tag:blogger.com,1999:blog-225399152024-03-06T14:01:37.579-06:00Change Doctor<b>Thoughts, anectdotes and experiences from a physician who enjoys change and innovation. </b>
<br> Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.comBlogger96125tag:blogger.com,1999:blog-22539915.post-44718449915589101132018-11-21T23:08:00.001-06:002018-11-21T23:08:14.590-06:00Viva la (Online) Primary Care! <span style="background-color: white; color: #2a2e2e; font-family: "Helvetica Neue", arial, sans-serif; font-size: 14px; white-space: pre-wrap;">Have been a PCP for 25 years, and am a big fan of Health Affairs.. but think they missed the mark on this recent article: </span><span style="color: #2a2e2e; font-family: Helvetica Neue, arial, sans-serif;"><span style="font-size: 14px; white-space: pre-wrap;"><a href="https://www.healthaffairs.org/do/10.1377/hblog20181115.163117/full/" target="_blank">No More Lip Service; It’s Time We Fixed Primary Care</a></span></span><br />
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<span style="background-color: white; color: #2a2e2e; font-family: "Helvetica Neue", arial, sans-serif; font-size: 14px; white-space: pre-wrap;">In this article, the authors argue for doubling down on our current Primary care system by "making more primary care docs" and "paying them more". Others arguments from the comment section are "let the NPs" do it. </span><span style="background-color: white; color: #2a2e2e; font-family: "Helvetica Neue", arial, sans-serif; font-size: 14px; white-space: pre-wrap;">Folks- that is like saying Blockbuster just needed to open some more stores to be a little closer to everyone! </span><br />
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<span style="background-color: white; color: #2a2e2e; font-family: "Helvetica Neue", arial, sans-serif; font-size: 14px; white-space: pre-wrap;">In other words, this argument is missing the forest for the trees...big time! As I've mentioned before, <a href="http://drlyle.blogspot.com/2013/01/we-dont-have-shortage-of-pcps-we-have.html" target="_blank">We don't have a shortage of PCPs, we just have a shortage of using them efficiently</a>. Every other industry has figured this out- online banking, shopping, travel, and media. Look at the <a href="https://www.statista.com/chart/9426/amazon-vs-retailers-market-capitalization/" target="_blank">market cap of Amazon</a> and Netflix vs. any brick and mortar company (hint <a href="https://www.cnbc.com/2018/09/06/22-major-retailers-worth-less-than-amazon-amzn-stock-valuation-trillion-market-cap-jeff-bezos-ecommerce-retail-sales.html" target="_blank">Amazon hit over $1 Trillion in 2018, making </a></span><span style="color: #2a2e2e; font-family: Helvetica Neue, arial, sans-serif;"><span style="font-size: 14px; white-space: pre-wrap;"><a href="https://www.cnbc.com/2018/09/06/22-major-retailers-worth-less-than-amazon-amzn-stock-valuation-trillion-market-cap-jeff-bezos-ecommerce-retail-sales.html" target="_blank">it worth more than 21 other major retailers, combined – from Walmart to Costco</a>)</span></span><br />
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<span style="background-color: white;"><span style="color: #2a2e2e; font-family: Helvetica Neue, arial, sans-serif;"><span style="font-size: 14px; white-space: pre-wrap;">The world has changed, and people want convenient, cost-effective care via web and mobile, just like every other part of their lives. We need to look at the vast majority of routine care and figure out how to delegate routine workflows like refills and pre-visit planning (see </span></span><a href="http://www.healthfinch.com/" style="color: #2a2e2e; font-family: "Helvetica Neue", arial, sans-serif; font-size: 14px; white-space: pre-wrap;" target="_blank">healthfinch</a><span style="color: #2a2e2e; font-family: Helvetica Neue, arial, sans-serif;"><span style="font-size: 14px; white-space: pre-wrap;">) and virtualize routine care like minor urgent issues, stable chronic care and preventive checkups (see </span></span><a href="http://www.mdlive.com/" style="color: #2a2e2e; font-family: "Helvetica Neue", arial, sans-serif; font-size: 14px; white-space: pre-wrap;" target="_blank">MDLIVE</a><span style="color: #2a2e2e; font-family: Helvetica Neue, arial, sans-serif;"><span style="font-size: 14px; white-space: pre-wrap;">). And automation needs to be a big part of all this- from expert rules to run workflows to intelligent interviews to triage out the more difficult cases to be seen in the offices. </span></span></span><br />
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<span style="background-color: white;"><span style="color: #2a2e2e; font-family: Helvetica Neue, arial, sans-serif;"><span style="font-size: 14px; white-space: pre-wrap;">Primary care needs to be virtual first- with automated triage to the right level of care, and an online provider to deal with the majority of issues. Fortunately no one will go out of business (except maybe the overly ubiquitous urgent care centers) as healthcare is big enough that both "Blockbuster" stores and Netflix can easily co-exist... with the good news is that the combination will be able to take our current number of providers and ensure great care for all in the time and place they want it. </span></span></span><br />
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<span style="background-color: white;"><span style="color: #2a2e2e; font-family: Helvetica Neue, arial, sans-serif;"><span style="font-size: 14px; white-space: pre-wrap;">By 2025, it's estimated that <a href="http://fortune.com/2017/05/02/brainstorm-health-2017/" target="_blank">over 50% of all care will be delivered online</a>, and that the number of office visits will go down.. but the ones who go into the office will be the ones who really need it. In other words, we need to "un-democratize" healthcare and embrace the fact that not everyone needs to go into the office - we still treat a 22yo with a sinus infection like a 72yo with CHF... but they don't want or deserve the same 15 minute office visit! Let's break that artificial construct (the quote that comes to mind is what Don Berwick referred to as the "Tyranny of the office visit"). Our future will be automation based triage with majority of care being handled online, and then the "<a href="https://www.nejm.org/doi/full/10.1056/NEJMp1710735" target="_blank">Office visit will be Plan B</a>" as detailed by Dr. Tom Lee in NEJM (Jan, 2018). </span></span></span><br />
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<span style="background-color: white;"><span style="color: #2a2e2e; font-family: Helvetica Neue, arial, sans-serif;"><span style="font-size: 14px; white-space: pre-wrap;"><b>Viva la (Online) Primary Care! </b></span></span></span>Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com0tag:blogger.com,1999:blog-22539915.post-43735513847841179802016-10-14T05:15:00.001-05:002016-10-18T12:58:08.474-05:00What can the healthcare system really learn from Uber and Lyft: Increased Automation and Smarter Regulations can go a LONG way!<div class="MsoNormal">
A<a href="http://www.cio.com/article/3125657/healthcare/doctors-e-health-records-raise-costs-dont-help-patient-outcomes.html" target="_blank"> new Study</a> found that doctors believe EMRs may help with reporting, but that they do NOT help with
outcomes. Furthermore, they note the downsides of EMRs include increased costs and distracting from direct
patient care. </div>
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However, I think an equally guilty culprit is the <b>over-regulation of our medical
system</b>- including </div>
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(1) The amount and detail in which everything needs to be
documented, and </div>
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(2) The amount of extra work that doctors now need to "review
and sign off on". </div>
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On one hand, EMRs actually may help with doing some of this
documentation (if we were still on paper, there is no way docs could do all the
documentation required these days!). On the other hand, EMRs have also caused extra work due to
their inflexible design requiring both multiple clicks to find or complete
tasks, as well as enforcing a "top of license" mentality that means a
doctor has to be involved with EVERYTHING.<o:p></o:p></div>
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Meanwhile, both
state and federal regulations make it incredibly hard to automate or delegate
even routine primary care... we are so behind other industries, and even behind other areas of healthcare! For exampe, we somehow allow <a href="https://en.wikipedia.org/wiki/Autonomous_car" target="_blank">AUTONOMOUS CARS</a> and <a href="http://www.allaboutroboticsurgery.com/surgicalrobots.html" target="_blank">SURGICAL ROBOTS</a>, but we have regulations that don't allow a computer
to automatically handle refill requests, order labs or manage minor medication
changes?!? We think making a well trained and time-strapped primary care doctor scour an EMR and do refills at the end of the day is better than using automation to handle this type of work? </div>
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Fortunately, there are companies like <a href="http://www.healthfinch.com/" target="_blank">healthfinch</a> building out tools to work within EMRs to delegate this
type of routine clinical work - meaning they automate everything to the last foot... but still have to hand it off to a nurse or similar professional to click on the final button. The result is that: </div>
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1. It takes work off the doctor's plate (the <a href="http://www.healthfinch.com/our-apps/" target="_blank">Swoop Refill Product </a>alone saves them 20-30 minutes a day). </div>
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2. It makes the delegation process to nurses much more efficient (usually 3-4X more efficient, which means you only need 3 nurses to support a task vs. 12 nurses... saving millions a year, and allowing you to deploy those nurses elsewhere)</div>
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3. It improves the quality of care for the patient... both in making the turn-around time faster, and in ensuring that evidence based rules are used to make a decision</div>
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But ideally- we really need to see a regulatory system that allows us to
<u>automate the process fully!</u> Then instead of complaining about EMRs - docs and nurses will actually love how it make their lives easier (while also improving patient care in a variety of ways), rather than
feel like the EMR is the hammer bringing down the pain on them!<br />
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I was pleased to see the recent <a href="https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-10-13.html" target="_blank">CMS announcement </a>that they are lauching a pilot initiative with the goal to "reshape the physician experience by reviewing regulations and policies to minimize administrative tasks and seek other input to improve clinician satisfaction". Amen! <br />
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The other, potentially simpler, idea I would recommend is simply to provide more guidance on current regulations around licensure. For example, every state has regulations about who can do what in a healthcare setting - often convoluted language that makes it unclear if a nurse or medical assistant can do nothing, something or many things based on protocols and standing orders.<br />
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Unfortunately, every hospital system has a cache of lawyers who may interpret the laws differently because there is no "case law" they can point to for a definitive understanding. The result may be wild swings in how one healthcare system allows work to be shared across a team. In a world in which we need more team based care, these types of "legal traps" make it much harder to try to use everyone to the "top of their license" when that very definition is confusing. <br />
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What if a state could provide specific examples with their regulations - for example, making it clear if an MA could sign for a refill based on an automated protocol vs. requiring it to be an RN, pharm tech, or in some systems- insisting only the doctor has the power to do that final touch. As I've often said, we don't have a shortage of physicians, just a shortage of using them efficiently... and this is a big case in point. Doing this right allows us to share the care across the team... doing it wrong means burdening the doctor with routine care that overwhelms and burns them out.<br />
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Hmmm... Maybe Uber
and Lyft should take over healthcare - as they certainly have figured a way
to work around "regulatory hurdles" that allowed them to use technology to make life
much easier, cheaper and better for so many! <o:p></o:p></div>
Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com0tag:blogger.com,1999:blog-22539915.post-68082240985510598532016-02-22T23:48:00.001-06:002016-02-22T23:48:23.959-06:00HIMSS 2016 (Las Vegas)<span style="font-family: inherit;">The world's largest healthcare IT conference is about to take off again Feb 29-March 4th. It's the Healthcare Information Management & Systems Society (HIMSS) Annual Conference: </span>http://www.himssconference.org/<br />
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<span style="font-family: inherit;">Someone asked me recently why I go and what I get out of it, the answer always seems to boil down to these two things: </span><br />
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</div>
<ul>
<li><span style="font-family: inherit;"><b>Connecting </b>with colleagues and others; H</span><span style="font-family: inherit;">earing and Seeing what others are up to</span></li>
<li><span style="font-family: inherit;"><b>Viewing </b>latest and greatest on the exhibit floor, while watching/listening for themes</span></li>
</ul>
<span style="font-family: inherit;"><b><i>What will be the big themes this year?</i> </b></span><br />
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<span style="font-family: inherit;">There always seem to be a few- here is my guess as to what we will see a lot of this year: </span></div>
<ul>
<li><span style="font-family: inherit;"><span style="font-family: inherit;"><b>Telehealth</b>: everyone is jumping in these days, whether we are ready or not! I think the hype around "video for everything" is peaking, and then we will realize that using video for routine care perpetuates an inefficient system - and is not our way out of this mess of a healthcare system. Over time, video will just focus on specialized care for remote locations; and asynchronous care will rise for routine care. </span></span></li>
<li><span style="font-family: inherit;"><span style="font-family: inherit;"><b>Predictive Analytics</b>: Last year the work "Analytics" was everywhere. I think this year it will be more focused and solutions based, with "Predictive" leading the charge. It is amazing, but everyone says they can do this better than the other guys... but there is no winner yet. Of course, predicting who will do poorly, and being able to do anything about it are very different things! Will be looking for companies that can do the latter as well! </span></span></li>
<li><span style="font-family: inherit;"><span style="font-family: inherit;"><b>Innovating with IT</b>: Now that most places have a stable EMR and HIT foundation in place, and we are more quickly moving from volume to value based care... The most innovative organizations will be building on top of these platforms - either by creating tools themselves, or integrating with 3rd party apps. Looking forward to talking about this at the <a href="http://www.himss.org/Events/EventDetail.aspx?ItemNumber=45803" target="_blank">AMDIS/HIMSS Physician Symposium</a>, as well as attending the <a href="http://hx360.org/" target="_blank">HX360 </a>"conference within a conference". And of course, you can still find my book on this subject (<a href="http://www.thehealingedge.org/" target="_blank">Innovation with Information Technologies in Healthcare</a>) as the topic heats up! </span></span></li>
<li><span style="font-family: inherit;"><span style="font-family: inherit;"><b>Doctor Burnout and the Need to Make IT more Usable</b>. This will span from tech ideas to research reports to policy discussions. Hopefully it will not just be talk - and we will see more solutions that actually help. I'm looking for full people/process/technology solutions which automate routine care, and/or virtualize services out of the office - but do it all in a way that takes work off the MD's plate, not adds onto it (as we have too often allowed HIT to do in the past). Companies that fit this bill include <a href="http://www.healthfinch.com/" target="_blank">healthfinch </a>(which I co-founded five years ago specifically to help automate routine physician work) and <a href="http://www.healthloop.com/" target="_blank">healthloop </a>(and others that are helping with post-visit care). Additionally, I'm intrigued by the remote scribe companies (there are many now)- I need to figure out if they will really make things easier or not for PCPs.</span></span></li>
</ul>
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I always keep notes at HIMSS, and am going to start "dumping" them into this blog - hoping they provide some value to me others in the future...look for an update after March 4th! In the meantime, feel free to follow me <a href="https://twitter.com/DrLyleMD" target="_blank">@drlyleMD</a></div>
Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com0tag:blogger.com,1999:blog-22539915.post-79553270394989099372015-07-12T13:17:00.000-05:002017-01-14T12:33:11.713-06:00Advice to Healthcare StartupsLike many in my role, I am constantly pounded by young entrepreneurs with the "next great innovative idea for healthcare". I appreciate their energy and enthusiasm, and in some cases they really do have something cool and special. However, I do find myself repeating many of the same thoughts and "rules" - so I thought that I would put some down on paper to prepare them ahead of time. <br />
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This is in part inspired by an GREAT blog by Todd Dunn (Director of Innovation, <a href="http://intermountainhealthcare.org/qualityandresearch/transformation-lab/Pages/home.aspx" target="_blank">Intermountain Healthcare Transformation Lab</a>): <a href="http://steveblank.com/2015/07/09/the-7-deadly-healthcare-startup-sins" target="_blank">The Seven Deadly Healthcare Startup Sins </a>(and his follow up advice). The summary:<br />
Sin 1: Healthcare startups assume hospitals will let them host patient data in “their portal.”<br />
Sin 2: Startups assume that clinicians will be willing to access yet another portal for their data.<br />
Sin 3: That one doctor or hospital lends enough credibility for other organizations to simply accept a startup’s solution.<br />
Sin 4: Believing that ONE key leader inside a hospital is the decision-maker, influencer, etc. all in one role….<br />
Sin 5: Thinking that conducting a “proof of concept” and/or pilot is a simple endeavor.<br />
Sin 6: There isn’t anyone else out there solving the problem.<br />
Sin 7: Believing that startups need to have more answers than questions.<br />
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His Advice:<br />
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<ul>
<li>Use the Lean Startup tools! Regardless of where you start, it comes down to your value proposition as a starter or non-starter. </li>
<li>This often tries the patience of entrepreneurs. I cannot overemphasize the need to use the learning loop in every single part of the Value Proposition and Business Model canvases. The only way to do that is to GET OUT OF THE OFFICE!</li>
<li>Be curious about workflow - Be empathetic to your user.</li>
<li>Study the industry more deeply. While you may have a great value proposition for one or two hospitals, how does your solution fit into the regulatory landscape, workflow, etc. of multiple hospitals?</li>
<li>Listen! Assume you don’t have enough evidence to scale your business yet. Act like you don’t know enough. While an entepreneur’s “go get ’em” attitude is appreciated, it isn’t appreciated when the entrepreneur isn’t open to feedback, seems to have all the answers, and has a condescending attitude toward the way “jobs” get done today. Test your assumptions! Come loaded with questions that are related to your assumptions.</li>
<li>Last but not least, structure a learning plan. Embrace the Lean Startup tools and methods. Following this structure will cause you to write a learning plan. A foundational question to guide your learning plan in every part of your business model is “What do we need to learn before we invest more time and money?”</li>
</ul>
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<b><u>Some thoughts and Rules I would add to enhance the above</u></b><br />
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<ul>
<li><b>There are basically no new ideas... a successful startup understands it is about execution</b>. So please don't tell me that you have a brand new idea and want an NDA because the idea is so priceless and if anyone else finds out about it they will copy it. If it's that easy to replicate, then you really don't have a business. I remember years ago when I was being mentored by the great informaticist Dr. Bob Greenes. He took me into his office and showed my his PhD thesis from around 1966. This was the dawn of the age of computers, and in his thesis was basically every idea we are now hearing from "startup" companies daily - computer guided interviews and diagnosis, telemedicine, artificial intelligence to read notes, etc... The key is rarely the idea, but how you combine the right people with the right technology and the right timing to make it all work. Bill Gross had a nice Ted Talk on the topic of "<a href="https://www.ted.com/talks/bill_gross_the_single_biggest_reason_why_startups_succeed?language=en" target="_blank">The Single Biggest Reason Startups Succeed</a>". So convince me you really understand a problem and solution well and that you can be THE company that executes on it better, faster, cheaper than anyone else!</li>
<li>Truly understand and be able to explain your "<b>Value Proposition</b>" - specifically, clarify (1) Who Pays for your tool, (2) Who Uses your tool, and (3) Who Benefits from your tool. In healthcare, the incentives are often not aligned - and the smart startup will fully understand and have a business plan that makes sense. Nothing turns me off quicker than a company that expects a doctor to pay for and use a tool, when all the financial benefit then accrues to another party. </li>
<li><b>Bring me a solution, not just a tool</b>. A lot of startups are talking about how they use "big data" to identify problems and opportunities for improvement. That is nice, but the truth is we have a lot of low hanging fruit in healthcare- I don't need to find more problems as much as I need solutions. So if all you are selling is a way to find more problems, that will not resonate as well as a packaged solution that also "fixes" them. For example, the analytics vendor <a href="https://www.healthcatalyst.com/" target="_blank">HealthCatalyst</a> is soaring because they realized that they need to use analytics to identify both the problem and the potential solutions to be successful. Another interesting company, <a href="https://transfusesolutions.com/" target="_blank">Transfuse Solutions</a>, combines analytics and process improvement techniques to focus on the specific issue of identifying when a hospital is doing too many transfusions and then offering solutions on how to improve on those metrics. </li>
<li><b>Be committed</b>... healthcare is not for the faint of heart. This is a big business, with long sales times, difficult implementations and hard change management. When something works and can improve efficiency, quality and financials at the same time - and can scale well... then you will have a winner, but nothing happens overnight like in so many other industries. So don't tell me how you have a part-time CEO, and you are out-sourcing all your IT work so some guys who have other jobs. That is not going to build a company which has the DNA needed to succeed in this industry - show me executives and staff that wake up every day obsessed with fixing a specific problem, and an IT team that understands the nuances of healthcare and can react quickly to solve issues. </li>
<li><b>Make it easy to do the right thing, especially if this is doctor facing</b>. I often say that the best healthcare IT can make life easier for doctors and better for patients at the same time. Do not try and tell me how "this system only asks the doctor to spend one more minute for each patient" - we don't have one extra minute! We want you to tell us how you save us time from mundane tasks so we can have more face to face time with patients - that is what will win our hearts and minds! This post from last year explains this thinking further: <a href="http://drlyle.blogspot.com/2014/11/the-three-keys-to-solving-our.html">http://drlyle.blogspot.com/2014/11/the-three-keys-to-solving-our.html</a></li>
</ul>
<div>
So yes, please keep innovating and trying to make things better. Our current healthcare system is clearly not sustainable as it stands, making for a "target rich environment". But when pitching to busy providers and healthcare organizations, remember that their plate if often very full - so <i><b>have your value high, your proponents lined up, your story straight, and your team ready</b></i> to truly make a difference in the lives of both providers and patients.<br />
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<br />
<b><u>Addendum: List of Other Relevant Blogs and Advice for Startup Entrepreneurs</u></b><br />
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<ul>
<li><a href="http://www.scoopwhoop.com/inothernews/how-famous-start-ups-were-started/" target="_blank">How Famous Start-ups Were Started (ScoopWhoop.com, 6/15)</a></li>
<li>S<a href="https://medtechboston.medstro.com/blog/2017/01/09/6-reasons-why-digital-health-startups-will-fail-obamacare-repeal-wont-be-one-of-them/" target="_blank">ix Reasons Why Digital Healthcare Startups Fail </a>(1/17)</li>
</ul>
</div>
Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com0tag:blogger.com,1999:blog-22539915.post-75741311000543635782015-05-18T00:08:00.000-05:002015-05-18T00:08:11.066-05:00Six Lessons in Health IT Innovation<span style="font-family: inherit;">I speak frequently on the intersection of HIT and Innovation.. especially around how can we be more innovative in using the HIT we already have in place via human centered design thinking ("ask, observe, think and feel" about what the end user has to deal with). At a recent healthcare conference, I spoke about this topic based on a combination of my own professional experiences as well as learnings from the book I wrote about the intersection of HIT and Innovation (see this </span><a href="http://drlyle.blogspot.com/2013/02/the-healing-edge-at-intersection-of.html" style="font-family: inherit;" target="_blank">post</a><span style="font-family: inherit;"> and check out </span><a href="http://www.thehealingedge.org/" style="font-family: inherit;">www.TheHealingEdge.org</a><span style="font-family: inherit;">). I didn't realize that a reporter was in the room, but was </span>pleasantly<span style="font-family: inherit;"> surprised a few days later when a nice article came out summarizing my "<a href="http://www.beckershospitalreview.com/healthcare-information-technology/6-lessons-in-health-it-innovation.html" target="_blank">Top 6 Lessons in HIT Innovation</a>". A listing of these lessons is below, along with some expanded thoughts and examples: </span><br />
<b style="background-color: white; font-family: inherit; line-height: 13.5pt;"><span style="color: #292929; font-size: 11pt;"><br /></span></b>
<b style="background-color: white; font-family: inherit; line-height: 13.5pt;"><span style="color: #292929; font-size: 11pt;">1. Identify the minimal viable innovation.</span></b><span style="background-color: white; color: #292929; font-family: inherit; font-size: 11pt; line-height: 13.5pt;"> Don't be afraid to borrow ideas from other people.
