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?

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

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

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

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

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

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

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

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

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

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

AND

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

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

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

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

Cause and Effect - Unintended Consequences

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

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

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

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

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

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

Who would have thought it!

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

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

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

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

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

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

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

Transcription - 0
Dictation - 0
Narrative - 0

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

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

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

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

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

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

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

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

I'm Henry The VIII I Am

Henry VIII continues to be a fascinating case study and the focus of movies, books, songs (if you wonder about the title it comes from Herman's Hermits' Song of the Same name)


and recently ShowTime's series "The Tudors" which has certainly captured much of the intrigue if not all the historical accuracy. So what does this have to do with clinical documentation you may ask.

Henry VII is famous for his six wives but is also subject to substantial debate as to the cause of death. He died on 28 January 1547 after suffering through a bad fever. As was common at the time he was bled during his illness by the "physicians" of the day, and like so many cases this likely contributed to his death. But here we are 462 yeasr later and we continue to debate the cause of his death. There have been many suggested causes of his death:

• Syphilis
• Untreated type II diabetes
• Obesity
• Tuberculosis
• An infection coupled with breathing problems

and probably the most commonly held view is that Henry VIII died of syphilis. A position promoted some 100 years ago but currently thought to be inaccurate. But the list of possible causes of death today would be a lot shorter had the method of data capture been an EMR. Imagine Henry's physician documenting the case - he would be presented with a list possible causes of death as known in 1547:

Tudor EMRCause of Death:

• Consumption
• Smallpox
• Consumption with SmallPox
• Other

But Henry's medical record was one of the best medical records of his time and included the following information (from Trivia Library):

At 22 he contracted smallpox..At 33 he had his first attack of malaria...At 35, after a serious jousting accident, ...develop chronic migraine headaches and the extraordinarily painful leg ulcers which eventually crippled him...at44, Henry suffered his worst jousting accident and lay unconscious for two hours....fits of blind anger ..acute insomnia, painful sore throats, and recurrent, agonizing headaches. ....became prematurely gray and abnormally obese; in one four-year period his waist measurement increased by an astounding 17 in., ....At 45 he developed a strange growth on the side of his nose...At 49 he probably became sterile or impotent...at age 55, he could hardly walk ...increasingly absentminded, ...his last eight days in bed, too weak even to lift a glass to his lips

But recent review of the notes suggest she may well have died from complications of Type II Diabetes. And it was the narrative that helped current researchers to come to that conclusion.

So unless we believe we know everything we need to know about healthcare, symptoms, signs and diseases then collecting the narrative is imperative to capture the maximum amount of information both now and in the future. If we loose the narrative we will be loosing information. Identifying data elements is important but these two worlds can live in harmony in Clinical Document Architecture Format (CDA) in the Healthstory Project that preserves the narrative but adds additional data elements.

If you want to hear more come listen to the presentation:

Clinical Narrative and Structured Data in the EHR: Venus and Mars Live in Harmony with CDA4CDT on Wednesday Oct 7th @ 11:15 in the Grapevine Ballroom D, Gaylord Texan, at the AHIMA Convention in Grapevine Texas. Hope to see you there