Time with the Doctor

Scientific American publish an article titled "Are Doctors getting slower or are patients getting sicker" that was based on a paper written and published in the Archives of Internal Medicine: Primary Care Visit Duration and Quality: Does Good Care Take Longer? Chen et al. Arch Intern Med.2009; 169: 1866-1872. (unfortunately subscription required). Apparently people are going to the doctor's office more often and for longer visits than 9 years ago. Whether this is because we need more medical attention or because there are more treatments available, the end result is the same as it is for imaging and radiology. Fewer resources spread over more work. In radiology the explosion of images (imagine the effect of single slice CT to 64 and more slices CT exams) has created less time to review per image for the number of radiologists available.

In medicine in general, if we the patient are consuming more time with more visits and for longer consultations - assuming the number of clinicians stays constant this should result in a decline in time per consultation. This represents a challenge in achieving the goals of modern healthcare

Two of the most pressing goals for the U.S. health care system are to deliver higher-quality care and to lower costs

Since most studies suggest that better care is linked to time spent with the clinicians - especially in complex cases. It turns out according to this study that

(they) found no evidence for the commonly held belief that physicians are spending less time with their patients or that quality of care has diminished

Time spent had increased from 18 minutes per consultation to 20.8 minutes. The investigators discount clinicians inefficiency as the reason for the increase:

Although it is possible that physicians are becoming less efficient over time, it is far more likely that visit duration has increased because it takes more resources or time to care for an older and sicker population

And while I think the complexity has increased in care delivery I think it is far more likely a combination of both (complexity of care and inefficiencies in the clinical care system) contributing to increase in time necessary to spend with the patient. Unfortunately much of this inefficiency is the new clinical systems and the complexity of capturing the information that has added significantly to the time required. No doubt we will see more studies that segment the time in more detail. In fact in some results published in this article in the Healthcare Ledger (Medical Transcription Relevance in the EHR Age - warning pdf) a study suggested that documentation time had quadrupled adding more than 110 minutes per day!

There is consensus on the value of clinical systems and digital information in particular the opportunity of providing more useful data at the time of the doctor-patient interaction. But it was clear from recent discussions that there is a divide in the way in which doctors and clinical staff should interact with these systems to capture and record information. There are those who view additional resources appropriate for assisting (Moving Transcription Back into the Hospital). And there are those that see a need for a change in approach and style to adapt to this process and incorporate into the doctor-patient interview. My own personal experiences support both answers. In some instances the interaction with the clinical system forces a change in the way doctors interact with patients and the process, work flow, methods and materials suit a new way of working. But in a recent experience at a clinician specialist's office (in this case a pulmonologist) it was very clear watching the interaction and in particular the flexibility and dynamic nature of the paper based note taking that any imposition of a digital system would not only slow the consultation to a grinding halt but would reduce the information captured dramatically. This is not to suggest that there is not (or will not be) a solution to this problem but the "standard" digital note capture system would be hopeless in this setting and be quickly rejected.

The comments to the article demonstrate some of the strong feelings - those of doctors overwhelmed with administrivia

Patients are NOT sicker and Doctors are slower, but only because of the inordinate amount of documentation required. My office note 40 years ago might have been: Sore throat-----Penicillin. We all knew what a sore throat was and that Penicillin was prescribed. In contrast Today's visit must include all vital signs, past history, a history of the presenting complaint, history of allergy, plus a rather extended physical exam, otherwise we do not get paid by the insurance companies or the Government. I used to see 50 or more patients a day and see them very well. Now, with all the rules I"m lucky to see 30 and am exhausted after doing so.
Dr. Michel Hirsch, FP, FAAFP (1967-present)
Donaldsonville, LA.

and the patients who feel they are getting less at a higher cost

I must live on another planet. Nurses have always performed all of the routine stuff like vital signs etc. I am 54 years old and have type 1 diabetes. I have never had a doctor spend more than 10 minutes with me, ever. It's usually 5 minutes and $70.

Both are right - doctors are required to do more in less time and patients are getting less. I like many others buy the vision of electronic medical records but perhaps not exactly as they exist today. The current large scale implementations and clinical systems struggle to account for the variations in specialties and their needs and while there is some element of best of breed approach many shy from this concept given the historical challenges of integration and intelligent sharing of information between systems from different providers. Things have improved - Healthstory (using HL7 CDA) as an example of an open standard that allows sharing of clinical data. This is a journey not a destination....and if there is a destination Ill bet that will be constantly changing! The challenge in the coming months and years will be guiding the beleaguered, over worked and underpaid clinicians through the maze of systems, their features and functions and helping them adapt their technology to their practice and vice versa.