"<i>Fail early, Fail fast, Fail often and Fail cheap</i>." I often give the story of three organizations in the book all talking about the same issue (how to use their EMR to automate and delegate some routine preventive maintenance and disease management care). Each organization had a different EMR and a different workflow, but the end result was similar- they figured out how to use the EMR to empower their staff to do more, resulting in a more efficient system with better quality. The idea thus is not to exactly copy what any one of them did, but to understand the essence, and figure out how you can make it work at your organizations. </span><br />
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<b style="font-family: inherit; line-height: 13.5pt;"><span style="color: #292929; font-size: 11pt;">2. People and processes are more important than the IT.</span></b><span style="color: #292929; font-family: inherit;"><span style="font-size: 11pt; line-height: 13.5pt;"> Do not except technology to be a silver bullet. The people
and processes behind the technology will be the forces that drive innovation. So many of my best "innovations" are the result of creating some content and workflows to take advantage of having a single communication tool (the EMR) that links everyone in an organization and allows for creation of consistent templates and routing... which allowed us to set up a care coordination system all the way back in 2008 which resulted in better experiences for patients and providers along with better, faster and cheaper care (we even </span></span><a href="http://www.ncbi.nlm.nih.gov/pubmed/23321584" style="color: #292929; font-family: inherit; font-size: 11pt; line-height: 13.5pt;" target="_blank">published on this data</a><span style="color: #292929; font-family: inherit;"><span style="font-size: 11pt; line-height: 13.5pt;">). In the book, we hear other examples, such as how </span></span><a href="http://childrensnational.org/" style="color: #292929; font-family: inherit; font-size: 11pt; line-height: 13.5pt;" target="_blank">Children's National</a><span style="color: #292929; font-family: inherit;"><span style="font-size: 11pt; line-height: 13.5pt;"> used their EMR to identify signals that indicated an "adverse events" had happened the night before (e.g. a low glucose, use of Narcan)... that was the easy part. The more important solution was having a dedicated nurse reviewing that data every day, tracking down what happened, and working with a team to minimize it from every happening again... with spectacular results. Another story involves the use of a </span></span><span style="color: #292929;"><span style="font-size: 14.6666669845581px; line-height: 18px;">ubiquitous</span></span><span style="color: #292929;"><span style="font-family: inherit;"><span style="font-size: 11pt; line-height: 13.5pt;"> technology Skype) to enable </span></span><span style="font-size: 14.6666669845581px; line-height: 18px;">multiple</span><span style="font-family: inherit;"><span style="font-size: 11pt; line-height: 13.5pt;"> hospitals across California to enable the concept of "virtual translators" across their disparate systems. So even though these were all separately owned, the hospitals could "borrow" translators from each other and thus all ensure they had enough of the right language. The innovation was less in the technology, and more in the idea- as well as the business agreement they had to set up.<o:p></o:p></span></span></span></div>
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<b style="font-family: inherit; line-height: 13.5pt;"><span style="color: #292929; font-size: 11pt;">3. You can start small.</span></b><span style="color: #292929; font-family: inherit;"><span style="font-size: 11pt; line-height: 13.5pt;"> Innovation
in health IT does not have to mean something big and radical from day one; In other words, <i>little bets make for big wins</i>. For example, we used a pilot of 5 iPads on the inpatient oncology floor to explore what happens if we offer free use of them while patients are "confined". We </span></span><span style="color: #292929;"><span style="font-size: 14.6666669845581px; line-height: 18px;">immediately</span></span><span style="color: #292929; font-family: inherit;"><span style="font-size: 11pt; line-height: 13.5pt;"> learned about workflow (how to distribute and track and clean the devices), as well as network issues we had to address as the top use of the iPads was to use FaceTime or Skype with friends and relatives... a use case we did not realize would be so popular. The result immediate</span></span><span style="color: #292929; font-family: inherit; font-size: 11pt; line-height: 13.5pt;"> patient
satisfaction as well as a much better understanding of what it will take to roll out a bigger effort in the future. </span></div>
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<span style="font-family: inherit;"><b><span style="color: #292929; font-size: 11pt;">4. Apply new innovations to old problems.</span></b><span style="color: #292929; font-size: 11pt;"> This is about using some established innovation methodologies to really rethink how we practice healthcare. I said "</span></span><span style="color: #292929; font-family: inherit; font-size: 11pt; line-height: 13.5pt;">We are cutting the cost curve, but not as much as we
need... and we must innovate or we will lose." An example I gave was use of "<a href="http://en.wikipedia.org/wiki/Video_ethnography" target="_blank">Video Ethnography</a>" to better understand poorly controlled diabetics. Working with <a href="http://www.gravitytank.com/" target="_blank">gravitytank</a>, a local innovation consultancy, we spent 2 hours with 8 separate patients and were able to understand this population in a whole new way. We condensed their videos into a 20 minute summary which was used as a kick off for a half-day brainstorming session that created a slew of ideas that resulted in new ways to educate both patients and providers about diabetes (we moved away from trying to scare them and towards simplifying the message). </span></div>
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<b style="font-family: inherit; line-height: 13.5pt;"><span style="color: #292929; font-size: 11pt;">5. Try different ideas and technologies that have found success
in other industries.</span></b><span style="color: #292929; font-family: inherit;"><span style="font-size: 11pt; line-height: 13.5pt;"> Thought leaders
consistently point out that healthcare is fell behind so many other industries
when it comes to technology and innovation. Try ideas from the airline or
retail industries; perhaps one of these will spark rapid innovation in your
organization. I'm a big fan of "<i>Innovation Safaris</i>", also called </span></span><span style="color: #292929;"><span style="font-size: 14.6666669845581px; line-height: 18px;">analogous</span></span><span style="color: #292929; font-family: inherit;"><span style="font-size: 11pt; line-height: 13.5pt;"> observations, in which we spend time in another industry to understand how they view quality or satisfaction or efficiency... and see what we can learn and bring back to healthcare. I am fortunate to be part of a group (<a href="http://www.iln.org/" target="_blank">The Innovation Learning Network</a>) in which we do this together every 6 months.. here is good <a href="http://centerfortotalhealth.org/iln-day-2-innovation-safaris/" target="_blank">write up</a> of what it can be like. </span></span></div>
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<b style="line-height: 13.5pt;"><span style="color: #292929; font-size: 11pt;"><span style="font-family: inherit;">6. Embrace the power of physician happiness.</span></span></b><span style="color: #292929; font-size: 11pt; line-height: 13.5pt;"><span style="font-family: inherit;"> Physicians can be both the source and users of innovation,
but without them technology cannot go very far. "T<i>here is no quality
without use</i>" is a quote I've been using for many years in explaining that creating super-complicated systems might look good on paper, but they will not provide any real benfit if your end users are not using them in everyday practice. Rather, we need to think about how we can use HIT to "<i>Make life easier for physicians, while also making it better for patients</i>". </span></span></div>
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Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com0tag:blogger.com,1999:blog-22539915.post-35397442225720946802015-01-14T09:51:00.000-06:002015-01-14T09:51:00.257-06:00Perspectives on the Future of Healthcare and IT.. a Video InterviewI was recently "Video-interviewed" about my thoughts on the future of healthcare and IT. These types of interviews are usually quick - two questions, five minutes... hopefully some value! Here are my two questions and a summary of my answers:<br />
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<span style="background-color: white; color: #333333; font-family: arial, sans-serif; line-height: 17px;"><b>Where is the healthcare industry headed?</b></span><br />
<span style="background-color: white;"><span style="color: #333333; font-family: arial, sans-serif;"><span style="line-height: 17px;">I believe healthcare is currently a runaway train with an unsustainable model. But there is hope if we can adapt reimbursement models to <u>incentivize value over volume</u>, and use HIT to simplif, automate and delegate all the care that needs to be done. With respect to HIT, s</span></span></span><span style="background-color: white; color: #333333; font-family: arial, sans-serif; line-height: 17px;">ince over 80% of physicians have an EMR in place, we now an infrastructure or platform on which to build "EMR Extender Tools" which allow for better</span><span style="background-color: white; color: #333333; font-family: arial, sans-serif; line-height: 17px;"> EMR functionality, efficiency, and effectiveness. Furthermore, we need to focus HIT efforts on </span><span style="background-color: white; color: #333333; font-family: arial, sans-serif; line-height: 17px;">Population Health, Virtual care, and Workflow Efficiency to meet the increasing demands for care that are upon us. With respect to </span><span style="background-color: white; color: #333333; font-family: arial, sans-serif; line-height: 17px;">population health; ACOs and other types of volume-based to value-based reimbursement changes will make it easier and financially viable to really manage the health population well - but we need the right HIT tools to risk stratify the population and then manage them more easily. Meanwhile, we should see a rapid expansion of virtual care as technologies and demand sync up. Lastly, as physicians (and staff) are burning out quickly, using HIT to create workflow efficiency by simplifying, automating delegating care, is vital to the performance of doctors, as well as the health of patients (which is why I helped found <a href="http://www.healthfinch.com/" target="_blank">healthfinch </a>to build software solutions that allow medical groups to redesign care more efficiently and effectively). </span><br />
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<span style="background-color: white; color: #333333; font-family: arial, sans-serif; line-height: 17px;"><b>What is an HIT Innovation you would like to see happen soon?</b></span><br />
<span style="background-color: white; color: #333333; font-family: arial, sans-serif; line-height: 17px;">I think we are getting closer and closer to “ubiquitous monitoring.” Wearable devices are available, but right now these are often just used by the “healthy and wealthy.” Although this is a good starting point, there is a need to develop patient monitoring tools that are fully ubiquitous - so that collecting biometric data becomes a simple byproduct of everyday life. These may start as being embedded in smart phones, and now we are seeing them woven into in clothes, but soon we will have watches, patches and even injected nanotechnologies. As these evolve, doctors will be able to receive regular, real-time monitoring of their patients. From there, one can feed data into a rules engine to notify doctors (or even patients themselves) if something is medically wrong. This portends a fantastic future for remote monitoring so that doctors do not have to rely on patients to manually input data all the time and wait for them to come into the office to explain there is a problem.</span><br />
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Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com0tag:blogger.com,1999:blog-22539915.post-29642034399499594862014-11-29T15:43:00.001-06:002014-11-29T15:43:10.080-06:00The Three Keys to Solving our Healthcare System are Getting SAD, FAT and Innovative!I was interviewed by a new magazine called <a href="http://www.healthcareinnovationnews.com/" target="_blank">Healthcare Innovation News</a> for their September 2014 issue and they asked a lot of interesting questions - so below (a slightly editedversion) to learn about the following: How did my career path wander from engineer to doctor to entrepreneur; Why the future of the EMR rests on innovators; Why healthfinch is called The Doctor Happiness company & why we started with automating the medication refill workflow; and finally - What are the three key components to solving our healthcare system (hint - getting SAD and FAT are two of them!).<br />
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<b style="text-indent: -0.25in;"><span style="font-size: 12.0pt; mso-bidi-font-size: 14.0pt; mso-fareast-font-family: Arial;">Q: <span style="font-size: 7pt; font-stretch: normal; font-weight: normal;"> </span></span></b><b style="text-indent: -0.25in;"><span style="font-size: 12.0pt; mso-bidi-font-size: 14.0pt;">Did you plan to become involved in healthcare technology when you
entered medical school? What was the impetus and what does it take for a
physician to become a health information technology (HIT) entrepreneur?</span></b></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 11.0pt; mso-bidi-font-size: 14.0pt;"><b>A:</b> I liked both medicine and computers
growing up, so I studied Biomedical engineering at the University of Pennsylvania, where I wound up programming and working with a variety of PhDs and MDs. When I went to the University of Illinois College
of Medicine, I was fortunate to have a mentor in <a href="http://www.ncbi.nlm.nih.gov/pubmed/13678075" target="_blank">Arthur Elstein, PhD</a>, who had
founded the <a href="http://smdm.org/" target="_blank">Society for Medical Decision Making</a> and created our med school's initial Informatics Department. I became his
research assistant, worked on a variety of informatics projects and realized
that I wanted this to be part of my career.
<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 11.0pt; mso-bidi-font-size: 14.0pt;">Over the years, in addition to being a
PCP, I accumulated a diverse set of technology and business experiences, from
serving as the Medical Director of IT for a large primary group to starting a consulting
company to serving as the Chief Medical Officer for two publicly traded
companies in the IT space. Then in 2008 I was able to merge technology and
innovation when I received philanthropic funding to start the <a href="http://www.theshiphome.org/" target="_blank">SzollosiHealthcare Innovation Program</a> at Northwestern, and have been able to learn a whole
new skill set of design thinking and methodologies. <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 11.0pt; mso-bidi-font-size: 14.0pt;">Over the years, I also advised a number
of startups, but eventually realized that to make the biggest impact (and have
the most fun), I should be starting companies myself. I knew I could bring an interesting variety
of real world clinical, IT, Innovation and business skills to certain
healthcare problems, but quickly learned that the key to success is always finding
great people that can execute on a vision… and I've been very fortunate in
finding the right people with which to partner. <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 11.0pt; mso-bidi-font-size: 14.0pt;">For physicians interested in being
entrepreneurs, my advice is to try and get a good variety of experiences, and
then become part of a team so that you don't have to give up your "day
job" of seeing patients. You will
find that keeping your day job will help financially during the early times,
will allow you to add in more real world flavor to your company, and will satisfy
a part of your soul that only taking care of patients can do. <o:p></o:p></span></div>
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<!--[if !supportLists]--><b><span style="font-size: 12.0pt; mso-bidi-font-size: 14.0pt; mso-fareast-font-family: Arial;">Q: <span style="font-size: 7pt; font-stretch: normal; font-weight: normal;"> </span></span></b><b><span style="font-size: 12.0pt; mso-bidi-font-size: 14.0pt;">Do you still believe that the electronic medical record is dead and that
instead, innovation in HIT rests on apps? <o:p></o:p></span></b></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-size: 14.0pt;"><b>A:</b> I do believe that "EMR version 1.0"
is dead, in the sense that this early vision of the EMR was mainly focused on putting
data into electronic media for legibility and easy access, with an overall bias
towards billing and compliance rather than making clinical care easier and
better. And while those were important
building blocks, the result has been difficult to use EMR systems, especially
in the primary are arena. <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-size: 14.0pt;">So now we are evolving to EMR 2.0, where
the classic EMRs become the platforms upon which innovators can build an
amazing variety of apps that fulfill every doctor (and patient's) dreams! Imagine what might happen if thousands of
programmers were able to easily build "EMR Extender Tools" on top of (or
within) all the EMRs which are deployed… how many great apps might we see that
would never come from the traditional vendors because there are simply <i>too many
ideas and not enough time</i>. <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-size: 14.0pt;">Already we have seen a surge in EMR
Extender Tools which provide content, decision support, and analytics
programs. And we are now starting to see
apps that focus on truly improving the <u>workflow</u> of care to create both
major efficiency and quality improvements. Ideally, future EMR Extender Tools
should have enough flexibility to adjust for multiple styles and types of care,
whether supporting a Cardiologist in California, a Rheumatologist in Rhode Island, or a Neurosurgeon in Nebraska.. <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-size: 14.0pt;">We are also seeing that some EMR vendors
have started to readily embrace this concept of being an open platform, while
others have been slower. But I suspect
all will come along because in the history of technology, a well known truism
is that "<b><i>closed wins early, but open wins late</i></b>". <o:p></o:p></span></div>
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<span style="font-size: 12.0pt; mso-bidi-font-size: 14.0pt;"><b><span style="font-size: 12.0pt; mso-bidi-font-size: 14.0pt; mso-fareast-font-family: Arial;">Q: <span style="font-size: 7pt; font-stretch: normal; font-weight: normal;"> </span></span></b><b>Why did</b><b> you decide to focus on medication refills when creating your
company <a href="http://www.healthfinch.com/" target="_blank">healthfinch</a>? How does streamlining the process affect population health?</b></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-size: 14.0pt;"><b>A: </b>We wanted to start with a workflow which
affected the majority of primary care doctors, but one they would happily
"give up" because losing it was non-threatening both clinically and financially.
The medication refill process was the perfect scenario for us - it is a
constant chore for any PCP, with the average doctor getting around 15-20
requests a day, which takes up to 30 minutes of their time to properly manage,
and they never get paid for it! <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-size: 14.0pt;">We thus created RefillWizard as a
workflow automation tool that intercepts any incoming refill, reviews it in a
cloud-based rules engine, routes it to the appropriate person (e.g. RN, Pharm
tech, MA) and instructs them on how to handle it. With this tool supporting care redesign, the doctor then only needs to be involved in
the 10-20% of refills where their judgment is truly required. This made for easy adoption since it actually
decreased the amount of work for physicians. Additionally, we found that that the quality
of care could actually improve due both to the speed of answering refills and
the consistent use of evidence based rules.
