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?

Moving Transcription Back Into the Hospital

What's old is new again......A recent article in USA Today (High-tech 'scribes' help transfer medical records into electronic form) highlighted the latest innovation in healthcare documentation - "High-Tech Scribes" who help "transfer medical records into electronic form. Is it just me or does that sound like something that is already going on in the electronic documentation industry with medical transcription and editing for the last 20+ years?

The challenge of capturing clinical documentation in digital format have remained the same and the continued struggle of adoption is highlighted by the poor adoption rate of electronic medical record systems

Today, only 1.5% of hospitals have a "comprehensive" electronic health record, and 8% have a basic version, according to Jha's March study in The New England Journal of Medicine. Most hospitals are intimidated by the cost, which can range from $20 million to $200 million.

Pretty poor given how long the industry has been working on this and despite the length of time still no clear exchange format or standard to facilitate the sharing of information

because there are no common standards for these records, doctors who do implement electronic charts may not be able to share them with a hospital across the street

But the value of digitizing medicine and implementing these systems has been clearly established and the terrifying level of errors that do occur as detailed in the landmark "To Err is Human - Building a Safer Health System" published in 2001 and many follow on reports and studies including he 2005 Health Affairs study that reported:

The country could eliminate 200,000 drug mistakes and save $1 billion a year if doctors in all hospitals entered their orders on computers

Despite these drivers we are still languishing in single digits of adoption and continue to struggle to roll out healthcare technology that effectively improves quality and safety without crushing efficiency and effectiveness of clinicians. So the University of Virginia Doctors elected to employ "scribes" to document the clinical encounter and these individuals such as:

Leiner, 22, a University of Virginia graduate who plans to apply to medical school

Who follow the doctors around and capture the clinical interaction on laptops. The consensus appears to be this will not catch on although a recent debate on the AMDIS list server offered some differing opinions that included some potential to reduce mistakes given the second set of eyes reviewing the documentation and the capture of the information real time with the patient. There is complexity in this approach made worse with gender conflicts (female patient and male scribe for example) but this approach appears to represent a modification of the current documentation process that uses dictation and transcription and perhaps offers some potential to free up clinicians to interact with patients rather than focusing on the clinical documentation and the electronic health record.

Moving the medical editor out of the bowels of the hospital just formalizes one of the well known methodologies in many transcription departments that attempts to link doctors to the same transcriptionists so they learn to "work together" (albeit remotely). This would make the bond stronger, the connection greater and the opportunity for error reduction using a trained and qualified "scribe" to document with the clinician. The medical editor is qualified, experienced and a highly knowledgeable resource that is currently disconnected from the clinical process.

Technology just becomes a facilitator in this process with speech understanding and speech recognition providing tools that can be used by one or both of the documentation team. The electronic medical record becomes integral to the documentation process. And although the real time aspects of alerts, evidence based medicine and the application of real time clinical knowledge to the interaction is still once removed from the physician the real time team documentation can provide direct access to the clinician through a combined approach to the capture and recording of the patient encounter.

How would you feel about a scribe being part of the clinician patient interaction - as the patient, as the clinicians or as the scribe?

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.

Proportional News Coverage - Skewing Health Perception

Our perception of health and risk is all wrong and instantly accessible media is one of the key reasons. The recent coverage locally in the Washington area demonstrates the point well. A quick Google search of "Metro Crash" in the news reveals a total of 6,132 results (no doubt this will increase over time). A tragedy occurred on the Washington DC Metro when one train collided with one car riding up and over the other. There were several fatalities (9 at the time of writing this post) and a range of injuries from severe to minor. Coverage in the hour long evening news on the night of the tragedy could be summarized as follows:

• Evening News Length: 60 Minutes
• Advertisements Time: ~20 mins
• Time dedicated to the Crash: 35 mins
• Time dedicated to remaining news: ~5 mins

This disproportionate level of attention skews our perception of risk. Anyone watching the news last night would find themselves focusing on the safety of the Metro system. A quick search for statistics (interestingly the Wiki Page on the Washington DC Metro's Security and Safety had already been updated with details of the latest crash!) reveals a list of accidents but no suggestion of significant problems or challenges facing this system. In fact the overwhelming commentary suggests "The DC Metro has a very good safety record". When compared to data on Traffic Fatality Rates for DC:

• Traffic's most recent data for 2007: 44 fatalities (US total fatalities 41,059)
• DC Metro 15 (subject to change based on the most recent crash) over the last 20 years

Healthcare is the same and our perception of risk is skewed based on media coverage and our own personal experiences. If the news media gave proportional coverage based on risk and causes of death it might look something like this

