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":

Medical Transcription the EMR and Speech Understanding

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

...medical transcription offers a bridge to EMR adoption

But the idea that

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

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

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

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

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

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

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

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

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

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

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

A Facebook Medical Record

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

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

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

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

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

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

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

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

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

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

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

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

Doctors in the Typing Pool

An interesting blog from Westby Fisher on the failures of EMR systems that what it has turned our clinical staff into:

"...the world's most expensive typing pool has been born"

As he notes

Each morning, without fail, there's one or two individuals circling the computer terminals waiting for access to these electronic monetary portals, like children waiting to grab the last chair when the music stops.

That's true but I think the missing comparison here is how it used to be before the advent of the EMR's.....I can remember the same scene on the wards I worked on but instead of waiting for a seat in front of a computer it was waiting to get access to the "notes trolley" and the wait and frustration was no different and in many respects worse since there was only one record and therefore only one person could access it and enter data into the record. Much of this could be fixed with more accessibility, more computers or even better mobile access to the clinical data (here's one example combining the latest user friendly gadget with EMR access - you can see a video of this in action here:

But the issue of canned content being generated in large quantities with shortcut codes and pulling information from other sources to create a document is a problem. To create my note I can type
.id .pmh .psh .cmed .all .soc ....... you get the picture. These commands pulling data from other sources that add little to the actual clincal value of the document:

....demographics from the Central Registration.....four pages of Past Medical History...the original work was completed by the patient's poor primary care physician, neatly organized, but never to be updated again

.......page and a half of the current medications, their dose, prescribing physician, half of which come from self-generated 'CYA' hypoglycemia orders are also self-generated in the interest of 'safety'.....

......."Mother died of CA" automatically spits out previously entered by the hospitalist - bless their soul - so that billing to Medicare can go from Level 4 to Level 5 for the rest of the health care team

When clinical documentation really was clinical documentation and not just an automatic regurgitation of previous clinical notes captured by other people, the process of documenting was part of the clinicians analytical process. Entering the details was important as it afforded an opportunity to think about the patient, their history, symptoms, and signs and provided real input to the diagnostic process to arrive at a differential diagnosis and plan for the next steps. Clinicians are still trying to do this but all the while working to satisfy the documentation requirements so they can bill for their services

The rest is for Medicare and has been added repetitively and
identically by countless other individuals, all whom enter the same
content to assure achieving the maximum amount billed by law for their
services. Not that any of it is read, mind you, but it'd better be
there, lest the Medicare auditors descend on your facility.

Technology has helped kill the richness and detail of clinical documents and turned detail rich
reports into dumbed down "fill in the blank" cookie cutter reports that do not
reflect the richness of the information that physicians wants to provide to the colleagues.

In a recent discussion with a busy radiologists he remarked that what the referring physician needs from him is "more detail". He wants to provide the referring physician
the clinical information they need to treat the patient giving them the confidence in the information they receive with a rich detailed report that speaks their language.

So as not to reach the destination for the future of medicine painted by Westby Fisher:

Will they (future doctors) actually process what is entered, or merely become
highly-efficient typists and plagiarists in the never-ending quest to
become more "efficient" health care providers?

we must provide the tools that allow for clinicians to document clinical information efficiently with the richness of medical language while still providing the computers and clinical systems with their bits and bytes of data that allows these tools to function and help support the clinicians in the delivery of clinical cared

Wired - Why Things Suck

Wired's magazine article earlier this year titled: The 33 Things that Make us Crazy
featured a section on Medical records

The review was spot on:

Most medical records are about as orderly as an ER on Saturday night. Because they're mainly confined to paper, they can't be easily transferred from one physician or hospital to another. And because they're not subject to any standards (or even legibility requirements), they're nearly impossible to compare and combine.

Harsh but true.....and the ongoing problem of getting everyone to cooperate and share information which is int he best interest of the patient but not necessarily in the best interest og the hospital, healthcare provider or even insurance company:

..because the software vendors selling electronic record-keeping systems are competing, their systems are proprietary and incompatible. Oddly, that's OK with many physicians. Another name for an all-knowing, all-seeing, all-compatible electronic system is database, and physicians don't want people mining theirs — not because of patient-privacy concerns, but because the info could be used for doctor-on-doctor performance stats. Plus, docs already hate filling out charts; you think they want to learn data entry?

