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?

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?

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?

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.

Three Body Problem - Transcription Productivity and Speech Understanding

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

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

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

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

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

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

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

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

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

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

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

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

Self Service Medicine

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

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

But in fact as Tim points out

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

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

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

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

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

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

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

Meaningful Use and the Missing Ultrasound

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.

Meaningful Use - Getting the Full Story

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

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

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

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

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

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

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

Interoperability and Data Entry - There are Solutions

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

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

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

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

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

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

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

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

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

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

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

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

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

Reinvestment is not Just About Technology

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

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

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

But that's not enough

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

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

Computers Don't Have to Depersonalizes Medicine

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

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

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

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

As the author says:

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

And the end result for her is

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

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

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

From Dictation to Direct Computer Input

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

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


Louis Cornacchia, MD, Doctations, Inc.
Doctations

Documentation at the Point of Care


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

Healthstory - Providing Data to Healthcare Business Analytics

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.

Jonathan Bush from Athena Health on Government Reforms

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

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

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

Step 1: Crap Removal

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

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

Pay for data and pay for results

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

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

David Brailer Weighs in on Health Information Technology

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

He highlights 4 key areas:

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

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

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

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

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

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

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

Plans to Computerize the US Healthcare Records

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

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

One observer put it this way:

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

and more worryingly:

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

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

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

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

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

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

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

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

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

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

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

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

Diagnostic Imaging Report Added to the Healthstory

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

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

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

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

Automating the Pull of Information from EHR's

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.