• Evening News Length: 60 Minutes
• Advertisements Time: ~20 mins
• Time dedicated to the Heart Failure and Cancer: 20 mins
• Time dedicated to Cerebrovascular Disease: 4 mins
• Time dedicated to remaining causes of death 6 mins
  

How can technology help - in this instance it appears not to be. The instant availability of news, our ability to blog and tweet the latest information and the way in which information can take on a life of its own (can anyone say Swine Flu H1N1). We need to filter information and it is the link to our clinician that helps provider that input and balance. Id be the first to encourage everyone to be their own primary care practitioner - in fact I said so last week but this has to be balanced with appropriate input from trained experienced professionals. There are a range of tools to help diagnose problems including some online symptom checkers and they have a place in the range of choices available to us. But this is not about replacing the education and experience of your clinical team. This is about supporting them with appropriate information.

In a recent discussion with a clinical colleague he was adamant that clinicians must use technology and clinical systems to be able to deliver better and safer care. I agree that technology must be used to help support the decision making - in fact I think it is as much about information as it is about technology. Technology just helps bring the information closer to the decision making point. This can be as simple as patients searching for information and bringing in printed material to the consultation (I know to some clinicians this is their nightmare but I remain convinced that there is no stronger more dedicated advocate for the successful outcome than the patient themselves).

But getting to this data and providing it not only in digital form but better yet in a form that can be consumed and processed by electronic systems takes this to the next level. Linking this information to the full Healthstory allows for some automated processing and relevance mark up that will help in filtering useful from distracting data.

Personal health management includes the capture of information and the intelligent sharing of this between the patient, the clinician and clinical systems. This is a team approach and the team will help balance the perception of risk. Finding balance is one of the keys to navigating through life. Have you found balance and if so how. What's your perception of coverage, risk and the media coverage distorting our perception of risk.

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.

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.

Why Doctors Don't Like EMR's

Mr HISTalk is on the money in his latest blog

Doctors, like 99% of people, want to be consumers of information, not creators of it

Doctors want to give great care - that's a universal maxim for the profession and anything that enables or facilitates this will be successful and will get used. But that's not what has been going on:

The model of forcing doctors to share their thoughts through manual electronic documentation is fatally flawed. There is no industry … none … where someone with the education and time value of a physician is expected to peck on a computer, especially in front of a client who’s only going to get seven minutes of time (I’ve never seen a CIO typing meeting minutes into a PC, yet they’re often the ones beefing about computer-avoiding doctors).

and my personal favorite part of this piece - philosophic johad:

....trying to force those small business owners to use computers based on some kind of naive philosophic jihad against the inefficiency of paper-based recordkeeping

He is right "speech recognition" (or better yet the newer and more relevant speech understanding) is ready for prime time.....

Gathering the data should not be the focus - it should be a natural by product of the interaction and speech can help in achieving this. The real value comes with driving clinical information to support to decision making allowing clinicians to focus on the healthcare process

Magical Thinking in Implementing Healthcare IT

There was a great article published in the Health Affairs Journal by Carol Diamond from the Markle foundation - "Health Information technology: a few years of magical thinking" - abstract here the full text requires a subscription

The concept of magical thinking in this context was that implementers must resist the concept where this notion that

..isolated work on technology will transform our broken system...Another tempting and related notion suggests that a lack of technical standards is the main barrier to health IT adoption..

Given that as they state

...the literature on computerization, stretching back to the 1980s, is unambiguously clear on this point: computers are amplifiers. If you computerize an inefficient system, you will simply make it inefficient, faster. IT can contribute to improving care only when underlying system processes are transformed at the same time.

To be successful instead of joining the stampede of standard creations from the likes of Health Information Technology Standards Panel (HITSP) and the Certification Commission for Health Information Technology (CCHIT) which are increasing awareness in the public and helathcare industry but have not according to recent testimony by Sam Karp of the California HealthCare Foundation stated

"Not a single data element has been exchanged in real world health care systems using standards this process has developed or deployed."

The point being that standards are adopted and the process of standardization is incremental. The internet being a great case in point that was developed over severalyears and floated to users unfinished and lacking consistency to allow usr interaction and use to help refine and develop a standard that we all use on a daily basis

So taking this concept to the next level and looking at the 60% of healthcare notes that are simply free-form notes - providing simple easy access to essential parts of this information would be invaluable. And there lies the beauty of the of the CDA4CDT system allowign for the capture and sharing of this infomation wihtout the impostion of structure, coding or limitations of choices. Sections can be easily identified and shared in a meaningful way. At a high level in the first instance but in more detail as people explore and adopt this standard and actually use it. THis is a standard to use without the imposed and artifical limitations that normally accompany the typical narrow "ideal" standard that does not meet the test for real use and genuinely useful interoperability