The potential cure cited is the arrival of Microsoft and Google as knight's in shining armour - not sure I buy this but I do believe that the entry of large organizations intent on shaking things up is going to have a positive impact. But the key point of advice:

Pressure your docs into accepting a more transparent system.

Agreed - interoperability and the sharing of data is essential. We have been sharing information since the beginning of time. Before the advent of writing, stories were shared, drawings made on walls and information was shared round a camp fire. When new more reliable media arrived (the pen and paper) information sharing moved to this media. Now we have digital media and bits and bytes and we need to wean the industry off its dependence on paper which is no longer effective and start sharing information using standardized compatible formats that everyone can use.

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)

Privacy of Information

There's a fun video posted to the ACLU web site - it is worth watching as it raises some legitimate issues on the privacy of information and the consequences of the sharing and linking of that information. You can watch the video here

What is interesting about this video is how close we are already to this reality. Many private companies can already link existing public sources of data to create an extensive and fairly detailed profile of individuals, their buying habits, preferences etc. You only have to visit your local Jiffy Lube to see how quickly they can pull up all the details on your car and based on this offer the best "treatments" for the "health" of your car! In this case best is probably as much about your car as it is for selling you additional services. In the case of you supermarket shopping card this tracks your purchases in excruciating detail and there have been many instances of this data being used against the individual. In this particular instance it turns out the data used while correct proved to be a red herring and in the words of Bruce Schneier:

The moral of this story is that even the most innocent database can be used against a person in a criminal investigation turning their lives completely upside down.

Clearly today we already see data usage beyond what might be expected, and many would say beyond reasonable limits. But at the same time I think most patients would agree that any visit to a medical office is an extremely frustrating experience. Such visits require patient's to hand write all their data onto a paper form. Data that already exists in many other systems and often in the very system that it is destined to be entered into.

So where is the balance - I believe unfortunately that as Lord Acton said:

Power tends to corrupt, and absolute power corrupts absolutely. Great men are almost always bad men

I also firmly believe that the sharing of information is essential to the delivery of high quality care. So while it is clear to me that ready access to the complete medical record is the most helpful to clinicians there has to be some limitations to accessibility.

So how do we balance the need to share relevant medical information with the concern that the sharing of that information could be used against you. The answer is unclear and the issue complex but several groups are working towards this goal, trying to balance the need for information with the need to protect everyone from the inevitable abuse that comes with total access and power.

Some of the EMR companies have a "Break the Glass" approach to urgent access - providing emergency access to anyone with a corresponding oversight in all cases where they felt the need to break the glass and access all the patient's data. The Voluntary Universal Healthcare Identifier (VUHID) group has taken a slightly different approach by creating a voluntary identifier which allows the individual to control and manage access to their clinical information on an ongoing basis:

.....to enable error-free linkage of clinical information,
enhance the privacy of patient information, improve the quality of
medical care, reduce the rate of medical errors, decrease the incidence of healthcare-related identity theft, and help control healthcare costs.

There are others solutions and ideas and no doubt there will be more added as the systems and ideas develop - whatever we end up with it is clear this is complex area and will require continued debate, careful consideration and ongoing participation by all parties from the vendor community, through government all the way to the individual to ensure we come out with a solution that everyone can live with

EMR Adoption in Small Practices

Why all the resistance and difficulty in getting EMR's adopted and in use across the board. Why is there not a queue along the street as there was for the Apple iPhone v1 and v2?

Is it the usability, the coolness, price point, ROI, design and features, overall complexity or just basic lack of time that prevents the adoption and take up of this technology.

In a recent posting on Mr HISTalk Jonathan Bush started a discussion on why getting small groups to use EMR's. The spirited discussion highlights some interestiung points including one of the reasons not to need an electronic medical record - in the words of one physician:

All I have to do is ask and someone will get me the information

It is hard to imagine a more frustrating experience for a patient let alone a doctor being asked the same question over and over again. Not to mention the implication that the physician has the time, full recall and insight into the patient's condition and possible risk factors to ask all the relevant and necessary questions to reach an accurate diagnosis. With the explosion of clinical data this seems an increasingly unlikely proposition. Far better to have the technology help guide that process, capture and store that information so that it can be reviewed quickly prior to and during the patient interaction. I am reasonably confident that I can review a chart (digital or otherwise) and garner more relevant clinical information in a shorter period of time than going through a question and answer session with a patient. I can pretty much guarantee that this is true if the information is presented in a consistent, structured format.