<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-size: 14.0pt;">Our philosophy is actually a very
different take on population health.
Rather than focus on computerizing the 20% of care which is most
complex, we instead focus on building tools to automate and delegate the 80% of
care that is relatively routine. This has two implications for population
health. First, since physician time is a HUGE commodity for population health
programs, freeing up their time from routine, repeatable tasks allows doctors
to take care of a higher volume of patients, focus more on high risk patients, and/or
simply catch their breath and keep their sanity. Second, by using the med
refill process as a model for how to centralize and standardize certain workflows,
we help create the type of team-based infrastructure and culture that will be
needed in the future to efficiently manage large populations. Refills first,
then other workflows later! <o:p></o:p></span></div>
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<b><a href="https://www.blogger.com/null" name="_GoBack"></a><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="font-family: 'Times New Roman'; font-stretch: normal;">Q:</span><span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-size: 14.0pt;">Why
is </span></b><span style="font-family: "Times New Roman","serif"; font-size: 12pt;"><b>healthfinch called the “Doctor
Happiness” company?<o:p></o:p></b></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><b>A: </b>In
other industries, it has become clear that <a href="http://www.forbes.com/sites/jennagoudreau/2010/10/26/are-you-investing-in-the-happiness-advantage/" target="_blank">making the front line workers happy</a>
invariably results in better products and service to the customers (think
Southwest Airlines, Google, or read Shawn Achor's "<a href="http://www.amazon.com/The-Happiness-Advantage-Principles-Performance/dp/0307591549" target="_blank">The HappinessAdvantage</a>"). Healthcare should
learn from these lessons, and we strongly believe that by focusing on creating tools which make doctors happy, the patient will invariable benefit as well. In fact, a recent article (</span><span style="font-family: Times New Roman, serif;"><a href="http://annfammed.org/content/12/6/573.full" target="_blank">From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider)</a> strongly </span><span style="font-family: 'Times New Roman', serif; font-size: 12pt;">suggests that we should expand the Triple Aim to include physician & staff satisfaction as soon as possible.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">We believe in this deeply, and so one
of healthfinch's driving mantras is to <i>Save our Primary Care Physicians</i>, and we
do this by waking up every day thinking about how to use HIT to <b>make life
easier for physicians and better for patients</b>.
In other words, this is not your normal healthcare software
company. Our first goal is to<u> literally
improve doctor happiness </u>(without hurting quality of course). And at the same time, we believe
we can "sneak in" a variety of quality improvements by helping to
ensure consistent use of evidence based guidelines in routine workflows (and ps, doctors are happier when quality goes up as well). <o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">I
think that EMRs have gotten a bad rap as always creating more work for
physicians. Of course, that should be no
surprise as the traditional EMR vendors are understandably focusing on functionality that is mandated by various regulations (i.e. documentation and billing and MU) over holistic
usability. And that is a problem since
no matter how good a function might be, <b><i>there is no quality without use, and
there is no use without usability</i></b>.
However, I believe that the Golden Era of using HIT to lessen the
workload for physicians is just around the corner! . <o:p></o:p></span></div>
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should adopt to improve healthcare delivery?</span></b></div>
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<span style="font-family: 'Times New Roman', serif; font-size: 12pt;"><b>A: </b>First,
we need to optimize our use of HIT to make doctors much more efficient and
happier. I call this </span><b><i style="font-family: 'Times New Roman', serif; font-size: 12pt;">Get SAD to Make Doctors Happy</i><span style="font-family: 'Times New Roman', serif; font-size: 12pt;">:</span></b></div>
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal"><b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">S</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">implify
their interaction with EMRs, such as by minimizing their direct hands on
experience (e.g. scribes, voice recognition, Google Glass) or using data
visualization to help make the cornucopia of data easier to view and
understand<o:p></o:p></span></li>
<li class="MsoNormal"><b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">A</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">utomate as
much of the workflow as possible<o:p></o:p></span></li>
<li class="MsoNormal"><b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">D</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">elegate the
things that can be delegated to the appropriate person on their team<o:p></o:p></span></li>
</ul>
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<span style="font-family: 'Times New Roman', serif; font-size: 12pt;">Second,
we need to better manage large populations of patients. I call this </span><b style="font-family: 'Times New Roman', serif; font-size: 12pt;"><i>Get FAT to make the Population Healthy</i>:</b></div>
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal"><b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">F</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">inancial
incentives need to be aligned around volume rather than value<o:p></o:p></span></li>
<li class="MsoNormal"><b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">A</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">nalytics
will be used to risk stratify and understand our populations better<o:p></o:p></span></li>
<li class="MsoNormal"><b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">T</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">eam based
care which will spread the workload appropriately across all the members
of the team.<o:p></o:p></span></li>
</ul>
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<span style="font-family: 'Times New Roman', serif; font-size: 12pt;">Third
we need to devote time and resources to being more innovative. I call this</span><i style="font-family: 'Times New Roman', serif; font-size: 12pt;"> <b>The Three EEEs of Innovation</b></i><b style="font-family: 'Times New Roman', serif; font-size: 12pt;">:</b></div>
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal"><b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">E</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">xplore new
technologies and thinking to get some insight and ideas on what you might
do and how you want to prioritize<o:p></o:p></span></li>
<li class="MsoNormal"><b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">E</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">xperiment
by building prototypes and pilots to test new ideas, care models and
technologies. Iterate often until
you have both a good clinical use case and business case.<o:p></o:p></span></li>
<li class="MsoNormal"><b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">E</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">xpand the
innovation to the rest of the organization<o:p></o:p></span></li>
</ul>
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<span style="font-family: 'Times New Roman', serif; font-size: 12pt;">If
we can do these three things effectively, we will find that <a href="http://drlyle.blogspot.com/2013/01/we-dont-have-shortage-of-pcps-we-have.html" target="_blank">we don't really havea shortage of physicians, just a shortage of using them efficiently</a>. And the
future will be one where the typical physician sees less patients face to face,
but is able to take care of more patients every day using an IT empowered,
team-based approach that utilizes everyone to the top of their license and
improves the quality and experience of care for both patients and providers.</span></div>
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Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com0tag:blogger.com,1999:blog-22539915.post-85016151110649962112014-11-10T00:12:00.000-06:002014-11-10T22:35:16.469-06:00Hacking to Innovate and Engage: Why Hackathons Will Change Healthcare for the Better<div class="MsoNormal" style="text-align: left;">
<span style="font-family: Calibri, sans-serif; font-size: 11pt;">In today’s
post-reform world, we hear time and time again that there is (or soon will be)
a physician shortage due to a variety of factors. </span><span style="font-family: Calibri, sans-serif; font-size: 11pt;"> </span><span style="font-family: Calibri, sans-serif; font-size: 11pt;">For example, with the millions of people who
now have access to healthcare services due to the Affordable Care Act and the
growing aging population (with their increased risks and needs) – it’s no
surprise a potential physician shortage is a regularly addressed topic. </span><span style="font-family: Calibri, sans-serif; font-size: 11pt;"> </span><span style="font-family: Calibri, sans-serif; font-size: 11pt;">However, I still strongly believe that <b>we do
not have a shortage of physicians, just a shortage of using physicians efficiently</b> (see <a href="http://drlyle.blogspot.com/2013/01/we-dont-have-shortage-of-pcps-we-have.html" target="_blank">past blog</a>).</span></div>
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<br /></div>
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<span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">As a PCP who
has been taking care of patients for over two decades, I know firsthand that the
amount of hours in a day is never enough to accommodate all we want to do (we
often get caught up in fire drills, and can't get to all the preventive and
chronic care management we would ideally address). Fortunately, I do believe that by combining technology,
innovation and teamwork, the potential to simplify, automate and delegate care
for a more efficient care delivery process exists, even if it’s not always easy
to accomplish. <o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">In this blog,
I want to touch on what some consider a surprising way to simplify the equation
and make better use of physicians and their limited time: <b>A motivated and engaged patient.</b> Care coordination can be achieved
when patients and physicians are aligned throughout the care continuum,
creating a more succinct care delivery process. Studies show an empowered
patient can lead to better outcomes – and potentially lower costs – so the
better we are at equipping patients with the proper care plan, the more we can alleviate
some of the burden providers face caring for nearly </span><a href="http://www.washingtonpost.com/news/to-your-health/wp/2014/05/22/how-many-patients-should-your-doctor-see-each-day/"><span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">20 patients per day</span></a><span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">.<o:p></o:p></span></div>
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<span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">I recently participated
in the Intel-GE Care Innovations </span><a href="http://www.careinnovations.com/intel-ge-care-innovations-hackathon-tackle-biggest-patient-engagement-hurdles/"><span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Patient Engagement Hackfest</span></a><span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"> as the closing keynote speaker and
a judge. The purpose of the event was to solve one of the biggest hurdles in
healthcare today: connecting patients to their health and healthcare providers
through better engagement. Not an easy feat. The major challenges I see are:</span><span style="font-family: Calibri, sans-serif; font-size: 11pt;"> </span></div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l1 level1 lfo1; text-indent: -.25in;">
</div>
<ul>
<li><span style="font-family: Symbol; font-size: 11pt; text-indent: -0.25in;"><span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><span style="font-family: Calibri, sans-serif; font-size: 11pt; text-indent: -0.25in;">Behavior
change is hard</span></li>
<li><span style="font-family: Symbol; font-size: 11pt; text-indent: -0.25in;"><span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><span style="font-family: Calibri, sans-serif; font-size: 11pt; text-indent: -0.25in;">Incentives
are misaligned</span></li>
<li><span style="font-family: Symbol; font-size: 11pt; text-indent: -0.25in;"><span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><span style="font-family: Calibri, sans-serif; font-size: 11pt; text-indent: -0.25in;">Information
overload</span></li>
<li><span style="font-family: Symbol; font-size: 11pt; text-indent: -0.25in;"><span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><span style="font-family: Calibri, sans-serif; font-size: 11pt; text-indent: -0.25in;">Patients
spend most of their time outside of the office or hospital setting</span></li>
</ul>
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<span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;"> </span><span style="font-family: Calibri, sans-serif; font-size: 11pt;">That last
point may be the most important to any physician out there. The disconnect is
real, and the ability to influence overall health is limited. So how do we –
healthcare leaders, physicians, innovators and disrupters alike – continue to
push the envelope further for a more connected healthcare system? In writing a </span><a href="http://www.amazon.com/Innovation-Information-Technologies-Healthcare-Informatics/dp/1447143264" style="font-family: Calibri, sans-serif; font-size: 11pt;">book
on the intersection of HIT and Innovation</a><span style="font-family: Calibri, sans-serif; font-size: 11pt;">, I found some pretty consistent themes
on how to innovate in a healthcare environment, which I would summarize as
follows:</span><span style="font-family: Calibri, sans-serif; font-size: 11pt;"> </span></div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo2; text-indent: -.25in;">
</div>
<ul>
<li><span style="font-family: Symbol; font-size: 11pt; text-indent: -0.25in;"><span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><span style="font-family: Calibri, sans-serif; font-size: 11pt; text-indent: -0.25in;">Have a
champion with passion and knowledge</span></li>
<li><span style="font-family: Symbol; font-size: 11pt; text-indent: -0.25in;"><span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><span style="font-family: Calibri, sans-serif; font-size: 11pt; text-indent: -0.25in;">Listen to and
observe the front line</span></li>
<li><span style="font-family: Symbol; font-size: 11pt; text-indent: -0.25in;"><span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><span style="font-family: Calibri, sans-serif; font-size: 11pt; text-indent: -0.25in;">Start with
crazy, out of the box ideas, then make them realistic</span></li>
<li><span style="font-family: Symbol; font-size: 11pt; text-indent: -0.25in;"><span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><span style="font-family: Calibri, sans-serif; font-size: 11pt; text-indent: -0.25in;">Fail Fast,
Fail Small, Fail Cheap</span></li>
<li><span style="font-family: Symbol; font-size: 11pt; text-indent: -0.25in;"><span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><span style="font-family: Calibri, sans-serif; font-size: 11pt; text-indent: -0.25in;">Figure out a
sustainable business plan</span></li>
<li><span style="font-family: Symbol; font-size: 11pt; text-indent: -0.25in;"><span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><span style="font-family: Calibri, sans-serif; font-size: 11pt; text-indent: -0.25in;">Spread your
idea with the IT systems in place</span></li>
</ul>
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<span style="font-family: Calibri, sans-serif; font-size: 11pt;">Hackathons incorporate
many of these concepts in a tightly focused and concentrated manner. They are a
fertile ground for giving life to innovative concepts and inspiring people to develop
healthcare’s next generation of solutions. The Intel-GE Care Innovations
Patient Engagement Hackfest brought together passionate and inspiring people – from
entrepreneurs to programmers to clinicians – who shared ideas and resources to
make the patient the most important part of the care team. And that’s a worthy
cause to get behind.</span></div>
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<span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; mso-ascii-theme-font: major-latin; mso-hansi-theme-font: major-latin;">Be on the
lookout for a hackathon near you! <o:p></o:p></span></div>
Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com0tag:blogger.com,1999:blog-22539915.post-22033845196077238622013-08-18T23:53:00.004-05:002013-09-21T13:24:33.296-05:00Defining Healthcare InnovationIn my recent post at Clinical Innovation + Technology, I tackled the issue of defining "Healthcare Innovation". I decided to do it by answering the typical questions I often hear, and so hope this helps you in explaining to others! Below are my answers, with a bonus answer for my blog :)<br />
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One of the most common questions asked these days is “<b><i>What is healthcare innovation?</i></b>” Like the story of the blind men touching different sides of an elephant and each describing something separate, you will hear a wide variety of answers to this question based on whom you ask.</div>
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The following is a way to address the common questions on this topic so you can start organizing innovation in your mind and within your organization.</div>
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<b>First, should the focus of innovation be on innovative information technologies, devices, workflow processes, care models or business models?</b> Obviously, it can be any or all of the above. In the past, it is fair to say the majority of innovation work was in the devices arena since there was a clear financial return to the organization if a new device was widely adopted. However, in a world changing to value-based reimbursement, we are seeing that process and care model innovations will likely be leading the charge, with information technology being an enabler of those innovations.</div>
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<b>Second, how is an innovation project different than an improvement project?</b> The short answer is that an improvement project is done to improve something, while an innovation project is done to blow up the current process or tool and create a new one. A classic example of this is polio: improvement experts would focus on designing a better iron lung, while innovation experts would consider how they might create a vaccine to stop this disease in the first place.</div>
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<b>Third, is there a science or methodology to doing innovation well? </b>Yes, similar to how improvement projects may use techniques like Lean and Six Sigma, the world of innovation relies on the concept of “Design Thinking” which has a different set of methodologies. The typical innovation project involves three main phases: discovery, incubation and acceleration. In the discovery phase, a problem is studied and observed and then various brainstorming techniques are used to create potential solutions. In the incubation stage, rapid cycle prototyping and piloting are done to quickly and cheaply find what fails and what works. In the acceleration phase, the successful pilot is spread using a variety of educational and other techniques.</div>
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<b>Fourth, do all innovators need to use this formal science of innovation to succeed?</b> It’s fair to say that many of the innovations we see in healthcare were done without formal innovation methods. Rather, innovation started with a passionate individual or team trying to solve a problem with which they had a deep understanding. They would try various iterations until they got something that worked and then maybe spread it to others. However, the creation of an innovation culture and infrastructure to support a formal process of design thinking is likely to help identify more of these projects and make them more successful.</div>
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<b>Fifth, what helps make up a successful healthcare innovation?</b> First, it always starts with a passion for making something better plus some time and resources to focus on the project. Second, it needs to have a real-world business model to keep the innovation sustainable. Third, the innovation needs to be well integrated into information technologies and clinical workflows so that it can be easily spread. Not surprisingly, it is this last part which is always one of the hardest and yet most important pieces. And it is why this intersection of information technology and innovation remains critical to the success of evolving our healthcare system to meet its potential.</div>
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<b>Bonus question: What is the difference between a sustainable and a disruptive innovation?</b> Sustainable innovations are those which sustain the current business model (e.g. things that promote volume in a FFS environment) and/or which add on features/functions with an increasing cost (e.g. the new MRI machine). Disruptive innovations are going to change the business model, often by offering same or less features, but at a much lower cost (e.g. TeleDerm visits, Nurse-managed protocols for Diabetics, a hand-held cardiac ultrasound which gives you just the heart information you need to make a clinical decision). A recent article from the Clay Christenson Institute reviews <a href="http://www.christenseninstitute.org/why-ehrs-are-not-yet-disruptive/" target="_blank">Why EHRs are Not (yet) Disruptive</a>.</div>
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<span style="line-height: inherit;">Clinical Innovation & Technology Article Link: </span><a href="http://www.clinical-innovation.com/topics/clinical-practice/defining-healthcare-innovation" style="line-height: inherit;" target="_blank">Defining Healthcare Innovation</a></div>
Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com0tag:blogger.com,1999:blog-22539915.post-7445427645796830322013-07-01T01:05:00.000-05:002013-09-21T13:20:51.626-05:00The Hat Trick: Physician + Informatics + Innovation Looks like June is Q&A month for me! <br />
Here are three recent interviews and articles where I answer questions about Healthcare IT and Innovation:<br />
<br />
<b><a href="http://www.beckershospitalreview.com/healthcare-information-technology/when-health-it-meets-innovation-qaa-with-dr-lyle-berkowitz-of-northwestern-memorial-hospital.html?A_With_Dr__Lyle_Berkowitz_of_Northwestern_Memorial_Hospital_" target="_blank">When Health IT Meets Innovation: Q&A With Dr. Lyle Berkowitz of Northwestern Memorial Hospital</a> <u>(Becker's Hospital Review)</u></b><br />
This interview focuses on lessons learned from my book (<a href="http://www.amazon.com/Innovation-Information-Technologies-Healthcare-Informatics/dp/1447143264" target="_blank">Innovation with Information Technology in Healthcare</a>) - so I review the history of the book, mention a few of the stories, discuss the biggest "takeaway" (get inspired by others, but modify innovations for your own organization), and explain how to start innovating right now!<br />
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<b><a href="http://communities.intel.com/community/healthcare/blog/2013/06/04/5-questions-for-dr-lyle-berkowitz" target="_blank">5 Questions For… Dr. Lyle Berkowitz</a> <u>(</u></b><b><u>The Intel Health Blog)</u></b><br />
This interview is more broad-based and we talk about how to change an organization's culture towards innovation, more lessons learned from my book, where healthcare innovation is heading in the coming years, and What is the Szollosi Healthcare Innovation Program.<br />
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<b><a href="http://www.clinical-innovation.com/topics/analytics-quality/hat-trick-physician-informatics-innovation" target="_blank">The Hat Trick: Physician + Informatics + Innovation</a> <u>(</u></b><b><u>Clinical Innovation and Technology)</u></b><br />
This is my monthly article as "Innovator in Chief", and I talk about one of the most common questions I am asked - how to balance clinical care, informatics and innovation. Full text is below:<br />
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I am a practicing physician with extra responsibility for informatics and innovation. I love being able to do multiple things in my day, but I do often hear “How do you juggle all those roles?” The simple answer is that I truly treat them as synergistic—they feed and support each other. My first love is being a primary care physician and taking care of my patients. Yet I also am constantly thinking about how I might do my job easier and better.</div>
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Sometimes there is an informatics answer, such as creating new content, alerts or reports within our EMR. Other times there are more innovative answers, such as creating a new process which helps delegate work across my team. But increasingly, there is a combined answer, such as creating a new workflow within our EMR or finding an innovative IT tool and figuring out how it fits into our system’s infrastructure.</div>
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Physician informaticists also ask me is how they can be more innovative. The good news is that most informatics doctors are perfectly set up to expand into the innovation space. They already have an appropriate skill set, such as an interest in new technologies and workflows, excellent problem-solving talents, an ability to work with a wide range of personnel, and an innate desire to constantly improve the current system. The trick is whether they have the time and resources to make these changes happen, so here are some thoughts to help you blaze this trail at your organization.</div>
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First, start small and let things evolve. In fact, a well-known innovation mantra is “Fail Fast, Fail Cheap, and Fail Often.” In other words, you should embrace piloting and the concept of an “n of 1,” often where you can and should be your own guinea pig and ground zero for your innovations. This means signing up for the many new apps, websites and technologies you see out there, healthcare related or not. Try them all for a little to see what they feel like and think about how they might apply to healthcare. Maybe come back to them at another time if you don’t see the value at first. Be the first to try new EMR functions to determine how well they might work in your system’s current workflow, or if they warrant a new workflow.</div>
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You will fail. A lot. That is okay, because each mistake is a golden piece of information which will help lead you to a better place. By starting small, you don’t need a lot of time, resources or permission to try something new.</div>
