EHR Initiative - Is it a Monkey on the Back

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

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

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

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. By focusing on the effective use of EHRs with certain capabilities, the HITECH Act makes clear that the adoption of records is not a sufficient purpose: it is the use of EHRs to achieve health and 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

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

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

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

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

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

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

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

That skills measured in this instance were divided up into 3 major categories - geography, Doctor/patient/EHR relationship and using the computer to teach and enhance care as follows:

• Adjust the geography

1. Student did not have their back to me during the exam.
2. Student adjusted the chair to be at eye level with me.
3. Student adjusted the screen so I could see it easily.
4. Student moved close enough for me to read the screen to construct a triangle between student/patient/computer (Signals like “Can you read the screen OK?”)

• Triad: doctor-patient-EHR relationship

1. Student introduced him/herself before turning to computer.
2. Student introduced the computer into the triad.
3. Student visually shared EHR information on the screen during the exam to bring me into the triad, rather than keeping me outside of his/her computer work.
4. Student maintained good eye contact with me during the encounter.
5. Student alerted me verbally when turning attention from me to the computer.

• Using the computer to teach/enhance the quality of care

1. Student showed me my vital signs.
2. Student graphed my vital signs or showed flowsheets or showed trends about my health.
3. Student asked if I’d like a copy of my data.
4. Student accessed other online patient education materials for me.

There are no real surprises to discover training an education can help improve the use of the EHR in the clinical setting but it was the feedback from the medical students that was interesting:

Medical students have expressed concerns about their ability to integrate the EHR into patient encounters. In a 2007 study, Rouf and colleagues reported that of 33 third-year medical students conducting electronic ambulatory encounters, only 64% were satisfied or very satisfied with doctor-patient communication when using an EHR.6 Further, only 24% thought the EHR improved their ability to establish rapport with patients, and only 21% believed that their patients liked them using the EHR. In addition, 48% of students reported they spent less time looking at the patient because of the EHR, and 34% reported spending less time talking to the patient.

So while a large number were satisfied with the doctor-patient communication when using the EHR they recognized that only 21% of patients liked them using the EHR. (the patient feedback directly would have been more useful). The 21% is not statistically significant since it is hearsay of the medical students not the patient but if my own personal family experience is anything to go by (Doctor please look at me not your EMR) then this may well underestimating patient dissatisfaction.

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

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

Are you getting the full story?

Myths and Lies in Healthcare Debate

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

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

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

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

With that all said moving the existing healthcare system to a new format is not going to happen. The challenge of "Getting from There to Here" was eloquently detailed by Atul Gawande in his New Yorker piece. The NHS was established on July 5, 1948 but what is lost in the mists of time is the sequence of events to reach that point:

Instead, the N.H.S. was a pragmatic outgrowth of circumstances peculiar to Britain immediately after the Second World War. The single most important moment that determined what Britain’s health-care system would look like was not any policymaker’s meeting in 1945 but the country’s declaration of war on Germany, on September 3, 1939.

The sequence of events and war time necessity created "a national Emergency Medical Service to supplement the local services" which expanded to cover essential services necessary to the population remaining int he country and dispersed by the war time bombing of cities and the returning veterans injured in the line of duty. For many groups providing free care was a necessity of the "war effort" and engaging the private system to supplement the rapidly assembled government system was an obvious step. The system was expected to be temporary but status quo had been destroyed and not least of all because the population, despite the war, had seen an improvement in the health of the population.

The medical and social services had reduced infant and adult mortality rates. Even the dental care was better. By the end of 1944, when the wartime medical service began to demobilize, the country’s citizens did not want to see it go. The private hospitals didn’t, either; they had come to depend on those government payments.

So in 1945 the concept of the NHS was really nothing more than extension of what had been created through necessity of the war.

By 1945, when the National Health Service was proposed, it had become evident that a national system of health coverage was not only necessary but also largely already in place—with nationally run hospitals, salaried doctors, and free care for everyone. So, while the ideal of universal coverage was spurred by those horror stories, the particular system that emerged in Britain was not the product of socialist ideology or a deliberate policy process in which all the theoretical options were weighed. It was, instead, an almost conservative creation: a program that built on a tested, practical means of providing adequate health care for everyone, while protecting the existing services that people depended upon every day. No other major country has adopted the British system—not because it didn’t work but because other countries came to universalize health care under entirely different circumstances.

So whatever we end up with in the US it won't be an NHS. It might take some of the elements of the NHS and it will be based on our countries experience and system drivers. But within the discussion lets focus on facts rather than anecdotal stories and fears (as seen here in the Scientific American article on "Anecdotal Evidence undermining Scientific Results":

Thinking anecdotally comes naturally. Thinking Scientifically does not

So please start thinking scientifically and base discussion on science and facts and help move this reform forward.

Agreement on Healthcare Reform

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

But there are some core principles that I think some level of agreement:

• Elimination of Waste
• Improve Patient Care
• Care for Everyone (Life sustaining not lifestyle sustaining)
• No one should be bankrupt paying for Care

Based on a totally unscientific poll with friends and colleagues who represent from both sides of the aisle there was agreement with the above principles. No doubt the devil is in the detail but if we can agree on some basic principles and start with agreement rather than disagreement perhaps there is some hope for much needed reform of our healthcare.

Each of these issues is complex and as I wrote in my other blog on a recent incident involving abuse of services for a bee sting it may seem obvious in this case but the problems arise when you look at cases that are not so obvious. The level of waste is staggering - based on this report from Price Waterhouse Coopers:

more than half of the $2.1 trillion spent on healthcare every year is

This is spread across many areas and reasons why but as they point out in looking at one large facility - John Hopkins which is representative of the complexities facing the other 4,500 hospitals around the US:

About 700 different organizations, health plans, and employers pay the bills at Johns Hopkins Health System in Baltimore. Each one has different rules about what’s eligible for payment, how much to pay and when to pay....Reducing the redundancies could save the hospital more than $40 million annually, and that’s only “numbers we could identify if we could just get computers talking to each other”

This is basic stuff and these savings alone could go along way to help pay for some of the proposed reforms that, on principle, we agree are desirable such as care for all. In the words of one reporter in the UK: US Healthcare - the Biggest waste of Money in the World. I might not go that far but the idea we are getting any degree of value for money. What is interesting in the breakdown shown is the public/private split of payment


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

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

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

Information Overload in Healthcare

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

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.