Cost pressures and the cost of implementing tied to the suitability seems more likey to create a barrier to suucessful adotpion. An attitude of:

We’ll take care of the aggravating stuff

Is more likely to engender success. Perhaps not lines down the street but certainly decrease resistance and increase the desire to use technology to help. There's a reason why we have appliances dotted around our house - most are there to make our lives easier. Some are those poor choice impulse buys that remain on the shelf but all the others do make life easier.

There is another big driver looming - the desire of individuals to have access to all their personal health records:

Consumers want access to their info online, hence PHR

There are those who consider this unimportant and even undesirable and there remains resistance to this concept of personalized
healthcare with
concerns ranging from confidentiality of information to patient’s inability to
understand complex medical diseases and the fear that a patient’s record may
become contaminated by inaccurate medical information if we allow patients to
enter and interact with their own medical record.

I fall clearly on the side of patient empowerment and providing more information and like many other areas I believe consumers want more access and more information. As Regina E. Herzlinger, the author of “Who Killed
Healthcare?” stated in a recent presentation that consumer driven healthcare with improved
access to information will follow the same course as we have seen with cars and
personal computer (PC). Consumers don’t need or even want to know all the
workings of a car or PC but ready access to performance, quality comparisons
and details on cars and PC's allows for intelligent choices and overall improvement of quality
and decrease in price by market pressures brought to bear by the informed
consumer. Healthcare needs to follow the same course and it is the consumer
that will be a key driver of this march towards electronic medical records, easier access and sharing of information and the resulting higher quality care

Getting Technology that Actually Works in Healthcare

There is a article in the fox news site titled: Let's See Gadgets That Actually Work which talks about the frustrations of twenty years of dealing with technology and the fact we are still "fussing" with it.

My own experiences are best represented by one of my favorite people who remains firmly in the camp of "technology needs to be simple to use and does what I need it to do"...

A lot of this has to do with the simple fact that I don't enjoy playing
with machines. I just want them to do what I need them to do with
minimum fuss.

Much of this has to do with a disconnect between designers and users....Motorola had a break out product when they made these two groups the same in designing the original Razr. They gave their engineers carte blanch to build a phone to specifications they would want as users; the result was the Razr which was a smash hit and redefined mobile phones for many.

In a recent thread discussion on the AMDIS listserv one of the participants asked for help in preparing a presentation: "Can IT actually improve medicine without killing the physicians". One of the insightful responses made this exact point:

IT folks tend to work physically isolated from clinicians, but physically proximate to one another, where they reinforce each others' views (and misconceptions).

Exactly! The author suggested that one of the ways to combat this is bring IT folks into your practice, force them to be there during busy working periods and to experience everything you experience from the failures and successes of the technology you deal with. I couldn't agree more...and have made this very point in every company I have ever worked in. Engineers, designers, coders, product managers, and others needs to immerse themselves in the working clinical environment..... maybe instead of bring a child to work day we should have bring an engineer to work day!

At the end of the day - to use Jonathan Weber's words

I just want tools that work. And in that, I don't think I'm alone

I think he's right and this is true in healthcare with some variations in tolerance for the failure and difficulties in using the technology represented by the typical adoption curve




For technology to be successful and rapidly adopted we have to appeal to the larger cohort of users in the tail of the chart. That's the "early and late majority" and that boils down to ease of use and the functionality the tools offer. If the tool makes a clinicians life easier, speeds up a process or reduces the time to carry out a process or procedure then adoption will be faster....

So how about it..... bring an engineer or programmer to work with you next week. However just for the record I disagree with Jonathan on the iPhone. It is cool, it is useful and it is functional but as always YMMV

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.