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Second, always make time to observe. Just watching your colleagues and staff in their day to day lives will help you quickly see bottlenecks and gaps. For example, I was approached by our hospital nursing executives recently as they were trying to be innovative with the discharge process. We formed two teams of three people each and went to the floors to observe and talk to the frontline staff—the nurses and other caregivers on the floor. We used a classic innovation method called “Love/Wish,” where we ask folks what they love about a process and what they wish would change to make it better. An hour later our two groups met and found we had a robust list of opportunities that involved improvements and innovations to both workflow and IT utilization. </div>
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Being a physician informaticist gives you a unique platform upon which to innovate, so keep your eyes and mind open and help make a better system for all of us.</div>
Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com0tag:blogger.com,1999:blog-22539915.post-21381404400438031662013-05-28T11:07:00.001-05:002013-09-21T13:11:55.549-05:00A Call to Action for HC Innovators: Do the Easy First (and then Google Glass)At HIMSS in March, I loved hearing Dr. Eric Topol's <a href="http://www.healthcareitnews.com/news/topol-talks-healthcares-digital-future" target="_blank">keynote talk</a> about the <a href="http://creativedestructionofmedicine.com/" target="_blank">Creative Destruction of Medicine</a>, and how future technologies like genomics and nanotechnology will make diagnosis and treatment so much better and easier. And then last month, I read Travis Good's HISTalk story about "<a href="http://histalkmobile.com/the-power-and-hype-of-google-glass/" target="_blank">The Power and Hype of Google Glass</a>", and searching online, I found many more:<br />
<br />
<ul>
<li><a href="http://www.imedicalapps.com/2013/03/google-glass-medicine/" target="_blank">How Google Glass Could Revolutionize Medicine</a> [iMedical Apps]</li>
<li><a href="http://venturebeat.com/2013/05/13/google-glass-healthcare/" target="_blank">How Long Until Your Doctor is Wearing Google Glass?</a> [Venture Beat]</li>
<li><a href="http://www.medicalelectronicsdesign.com/blog/medblog/what-will-medical-and-health-applications-be-google-goggles" target="_blank">Potential Medical Applications of Google's Augmented Reality Project</a> [Medical Electronics Design]</li>
<li><a href="http://www.medcrunch.net/google-glass-change-healthcare/" target="_blank">How Will Google Glass Change The Health Space?</a> [MedCrunch]</li>
<li><a href="http://www.hl7standards.com/blog/2013/03/21/google-glass/" target="_blank">Google Glass and the Future of Medicine</a> [HL7 Health]</li>
<li><a href="http://www.medicaldaily.com/articles/14237/20130312/google-glass-features-revolutionize-medical-personal-healthcare.htm#DPE8aCi6JA1GCqXW.99" target="_blank">Google Glass Features: How Medical Uses Will Revolutionize Your Healthcare</a> [Video at Medical Daily]</li>
</ul>
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It got me to thinking that there are so many cool and futuristic things we can (and should) be doing in healthcare. However, if all the best thinkers are focusing on the "future" - who will be focusing on the present? By always coming out with new technologies, we seem to have created a "<b>time-shift brain drain</b>", which means we may not be focusing on how to improve or innovate with the stuff we have RIGHT NOW. It might not be as fun to optimize the slow, clunky "EMR 1.0" we use today, but it is important, and will help free up time for doctors and others to actually take a breath and do what they are good at (e.g. higher order thinking) rather than the rote, repeatable tasks which have to be done every day (e.g. med refills, reviewing every single lab, documenting every single action...)! And this is especially important as a <a href="http://www.amednews.com/article/20130311/profession/130319973/2/" target="_blank">new study</a> illustrates how "<i>time constraints make it harder for physicians to solve the medical mysteries that confront them</i>".<br />
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So it led me to write my May "Innovator at Large" column in Clinical Innovation + Technology, it's called "<a href="http://www.clinical-innovation.com/topics/practice-management/do-easy-first" target="_blank">Do The Easy First</a>"... which is a "Call to Action" for healthcare innovators everywhere to start thinking about both the present and the future... as it will be much easier to evolve our healthcare system if we make sure it does not go extinct first!<br />
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<b><u>Do the Easy First (April 24, 2013)</u></b><br />
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I love reading about advanced technologies that have the potential to help with our most complex patients. It will be a fantastic future where natural language processing mixed with big data analytics will help diagnose difficult cases and suggest novel management strategies.</div>
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A future where Google Glass will help doctors more easily recognize dermatological manifestations of systemic diseases while also providing patients with a video of their visit to the physician. And where a nanotechnology sensor floating in the bloodstream can identify DNA changes related to early cancer or heart disease and send an alert to let patients and their providers know to start intervention quickly. </div>
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However, I am also a pragmatic physician and know that while all of this may eventually happen, I have to live in the here and now of technical and financial limitations. Currently, we still struggle to get reasonably accurate data into EMR systems, doctors are not paid extra to identify anything early and most physicians feel they are running out of steam as they spend half their time doing non-clinical, or certainly non-advanced, duties. </div>
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I believe some innovators need a wake-up call. Instead of focusing all your time trying to figure out the hardest and most complex issues, how about figuring out the easy stuff first? For example, many physicians spend a big chunk of their day documenting what they just did, filling out administrative paperwork, trying to keep everyone up to date on preventive care and disease management protocols, and answering the same questions over and over again.</div>
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In other words, physicians are not being used at the highest level of their abilities and, thus, we have created an artificial shortage of doctors. Furthermore, physicians are not great at taking care of all this routine care and administrative paperwork, resulting in decreased quality and patient satisfaction. It’s no wonder our healthcare system is the costliest and not the most effective in the world.<br />
<br />
But who says doctors should be doing all this work? State laws on scope of service need to be respected (or at some point reviewed for best practice). But ironically, the current use of IT has often shifted more work onto the physicians than ever before due to poorly created IT systems which were built for a physician-centric setting rather than a team-based setting. </div>
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What if we started applying our innovative technologies and thinking to help streamline the routine and repeatable workflows which clog up a physician’s time? What if we could use automation to cut down on the unglamorous paperwork chores which are slowly strangling our physicians? What if we used HIT to empower a physician’s team to manage a large chunk of their stable patients remotely based on the doctor’s electronic care plan? What if we saved physicians one, two, even four hours a day of this drudgery so they could spend that time focusing on their truly complex patients? What if we could have a future where care could be delivered in a safer, cheaper and more efficient manner and doctors could focus their time on tasks for which their abilities are best matched?</div>
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Maybe they’d even have some time to try out that new Google Glass!</div>
Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com1tag:blogger.com,1999:blog-22539915.post-47574691830274704302013-04-15T01:39:00.002-05:002013-09-21T12:43:37.492-05:00Population Health or Bust!My April editorial post for Clinical Innovation + Technology is called "<a href="http://www.clinical-innovation.com/topics/analytics-quality/population-health-or-bust" target="_blank">Population Health or Bust!</a>". The premise is that we know reimbursement models are changing from "Volume-Based to "Value-Based care", which may range from gain-sharing to bundled payments to full capitation... And thus we need certain types of tools to better manage our populations of patients. So I defined what these population management tools should do and what to consider when purchasing them:<br />
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<i>First, population health management means that you (1) define a specific population and (2) manage that population in the most efficient, cost-effective and highest quality manner possible. In other words, instead of treating everyone the same, you provide the right care to the right people in the right time and in the right format. This helps to ensure that we focus our limited resources on the people who need them most, while using innovative strategies and technologies to leverage care for others.</i></div>
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<i>Second, be on the lookout for some key functionalities when choosing your population management tools. These include risk stratification, impactability analysis, care gap identification, outreach capabilities, care coordination dashboard, patient engagement systems and analytics reporting.</i></div>
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<i>Third, population health tools are everywhere right now, including offerings from your EHR vendor, your insurance companies and various third parties. Factors to help guide your decision will include not just the strength of their offering, but their ability to integrate into your workflow, their ability to work with multiple data sources, and their future visions. Additionally, we are starting to see interesting gain-sharing business models that may make initial investments free or cheap.</i></div>
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I ended my post explaining why I believe that when dividing populations into "Low, Medium, and High" risk, that the really cool innovations (e.g. mobile monitoring, telehealth, automated care) will be in the Low and Medium categories, rather than the High risk ones. And furthermore, that this will hopefully open up more free time for physicians to spend with the "High risk" patients who needs more of the face to face care we consider traditional right now. Said another way... let's automate the easier stuff so we can allow for more time, critical thinking and compassion for the tougher stuff! </div>
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<b style="font-family: "Times New Roman"; font-size: medium; line-height: normal;"><u>Companies in the Population Health Space (at least a partial list)</u></b></div>
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</span></span><!--[endif]-->Advisory Board Company: <a href="http://www.advisory.com/" target="_blank">www.Advisory.com</a></div>
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</span></span><!--[endif]-->CareMerge (focus on elderly): <a href="http://www.caremerge.com/site/" target="_blank">www.caremerge.com</a></div>
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</span></span><!--[endif]-->Care Team Connect: <a href="http://www.careteamconnect.com/" target="_blank">www.careteamconnect.com</a></div>
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</span></span><!--[endif]-->Clairvia http: <a href="http://www.clairvia.com/" target="_blank">www.clairvia.com</a></div>
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</span></span><!--[endif]-->Click4Care: <a href="http://www.click4care.com/" target="_blank">www.click4care.com</a></div>
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</span></span><!--[endif]-->Clinigence: <a href="http://www.clinigence.com/" target="_blank">www.clinigence.com</a></div>
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</span></span><!--[endif]-->Curaspan (SAAS – Handoffs):
<a href="http://connect.curaspan.com/" target="_blank">http://connect.curaspan.com</a></div>
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</span></span><!--[endif]-->Essence HC: <a href="http://www.eghc.com/" target="_blank">www.eghc.com</a></div>
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</span></span><!--[endif]-->EvolentHealth (UPMC + ABC): <a href="http://www.evolenthealth.com/" target="_blank"><span style="color: #3d85c6;">www.evolenthealth.com</span></a>
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</span></span><!--[endif]-->GSI Health (Lori Evans) (CC Platform):
<a href="http://www.gsihealth.com/" target="_blank">www.gsihealth.com</a></div>
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</span></span><!--[endif]-->Healarium (Mobile Pt Activation Apps):
<a href="http://www.healarium.com/" target="_blank">www.healarium.com</a></div>
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</span></span><!--[endif]-->Humedica (bought by Optum 1/13): <a href="http://www.humedica.com/" target="_blank"><span style="color: #3d85c6;">www.humedica.com</span></a> </div>
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</span></span><!--[endif]-->Intelligent Healthcare: <a href="http://www.intelhc.com/" target="_blank">www.intelhc.com</a></div>
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</span></span><!--[endif]-->Lumeris (ACO for hospitals): <a href="http://www.lumeris.com/" target="_blank">www.lumeris.com</a></div>
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</span></span><!--[endif]-->Medventive (bought by HBOC 2012): <a href="http://www.medventive.com/" target="_blank"><span style="color: #3d85c6;">www.medventive.com</span></a></div>
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</span></span><!--[endif]-->Outcome Advantage:
<a href="http://www.outcomeadvantage.com/" target="_blank">www.outcomeadvantage.com</a></div>
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</span></span><!--[endif]-->Patient Point: <a href="http://patientpoint.com/" target="_blank"><span style="color: #3d85c6;">http://patientpoint.com/</span></a></div>
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</span></span><!--[endif]-->Pharos (Dz mgt, Randy Williams):
<a href="http://www.pharosinnovations.com/" target="_blank">www.Pharosinnovations.com</a></div>
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</span></span><!--[endif]-->Phytel: <a href="http://www.phytel.com/" target="_blank">www.phytel.com</a></div>
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</span></span><!--[endif]-->RipRoad: <a href="http://riproad.com/" target="_blank">http://riproad.com/</a></div>
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</span></span><!--[endif]-->See Change (Insurance and Systems for Employers):
<a href="http://www.seechangehealth.com/" target="_blank">www.seechangehealth.com</a></div>
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</span></span><!--[endif]-->Symphony (ACO Software):
<a href="http://www.symphonycaresolutions.com/" target="_blank">www.symphonycaresolutions.com</a></div>
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</span></span><!--[endif]-->TCS: <a href="http://www.tcshealthcare.com/" target="_blank">www.tcshealthcare.com</a></div>
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</span></span><!--[endif]-->US Health Centric (Dx/Wellness mgt): <a href="http://www.ushealthcenterinc.com/" target="_blank">www.ushealthcenterinc.com</a></div>
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</span></span><!--[endif]-->Valence Health: <a href="http://www.valencehealth.com/" target="_blank">www.valencehealth.com</a></div>
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</span></span><!--[endif]-->Vital Health:
<a href="http://www.vitalhealthsoftware.com/" target="_blank">www.vitalhealthsoftware.com</a></div>
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</span></span><!--[endif]-->Wellbe.me (Checklist based Workflows for
Discharges): <a href="http://wellbe.me/" target="_blank">wellbe.me</a></div>
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</span></span><!--[endif]-->Wellcentive: <a href="http://www.wellcentive.com/" target="_blank"><span style="color: #0b5394;">www.wellcentive.com</span></a></div>
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</span></span><!--[endif]-->xG Health Solutions (Geisinger Spin-off): <a href="http://xghealth.com/" target="_blank">http://xghealth.com/</a> </div>
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I will edit this list over time - but it gives one a sense of how many companies are already in the space in one form or another (and this does not even include all the EMR vendors and their offerings).</div>
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Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com0tag:blogger.com,1999:blog-22539915.post-49542195565281240972013-04-03T01:38:00.004-05:002013-09-21T11:40:47.858-05:00HIMSS 2013 ReviewSome thoughts on the HIMSS 2013 Conference in New Orleans (March 3-7)<br />
<br />
<b><u>Pre-Conference Advice</u></b><br />
I wrote a short column on "<a href="http://www.clinical-innovation.com/topics/interoperability/innovators-himss" target="_blank">Innovators at HIMSS</a>" - my advice on how to Find, Share or Sell Innovation - by breaking down the conference into three chunks: Educational Sessions, the Exhibit Hall and Networking.<br />
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<u><b>Overall Impression of the Conference</b></u></div>
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I still love New Orleans as a city and
as a convention spot (not an opinion shared by everyone)! Of course I did
have a hotel within walking distance. I
also liked that the "exhibit floor" was constrained and thus the
vendors had smaller booths… but it seemed they all had plenty of room. With that said, I felt more rushed than ever
trying to see everything on the vendor floor, and for the first year ever, I
didn't even have time to attend many of the educational sessions. Is HIMSS becoming more vendor fair than
educational? Not necessarily, when you
have 35,000 people - there are different needs and I still think the educational
sessions are important for different people in different roles in different
stages. But this year, my role was more
about exploring - especially in the population health arena, of which EVERYONE
seemed to have an answer. </div>
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<b><u>Personal Highlight</u></b></div>
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Getting to meet and talk with Dr. Larry Weed, who gave a brilliant closing keynote
at the Physician Symposium on Sunday... he is a hero and legend to many of us in
the healthcare informatics field. He developed the concept of organizing the
medical record in the SOAP format, created one of the first computerized
medical record systems, and has been a long-time voice in helping doctors learn
how to "think better" in taking care of our patients. I plan to write an expanded blog on his talk in the near future, but <a href="http://drlyle.blogspot.com/2012/07/dr-larry-weed-is-oracle-medical-records.html" target="_blank">here</a> is what I've said in the past.</div>
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<b><u>Hot Topics</u></b></div>
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I think there were two clear camps: (1) Meaningful Use:
finishing up stage 1, getting ready for stage 2; and (2) Population Health
tools: understanding who were the players, what do they do, what are the
business models, etc. </div>
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<u><b>Population Health Companies</b></u></div>
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Here are some I saw and/or I think have good relevance in this space (and it is far from complete):</div>
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<ul>
<li><a href="http://www.activehealth.com/" target="_blank">Active Health</a>: From Aetna</li>
<li><a href="http://www.evolenthealth.com/" target="_blank">EvolentHealth</a>: The UPMC + ABC combo company</li>
<li><a href="http://www.humedica.com/" target="_blank">Humedica</a>: Now owned by Optum</li>
<li><a href="http://www.lumeris.com/" target="_blank">Lumeris </a></li>
<li><a href="http://www.medventive.com/" target="_blank">Medventive</a>: Now owned by HBOC</li>
<li><a href="http://patientpoint.com/" target="_blank">Patient Point</a></li>
<li><a href="http://www.phytel.com/" target="_blank">Phytel </a></li>
<li><a href="http://www.symphonycare.com/" target="_blank">Symphony Care</a></li>
<li><a href="http://www.valencehealth.com/" target="_blank">Valence Health</a></li>
<li><a href="http://www.wellcentive.com/" target="_blank">Wellcentive</a></li>
</ul>
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<u><b>Some Assorted Cool Things I Saw</b></u></div>
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<a href="http://www.healthcatalyst.com/" target="_blank">HealthCatalyst</a>: An analytics company with a really good
story of what they do… They start with an analysis of high cost and high volume
activities which also have a high variance in your health system. After mutually agreeing on where to focus and
how much money might be saved by reducing variance closer to the mean scores,
they help you determine why the variance is high (via more in-depth analytics) so you can correct it. Concept is simple, but the execution is the
critical part and they seem to have captured some secret sauce that makes them
very good at this. And they've got some great people, including all start CIO Dale Sanders.</div>
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<a href="http://healthspot.net/" target="_blank">Healthspot.net</a>: An interesting "telemedicine in a box" concept... where they will build a self-contained telemedicine "box" wherever you want it (e.g. a pharmacy, a company's warehouse, an underserved youth center, etc.). A patient goes in the box, fills out some computerized forms, and they then have a live video feed with a doctor. But the key is that they also have access to a variety of "tools" which they can use on themselves to show the doctor everything they need to see - including a stethoscope, and devices to look at eyes, ears and skin at visual magnifications greater than one could even get in the office! A medical assistant staff person can help if there is confusion. The MA also does basic clean-up, and there is some automated UV-light cleansing as well. Is this better than Skype and buying the tools separately... not sure, but it's something to consider. </div>
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<a href="http://readydock.net/" target="_blank">ReadyDock</a>: A simple little "iPad Dishwasher" which stores, charges and
sterilizes handheld computers, such as the iPad. I think we will be seeing more iPad use in
hospitals, by both providers and patients… so this could be a really good
idea. I do wonder if just having a plastic "cleanable" cover over these iPads might be a simpler, cheaper idea... this is something that has to be tested out.</div>
Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com0tag:blogger.com,1999:blog-22539915.post-7151561273141236182013-03-10T23:18:00.002-05:002013-09-21T11:22:51.887-05:00The HIT Productivity Paradox - It's Gonna Be OK!<br />
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The NY Times
published another<span class="apple-converted-space"> </span><a href="http://www.nytimes.com/2013/02/20/business/a-digital-shift-on-health-data-swells-profits.html?_r=0&adxnnl=1&adxnnlx=1361423509-udCKNOUICsSljkcSbfXTyA" target="_blank">article</a> recently with a negative vibe about EMRs... implying that spending money on EMRs is a waste since the benefits are not obvious, and questioning the ethics of EMR vendors for asking the government to help subsidize these systems. <br />
<br />
<b>Really?</b> It seems like that is incredibly backward thinking which was also likely used against the stethoscope, anti-sepsis, penicillin, cars, planes, TVs, computers and the Internet when they first started out. I get it, change is hard and technical progress is slow - but let's not throw the baby out with the bathwater, let's give it a chance to grow up! And, of course, what is even more interesting is that like so many media cycles,
the media happily built up how great healthcare IT would be, and then gladly tear it down when it does not happen right away. <br />
<br />
Glen Tullman (HIT entrepreneur and former Allscripts CEO) had some great thoughts on this issue in a recent Forbes Editorial he wrote <a href="http://www.forbes.com/sites/glentullman/2013/03/04/why-havent-electronic-health-records-made-us-healthier/" target="_blank">Why Haven't Electronic Health Records Made Us Healthier</a>? He essentially said that we are a lot further along than when we started, but certainly still have far to go. I especially liked that he reminded us of Amara’s Law: “<i>We tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run</i>.” <br />
<br />
SIDE NOTE: I did a little research to find out that <a href="http://en.wikipedia.org/wiki/Roy_Amara" target="_blank">Roy Amara</a> was a Stanford Systems Engineering PhD who was President of the <a href="http://www.iftf.org/" target="_blank">Institute for the Future</a>. I also found that his law was one of <a href="http://www.neatorama.com/2012/09/05/Four-Geeky-Laws-That-Rule-Our-World/" target="_blank">Four Geeky Laws that Rule Our World</a>, the four together are:<br />
<ul>
<li><b>Amara's Law</b>: "We tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run."</li>
<li><b>Brooks' Law</b>: "Adding manpower to a late software project makes it later."</li>
<li><strong>Thackara's Laws:</strong> "If you put smart technology into a pointless product, the result will be a stupid product."</li>
<li><b>Reed's Law</b>: "The Value of a Network Increases Dramatically When People Form Subgroups for Collaborations and Sharing."</li>
</ul>
<br />
So I wrote a little reply to the NY Times article as well and the wonderful folks at HISTalk published my piece at: <a href="http://histalk2.com/2013/02/21/the-hit-productivity-paradox-its-gonna-be-ok/" target="_blank"> http://histalk2.com/2013/02/21/the-hit-productivity-paradox-its-gonna-be-ok/</a> <br />
I actually received a lot of positive feedback on this - so here it is: </div>
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<b><u>Fair
enough - are EMR's worth it, was MU worth it?</u></b><o:p></o:p></div>
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I've said before
that I don't think I would have spent the $30-40 billion that way (remember,
they use the $19 billion figure because they assume $10-20 billion in savings).
