become increasingly important to the successful implementation of electronic medical records to meet the burgeoning need for better more cost effective healthcare.

Clinical information is critical to the systems that are necessary to support our increasingly complex healthcare delivery. Clinical information comes from the patient via the clinician, the vast majority of whom are dictating that information for a medical transcriptionist to transcribe. Years ago this was done with tapes or even wax drums and type writers..... we have moved on from this paper based communication to digital information and sharing of data like every other part of society as detailed in a report The Digital Workplace and the Information Worker:

...the nurse who enters patients' vital signs into a patient-tracking system on a wireless PDA
...the pilot who uses a laptop to download flight manuals and who calculates flight plans based on weight and balance inputs

and in our personal lives as well.... I am sure many can relate to my experiences with my own 81 year old mother who is digitally connected despite distance and time to me and my family. I am grateful to receive regular e-mails and text messages and we both know what is going on in each others lives and schedule. This connection has morphed from traditional (snail) mail and letters, through telephone calls, faxes into full digital connectivity and near instantaneous updates.

Medical Transcription and the medical transcriptionist have moved on too and the transcriptionist, like everyone else, has become a knowledge based worker and increasingly applies technology to assist in producing accurate, timely clinical documents. And it is this production of documents that remains a barrier to the growth. 60% of the current inputs to the EMR are clinical documents that have been dictated and transcribed. It is hard given the length of time we have depended on documents and in particular paper to leave that paradigm behind but to grow into the value added profession that clinical documentation specialists/medical editor/medical transcriptionist needs to become, it is imperative to move away from two dimensional documents and start to think about clinical data that has been locked away in these documents and needs to be set free.

Those in the profession already know the extensive clinical knowledge stored by those in the industry. This was brought home to me some years ago when I discovered that a favorite past time amongst transcriptionist's was to guess the final diagnosis for the patient as they transcribed a dictation - before reaching that point in the dictation. That's a tremendous amount of clinical knowledge available to be applied and will make this transition to knowledge based worker a breeze!

And the technology is heading that way too - documents are so version 1.0. Structured encoded clinical data in semantically interoperable form is available today in the HL7 Clinical Document Architecture and the CDA4CDT format is available and implementable and brings the value of structured clinical data moving away from v1.0 documents to v2.0 clinical data container (I don't like this term either but I'd be interested in suggestions for another term that doesn't use "document" and captures the idea of data and knowledge)

We are all knowledge based workers. Knowledge and in particular clinical data is one of the key ingredients necessary to help automate clinical care and provide safer more cost effective care. Dictated documents contain clinical data and knowledge that is locked in a proprietary format that is human readable but not machine readable. Clinical documentation specialists/medical editor/medical transcriptionist provide the key to unlocking this data and placing that data into a CDA computer readable format.

Medical Transcription Knowledge Based Workers - Increasing Demand

2008-08-04T09:00:00.007-04:00

A working from Home blog "Undress4Success - Work From Home" posted an interesting article on the Medical Transcription industry and the increased demand for Medical Transcriptionists

.... (Overseas) rates are going up too, particularly in India, because they’ve realized that they can demand higher prices thanks to growing need and scarce availability of experienced MTs

The author is right on target - Medical Editors are going to be in high demand. They are and will become key knowledge workers in healthcare. As Tom Harnish says in the blog

...qualified medical transcriptionists (MTs) are in short supply

Good news for those who fear the flatening of the world and the application of technology. Speech recogntion will improve the productivity by automating the rote task of converting the spoken word into text:

The (speech recognition) technology may increase costs by 15% to 20%, but it can increase output 100% to 200% according to one MTSO owner

But to add even more value to this process knowledge based workers will need to do more than just listen to the audio and convert this into text (either by pure typing or editing/proofing a draft output from a speech recognition engine). Adding clinical data that is machine readable and semantically interoperable between all the clinical systems being implemented in our healthcare system will become a must. That process is mostly manual and much information is lost in the avalanche of text based documents that contain the information but only in human readable form. Knowledge based workers will need to provide data elements and structure to these documents turning them into data that can be fed into clinical systems.

CDA4CDT provides an ideal common environment that is designed to flexibly cope with the varied levels of data encoding but still provide the healthcare system with the text based document that can be printed and used as it is currently. But the additional information incorporated into this file allows for semantic interoperability and data exchange at a level that EMRs want and need turning the huge volume of clinical text documents into clinical data inputs to the medical record that can be shared and exchanged between systems

Medical Editors can provide this manually by tagging documents and encoding using the CDA4CDT standard or by using speech understanding technology. Speech understadning outputs a document that is tagged and structured with clinical data. This merges the role of medical editor with a true knoweldge based fuctnion of reviewing and correcting clincal data embedded in the file and clinical document.

Medical Editors are knowledge based workers and are in short supply......