Crisis on the Front Line of Health

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

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

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

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

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

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

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

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

Medical Transcription the EMR and Speech Understanding

The Medical Records institute e-Newsletter from September contained an article by Claudia Tessier from the Medical records institute titled: "Medical Transcription and EMRs: Opportunity Lost?" that discussed the relationship between medical transcription and the electronic medical record (EMR). As the Claudia says:

...medical transcription offers a bridge to EMR adoption

But the idea that

the EMR offers the best opportunity yet to get rid of transcription and its concomitant headaches

Misses the opportunity for medical transcription and valuable data that is lost with the push towards the structured form based hunt and click style documentation. In a recent discussion with a clinician he lamented the loss of "the beauty and descriptive nature of medical language that has been used to describe medical conditions and image findings". Instead as he put it "we have turned detail rich clinical information into dumbed down fill in the blank cookie cutter reports" which do not reflect the richness of the information he wants to provide to his colleagues.

To date medical transcription is estimated to constitute 60% of the input into current EMR systems but that input is in the form of text blobs and not clinical data. The article goes on to suggest that:

...EMR vendors should ramp up their cooperation to create uniform integration. Let every one of the 300+ EMR systems allow dictation and let the market determine whether the related turnaround time, quality, costs, etc. (see below) are acceptable. Let users dictate on cell phones and dictation devices, or through laptops and tablets—whatever their preference.

Is spot on - the systems work and with better integration and more choices for input we open the doors to capturing input from our clinicians caring for patients and struggling to document for the benefit of communication with others members of the team as well as capturing sufficient information to be paid for the services they are delivering to their patients.

But this input is still not resolving the necessity to feed EMR's with clinical data which is essential for computer based systems to understand the information and be able to act on it. There are existing standards to hold and transmit this information including the Continuity of Care Record (CCR) which is "....working in collaboration with HL7 on the expression of ASTM's Continuity of Care Record content within HL7's CDA XML syntax and the seamless transformation of clinical and administrative data between the two standards.” - Rick Peters, MD

Transcription companies are already offering xml-based solutions that support structured output and the significant value this brings to EMR's is that this structured data has been checked and reviewed by medical transcriptionist/editor with expertise and knowledge to validate that content relative to the original dictation input of the clinician. More value from the validated data output from Medical transcription will make the transcription industry more of a partner and even more important in their contribution and ongoing role in the delivery of high quality healthcare.

So where does Speech Understanding come into all of this - unlike the traditional speech recognition technology which Hollywood conditioned us to expect far more comprehension on the part of the engine as captured in this classic clip from Star Trek IV - the voyage home where Montgomery Scott (Scotty) of the original series of Star Trek fame is trying to interact with a computer circa 1980.....

But his experience is typical of traditional speech recognition systems and a typical response either visually or verbally would be "Directions unclear - please repeat request"

Speech Understanding is the next generation of the technology, crossing the chasm between the need and desire of physician to dictate using all the richness and expressivity of language but that is recognized and understood and not only creates an accurate representation of the free form text but also produces a structured and encoded document. Structure is captured and stored in native CDA format and encoding is achieved using clinically relevant encoding systems such as RadLex for radiology, RxNorm for drugs, Universal Medical Language Systems (UMLS) and SnoMed for clinical terminology etc

You can have the best of both worlds and Medical Transcription will be around for years to come - albeit in a updated MTv2.0 form where the transcriptionist is a knowledge based worker proofing, editing and validating clinical data......so in the words of Spock: "Live Long and Prosper"

A Facebook Medical Record

What are we trying achieve with medical records....? Asides from the obligatory proof that the care was delivered (billing) and determining how much should be paid for the delivery of that care medical records are about sharing information between care givers. It has always been that way. Years back the number of care givers was lower and specialization less so the number of people needing accessing to the this information was lower. Now with the tsunami of medical information it is impossible for single care givers to deliver all the possible ranges of care and it takes a village team to deliver care.

And the latest explosion on online activity - one who's traffic can exceed that of Google and you tube is Facebook, which according to their own description

...is a social utility that connects people with friends and others who work, study and live around them. People use Facebook to keep up with friends, upload an unlimited number of photos, share links and videos, and learn more about the people they meet.

Now take this concept and adjust the wording.....

FaceBookHealthRecord is a social utility that connects patients with their care givers and others who provide diagnostic services, imaging, laboratory tests, results and pay for that care. Patients and clinical care givers use FaceBookHealthRecord to keep up with the status of their healthcare, their wellness and long term disease outlook as well as communicate quickly and effectively with specialists. All images, diagnostic study videos and diagnostic testing information can be uploaded and shared withe the clinical team allowing everyone to learn more about he care of that patient.

