Change Doctor

Care Innovation Summit (Jan 26, 2011 in DC)

2012-01-30T00:18:00.012-06:00

I was one of 1200 "healthcare innovators" attending the annual Care Innovation Summit last week, sponsored by CMS, the West Wireless Health Institute, and Health Affairs magazine. The day started with a fantastic keynote by Atul Gawande, MD, and then there were assorted panels talking about healthcare innovations across the US.
My thoughts and reflections on the day:

First, it was a good use of time. It is hugely important to be able to hear innovation stories, and it is important the providers, industry, and government are all sharing with each other and trying to figure out this mess we call a healthcare system. Additionally, the networking is always fantastic at a place like this. I was able to see some old friends like Ted Eytan (Physician Innovator and awesome blogger), Margaret Laws (CHCF), and Carleen Hawn (Healthspottr), as well as meet some new friends who do great blogging, like Andre Blackman (Pulse and Signal) and Dr. Joseph Kim (Medicine and Technology).

Second, Gawande's keynote was really great - how can a surgeon be such a good writer and excellent speaker?!?!? He focused a lot on the importance of creating easier systems which cost less and deliver all the appropriate care to as many people as possible. A few comments he made which stood out:

Healthcare Costs are Killing the American Dream. The "typical" US family has seen almost all of their increase in take home pay in the past decade go to paying for their healthcare costs.
We need Automation and Teamwork. The complexity of healthcare is increasing exponentially but we have not really altered how we deliver care - one physician at a time. In the past "2 generations" (about 100 years), we have expanded to over 13,000 known conditions, 6,000 meds, and 4,000 types of procedures - physicians have to know all these and then deliver them to every single American - not exactly efficient (and rarely consistent). In other words, "We need Pit Crews, not Cowboys". Every other industry has learned how to automate and task shift… it's time for healthcare to do the same! [Side note... I think this is so important for the future of healthcare - that it is the basis of a new company I helped create in the past year... more to come later]
We need better Data! I love the analogy he gave… He said, "the way we currently provide data is like driving your car, but when you look at your speedometer, all you see is the speed of other cars from 4 yrs ago." We need to have real time data, specific to our needs!
The Best Places Act like Systems. He noted these three key skills are needed:

The ability to recognize Success vs. Failure (i.e. need up-to-date data which is focused on a specific issue).
The ability to identify failures and then devise solutions for them… he of course pointed out that you should consider Checklists to help organize the "best care". I agree!
Make solutions easy to implement. Keep them simple and cost-effective, and recognize the importance of consistency and teamwork.

Third, the government folks said that they know we have to become more innovative. Dr. Richard Gilfillan (acting director of the CMS' Center for Medicare and Medicaid Innovation) said, "We need to decide now whether to make the commitment to adopt innovation that will fundamentally change the way we operate, change the way we deliver care, change the way we think about these organizations that we run. This is not an abstract notion; this is a very concrete question that each of us will have to answer."

Marilyn Tavenner (acting administrator for the Centers for Medicare & Medicaid Services) highlighted a variety of innovations, and expressed urgency in pressing forward with the “triple aim” goals of better individual healthcare, better population health and lower costs called for in the health reform law.

As a reminder, the summary of the Healthcare Reform law essentially comes down to four things:

Value: improve quality and cut costs (and the part that is TOP on the mind of everyone)
Access
Insurance reform
Medicare improvements

And the Triple Aim (as defined by Dr. Berwick) is:

Better care (at an individual level) - including the STEEP criteria (Safety, Timeliness, Effectiveness, Efficiency, Equitable, Patient-Centered)
Better health (at a population level)
Lower costs

CMS also recognizes that the only way to do all this is for government and payors to better align incentives (hence the experimenting with ACOs and other reimbursement changes). And as Todd Park (CTO for CMS) said, do anything they can to help America's "innovation mojo" heat up to start solving problems (such as by promoting the challenges below).

Fourth, they released a series of private-backed Challenges throughout the day. ONC posts these challenges at www.Challenge.gov/ONC. Here are the ones announced at the Summit:

Sanofi Diabetes challenge: www.datadesigndiabetes.com
JNJ-Janssen care coordination (hospital handoffs): http://www.janssenhealthcareinnovation.com/connected-care-challenge
KP HIV challenge: www.kp.org/hivchallenge - actually more of a self-help tool for any HIV clinic in the nation to learn from what KP has done
Allscripts CDS Challenge for CAD: www.Allscripts.com/cdschallenge
Janssen, Pfizer and Geoffrey Beene Foundation Alzheimer's Challenge: http://www.alzheimerschallenge2012.com/

Fifth, they had a variety of payors, disease management companies and providers talk about "innovative programs". Health 2.0 blogged on some of these innovators, and here are two that stood out to me:

The WellPoint "Care More" model focuses on the 15% of patients which account for 75% of costs. "Extensivists" work with PCPs to provide early and quick intervention (e.g. patients see the Extensivist clinic a few times a year, in addition to the PCP). This model also uses a host of other providers as well (e.g. home care, social workers, dietitians...) to create a fabulously deep and rich team for these patients.
ChenMed is a provider group which focuses only on complex elderly patients. Their mantra is "Coordination, Collaboration, Convenience, Compliance". They succeed because they limit MDs to just 350-400 patients and build a whole system around these patients.

So while these are both great programs, they also represent the weaknesses in the conference:

The majority of presenters focused on Medicare patients - understandable since that is of utmost interest to CMS… but there is much to learn with younger patients too. Additionally, CMS must realize that poorly controlled younger patients will wind up in their lap eventually! We have to somehow integrate CMS with the private insurers in some way to keep them both aligned.
The majority of presenters said they achieved some quality benefits by focusing a high amount of care on the "most complex 15%" of patients. On one hand, this is great stuff - and important to learn how they did it so it can be replicated. On the other hand, it should not come as a shock that expensive heavy lifting on those folks improved outcomes… were these innovations or simply sound logic? Are they reproducible? And did they cut costs (e.g. what was the ROI)?

Additionally, I think a key quote of the day came from Aetna's CMO when describing a program they implemented to help patients after a heart attack. He said, "we gave them free meds after an MI, and compliance was still only 49%!" So whatever we do we better make sure it is "easier" for patients than their current lives... because behavior change is really hard!!!

And one other great quote came from a nurse who was talking as a patient, knowing she was dying from cancer. She did her research and chose to not try end-stage treatment that would hurt her quality of life and only possibly give her a small amount of extra time. She reminded us not to "force" care onto everyone, for as long as someone has been educated, "There are no wrong choices, only informed choices."

Finally, how about some more IT Innovations?
We heard how IT could help collect, analyze and display data… which could be used to find problem areas or identify high risk patients (e.g. predictive modeling). We even heard how the Archimedes Model can help predict the outcomes of various interventions. However, we did not hear how IT innovations could allow for better economies of scale (via automation) and easier spread of improved processes. My theory is that we use IT to help automate the care for the 85% of patients which are "healthy and stable", so that the high touch care for the complex 15% can continue. I plan to do my best to support companies that fall into either of these buckets!

Welcome to 2012!

2012-01-14T02:06:00.011-06:00

Wow… I am officially in awe of all bloggers who can post once a day, once a week or even once a month at this point. I have clearly fallen off the horse - but am saddling up again for what looks to be an amazing 2012! Yeah, I've been a bit distracted - helped start up a new HIT company (more to come), am working on a book highlighting the intersection of HIT and Innovation, and am juggling all the regular doctor and CMIO type of things. BUT - no excuses… I've got to find some time to get my thoughts down!

I actually have a couple of blogs half-written in emails to myself, but I'm going to start with something more current… my take on various stories from one of my favorite blogs - HISTalk. In their recent blog, they mentioned the following three stories (among others), and I thought each had some major importance so I want to highlight them and give my 2 cents:

First, Meaningful Use (MU) Attestation
CMS has provided the database for the statistics on numbers of physicians who have currently attested for MU. Modern Healthcare did a nice breakdown in their story on it:

· For Ambulatory: Epic was the EHR of choice for 6,045 physicians and other eligible professionals, grabbing a 28% market share of the eligible-professionals segment, a slice larger than that of the next four vendors combined. Those others in the top five, in rank order, are eClinicalWorks, 1,847 (9%); Allscripts, 1,449 (7%); Athenahealth, 1,158 (5%); and Community Computer Service, 999 (5%). These top five vendors claimed 54% of the market of early adopters and meaningful users. The top 10 vendors also claimed 71% of the incentive payments thus far. But it's still a wide-open market. The database lists 217 EHR vendors as having products that had been used successfully by at least one eligible professional to either achieve meaningful use or receive incentive payments under Medicaid. Of those 217 developers, 131, or 60%, had 10 or fewer installations.

· For Acute Care (Hospitals): Epic also led among hospitals that received federal incentive payments for using a complete EHR, but the privately held company was not nearly so dominant in this indicator of the hospital IT market as it was in the EP segment. According to federal data, there were 627 hospitals that have been paid using complete EHRs developed by 22 different companies or organizations. Of them, 165 were Epic customers, 26% of that niche. Ranked second was Computer Programs and Systems, commonly known as CPSI, used by 140 hospitals (22%), followed by Cerner Corp., 71 (11%); Healthland, 54 (9%); and Meditech, 47 (7%).

Mr.HISTalk said the following: Here’s a point/counterpoint issue to mull over. Inga and I disagree on the value of CMS’s attestation statistics. Inga thinks the percentage of each vendor’s customers that have attested is a good benchmark, so she did lots of spreadsheet work to compare vendors and to assume that varying percentages among them must be reflective of product capabilities and ease of use in meeting Meaningful Use requirements. I said the information is useless for that purpose since it’s more reflective of unmeasured customer demographics and buying criteria than anything else and that it would be wrong (not to mention statistically indefensible) to use the CMS figures to infer that vendors with a higher percentage of successfully attested users have a better product for earning Meaningful Use money. Feel free to take sides. One thing’s for sure: vendors who massage the data into slick marketing collateral won’t be footnoting their handouts with statistical disclaimers.

Here was my response: I'm siding with Inga on this Point/Counterpoint… although the numbers are not perfect - they should provide value in two ways:

1. Totals. A general idea about the total number of real EMR users. I’m sick of the vendors each claiming to have 50-100K users. Sorry - there are only about 600K total active doctors… and only 25% using EMRs – so you are all splitting about 150,000 docs at best right now. Although this initial data is a good start, I think very soon we will get a much better idea of how many docs are attesting with each vendor (since many are waiting until end of 2011) and then at least the general proportions will be easier to assess… will it be EPIC with 30%, and the next tier of 5-6 vendors at 5-10%, and then 210 more with under 1% each… or will we see a surprise pop up somewhere?!??!

2. Successes. Fair enough – it is possible some EMR vendors will have a higher percent of attestations because they are better at implementation, etc… but hey - that’s OK, I think that is a key indicator too… and am fine if that “biases” the numbers. But they are still valuable.

Second, Most Online Diabetes Management Tools are Ineffective

CMIO Magazine did a nice summary of the JAMIA study. It turns out that over 75% of the time - the tools were NOT clinically useful or usable (or said another way- they were only useful and usable 25% of the time). But perhaps more importantly was the second finding which is that patients just don't use these tools consistently. Hey - that should be a surprise! Yet it may shock or offend some in the "consumer empowerment" community who keep saying patients want more tools to use online. While I think a subset do want these, it is just not the majority. Unfortunately, the reality is that any tool or business model that relies on behavior change is a really tough sell. Patients have shown for a very long time how resistant they are to change, and just having a website or app telling them what to do is not going to make that magically happen. I do look forward to the next slew of websites claiming to have that "secret sauce" that will make patients change (e.g. games, rewards, social interactions), but think that the vast majority of folks who try to crack that code don't fully understand human behavior, especially as it relates to health. It is much more complex than buying stuff online, banking and Facebook... but I do think we are getting better - and a well researched article like this will help us continue to move in the right direction.

Finally, "Smart Contact Lenses Keep Eye On Your Health"… Sensors are here baby!

This news story asks "What if the lenses could look inside of you to diagnose, monitor and even treat disease? Sound far-fetched? Well, it may not be too far away… The new generation of contact lenses is being called “smart lenses”, and they are packed with circuits, sensors and wireless technology – all designed to "keep an eye on your health". It is indicative of a big and growing trend towards ubiquitous biomedical devices, especially involving sensors, which we will be hearing more and more about in the months and years to come. Of course, it pairs well with the other big trend around big data - because this many sensors are going to need some major analytics to make them useful.

Bottom line - there is so much amazing change and innovation going on in healthcare, cannot imagine a better industry to be in for the next few decades!!!

A Busy HIT & Innovation Summer - Book, Upgrades, Usability and ExpectED Highlight

2011-08-24T09:14:00.002-05:00

Well... it's been a busy summer, and I have a lot of blogs in me, but have been diverted by two major issues going on which will eventually lead to some good blogs in the future:

The Book: I'm writing/editing a book on the intersection of HIT and Innovation. It's been a great experience as we are putting together a series of essays from a variety of innovative physicians and healthcare experts on how they have used HIT in an innovative fashion. These will range from using their EMRs in new and different ways, to a wide range of telehealth activities, to creating an online survey system which allows patients to become increasingly involved with an organizations strategic direction.
The Upgrade: Our Cerner EMR was finally due for an upgrade... and after months of many people working together to make it happen, we had a very successful go live last week. There are still a lot of busy days and late nights as we are in the fine-tuning stage, but it sets us up for MU and more abilities to start managing quality and providing even higher quality care... so yeah, I'm sort of excited about it! Of course, now that I've delved into the world of EMR Usability, my eyes have been opened to usability heuristics issues like Consistency, Recognition rather than Recall, and the importance of expert Accelerators to promote more efficient use. And so whenever I look at the new screens, I start thinking "how could this be better" and in talking to other "usability junkies" - it turns out this is a curse we now carry as we look at anything on the web or in the "real world" - why can't things be more usable!?

I've also gotten more involved with the government in the past year as the push to promote EMRs spreads, and they are looking for input from folks who have been involved in getting EMR systems up and running. I had a particularly good time attending and presenting at the NIST EMR Usability Workshop in June. I plan to dedicate a whole blog to my thoughts on this - but in the meantime you can read some of my ideas at the Healthfinch blog.

Finally, I wanted to make sure everyone knows about the AHRQ Healthcare Care Innovations Exchange.

The U.S. Agency for Healthcare Research and Quality (AHRQ) created the Health Care Innovations Exchange to speed the implementation of new and better ways of delivering health care. The Innovations Exchange supports the Agency's mission to improve the quality of health care and reduce disparities. The AHRQ Health Care Innovations Exchange offers busy health professionals and researchers a variety of opportunities to share, learn about, and ultimately adopt evidence-based innovations and tools suitable for a range of health care settings and populations. More info at: http://www.innovations.ahrq.gov/about.aspx

In July of 2011, the AHRQ Innovation Exchange published a profile of ExpectED, one of the first projects from the innovation program I run - the Szollosi Healthcare Innovation Program (SHIP). The profile was entitled "Referring Physicians Send Electronic Handoff Note with Pertinent Patient Information to Emergency Department, Improving Physician Efficiency and Quality of Care" and the summary was:

Community-based physicians referring patients to Northwestern Memorial Hospital for emergency care send an electronic handoff note to emergency department personnel to notify them that a patient will be arriving and to provide clinical details pertinent to his or her condition. The note, which includes the patient's name, date of birth, the referring physician's name, a clinical summary, and other information, is entered into the system's electronic medical record, where emergency department clinicians can easily access and review it at the point of care. Anecdotal feedback from physicians suggests that the program has improved physician efficiency and satisfaction, care coordination, and the quality and timeliness of care.

Direct link to the write-up is at: http://www.innovations.ahrq.gov/content.aspx?id=3107

They did a great job in this write-up, I love how they break each innovation down into:

What They Did
Did It Work? (we can learn from failures too!)
How They Did It
Adoption Considerations

Take a minute to peruse the Innovations Exchange - it will expand your mind and make you feel good about the potential for innovations in healthcare care!

The Importance of Looking into the Future: Horizon Scanning at AHRQ

2011-06-15T22:38:00.004-05:00

I was in DC last week and spent some time with AHRQ's Healthcare Horizon Scanning System folks. Their job is to identify, monitor, and track new and emerging health care technologies and interventions that could signal important changes to patient care, health outcomes, and the United States health care system - ranging from drugs and medical devices to new services and innovative care processes. The HHSS is a resource for the Effective Health Care (EHC) Program as it makes decisions about allocating resources for patient-centered outcomes research. It will also be a tool for the public to identify and find information on new health care technologies and interventions. Any investigator or funder of research will be able to use the HHSS to select potential topics for research.

While this is a relatively new group at AHRQ, it turns out this type of formal "Horizon Scanning" process is common in Europe, although more centered on meds, devices and procedures. For example, there is the UK's National Horizon Scanning Centre as well as the larger International Information Network on New and Emerging Health Technologies (EuroScan), a collaborative network of member agencies for the exchange of information on important emerging new drugs, devices, procedures, programmes, and settings in health care.