I would have focused on mandating standards and trying to push for a
uniform data model platform upon which vendors could then build their more
external facing products. However, I will happily admit that MU has done
it's job - it has stimulated the adoption of EMRs… it won't be the 80+% they
were hoping, but it's still got a lot of people off their asses and moving.<u1:p></u1:p><o:p></o:p></div>
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<b><u>So next
question - Will they provide all the great things we are hoping for?</u></b><u> </u> <o:p></o:p></div>
Certainly we've got some issues - EMRs are
still not mature, nor is our understanding on how to best use them. But no technology, from cars
to computers, started out perfect. I've been reading "The Signal and the Noise" -
and very early on it reminds readers of "<b>The productivity paradox</b>" which helped explain why the early
computer age (1970s-1990s) actually saw a LOWER productivity as everyone was
figuring out how to build them well and how to use them! Sound familiar?<br />
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<o:p></o:p><br /></div>
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From <a href="http://en.wikipedia.org/wiki/Productivity_paradox" target="_blank">Wikipedia</a>: <i>The productivity paradox was analyzed and popularized in a widely-cited article<a href="http://en.wikipedia.org/wiki/Productivity_paradox#cite_note-Brynjolfsson1993-1" target="_blank">[1]</a> by <a href="http://en.wikipedia.org/wiki/Erik_Brynjolfsson" target="_blank">Erik Brynjolfsson</a>, which noted the apparent contradiction between the remarkable advances in computer power and the relatively slow growth of <a href="http://en.wikipedia.org/wiki/Productivity" target="_blank">productivity</a> at the level of the whole economy, individual firms and many specific applications. The concept is sometimes referred to as the Solow computer paradox in reference to <a href="http://en.wikipedia.org/wiki/Robert_Solow" target="_blank">Robert Solow</a>'s 1987 quip, "You can see the <a href="http://en.wikipedia.org/wiki/Computer_age" target="_blank">computer age</a> everywhere but in the productivity statistics."<a href="http://en.wikipedia.org/wiki/Productivity_paradox#cite_note-2" target="_blank">[2]</a> The paradox has been defined as the “discrepancy between measures of investment in information technology and measures of output at the national level.”<a href="http://en.wikipedia.org/wiki/Productivity_paradox#cite_note-turban-3" target="_blank">[3]</a> It was widely believed that office automation was boosting <a href="http://en.wikipedia.org/wiki/Labor_productivity" target="_blank">labor productivity</a> (or <a href="http://en.wikipedia.org/wiki/Total_factor_productivity" target="_blank">total factor productivity</a>). However, the <a href="http://en.wikipedia.org/wiki/Growth_accounting" target="_blank">growth accounts</a> didn't seem to confirm the idea. From the early 1970s to the early 1990s there was a massive slow-down in growth as the machines were becoming ubiquitous. (Other variables in country's economies were changing simultaneously; <a href="http://en.wikipedia.org/wiki/Growth_accounting" target="_blank">growth accounting</a> separates out the improvement in production output using the same capital and labour resources as input by calculating growth in total factor productivity, AKA the "<a href="http://en.wikipedia.org/wiki/Solow_residual" target="_blank">Solow residual</a>".)</i></div>
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<b>So if and how can this best be applied to healthcare IT? </b><br />
Well, it turns out that some smart authors actually addressed this exact issue in a June, 2012 NEJM article entitled: <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1204980" target="_blank">Unraveling the IT Productivity Paradox — Lessons for Health Care</a>. In this article, they explain that sure, we are seeing problems with HIT… but it is as expected - just like every other new industry has to evolve. They conclude with the following paragraph:<br />
<i>The resolution of the original IT productivity paradox suggests that current conclusions about the value of health IT investments may be premature. Research suggests<u> three lessons for</u> physicians and health care leaders: <b>invest in creating new measures of productivity that can reveal the quality and cost gains that arise from health IT, avoid impatience or overly optimistic expectations about return on investment and focus on the delivery reengineering needed to create a productivity payoff, and pay greater attention to measuring and improving IT usability</b>. In the meantime, avoiding broad claims about overall value that are based on limited evidence may permit a clearer focus on the best ways of optimizing IT's use in health care. </i><br />
<br />
Clearly we are not at perfection - HIT can affect
efficiency and quality in both good ways and bad. But rather than try
to create some artificial polarization that it is all good or all bad… let's continue
doing our job (for the medical informatics professionals reading this) to <b>keep making HIT better serve our providers and patients, while
educating those who get freaked out every time a new stat or story comes out
pointing out its imperfection</b>.<br />
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Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com1tag:blogger.com,1999:blog-22539915.post-63898842802990658762013-02-02T11:49:00.000-06:002014-07-18T11:47:21.595-05:00The Healing Edge: At the Intersection of Innovation and HIT<a href="http://www.amazon.com/Innovation-Information-Technologies-Healthcare-Informatics/dp/1447143264" target="_blank"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgwcQLOOdzskE_TeMSZkCvKUiwD8XkYNNFaQar7W8O_X2KkViQ_cIVUZSVp1QsAvMBhYThLSIfpYS6VYO6rfYuWLdIKZXq5UgYkxHV8WB5wpty1Ps5c3EG0FIsiDuO371VQm6KTFQ/s400/BookCoverChapter_InnovatingHIT.tiff" height="400" width="266" /></a><br />
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Three years ago I was asked by <a href="http://www.amia.org/about-amia/leadership/acmi-fellow/marion-j-ball-edd-facmi" target="_blank">Marion Ball, EdD</a> (a well respected informaticist and long-time colleague) to write a
book about the <u>intersection of healthcare IT and innovation</u>. I was smart enough to initially say no, but
she kept asking because she knew I had been combining my long background in informatics with
a newer interest in the science of innovation as part of the <a href="http://www.theshiphome.org/" target="_blank">Szollosi Healthcare Innovation Program</a>, a charitable organization I established in 2007
with a mission <i>to use creative thinking and diverse technologies to produce a
better healthcare experience for patients, physicians and others associated
with their care</i>. </div>
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After about 6 months I finally accepted the challenge,
realizing that since I was an early pioneer in this world of HIT meets innovation - I might as well try and give the area a good book. I was wise enough to quickly get a partner
in this endeavor, the amazing <a href="http://www.linkedin.com/in/cjmccarthy" target="_blank">Chris McCarthy, MPH, MBA</a>. Chris is a friend and my #1 innovation mentor, as
well as the Director of the <a href="http://www.innovationlearningnetwork.org/" target="_blank">Innovation Learning Network</a> and an Innovation
Specialist with <a href="http://xnet.kp.org/innovationconsultancy/" target="_blank">Kaiser Permanente’s Innovation Consultancy</a>. We liked the idea of storytelling and wanted
to make the book an enjoyable read about the many awesome healthcare innovators
who have used IT to make the healthcare system better, faster and/or
cheaper. We also realized that it would
make sense to truly hear the "voice of the innovators" by having them
each write their own stories within the framework we created. </div>
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<b>The result is our book, <u><a href="http://www.amazon.com/Innovation-Information-Technologies-Healthcare-Informatics/dp/1447143264" target="_blank">Innovation with Information Technology in Healthcare</a></u>,</b> which describes the stories of over 20 organizations who have combined
innovative thinking with information technologies to improve their processes of
care and solve a need at their organizations. <u><o:p></o:p></u></div>
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The first chapter sets the stage, describing how this work should
be viewed like a big cookbook of recipes, with <b>sections on EMR Innovation,
Telehealth Innovation, and Advanced Technology Innovation</b> (e.g. analytics,
portals, mobile and gaming). The second
chapter describes the science of innovation itself, including an assortment of
methodologies which help move the innovation process from <b>ideation to
prototyping/piloting to spreading it across an organization</b>. The
authors, from Kaiser's Innovation Consultancy, give examples from the very real
work they have done over the past decade.</div>
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The rest of the chapters are the stories, <u>written by the
innovators themselves</u>, about what they did, why they did it, how they
succeeded, lessons learned, and their plans for the future. It is especially fun to read about the
origins of these innovations and peer into how an organization moves from a
problem to an innovative new way of doing things. I wrote a short editorial on the "<a href="http://www.clinical-innovation.com/topics/technology-management/healing-edge-intersection-innovative-thinking-and-hit" target="_blank">Big Lessons Learned</a>" from these stories, including the following ideas:</div>
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<ul>
<li><b>Use What You Have:</b> Our first group of stories highlights how a lot of innovation can be made with the underlying HIT you already have in place, especially EMRs. Examples include use of messaging to support care coordination, CDS tools to support delegation of preventive care and other duties to staff, and reporting tool to identify adverse events.</li>
<li><b>Innovation is More Than Technology</b>. For innovations to succeed, it's critical to also address culture issues, new business models, legal and political hurdles, and process change. And, of course, it's often a good idea to be innovative in doing so! The stories about telehealth give some great examples of this!</li>
<li><b>Look Around</b>. Learn from all the new technologies and companies appearing in every aspect of our life... from mobile apps to business intelligence to RFID tools to gaming systems. The final section on Advanced Technologies provides many examples of this rule. </li>
<li><b>Dream Big (and Wild)! </b> We all are faced with problems in our healthcare organizations, and while sometimes the answer is a small improvement in what we do, in other cases we truly need to innovate - to rethink how we do everything and at that time it's important to come up with wild and crazy ideas which can really make a difference. Don't worry, there will be time later to mix in reality and pragmatism - but in brainstorming, don't be afraid to dream big! </li>
</ul>
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Finally, it's important to understand that we don't expect readers to follow the exact "recipes" in the book, but rather to be <b>inspired and educated</b> to innovate themselves! Ideally, you will see what
others have done and find the "<u>essential innovation</u>" in each story
and be able to apply that to your organization. It
is truly meant to serve as both an educational platform for stimulating ideas in any
organization, as well as an inspirational read to help you realize that you too
can innovate. Whether you are a CEO, a CIO, a department head, a clinic
manager, a physician, a nurse, an empowered patient, an EHR vendor, an HIT
consultant, or anyone else involved in the healthcare system, we hope this book
helps you in your quest for <b><i>The Healing Edge!</i></b><br />
<b><i><br /></i></b>
<b><u>Reviews, Editorials, Interviews, Webinars...</u></b><br />
<ul>
<li><a href="http://www.amazon.com/Innovation-Information-Technologies-Healthcare-Informatics/product-reviews/1447143264/ref=cm_cr_dp_see_all_btm?ie=UTF8&showViewpoints=1&sortBy=bySubmissionDateDescending" target="_blank">Amazon Customer Reviews</a></li>
<li><a href="http://histalk2.com/2012/12/04/news-12512-2/" target="_blank">HISTalk Blog Review</a> (Dec, 2012)</li>
<li><a href="http://ihealthtran.com/wordpress/2012/12/powerpoint-keynote-presentation-the-healing-edge-where-innovation-meets-information-technology/" target="_blank">IHT2 Keynote Presentation</a> (Dec, 2012)</li>
<li><a href="http://www.clinical-innovation.com/topics/technology-management/healing-edge-intersection-innovative-thinking-and-hit" target="_blank">Clinical Innovation & Technology Article</a> (Jan, 2013) </li>
<li><a href="https://himss.webex.com/himss/lsr.php?AT=pb&SP=MC&rID=63984707&rKey=f278c9dc9a1947ec" target="_blank">HIMSS Innovation Community Webinar</a> (Jan, 2013 - my talk starts about 30 minutes in) </li>
<li><a href="http://thehealthcareblog.com/blog/2013/01/15/new-on-bookshelves-%EF%BF%BCinnovation-with-information-technologies-in-healthca/" target="_blank">Video Interview of Lyle and Chris</a> by Matt Holt on The Healthcare Blog (Jan, 2013)</li>
<li><a href="http://www.clinical-innovation.com/topics/technology-management/healing-edge-intersection-innovative-thinking-and-hit" target="_blank">My Editorial Reviewing Lessons Learned</a> (Feb, 2013)</li>
<li><a href="http://www.nmhnewsblog.org/blog/healing-edge%E2%80%A6-where-innovation-meets-information-technology" target="_blank">Northwestern Memorial Hospital Blog</a> (Feb, 2013)</li>
<li><a href="http://www.healthleadersmedia.com/print/TEC-288958/HIT-Innovations-Spring-from-Strategy-Design-and-Need" target="_blank">HealthLeaders Book Review</a> by Scott Mace (Feb, 2013)</li>
<li><a href="http://www.healthcareinnovationbydesign.com/blogpost/570061/158888/HIxD-Pioneers-Meet-the-Author-Lyle-Berkowitz-MD-FACP-FHIMSS" target="_blank">"The Healing Edge" Webinar</a> via Healthcare Innovation by Design (Feb, 2013)</li>
<li><a href="http://www.healthcare-informatics.com/article/learning-doctors-practice-pushing-towards-innovation" target="_blank">Healthcare Informatics Interview on HIT and Innovation</a> (April, 2013)</li>
<li><a href="http://www.americanehr.com/blog/2013/04/book-review-innovation/" target="_blank">American EHR Book Review</a> (April, 2013): "One of those rare gems that bridges the gap between implementation and use of information technology..."</li>
<li><a href="http://medinnovationblog.blogspot.com/2013/05/bookreview-innovation-with-information.html" target="_blank">MedInnovation Book Review</a> (May, 2013): "This book is not a book about a solitary innovator or great guru, like Steve Jobs, working out of a garage. It is about teamwork in large organizations. It is not about a single transformation idea. It is about multiple ways EHRs [and other HIT tools] are incrementally transforming care."</li>
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Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com1tag:blogger.com,1999:blog-22539915.post-27140660172615612142013-01-29T09:49:00.001-06:002013-02-12T12:19:29.343-06:00 In Defense of Copy-Forward!The wonderful folks at HISTalk posted my thoughts "<a href="http://histalk2.com/2013/01/28/readers-write-in-defense-of-copy-forward/" target="_blank">In Defense of Copy Forward</a>" this week (full text below), and as usual - I've had additional thoughts on it... especially when one of my CMIO colleagues said that their auditing folks were actually asking him to look into plagiarism software! Here was my response to that, as well as some ideas on how we might address the ugly side of Copy Forward (especially on the inpatient side):<br />
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<span style="font-family: inherit;">Folks - our role as CMIOs is often to serve as the bridge between
real-world clinicians and pie-in-the-sky (or at least non-clinically oriented)
legal/admin/executives/IT/politicians, etc… And one of our chief
responsibilities is thus to bring everyone <b>back to common sense</b> when
hysteria starts to set in.<o:p></o:p></span></div>
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<span style="font-family: inherit;">So please, everyone take a breath - and repeat, "If I am
asked to review plagiarism software for my organization, I will tell them they
are off their freakin' rocker"… and make them write it down 100
times. </span><span style="font-family: inherit;">Or maybe I will make a deal, if we use it on medical records,
then we can also use it on all their legal documents, managed care contracts,
annual reports, etc... again, let's just use common sense! </span><span style="font-family: inherit;">We are </span><u style="font-family: inherit;">supposed to be using standardized
format and structure</u><span style="font-family: inherit;">… so it is expected that notes should be 60-90% similar
from visit to visit, or day to day in the hospital. On the other
hand, I know it can get bad - especially on the inpatient side, especially in an
AMC where residents, students, fellows and attending are all writing notes!</span></div>
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<span style="font-family: inherit;"><b>So what can we do? </b>Telling docs to not use a key functionality
doesn't make sense and is very much the "bad apple" approach of
punishing everyone because a few abuse the system. We need to think about
big picture innovations we can do to improve the system for everyone. </span><span style="font-family: inherit;">I think there are two core issues we need to figure out:</span><br />
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<span style="font-family: inherit;"><b>(1) Multiple authors:</b> For this issue, I'd
suggest rethinking how notes are created, and consider a multi-contributed
note… similar to a Wiki, but would need to meet the legal
standards. I believe some EMR vendors are exploring the concept of
a multi-contributed note, and I do think there is some balance here in making
it both easy to use and higher quality than what we currently do… which is
often like a mid-1990s version of MS Word.</span><br />
<span style="font-family: inherit;"> <o:p></o:p></span></div>
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<span style="font-family: inherit;"><b>(2) Poorly trained providers:</b> I'd put this issue
on all of us (GME, Informatics, Clinicians)… I think we have not done nearly as
good a job as we should in understanding how to document and then explaining
that to those we teach. And we certainly have not made them feel very
responsible. I think one way to "monitor/measure" this would be
to have random chart audits looking for these type of issues, and present them
in an <u>"Morbidity & Mortality" style format</u> that will make providers take
documentation a bit more seriously… hmm, I actually like that idea!