How important is the digital record and if given the choice of doctors with and without what would you choose. For the practicing physicians that has an electronic medical record - is it a good or bad experience. For doctors still working in the paper world - can you see this changing or are your needs met currently and cannot be sustained in any of the digital models you've seen?

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?

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?

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.

More is Not Better

It is customary to believe that more is better. Higher availability and more access = better care...right? Wrong! A recent interaction at the pediatricians office amplified the point and the influence that the patient can have. In a case of extended week long general malaise some level of investigation and therapy was warranted and we agreed on some basic blood work. But in the conversation with the pediatrician she explained that many of her patients were insisting on "Lyme Titre's" based on local reporting of "huge increases in Lyme disease". Nationally the incidence runs around 0.04% and is considered "rare". I could have insisted but logically it made no sense - there had been no possible instance of exposure to risk factors (tick bites) so what would that test bring. But my choice was clearly not the norm.

It is this excess utilization driven by the system that is detailed in in Atul Gawande article penned a another insightful piece in the New Yorker that shreds the notion that we are getting better care just based on higher access. "The Cost Conundrum" is the talk of the town and rightly so.

In his tale of two cites - 800 miles apart in Texas the data available on healthcare costs and results shows that McAllen, Texas is spending approximately twice the cost (~ $15,000 per enrollee). Currently Medicare income per capita is $12,000....! In El Paso - some 800 miles away the costs are half as much running at around $7,504 per enrollee. Similar mix of demographics and public health statistics.

His discussions with local residents and providers was revealing in the wide variation of possible causes:

• McAllen is providing unusually good care (it's not)
• Better technology availability (it's not)
• More doctors (no difference)
• The service is better
• Malpractice is a bigger problem (not based on the recent Texas law capping malpractice claims)

In Fact on the quality metrics published by Medicare:

Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse, on average, than El Paso’s.

Not only is the cost troubling but the outcomes show that the population is not getting value for their expenditure. As is so often the case if you follow the money" the answer becomes evident. Our system incentivise use not results. As the cardiologists put it when asked about a hypothetical patient with chest pain that goes away and has no associated family history or other clinical indicators to suggest heart disease...

“Oh, she’s definitely getting a cath,” the internist said, laughing grimly.

And for many patients this would be a great outcome. They got the test they needed and ruled out heart disease. Not so for the sub group who are unfortunate to suffer complications some minor and transient and some major and permanent (you can get a good overview of the procedure and complications here):

The1-2% of people who get major complications from the procedure, the 0.08% who die from the procedure, the 0.03% who have a myocardial infarction precipitated by the procedure, the 0.06% who have a devastating stroke or the 0.62% or 0.06% depending on the approach Hospital Acquired Infection, the 1% who have an allergic reaction to one of the many agents used, the 1% who may go on to develop renal dysfunction....still feeling good about the investigation?

In McAllen the analysis of the Medicare data revealed some troubling variation compared to El Paso:

Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits.

As Atul Gawande put it:

The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.

The good news is that just having the technology does not necessarily translate into over use. The Mayo clinic in Rochester has some of the highest levels of technological availability but one of the lower rates of Medicare spending (in the lowest 15% of the country at $6,688).

At the core of this story is data - the lack of insight and availability of data was troubling:

It was a depressing conversation—not because I thought the executives were being evasive but because they weren’t being evasive. The data on McAllen’s costs were clearly new to them. They were defending McAllen reflexively. But they really didn’t know the big picture of what was happening.

The most expensive piece of equipment in the hospital is a doctor's pen. But this tool has been heavily influenced by knowledge and availability of best practices. Where best practices are well defined there is close alignment in the clinical choices. Where the science is unclear the variations arise from high levels of investigation (in areas of low cost healthcare delivery) to low levels and conservative treatment (in areas of low cost healthcare delivery). Overall the intent is not to over charge or provide more care but the underlying drivers change behavior for clinicians who try to cope with a complex and overwhelming system that they have little training to deal with.

