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?

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?

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

Meaningful Use and the Missing Ultrasound

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.

Physicians Morphing into Data Entry Clerks

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

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

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

Wrapped up in this piece are two major issues:

• Capturing the data
• Communicating the data

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

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

But as he rightly points out

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

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

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

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

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

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

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

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

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

Annoying Hard to Use Systems Won't Be Used

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.

Healthstory - Providing Data to Healthcare Business Analytics

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.

Automating the Pull of Information from EHR's

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

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

EMR Adoption and PHRs

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

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

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

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

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

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

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

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

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

Transcription the WD-40 of Healthcare

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

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

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

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

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

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



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

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

The Medical Transcriptionist - Knowledge Based Workers Setting Clinical Data Free

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.

Speech Understanding will Bring More Information to the Doctor

Came across an interesting post by Steven F. Palter, MD from the docinthemachine blog. Specifically the blog he wrote on EMR=Clonewars

He notes that there is a hidden danger in EMRs of the inadvertant cloning of patients.

I don't think it is so much hidden or inadvertent - it's human nature and doctors are like everyone else - we always look for the path of least resistance. Copying from a previous note especially one using templates with a series of choices can be helpful.

But what he gets in his practice

..... is EMR records from other practices .... and the patients look identical.....Instead of all the details of a past treatment cycle it will list drug dose and failure with no detail of WHY it did not work. The diseases all look the same. There is never any detail on the nuances and subtle aspects of that individual’s condition. So when a group uses these records and they review a treatment every single person with the same disease (the “patient clones”) end up looking identical and treated identically. Cookie cutter assembly line medicine.

There's hope - Speech Understanding and in particular the use of CDA4CDT documents which make narrative notes interoperable with electronic medical records - bridging the divide between where we are today:

• More than 60% of clinical content produced, stored and locked in narrative documents

and where we want to get to

• Structured encoded information that is semantically interoperable and can be automatically processed and used by computer systems to help apply the best knowledge of healthcare diagnosis and treatments available today
  

What this means is a at the most basic level virtually any clinician can produce a minimal CDA document utilizing the simplest form of the structure which includes all important uniform metadata for all documents that allows them to be indexed, searched and the content integrated in a meaningful way into the EMR.

And at the high end, lab systems, pharmacy systems and EMR's can produce richly-structured, fully machine-processable CDA documents that remain human-readable as well as machine readable which will satisfy Steven's needs of :

the nuances and subtle aspects of that individual’s condition

So as Steve rightly points out quoting from AHIMA 2006 study:

....65 percent of chief information officers planned to get it (Speech Recognition) by 2008. It’s being touted as a natural add-on to the electronic medical record, since doctors are used to recording their notes, says Harry Rhodes, director of practice leadership for the American Health Information Management Association.

Voice can help solve the cloning of patients and the technology and the standard is available today.

Political Comparisons of 2008 Presidential Candidates Heathcare Proposals

Now we are down to two candidates (or at least today we are down to two presumptive candidates) it is good to see where they stand on healthcare (props to Mr HisTalk for the pickup)

You can see a side by side comparison here

Both contain good ideas but the cost containment concepts make for interesting reading and will be important as the industry starts to address the soaring costs associated with delivering healthcare to our existing population and the burgeoning number of over 60's.....

Invest $50 billion toward adoption of electronic medical records and other health information technology.

Good to see some level of realism of investment needs to make this happen

Promote competition among providers by paying them only for quality and promote use of alternative providers (e.g., nurse practitioners) and treatment settings (e.g., walk-in clinics in retail outlets).

Provide consumers with more information on treatment options and require provider transparency regarding medical outcomes.

Require hospitals and providers to publicly report measures of health care costs and quality.

And for the cost and quality measures it will be essential to build in the collection, capture and reporting of this information as part of the normal clinical work flow, not as some after thought or adjunct process. Once again the concept of capturing clinical data directly from the clinician represents an efficient method of gathering data especially if this can be done in real time or near real time without any additional burden on the already over stressed and time pressured clinician. Once this information is captured it needs to be held in a form that can be transmitted to other systems in both human readable form as well as computer readable data that requires little or no human intervention to populate clinical database that can then use and report on this data.....Clinical Document Architecture for Common Document Types (CDA4CDT) does just that.

Consumerism and Clinical Knowledge

Providing the population with the right information at the right time to help them navigate the murky waters of health care delivery, insurance, hospitals, payors, denials, quality indicators and pay for performance statistics is going to be a key facet to the success or failure of any consumer driven revolution in health care.

The recent study by McKinsey “What Consumers Want in Health Care“ - summary here

Faced with health care decisions, consumers are concerned, confused, and unprepared. They rely heavily on personal recommendations and brand recognition, according to a recent McKinsey study

No big surprise here but if this is to change and the consumer is really to become informed and help drive change in health care delivery they need to have access to the right information

...48 percent report being prepared for common medical problems but only 15 percent for more disruptive medical scenarios...

To help satisfy this need consumers are already turning to the web in increasing numbers and estimates range from 50% to as high as 75/80% of patients use the web before and after visiting their physician. But much of the information available comes from a range of sources some less qualified than others. By providing structured data output as part of the clinical documentation process and delivering documents in a standard form that can be read but also imported into computer systems it should be possible to support this burgeoning need for clinical data as a natural part of the process - this is exactly what Clinical Document Architecture for Clinical
Clinical Documentation Architecture for Common Document Types (CDA4CDT) is intended to provide directly from dictation.

You can read more about the process and the concept in these articles
Guidelines Will Standardize Dictated Documents
HL7's first ballot in expected series under way
HL7 CDA: The Missing Link in Healthcare IT

As the McKinsey study revealed

Most people need additional guidance, education, and advice to make decisions
Innovative, cross-industry products that assist with the complex decision making will be highly valued by an influx of consumers eager for options but unsure where to turn

That's going to be difficult until we can standardize the clinical information coming out of clinicians offices and hospitals and make it available in machine readable form to consumers to aid their voyage of discovery in the new health care world of consumer driven choice