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

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

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

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

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

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

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

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

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

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

AND

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

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

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

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

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.

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.

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.

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.