One thing that struck me was the clear distinction between Products and Technologies (e.g. pharmaceuticals, medical devices, procedures) vs. Information Technology (e.g. EMRs and "health apps") vs. Care Innovations. For products, it appears that the methodology is relatively consistent (e.g. you can easily find early items via phase 2 trials, prioritize based on significance and effectiveness, and do comparative evaluations against similar products -- and then market forces help with diffusion since some companies can make so much money on successes).

But the same process cannot be applied to Care Innovations or HIT. So what is the best way to "find, filter, evaluate and diffuse" these items? Here are some ideas:

• Scanning: The AHRQ Innovations Exchange is an amazing collection of healthcare service and IT innovations and is a great starting point for those who are looking for new ideas to stimulate them! Other obvious resources are a wide a variety of conferences and newsletters. Some conferences I like for cutting edge ideas are Health 2.0, HIMSS (yes, it's big and corporate - but there are always things bubbling there) and World Congress Innovation Summit. I also have stumbled onto a few non-healthcare conferences dealing with User Interface/Human Centered design which are amazing. For blogs, some favorites are HISTalk, Ted Eytan, Jay Parkinson, and Halamka's. For newsletters, I follow CHCF, ModernHealthcare, HIT Strategist, iHealthbeat, H&HN, HDM, CMIO and FierceEMR.

• Filtering/Evaluation: This will involve watching how pilot project fare, creating models to help extrapolate to different environments (e.g. based on size, payment methods…), and ideally help support funding to try additional pilots in different environments to understand if reproducible and scalable.

• Diffusing: Major education, funding for early beacon programs, possible policy change around reimbursement and other (e.g. allowing more tele-care). A recent CHCF paper on Spreading Innovations is particularly relevant.

So thank you AHRQ for being on the lookout for Care and HIT Innovations and trying to figure out how to spread those that are doing well!

Taming HIPAA Insanity

2011-05-22T16:57:00.003-05:00

The HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) has been around since 1996 - and it's amazing how many healthcare people still over-interpret the privacy and security regulations (and mis-spell it as HIPPA!). Here is the actual law and check out HIPAA.org, a nice website which brings together many sources of info.

With respect to HIT, it focuses on Privacy and Security - and basically puts common sense into law:
* Privacy: This addresses policies - and says you can't just give personal health information (PHI) to anybody you want, such as Pharma or the local drugstore (before HIPAA, docs could actually do that legally).   But importantly - it does exclude "TPO" (Treatment, Payment and Operations).   In other words, there are no restrictions to healthcare organizations sharing PHI with one another as long as it involves treating a patient (or dealing with payment or other operations)!
* Security: This addresses technology - and says you should have good technology in place to make sure your IT systems are not open to the free world.   Simple enough.

So it is fascinating how many healthcare organization still use HIPAA as an excuse for not sharing information. I can't tell you how many fights I've been in with medical record departments who say that they can't fax me a report because they don't have a "HIPAA waiver" signed by the patient - even if I ordered the test!!!   Agghhh! Usually the problem is that the bigger organization scared lower level staff with too many HIPAA emails... but the result is the same - making it harder to get the data which is needed.   And while I think this scenario has improved a bit, it is still happening every day.

So I saw this Healthcare IT News article last month entitled "Five social media tips for docs worried about HIPAA" - and thought it was good to share, as it is nicely worded, and I think extends beyond social media in its relevance (my comments will be italicized):

SEATTLE – While many doctors shy away from use of the Internet because of concern over HIPAA penalties, one company is advising the physician community to not become victim to HIPAA hand-wringing and fall out of sync with their colleagues who have learned how to responsibly utilize today's most valuable online visibility tools.

Avvo, the world's largest online directory for doctors and lawyers that provides free rankings for 90 percent of the working physicians in the U.S., offers five tips for physicians who are hesitant, because of perceived HIPAA restrictions, to embrace online and social media marketing.

The company, which was founded to service the legal sector, is no stranger to the impact of regulatory issues on the healthcare industry. Avvo is now striving to help doctors, who may be missing valuable networking opportunities because of unnecessary HIPAA fears, to adopt widely accepted, HIPAA-compliant practices for tapping the Web's significant marketing and reputation building channels.

"HIPAA is a well-intentioned, but poorly implemented law that is unnecessarily scaring doctors and keeping them in an unrealistic 'technology lockdown'," explained Avvo founder and CEO Mark Britton. "Avvo sits at the vortex between law and healthcare – and we believe passionately that physicians are needlessly hand-tied by HIPAA legalities. We want every working doctor out there to know that there are many appropriate and safe channels through which they can build their profile and reputation on the Web."

Avvo, which offers free phone consultations to physicians who have questions about how to safely market their reputation on the Web, equips doctors with the following five tips for managing their career online:

1. DO: Use email, SMS and social media messaging. These are acceptable tools for making outreach to patients, the media, medical industry influencers, and other doctors. The HIPAA regulations actually encourage the use of alternative communication methods, particularly as patients express their preference for a particular mode of communication.
(HIPAA does not ban email, in fact it encourages it... but it does say that patients have the right to tell their doctors if they don't want to be contacted by email, or phone, etc...)

2. DO: Feel free to share information with other providers. Many health professionals set up unnecessary procedures that make it harder to share patient information with other providers. If you need input from another provider, you don't have to worry about HIPAA compliance. In fact, HIPAA guidelines specifically permit the sharing of information with other providers (freely and without patient consent) for the purposes of patient treatment.
(Correct - let's use common sense for the sake of the patient!)

3. DO: Feel free to answer general patient questions - there is no HIPAA bar to providing this information. Whether it's participating in Avvo's free online Q&A or other forums on- or off-line, answering general health-related queries in a public forum will not present a HIPAA-related problem for doctors. These tools offer a powerful means for patients to take the first steps to getting the care they need.

4. DO: Keep family members in the loop. It is unwarranted to let HIPAA be an excuse for not keeping family members engaged and involved, where relevant, to provide support that is in the best interest of the patient. There is wide latitude under HIPAA to inform a patient's family members about his or her status – and this extends to liaising with family members electronically as well.
(I've been guilty of this as well... and now go back to good old common sense if I am unsure. I will also make sure to check with certain patients as to their wishes on this - particularly new adults or the elderly.)

5. DO: Exercise common sense and reasonable practices in all instances to ensure the privacy and security of your communications with patients. This general rule of thumb applies whether the communication is by email, SMS, fax or instant message.

While Britton agrees that HIPAA has created a general "culture of paranoia" among medical practitioners and has in many ways served to logjam the essential progress of technology's role within the healthcare industry, he adds that it is just "unreasonable" for doctors not to embrace the social media revolution because of over-exaggerated fears of privacy and security violations. That level of restrictive behavior, he cautions, is "wholly impractical in today's business climate" and he advises doctors to go ahead and embrace digital tools while still preserving the health and integrity of the patient-physician relationship.

Social Media and Healthcare

2011-04-14T00:49:00.005-05:00

I have not written much on social media in healthcare, which might range from a practice with a facebook site for marketing, to a surgeon tweeting that the gallbladder is out so the family can relax a bit sooner, to a Groupon for reduced botox, or to a system which texts patients to motivate them to eat better or take their meds on time. But instead of commenting myself, this blog entry will mainly be a list of relevant links, including a list of great bloggers and interesting news stories.

Healthcare Social Media Bloggers
* 33 charts focuses on social media in health and is written by Bryan Vartabedian, MD.
* http://www.tedeytan.com/ is written by Ted Eytan, MD - an extraordinary thinker and blogger who often writes about the impact of social media and web 2.0 in healthcare.

Stories of Interest
* Could Facebook be your Platform for Care Coordination? (e-Care Mgt Blog, May, 2011)
* Social media could 'accelerate clinical discovery' (Article about PatientsLikeMe.com, April, 2011)

* Five social media tips for docs worried about HIPAA (April, 2011): Great advice about how to understand that HIPAA actually promotes email and other electronic forms of communication - and is often misunderstood due to paranoid legal beagles!
* What do Physicians Really Think about Social Media?: A series of blogs by Dr. Ted Eytan based on interviews with doctors from Sermo as well as some Academic sites (Spring, 2011).
* Social media tools may reduce attrition in online health programs... and prove an effective way to boost participation in online health programs, according to researchers at the University of Michigan Medical School (Dec, 2010)
* AMA Guide to Social Media (Nov, 2010): The American Medical Association has adopted a new policy that gives guidance to physicians using social media.
* Tips on mitigating risk of social networking in healthcare organizations (Nov, 2010): like it sounds!

HIMSS 2011 Wrap-up: Big and Small

2011-03-05T16:57:00.006-06:00

The Buzz: Rise of the "Extender Companies"
It was the biggest HIMSS ever (over 31,000 attendees) and yet it was the smaller companies that were the ones to watch. In the past, HIMSS was mostly about the HUGE booths and parties thrown by the top vendors. But this year the buzz was shifting away from the big vendors and towards the rise of the "Extender Companies", who are creating products and services which build around the larger ecosystem created by the established HIT infrastructures in place (and yes, "ecosystem" is already threatening to become the most overused buzzword of 2011).

This should not be a shock, the newer, smaller companies can be quick and innovative while the major HIT vendors (running the gamut from the giants like GE, Siemens and McKesson, to the big boys like Cerner and EPIC, to the now well established middle-tier companies like Allscripts, NextGen and eClinicalWorks) all are BIG BOATS that can't maneuver quickly and are pretty much focused on MU for the next few years anyway. But that's OK - this is a good thing, and parallels the situation seen in other IT industries… the "base level" is being set (just like Microsoft and Apple did with operating systems) and it's time for the next generation of HIT companies to start creating the products that actually move the pointer from "up and running" to actually "usable and useful". The good ones will thrive (and likely be acquired), the bad ones will fade away quickly - and there are books to be written and movies to be filmed about it all in the years to come.

Examples of companies to be on the lookout for (in no particular order or ranking):
• Quipp from Medicomp: a new way to document
• Salar: also new modules replace the note
• Phreesia: office "check in" tools
• Epilogue systems: automated creation of help tools, simulation environments, and testing for EMRs
• Aventura: technology to make computer logins quick and easy
• Precyse: coding support
• dbMotion: system integrator
• Elsevier: content, content, content
• MeDecision: data aggregation and analytics
• Halfpenny Technologies: data integration tools and services
• Merge: kiosks, patient portals
• IMO: standardized vocabulary (so your docs never need to learn ICD 10!)
• CareFx: web-based data aggregator (bought by Harris Corporation)
• AnvitaHealth: data analytics and content tool
• Eprocrates: various content tools
• Sensible Vision: fast access and continuous security authentication via facial recognition
• Logical Images: database of images for every disease
• Phytel: identify patients who need care gaps resolved
• Symphony Care: ACO software

The HIT X.0 Conference: Innovation and Future Thinking
HIMSS knows that it cannot just serve the needs of large hospitals installing monolithic HIT systems, and so I give them a lot of credit for creating the HIT X.0 sub-conference. The idea was to create a series of sessions that spoke more to innovative ideas in HIT and a look at the future. I was fortunate to moderate several sessions including the following:

HIT Geeks Got Talent
This was a take on "America's Got Talent" or "American Idol", in which six "contestants" got to show their "newest product" to a panel of judges who got to provide feedback to each of them. Based on judge and audience feedback, the top four advanced to the final round the next day. General criteria to use for assessment include: Usable, Unique, and Useful
In other words (1) Is it usable (easy to use), (2) Is it Unique, and (3) Is it useful (how does it provide value).
The best part of this was easily hearing the judges frank and incredibly insightful comments to each of the contestants - basically they each got invaluable consulting and coaching from some of the top minds in the business. Additionally, anyone in the audience who might be thinking about starting a new company or launching a new product benefitted from hearing these folks think out loud.
* Erica Drazen, FHIMSS: Partner in Emerging Technologies, CSC Healthcare Group
* Dave Garets, FHIMSS: Executive Director, Advisory Board Company
* Jonathan Teich, MD, PhD, FHIMSS, FACMI: Chief Medical Information Officer, Elsevier

And now, here are the list of the six contestants (in alphabetical order), what they presented, and what happened to each of them:
* Anagraph (http://www.anagraphmedical.com/): A mobile application to support provider communication. The judges and I thought it was a cool concept, but the audiences didn't quite get it, and they were knocked out in the first round.
* Datatech Solutions (http://www.dtsdss.com/): A data analytics solution from a programmer in Canada. It allowed for a very cheap, very graphical view of complex data sets. Jeremy (the programmer and head of the company) was easily the worse presenter - a true data geek who had trouble explaining his solution in the few minutes he had. However, the judges "got" what he was doing and rewarded him the top prize "The HIT Geek Champion".
* Epilogue (http://www.epiloguesystems.com/): This tool automates the process of creating EMR help documentation, as well as allows for creation of a "simulation" environment and a testing application to help confirm user proficiency in the EMR system. The judges were worried that Help documentation wasn't "sexy" enough, but the audience understood the need for this type of application and pushed them into the final round.
* Napochi (http://www.napochi.us/): They created a very graphical "Wound Module" that could be used with their EMR or others. The judges felt it was an interesting niche, but they did not make it to the final round.
* PatientKeeper (www.patientkeeper.com/products/clinical_applications/cpoe.html): They unveiled their latest product - a mobile CPOE application. While the judges liked the concept, they worried this product might run into trouble truly integrating with the native CPOE products, and questioned whether all the clinical decision support could be handled as well on a small screen. In the end, they were first runner-up in the contest.
* YourNurseIsOn (http://www.yournurseison.com/): A SAAS communication staffing tool which allows hospitals to more easily staff nurses and other positions. The judges liked the concept, but wondered if a small company could challenge a big dog like Chronos. The rumor is that this company got so many requests for work after the contest that they felt they could easily out-innovate anyone else.

Iron Programmers
I started off this session with an overview of the importance of agile programming and why hospitals and vendors need to start thinking outside the big EMR box and recognize there is also room for agile development to create quick wins to solve problems as well as "lead the way" to better thinking about how to evolve their EMRs in the future. The full slides are below.

The basic definition is that agile programming involves two core elements:
• Rapid cycles of iteration
• User-Centered Design (Strong customer focus and interaction)

Why is this concept important? Ask yourself these four questions:
• Do your clinicians feel your current HIT system provides the most efficient and highest quality way to practice?
• Do your clinicians ever look at your EMR system and say, “How come it can’t do that?”
• Do you ever feel like you can’t do anything outside the scope of your current EMR system because it would “distract” from your core competencies?
• Do you feel like you can’t do anything “extra” because it costs too much in time, resources and money?

I then reviewed the idea of a paradigm shift away from incremental improvements to an EMR (e.g. annual upgrades) towards the concept of "Focused Innovation" (e.g. create a specific solution for a specific problem and then use it alongside or within your EMR). The results are:
• Solve an immediate need
• Provide an easy and cheap way to "pilot" or test out a new concept or workflow
• Be more creative in your approaches to problem solving
• Create the building blocks or direction to help guide development of more robust solutions within your EMR system

Then I presented an example of this type of "agile project", which was supported by the Szollosi Healthcare Innovation Program (http://www.theshiphome.org/). The concept was how could we help our physicians more easily communicate with our emergency department (ED). The result was ExpectED (http://www.theshiphome.org/ExpectEd.html) - a web-based system which allowed physicians to fill out an "Expect Note" to send into the ED. It was launched independently in 2008, and by 2010 we had incorporated it into our EMR. A more complete explanation will soon be available on the AHRQ Innovations Exchange (http://www.innovations.ahrq.gov/).

Next, we highlighted this concept further by using the "Iron Chef" format of challenging two teams to use agile programming to create a product in two weeks - thus was born "Iron Programmers"! Each team was comprised of a front-end user interface expert and a back-end database programmer. About 2 weeks before HIMSS, they were given instructions to build a system which allowed for physicians to more easily communicate with the ED about incoming patients. This was not a competition as each team was asked to focus on different aspects of programming - Team one was focusing more on web based solutions, Team two on mobile based solutions.

Team One was Jon Baran and Ash Gupta from Healthfinch (http://www.healthfinch.com/) - a new company creating workflow tools which make life easier for physicians and their staff (BTW - I like this concept so much I'm working with these guys to build out these types of tools). They showed a web-based version of their "ExpectER" program, including the ability to access on a smart phone, and ways to send messages via text or automated voice technologies.

Team Two included Hunter Whitney (www.hunterwhitney.com/) and Doug Naegele (www.infieldhealth.com/). They showed a pure mobile-based app, as well as a web-based "control system" to help edit the questions asked in the mobile version.

It was a very impressive showing of programming prowess as all of these were working versions of software. To make it even more fun, we had each team give the audience a choice of options for an additional function to be added to their systems. Then each team had to program live on stage to show their completed results… they each finished strong and wowed the audience.