The Medical Transcriptionist - Knowledge Based Workers Setting Clinical Data Free

Sitting in the Medical Transcription Industry Association Board meeting recently the group spent some time discussing the future of the industry and the changes we need to demonstrate the key value that our members and their organizations bring to the healthcare setting.

The Medical Transcription Industry is transforming and will become increasingly important to the successful implementation of electronic medical records to meet the burgeoning need for better more cost effective healthcare.

Clinical information is critical to the systems that are necessary to support our increasingly complex healthcare delivery. Clinical information comes from the patient via the clinician, the vast majority of whom are dictating that information for a medical transcriptionist to transcribe. Years ago this was done with tapes or even wax drums and type writers..... we have moved on from this paper based communication to digital information and sharing of data like every other part of society as detailed in a report The Digital Workplace and the Information Worker:

...the nurse who enters patients' vital signs into a patient-tracking system on a wireless PDA
...the pilot who uses a laptop to download flight manuals and who calculates flight plans based on weight and balance inputs

and in our personal lives as well.... I am sure many can relate to my experiences with my own 81 year old mother who is digitally connected despite distance and time to me and my family. I am grateful to receive regular e-mails and text messages and we both know what is going on in each others lives and schedule. This connection has morphed from traditional (snail) mail and letters, through telephone calls, faxes into full digital connectivity and near instantaneous updates.

Medical Transcription and the medical transcriptionist have moved on too and the transcriptionist, like everyone else, has become a knowledge based worker and increasingly applies technology to assist in producing accurate, timely clinical documents. And it is this production of documents that remains a barrier to the growth. 60% of the current inputs to the EMR are clinical documents that have been dictated and transcribed. It is hard given the length of time we have depended on documents and in particular paper to leave that paradigm behind but to grow into the value added profession that clinical documentation specialists/medical editor/medical transcriptionist needs to become, it is imperative to move away from two dimensional documents and start to think about clinical data that has been locked away in these documents and needs to be set free.

Those in the profession already know the extensive clinical knowledge stored by those in the industry. This was brought home to me some years ago when I discovered that a favorite past time amongst transcriptionist's was to guess the final diagnosis for the patient as they transcribed a dictation - before reaching that point in the dictation. That's a tremendous amount of clinical knowledge available to be applied and will make this transition to knowledge based worker a breeze!

And the technology is heading that way too - documents are so version 1.0. Structured encoded clinical data in semantically interoperable form is available today in the HL7 Clinical Document Architecture and the CDA4CDT format is available and implementable and brings the value of structured clinical data moving away from v1.0 documents to v2.0 clinical data container (I don't like this term either but I'd be interested in suggestions for another term that doesn't use "document" and captures the idea of data and knowledge)

We are all knowledge based workers. Knowledge and in particular clinical data is one of the key ingredients necessary to help automate clinical care and provide safer more cost effective care. Dictated documents contain clinical data and knowledge that is locked in a proprietary format that is human readable but not machine readable. Clinical documentation specialists/medical editor/medical transcriptionist provide the key to unlocking this data and placing that data into a CDA computer readable format.

Medical Transcription Knowledge Based Workers - Increasing Demand

A working from Home blog "Undress4Success - Work From Home" posted an interesting article on the Medical Transcription industry and the increased demand for Medical Transcriptionists

.... (Overseas) rates are going up too, particularly in India, because they’ve realized that they can demand higher prices thanks to growing need and scarce availability of experienced MTs

The author is right on target - Medical Editors are going to be in high demand. They are and will become key knowledge workers in healthcare. As Tom Harnish says in the blog

...qualified medical transcriptionists (MTs) are in short supply

Good news for those who fear the flatening of the world and the application of technology. Speech recogntion will improve the productivity by automating the rote task of converting the spoken word into text:

The (speech recognition) technology may increase costs by 15% to 20%, but it can increase output 100% to 200% according to one MTSO owner

But to add even more value to this process knowledge based workers will need to do more than just listen to the audio and convert this into text (either by pure typing or editing/proofing a draft output from a speech recognition engine). Adding clinical data that is machine readable and semantically interoperable between all the clinical systems being implemented in our healthcare system will become a must. That process is mostly manual and much information is lost in the avalanche of text based documents that contain the information but only in human readable form. Knowledge based workers will need to provide data elements and structure to these documents turning them into data that can be fed into clinical systems.

