Thursday, April 30, 2009

Information Overload: Don't over-encourage national interoperability

I posted on this subject at HIS Talk Blog (link), and thought I'd expand some more. Basically, I was saying that while many are crying out for national interoperability so that we can have ALL THE DATA, ALL THE TIME on ALL THE PATIENTS... I am asking for a reasonable minute to think about what that might actually mean for real world docs. In other words, interoperability is important (particularly locally), and we need to spend some time on it, but we currently are obsessed with it in an unhealthy way - and we need to rethink our priorities (e.g. make EMRs more usable, cheaper, faster...).

Specifically- most care is (or should be) delivered via a relationship with a primary care doctor and their network of doctors and hospitals. We want an EMR system that connects all those folks ideally, but we could be overwhelmed by a system that connected us with every single piece of data that happens with the patient across the world.

Of course, we can certainly play the anectdote game of "a complex patient was visiting Florida and fainted and because the other hospital had access to all her data, they were able to do the work up quicker, better, cheaper..." - but let's review why this is an interesting story, but not a fact that should drive too much of our resources:

1. That situation simply does not happen in the vast majority of care delivered... most healthcare is local. Yes, people travel and need medical care- but we should not be focusing our energies and monies on just that particular situation. Rather, let's put that energy and money into the 99% of time where healthcare is an outpatient and their primary physicians and their primary hospital.

2. Even when it does happen, doctors are resistant to going onto another system to look for more data. There is the problem of "data overload", AND they usually want to recheck everything anyway - they often don't trust what "another institution says"... especially if they can get reimbursed to check tests again. In other words, change the reimbursement system to favor a shared culture first, then start offering the technology to make it happen.

3. We have other options... when this situation does happen to a patient of mine, I can usually call that Florida ER and tell the attending all they need to know in a 3 minute phone call and maybe fax them some key documents. OR - the patient can just keep a card in their wallet with all the pertinent info... that's cheap interoperability that is always available!

So if we want to talk about interfaces and interoperability, let's keep the eye on the ball - start with local systems first... worry about national systems later... and use the extra time and resources you've saved (government especially) to help make EMRs more usable - because sharing data is meaningless if we don't get good data into the system in the first place.

Wednesday, April 29, 2009

Meaningful Use Committee meetings

Hearing on "Meaninful Use" of Health Information Technology
April 28 - 29, 2009

This is really an important time for EMR vendors and users... starting to define "Meaningful Use" - there will be immediate implications for the HITECH bill, but even more resounding implications for the future of EMRs in so many ways. My fear is that they focus on adoption of certain technologies and workflows (e.g. "Physicians must personally use electronic prescribing"). My hope is they focus on realistic outcomes (e.g. risk adjusted ER visits, hospitalizations, and specialty visits; and/or standard metrics like preventive care guidelines, lab results, etc...).

I don't think we need to mandate physicians directly using EMRs, we need to reward effective use of systems that improve quality in whatever manner works. This will invariably mean use of IT, but it can be in many different ways. Keep the eye on the outcomes, not the means...

Sunday, April 19, 2009

Improving EMRs: Usability, Usability, Usability

I've been working on physician adoption of EMRs my whole career, sticking to the mantra that "there are no benefits without use". And I've been fortunate in the past few months to be able to focus some extra time on this topic as part of a project on "The Future EMR" sponsored by the Szollosi Healthcare Innovation Program (

I think this topic of Physician Adoption of EMRs is particularly relevent due to the recent Health Information Technology for Economic and Clinical Health Act (HITECH) bill for funding "meaningful use" of EMRs in an environment which has not yet seen much adoption, as evidenced by a Fall, 2008 NEJM article which found just 4% of US doctors using a "fully functional" EMR in the outpatient environment, and only 15% using a "basic one" (NEJM, July, 2008: Electronic Health Records in Ambulatory Care — A National Survey of Physicians).

So while adoption has many mothers, I'm going to suggest we are wise to focus on the "Three I's" to understand how to improve adoption:

(1) Interoperability: What a bugaboo. While many say that we don't have enough, I'd actually argue that we are so obsessed with this issue that we are losing the forest for the trees. In other words, let's get doctors using systems first, and worry about interoperability later. I realize that is a bit heretical, but the truth is that the majority of healthcare is local - and what we really care about is making sure that our EMR interfaces with our local PM system, lab, Xray facility, etc... rather than worrying about some regional or national sharing. The latter is still important, and there are always great anectdotes about having access to an ECG when on vacation, but let's start shifting some of the interoperability obsession to usability obsession (which I understand CCHIT is doing - and I approve!). Meanwhile - tell your patients (at least the sick ones) to keep a piece of paper in their wallet with: allergies, meds, problems, the names of their doctors and perhaps a copy of their ECG. I guarantee that one of the first thing paramedics do is go through someone's wallet or purse to look for this type of info.

(2) Incentives: No surprises here - we all know a system gets what it is designed to get, and right now, our healthcare system reimburses based on volume over value, and quantity over quality... and the former is pretty much what it gets. So clearly we need to create a reimbursement system that rewards physicians for value and quality... and if they achieve these things, they should get those rewards whether they use EMRs or not (but I suspect it will be easier to do this with EMRs than without). I think the HITECH bill is a positive step and truly a "stimulus", but we still need to figure out how to improve long term, day to day reimbursement to make sure doctors are rewarded for doing the right thing.

(3) Interface ("User interface" or "Usability"): This third point has always held great interest for me, since I have often had to use the systems I build. So I feel the pain when it takes 25 clicks to refill a med because EMR vendors still don't seem to understand that for me to refill a med, there is a ton of contextual data needed. For example, I need to know: what I was thinking at the last appointment (e.g. did I tell the patient to return in 3 months, and it has now been 5 months without a return), do they have an upcoming appointment, did the labs from the last visit alter my thinking on their follow-up, or has anything happened in the interval. In a typical EMR, I need to click all over the place to find this information - how come it can't just bring it all to me (answer- technically it is possible, but the EMR vendors just don't seem to get it).

This idea that the EMR needs to pull together and present "what we need to know and what we can do" is a recurring theme in my diatribe on Usability - the screen shots for specific workflows (e.g. med refill, lab review, phone message, office visit) should consolidate all the information I would likely need to review to complete that workflow (e.g. meds, labs, visit dates, notes) - ideally in a manner that is easy and quick to read: "Data visualization" may include graphics or other data manipulation (e.g. calculate the anion gap, or the Total/HDL values for me). Furthermore, the EMR should predict what I might want to do next and offer up those options to me (e.g. refill a med, order another potassium test, etc...). The result is LESS CLICKS - I don't need to go looking everywhere for data or orders- the EMR has brought them to me!!!

I talked in depth on this topic at the recent HIMSS conference and hired several graphic designers to actually build out some of these concepts as either screen shots or flash animation - these are by no means perfect, but they give some sense of interfaces that take advantage of how an EMR can make workflows easier. They will hopefully stimulate more thought and ideas in this area. The PPT below provides a summary of this talk (although I could not figure out how to upload the flash applications - so it will all be static screen shot here). I used SlideShare to upload the PPT and embed into Blogger:
Post-Blog stories of interest
Wired magazine "re-imagines" lab reports:

The Change Doctor

This is my blog with a catchy name (I hope). I'm a creature of change, but really do strive to focus on change for the better over change just for itself... still, sometimes, just gotta try something once to see if it alters your thinking. For example, I got the iPhone last year... Not the best phone in the world... but wow, it's a great device. It's a computer in my hands, but more, and it has changed my thinking in a lot of ways. I sometimes find myself reaching up to touch the screen on my regular computers - damn you iPhone!