EHR Initiative - Is it a Monkey on the Back

In an interesting post by Evan Steele in his EMR Straight Talk blog: "Government EHR Teetering on the Backs of Physicians" talked about the recent HIT Policy committee response to the CMS proposed Meaningful Use regulations and the disconnect between the regulatory requirements and the practicalities of introducing these technologies into the complex clinical environment.

All this was nicely summarized in this graphic

As Evan points out

The government continues to ignore the fundamental problem that has discouraged EHR adoption in the past, particularly for high-volume, community-based specialists—and that is the EHR products themselves. The government has created an unstable program, basing it on unproven, difficult-to-use, traditional EHRs, and then has imposed additional layers of complexity on top of these products.

Demanding direct data entry by the provider into a Computerized Physician Order Entry System (CPOE) is a sure fire way to limit adoption. Did we learn nothing from the Cedars-Sinai failed CPOE implementation back in 2003

Cedars-Sinai failed despite having a very strong track record and deep experience in informatics, strong leadership, and substantial resources. There were several reasons for this failure: many decision-support mechanisms were introduced at the outset, especially for drug-drug interactions; with the way the application was set up, alerts could not be overridden; and it was hard to achieve buy-in from the very large number of providers using the system (Ornstein C. Hospital heeds doctors, suspends use of software: Cedars-Sinai physicians entered prescriptions and other orders in it, but called it unsafe. Los Angeles Times, January 22, 2003: B1)

So despite deep experience they failed and had to suspend use of the system. Meanwhile we see the government meaningful use objectives mandate CPOE from the start. The impact on physicians is likely to be negative and the impact on the vendors and their products will likely create more challenges:

First, EHR vendors will have to rush to modify their products to meet HHS certification requirements, resulting in even more cumbersome EHR products. Then, over the next five years, they will have to constantly hustle to keep up with the continuously evolving meaningful use criteria, as well as implementing the Y2K-like conversion from ICD-9 to ICD-10. In the technology world, rushing development efforts to meet unrealistically aggressive timeframes typically results in unusable and clumsy software. Unfortunately for physicians, the government will expect them to use these more complex EHRs to meet onerous meaningful use requirements that become increasingly stringent from 2011 to 2013 and 2015.

Building on existing processes and systems and in particular clinical practice that collects information as a natural part of the clinical interaction with patients would seem to be a much more constructive approach that would garner support all round. The narrative has been the mainstay of clinical practice and to date the most efficient way of capturing that narrative has been dictation. Facilitating and including the narrative dictation and building on it to satisfy the data needs of EHR's and even CPOE systems is the bridge between these two opposing views and the Healthstory Initiative creates an open and widely accepted infrastructure of standardized implementation guides for the common note types. The project members have been submitting commentary on the Meaningful use specifications and continue to push for the inclusion of narrative in the specifications.

EHR's should be in our future but on terms we can accept and will work in the complex and demanding clinical environment - that requires inclusion of narrative in meaningful use and sensible standards that focus on flexibility and adaptability of technology to meet the needs of clinicians.

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?

Ready or Not Electronic Health Records are Coming

The games afoot or as they say in England "Game on".....healthcare standards are published (actually the Notice of Proposed Rule Making NPRM - which can be found here) and supplemented by an article posted by David Blumenthal "Launching HITECH" posted by the New England Journal of Medicine.

As before there are multiple stages that include incentives linked to each of the stages but if we focus on Stage 1 that starts in 2011. This includes electronically capturing health information, clinical decision support for disease and medication management, clinical quality measures all tied with protection and securing of the information (don't forget liability for security breaches is now much further reaching). The investment is made (numbers vary but range from $14 - 27 Billion). To receive incentives providers must use their electronic medical records to improve the overall quality of healthcare delivered by demonstrating achievement of a series of objectives. These include (this is not an exhaustive list but captures the main elements):

• Entering orders, medications etc in CPOE
• Maintaining problem lists in ICD9-CM or Snomed-CT coding
• Maintain active medication list and electronic prescribing
• Recording vital signs, smoking status
• Receive and display lab results encoded with LOINC codes
• Generate patient lists based on specific conditions and generate patient reminders
• Provide patients with electronic copy and electronic access to their record and discharge instructions
• Generate a clinical summary for each visit
• Exchange clinical data with other providers
• Protect the information, encrypt it and record disclosures

There are others but these are broad categories and groups and represent a major push to genuine electronic medical records that are digital, contain useful data and are shareable between systems. Certification (as currently provided by CCHIT based on their existing criteria and what we know to date about the requirements for meaningful use) has 11 products certified for 2011 - list here. This is a work in progress and expect to see many more and probably other certification bodies.