If you want some more info, well known HIT writer Neil Versel did a nice writeup at: http://mobihealthnews.com/10287/agile-health-app-developers-bring-the-heat-in-iron-programmer-challenge/

And finally, my slides for the Iron Programmer session:

View more presentations from Lyle Berkowitz, MD.

HIMSS Mania 2011

2011-02-18T00:59:00.001-06:00

The big HIMSS conference is here once again (for those not in the field - that is the Healthcare Information Management Systems Society... the conference is 5 days, about 30,000 people).

I'm looking forward to hearing keynote talks from former Secretary of Labor Robert Reich and Actor/Parkinson's Advocate Michael J. Fox, as well as CMS chief Don Berwick. And I'm wondering if David Blumenthal will give his usual rah-rah talk to the audience he has been giving (as head of ONCHIT), or if he will plan to unleash how he might really feel as he is "retiring" this spring.

I'm also looking forward to catching up with a lot of friends and colleagues, as well as meeting new folks, hearing new ideas and seeing new products - it's a big event and a long haul, but I always walk away with some new ideas and inspiration at this event (as well as achy feet).

I've been helping out with a "sub-conference" at HIMSS called HIT X.0. It is basically a track of "special" educational sessions which highlight innovation and future thinking, with a fun twist. It will be held in a single auditorium that seats up to 900 people and I'm moderating/presenting at four of these sessions - so if you are at HIMSS, hope you can make these!

FYI, if you registered for the HIT X.0 "sub-conference" separately - you will be guaranteed seats (they limited registrations to around 900)... BUT, if you didn't register for it - you can just show up a bit early and about 5-10 minutes before the event starts they will open the doors to everyone (since you have to assume that all 900 won't be showing up for every session).
Here is what will be keeping me busy for part of each day:

HIT Geeks Got Talent? Round 1
Monday, February 21, 12:15 PM - 1:15 PM
Description: HIT Geeks Got Talent?" HIT X.0 is a multi-media educational series that takes attendees on a trip to the not-too-distant future of healthcare technology. Building on the blockbuster reality show "America's Got Talent", these sessions will host a talent-search-like format featuring eight contestants demonstrating their latest technologies developed for the healthcare IT space. The three judges will be:
* Erica Drazen, FHIMSS, Partner, CSC Healthcare Group
* Dave Garets, FHIMSS, Executive Director, Advisory Board Company
* Jonathan Teich, MD, PhD, FHIMSS, FACMI; Chief Medical Information Officer, Elsevier
AND the Audience gets to help choose the four finalists

HIT Geeks Got Talent? Final Round
Tuesday, February 22, 2:15 PM - 3:15 PM
The four finalists vie for a shot at top HIT Geek!
Same judges, same audience participation!

Iron Programmer Challenge: Agile Programming for Web and Mobile
Wednesday, February 23, 2:15 PM - 3:15 PM
Description: Iron Chef meets HIT! We give two teams the same "ingredients" (specifications for a new tool) and they use "agile software development" (quick, iterative) to create a web or mobile solution.
Objectives:
* Learn about the benefits of agile programming methodologies and how it can be used to create solutions which can work in parallel or be interfaced with your EMRs and other IT systems.
* Think about how own organization can use agile programming techniques to build small focused tools which result in "quick wins" for your users.
* See and hear how two teams of agile programmers addressed this challenge and created brand new tools. These tools will be demonstrated at the session.
Check out Healthfinch ("We create easy-to-use medical apps for clinicians.") and their blog to get an idea of what one team is working on for this challenge!

Expensive, Exasperating and Exhausting - EHR the Extormity Way
Thursday, February 24, 11:15 AM - 12:15 PM
Description: Fictional Extormity CEO Brantley Whittington explains how his company combines the principles of extortion and conformity to extract revenues from hospitals and physicians who pay dearly for its proprietary EHR solutions.
Objectives:
* Describe the need for physicians and healthcare executives to suspend disbelief and allocate significant budgets to the purchase and maintenance of an inflexible client-server EHR from Extormity.
* Learn to self-attest to meaningful use in a convincing manner, confidently proclaiming that with the aid of Extormity, you have met all the requirements and there is absolutely no need for an audit.
* Practice endorsing your stimulus checks over to Extormity, as this EHR solution will require every penny of the ARRA funds you receive.
* Prepare for breach notification, as the security protocols embedded in the Extormity EHR will no doubt result in a leak of PHI.
* Learn about Extormity's shackled PHR solution that takes the tethered patient portal model to a new level, turning patients into indentured servants.

EMR's and Typewriters: They both have potential

2011-02-10T01:41:00.004-06:00

A couple of weeks ago an article came out in the Archives of Internal Medicine which essentially said that "Ambulatory EMR's don't improve quality", based on a meta-analysis (review of multiple research published in the past few years). Wow - that's like saying 'typewriters don't help create better stories' just a few years after typewriters were invented because there wasn't a lot of evidence proving that they did. Clearly I'm not a fan of this article. Let me break it down as follows:

First, I personally think it is crazy to expect research on individual EMR implementations to mean anything right now - the systems are all immature and evolving quickly, the implementations are all different, and individual usage is all over the place. Any research that is done at one location at one time is pretty much limited to that place and time. It is not like a drug study, where the drug is made and used the same way every time and thus research will be consistent. It will be a long time before research on any single EMR provides any value except to show what the POTENTIAL is for EMRs - and since it is a tool, we already know that there is good potential if done well, and poor potential if done poorly. So what would be much more interesting and relevant would be if we could start by assuming EMRs have the potential to help (since we know some research studies show they can), and focused research dollars on figuring out WHY an EMR did or did not improve quality at a specific time and place - I bet we would really learn from that!

Second, the follow-up discussion in the Archives by Clem McDonald (a true father of medical informatics) highlighted multiple studies that did show benefits and had a good breakdown of why this meta-analysis was not very valid. It is certainly worth a read, especially if you are getting asked by your friends at cocktail parties about "that report on CNN which said EMRs don't improve quality"… Now you can have some snippy comebacks like:

• "Sure, if you like meta-analyses which only include medication quality indicators, but I prefer my meta-analyses the way I get my annual physical exams - with vaccines and screening labs."
or
• "Those chumps only looked at single visit outcomes, not multi-visit ones- can you believe that?!? And umm, pass the wine please."
Or one more provided by my friend and colleague Dr. Bill Galanter:
• "You mean the one that shows that the American healthcare system doesn't deliver reliable, quality care no matter what kind of tools you give them? Since in addition to the physicians, insurance reimbursement, short visits, ill-advised mandatory government regulation, uninsured patients, pharmaceutical advertising, a terrible diet, overly expensive drugs and EMR's, co-pays, donut holes (will come back if republicans get their way) and a trillion other factors are also to blame..."

Or you can quote Dr. McDonald specifically, who wrote:
First, and most important, the current article tells us nothing about which CDS guidelines were implemented in the systems that they studied. Practices and EHRs vary considerably in the number and type of CDS rules that they implement, and we do not know whether the CDS rules implemented by the practices that participated in the surveys addressed any of the 20 quality indicators evaluated by Romano and Stafford. Second, the current study and Garg and coauthors' review considered very different categories of guidelines. Most of the guidelines (60%) in Romano and Stafford's study concern medication use; none of them deals with immunizations or screening tests, which were the dominant subjects in the studies reviewed by Garg et al. Furthermore, in our experience, care providers are less willing to accept and act on automated reminders about initiating long-term drug therapy than about ordering a single test or an immunization. The third difference is that the current study examined the outcome of a single visit, while most of the trials reviewed by Garg and colleagues observed the cumulative effect of the CDS system on a patient over many visits. Finally, the data available from NAMCS/NHAMCS may be limited compared with what is contained in most of the EHRs used for Garg and coauthors' trials. For example, the NAMCS/NHAMCS instruments have room to record only 8 medications, even though at least 17% of individuals older than 65 years take 10 or more medications.

Finally, this whole issue reminds me of what Don Berwick has been preaching for many years… that the way academic researchers study the effect of a new medication or procedure is great for those scenarios, but is not so good in studying the process of quality improvement, which usually relies on a combination of factors, including IT, cultural shifts and process changes. In this 2008 JAMA article called "The Science of Improvement" he explains how to improve the measurement of quality improvement programs:

Four changes in the current approach to evidence in health care would help accelerate the improvement of systems of care and practice. First, embrace a wider range of scientific methodologies. To improve care, evaluation should retain and share information on both mechanisms (ie, the ways in which specific social programs actually produce social changes) and contexts (ie, local conditions that could have influenced the outcomes of interest). Evaluators and medical journals will have to recognize that, by itself, the usual OXO experimental paradigm is not up to this task [observe a system (O), introduce a perturbation (X) to some participants but not others, and then observe again (O).]. It is possible to rely on other methods without sacrificing rigor. Many assessment techniques developed in engineering and used in quality improvement—statistical process control, time series analysis, simulations, and factorial experiments—have more power to inform about mechanisms and contexts than do RCTs, as do ethnography, anthropology, and other qualitative methods. For these specific applications, these methods are not compromises in learning how to improve; they are superior.

Second, reconsider thresholds for action on evidence. Embedded in traditional rules of inference (like the canonical threshold P<.05) is a strong aversion to rejecting the null hypothesis when it is true. That is prudent when the risks of change are high and when the status quo warrants some confidence. However, the Institute of Medicine report Crossing the Quality Chasm calls into question the wisdom of favoring the status quo.

Auerbach et al warned against “proceeding largely on the basis of urgency rather than evidence” in trying to improve quality of care. This is a false choice. It is both possible and wise to remain alert and vigilant for problems while testing promising changes very rapidly and with a sense of urgency. A central idea in improvement is to make changes incrementally, learning from experience while doing so: plan-do-study-act.

Third, rethink views about trust and bias. Bias can be a serious threat to valid inference; however, too vigorous an attack on bias can have unanticipated perverse effects. First, methods that seek to eliminate bias can sacrifice local wisdom since many OXO designs intentionally remove knowledge of context and mechanisms. That is wasteful. Almost always, the individuals who are making changes in care systems know more about mechanisms and context than third-party evaluators can learn with randomized trials. Second, injudicious assaults on bias can discourage the required change agents. Insensitive suspicion about biases, no matter how well-intended, can feel like attacks on sincerity, honesty, or intelligence. A better plan is to equip the workforce to study the effects of their efforts, actively and objectively, as part of daily work.

Fourth, be careful about mood, affect, and civility in evaluations. Academicians and frontline caregivers best serve patients and communities when they engage with each other on mutually respectful terms. Practitioners show respect for academic work when they put formal scientific findings into practice rapidly and appropriately. Academicians show respect for clinical work when they want to find out what practitioners know.

Additional Studies/Articles on this subject
* Health Affairs article (March, 2011) from Dr. Blumenthal: Meta-Analysis of recent studies shows more positive effect of EHRs on quality (less on provider satisfaction).

What Motivates us? Autonomy, Mastery and Purpose.

2011-01-31T00:30:00.001-06:00

My friend Shelly posted a great video the other day entitled "Drive: The surprising truth about what motivates us", (video is below). It's a fun, quick breakdown of Daniel Pink's book of the same name, which illustrates the hidden truths behind what really motivates us at home and in the workplace.   He starts out by laying this on us: "Our motivations are unbelievably interesting and the science is a little freaky! We are not as predictable as we think."

What really motivates us? Once basic money is off the table (i.e. get enough to buy the basics), there are really three main things that drive us:

1. Autonomy: We like to be self-directed.  Pink says employers should realize their employees probably want to do something interesting, they just need to get out of their way.

2. Mastery: It is fun and satisfying to get really good at something (i.e. learning the guitar, working on open source software).

3. Purpose: We want to feel we are doing something important with our lives. Additionally, when the profit motive is not aligned with the purpose motive, bad things happen - a common problem in healthcare!

I think these apply very well to a physician's life, and explain why we will push ourselves very hard - we enjoy our autonomy, we enjoy mastering our skills, and our high level purpose is fulfilling.   However, what we don't like is when others try and tell us what to do (i.e. insurance company, poorly designed clinical decision support), when we are told to master something we don't particularly enjoy (i.e. not all doctors love EMRs - especially when they are really hard to master), and when we start feeling like our purpose is to make someone else money instead of focusing on patients.

As for patients, I think this theory helps explain why we fail so often at helping them make significant lifestyle changes. They need to feel they are doing it themselves (autonomy), they need to find something they enjoy mastering (a lot of people don't like exercise), and they need to see a tighter link between their actions and their ultimate "purpose" (which is likely to be healthy).

So as we talk about further implementing EMRs, expanding insurance access, reforming reimbursement schemas, and changing the very nature of patient care... let's remember both patients and physicians are still human, and will be driven by these age old motivations. In other words, when making a change... think deeply about how you can best align autonomy, mastery and purpose - and you will clearly improve your chances of success!

DC Hearings for Meaningful Use

2011-01-22T18:56:00.003-06:00

I went to DC earlier this month to speak at a governmental "hearing" about Meaningful Use. Since the Feds are about to spend up to $40 billion on creating incentives for EMRs - I give them credit for wanting to make sure they hear as early as possible if there might be problems with their program.

I blogged about my experience at the HISTalk Blog, so full details are here:
http://histalk2.com/2011/01/18/the-mu-hearings-drlyle-goes-to-washington-11811/

For those who just are looking for a quick summary, here you go:
ONCHIT's Implementation Committee wanted to hear from Eligible Providers (EPs) and Hospitals about their early experience in preparing to meet MU requirements for this year.

The good news is that this bill has indeed "stimulated" many organizations to move forward with various upgrades and focus on how to produce quality reports from the data in their EMRs. But mostly we heard about the challenges:
• This is hard. It’s not impossible, but it’s a higher bar than many had anticipated because the requirements are not simple, nor are they fully explained.
• Time crunch. There is a very tight time frame between the release of the requirements, embedding them into EMRs, the "rollout" of the new EMRs, and the updating of workflows and reports to ensure users are actually meeting the MU requirements.
• Resource crunch. This is often a zero-sum game with resources.
• We need more flexibility. Not every practice is the same, and requiring 100% mandate of every requirement is not reasonable.
• Functionality is not the same as usability. An EMR vendor can get MU certification for their functionality whether their usability is great, good, or poor. Fortunately, the government is starting to look into usability requirements for the certification process, so let’s hope they follow through on that sentiment.
• Standards. "We’d rather have one bad standard we can work with than three good ones without a clear winner." On the other hand, we should make it clear we do NOT want the government to make standards about actual functionality – we can and should be creative in that domain.
• The cost of implementing MU may often be more than the actual monies themselves, when you factor in costs for various software upgrades, consultants, and change management.
• Certification requirements don’t always exactly match MU process requirements. Someone has to keep a better eye on this.
• Communication with CMS and ONCHIT has not been easy.
• The result of most of the above is that the biggest and the best are struggling with MU… so you have to wonder, how much harder will it be for others?

It has been interesting that this is in stark contrast with recent ONCHIT announcements about a recent survey showing that the majority of doctors plan to apply for MU. However, let's be serious - most docs don't even know what MU means, and less than 25% even use a "basic" EMR (and under 10% use an "advanced" EMR). So if a doctor gets asked, "Do you plan to apply for free money from the government for using EMRs in the coming years?"... it should not be a shock that most will say, "Sure, I'll give it a try."

I know ONCHIT is trying to keep an optimistic view here, but I wished they spent some time at these hearings listening to real world users and less time crowing about a survey asking a hypothetical question. In fact, no one from ONCHIT actually came to these hearings - even though they paid for people from all across the country to fly in (to be fair and balanced, someone from ONCHIT did listen on the phone during the morning session, and the Committee did summarize and report to ONCHIT later on).

I think we all agree that ONCHIT's goals are noble, but if they don't get feet first into the reality of the situation, they will have a hard time getting there - these hearings were a good step in the right direction, and I hope they continue to keep their ears on the ground and make adjustments as appropriate.

Relevant Links
- Full details and testimonies from the hearings
- Review of the different types of ONC Certifications

Health Innovation in 2011

2011-01-02T22:19:00.002-06:00

This is going to be a big year - healthcare needs more change and innovation than ever! So one of my resolutions is to do more regular blogging. I will likely move to shorter blogs about news stories of interest, with a plan to distill them down to points which will be relevant to those interested in promoting innovative thinking and action in healthcare.

I'm going to start with two new stories that are more related than one might think - one on healthcare value, the other on snow removal.

How Measuring Outcomes Drives Innovation
I just read Michael Porter's latest NEJM essay entitled, "What is Value in Healthcare?". The key points are:

1. We need to base our reimbursement system on Value (Outcomes/Cost) not Volume. In 2009, Porter described this in more depth in his NEJM article "A Strategy for Health Care Reform — Toward a Value-Based System".