I hope someone does this and will let me know what happens!</span><o:p></o:p></div>
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<span style="font-family: inherit;">Full text of the original blog:</span></div>
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I’m part of the Association of Medical Directors of Clinical Information Systems (AMDIS), a group of 2,000+ physicians who are the experts in implementing and using EMRs. We have a pretty lively listserv discussion board, and I enjoy seeing what my colleagues are thinking, as well as posting my own thoughts. I especially enjoy posting when I feel like certain studies or comments by non-clinical researchers, administrators, or politicians make us start to question common sense.</div>
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One of my favorite topics recently came up — the fear and horror associated with actually reusing some of a previous note. This usually falls into the concept of "Copy-Forward" (when you copy forward the whole note and then edit for today’s visit), or "Copy-Paste" (when you select certain parts of a past note and just copy that part of it. I posted my reply and thought I’d share and expand a bit.</div>
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So as not to bury the lead, I think Copy-Forward of a note is a great tool and supports both efficiency and quality, when used appropriately. Turning it off is a classic throwing the baby out with the bathwater analogy. To clarify my biases, my thoughts and ideas are mainly from the perspective of an outpatient physician using Copy-Forward over the past decade, but much of this certainly can be applied to the inpatient world in various ways.</div>
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Also, the use of Copy-Paste has some similarities to Copy-Forward, but I agree Copy-Paste is not nearly as efficient and poses more quality issues since it does not have the automatic updating features you might see with Copy-Forward. Here are the points I would suggest we consider.</div>
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First, I am sick of these reports which say that things like, "We used plagiarism software to show that 60-80 percent of a doctor’s note is the same as their last one." Um, of course! Since when did progress notes become creative writing endeavors about coming up with different ways to document diabetes, hypertension, and obesity in the same patient visit after visit?</div>
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The creative parts of doctoring should involve being "House": figuring out the diagnosis, figuring out the best treatment plan, and artfully explaining it all to the patient. It should not be writing Edgar Allen Poe-like short stories to amuse our auditors or confuse our colleagues. Although, it could be fun, hmmm… what if I described a diabetic’s problems with hypoglycemia in Poe’s style: "Arousing from the most profound of slumbers (due to a glucose of 45), the patient states he feels as if he was in a gossamer web of some dream. Yet in a second afterward, so frail may that web have been, he claims to not remember that which he was dreaming."</div>
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Second, there are obvious efficiency benefits to Copy-Forward, but there are very real quality benefits as well. The most obvious is that this type of workflow makes it less likely that important diagnoses will be missed or forgotten over time. Additionally, many systems update certain pieces of data during the Copy-Forward process, so that you can see the most recent results (discussed more below). Obviously incorrect information can be duplicated, especially when a note is being authored by multiple providers over time, but this is where good training and leadership are needed to ensure every provider feels fully responsible for everything in their notes.</div>
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Third, getting rid of Copy-Forward or even Copy-Paste is certainly overkill, but we do need to use some common sense in designing technology, workflows, and processes that make it easy to do the right thing when documenting. In the ideal system, much of the critical data would either be updated automatically (e.g. the most recent lab would appear when a note is copied forward), or the system would date entries so it is clear what was done in the past versus today. To clarify, let me break down how an ideal progress note might look like when Copy-Forward is used:</div>
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<u style="background-color: transparent; border: 0px currentColor; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Allergies, Meds, Problems </u><br />
These update automatically, which is great, and means the note has the most recent data. I would hope all EMRs have this functionality already.</div>
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<u style="background-color: transparent; border: 0px currentColor; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Past Histories (Social, Surgical, Family) </u><br />
These copy forward and allow for easy editing in the note. Ideally, they could be managed in a widget external to the note and have them update from those profiles as well.</div>
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<u style="background-color: transparent; border: 0px currentColor; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Physical Exam </u><br />
Want to ideally be able to view old physical exams, and even reuse them when desired (except for vitals). In my current system, the full exam (sans vitals) does copy forward. So I usually just delete it and drop in a new macro and edit that. However, some patients have findings I want to compare from last time (e.g. size of a rash), or consistent findings (e.g. murmur) which I want to be reminded about</div>
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<u style="background-color: transparent; border: 0px currentColor; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Labs/Studies </u><br />
For labs (e.g. CBC, chem, chol profile) and certain studies (e.g. mammogram results, last ECG), we use macros which "auto-updatem" so when a note is copied forward, they update automatically to the most recent dates and values.</div>
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<u style="background-color: transparent; border: 0px currentColor; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">HPI/Impression/Plan </u><br />
As some have heard me detail before, I use a form of "problem-oriented charting" in which I type out the history, impression, and plan for a diagnosis (e.g. diabetes) or system/problem area (e.g. "GI issues") all on one line. I also use a macro which includes the date of the entry and my initials.</div>
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<li style="background-color: transparent; border: 0px currentColor; margin: 0px 0px 0px 25px; outline: 0px; padding: 0px; vertical-align: baseline;">Example for a diabetic patient. "01/19/13(LLB): Stable on Metformin 500bid, CS 100-120s before meals, no med side effects or other complaints. Impr: Stable DM, PLAN: CPM, labs, rtc 4 mos". No flourish is needed. The result is that when copied forward I can see the last time I addressed the DM and if I made any changes. In the same "area" for the problem, I would also have a list of relevant meds, labs, and testing results (e.g. ECGs and ECHOs for hypertension). This way I can see everything I need about a problem all in one place – which means I can make quicker and more accurate decisions.</li>
<li style="background-color: transparent; border: 0px currentColor; margin: 0px 0px 0px 25px; outline: 0px; padding: 0px; vertical-align: baseline;">Summarizing old entries over time. I will either retain the old entry, or can summarize over time (e.g. I might take four entries from 2012 and summarize into one line such as, "2012: Dx with DM 4/12, added Metformin 500qd, 6/12 incr to 500 bid and did well").</li>
<li style="background-color: transparent; border: 0px currentColor; margin: 0px 0px 0px 25px; outline: 0px; padding: 0px; vertical-align: baseline;">Multiple issues. Since I often address multiple issues in a given visit, I created a line which reads, "Problems below not addressed this visit" so that I can clearly demarcate what I did and did not address on a certain day. I think this method is extremely efficient and higher quality than the method of trying to document all the HPI about multiple issues at the top of a note, and then separating out the Impr/Plan at the bottom.</li>
<li style="background-color: transparent; border: 0px currentColor; margin: 0px 0px 0px 25px; outline: 0px; padding: 0px; vertical-align: baseline;">What is a SOAP note? Larry Weed, MD devised the concept of problem-oriented charting 50 years ago, but I think it’s fair to say we have over-complicated it over time. The SOAP note is supposed to be based around a problem. In other words, each problem should have a documentation area for Subjective, Objective, Assessment and Plan. Instead, we create one large SOAP note where we break away all the Subjectives into their own paragraph ("HPI"), thereby distancing your thinking about the complaint and what we are going to do about it. I hope we will soon see more EMRs going "back to the future" by embracing the true problem oriented charting philosophy.</li>
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Fourth, the outpatient world is different from inpatient, but there are similarities. I understand that inpatient notes can be more difficult to manage due to quickly changing problems, and especially multiple authors. Personally, I hope we put some more thought into the concept of an "Inpatient Wiki," a single type of inpatient note that can automatically pull in the relevant information for each specialty (e.g. different for medicine, OB, and various types of surgery). Then each author could see what they need to see – it would pull in the labs, tests, consult suggestions, or a nursing note – why make the doctor repeat this themselves every time?</div>
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The care provider would then be prompted to write what they are supposed to add, and the note would be a living document which flexes to the individual, but can be time-stamped for medico-legal purposes as well. It could have clear sections (similar to above), as well as an organ or system based areas (e.g. Cardiology issues, GI Issues, Neuro Issues, F/E/N issues) for documenting the SOAP note .</div>
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In summary, I would go as far as to say that we need to change our paradigm to "The Note is the Chart." The chart should no longer be a collection of distinct and incomplete notes, but rather the last note can really be the complete chart which contains everything a provider needs. If we do this, then we can reframe our expected workflow from, "You need to read every note ever written to understand the full patient" to, "You just need to read the last note".</div>
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The result: when a patient goes to the ER or sees another doc, those providers will find that the most recent note in the system will have all the info they need, so they won’t need to try and dig through 48 notes over 10 years (and let’s face it, they never do that anyway). Granted, the paper record allowed for a much easier way to flip thru past notes, but sooner or later we have to acknowledge that computerized systems have different attributes than paper. We can either keep trying to force the computer to act like paper, which never works out well, or we can start embracing the differences and truly take advantage of them.</div>
<br />Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com0tag:blogger.com,1999:blog-22539915.post-35225070396016846202013-01-06T13:47:00.002-06:002023-02-04T12:48:45.978-06:00We Don’t Have a Shortage of PCPs, We Have a Shortage of Using Them EfficientlyI've been asked to serve as the "Innovator-at-Large" (aka Editor-at-Large) for the magazine "<a href="http://www.clinical-innovation.com/" target="_blank">Clinical Innovation and Technology</a>"... which I was happy to accept as it's the perfect intersection of my worlds!. In my first post, I've expanded on a phrase I've been using for several years - that "<i>We Don’t Have a Shortage of PCPs, We Have a Shortage of Using Them Efficiently</i>". I go on to describe the future of healthcare in a world where innovation and IT are being used to their potential to make life easier for physicians and better for patients (of course assuming our reimbursement system equally evolves). I hope it inspires you!<br />
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<u><b><a href="http://www.clinical-innovation.com/topics/practice-management/we-don%E2%80%99t-have-shortage-pcps-we-have-shortage-using-them-efficiently" target="_blank">We Don’t Have a Shortage of PCPs, We Have a Shortage of Using Them Efficiently</a></b></u><br />
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Every few months another study warns of a severe shortage of primary care physicians (PCPs) in the future. A recent report published in the Annals of Family Medicine explained how we will require 52,000 more PCPs by 2025 due to population growth, aging demographics and insurance expansion (<span style="font-family: monospace;">Reference: 1. Ann Fam Med 2012;10(6):503-509)</span>.</div>
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Fortunately, both clinical IT and innovation will deeply change medicine over the next decade, resulting in a new paradigm with the potential to improve both efficiency and quality of care. In this paradigm, software will be able to automate or delegate much of the routine care usually provided by physicians. If automated systems and empowered staff members manage stable patients according to evidence-based protocols, physicians can focus on more complex patients who truly require their attention. Individual physicians will actually see fewer patients, but oversee a team who will care for more patients. Thus, we won’t need more physicians; we will just need a better system to help most appropriately leverage physicians, staff and IT.</div>
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A typical physician’s office in 2025 might look something like this: Dr. Blake Willoca arrives around 9a.m. and sits in front of a bank of computers and video screens. Dashboards provide real-time analysis of the status of his panel of 5,000 patients. Patients in the Green Zone will be managed mainly by computerized systems which check on patients virtually to provide positive feedback and ensure they stay on track. Meanwhile, patients in the Yellow Zone will be visited by the physician’s care team at home or work, or perhaps have a virtual conference with the physician to answer their questions. Finally, those patients in the Red Zone will be seen in the office or home for longer sessions with the physician and his or her care team to help determine what is going on and how to get it under control. Today, Dr. Willoca will spend an hour with each of these four Red Zone patients in his office, he will do five-minute video conferences with staff members taking care of 20 Yellow Zone patients, and he will spend some time in a virtual reality game teaching med students about how this new system works. As Dr. Willoca leaves his office at 5p.m., he knows he’s helped the patients who most needed it today in a relaxed and livable manner, and he knows that his IT tools and care teams will continue to monitor and help manage his patients 24 hours a day. </div>
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This might all seem like a PCP’s dream, but we need to recognize and accept that we are the generation who will make this happen. There is much to do in healthcare, and there could not be two greater tools to use than clinical innovation and IT.</div>
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<samp style="font-family: sans-serif;"><span style="font-family: 'Times New Roman';">Online at </span></samp><a href="http://www.clinical-innovation.com/topics/practice-management/we-don%E2%80%99t-have-shortage-pcps-we-have-shortage-using-them-efficiently" target="_blank">http://www.clinical-innovation.com/topics/practice-management/we-don%E2%80%99t-have-shortage-pcps-we-have-shortage-using-them-efficiently</a><br />
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ADDENDUM<br />
As questions come up on this article and topic, I'll make sure to post answers here.<br />
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* <b>Barriers</b>: Someone asked why we don't see more of this type of attitude from doctors? My answer: I think there are two main barriers we need to overcome to increase the spread of this type of "team-based CDS" which automates and delegates clinical work: First, we need to continue to better align incentives (i.e. Value-based vs. Volume-based reimbursement and legal systems)... How can we expect doctors to delegate work if they are not protected financially or legally from doing just that? Second, we need to make CDS easy and intuitive to use and ideally integrate them fully and elegantly into our EMR systems (see examples below of companies working on these types of tools).<br />
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* <b>Speed</b>: Someone asked why this can't happen sooner (i.e. why did I say 2025 instead of 2015). It's a good point, as I think it is technically feasible today. I used 2025 because (1) It was the year used in the article I initially quoted about MD deficits, and (2) I did want to describe a future world where this vision of team-based care and HIT would be completely common and routine, not simply possible. I think there are financial and legal issues which will slow it down, but I also think that we will be seeing more and more of this happening in the near term as well - just not as widespread and pervasive as we'd like for another 10 years or so. <br />
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* <b>Risk Stratification:</b> Someone asked how many patients would fall into the Green/Yellow/Red zones. <a href="http://www.ahrq.gov/research/ria19/expendria.htm" target="_blank">Studies</a> have shown that 1% of the population accounts for 20 - 30% of the cost, and 5% account for 50%, whereas the healthiest 50% account for just 3% of the total cost. So I'd suggest the "Red Zone" is about 5% (e.g. 250 patients in a panel size of 5000), the Yellow Zone would be around 20% (1000 in a panel size of 5000), and then the other 75% in the green zone. Using another way to measure it, today's typical panel size is 2500, which requires a PCP to see about 25 of these patients in a given day. If the panel size were 5000, the old system would require them to see 50 patients a day. In the "new" system, I'd suggest they will need to see about 5 "Red Zone" patients a day in the office while interacting with another 20 "Yellow Zone" patients (or answer questions for their staff members) - which could take anywhere between 1-5 minutes. The reason that this number stays relatively high is that the Red and Yellow patients do need to be actively managed on an ongoing basis - some will eventually move into Green territory, but others simply have too many interacting or unique problems and medications which are beyond the scope of even advanced protocols and is where the cognitive skills of physicians will shine. Of course, when artificial intelligence gets good enough to figure all these things and how to communicate it all to patients - then we may see even more automation in healthcare... but if/when computers have gotten that good - we will likely see automation in every other professional career as well - from lawyers and judges, to politicians and marketers, to stockbrokers and Venture Capitalists. In other words, while I agree with <a href="http://techcrunch.com/2012/01/10/doctors-or-algorithms/" target="_blank">Vinod Khosla's assessment</a> that we will see HIT further automating healthcare... I don't think it will "replace 80% of doctors" - but it will allow us to effectively leverage the current amounts of physicians.<br />
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<b><u>Companies Making "Physician Efficiency Apps" (or "Doctor Happiness Tools" as I like to call them)</u></b><br />
* <a href="http://www.healthfinch.com/" target="_blank">healthfinch</a>: A cloud-based decision support system which integrates with EMRs to automate and delegate repeatable work away from physicians and towards their staff in a safe and consistent manner (e.g. Medication Refills). I founded this company in 2011 with two very smart HIT experts focused on human-centered design, and have mentioned in some past blogs about "<a href="http://drlyle.blogspot.com/2012/11/saving-primary-care-computerized.html" target="_blank">Saving Primary Care with Team-based Delegation Software</a>" and another about "<a href="http://drlyle.blogspot.com/2012/10/why-next-wave-of-health-it-innovation.html" target="_blank">EMR Extender Tools creating Doctor Happiness</a>". The first product, <b>RefillWizard</b>, which integrates with some of the main outpatient EMRs to help decrease the amount of
time doctors must spend approving medication renewal requests, saving them up
to 30 minutes daily. If we apply that 30 minutes of savings to the 400,000
primary care physicians in the US, we can effectively<u> "create" 25,000
new physicians</u>—half the expected shortfall in physicians caused by population
growth, aging demographics and insurance expansion! Now just create a few more of these and we save the healthcare system!<br />
* <a href="http://www.healthloop.com/" target="_blank">healthloop</a>: Automates the "follow-up" process to check on patients after their in-person visits. Founded by Dr. Jordan Shlain, another of the rare but growing breed of working PCPs who understands how HIT can help make life easier for docs and patients and is building tools to fulfill that vision.<br />
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<b><u>Other Relevant Articles</u></b><br />
* <a href="http://content.healthaffairs.org/content/32/1/11.abstract" target="_blank">Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication</a>, Health Affairs, Jan, 2013 (vol. 32, no 1): 11-19. Says that there will not be a doctor shortage as long as we optimally utilize team-based care and HIT.<br />
* <a href="http://www.annfammed.org/content/10/5/396.full?sid=22aa5692-d474-4367-a37d-587dd69abfa2" target="_blank">Estimating a reasonable patient panel size for primary care physicians with team-based task delegation</a>. Altschuler J, Margolius D, Bodenheimer T, Grumbach K. Ann Fam Med. 2012 Sep-Oct;10(5): 396-400. doi: 10.1370/afm.1400. Estimates how much care can be delegated in a team-based model, and thus what an optimal panel size could be to do perfect care.<br />
* <a href="http://www.modernhealthcare.com/article/20130111/NEWS/301119966?AllowView=VW8xUmo5Q21TcWJOb1gzb0tNN3RLZ0h0MWg5SVgra3NZRzROR3l0WWRMWGJWZndBRWxiNUtpQzMyWmVxNW4wWUpicW4=&utm_source=link-20130111-NEWS-301119966&utm_medium=email&utm_campaign=hits" target="_blank">Project Doc Shortage is Real, Experts Say</a>. Modern Healthcare, Jan, 2012. Discusses that while team-based care and HIT will improve efficiency, we will still have some need for more PCPs - especially in underserved areas. <br />
* <a href="http://www.cnbc.com/id/100546118" target="_blank">Doctor Shortage Getting Worse</a>. A CNBC article (Mar 13, 2013) where they use the usual claims (again, based on the current model of care) and I appear to be the "poster doc" for the concept of using IT to improve efficiency and save time. My section: And one expert says it's not so much a scarcity of physicians but of using them in the right way. "We don't need more physicians, but rather better "team-based workflow tools" to ensure that everyone on the team can work to the highest level of their ability in a safe and efficient manner every day," said Dr. Lyle Berkowitz, Associate Chief Medical Officer of Innovation for Northwestern Memorial Hospital. "That means using information technology and freeing physicians to spend their time on more complex patients," Berkowitz added.</div><div style="background-color: white;">* <a href="https://www.medicaleconomics.com/view/what-doctor-shortage-" target="_blank">What Doctor Shortage?</a> Published in Medical Economics (Jan, 2023) - I revisited this topic 10 years after the original post and talk more about the execution of expanding panel size via a combination of technology and virtual team-based care. This is playing out in real life with my new company <a href="http://www.Keycare.org" target="_blank">KeyCare</a> (where we provide health systems access to a tech-enabled virtual care workforce practicing on an Epic platform optimized for telehealth).</div><div style="background-color: white;"><br />
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Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com1tag:blogger.com,1999:blog-22539915.post-77928680890266982582012-11-02T00:43:00.002-05:002012-11-09T10:40:03.148-06:00Saving Primary Care: Team-Based Delegation Software may be our Best Chance!<span style="color: black; font-family: Times New Roman;"></span><br />
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This <a href="http://annfammed.org/content/10/5/396.full" target="_blank">new article by Bodenheimer, et al</a>. points out
that our current system (making docs do everything) is absolutely not
sustainable. So what can we do? It turns out<b> the critical solution to make our system sustainable is to start
delegating certain activities to the physician's team using protocols! </b></div>
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But now I'll ask the more tactical question - <b>does anyone expect us to use paper based protocols???</b> We all know those are hard to maintain and no one actually looks at them. So what if there was a new type of healthcare IT software which could hold all these protocols in "the cloud", and then apply them against the data stored in EMRs, and then send back specific messages into the EMR - pushing the right information to the right person on the team. In other words, automating the process so everyone works "to the height of their license".</div>
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Is there an app for that? YEP!! I've been working with the great team at <a href="http://www.healthfinch.com/" target="_blank">healthfinch</a> the past two years to develop this type of "<b>Team-based Delegation Software</b>" which uses a cloud-based protocol system (all protocols are held and edited in the cloud) integrated with a variety of EMRs to produce a "team-based decision support and workflow tool" that saves physicians time, while also ensuring high quality care is delivered in a consistent and documented way by their team. </div>
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We have <a href="http://www.refillwizard.com/" target="_blank">RefillWizard</a> for medication renewal requests (this alone saves docs 30 minutes a day)… and we plan to keep making more on the electronic delegation platform that has been developed. We seem to be in the RIGHT space at the RIGHT time! :)</div>
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<i>For more info, here is a summary of the Bodenheimer article from a Medical Economics story:</i></div>
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<b><u><a href="http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=794106" target="_blank">Study: PCPs must delegate some preventive, chronic care</a><o:p></o:p></u></b></div>
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Publish date: Oct 25, 2012<br />
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There is one primary care physician per 1,500 Americans, yet
most PCPs have panel sizes in excess of 2,000 patients. With no surge in PCP
numbers expected anytime soon, a new report suggests a shift from
physician-based care to team-based care, with PCPs delegating up to 77% of
preventive services to non-clinicians. <o:p></o:p></div>
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“Our nation will need to implement models that reengineer
the delivery of primary care and deploy our physician supply in a more
efficient manner,” say researchers from the University of California at San
Francisco in a new paper titled, <a href="http://annfammed.org/content/10/5/396.full" target="_blank"><i>“Estimating a Reasonable Patient Panel Size for Primary Care Physicians with Team-Based Task Delegation.”</i></a> The paper was published in the <a href="http://www.annfammed.org/" target="_blank">Annals of Family Medicine</a>
in the September/October 2012 issue. <o:p></o:p></div>
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The average PCPs panel size is too large to deliver
consistently high quality care, according to the report. Researchers estimated
that it would take a PCP nearly 22 hours a day to provide all the recommended
care for the average 2,300-patient panel. But decreasing PCPs means panel sizes
will continue to rise, especially considering about half of all Americans have
at least one chronic condition. <o:p></o:p></div>
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The study highlights two alternative practice models that
might hold the key to solving this dilemma. The first model is to reduce panel
sizes so physicians can provide comprehensive patient care. Concierge medicine,
for example, utilizes panel sizes of 200 to 600 patients. However, without
enough PCPs to go around using this type of model, the study determines this
model would leave many patients without primary care. <o:p></o:p></div>
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The alternative model, the Organized Team Model, advocates
building primary care teams that delegate patient care responsibilities among a
healthcare team, allowing the physician to practice high-quality care without a
large, but manageable panel size. Screening and performing certain tests should
be left to the physician, according to the report, but tasks such as
administering immunizations could be delegated to non-clinicians—with the
clinicians explaining the services to their patients. All routine preventive
counseling could be delegated, the report authors note, freeing up too
three-quarters of a PCP’s time. <o:p></o:p></div>
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For chronic disease management, the report recommends that <b>PCPs
could delegate 75% of the time spent on chronic cases in good control and 33%
of the time spent on patients in poor control</b>. Non-clinicians could provide
most of the routine chronic services such as patient education, behavior-change
counseling, medication adherence counseling and <u>protocol-based services
delivered under standing physician orders.</u> <o:p></o:p></div>
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Overall, this model would allow 77% of preventive care and
47% of chronic care to be delegated to non-clinical staff. All acute care would
be provided by physicians, the authors note. The study does not address
the additional staff training that would be needed to prepare non-clinicians to
handle additional tasks, or the payment reform that would be needed.