To borrow form the Six Sigma and Deming's "Plan-Do-Check-Act" Cycle Six Sigma attacks problems with DMAIC

• Define high-level project goals and the current process.
• Measure key aspects of the current process and collect relevant data.
• Analyze the data to verify cause-and-effect relationships. Determine what the relationships are, and attempt to ensure that all factors have been considered.
• Improve or optimize the process based upon data analysis using techniques like Design of experiments.
• Control to ensure that any deviations from target are corrected before they result in defects. Set up pilot runs to establish process capability, move on to production, set up control mechanisms and continuously monitor the process.

Rinse lather and repeat. Critical to this process is developing measures and collecting the data to measure. But healthcare has lived in a wilderness of data both clinical and financial. Everything about the current system is focused on increasing volume in part to offset the decreasing levels of reimbursement. Creating systems like the Mayo that deliver care where "the needs of the patient come first" is at the core of the changes necessary. What is interesting is that most here would love access to the Mayo care but in the political battlefield the concepts and ideas are tainted as rationing and limits to our supposedly great service.

Everyone likes to bash the NHS in the United Kingdom and roll out the legion of complainers who list the reasons why the system is not working while failing to acknowledge the integrated care and access helps deliver better care. While the NHS may not be the perfect system it does encompass elements that we should learn from. I know which care I'd prefer to receive - that of the Mayo style; balanced and high quality. I avoid the McAllen experience where possible recognizing that the "MD" at the end of my name can influence the clinical interaction positively or negatively. I can invariable force the investigation or test if I choose to but I elect to be far more conservative in my approach for me and my family. As I did with the Lyme Titre and do repeatedly - I remain conservative bucking the trend.

Do you? Would you have insisted on the Lyme Titre or just accepted it when it was mentioned simply because you had heard about Lyme disease, were worried and your physician had mentioned it? More is not always better. What's your experience?

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.

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 Speech Recognition is no Longer Sufficient

Speech recognition has been around for over 30 years and part of our consciousness since the mid 1960’s but it is only in the last 3-4 years that we have see the technology really start to deliver some value to the much beleaguered and over worked clinician. There are innumerable studies that demonstrate the savings linked to the efficiencies possible with faster report turnaround. Unfortunately producing more reports faster is not always the best answer and oftentimes this is simply making the patient information haystack larger. This tsunami of data is overwhelming even the best organized clinicians and many are struggling to keep up with this alongside the explosion of diagnostic and treatment choices. Keeping up with the medical knowledge is a full time job if anyone had the time – but they don’t.

Clinicians want to give great care - that's a universal maxim for the profession and anything that enables or facilitates this will be successful. But that's not what has been going on with speech recognition which has not only required a change in behavior to enunciate in special ways, dictate commands, speak slowly and add punctuation and in the ultimate punishment requiring the highly skilled and time pressured expert to review and correct poorly drafted content. The output is a blob of text that cannot be read or interpreted by the electronic medical record (EMR) since it is not machine readable.

Innovation in speech recognition was last made in 1993 when continuous speech recognition was rolled out. Since then the technology has stagnated and while allowing clinicians to type with their tongue has provided some efficiencies and improvements, speech recognition has failed to address the underlying challenges facing clinicians today. So now we have reached this point what’s next?

It is the capture of structured clinical data that can automatically feed the EMR that is the real goal. Achieving this requires an alternative approach to speech recognition, not just recognizing the words but actually understanding the meaning and context. Comprehending normal human speech is not a word recognition process but speech understanding process that takes as input not just the phonemes or parts of words but the complete context of a conversation including the intonation, the subject matter and relevant prior information which is all applied to the complete conversation. It is this process that enables humans to exhibit the “cocktail effect” which allows us to listen in to more than one conversation at a time even though we are not fully participating in either. The added knowledge allows for inferring of missed words and understanding the content allows us to complete the picture producing a fully understood interpretation of the speech. Speech understanding is the next frontier of innovation in clinical documentation.

This content can be stored as part of the full story - the Healthstory that contains the computer interpretable data AND the fine detail in the narrative that is the essence of clinical insight, judgment and essential to the transmission and flow of useful clinical information between all the team members delivering care in our multi disciplinary model.