2. Measuring real outcomes is critical (what really happens to the person, not simply their lab values or process followed). For example, for a diabetic - real outcomes are whether someone loses their sight, needs to go on dialysis or has a heart attack (not what their HbA1C value is and how often it is checked).   He defines these in an "Outcome Measures Hierarchy" that involves three tiers: Tier 1 (Degree of Recovery), Tier 2 (Time to Recovery) and Tier 3 (Sustainability of Recovery).   This spectrum is what we really care about and encompasses both short and long-term outcomes, as well as "cycle time" (how quickly one gets to recovery).

3. The main purpose of measuring actual outcomes is to enable "innovations in care". He describes how measuring, reporting and comparing these actual outcomes are what allows us to think and act in innovative ways.

Dr. Thomas Lee follows up on Porter's essay with his own complementary one: "Putting the Value Framework to Work". He says, "When measurement is oriented toward what happened to patients instead of what services were performed, interesting challenges and opportunities arise." For example, he notes that their typical PCP reports included data on number of office visits and RVUs, but not on the number of ER visits and hospital re-admissions, nor on the cycle times for how quickly discharged patients are seen in follow up clinic. Dr. Lee also notes that "just the collection of such data requires organizational change and the weakening of walls between our silos", (which I assume he means is a good thing!).   He notes that his system (Partners) is currently working on creating "value dashboards" for issues such as stroke, diabetes and colon cancer. They will identify "pause points" in patients care and define what should be routine at those points via checklists. That is basically what we have been developing with our Process Checklist System (we call them "Pathways") - for things like new diagnoses of Hematuria, Afib and Cancer - so I am a big can of that concept!

Paying plows by inch, not hour, can save a city’s snow budget (link to story)
The second story which caught my attention was an NPR interview I heard with the Mayor of small town in Massachusetts... and how they saved time and money by creating a value based system for snow removal. Apparently, the typical reimbursement mechanism for snow removal has been to pay for the amount of time to remove snow ("hourly rate"). Thus the incentive for truckers has been to go slow so they can charge more.  The Mayor of Quincy changed the incentive to paying by the inch. The result is that they saved money AND the snow was removed more quickly!   Yep - just common sense, and something that I'd like to see more of in the healthcare system as well!!!

Clinical workflow that is just not sustainable

2010-11-21T23:42:00.003-06:00

I am officially a huge fan of "futurist" Jeff Goldsmith (President of Health Futures). In my last post (I can't believe it was over a month ago), I quoted his thoughts about how "core measure mania" and the lack of innovation in HIT are resulting in a failure to address horrible EMR interfaces which make it harder for physicians to improve quality and efficiency.

In a recent interview in California Healthline, he elaborated further by explaining, "It isn't merely the tools that are the problem, but the fact that we have this micro accountability problem with the payment system and increasingly with the quality measurement process. We're absolutely inundating caregivers on the front lines with a level of detail that's required for them to document in their clinical workflow that is just not sustainable…. we're diverting a huge chunk of the clinical work force's available time to feeding the machine."

Bang - he nailed it right on the head. Said another way, one of our fundamental problems is that we are using EMRs to force doctors to document for billing purposes - which takes a lot of time and energy.   And our EMR vendors keep giving us slightly refined versions of the same process, essentially saying "this upgrade will make it a little easier to do this really hard and unsatisfying task".   Instead, we need systems that focus on helping physicians (and other clinicians) actually take care of their patients, and make documentation the "byproduct" of that care.   I know, it sounds like common sense... but it just is not happening to any significant degree (don't worry - I, and hopefully others, are working on it).

Other great quotes from this interview:

I would have given meaningful users of clinical IT who actually followed the embedded care guidelines ... a malpractice shelter. That would have been the approach I would have taken is to carve out some kind of exception and reduce their malpractice expense.
Cool - I like this idea. Instead of the government "piecemeal" giveaway of $40 billion dollars, why not use that force and energy to actually change the system... with the knowledge that short term incentives rarely provide long-term gains... it is much better to change the system at a large sense.

I think at this point the meaningful changes are going to come from the margins not from the core vendors.
As with every industry with a lot of "big companies" who have trouble innovating due to their size, watch for the rise of smaller companies who will be creating products and services that will work both with and without the existing HIT infrastructure in place.

Other interesting announcements of particular relevance:

* CMS launches their Innovation Center, with a goal to create better experiences of care and better health outcomes for all Americans and at lower costs through improvements.   It appears their method will be to "identify and test care models that provide beneficiaries with a seamless care experience, better health and lower costs” (per physician Richard Gilfillan, the acting director for the new center, in their news release).
* ONCHIT launches SMArt (Substitutable Medical Apps, reusable technologies) - an iPhone like platform which will allow developers to create apps using consistent standards.   And yes, this is VERY exciting stuff - something I've been talking and lecturing about for the past few years... can't wait to see how this unfolds!
* Video montage of HIT Usability Problems - from Canada's Healthcare Human Factors Group

Health 2.0 Conference and Innovation

2010-10-10T22:24:00.006-05:00

I was just at the Fall Health 2.0 conference last week in San Francisco - it was the biggest (over 1000 people) and the most well-run Health 2.0 conference to date (kudos to Matthew and Indu). The conference was enjoyable as usual - good networking and stimulating thinking galore. There were some definitely interesting companies and ideas (more on those in another quote) - but still so many companies that don't yet understand the difference between creating software which allows users to do a task online that they don't really want to do vs. creating solutions which automatically does things you don't want to do. In other words, we don't need an app that allows users to enter in their daily weight or glucose or med compliance, we need real life solutions which can "sense" each of those things as they happen and then send those to a "cloud" for analysis. The good news is that we are seeing more of these "connected" devices, such as the Withings Scale, the Gluconix wireless meter, the MIT Mirror that can check your pulse and the Vitality GlowCaps which helps remind you to take your meds... and I hope to see more solutions taking advantage of them in the future.

Tonight, I want to comment on the keynote presentations - some of the best I've EVER seen...I think due to the fact that the two presenters were not just smart, but they were really prepared for their audience. This article from Healthcare IT news was an excellent write-up. I have added a few of my own comments:

Health 2.0 keynoters differ on health IT innovation
Two keynote speakers at the fourth annual Health 2.0 Conference yesterday – a futurist and the "godfather” of Web 2.0 – disagreed over whether innovation was happening in the healthcare industry. While Jeff Goldsmith, author, futurist and president of Health Futures, said the industry is experiencing an innovation “drought”, O’Reilly Media founder Tim O’Reilley said innovation is coming from outside of the formal healthcare industry.

Goldsmith attributed the dearth of creativity on “management menopause" – wrong-business-model, risk-averse management that used to be run by scientists and engineers but is now overseen by lawyers and marketing people – and slow decision making. “This doesn’t get you to innovation,” he said. He questioned whether public companies can successfully create new knowledge, saying it was easier for large firms to buy than to grow new intellectual property. The drought is most prominent in the medical imaging, medical device and enterprise clinical IT markets.
(LB: Ummm...wow, this is so dead-on accurate!)

“Health IT has degraded clinical care,” he said. "The industry is suffering from core measure mania, and the solution is to tame the 'documentation monster',” he said. "Interfaces today are too hard to use and can’t be connected," Goldsmith said. "The health IT community must help people find the information they need effortlessly, accommodate the diversity of people and their lifestyles, and equip families with tools to manage their healthcare. The goal is to get to human connection,” he said.
(LB: Yes, yes, yes...see some of my recent past blogs on Usability.)

At the same time, said O'Reilly, medicine needs to be turned into a science. The data exists, but it just needs to be used effectively to understand the customer. Analysis is not sufficient, he said. Healthcare needs an information nervous system that reacts in real time. “The power of the real-time enterprise is absolutely critical."

Sensors, data monitoring, collective intelligence and predictive analysis are everywhere. “Healthcare must be a part of that,” O’Reilley said. “We focus our energy on the wrong things,” he added. “We need to work on stuff that matters. We need to work on the hard problems.”
(LB: He gave an example of a recent announcement about work on a potato chip bag that makes less noise - which got a good laugh from the audience, as we know that more money will likely be spent on that than on improving EMR interfaces in the coming year.)

"We know the right treatment in 98 percent of medicine," said O'Reilly. "The two percent is art and we need systems to do the right thing. That’s the end state of IT."
(LB: in other words, we need to figure out systems that make us consistent with the 98% of medicine we already know and support our data needs for the 2% of medicine that requires more critical thinking - see my past blog of Process over Product Innovation.)

Other resources
* Review of the Healthcamp during HC Innovation Week in SF - including a video from Todd Park about the government's release of health data via the Community health data initiative. Check out more about this topic at: http://www.hhs.gov/open.

The Real EMR Incentive: We want LONG-TERM EFFICIENCY, not short-term funding!!!

2010-09-26T18:30:00.002-05:00

This is a mantra I have long been espousing, and it was nice to see a recent report from the CapSite research firm backing up this assertion. More specifically, this study of more than 2000 medical groups across the US found that "the most important reason driving Ambulatory EHR purchases was the goal of physicians making their practice more efficient and not the ARRA / HITECH Act Stimulus funding".

Said another way, to get real adoption - we need to figure out how to promote USABILITY not just Certification. And let's continue to move from the inefficient paper-based paradigm (EMR 1.0) to the much more appropriate web-based or iPhone paradigm (EMR 2.0). My last post, which talked about "The Future of EMRs", provides more details on this idea. And I am looking forward to learning more on this topic when I go to SanFran this week for the "Annual Meeting of the Human Factors and Ergonomics Society" - where I will be listening to the top experts across all fields, as well as speak on a panel of EMR aficionados discussing the importance of improving usability of these tools.

So what can we (especially the government) do if this concept is true (the key to adoption is Efficiency)? Maybe we should reconsider how we spend the $30+ billion in HITECH funds? Perhaps instead of giving "relatively" small grants to a lot of doctors, we use the money to help the whole industry create more Efficient and Usable products? Myself, and others, have brought up this concept before (see "How should we use $36 billion to promote EMRs"). But it becomes more relevant when one of their own ask the question, which just happened:

As reported in this article, at a recent DC conference, former Secretary of the Treasury Paul O'Neill (who has authored academic papers on patient safety with current Medicare chief Dr. Donald Berwick and Lucian Leape) posed a technical question to keynote speaker Dr. David Blumenthal, the National Coordinator for Health Information Technology: "Why is it that we're reluctant to declare that we are going to design the best prototype that we can with an idea that we will have [iterative versions] as we learn more and we identify more needs? Why is it that we can't call to question and get on with what's a clear and apparent need for a national standard that's a work in progress? It's not that it has to be perfect from day one, but your office basically says, 'We're going to do this now?'," O'Neill said before a packed house of doctors and administrators of corporatized health systems.

Dr. Blumenthal's answer did not clear things up as he talked about analogies to the interstate highway and the Internet - which actually seemed to hurt his own conclusion. In other words, if you look at those government investments - you see that they created the infrastructure upon which others could build. They did not involve the government giving money to end-users (e.g. local truckers) to buy and install concrete paths themselves, nor did the government give money to Internet end-users to buy and install web-servers themselves. And yet, here we are - giving money to end-users (physicians) to buy and install a variety of proprietary systems that don't talk to one another without heavy lifting since each vendor creates their own versions of the concrete road - with proprietary data models and back-end functionality.

If the government believes in these past analogies - then they need to reconsider how they distribute their EMR monies...perhaps building a single standardized EMR platform (like they do with highways or Internet protocols) upon which the vendors can add their "value" and healthcare providers and patients can benefit from consistency and competition around the key issue at hand - Efficiency.

Mayo Clinic Center for Innovation: 2010 Transform Symposium

2010-09-20T00:34:00.004-05:00

I finally visited the Mayo Clinic this past week! I was there for the Mayo Clinic's Center for Innovation Annual Conference - The 2010 Transform Symposium, where the theme was "Thinking Differently about Healthcare".
I got a tour of the Clinic, as well as their Innovation Center… so you can imagine, I was like a kid in a candy store! The Mayo Clinic has a culture of innovation that starts with "Drs. Will and Charlie" (the Mayo Brothers) as well as their father (William W. - who mortgaged his house to get a crazy device called a microscope so he could study disease better).   And while this is part of their culture, they also recently recognized the importance of having a full Center dedicated to expanding on this arena - thus launching their Center for Innovation in 2008, which now includes around 50 people - a very impressive size.

There were some great people and speakers at the conference. I was inspired in various ways - including the need to eat better (more whole grains, less processed foods and fats), the need to walk more (NEAT = Non-Exercise Activity Thermogenesis), the need to relax in whatever manner works for you, and the importance of living and working in a space that is designed well. I realize those don't sound like they actually met the theme of the conference (since we've been preaching those themes for a long time) but it was how these people said it and what they are doing differently that made an impact.

The first speaker (Dr. Coombs, president of the Mass Medical Society) pointed out the importance of both empowering patients to ask questions AND giving them resources to find answers. Jaime Heywood (PatientsLikeMe) always gives a great talk about the power of patient data. Mrs. Q (who blogs at "Fed up with School Lunch") made me very happy my kids are in a school that treats lunch with respect. Dr. Dean Ornish opened my eyes once again to the importance of Lifestyle and a focus on "health care, not sick care" (FYI - he also told us Medicare is now paying for wellness programs - wow!). And the conference walked the walk by having a fantastic chef make healthy and delicious meals and snacks for us the whole time - check out his recipes at NewTaste.com. Various Design experts gave examples of the importance of their work. And anything by Sekou Andrews (a "spoken-word artist") was amazing.

I was fortunate to have a little time on stage as well to present some of the work we've been doing with the Szollosi Healthcare Innovation Program (http://www.theshiphome.org/) around "Thinking Differently about EMRs" (Electronic Medical Records). The summary is that today's systems (EMR 1.0) are failed paradigms which try to simulate paper rather than try to take advantage of what computers can do well - information visualization, predictive analysis, etc. Part of this is due to doctors and IT people who don't understand the difference between tasks/workflow and "thoughtflow".  Another part is due to the vendors who don't utilize true information designers in creating their systems, and the last part is due to the evolution of monolithic 3-tiered siloed systems which don't allow for easy innovation (see the NRC Report for more details). I then displayed a few screen shots of the potential for future systems (EMR 2.0) - to hopefully stimulate the audience into realizing we can do better. This was similar to a talk I gave in 2009 at HIMSS - here is a blog with the slides.

Finally, kudos to the Mayo Center for Innovation (and particularly Dr. David Rosenman, the conference coordinator) for an excellent meeting.   For more thoughts on the conference - check out the Mayo Center for Innovation's Blog.

SHIP in the Harvard Business Review article on Healthcare Innovation

2010-08-20T01:54:00.009-05:00

Healthcare remains one of the largest parts of the US economy, accounting for $2.5 trillion dollars, or about 17% of the GDP in 2009, which is estimated to rise to 25% of the GDP by 2025 (unless major changes are made).

So it is no surprise that mainstream business magazines will be writing more about healthcare innovation in the years to come. This month's issue of the Harvard Business Review (September, 2010) has an article entitled “Kaiser Permanente’s Innovation on the Front Lines”.

The first part of the article talks about how Kaiser funds an internal "Innovation Consultancy" group (led by good friend Chris McCarthy) whose focus is to develop "service line innovations" to improve the quality and efficiency of care, as discussed below:

The Innovation Consultancy takes on carefully chosen projects throughout Kaiser Permanente, which is based in Oakland, California, and serves the health needs of more than 8.6 million members in nine states and the District of Columbia. That’s a huge laboratory for tackling opportunities to improve health care practice. McCarthy and his colleagues pursue an expansive, service-focused version of innovation, not the conventional one that by definition excludes everything but new technologies or tangible products. Surprisingly little attention has yet been paid to this version. But, as Kaiser is discovering, the bucks are relatively few and the bang can be disproportionately big. Compared with costly, long-horizon, research-driven innovation, service-focused innovation can be done both rapidly and economically.

The second part of the article talks about how Kaiser’s Innovation Group helps lead the Innovation Learning Network (ILN) – a consortium of non-profit organizations who have banded together to learn about and share healthcare innovations. The innovation program I direct (the Szollosi Healthcare Innovation Program , aka SHIP) has been an active member of the ILN and was featured in this article. The author highlights our “Inflection Navigator” project as an example of the importance of open collaboration between institutions to create these “service line innovations” which focus on both increasing quality while also improving the patient experience. Here is what he wrote:

Care Coordinators
Lyle Berkowitz is a Chicago primary-care physician who also runs the Szollosi Healthcare Innovation Program, a charitable foundation that belongs to the Innovation Learning Network. Berkowitz has worked with the ILN on a process to help patients who’ve received a frightening diagnosis more easily negotiate the ensuing flurry of necessary activity: follow-up tests, visits to specialists, decision making about treatment and care. The process is called Inflection Navigator, because a diagnosis of cancer or serious cardiac disease, for example, presents the patient with a profound inflection point.