<o:p></o:p></div>
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“Such an unprecedented change in both the culture and
structure of primary care practice can be accomplished only through a change in
clinical mindset, the training on non-clinician team members, the mapping of
workflows and tasks, the creation of standing orders that empower
non-clinicians to share the care, the education of patients about team-based
care, and the reform of primary care payment,” the study authors conclude. <o:p></o:p></div>
Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com0tag:blogger.com,1999:blog-22539915.post-9173314536573871992012-10-04T23:54:00.002-05:002012-11-09T10:26:36.343-06:00Why the next wave of health IT innovation will build on EMRs, cater to “physician happiness”<div class="MsoNormal" style="line-height: 19.6pt; text-align: left;">
<span style="font-size: 12pt; line-height: 115%;">I am always impressed when a reporter can ask a few
questions, listen to me talk for 30 minutes, and then assemble it into a great
article which really explains my thoughts well... and I am even more amazed when they can
do it in 24 hours! Thanks to reporter Deanna Pogorelc from MedCityNews
for doing such a great job - and I love the title too: <a href="http://medcitynews.com/2012/10/why-the-next-wave-of-health-it-innovation-will-build-on-emrs-cater-to-physician-happiness" target="_blank">Why the next wave of health IT innovation will build on EMRs, </a></span><span lang="EN" style="font-size: 12pt; line-height: 115%;"><a href="http://medcitynews.com/2012/10/why-the-next-wave-of-health-it-innovation-will-build-on-emrs-cater-to-physician-happiness" target="_blank">cater to “physician happiness”</a>... Here it is (with a few bolds and comments in brackets from me):</span></div>
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<span style="font-family: Georgia, Times New Roman, serif;"><span lang="EN" style="color: #333333;">There’s no <a href="http://medcitynews.com/2010/12/not-enough-doctors-states-should-solve-the-problem/" target="_blank">shortage of primary physicians</a>, but rather<b> a shortage of primary physicians who are able to use their time efficiently </b>in today’s healthcare environment. </span><span style="color: #333333; line-height: 12.1pt;">That’s why the industry is moving away from the first version of the </span><a href="http://medcitynews.com/tag/emr/" style="line-height: 12.1pt;" target="_blank">EMR</a><span style="color: #333333; line-height: 12.1pt;">, according to </span><a href="http://www.drlyle.com/" style="line-height: 12.1pt;" target="_blank">Dr. Lyle Berkowitz</a><span style="color: #333333; line-height: 12.1pt;">, the associate chief medical officer of innovation at Northwestern Memorial Hospital and Medical Director of IT & Innovation at for Northwest Memorial Physicians Group in </span><a href="http://medcitynews.com/tag/chicago/" style="line-height: 12.1pt;" target="_blank">Chicago</a><span style="color: #333333; line-height: 12.1pt;">. </span></span><br />
<span style="color: #333333; font-family: Georgia, Times New Roman, serif; line-height: 12.1pt;"><br /></span>
<span style="font-family: Georgia, Times New Roman, serif;"><span style="color: #333333; line-height: 12.1pt;">The inaugural EMRs are basically computerized versions of paper records that </span><span style="color: #333333;">weren't</span><span style="color: #333333; line-height: 12.1pt;"> necessarily designed with usability in mind, he noted. So rather than saving time and making administrative processes easier, they’re in some cases adding to doctors’ workloads.</span></span><br />
<span style="font-family: Georgia, Times New Roman, serif;"><span style="color: #333333; line-height: 12.1pt;">[Or as many say - they focused on just documentation and billing, not clinical workflow] </span></span></div>
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<span lang="EN" style="color: #333333; font-family: Georgia, Times New Roman, serif;">Enter the next wave of health IT innovators, who are taking EMR data and
using it elsewhere to improve workflow. “(EMR vendors) are kind of stuck to
Meaningful Use and creating a standardized format to make sure everybody is at
the first-base level,” Berkowitz said. “That’s a good start, but <b>we have to
start building tools that can fit on top of these</b>. A whole ecosystem is going
to build up on top of EMR systems to make them easier and faster to use.”</span><br />
<span lang="EN" style="color: #333333; font-family: Georgia, Times New Roman, serif;">[Check out the ONC <a href="http://www.healthit.gov/policy-researchers-implementers/meaningful-use-stage-2-0/standards-hub" target="_blank">Standards Hub</a> to see how Meaningful Use Part 2 will require all EMR vendors to adhere to certain standards which will make it even easier for 3rd party vendors to work with them]</span></div>
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<span style="font-family: Georgia, Times New Roman, serif;"><span lang="EN" style="color: #333333;">And, it seems that
EMR companies are getting on board with that as well. </span><span style="color: #333333; line-height: 12.1pt;">“They buy into
this idea that innovation comes from the outside by saying, we’re going to open
up our system and let others build on it,” he said. “</span><a href="http://medcitynews.com/tag/allscripts/" style="line-height: 12.1pt;" target="_blank">AllScripts</a><span style="color: #333333; line-height: 12.1pt;"> I think is </span><a href="http://www.healthdatamanagement.com/news/allscripts-physician-hospital-integration-open-architecture-44849-1.html" style="line-height: 12.1pt;" target="_blank">leadingthe charge</a><span style="color: #333333; line-height: 12.1pt;">. Athenahealth is moving that way, and some others. EMR vendors
are going to be end up being able to provide more and more solutions to their
users this way.”</span></span></div>
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<span lang="EN" style="color: #333333; font-family: Georgia, Times New Roman, serif;">EMR extender
companies have been around for a while; business intelligence and data
analytics are well-established industries. But we’re seeing the <b>dawn of a new
category of innovation focused on workflow tools to make doctors more productive
and efficient – what Berkowitz calls “physician happiness.”</b><o:p></o:p></span></div>
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<span lang="EN" style="color: #333333; font-family: Georgia, Times New Roman, serif;">There’s evidence
of that, in the form of companies like Modernizing Medicine, which makes a
touch-based “<a href="http://medcitynews.com/2012/09/touch-based-mobile-emr-and-then-some-for-dermatologists-coming-to-other-specialties-this-fall/" target="_blank">electronicmedical assistant</a>” for specialists, and SchedFull, which is working on a
way to help <a href="http://medcitynews.com/2012/09/doctors-this-physician-entrepreneur-wants-to-cut-back-lost-time-from-canceled-appointments/" target="_blank">physiciansfill canceled appointments</a> that it hopes to integrate with web-based EMRs.<o:p></o:p></span></div>
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<span lang="EN" style="color: #333333; font-family: Georgia, Times New Roman, serif;"><b>There’s also <a href="http://www.healthfinch.com/" target="_blank">healthfinch</a>,</b> the company Berkowitz
co-founded with designer Jonathan Baran and programmer Ash Gupta in 2010. It’s
focused on <b>making the practice of medicine more enjoyable for physicians by
letting them focus on the higher-order thinking they’re good at, rather than
spending their time on paperwork.</b> (He compared this to the process of making a
new car, and the absurdity of the idea that the people who design technology
for the cars would spend part of their time working on the assembly line.)</span><br />
<span lang="EN" style="color: #333333; font-family: Georgia, Times New Roman, serif;">[What I was trying to say is that a car company knows that their smart car engineers should spend time on solving problems and designing
cars, not on screwing in car seats… let them focus on the higher order stuff, and
delegate the assembly line work to the people on the floor… another
analogy would be that you don't walk into a bank and ask the VP to withdraw
$200 - you go to the teller, or the ATM!]<o:p></o:p></span></div>
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<span lang="EN" style="color: #333333; font-family: Georgia, Times New Roman, serif;">The place where
doctors can best apply their skills is the 10 to 20 percent of very sick,
complex patients they see, Berkowitz said. That’s precisely why healthfinch
focuses on the other 80 percent of patients who might be fairly stable. By
creating protocols and automated processes for meeting the needs of these
stable patients, other staff members can work together to take care of them,
and the doctor has more time to spend with sicker patients.<o:p></o:p></span></div>
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<span lang="EN" style="color: #333333; font-family: Georgia, Times New Roman, serif;">Its first product
focuses on using data to design a protocol for handling medication refills.
Doctors receive many refill requests every day, many of which require them to
review charts to ensure patients have completed follow-ups or lab tests. Some
of this work could be delegated to the nursing staff or medical assistants. To
make that happen,<b> <a href="http://healthfinch.com/how/analysis" target="_blank">RefillWizard</a>
leverages EMRs to help practices manage prescriptions more efficiently</b>.</span><br />
<span lang="EN" style="color: #333333; font-family: Georgia, Times New Roman, serif;">[By using their rules based workflow software to allow for safe and easy delegation of tasks away from docs and towards their team]</span></div>
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<span lang="EN" style="color: #333333; font-family: Georgia, Times New Roman, serif;">Healthfinch plans
on using the same technology and philosophy to continue developing products
that will save doctors more time by using every person on the staff to the
highest level of his or her licensure. </span><span style="color: #333333; font-family: Georgia, 'Times New Roman', serif; line-height: 12.1pt;">“I’m always on the
lookout for things I do repetitively, to see if they can be
automated,”Berkowitz added, in illustrating what inspires his innovation. “I’m
always trying to figure out how to take something I do in 20 steps and cut it
down to five steps or, even better, zero steps.” [That's one of our new slogans - "<b>The Power of Zero</b>"!]</span></div>
Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com0tag:blogger.com,1999:blog-22539915.post-36821919966891156912012-10-03T00:12:00.002-05:002013-02-11T23:15:19.779-06:00Abuse of EMRs? Really - Let's Take a Closer Look!The New York Times recently published an article called "<a href="http://www.nytimes.com/2012/09/26/opinion/abuse-of-electronic-medical-records.html" target="_blank">Abuse of Electronic Medical Records</a>", in which they started off by saying "<i><span style="background-color: white; font-family: georgia, 'times new roman', times, serif; font-size: 15px; line-height: 22px;">The Obama administration </span><a href="http://www.nytimes.com/2012/09/25/business/us-warns-hospitals-on-medicare-billing.html" style="background-color: white; color: #666699; font-family: georgia, "times new roman", times, serif; font-size: 15px; line-height: 22px;" target="_blank" title="A Times article">has issued a strong and much-needed warning to hospitals and doctors</a></i><span style="background-color: white; font-family: georgia, 'times new roman', times, serif; font-size: 15px; line-height: 22px;"><i> about the fraudulent use of electronic medical records to illegally inflate their billings to Medicare.</i>"</span><br />
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REALLY?!?! Let's take a closer look: First, the evidence is that billings and coding has gone up over the past 5 - 10 years, and EMR vendors tout better billing as one of their benefits. Hmmm... that's not exactly a smoking gun.<br />
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But fair enough, so let's review why we might get increasing billings and coding:<br />
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<b>1. The EMR makes it easier to code appropriately.</b> I hate when they say "upcode", which implies fraud. Rather, I think that many doctors (especially primary care and other non-proceduralists) have undercoded for years... and the EMR actually allows them to document all the "thought work" they have been doing for a long time. The E/M system was designed to help value "thinking doctors" - and it's starting to work! Let's applaud that, not try and make it sound like fraud.<br />
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<b>2. The EMR allows docs to do more at a single visit.</b> I think this is an often overlooked reason to explain what has happened. I know in my practice that having an EMR allows me to get to more things in a single visit than in a paper-based system. So without an EMR, if a patient came in for a sprained ankle - I might just take care of that and told them to come back for their other issues. With an EMR, it makes it easier to see everything at once and manage multiple issues. This is an incredibly GOOD thing for the patient, and for the system - since one "bigger visit" (e.g. "Level 4") is cheaper and more efficient than two "smaller visits" (e.g. Level 3). So maybe the government should not just look at billings, but also at the total number of visits a patient had - and see if that decreased over the past 5 - 10 years... maybe because docs were doing more work in less visits! <br />
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Oh wait, they did do this!? One of my favorite blogs (<a href="http://histalk2.com/2012/10/02/news-10312/" target="_blank">HISTalk</a>) actually ran this snippet of info today: <i>The Census Bureau <a href="http://www.census.gov/prod/2012pubs/p70-133.pdf" target="_blank">says</a> adults under age 65 made an average of 3.9 visits to
physicians in 2010, down from 4.8 visits in 2001. Possible explanations: more
uninsured, fewer physicians, higher patient costs, i<u>nnovation that allows
providers to accomplish more in a single visit</u>, and more meds available without
a prescription.</i> So maybe the attorney general and HHS could talk to their own colleagues a bit more before throwing around accusations slandering docs who use EMRs?<br />
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<b>3. Docs are using EMRs to defraud the government.</b> Obviously, there will always be some small amount of doctors who commit fraud - whether that is on paper or EMRs... but I certainly don't think that using an EMR all of a sudden makes doctors more fraudulent. And by the way, since this fraud is happening in both paper and IT systems... I'd appreciate if our government didn't just pick on EMRs, and said something like this instead: "We know most doctors are outstanding citizens who give of their time to help others, but there are a few who commit fraud... and whether they do so on paper or EMRs - we will find them and prosecute them! And while healthcare IT may make it easier for some to perform some fraud, it also makes it easier for us to catch them - so watch out bad guys!" <br />
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<b><u>Addendum</u></b><br />
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<li><a href="http://www.healthdatamanagement.com/issues/21_2/Coding-Up-Down-or-Around-45627-1.html" target="_blank">Coding: Up, Down or Around? </a>I'm quoted in this HDM article - basically saying EMRs make us more efficient docs and better coders (in contrast to the HHS report trying to make EMRs sound like fraud machines)!</li>
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Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com1tag:blogger.com,1999:blog-22539915.post-91795468684929644352012-08-13T01:41:00.000-05:002012-08-19T10:12:55.544-05:00Reducing ReAdmissions... Another Obvious Thing We Need To Do!Reducing readmissions is a very hot topic now since the government and other payors are starting to create an incentive system which punishes hospitals who have high readmission rates (at least for some of the top categories like CHF and Pneumonia), they do this by basically saying they will not pay if the patient is readmitted within 30 - days of discharge. So I do like the idea of creating well aligned incentives... as long as there is also upside to doing things well.<br />
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So how can a hospital succeed here? CSC recently published a <a href="http://assets1.csc.com/health_services/downloads/CSC_Preventing_Hospital_Readmission.pdf" target="_blank">report about reducing readmissions</a>. Key Points include: <br />
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• Hospital efforts to reduce readmissions have become more visible and important because of the financial stakes — disincentives being incorporated into payment reform — are now high enough to be noticeable in the bottom line. <br />
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• Variability in rates across hospitals and regions of the country suggests that significant reductions are possible if practices in better performing hospitals are adopted more uniformly. <br />
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• Current measures employed in Medicare incentives target acute care hospitals and high-risk patients defined as those with heart failure, pneumonia, or an acute myocardial infarction. Any re-hospitalization to any hospital within 30 days, for any condition, is counted. <br />
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• Preventing readmissions is very challenging because so many community and patient factors contribute to the problem, many of them outside of the direct control of the hospital. <br />
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• However, research, combined with practices in hospitals with a track record of reducing readmissions, shows that comprehensive discharge planning and post-discharge care and support during the transition period reduces readmissions in high-risk patients. <br />
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• The next scope of work will be to achieve a formal connection with organized care management for every patient covered by this type of program. <br />
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• As more high-risk patients are covered by these programs, this will decrease the role of the hospital in providing post-discharge care and support, but formally link patients back to organizations accountable for ongoing care. <br />
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• Key elements of the resulting model will be organizing and operating transitional care as a process in its own right, laying out each patient’s transition and hand-off in a time-limited transition clinical pathway, and new uses of health IT in patient tracking and transition care planning.<br />
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So the report states that one major key to reducing readmission rates is patient-centered discharge planning. That absolutely makes sense... but hey - it is certainly not a surprise! The real surprise is simply that it is not done more often (Why? Because payors don't pay for it - they pay for procedures over process or thinking). Like much of what we do, if you ask someone outside of healthcare if they thought we did this routinely - they would assume that of course we did it - it just makes sense to create a highly personalized and integrated discharge plan for a complex medical patient when they are discharged from the hospital.<br />
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Of course, times and incentives are changing, so clearly we will hear about more emphasis on this type of patient centered planning; on the other hand, we will see hospitals having to cut corners by firing discharge planners and asking RNs to do more of it themselves.<br />
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But assuming we are doing more of this, the next issue is "The Details"... will there be a secret sauce or consistent algorithm to make this easy, safe and cheap? Or is it simply about having a smart person use higher order thought processes to create a very personalized approach to each patient. I think it will be a bit of both; the more in the former category - the more likely we can spread this work and make it cost-effective and successful! Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com0tag:blogger.com,1999:blog-22539915.post-42778445307630767272012-07-15T16:19:00.002-05:002012-08-01T17:34:35.285-05:00ER Visit Cost Reduction Theory; Patient "Web Searchers"<br />
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<span style="background-color: white;">I get a lot of eNewsletters sent to me about healthcare IT and innovation - and there are often articles which catch my eye (AWCME). They might talk about an interesting study or person, and when I read them I have some immediate thoughts because it resonates with my experiences or thinking in some way. I'll sometimes do a quick post to FB or twitter so I can track the stories, but I've never been great about blogging on them since it takes extra time... but I'm going to try and get a little better at it. </span><span style="background-color: white;">So this will be the first edition of Articles Which Catch My Eye (AWCME)! I will provide summaries of the article and then my "biased thoughts" (being a PCP, IT-savvy, Innovation promoting doc)!</span></div>
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<span style="background-color: white;"><b><u>A Novel Approach to Identifying Targets for Cost Reduction in </u></b></span><span style="background-color: white;"><b><u>the Emergency Department</u></b></span></div>
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<span style="background-color: white;">(</span><a href="http://www.annemergmed.com/webfiles/images/journals/ymem/FA-pbsmulowitz.pdf" style="background-color: white;" target="_blank">Link to the article in the Annals of Emergency Medicine</a>)</div>
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A <a href="http://www.modernhealthcare.com/article/20120713/NEWS/307139953#ixzz20iwXfXnF ?trk=tynt" style="background-color: white;" target="_blank">Modern Healthcare story</a> on this article summarizes: "To maximize cost savings, hospitals and health
systems should focus on reducing avoidable patient admissions to the hospital
from the emergency department rather than on preventing non urgent emergency
department visits… Researchers with
Boston's Beth Israel Deaconess Medical Center and Harvard Medical School argue
that more money can be saved by reducing the number of patients admitted to the
hospital from the ED because there are no other good care options for them at
the time or because a patient's complex chronic conditions were not treated
properly. The researchers estimated that <a href="http://www.modernhealthcare.com/article/20120711/NEWS/307119987/reforms-needed-to-cut-er-costs-report" target="_blank">minor injuries and illnesses</a> accounted for 12% to 40% of ED visits but only 0.4% to
1.6% of overall healthcare expenses, so even reducing these visits by 50% would
result in savings of less than 1% of costs. On the other hand, patients with
intermediate or complex conditions account for 31% to 57% of all ED visits. <br />
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MY THOUGHTS:</b> One on hand, I love that they did this relatively logical analysis on the stats (and it's amazing how rarely this is done in healthcare - other industries live and die by these types of stats, of course they also have an incentive system which is more consistent than our hodgepodge). And their findings make sense: that even if the "low acuity visits" are high volume, they don't cost that much - so don't worry about them - just focus more on the high acuity visits. However, this is where I think they missed the big picture. IF we actually spent a bit more time figuring out how to deal with the low acuity visits (e.g. a free Primary care clinic next to the ER; or even machines which dispense antibiotics based on a few questions) - then we'd actually have much more time to spend on the high acuity patients, making it more likely they won't get admitted. In other words, instead of thinking about absolute value, we need to look at this equation with the understanding that a given physician or ER has a limited amount of time and "cognitive load" they can use... so let's create a system where the top people (doctors) are focusing on the sickest people, and we create a system which automates or appropriately delegates lower acuity visits to other members of their health team. </div>
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<b><u><span style="background-color: white;">The Prepared Patient: Information Seeking of Online Support Group Members Before Their Medical Appointments</span></u></b></div>
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(<span style="background-color: white;"><a href="http://www.tandfonline.com/doi/abs/10.1080/10810730.2011.650828" target="_blank">Link to the article in the Journal of Health Communication</a>)</span></div>
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<span style="background-color: white;">Abstract: The
authors examined online support group members’ reliance on their Internet
community and other online and offline health resources as they prepare for a
scheduled medical appointment. Adult members of an online support group (</span><i style="background-color: white;">N</i><span style="background-color: white;"> = 505)
with an upcoming medical appointment completed an online questionnaire that
included measures of illness perceptions, control preference, trust in the
physician, and eHealth literacy; a checklist of actions one could take to
acquire health information; and demographic questions. A factor analysis
identified 4 types of information seeking: reliance on the online support
group, use of other online health resources, use of offline health resources,
and personal network contacts. Pre-visit information seeking on the Internet was
extensive and typically augmented with offline information. Use of online
health resources was highest among those who believed they had control over
their illness, who attributed many symptoms and negative emotions to it, and
who were more eHealth literate. Reliance on the online support group was
highest among those who believed they had personal control over their illness,
expected their condition to persist, and attributed negative emotions to it.
