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.

Cause and Effect - Unintended Consequences

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

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

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

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

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

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

Who would have thought it!

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

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

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

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

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

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

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

Transcription - 0
Dictation - 0
Narrative - 0

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

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

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

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

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

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

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

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

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.

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.

Meaningful Use - Getting the Full Story

There has been much activity relating to the term meaningful use cited in the health care reform proposals form the government that includes AMDIS that includes a new web site to encourage "meaningful" discussion (the website: http://meaningfuluse.org) and various others.

The Healthstory project is carrying the torch for the inclusion of narrative in a written response: Written Testimony Regarding “Meaningful Use” (Word document). Narrative and free expression has been under fire for some years as inefficient and requiring replacement with semantically interoperable information. But since the vast majority (by Gartners estimates 60%) of content is created using the traditional dictation and transcription methodology we fail to leverage this information by discounting it. Trying to force a behavior that is not natural and removes much of the value contained in the fine detail in our rich and expressive language is counter intuitive.

Meaningful use of the Certified Electronic Health Record (EHR) must encompass dictation for creation and exchange of standards-based clinical documentation. This comprehensive view of the EHR supports the immediate needs of front-line physicians and patients, is complementary with structured data, and lays the ground work for increasing EHR adoption and information reuse

Narrative documentation enhances clinical care and the use of free form narrative is essential to the delivery of high quality care ensuring that the care team get the full story and all the fine details necessary to contribute to high quality health care

The Healthstory format - CDA for CDT or Clinical Document Architecture for Common Document Types (CDA4CDT) uses HL7 Clinical Document Architecture (CDA) documents that are XML representations of familiar clinical documents designed for exchange, recognized by ISO, ANSI, NCVHS, CHI, HITSP, CCHIT.

Healthstory represents disruptive technology that has the greatest capacity to transform practice and deliver the benefits of standardization of dictated notes. This is an achievable step for providers that will inject massive amounts of important information into our fledgling networks, lower costs, and provide a clear pathway towards standardized computable data.

Get on board - join now and start insisting on getting the Full Story from your provider, hospital, vendor.....