At such times many patients feel too overwhelmed to ask important questions or undertake important tasks. Inflection Navigator assigns to each patient a care coordinator, who explains, assists, sets up appointments, anticipates questions, and provides answers. The care coordinator sequences activities to minimize the inconvenience to patients and maximize the value of the time they spend with doctors. For example, a patient’s visit to a specialist might be scheduled only after the necessary tests have been done and the results can guide a recommendation. “It decreases the burden on both the patient and the doctor,” Berkowitz says.

It also bends the cost curve down. Care coordinators don’t have to be highly trained and heavily compensated. They depend on a database of medical protocols reflecting best practices for diagnostic procedures and the latest treatments for various diseases. This frees physicians to spend more time where their expertise makes the greatest difference. The process bends the learning curve, too. If, say, the standard treatment for atrial fibrillation changes, “the cool thing is I don’t have to go and try to educate all my doctors,” Berkowitz says. “Because it can take years to do that. All I have to do is change the protocol that’s already built into the system.” The physician makes the diagnosis and then hands the patient off to the care coordinator.

Democratizing Health Care
Lyle Berkowitz mans one corner of a small booth on the modest show floor of a conference and expo in Boston. The event is a joint production of the Innovation Learning Network and the Center for Integration of Medicine & Innovative Technology, a nonprofit consortium of Boston-area teaching hospitals and engineering schools. The proceedings might best be described as a festival for health care geeks. Berkowitz is busy explaining Inflection Navigator to interested attendees. The emphasis here is on sharing, not selling. No booth bunnies, blaring music, flashing lights, or branded tchotchkes, just conversation—enough conversation that superior listening skills are needed to hear above the din. The exhibitors have zeal in common. They want to make health care better, smarter, cheaper, and more accessible.

Chris McCarthy hovers and circulates. It’s the last day of the event, and he has the semirelaxed look of someone who has either dodged or dealt with whatever might have gone wrong and is finally surrendering to satisfaction. Sharing real-world evidence of what works—ideas, practices, protocols—exhilarates people like McCarthy and Berkowitz. To them, there’s nothing odd about 16 independent organizations coming together to improve more quickly than they could if they were left to themselves. It simply makes sense to spread improvement as broadly as possible. This is not the vision of health care that emerged in the grinding yet cartoonish debate leading up to the passage of what is now called Obamacare. It was easy then to imagine that the whole system was willfully committed to cruelty, greed, vanity, and ineptitude. Beyond the fray, however, creativity flourishes. McCarthy and others, by democratizing the methods of innovation, are democratizing health care, giving patients and non-physician caregivers a louder voice in designing the future.

Minute Clinics - Destruction or Inspiration

2010-08-10T00:47:00.003-05:00

A poster at The Health Care blog recently pointed out that Minute Clinics (and similar) are seeing increasing number of visits while Americans are going to their doctor less... and wondered if this was the dawning of a new age (and sun-setting of an old one).

Here was the comment I posted:

What is old is new again... "quick care clinics" have come and gone many times over the past few decades - are they really the be-all and end-all answer this time? I think they have a role, but certainly don't solve everything - and their major benefit may be in making doctors think more innovatively about how they deliver their care for low complexity cases.

More specifically - let's start with the clinical perspective: there will be anecdotal stories of great convenience, but also those of horribly missed diagnoses. From an efficiency perspective, there will be wonderful stories of quicker access vs. going to the standard practice... but two things are critical to understand:
1. There are not enough NPs and quick care clinics to truly handle all the demand out there.
2. Practices aren't going to stay standard forever. Many are now doing virtual visits via phone or the web - and hey, that's even easier and more convenient than having to find a clinic with an NP and register there. So boom... the efficiency rod strikes right back at them.

Of course, the truth is that there is PLENTY of DEMAND right now, and not nearly enough supply, so everyone will be busy for awhile. But this is an important time for care providers to start rethinking how they deliver care, especially to the "easy, highly structured" cases (e.g. URIs, UTIs, as well as stable Htn, DM...) and hopefully we will start seeing more innovation in this model - thus freeing up doctors to have more time for the more complicated cases as well!

I wrote a more thorough review of all this back in 2007 when the same questions were coming up... check it out:
A Time of Change: New technology-enhanced care models may change everything. Will you be able to adapt?

DrLyle's Take on the Meaningful Use Rules

2010-08-02T23:36:00.007-05:00

I wrote up some notes about MU last week and the folks at HISTalk published it - here is the link to that posting (as well as some interesting comments from others):
DrLyle's Take on the Meaningful Use Rules 7/30/10

And here is the text from that post, with links to resources on the bottom:

In mid-July, the government released the final rules on MU and EHR certification. I was actually at the perfect place for this — the annual meeting of AMDIS (Association of Medical Directors of Information Systems). So we had 200 CMIO-type docs and a panel of speakers ready to talk about this topic. HIT geek heaven!

From my bias of focusing on ambulatory EMRs, here is what I learned at this meeting from listening and talking to some very smart people on the topic and reflecting on everything the past few weeks:

Big picture stuff
MU Rules are reasonable. The government listened to the end users and decreased the expectations on the "Core Rules" (decreased the percentage of eRx required), while putting other rules in an optional "Menu" (i.e. choose five of 10). But be aware, anything optional you don’t do in Phase 1 will be required in Phase 2 in 2013 (i.e. you’ll need to do 10/10 from the Menu)… and they will likely think of more things to add by then.

MU Rules are still not a slam dunk. Even for mature users, there will be work that needs to be done. It is hard to believe that a non-mature user, or users without a lot of resources, will be able to easily accommodate everything.

The government seems to think this will really work well and we will see over 50% adoption by 2015. I would love that, but am less optimistic. Best quote I have heard is that MU incentives are like giving someone money to have a baby. You will have a baby if you want a baby. The money is a nice extra, but not the main driver. Change is hard, so I am hoping that while we keep asking vendors and users to add functionality, we consider how we can improve usability at the same time.

I do hope the government is at least working on a secret Plan B in case 2015 comes and we are only at a fraction of where we need to be (e.g. maybe they give money to innovation think tanks to figure out better EMR user interfaces). If you want to read more about the rationale behind having a Plan B, check out the great Kuraitis/Kibbe blog on this topic.

Per John Glaser, we need to think about MU not as a simple, one-time incentive, but rather as a stepping stone to bigger reimbursement reform. In other words, it helps groups create the HIT foundation for alternative care models and payment reform of the future (e.g. Medical Homes, ACOs). In that future, an EMR is no longer a competitive differentiator, but rather how we use our EMRs will be the differentiator (e.g. care efficiency and improvement, use of clinical decision support, secondary use of data, and patient engagement).

Some details that popped out at me
1. The denominator is now "unique patients" rather than patient visits. So if a patient is seen three times in a year, you just have to fulfill the rule at least once for that patient.
2. Scoring will be done on an individual physician basis, not on a group-wide analysis.
3. To correctly measure many of these details (e.g. give clinical summary to 50% of those who ask) we would need to figure out a way to keep track of who "asks". That seems like a strange request for structured data and certainly should not be what a doctor is spending his time doing. So either we need to make it an easy administrative chore or consider doing it for 100% of people automatically.
4. For patient reminders (for patients over 65), physicians can decide content and format. For example, we can decide to just do colonoscopy reminders and only do it via mailers to patients — it does not have to be electronic. The point is to just prove we can identify patients by age and communicate with them in some way.
5. Patient education. We need to figure out a way to document when we provide these handouts. Some EMR systems may have that built in, but even then, just for the handouts they have. What if I go online and print something else out? Or give them a special handout I have created? We may need to create a special patient education section to document this, but it is again more busy work for physicians (which I am not a fan of!).
6. EMR vendors are on the hook. They are required to ensure some level of MU reporting from their EMRs to get certification. The result will likely be that they will be spending a lot of extra time and money preparing their EMRs and then trying to get everyone to take those upgrades. They will then likely just certify the most recent version of their system.
7. EMR users need to upgrade, due to above point. It is unclear how all current EMR users are going to be able to quickly upgrade their systems in the coming 6-12 months. That takes a lot of planning, time, resources, and money. I wonder if users of "older versions" will band together to try and get their older versions certified, or if the vendor will help at all?

Resources
• The NEJM summary from Dr. Blumenthal
• A summary from Computer Science Corporation (CSC)
• Full text of the MU rule from HISTalk
* MU PPT Slides from CMS
* The HHS FAQ about MU

Usability and EMRs: An Update

2010-07-11T23:12:00.020-05:00

I've talked since the start of this blog about the importance of improving "Usability" for Electronic Medical Records (EMRs), and this post is an update which provides a single collection of relevant information:

First, a report raises growing concerns that electronic health record products are being developed without specific best practices and design standards related to EHR product use in a healthcare setting. To overcome this difficulty, many vendors support an independent body guiding development of voluntary usability standards for EHRs, the study found.

Second, here are two stories on the recent debate about how Usability should be part of EHR Certification - one is from Healthcare IT News, the other from CMIO.net.

Third, a Comparison of Questionnaires for Assessing Website Usability - while this is not healthcare specific, it provides some insight into Usability testing.

Other Links of Interest
• The HIMSS WhitePaper on EMR Usability
-- This paper is a very well done introduction and review of this topic, so definitely a good place to start. Or if you want the very short version, here is an HISTalk Reader post (kudos to Odell Tuttle) which summarizes the 11 HIMSS EHR Usability Principles as follows:
Simplicity
Everything from lack of visual clutter and concise information display to inclusion of only functionality that is needed to effectively accomplish tasks.
Naturalness
This refers to how automatically “familiar” and easy to use the application feels to the user.
Consistency
External consistency primarily has to do with how much an application’s structure, interactions, and behaviors match a user’s experience with other software applications. An internally consistent application uses concepts, behavior, appearance, and layout consistently throughout.
Minimizing Cognitive Load
Clinicians in particular are almost always performing under significant time pressure and in environments bursting with multiple demands for their attention. Presenting all the information needed for the task at hand reduces cognitive load.
Efficient Interactions
One of the most direct ways to facilitate efficient user interactions is to minimize the number of steps it takes to complete tasks and to provide shortcuts for use by frequent and/or experienced users.
Forgiveness and Feedback
Forgiveness means that a design allows the user to discover it through exploration without fear of disastrous results. Good feedback to the user supports this goal by informing them about the effects of the actions they are about to take.
Effective Use of Language
All language used in an EMR should be concise and unambiguous.
Effective Information Presentation – Appropriate Density
While density of information on a screen is not commonly measured (though it can be), it is a very important concept to be cognizant of when designing EMR screens.
Meaningful Use of Color
Color is one of several attributes of visual communication. First and foremost, color should be used to convey meaning to the user.
Readability
Screen readability also is a key factor in objectives of efficiency and safety. Clinical users must be able to scan information quickly with high comprehension.
Preservation of Context
This is a very important aspect of designing a “transparent” application. In practical terms, this means keeping screen changes and visual interruptions to a minimum during completion of a particular task.

• Some excellent posts from John Halamka on this subject:
-- EHR Usability
-- Top 10 Barriers to EHR Implementation

• Improving Usability of Health IT for Physicians
-- A great article in Healthcare Informatics which starts by pointing out that most health professionals do not use available health IT systems because they actually increase their work effort and can too frequently hurt quality, whereas the objective should be to help physicians decrease their work effort while increasing their quality consistently. They offer thoughts on a "physician-specific point-of-care system that continuously adapts to practice patterns that could result in dramatic improvements to the quality and efficiency of healthcare delivery".

• Some past posts from me on this subject which I love so much!
-- The Dark Side of EHRs: Explores the issue of unintended consequences, often due to poor usability.
-- Good software includes superb usability: Discussion about how EMR vendors need to improve how they create their products.
-- Improving EMRs: Usability, Usability, Usability: My first ever blog post, the name speaks for itself.

And in case anyone is interested in "building a better mousetrap" - the charitable endeavor I manage, the Szollosi Healthcare Innovation Program (www.TheSHIPHome.org), is sponsoring one of the inaugural challenges in The Health 2.0 Developer Challenge. Our specific challenge is to rethink how we document in EMRs by using publicly available blog or wiki software to create a longitudinal medical record that represents a patient's multi-day hospital stay, or a multi-year relationship with a physician in the outpatient setting.

* NEW ADDITIONS *
* July, 2010: Usability in Health IT: Technical Strategy, Research, and Implementation (National Institute of Standards and Technology Conference) - this actually has about 20 different presentations on this topic.
* Sept, 2010: I presented at the Mayo Center's Innovation Conference about the need to rethink how we use computers in healthcare and shift from EMR 1.0 to EMR 2.0. Full blog is online at: http://drlyle.blogspot.com/2010/09/mayo-clinic-center-for-innovation-2010.html
* Nov, 2010: Incorporating Health IT into Workflow Redesign, prepared by the University of Wisconsin-Madison’s Center for Quality and Productivity Improvement (CQPI): or PDF of full summary: http://healthit.ahrq.gov/workflowfinalreport
* Nov, 2010: From NIST (and Usability expert Bob Schumacher), as report entitled "Customized Common Industry Format Template for Electronic Health Record Usability Testing" (PDF)
* Dec, 2010: The Usability Toolkit is a collection of forms, checklists and other useful documents for conducting usability tests and user interviews.
* Feb, 2011: Promoting Usability in Health Organizations: Initial Steps and Progress Toward a Healthcare Usability Maturity Model (HIMSS White Paper)

Our Healthcare System: Update

2010-07-11T22:40:00.007-05:00

A variety of websites and stories which I found to be important or at least thought-provoking:

Key Web sites
• http://healthcareforamericanow.org/
-- The best site I have found to simply explain, "What does the new health reform law mean for YOU?"

• http://www.healthcare.gov/
-- The federal government's site that includes specific advice on how to find health insurance and how that is impacted by the new health reform law.

Healthcare IT stories
• Use of HIT Improves the Quality of Care
-- A Kaiser Permanente Study Finds Quality of Care Scores Increase as Patients and Physicians Communicate via Secure E-mail.

• Improving Usability of Health IT for Physicians
-- A great article in Healthcare Informatics which starts by pointing out that most health professionals do not use available health IT systems because they actually increase their work effort and can too frequently hurt quality, whereas the objective should be to help physicians decrease their work effort while increasing their quality consistently. They offer thoughts on a "physician-specific point-of-care system that continuously adapts to practice patterns that could result in dramatic improvements to the quality and efficiency of healthcare delivery".

General Healthcare Stories
• Process improvement to improve compliance with specialty visits
-- Turns out that when a PCP refers a patient to a specialist, they only make the appointment 70% of the time, and of those - only 70% show up - thus less than 50% of people go to the specialists when they are referred! This article talks about how a process improvement improved those metrics. Our medical group (www.NMPG.com) does something similar to help with this process and we believe it provides a higher quality and more efficient process for sure!

• Better ways to manage the flood of test results
-- New recommendations target how physicians and hospitals can best communicate test results and prevent harm to patients.

• Aftercare Tips for Patients Checking Out of the Hospital
-- NY Times article on how good discharge planning can keep patients from needing to be re-admitted after leaving a hospital, and could save Medicare billions.

• How the Performance of the U.S. Health Care System Compares Internationally (2010 Update)
-- Yet another report, placing the US healthcare system last among industrialized nations. US spends $7,300 per person per year on healthcare and gets the worst results. UK spends $3,000, New Zealand $2,500; Canada $3,900; Australia $3,400.

• Health overhaul may mean longer ER waits, crowding
-- Due to a shortage of primary care physicians (PCPs), Emergency Rooms may grow even more crowded with longer wait times under the nation's new health law since there will be many more patients with insurance, but no increase in PCPs.

• The Variability of Patient Care - by John Glaser
-- One of the smartest guys in healthcare explains the theory from one of my favorite books (Designing Care by Richard Bohmer),which I talked about in a previous post about Checklists and process improvement. The key point being that there are two classes of care in a hospital and in a physician's practice, and the importance of understanding that these two very diverse scenarios need to be recognized when designing process/workflows for care (especially including use of EHRs). Glaser explains further;
---- Sequential care is a form of production: It involves performing well-understood tasks in a well-understood sequence (e.g. routine heart surgery). Sequential care's mental image is that of a production line. With sequential care it is possible to engineer a preferred sequence of steps and have the EHR guide the care team in performing these steps. And it should be quite possible to measure the outcomes of these steps. (This is similar to Clay Christensen's Value Added Process)
---- Iterative care is a form of discovery: It addresses complex diagnoses and conditions for which the diagnosis and treatment are a repeating series of hypothesis-test/treat-revise hypothesis steps. Iterative care is different. The mental image should not be the factory floor but a group of scientists in the laboratory. In this scenario we must encourage collaboration, enable an unpredictable set of actions to be taken, and provide easy access to information and other experts that might help the team form and test hypotheses. Measuring the outcome of discovery is very difficult. (This is similar to Clay Christensen's Solution Shops)

Allscripts and Eclipsys Merger - A Review

2010-06-27T16:59:00.007-05:00

Earlier this month, outpatient focused vendor Allscripts announced a major move - merging with (or more officially buying) hospital focused vendor Eclipsys… and thank goodness, because I always had trouble spelling Eclipsys! We seem to get 1-2 of these major acquisitions a year, and I would predict we'll continue to see about that rate until there are only 3-4 major healthcare IT vendors standing. And don't be surprised if one or two of those are not the classic ones, but rather larger IT companies who finally want to get into this market (e.g. IBM, Microsoft).