The interaction concept has been tested and reported on - Bob Wachter wrote an article just recently on this very concept "Creating a Facebook-like medical record" where he slams home the point on interoperability

In fact, today’s medical record virtually guarantees the silo-ization of care. Few physicians ever read nurses’ notes, even though all of us depend on the nurses to be our eyes and ears. And the situation iteratively worsens every day. Why would a nurse, realizing that no doctor ever reads her notes, even try to write them to be useful to physicians? And visa versa, obviously. Over the years, this divergence has been codified into ritual, calcified by templates, and hard wired through regulations whose original rationale no one can remember

Interestingly he points out that the spooks have gotten in on the concept with FaceBook-007 aka A-Space (I am guessing short for Analytical Space...?). Launch is set for Sep 22, 2008. UCSF back in 2003 launched a concept very much in line with the sharing of information amongst all the related parties (notably not the patient in this case) called Synopsis

As with all folklore associated with good concepts it was an rapid victim of its own success receiving requests for access, being copied and installed at other locations by users and even covered on a Web based M&M rounding on the Agency for Healthcare Research and Quality (AHRQ) site

There is work on these concepts underway and even some launches - if you live in New York you can sign up with HelloHealth from MyCA Health group who liked the approach taken by Jay Parkinson (the Hipster-MD from New York- pdf) who launched his own home made system with a similar ideal of sharing information digitally and providing easy, affordable access to patients some months ago. The NHS in the UK is getting in on the act with the "Individual Health Record" and covered in a recent article "Personal Healthcare Management" (subscription required) in my regular column in the British Journal of Healthcare Management.

There is even a Facebook application - MedCommons available today for a subscription plus monthly storage charges. Unfortunately much of what will be transferred in is likely to be scanned images and print outs. The introductory video even shows your physician office receiving access to your medical data and printing it out.....sigh! This will change but for now we are stuck with the legacy information

No doubt there will be detractors and there are bound to be issues and problems but overall you have to like the idea of sharing data on the quickly and effectively with the full clinical team. And there lies a key point.... the information must be be clinical data and should be tagged to a controlled medical vocabulary to make this information valuable for automatic machine processing. But lets not burden the clinicians with entering data in online forms but provide tools that capitalize on clinical documentation and the natural expressivity of language while still creating the structured data that can be used by these connected applications.

EHRs and Data Collection

The latest issue of the Journal of American Medical Informatics Association features a case report titled:

Opportunities for Electronic Health Record Data to Support Business Functions in the Pharmaceutical Industry—A Case Study from Pfizer, Inc. - you can view an abstract here (you need a subscription to see the full article).

I am all in favor of data collection and firmly believe that we must move to a data rich model in healthcare to allow the use of technology to support all the complex interactions and activities associated with the delivery of care. But the capture and collection of data has to be linked to a value for the beleaguered physician who is more often than not the one tasked with the collection.

What I found interesting about this paper was the focus on pharmacy data – not surprising given the authors affiliation but this particular quote stuck out

“Drug Safety & Surveillance,” “Clinical Trial Recruitment,” and “Support Regulatory Approval” were the most oft-mentioned scenarios during the interviews (Table 2), in which the senior executives believed that EHR data would prove valuable.

Drug Safety and Surveillance is a genuine crowd pleaser but Clinical trial recruitment and Support Regulatory approval is not likely to feature in many clinicians minds who are facing a waiting room chocked full of patients. Then in the summary

While EHRs can clearly provide some support to the pharmaceutical industry for data re-use, an ongoing dialogue must continue among EHR companies, research based organizations, and the pharmaceutical industry to ensure that the data being captured, aggregated, and analyzed can produce the value necessary for all stakeholders.

The problem is while the Pharmaceutical industry can see great value in the data from the EHR's they do not (or cannot) provide resources to help capture it. Everyone is tuned to the same radio station – WIFM (What’s in it for me) and in the case of the beleaguered physician there is little if anything in capturing data to suit the Pharma companies that offers the physician anything in return….. so why should they focus or pay any attention to this need of Pharma companies.

Better to focus on the opportunities related to:

1. Improve quality of care
2. Provide support to the delivery of that care, and
3. Save the physician time
   

All this needs to occur while helping clinicians capture more complete information at the point of care. Doing so will support the above elements but from the business perspective will show capture the information to prove the physician is performing all the relevant tasks to allow them to bill effectively. To that point in For the Record Magazine: Getting in Tune — New Survey Spotlights the MT’s Role in Healthcare. The article reviews the results of the "2007 Survey of Medical Transcriptionists". The lead author Gary David, PhD, an associate professor of sociology at Bentley College reviews some of the studies findings

One of the quotes sums up the current state of affairs

“Doctors do not generate revenue; documents do"

Or put another way "If it's not Documented then it didn't happen" (one of many references to this)