CDA4CDT provides an ideal common environment that is designed to flexibly cope with the varied levels of data encoding but still provide the healthcare system with the text based document that can be printed and used as it is currently. But the additional information incorporated into this file allows for semantic interoperability and data exchange at a level that EMRs want and need turning the huge volume of clinical text documents into clinical data inputs to the medical record that can be shared and exchanged between systems

Medical Editors can provide this manually by tagging documents and encoding using the CDA4CDT standard or by using speech understanding technology. Speech understadning outputs a document that is tagged and structured with clinical data. This merges the role of medical editor with a true knoweldge based fuctnion of reviewing and correcting clincal data embedded in the file and clinical document.

Medical Editors are knowledge based workers and are in short supply......

Only 14% of Doctors Using an EMR

The July 2008 For the Record newsletter contained an interesting article that reaffirms the lack of penetration of EMRs in healthcare today

Electronic health records seem so intuitive. Most of us assume our medical records are digitized to save time and help doctors track patients’ medical history. Americans would probably be surprised that a mere 14% of doctors in the United States use electronic medical records (EMRs)

In this particular instance the point is brought home in relation to the daughter of the Queens who was diagnosed with a rare condition DiGeorge syndrome that requires multiple visits and complex treatments. It is true that this example is at the higher end of complexity and requires many more medical interactions and participation but we will all experience some level of medical interaction that will certainly not be getting simpler or less detailed. Medicine continues to innovate at an ever increasing pace and customized drugs therapy and treatments and personalized medicine is within sight. So the problems this family faced which included

....when a procedure was delayed for more than fours hours, while doctors and nurses waited for Courtney’s lengthy file to arrive from another hospital floor. Finally, the records arrived when an aide brought the soaring stack of papers and manila folders on a wheelchair

Will be our problems now and in the future as well. We can look to other countries for their experiences and perhaps even be a little envious as the article cites:

• 90% of doctors in Sweden
• 60% in the United Kingdom

Although the United Kingdom's experiences is not without its own set of challenges and problems and there are those in the US that would question the value derived from such implementations, in general, clinicians and the health care community is agreed - we need to implement electronic medical records for everyone and allow this information to be shared. There is and will continue to be discussion and disagreement on what should be shared, who can see the information and even how it is shared but sharing medical knowledge effectively and efficiently is highly desirable.

Even the technology press is getting in on the commentary with an article from ComputerWorld that makes the point that much of the lack of success in rolling out these systems boils down to the old adage

"Follow the Money"

But the biggest obstacle may be a payment model that offers little financial incentive for most health care providers to invest in using electronic records internally, let alone share them with other providers.

And John Halmka, the CIO for Harvard Medical School and Beth Israel Deaconess Medical Center is quoted as saying

"The provider bears the cost, but most of the benefits accrue to other parties," mainly "payers" -- insurance companies -- and patients who reap the benefits of higher-quality care

So while we wait for the government agencies to fix the incentive problem we need to show value in the implementation and improve the working environment for our clinicians. Taking a leaf out of Apple's play book might help given the impressive (recent stock slides aside) of Apple in the Music Player business (one they were not even in until 2001) and the more recent iPhone. They do come with faults, contrary to the pleadings of your average teenager everyone does not need an iPhone and lining up for hours or even days to get the latest model is not typical behavior. But with their attention to detail and focus on ease of use and intuitiveness I have to believe that with that same level of attention to detail and actually designing a solution that physicians want to use we could accelerate adoption. I'd bet that an EMR designed to be accessed using an iPhone would be a lot more attractive and receive wider uptake and participation by clinicians than one designed using older technology.

And the market is large:

....there are 921,904 physicians, 723,118 practices and 5,756 hospitals in the U.S., according to the American Medical Association and the American Hospital Association.

But more importantly based on the US Census population clock there are around 304 Million customers and the numbers increasing....so perhaps the key driver as Grannis suggests will be Personal Health Records

....efforts by Microsoft Corp., Google Inc. and others to build personal health record repositories...... will put pressure on the industry to embrace EMRs

I know Courtney Queen and her parents are grateful for some level of EMR's in the "Vandy Zone" but I am willing to bet that everyone would benefit. 304 million people asking for electronic records and real sharing of their medical information rather than endlessly filling in the same information on paper forms has to carry some weight....