This particular merger is a reasonably logical acquisition since they were both likely losing out on deals where the buyer wanted an integrated inpatient and outpatient system from the same vendor. Of course, it will take awhile (at least 1-2 years) to really allow them to offer a well interfaced product (and don't be fooled - it will never be a truly integrated one, see below for more). In the meantime, the following business logic makes sense:
• Current organizations who work with both companies will immediately benefit as they should be able to assume that the products will start integrating and that the vendor should now pay for that (that's certainly what I'd ask of them).
• Current organizations who use Eclipsys and want to buy an outpatient EMR for their affiliated physicians will make Allscripts their "vendor to beat".
• Current organizations who use Allscripts and are looking to replace their inpatient systems will make Eclipsys their "vendor to beat".
• Organizations who are ready to "start from scratch" right now should at least be willing to hear what Glen Tullman has to say, and maybe he'll convince a few to be "early partners" in this great experiment…

Here is what various pundits are saying about this merger:
The official Press Release on June 9, 2010
Allscripts and Eclipsys announced a definitive agreement to merge in an all-stock transaction valued at approximately $1.3 billion...The combined company's client base will include over 180,000 U.S. physicians, 1,500 hospitals, and nearly 10,000 nursing homes, hospices, home care and other post-acute organizations. In addition, Allscripts will buy back the majority of their shares from Misys (who will go from a 54% to a 10% owner).

Glen Tullman will remain CEO of the company. Eclipsys President and CEO Philip Pead will be chairman of the company and will focus on strategic relationships, product and process integration and international business. The companies project $25 million in cost savings in 2011 and more in subsequent years. The transaction is expected to close in four to six months.

Healthcare IT News Story (June 9, 2010): Allscripts, Eclipsys to merge in $1.3 billion deal
- A simplified version of the press release.

Information Week (June 9, 2010): Allscripts Eclipsys Merger Saps Resources
This author points out how "the costs of integrating the ambulatory and acute expertise of Allscripts and Eclipsys may outweigh the synergies of combining the two companies".

Health Data Management (June 10, 2010): The Early Take on Allscripts-Eclipsys
Allscripts' pending acquisition of Eclipsys makes sense but has perils, according to several consultants specializing in helping providers select information systems.

Modern Healthcare (June 14, 2010): Allscripts' Eclipsys deal: the financial details
Allscripts-Misys Healthcare Solutions, Chicago, a developer of electronic health records systems for ambulatory-care physicians, will borrow most of the $577 million or more needed to extricate itself from the majority control of British IT developer Misys and then swap $1.3 billion in stock to buy all of Atlanta-based hospital and physician electronic health-record system developer Eclipsys....

Modern Healthcare (June 15, 2010): Allscripts deal: Success is in the execution
“If they perform really well, this strengthens them, because this is what the market wants, inpatient and ambulatory,” said Adam Gale, president of healthcare information technology market watcher KLAS Enterprises, based in Orem, Utah. “But can they deliver it? That's a whole other question. I guarantee you that is heavy on their minds.”

HISTalk Blog (June 15, 2010): Interview with Glen Tullman and Phil Pead
Glen Tullman is CEO of Allscripts. Phil Pead is president and CEO of Eclipsys.

HealthSystemCIO.com (June 16, 2010): Will Allscripts and Eclipsys truly integrate?
"True & total integration is almost impossible in the maddeningly complex world of HIT today…When a company like AllScripts buys a suite of products from another firm like Eclipsys, all they can truly integrate are the brochures, Powerpoints, proposals and contracts. The rest is interfaces, like every HIS vendor (and hospital) has plenty of already."

HIStalkPractice (June 21, 2010)
HIT Vendor Executives on Reactions to the Allscripts/Eclipsys Acquisition.

10 Point Program to Improve EHR software

2010-06-16T02:05:00.004-05:00

The HISTalk Blog lets users write in with ideas, rants, and raves now and then - and a recent post by an anonymous writer was so good - I am reposting it here. He wrote up a ten point program to improve EHRs... it was great. I think the first four points are key for actual development, the others are important for deployment. Read on:

10 Point Program to Improve EHR software
1.Less configurable. The Demotivators® said it best “When people are free to do as they please, they usually imitate each other”. Every hospital or physician practice is unique — they uniquely solve the exact same problems everyone else is facing.
2.Better designed. End-user input and UI design should be part of the specs, not the pilot.
3.Customer-prioritized enhancements. Fifty percent vendor-driven (sales and demo feedback, regulatory requirements, infrastructure, etc.), 50% prioritized by customers. Yearly process, projects grouped to be equal number of hours, one vote per licensed bed, top x projects will be roadmapped to fill 50% time.
4.Consensus-driven standard content and configuration. Vendor designed, large group customer editing — majority rules, everyone uses.
5.Remote hosted. 99.999% uptime, capacity and response time are key requirements.
6.Rapid install. If you’ve followed 1-5, training the end-users should be the most time-intensive phase of the implementation.
7.Qualified buyers. We’ll sell to you if you agree to: follow our standard workflows, use our standard build and participate (end-user input, content design, and prioritization). Must agree to mandate adoption! Better to support 50 involved, committed customers than 100 unhappy, non-standard, partially-implemented, low-adoption targets.
8.Equitable pricing. Low upfront, subscription-based. Every customer pays the same, scaled by size or volume.
9.Play nice with other vendors. Integration > Interfacing > Interoperating.
10.Record portability. Remove vendor lock-in. The intersection of the NHIN and CCDs with the market transitioning to replacement will make this a necessity. You know it will be mandated eventually.

The only thing I'd add is the concept of "Open those platforms" - meaning the vendors should release APIs that allow 3rd parties to innovate on the user interfaces and functionality that can interact with the data model without changing it (as per some past posts).

Physician Ratings vs. Healthcare Narratives

2010-05-26T00:41:00.006-05:00

An interesting study came out last week which aligns with some of my thinking and thoughts on individual physician ratings:
• The overall activity of ratings is pretty low (e.g. there are not many ratings being posted by patients). I think a major part of that is because consumers are not really confident in how to rate doctors since (1) there is a fair amount of subjectivity which makes it hard to put into a "standardized rating" and (2) they don't do it often. In other words, consumers might feel they can be experts on restaurants and movies since they have a lot of experience at those venues AND there are often obvious metrics. Meanwhile, most people just see a doctor 2-3 times in a year (and then it's just for 15 minutes), they usually just see 1-2 doctors (so not a lot of comparisons), AND the experience each time might be different depending on a variety of factors (e.g. how sick they are, the type of syndrome they have, how they respond to the therapy, etc.). In other words, most patient's actual experience with the doctors is often short and incomplete (at least with respect to fully rating them).
• Most of the ratings are positive… which makes sense since that is often human nature. But at least this dispels the myth that only "haters" would post! However, it should be pointed out that it often only takes 1 bad review to sour most people, unless there are over 5-10 good ones also present. A small amount of reviews can be easily biased by one bad one.

The LA times even did an article about this study: Physician rating websites mainly sing doctors' praises, study finds. It is a good story, although I think they used this study to too quickly dismiss these sites. Rather, I would use this study to explain that:
1. Physician rating sites are still in their early phases and the jury is still out on how important they will be.
2. For a true objective rating of doctors, we ideally need much greater numbers of consumers doing these ratings, and ideally in a more consistent manner (e.g. randomly poll patients, otherwise you will mostly get the most extreme examples on either end to post a review).
3. There needs to be a way for physicians to respond, particularly to negative posts (although without violating patient confidentiality). For example, I am impressed that Vitals.com now does allow for that function.

With that said, I think there is also a very important role for more "narrative" reviews of healthcare as well. However, that is likely to be best done at the systemic level (e.g. total healthcare experience across an enterprise), rather than geared towards a single physician. For example, I recently heard about a website called Patient Opinion . This is a non-profit organization in the United Kingdom founded by Paul Hodgkin, a GP who wanted to make the wisdom and insights of patients, available to the NHS (National Health Service). He states "the old ways of doing this – inviting a patient to sit on a working party or carrying out a survey – did not work very well", so he devised Patient Opinion as a way for thousands of patients to both share their own experience and gain support from others. The results are story after story about the good and bad in the system. And hospitals and other entities actually read and respond to these stories. They have found that these stories have more power and information than any objective rating scale could ever provide - and that they are often able to fix systemic problems based upon these narratives. Wow - that's a very powerful thought...

Storytelling and Innovation

2010-05-13T00:52:00.003-05:00

I am fortunate to be part of the Innovation Learning Network (ILN) which "brings together the most innovative healthcare organizations in the country to share the joys and pains of innovation. Its purpose is to foster discussion on the methods of Design Thinking and application of innovation / diffusion, ignite the transfer of ideas, and provide opportunities for inter-organizational collaboration." Some other members include Kaiser, Partners Healthcare, the VA system, UPMC and the Ascension Health System.

We meet twice a year for "in person" meetings where we learn formal innovation techniques, brainstorm on how they can be applied at our institutions, and share stories of successes (and failures - since the nature of innovation requires some failures!). Our most recent meeting was last week and was in Chicago - it was primarily hosted by a fantastic innovation and design consultancy called gravitytank (and the Szollosi Healthcare Innovation Program helped to co-host since it was in our home town!). As usual, my friend and fellow blogger Dr. Ted Eytan has already written this up a bit - check his ILN report out and you might also be able to see a picture of me about to be adorned with a leopard robe...

The theme for this meeting was "Storytelling" - particularly around how can stories help one develop or spread innovative ideas. I took away a couple of major learning's:

• Stories are a very powerful communication tool - humans are innately and culturally programmed to hear and understand stories. It is much easier and better to explain a problem or solution in the context of a story than as a bunch of numbers and statistics. What would you rather hear as a prelude to a decision to open up a new medical office in a certain area of town: "Bob and Jane were 25 years old when they met at Margie's Candy store, fell in love, bought a house in the new section of Lakeview, and then had a son named Bobby Jr. and later a daughter named Scarlett", or "The average age of marriage in Lakeview is 27 and the majority of couples have two children". Think about how much of the story of Bob and Jane you already filled in with your own mental images (the look and smell of the candy store, the kids playing in the house…) and how much you are already interested in their lives vs. how little you care about the stats.

• There is an art and a science to creating stories. First, define your Hero, the Villain, the Weapon (the tool which the hero uses to defeat the villain), and the Treasure that is received. Consider adding in a Mentor, a Companion (an important partner), some sidekicks (humorous extra characters). Next, set up your plot to mirror some of the typical archetype stories that people are used to hearing… almost all stories have a Hero overcoming a Villain to get to the treasure, but more specific stories each have their own subtleties, such as "Rags to Riches" (think Aladdin), "Overcoming the Monster" (think Jaws) and "A Quest" (think Indiana Jones). Finally, always make sure to humanize any data and keep things interesting by doing things like proposing puzzles, using props and interacting with your audience.

• Storyboarding is an excellent tool for brainstorming. Draw picture panels of the current state, put them up for everyone to see, and then step back and think about how else it could be done. Draw new panels and put them up, mix and match.. and create a whole new story. We broke into groups and looked at the problem of getting thru the airport - some groups looked at this from the eyes of a single mother with two children, others from the eyes of a busy consultant, others from the eyes of an aging couple. Within 30 minutes, the amount of great ideas was staggering - from "Family tickets" (one ticket for the adult and kids) to "amusement-like rides" through security, to pat downs with cooking-like gloves which smelled of warm cookies (hey - no holds barred on innovating!).

There are a ton of books on how to more effectively use stories; one of my favorites is Squirrel, Inc. Others include Made to Stick and The Seven Basic Plots: Why We Tell Stories.

The Dark Side of EHRs

2010-04-21T10:07:00.009-05:00

Sir Cyril Chantler noted, "medicine used to be simple, ineffective and relatively safe; now it is complex, effective and potentially dangerous." His quote was from a Lancet article in 1999 - much before EMRs were being used regularly. I wonder what he would say now!

I blogged back in February about the FDA's consideration of regulating EMRs... and a series of recent stories have come out reminding us of the unintended consequences of using information technology in healthcare… the truth being that problems occur due to a combination of issues, including;
• Implementation problems, such as forcing through awkward workflows.
• Technical problems, such as failed integration, slow speeds, system outages and true errors in the system design (e.g. 1 + 1 = 3).
• Usability problems, such as difficult to read screens, which can affect speed and judgment. Something I've been commenting on a lot in the past year, as in blogs of April, 2009 and August, 2009.

Here are two interesting stories from the Huffington Post Investigative Fund (a new nonpartisan nonprofit dedicated to in-depth reporting):
As Doctors Shift to Electronic Health Systems, Signs of Harm Emerge : A device that is central in the shift toward electronic medical records systems has been linked to instances of death or injury, according to an Investigative Fund review of Food and Drug Administration data.

Amid Digital Records Surge, a Lack of Policing by the FDA: As federal officials encourage the rapid expansion of electronic medical records to help doctors improve care and cut costs, they lack a reliable and systematic method for tracking the safety of these products, agency data and audits show.

Finally, my friend Dale Sanders, a well-known healthcare CIO, wrote an excellent blog bringing the personal touch and common sense thoughts to this topic of Patient Safety and EHRs.
I love this quote: Remember when safety belts in automobiles first became popular? They were simple lap belts, no shoulder strap. Did they aid passenger safety? Yes, in some ways… but they also introduced the danger of a whole new range of injuries, such as lumbar separation and paralysis, which hadn’t previously existed. It wasn’t until we added shoulder straps and the three point anchor to seat belts in cars that the evidence of benefit to passenger safety became clear and without question. We need pause now and add shoulder straps to EHRs.

If you are interested in searching the FDA's database for HIT problems, or submit one of your own, you can do so at MAUDE (Manufacturer and User Facility Device Experience)

With all that said, this should not stop the forward march of EMRs and HIT from helping us improve the quality and efficiency of healthcare... but it should certainly remind us that we are FAR from our ultimate destination and we all (vendors and users) have to figure out how to build, implement and use these systems better and better...

Other stories and articles
NY Times article (April, 2010) on how EMRs in the exam room can provide so much info that it pushes a doctor into “cognitive overload”

The Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry (JAMIA, 2007)

Overdependence on Technology: An Unintended Adverse Consequence of Computerized Provider Order Entry (AMIA Conference, 2007)

The unintended consequences of computerized provider order entry: Findings from a mixed methods exploration (Intl J of Med Informatics, 2009)

Rush to Electronic Health Records Could Increase Liability Risk
(Insurance Journal, June, 2010) which references this paper:
E-Health Hazards: Provider Liability and Electronic Health Record Systems

Nov, 2011: EHRevent.org has been created in collaboration with medical professional insurance carriers and adverse event reporting and government experts to improve EHR and patient safety and help to reduce professional liability. EHR event reports will be provided to participating EHR vendors and kept confidential by PDR Secure™. Information from the PDR Secure PSO may be used by medical professional insurance carriers and the FDA to better understand EHR events and to develop education materials that will increase patient safety and benefit physicians and other clinicians in their use of EHR technology.

Stats and Stories

2010-04-13T10:40:00.008-05:00

With the recent passage of the Healthcare Reform bill (meaning more patients will be looking for PCPs), along with HITECH getting closer to reality... we will be seeing more and more stories such as these:

Physician Shortage
WSJ Article (April, 2010)
The new federal health-care law has raised the stakes for hospitals and schools already scrambling to train more doctors. Experts warn there won't be enough doctors to treat the millions of people newly insured under the law. At current graduation and training rates, the nation could face a shortage of as many as 150,000 doctors in the next 15 years, according to the Association of American Medical Colleges. That shortfall is predicted despite a push by teaching hospitals and medical schools to boost the number of U.S. doctors, which now totals about 954,000. The greatest demand will be for primary-care physicians. These general practitioners, internists, family physicians and pediatricians will have a larger role under the new law, coordinating care for each patient. The U.S. has 352,908 primary-care doctors now, and the college association estimates that 45,000 more will be needed by 2020. But the number of medical-school students entering family medicine fell more than a quarter between 2002 and 2007. A shortage of primary-care and other physicians could mean more-limited access to health care and longer wait times for patients....