The overall tenet of this initiative is summarized by Dr Blumenthal in his article:

...so as to reward the meaningful use of qualified, certified EHRs — an innovative and powerful concept. By focusing on the effective use of EHRs with certain capabilities, the HITECH Act makes clear that the adoption of records is not a sufficient purpose: it is the use of EHRs to achieve health and efficiency goals that matters.

There are other strands/programs that are designed to address the obstacles to adoption - summarized in this chart from the NEJM article:




Behind the scenes the health information exchanges that allow for the easy sharing of clinical data between systems, clinical users and patients will be essential.

This is a broad set of criteria and for many clinical practices a long way from where they are now. The shape of this program is clear - sign up and participate now and receive additional funding/payment or wait and be punished later if you do not implement. There remain many challenges not least of all the products and expertise required to roll these technologies out but to me the message is clear - this train is leaving and failing to get on board will will cost you more in the future.

In the first instance we have an opportunity top provide input to the NPRM - the link for this can be found on the main page of the HHS HealthIT page here or the actual system here. Have you managed to wade through the 600+ pages or found a great summary of the content highlighting key aspects - share the knowledge, leave a comment with your thoughts and/or links and help everyone get up to speed with this material and provide input to the rule by the end of February 2010.

HIT as a Catalyst to Healthcare Improvement

The Center for American Progress - a think tank group dedicated to improving the US through policy and innovation) published a report: "A Historic Opportunity - Wedding the Health Information Technology to Care Delivery Innovation and Provider Payment Reform". You can download the executive summery here (pdf) or the full report here (pdf)

They make the point tat the American Recovery and Reinvestment Act’s HITECH $19 billion investment is not just about technology. In fact if this is the way the program is actioned:

failure is effectively guaranteed if the HITECH program embraces technology adoption for the sake of adoption. But if this new health IT investment program is wedded to a strong commitment to provider payment reform in forthcoming health care reform legislation and implemented specifically as an accelerator of health care delivery innovation and payment reform, then the investment program can help transform U.S. health care as we know it.

We know technology can contribute significantly to our lives. Everything from basic tools in our homes from cell phones to computer access that replaces the limited access to the Encyclopedia Britannica that we had some years back based on the sale to individual homes. This has been replaced for school children and households with access online to all this information in an instant.

Technology has had similar extended effects in healthcare that have seen revolutions in the diagnosis and treatment that previously were unimagined. But technology alone will not solve the underlying problems of our healthcare system and in the US we must change the payment model that currently incentivises everyone int he system to "do more". The system rewards for volume of service delivered and this is the underlying challenge faced by clinicians and facilities that continue to strive to maintain income when presented with the decreasing reimbursement per unit are forced to increase volume. This leads to the current circumstance where a consultation and patient interaction must be limited to minutes if the number of patients to be seen is to increase and the income stream to be maintained.

But seeing more patients for less time does not help manage chronic conditions, allow for a focus on prevention and chronic condition management that demands time and attention to detail. So as they suggest health care reform should include:

• Proactive improvements in individual and population health status
• Collaboration among health care providers necessary to accomplish these improvements
• Achievement of efficiencies in care, such as the elimination of duplicate services, avoidable hospital readmissions, and unnecessary in-person visits

and should also include a change in the documentation and in particular coding requirements. As they rightly point out the current system of coding

so called evaluation-and-management, or E&M, coding of office visits—which drives extraordinary complexity into clinical documentation and EHR workflow—could be replaced by payment-and-documentation standards that are simpler and more focused on what is actually valuable for patient care.

The much used term "meaningful use" comes up again and the suggestion that this be focused on Health IT that actually helps improve care and accelerate payment reform. IN fact the suggestions include:

• Tracking key patient-level clinical information in order to give health care providers clear visibility into the health status of their patient populations
• Applying clinical decision support designed by health care providers to help improve adherence to evidence-based best practices
• Executing electronic health care transactions (prescriptions, receipt of drug formulary information, eligibility checking, lab results, basic patient summary data exchange) with key stakeholders
• Reporting a focused set of meaningful care outcomes and evidence-based process metrics (for example, the percentage of patients with hypertension whose blood pressure is under control), which will be required by virtually any conceivable new value-based payment regimes.

And in each of these is the implied requirement to capture this information at the point of care which has been a significant challenge to date. I've said it before and I'll say it again - turning our clinicians into data entry clerks does not make sense. Whatever systems are put in place must allow for the capture of this information in way that does not interfere with the patient/clinicians interaction and includes the ability to capture the detail and the data to drive these activities of tracking, clinical decision support and evidence based metrics. There does not seem to be many technologies that can fulfill this at the time of care delivery and one that shines out constantly is that of speech and in particular speech understanding that is able to understand the meaning and generate meaningful clinical documents that can be used in these clinical systems to help deliver this higher quality care.

To this commentator, speech technology and in particular speech understanding must be a fundamental component of the success of healthcare IT as part of the HITECH investment act. What do you think - are we there yet?