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

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

Healthcare CIO's Grappling with EMR Adoption

SearchCIO online magazine ran an article on EMR adoption that made for interesting reading:

When patients, physicians and payers embrace the electronic health record (EHR), life will be different in pretty amazing ways.....For the first time, patients will be treated by a personal team of clinicians. When a new drug for hypertension comes on the market, all patients (not just Nobel laureates like James Watson) will be able to map their genotypes and phenotypes to that medication to determine if it's right for them. Hospitals will be held to the "perfect care" standard -- the elimination of all medical errors in instances of preventable harm.

Wow! But the problem is we are nowhere near the level of adoption necessary to achieve these kinds of advances and the barriers to adoption remain frustratingly present and challenging. Privacy, interoperability, liability issues and physician reimbursement are all main stays of resistance to the move towards wide scale adoption of the EMR. As expected there are some frightening stories to hammer home the point from an emergency room physician who estimated he treated 80,000 patients "with my own hands

...the thing that stuck out as he looked back on his career was how many times he was put in a position of "guessing over and over," "flying solo," in an information vacuum. In situations where people "die right in front of you," he said he often felt he was "one data element away" from stopping a patient from dying.

Needless to say there continues to be the naysayers who are convinced that physicians " know what they are doing; why do you want to tell them what to do" but in all this seem oblivious to the tsunami of knowledge rushing down the luge of clinical practice that is impossible to keep up with.

I agree with John Halamka

that the lives of primary care physicians -- snowed under by paperwork that does not require an M.D. but is required nonetheless, frustrated by prescribing a medication only to find out it's denied by the insurance company and terrified of making a mistake -- is sheer misery. He predicted they will welcome the help, and patients will be better off for it. As the system stands now, "all the medical students are becoming dermatologists," he said.

And it's easy to see why with the information overload with "medical literature published every month that is is more than a doctor could read in a year". Not to mention declining reimbursements and shattered dreams that litter the halls of our hallowed medical facilities. We need EMR's and EMRs need data to provide the decision support that an automated and optimized medical technology infrastructure can provide physicians in their daily practices. But all of this should not turn clinicians into data entry or data capture clerks - they are not good at this task and technology is available to facilitate this issue and provide clinicians with the tools to ease the burden and provide them with the necessary clinical decision support they want and need.

Transcription the WD-40 of Healthcare

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

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

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

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

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

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



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

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

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)

What to Believe in Todays Information Tsunami

It is a confusing world we live in and making choices is becoming increasingly difficult
Today is a great example of the conflicting nature of information available for our own personal healthcare

Half of overweight adults may be heart-healthy, which includes statements such as

The first national estimate of its kind bolsters the argument that you can be hefty but still healthy, or at least healthier than has been believed.

and Obese people not always unhealthy

... 1/4 of people who were a healthy weight actually had health problems such as high blood pressure, low levels of good cholesterol and high levels of bad fats in the blood.

....over half of overweight adults and almost a third of obese adults did not have these problems.

Versus the long standing advice you can see here, and here, and here
and published articles such as this one published yesterday: Measures of Obesity and Cardiovascular Risk Among Men and Women from the American College of Cardiology that concludes:

This study adds to extensive prior findings, which associate adiposity, in particular abdominal adiposity, with increased risk for CVD

On the same day as news feeds such as CBS and the Times included Why elderly joggers just keep on running.The conclusions included:

California Couch potatoes might not like to hear it, but running regularly has long-term health benefits that last well into old age, according to a study.

Elderly joggers remained fit and active for longer than non-runners and were half as likely to die early, scientists at the University of California at Stanford found. They were also less likely to succumb to age-related illnesses, including heart disease, cancer and neurological disorders.

It's a complex world and making sense of all of this "information" is a significant challenge for everyone, users, patients and professionals alike. The key to helping sort through this data is providing ready access to latest validated research and pushing this data into the consciousness of the users and clinical professionals. Pushing means we need to comprehend the clinical findings, signs, symptoms and tie them back to our clinical databases. This will link the knowledge and information in these clinical databases and push out supporting information to the decision makers which includes the clinical professionals as well as patients themselves. Capturing clinical information as data is one of the first steps in this process - entering it as items on digital forms is one way but that process can be laborious and time consuming so providing alternatives that match current processes is helpful. Dictation of clinical documentation is a prime example that needs to update the way it captures this data and how we achieve this should reflect this growing need for data not text.

As we think about the future of documentation, the data content locked in our traditional documents must be set free to help our healthcare providers and patients start to make sense of the conflicting information feeding in to our clinical decision making

Oh..... and for what it's worth; exercise good and obesity bad.