No surprise, a big part of this is due to:
Gap between PCPs and specialist compensation
MGMA Study (April, 2010)
Annual compensation for primary care and specialty care groups in academic practice slowed between 2008 and 2009, increasing only 2.93 percent for primary care physicians and 2.43 percent for specialists, according to the MGMA Academic Practice Compensation and Production Survey for Faculty and Management: 2010 Report Based on 2009 Data. Primary care physicians reported compensation of $158,218, while specialty care physicians reported compensation of $238,587, a difference of $80,369. From 1999 to 2009, compensation in academic practices continued to trail that in private practices.

Problems with the US Healthcare System, and Kaiser as a shining beacon.
This short story in the Economist (April, 2010) aptly (and somewhat pessimistically describes) how; for the most part, the American health system is dominated by cream-skimming health insurers and the myriad “fee for service” providers they do business with, which drive up costs by charging high prices for piece work. Whereas Kaiser is able to balance quality with cost AND patient satisfaction because it "aligns incentives both to promote parsimony and to improve the quality, rather than merely the quantity, of the care it gives." Thanks for Dr. Ted Eyten for finding and posting this in his blog first.

And we have to deal with this...

The Invisible (Uncompensated) Burden of PCPs
A NYT story (April, 2010) highlighted a NEJM article on this topic and points out the need to change how PCPs are paid — particularly as the new health care law promises to add millions more patients to the system.
The NEJM article (April, 2010) details the uncompensated work burden on PCPs, including about 100 extra tasks a day - including telephone calls and emails for various questions and refills, labs and other studies which need interpretation and communication to patients, as wells as forms and other paperwork for things like school paperwork and medication approval.

The Challenge of Multiple Comorbidity for the US Health Care System
Article in JAMA (April, 2010)
The aging of the US population, combined with improvements in modern medicine, has created a new challenge: approximately 75 million people in the United States have multiple (2 or more) concurrent chronic conditions, defined as "conditions that last a year or more and require ongoing medical attention and/or limit activities of daily living". Is the 21st-century US health care system prepared to deal with the consequences of successfully treating patients who have conditions, often multiple, that they would not have survived in the early 20th century? Current indications suggest that it is not. As the number of chronic conditions affecting an individual increases, so do the following outcomes: unnecessary hospitalizations; adverse drug events; duplicative tests; conflicting medical advice; and, most important, poor functional status and death. Approximately 65% of total health care spending is directed at the approximately 25% of US population who have multiple chronic conditions.

A wider look at health in the US
CDC Report on Health in the United States, 2009
- Use of MRI, CT and PET imaging has soared in the past decade
- Rates of many procedures have increased dramatically: knee replacements (up 70%), Angioplasties with stents (75% of all PTCA in 2006), Fertility treatments (especially in females > 40), Outpatient endoscopies (rose 90%).
- Prescription med use is also up: Diabetes drugs (up 50% in patients over 45), Statin (up 10-fold in past decade), Percent of people on at least 1 drug (increased from 38 to 47%), those taking three or more drugs (increased from 11% to 21%).
- Life expectancy has improved a little. Overall mortality from Cancer, Stroke and Heart disease has declined. Deaths from Respiratory illness and accidents are stable.
- Leading causes of death (by age): 1-44 (accidents), 45-64 (cancer), over 65 (heart disease)
- Chronic conditions: steady at 10% of people reporting chronic conditions limit their activity - most likely arthritis and other musculoskeletal issues. Second leading cause was Mental illness (age 18-44) or heart/circulatory disorders (over 45) - with mental illness a third in that age group.

Meanwhile, with respect to HIT...
Health IT: The Road to 'Meaningful Use'
Health Affairs (April, 2010)
A series of articles that reviews many of the pros/cons of trying to adopt HIT/EMRs to meet our growing needs for quality and care coordination. On one hand, there are definite theoretical advantages to using HIT, and there is a push to do something NOW rather than wait forever for "perfect systems". On the other hand, these systems are still immature and success is often more about workflow re-engineering, executive support, and process and culture change rather than on any specific technology... thus implying that attempting to rapidly adopt IT tools may result in more problems and implementation failures since the other non-IT support needs are so high.

Electronic Medical Records and Communication with Patients and Other Clinicians: Are We Talking Less?
Center for Studying Health System Change (HSC) study (April, 2010)
Commercial electronic medical records (EMRs) both help and hinder physician interpersonal communication—real-time, face-to-face or phone conversations—with patients and other clinicians... EMRs assist real-time communication with patients during office visits, primarily through immediate access to patient information, allowing clinicians to talk with patients rather than search for information from paper records. For some clinicians, however, aspects of EMRs pose a distraction during a visit . Moreover, some indicated that clinicians may rely on EMRs for information gathering and transfer at the expense of real-time communication with patients and other clinicians. Given time pressures already present in many physician practices, EMR and office-workflow modifications could help ensure that EMRs advance care without compromising interpersonal communication. In particular, policies promoting EMR adoption should consider incorporating communication-skills training for medical trainees and clinicians using EMRs.

Re-Inventing Primary Care
From Health Affairs (May, 2010): "The nation’s primary care system is broken, and fixing it is an urgent priority—all the more so because of the enactment of national health reform." The May 2010 issue of Health Affairs examines what it will take to reinvent primary care in the United States. Operational, payment, regulatory, legal, and educational reforms will be necessary to improve care and achieve savings —and to prepare for the influx of millions of Americans who will be insured for the first time as of 2014.

Why I Blog...

2010-03-28T21:33:00.005-05:00

Last month, a friend and fellow blogger asked me why I blog... and I had to stop and think about it for a second, but it became quickly clear to me there are two main reasons:

1. So that I can document my ideas and experiences in a single repository, which I can then refer to later. Sometimes these are thoughts stirred by the current climate or an experience I've had. Other times I am directly "responding" to articles I have read - and thus this blog allows me to save a link to the article and why I thought it was particularly good or at least thought-provoking.

Although I mainly am just creating these blogs as a placeholder for ideas I want to think more about at another time... It turns out that I often use them as a source to explain myself more quickly to others. So if I get an email asking about my thoughts on EMR adoption or usability or the new healthcare plan, I can provide a quick summary and then a link to my blog which has details. In other words, although it takes some time to write the blog, if I can re-use it in these ways, I can actually be more efficient.

2. Writing helps me take some whirling thoughts and put some order into them - forcing some definite structure. In other words, it helps me generate a clear product that both I, and others, can understand and ideally use in some way.

So while I mainly write for myself, if these blogs stimulate thoughts, ideas and motion from others- then all the better. Last month, my little blog actually was recognized in the list of "Top 50 Healthcare IT Blogs", which I really appreciated (of course, maybe there are only fifty of us?). So hope everyone out there is enjoying reading along!

Healthcare Reform (well, at least Insurance Reform)

2010-03-22T22:27:00.006-05:00

The Change Doctor Blog has to comment on this important moment in our country's history... On Sunday night, the House passed “The Patient Protection and Affordable Care Act,” a landmark health care reform bill. This legislation, along with a crucial package of specific improvements, aims to lower costs and expand access to millions of Americans. It's been a long road, but the echo of "Yes, We Can!" rings a bit louder this week.

While it is not ideal, we are at least closer to reaching what I believe is both an ethical and financial imperative in making healthcare insurance affordable to every American. A good summary of this bill is found in this MarketWatch article. Also check out: http://www.healthreform.gov

But let's not kid ourselves- the race is far from over. We need to realize that this is just "Insurance Reform", meaning that it makes insurance companies act as they should act: like risk pools who do not get to cherry pick who is in their pool (i.e. no more exclusions based on past history). At the same time, it makes the game fair for insurers by pushing everyone to get insurance - thus making sure that young, healthy adults don't get to completely opt out of the system. There are nuances, but that is the core part of what is happening - and it will take a few years to get into full effect.

What this does NOT do is stop the spiraling cost of healthcare related to increasing illnesses, tests and treatments... in a system that predominately rewards Volume over Value. In other words, the second part of this movie is "Reimbursement Reform", in which the government helps shift reimbursement of quality and efficiency over simple volume. For example, in the current volume-based system, a Primary Care Physician (PCP) makes money by seeing as many patients as possible in their office. The result is increased cost for patients and insurers, and a shortage of PCPs to do all this work. In a value-based system, a PCP could oversee a team of nurses who manage a much larger group of patients - taking care of the stable ones via phone and web-based services, and only needing to see the sickest and most complicated patients in the office. The result would solve both the cost and access problems we face!

Fortunately, this issue is not lost completely in this insurance reform bill. Atul Gawande, MD, correctly points out in a December 2009, New Yorker article, that the current bill does provide some ability to "test" new reimbursement ideas. Let's hope that those tests quickly prove some ideas which can then be extrapolated... because otherwise we will look back on a collapsed healthcare system in a few years and point to all these problems we know about, and say we wish we had done reimbursement reform sooner.

The Dawning of the EMR as a Platform...allowing us to "get the health care that we build"

2010-03-13T23:34:00.007-06:00

Joe Flower continues to be one of my favorite healthcare writers. In a recent article in HHN Online, he talks about the heroes in healthcare who are constantly trying to improve the system. I love the quote on which he ends his article:

As Aristotle famously shaped it, "We are what we repeatedly do. Excellence, then, is not an act, but a habit." We will not get the health care that we want. We will not get the health care that we deserve. We will get the health care that we settle for. We will get the health care that we build, where we are, with the tools that we have, with the courage and compassion and collaboration and hard insistence on excellence that lies within us.

At the recent HIMSS conference, I think we began to really see the first signs of an important paradigm shift in the EMR world which will help make this ability to build a better healthcare system more feasible. Specifically, we saw the rise of the "Ecosystem" or "Platform" - terms which will become the buzz word of the coming year as vendors are starting to "open" up their systems (e.g. via APIs, or other technical and business transparency).

Stepping back, the historical scenario for an EMR vendor is to sell you all three tiers (database level, application/functionality level, and user interface level) as a tightly integrated unit. The upside is they should all work well together, the downside is minimal ability to customize one layer without having to get involved with the other layer because they were so tightly linked. For example, if you wanted to display vital signs in a different way in your user interface - you would also have to change the underlying data model and application abilities. We can refer to this as the "Tyranny of the Three-Tier Architecture".

Unfortunately, what we have seen are quite bad user interfaces from the EMR vendors and minimal ability for real life users to improve upon them. The result has been poor adoption of EMR systems, as well as multiple instances of "unintended consequences" from poorly defined user interfaces. Fortunately, the EMR vendors must have realized this was the case (or they are getting spooked by the new crop of HIE vendors and system integrators who are trying to take their data and allow for more customized user interfaces).

So at HIMSS, I found that many EMR vendors are now allowing at least some ability for users or third parties to create new widgets and user interfaces to "put on top of" their EMRs. We are still pretty early in this phase, but eventually- the hope is that this will become analogous to Apple creating the "iPhone Platform": The EMR vendors will ideally compete to create the best platform which will then allow for some true innovation at both the application and presentation layers, or alternatively brand new vendors will come along to create platforms which take what is needed from legacy systems while allowing for others to build on top of them in a unified environment (e.g. GE's new Qualibria). Either way... the ideal result will be an Ecosystem where we can indeed Build the Healthcare System we need and deserve.

FDA Considers Regulating Safety of Electronic Health Systems - Now that would shake up the industry!

2010-02-25T00:27:00.013-06:00

WOW - now this is a true news alert to think about!
FDA Considers Regulating Safety of Electronic Health Systems

Here are some quotes from this article - with my thoughts in parentheses:

But digital medical systems are not risk-free. Over the past two years, the FDA's voluntary notification system logged a total of 260 reports of "malfunctions with the potential for patient harm," including 44 injuries and the six deaths. Among other things the systems have mixed up patients, put test results in the wrong person's file and lost vital medical information.
(Hmmmm... let me add some more: how about crashes, slowness, broken decision support tools, awkward workflows that result in both errors of omission and commission.)

The FDA official outlined three possible approaches for tighter scrutiny. The agency could require makers of the devices to register them with the government and to submit reports on safety issues and correct problems that surface. The FDA could track this information "to help improve the design of future products."
(I wonder if the government would have any better luck than the rest of us in asking our vendors to fix technical and design problems that cause safety issues!)

In a second scenario, the agency could require manufacturers to report safety concerns and set minimum guidelines to assure the quality of products on the market. In a third approach, the systems could be subject to the broader regulatory actions that new medical products must face before they ever reach the market.
(I have a feeling the government has no idea how poorly designed most EMRs are... they would never allow clunky, erratic software to be put into pacemakers, IV pumps, etc...I also wonder if they truly understand the difference between inpatient and outpatient systems.)

The manufacturers of the systems generally have opposed regulation by the FDA, arguing in part that imposing strict controls would slow down the government's campaign to spur widespread adoption of the technology.
(Sure- let's put cars on the road that have hard-to-turn steering wheels, and which only go 10 mph - because we need to stimulate buying of cars!)

Regulation will not necessarily create a "safer" electronic medical record "and might actually limit innovation and responsiveness when it is needed most," Carl Dvorak, executive vice president of Epic Systems Corporation....
(Well, that is true - but I'm still waiting for any significant innovation and responsiveness from the EMR vendors... the systems we use today are honestly just slight variations of the same paper-paradigm based EMR systems originally developed in the 19060's - except those were actually more consistent and reliable to use.)

Yet some inside the industry favor stepped-up scrutiny. One major vendor, Cerner Corporation, which has voluntarily reported safety incidents to the FDA in recent years, signaled its support for a rule that would make those reports mandatory. Cerner has reported potential safety concerns because it is the "right thing to do," a company official said.
(Really, that's great- I've got to find out from Cerner who is collecting those incidents... I wonder if they fully understand the volume they might face if they really wanted to hear it all. Did my sarcasm come through? I can't believe any EMR vendor wants to REALLY hear how screwy their systems can act in ALL its different forms and types of implementations.)

The federal government's Office of the National Coordinator for health information technology also has recognized the need for better surveillance. In January, the office issued a contract to address "undesirable and potentially harmful unintended consequences" of the systems.
(Tricky part here is clarifying the difference between an error, a safety issue, and unintended consequence. There is some overlap but also some parts that are clearly separate issues.)

Though officials in some other countries have tightened oversight of the systems, U.S. manufacturers have managed to stave off formal regulation, telling the FDA in May 2008 that their products should be excluded from review partly as a means to speed up their adoption.

But critics argue that tighter scrutiny is needed to protect the public. "Oversight and quality control may slow things down, but it's absolutely critical," said Hoffman, the law professor. "Patients' lives are at stake."

In all honesty, it's a tough call - one on hand it seems insane that these important systems have no regulation as to how crappy they might be - they directly impact care! On the other hand, over-regulation may increase costs, stifle innovation and create new problems we can't fully predict...and finally, who is the final decision maker on what is truly a safety issue vs. just an unintended consequence?

Addendum (3/13/10)...things could start getting more interesting...
FDA Asks Hospitals to Report Safety Glitches in Digital Health Systems

And another perfect Dilbert reflects the confusion in understanding the difference between a true error and a poorly designed system...

Checklists: Moving from Procedures to Clinical Care Workflow

2010-02-22T22:16:00.006-06:00

I am a big fan of the Checklist philosophy (see past post reviewing this), as espoused by docs like Atul Gawande and Peter Provonost. And I like to combine that with the writings of Dr. Richard Bohmer (Designing Care) who talks about "Islands of Standardization" that stand out in a sea of unstructured medical thinking (those areas where docs need to take in a lot of info and make a decision). In other words, we should use checklists for those areas of clinical care that should be standardized... and be careful not to overuse them in places where the care cannot be as structured.

For example, as part of the Szollosi Healthcare Innovation Program , we have studied some "inflection points" in healthcare (i.e. A new and important finding that can have a large impact). Whereas traditional checklists focus on procedures, we have started adopting the concept to parts of the clinical care process. To help understand this, it's important to understand that the clinical care process has three basic phases:

1. The Initial Diagnosis Phase: : An "unstructured" time where the doctor takes in all history, physical exam, and test elements and decides on a "final diagnosis". To date, we have explored (in order of increasing complexity): Hematuria, Atrial fibrillation, and Cancer.

2. The "Workup" Phase: Once one of these "Diagnoses" has been decided by the physician, there is usually an "island of standardization" that often involves further testing and a consult to a specialist. For Atrial fibrillation, it involves getting a stress ECHO and a Holter monitor, and then seeing a Cardiologist after those tests are completed. We therefore created a "Checklist" within an EMR message that allows the doctor to send a note to our Care Coordination team. The doctor needs to choose the message type (called "PATHWAY - Atrial Fibrillation"), answer one question within the message (which helps decide how acute the problem is), and then send it to a coordinator who follows the directions of the message (e.g. set up the tests, and then the consult).

3. The Management Plan Phase: This is another unstructured time where the PCP or specialist reviews all the information and decides on the treatment plan. But note, depending on certain issues, it is possible to make this part somewhat standardized as well.