Trust in the physician and preferences for involvement in decision making were
unrelated to online information seeking. Most respondents intended to ask their
physician questions and request clinical resources based on online information.</span></div>
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An <a href="http://www.ihealthbeat.org/articles/2012/7/13/patients-who-consult-web-not-motivated-by-mistrust-of-physicians.aspx" style="background-color: white;" target="_blank">iHealthBeat story</a><span style="background-color: white;"> on this article summarizes as follows:</span></div>
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<span style="background-color: white;">Researchers found that patients were more likely to look for health information online if they (1) </span><span style="background-color: white;">Believed their medical conditions were long-term; (2) </span><span style="background-color: white;">Felt they had some degree of personal control over their illness; or (3) </span><span style="background-color: white;">Were distressed about their medical condition. </span><span style="background-color: white;">Researchers also found that: </span><span style="background-color: white;">70% of study participants said they planned to ask their doctor questions about information found online; </span><span style="background-color: white;">More than 50% planned to make a request of their doctor based on information found online; and </span><span style="background-color: white;">40% printed information from the Internet to bring to their doctor's appointment. </span></div>
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<span style="background-color: white;"><b>MY THOUGHTS</b>: Most of this is consistent with what I've seen - that many patients will find info online and share it with me and ask questions (although not close to 40% would print it out ahead of time). I generally find that the online patients fall into three categories: </span></div>
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<span style="background-color: white;"><b>1. The Worried Well:</b> They will look online anytime they have any symptoms, and find something scary, and then make an appointment to be reassured. This is usually the largest group, and their web activities usually drive up the volume of business. Which may be an ironic twist as there once was an assumption that having information online would avoid visits - but that is the exception - there is often just too much information for a consumer to fully understand. These are usually quick and easy discussions - most of these patients know they over-reacted, and just need the reassurance from their physicians. </span></div>
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<span style="background-color: white;"><b>2. The Savvy Searcher: </b>Someone who knows what they have and does the research to help either diagnose or manage their care better. An example might be if I tell a patient they have high cholesterol, and they use the web to find better diets for them; or patients with a "strange problem" who identifies a possible diagnosis or new medicine to try. These folks are very much partners in the process - and I love working with them. </span></div>
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<span style="background-color: white;"><b>3. The Truly Tragic:</b> People who have a very bad diagnosis (e.g. Cancer, Lou Gehrig's disease...) and then obsess about it - and look at every website they can... to the point where they often drive themselves crazy because of the immense information overload. And the worst case scenario is that if you look hard enough, they can almost always find what they want to find - such as the side effect to a drug, or that some obscure tree root is the cure which is being hidden by the establishment. It is important that we let these patients know they should keep us in the loop because they sometimes can go on dangerous tangents if they think everything they find online is true. </span></div>
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<br />Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com0tag:blogger.com,1999:blog-22539915.post-60083975283094143232012-07-08T22:39:00.000-05:002012-12-02T14:33:27.267-06:00Dr. Larry Weed is The Oracle: Medical Records Should Guide and Teach!Dr. Larry Weed was an amazing visionary physician. Let me start by summarizing what he started saying in the 1960s: "We need to better organize our records, better utilize paramedical personnel and appropriately use computers" - over 40 years later, and we still haven't followed his advice very well! But we know it's true more than ever now, and we better start moving in that direction quickly!<br />
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Thanks to the internet, much of his original work exists, and it should be mandatory reading (and viewing) by anyone developing healthcare IT software or trying to change the system in any way. Here are some of his papers:<br />
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<ul>
<li><a href="http://imed.stanford.edu/curriculum/session17/content/NEJM%20-%20Medical%20record%20that%20guide%20and%20teach%20(Weed%20-%201968).pdf" target="_blank">Medical Records that Guide and Teach</a>: His original 1968 paper in the NEJM explained the Problem-Oriented Medical Record (POMR) - which has since become the standard of documentation across the globe. NOTE: Unfortunately, this system has often been incorrectly thought to mean the whole note should be in <a href="http://en.wikipedia.org/wiki/SOAP_note" target="_blank">SOAP format</a> (Subjective, Objective, Assessment, Plan) vs. having a SOAP component for each individual problem. The result is that many notes are harder to create and read since they don't group relevant information together. </li>
<li><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1483379/?page=1" target="_blank">Managing Medicine</a>: His 1983 book which: "Contains the best of previously-published materials on Problem-Oriented Medical Records, and explains the Knowledge Couplers which have occupied Dr. Weed up to the year 2000. Much of this material is transcribed from lectures and conversations, so it preserves the candid tone, energy, and eloquence of Dr. Weed that can usually only be experienced in person or on videotape. Illustrated, with highlights captioned throughout." (per Amazon description).</li>
<li><a href="http://ukpmc.ac.uk/articles/PMC2911807//reload=0;jsessionid=WQULIx1XuwA4jeV4EK9m.4" target="_blank">Interview with Dr. Weed</a>: A 2009 article written by a former student who says, "We discussed when he first was alerted to the nonscientific approach clinicians use to make decisions on patients. The rest of the interview time was spent with Dr Weed teaching me about the solution that he has spent the last 30 years designing and implementing."</li>
<li><a href="https://www.createspace.com/3508751" target="_blank">Medicine in Denial</a> (2011) According to Dr. George Lundberg's <a href="http://www.medpagetoday.com/Columns/30051" target="_blank">commentary</a>, "<span style="background-color: white;">In 267 pages, they sharply dissect virtually every sphere of medical education and medical practice. The tenet is familiar; the need to couple patient data with medical knowledge. This is not just a critical rant; it is a detailed "how to" fix the broken system. </span><span style="background-color: white;">Specifics such as "Changing medical education from a knowledge-based to a skills-based approach" and "Information processing, clinical judgment, and the two stages of decision-making" are good examples of the original 1970s premise still awaiting mass application in this century." You can get a PDF overview <a href="http://www.thepermanentejournal.org/files/MedicineInDenial.pdf" target="_blank">here</a>.</span></li>
<li><span style="background-color: white;">Other: "<a href="http://www.ncbi.nlm.nih.gov/pubmed/14160426" target="_blank">Medical Records, Patient Care and Medical Education</a>" (1964), his first paper on the topic, and in a later paper he explains, "</span><a href="http://ptjournal.apta.org/content/69/7/565.full.pdf+html" target="_blank">The Problem-Oriented System, Problem-Knowledge Coupling, and Clinical Decision Making</a>" (1989).</li>
</ul>
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Finally, <span style="background-color: white;">I especially enjoyed</span> this video of his 1971 Grand Rounds at Emory University (see be<span style="background-color: white;">low). S</span><span style="background-color: white;">ome key takeaways from his presentation include:</span><br />
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<ul>
<li><span style="background-color: white;">Physicians need to be guidance systems, not oracles. </span></li>
<li><span style="background-color: white;">The medical record provides the data needed to be a successful guidance system, and is critical for the best Education, Care and Research. </span></li>
<li><span style="background-color: white;">Every patient and their problems are unique - just like there are 88 keys on the piano, but millions of symphonies can be played. </span></li>
<li><span style="background-color: white;">Treating a sick patient is like a Chess game... you make your move, Nature plays her move, and then back to you.</span></li>
</ul>
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<iframe allowfullscreen="" frameborder="0" height="315" src="http://www.youtube.com/embed/qMsPXSMTpFI" width="420"></iframe>Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com1tag:blogger.com,1999:blog-22539915.post-16662688535088196182012-06-15T02:15:00.002-05:002012-08-01T17:03:42.543-05:00The EMR Race is Over, Long Live EMR Extender Tools!<br />
I've been increasingly talking about the concept that the EMR race is over, and that EMRs now serve as the infrastructure and platform upon which innovative companies will develop "<b>EMR Extender Tools</b>", in areas such as: Physician Productivity (e.g. <a href="http://www.healthfinch.com/" target="_blank">healthfinch</a>), Decision Support (e.g. <a href="http://www.zynxhealth.com/" target="_blank">Zynx</a>), Business Intelligence (e.g. <a href="http://drevidence.com/" target="_blank">DrEvidence</a>), and Patient Outreach (e.g. <a href="http://www.healthloop.com/" target="_blank">Healthloop</a>). This seems to resonate well with mature EMR users since they often feel like the EMRs they have are rather stagnant - and the vendors will be focusing for years on just getting basic things right and fulfilling Meaningful Use, and thus has no ability to add innovative features. <br />
<br />
This is particularly relevant as a recent article came out asking, "<a href="http://www.forbes.com/sites/davidshaywitz/2012/06/09/epic-challenge-what-the-emergence-of-an-emr-giant-means-for-the-future-of-healthcare-innovation/" target="_blank">What is the future of healthcare innovation now that Epic has become the dominant EMR player</a>?" The author offered a variety of scenarios, but I think <a href="http://histalk2.com/2012/06/14/news-61512/" target="_blank">Mr. HISTalk</a> had the best analysis when he said: "Companies should stop fixating about mounting a full frontal attack on Epic that’s sure to fail and instead innovate on building products and services for Epic’s large client base just like the companies that coexist successfully with Meditech."<br />
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Oh yeah! Now we are talking about an ecosystem that will really let innovation flourish (I think it will be Epic and a few others). Big Kudos to Allscripts and Greenway for walking the walk and being the first to launch official "platforms" for allowing third parties to build tools upon them. And nod of the hat to other EMR vendors who are at least talking the talk - even if their "Platforms" are not quite launched yet... such as GE, NextGen, AthenaHealth. And here is hoping that Epic and ECW will eventually come around and create official platforms to encourage innovation... I think they will eventually move to this, and/or their customers will do it for them. Finally, I'll be closely following a few other companies trying to build "Uber-Platforms" in this space, including <a href="http://www.optuminsight.com/" target="_blank">Optum</a>, Aetna's <a href="http://www.medicity.com/" target="_blank">Medicity </a>and the GE/MS spinoff <a href="http://www.caradigm.com/" target="_blank">Caradigm</a>.<br />
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Of course, how cool would it be if we had one platform upon which any third party vendor could integrate their tool... and it would magically work with any EMR? Oh wait, we actually do have the government sponsored <a href="http://www.smartplatforms.org/" target="_blank">SMARTPlatform</a>... now we just have to get the vendors to agree to work with it! The geniuses behind this platform (Kenneth D. Mandl, M.D., M.P.H., and Isaac S. Kohane, M.D., Ph.D.) just wrote another NEJM article (<a href="http://www.nejm.org/doi/full/10.1056/NEJMp1203102" target="_blank">Escaping the EHR Trap — The Future of Health IT</a>), if you are interested in hearing what they think the future should look like. Here are a few good quotes from their article:<br />
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<ul>
<li><span style="background-color: white;">“[T]here’s a clear path toward </span><u style="background-color: white;">better, safer, cheaper and nimbler
tools for managing healthcare's complex tasks.</u><span style="background-color: white;">”</span></li>
<li><span style="background-color: white;">“Programs should not be held hostage to EHRs that reduce their
efficiency and strangle innovation,” the authors concluded. “</span><u style="background-color: white;">New companies
will offer bundled, best-of-breed, interoperable, substitutable technologies …
that can be optimized for use in healthcare improvement</u><span style="background-color: white;">. Properly nurtured,
these products will rapidly reach the market, effectively addressing the goals
of ‘meaningful use,’ signaling the post-EHR era, and returning to the
innovative spirit of EHR pioneers.”</span></li>
</ul>
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<span style="background-color: white;">Getting back to reality (meaning we don't have seamless platforms to do all this yet)... I do think we are seeing an explosion of small companies creating great niche products and figuring out how to work with EMRs. So whether there is an official platform or not, the EMR Extender Tools are here to stay and they are only going to grow bigger and better!</span><br />
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<u>Past Blogs on this topic</u><br />
* <a href="http://drlyle.blogspot.com/2011/03/himss-2011-wrap-up-big-and-small.html" target="_blank">Rise of the EMR Extenders</a> (March, 2011)<br />
* <a href="http://drlyle.blogspot.com/2012/04/emr-apps-taking-off-starting-with.html" target="_blank">EMR Apps Taking Off</a> (April, 2012)<br />
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<br />Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com0tag:blogger.com,1999:blog-22539915.post-51368957803679322522012-06-11T00:52:00.002-05:002012-08-01T16:55:52.719-05:00Six Steps to Saving the Country with Preventive Care<br />
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<a href="http://www.imaginewhatif.com/" target="_blank">Joe Flower</a> is one of the best healthcare futurists an
authors out there… which is why I quote him so often! In his recent article, "<a href="http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?id=7780005849" target="_blank">Save the Country with Preventive Care</a>", he explains how we can save the healthcare system by focusing
on the treasure in plain sight: "It is those thousands and millions of
patients with poorly treated and untracked chronic disease that flood our EDs
every day. We can mine those cases to reduce health care costs drastically, put
our hospitals and health systems on a sound economic footing, make people
healthier and, by the way, save the country."</div>
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He then goes on to describe the SIX WAYS to do this, which I will help summarize:</div>
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1.<span style="font-size: 7pt;">
</span><b>Coverage.</b>
Everyone needs to be covered, even illegals and those who won't pay for it -
because otherwise they just cost everyone more later on. He notes, "If they are covered, it is
much easier to fashion preventive and outreach programs to keep them from your
door."</div>
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2.<span style="font-size: 7pt;">
</span><b>Shift in risk</b>.
He explains this well, "Shift from the standard model (fee-for-service,
with all financial risk in the payer) to various models in which the provider
takes on some risks (as with bundles, warranties, capitation, minicaps,
alternative quality contracts and other models) and the patients take on some
risk for making a good decision (going to a clinic or an urgent care provider
instead of the ED with a minor matter). </div>
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3.<span style="font-size: 7pt;">
</span><b>Incentivized
wellness</b>. These types of programs "give people financial rewards (such
as lower premiums) when they participate and meet simple goals. Correctly done,
these programs reduce the actual costs for covering the whole population
(including those who do not participate) by 10 percent or more."</div>
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4.<span style="font-size: 7pt;">
</span><b>Targeting</b>. "Find
and go after that 5 percent, that 1 percent who are costing the most money.
Some of the cost will be recoverable, some will not; but go after them anyway,
because the costs spiral out of control once they cross your threshold." This includes putting in more clinics in high
risk sections of town, as well as "<a href="http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande" target="_blank">HotSpotting</a>" individuals, as popularized
by Dr. Atul Gawande. There is a lot of
energy and momentum to do this - which is a good thing. I'd just point out at the same time we pour resources
into these folks, we need to efficiently take care of the other 95% to make
sure they stay stable and healthy (which is a focus of a lot of my recent <a href="http://drlyle.blogspot.com/2012/04/emr-apps-taking-off-starting-with.html" target="_blank">work</a>).</div>
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5.<span style="font-size: 7pt;">
</span><b>Public health</b>.
Consider how you can better work with your federal, state and local public
health officials to address the health needs in your community. </div>
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6.<span style="font-size: 7pt;">
</span><b>Healthy
Communities</b>. "Finally, at the furthest remove from your ED threshold
is the Healthy Communities movement. There are local groups in most places
across the country, supporting programs dealing with everything from effluents
to traffic to education to AIDS awareness. The return on investment is always
large because the investment is so small compared with the ED visits,
surgeries, premature births, and NICU and ICU use that they eventually prevent."</div>
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He finishes with: "We will save much more money, shore up
our finances and help solve the deficit problem when we stop waiting passively
for people to cross our threshold and begin aggressively exporting health to
those who need it the most."</div>Lyle Berkowitz, MDhttp://www.blogger.com/profile/16542742012919536155noreply@blogger.com0