CMS Physician Quality Reporting Initiative - Breaking down the Resistance

CMS continues to push the Physician Quality Reporting Initiative (PQRI)
which represents the move towards quality measurement and comparison healthcare shopping for consumers. While there are many concerns related to the comparability of data and the different case loads and risks adversity fo different phsycians and thier patient load. But it is the burdensome overhead of collecting data

Participating in the program, established by a 2006 tax bill, will require time, resources and staff-something not all physician practices are willing or able to provide, industry experts say. As a result, the physicians that decline to participate in the CMS' Physician Quality Reporting Initiative will lose out on the 1.5% bonus payment the initiative pays.

That makes for interesting reading given the increasing number of factors to collect

2008 PQRI consists of 119 quality measures, including 2 structural measures. One structural measure conveys whether a professional has and uses electronic health records and the other electronic prescribing.

The measures include:

In Diabetics:

• Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes Mellitus
• Low Density Lipoprotein Control in Type 1 or 2 Diabetes Mellitus
• High Blood Pressure Control in Type 1 or 2 Diabetes Mellitus

In Cardiac Disease:

• Left Ventricular Systolic Dysfunction (LVSD) - placed on ACE
• Oral Antiplatelet Therapy Prescribed for Patients with Coronary Artery Disease
• Beta-blocker Therapy for Coronary Artery Disease Patients with Prior Myocardial Infarction (MI)
• Heart Failure: Beta-blocker Therapy for Left Ventricular Systolic Dysfunction

You can see the complete list here

Capturing this data can be a burden but imagine if you were able to extract this information using the standard clinical documentation practice of dictation. With the addition of speech understanding and extracting this information to a CDA4CDT document that contains the detailed human readable narrative but is linked to the extracted machine readable semantically interoperable clinically actionable data this point of resistance should diminish and capturing this data should become part of the normal clinical documentation process.

Speech Understanding will Bring More Information to the Doctor

Came across an interesting post by Steven F. Palter, MD from the docinthemachine blog. Specifically the blog he wrote on EMR=Clonewars

He notes that there is a hidden danger in EMRs of the inadvertant cloning of patients.

I don't think it is so much hidden or inadvertent - it's human nature and doctors are like everyone else - we always look for the path of least resistance. Copying from a previous note especially one using templates with a series of choices can be helpful.

But what he gets in his practice

..... is EMR records from other practices .... and the patients look identical.....Instead of all the details of a past treatment cycle it will list drug dose and failure with no detail of WHY it did not work. The diseases all look the same. There is never any detail on the nuances and subtle aspects of that individual’s condition. So when a group uses these records and they review a treatment every single person with the same disease (the “patient clones”) end up looking identical and treated identically. Cookie cutter assembly line medicine.

There's hope - Speech Understanding and in particular the use of CDA4CDT documents which make narrative notes interoperable with electronic medical records - bridging the divide between where we are today:

• More than 60% of clinical content produced, stored and locked in narrative documents

and where we want to get to

• Structured encoded information that is semantically interoperable and can be automatically processed and used by computer systems to help apply the best knowledge of healthcare diagnosis and treatments available today
  

What this means is a at the most basic level virtually any clinician can produce a minimal CDA document utilizing the simplest form of the structure which includes all important uniform metadata for all documents that allows them to be indexed, searched and the content integrated in a meaningful way into the EMR.

And at the high end, lab systems, pharmacy systems and EMR's can produce richly-structured, fully machine-processable CDA documents that remain human-readable as well as machine readable which will satisfy Steven's needs of :

the nuances and subtle aspects of that individual’s condition

So as Steve rightly points out quoting from AHIMA 2006 study:

....65 percent of chief information officers planned to get it (Speech Recognition) by 2008. It’s being touted as a natural add-on to the electronic medical record, since doctors are used to recording their notes, says Harry Rhodes, director of practice leadership for the American Health Information Management Association.

Voice can help solve the cloning of patients and the technology and the standard is available today.