4. The Stable Follow-Up Phase: This is a very structured time where the patient is stable on their treatment plan and just needs routine follow-up care, such as checking some blood tests and vital signs every 6 months. This can often be done by an NP or even an RN, and the doctor is only notified if a patient's findings veer off course. This area is particularly ripe for Checklists.

In other words, we do not want to try and create checklists for the unstructured thinking part of the physician's job- that part is critical and is very hard to replicate or standardize- but the time it takes is relatively small. Unfortunately, physicians instead waste their valuable time on trying to remember the exact protocol for the workup phase, and helping their patients complete them as quickly as possible and make sure they do so in the right order. THAT is where a checklist helps, and even better if we can hand it off to a "lower level" person on our team! As the saying goes, make sure each team member is working to the top of their ability and licensure!

__________
Since we are on the topic of using Checklists appropriately... you should read this new article from HealthLeaders magazine: "Use Medical Checklists as Tools, Not Cure-Alls, for Patient Safety Problems". Three great quotes from this article point to how we need to be careful in further understanding how to be successful with Checklists:

However, in reality, these checklists need to be accompanied by a "change in the culture"—where nurses, for instance, are empowered to question doctors who don't follow the steps properly or where members of a healthcare team toss out long held beliefs that infections are an inevitable cost of being in the hospital. "Just having a checklist on a piece of paper isn't going to be enough," Pronovost said in a statement.

"Everyone wants to do a checklist. The message becomes that . . . checklists are the simple solution for solving an adaptive problem with a technical solution," he says. "It needs to be embedded in a broader effort to evaluate and address local context. It needs to add value. If providers don't believe in the value of the checklist, they'll just check a box." (Sean Berenholtz, MD, an associate professor with the departments of anesthesiology, critical care medicine, and health policy and management at Hopkins)

The eventual goal, the researchers wrote, is that checklists should be created that are "succinct, unambiguous, focused, and ultimately effective, and efficient." And, when ultimately faced with a crisis, "we can react quickly and decisively, knowing that the items we act out from the checklist are well thought out, tested, and will provide us with the results we want."

UPDATES
Medical Personnel Taking a Page Out of the Pilot Handbook
Dec, 2009: Medical personnel who used procedural checklists modeled after preflight checklists used by pilots were more likely to report safety-related incidents and feel empowered to address safety issues, according to an online report in the December 21, 2009 Archives of Surgery (PDF). After preoperative checklists were introduced to certain medical teams, their use rose from 75 percent in 2003 to 100 percent in 2007, the study found. The introduction of checklist-based programs, known in the aviation industry as "crew resource management programs," or CRMs, was accompanied by an increase in self-initiated reports of safety breaches among medical staff, from 709 per quarter in 2002 to 1,481 per quarter in 2008 among teams using the checklists.

HITECH Showers...really, how come we aren't just focusing on Paying for Value?

2010-02-22T00:23:00.008-06:00

I am involved with the Association of Medical Directors of Information Systems (AMDIS), and our list-serv often brings up good topics. I'll often post my thoughts, with my bias of being a very pragmatic, in-the-trenches primary care physician. I've incorporated some of those thoughts into past posts, but will also occasionally blog the (almost) verbatim posts I've made.

Here is a recent one I wrote, in response to discussions about whether the government is doing the right thing by using the HITECH funds ($39 billion) as "EMR Stimulus money" vs. thinking about restructuring how we pay for care so that EMRs will actually make business sense for physicians:

Yep- we've said it all before, the government (and other payors) need to pay for value, not volume. Align the healthcare system wisely, and there is no need for "stimulus dollars" to push for something which does not make business sense in today's environment. Make it valuable for us to practice high quality medicine - and that will happen… and in fact, the level of innovation in making that happen will be much greater than by trying to force untested EMRs onto everyone… it will mean more teamwork, more clinical standards of care, more checklists, more follow up, more competition…

What I don't get is that almost EVERYONE in healthcare policy knows this to be the case - and yet neither the HITECH bill nor the current healthcare legislation really touches on this.

Yes, there is some money for "experiments" - but we need payment reform as one of the foundations for care improvement. Can you imagine how much better the EMRs and other IT applications would be if they were being created in a world where payment didn't:
1. Rely on massive documentation of visits for any payment - and forced doctors to be the one to do this documentation themselves
2. Insist only doctors to be the ones to deliver care
3. Encourage volume over value

Take away those three restraints and replace with these two tenets… and just imagine what would happen:
1. Allow doctors to be part of a team that took care of patients as a whole - the right type of provider can do the right type of care and document in the way that makes the most sense for care
2. Encourages value over volume - so you can take care of many more people, but actually see less people

Sorry… dreaming again…

So what will happen in the meantime? Smart EMR companies will hopefully start making products that at least allow for better efficiency…It's hard to believe how poorly they have done in this arena to date… mainly all they have done is make it easier to document for higher level visits.

But in this real world, I do give HITECH some credit - MU is painful to look at right now, but at least it is making EMR vendors think more about how their systems can deliver quality. And while the overall reimbursement system has not yet caught up, it is fulfilling its promise of being a "stimulus".

The question will be whether this will be more like the April showers bringing May flowers… or a hailstorm that f's up your car.

Replicating High-Quality Medical Care Organizations

2010-02-14T22:55:00.003-06:00

Just as I posted my blog about this topic of understanding and replicating "the best places"... I read another article discussing it: "Replicating High-Quality Medical Care Organizations" by David Mechanic, PhD in the Feb 10th issue of JAMA.

Dr. Mechanic starts by proposing that there is strong interest in developing accountable care organizations (ACOs) that have the capacity to:
1. Monitor meaningfully patient needs and outcomes
2. Use performance indicators for assessment of physicians and other professionals
3. Implement new forms of reimbursement that result in improved quality while constraining increases in cost.

He notes the typical examples (Mayo, Kaiser, Cleveland Clinic, Geisinger) don't match well with the typical medical organization and thus pushes us to think about how other organizations can replicate the giants.

He proposes that even if reimbursement systems improve, there is still a need for a strong collaborative organizational culture which has 4 key elements:
1. Strong focus on mission
2. Strong Leadership
3. Good measures and feedback of results including clinical quality indicators
4. Tools for care coordination, operational system support, and an outstanding clinical information system.
More info on these key elements can be found in a 2008 Kaiser report entitled "Keys to Stronger Hospital/Physician Relationships: Culture and Incentives".

Then, Dr. Mechanic wisely points out that "Few organizations use pure payments types without modifications and additional incentives to encourage initiative, productivity, performance quality and loyalty to the organization. The distinction between how these organizations are reimbursed and how they pay their professionals is important".

He points out that "there is considerable agreement about essential tools, including development of information technology, electronic medical records, and system connectivity; better dissemination and use of evidence for making decisions; and improved clinical measures with continuing feedback to clinicians. Better organized teamwork, coordination and collaboration are also needed". Be he then adds that "Although financial and organizational coordination are important, the ultimate test is success in clinical integration, which is the most challenging of the changes needed".

He ends with the thought that "Innovative approaches to primary care are needed along with new ideas for how physicians and other primary care clinicians can be educated to work together effectively and to fill their roles in thoughtful and more satisfying ways". Amen to that.

Mayo - The Mirage of the Mirage

2010-02-13T15:20:00.005-06:00

I have always been intrigued with how the Mayo Clinic (and Cleveland Clinic) succeeds in the same vein as organizations like Kaiser and Group Health. They all are regarded as "the best" - those healthcare organizations which provide high quality care at a lower price and with high patient satisfaction - but Mayo and Cleveland Clinic have to do it in a predominantly FFS (fee for service) environment which rewards Volume over Value, in contrast to the capitated environment of a Kaiser or Group Health.

Sort of like the old joke about Ginger Rogers - she had to do everything Fred Astaire did, but she had to do it backwards and in heels. I blogged on this issue a bit back in September, 2009 when I described futurist's Joe Flower's discussions of "How to Mayo Up".

I recently stumbled upon a Washington Post article from September, 2009 entitled "Is the Mayo Clinic a Model Or a Mirage? Jury Is Still Out". It suggests their success is due to the fact that "their patients are wealthier, healthier and less racially diverse than those elsewhere in the country" - and thus they can make more money and have better outcomes. Therefore, their model of care cannot be easily replicated (unless you have the same type of wealthy, healthy patients I assume). Hmmmm... I could see why one might say that on a superficial level, but it really disrespects what they have done at that Clinic over a hundred-year plus odyssey. And yes, that success has brought in some money - but their core ideals are the same as they ever were.

I thought a follow-up opinion piece called "Mayo Clinic's Model" summarized Mayo's success factors very well. It was written by Dr. Henry Weil (assistant dean for education at the College of Physicians and Surgeons of Columbia University) and Stuart Guterman (assistant vice president of the Commonwealth Fund for the program on payment system reform). Here are some of the salient parts:

"Mayo's performance is no mirage. In fact, there are multiple examples of health systems -- the president and other policy makers also have cited Geisinger, Cleveland Clinic, Bassett, Kaiser Permanente and others as models for health-care reform -- that consistently and reliably achieve similar results: providing good care at low cost, with high patient satisfaction."

"What these systems have in common is that they are integrated systems that employ their physicians, emphasizing patient-centered care, better outcomes, and prudent stewardship of health-care resources, with accountability for results. A group of these systems met in Washington earlier this month to discuss how the elements of their success could be adopted more broadly in the context of health-care reform. They concluded that comprehensive care, collaboration, integration, and measurement and accountability, as well as strong corporate leadership, were key to their success and could provide an example for other systems."

So would this be easy to replicate in any environment (rich or poor)? No way. But is it something for all of us to strive for? Absolutely!

Scribes may be the answer to EMR adoption

2010-02-09T23:37:00.004-06:00

One of my favorite HIT writers, Joe Conn, just published a two part article in Modern Healthcare about the use of scribes by physicians using EMRs - part 1 and part 2. He pointed out the increasing use of scribes in ER departments, as well as some early projects in primary care offices.

Here are some of the key quotes from this article:
Today, however, organizations seeking to implement the latest wrinkle in medical record-keeping, electronic health-record systems, are looking to new generations of scribes—to increase physician productivity and to overcome the pitfalls of the still typically clunky physician/EHR interface, and to ease the strain of EHR implementations and replacements...scribes do more than transcriptionists by assisting physicians in fully documenting a patient encounter, most recently, entering encounter data in an EHR.

Randall Oates is a family physician who founded an EHR-system development company, Soapware, Fayetteville, Ark., with software products designed for office-based physicians. Oates said the combination of scribes, EHRs and practice redesign, could provide the saving grace for economically threatened primary-care physicians.
The current approach to EHR implementation, in which the physician is supposed to document the encounter on a computer, is, Oates said, “complete insanity, turning doctors into data-entry clerks. We're going to look back on these days the way we look back on bloodletting with leeches."

Physicians using the system have one computer in the exam room with the patient and another computer in a room set aside for the scribe, who listens in via a microphone in the exam room and documents the encounter. “Both the scribe and the physician have to be able to control the desktop,” Oates said. “The scribe is creating the documentation, but most of the documentation is already collected before the doctor ever gets in the exam room. If the patient is in for hypertension, the scribe will know to automatically pull up the vital signs in a view. The doctor should not have to do that navigation. The doctor should be able to be empowered to do the high-touch patient care."

The system radically accelerates patient throughput, according to Oates. “They're scheduling eight an hour with very high patient satisfaction, structured data entry and the note is completed at the end of the encounter,” Oates said. “The bottom line, and I'll make it real simple, the family practitioner only has to see one extra patient every three hours to cover the cost of the remote scribe and the technology.”

And then my part at the end:
Lyle Berkowitz is a physician informaticist who has written extensively on the need for an improved interface between computers and physicians. He uses an EHR in his outpatient internal medicine practice in Chicago. Berkowitz said he has never used a scribe, but in doing personal research on high-performance “superpractices,” he has run across several examples of physicians who do.

Berkowitz said he doesn't view scribes as an interim measure, but “as part of the evolution to get to the better solution.”

“A scribe is the ultimate of artificial intelligence,” he said.

Well, I know what I meant, but I think it makes sense to explain further. I think the ultimate holy grail is when the physician can walk into a room and the EMR can be the perfect assistant - gathering history from the patient ahead of time, displaying exactly what is needed to help the physician make a decision, listening to the physician and documenting the visit as well as creating orders, making pertinent suggestions at the right time…

But while that level of EMR artificial intelligence is not yet available, a scribe can fulfill many of those same functions. The result is that the physician can concentrate their time on the patient and not on the computer.

In other words, we have to decide "what is the doctor's job". Is it to take care of patients, or document that they took care of a patient? I think we will all agree that it is the former, and so we have to start rethinking the current paradigm where doctors are using EMRs more like data clerks than healers. This will likely be a combination of (1) making documentation a BYPRODUCT of care, and (2) Figuring out other ways to get our care documented in the system easily - whether that be from scribes or voice recognition combined with artificial intelligence that supports both care and documentation.

Well... at least until the computers overtake everything we can do and tell us to go retire!

UPDATES
* Electronic medical records systems create need for scribes to input data (April, 2011)

Will Apple's iPad save EMRs and Healthcare?

2010-01-26T10:53:00.006-06:00

Apple is about to launch their new device - the iPad or iSlate or something similarly named. Since it is supposed to be the miracle cure for so many things - how about healthcare?

Assuming they have created a cheap, lightweight device that has high speed connectivity and allows for easy data entry similar to an iPhone (type, touch, voice)... how could a physician use this in their clinic workflow... how would an EMR optimized for this product work?

It might make sense to have "apps" for different workflows. In the exam room, a physician would want an app that displays the relevant data for a patient, and allows for easy documentation and ordering. Of course, we want that now with our big PCs...and are usually somewhat disappointed as no EMR is perfect at this point. So is there anything that makes the iPad concept better for doctors?

Carrying around a "pad" is most similar to paper and thus doctors will accept it more - right? Well, so far that philosophy has usually not worked in a busy office setting. The previous "pads" (e.g. handheld tablets) have been too heavy and bulky, too expensive and the battery life too short. Additionally, data entry has been limited to touch pen. The new iPad would likely be better in all categories... and so I could see it being used for data retrieval, some ordering, and possibly some basic documentation - although I think the majority of documentation would likely be voice (e.g. Dragon voice recognition).

Overall, this might make the most sense in the inpatient setting where there is a lot of movement and a big limiting factor has been not enough computers for all the rooms... or the COWs are too bulky to move around easily. We have already seen many EMR vendors come out with iPhone apps... so there is even some software to start using in these situations.

In the outpatient setting, where one doctor usually works consistently in 2-4 rooms, I think having a regular PC type device (or net device) with a large monitor and keyboard still makes the most sense for now. And even when voice recognition improves, this set up will still likely be easier and cheaper for this more controlled situation.

Of course, since EMR adoption is low now... any new technology that provides for the ability to innovate is welcome with open arms - and I am very much looking forward to see if this is going to be closer to the Newton or the iPhone in it's success.

Meaningful Use Final Matrix Posted

2009-12-30T18:31:00.010-06:00

HHS has issued proposed final regulations that list the "meaningful use" criteria which healthcare providers must meet in order to quality for the HITECH incentive payments. This story from Health Data Management has a good breakdown of the Matrix, starting on page 26:
http://digital.healthdatamanagement.com/healthdatamanagement/201002?pg=6#pg26

Quick impression is that the bar is set low in some areas, but higher in other areas. Also, it is not fully clear how to fulfill the criteria. For example, one "box" says to have drug-drug interaction checking (which is pretty routine), but in the same box it says to also have drug-formulary checking... that is much more complex, and involves extra fees to the EMR vendor, as well as an assumption that the system allows for input of a patient's drug benefit plan (which is often different from their insurance).

Other confusing things include allowing patients "timely access" to their healthcare data, and something that says "Reminder sent to at least 50% of all unique patients seen by the EP that are age 50 or over" - reminder about what exactly, and does it matter how/when/where we remind them? But it's a start and I assume there is clarification in the other 553 pages of this document, but I'm just looking at the Matrix for now.

Other good links
* Dr. Blumenthal's summary of all the HITECH monies are going:
http://healthcarereform.nejm.org/?p=2669

* MU summary from Mr. HISTalk:
http://histalk2.com/2009/12/30/onchit-releases-preliminary-definition-of-meaningful-use/

* An MU Excel Spreadsheet created by Mr. HISTalk:
http://drop.io/meaningfuluse/asset/meaningful-use-xls

* Dr. John Halamka's MU Summary:
http://geekdoctor.blogspot.com/2010/01/achieving-meaningful-use.html

* Matrix of Numerators and Denominators
http://mycourses.med.harvard.edu/ec_res/nt/36980CA6-E154-4820-A0ED-8B235138B79F/measures.pdf

Top Medical Advances of the Decade

2009-12-30T18:13:00.003-06:00

I was recently asked to comment on my thoughts about the "Top Medical Advances of the Decade". Clearly, I'm biased towards the Use of Information Technology in Healthcare – but this made me put down my reasons on paper, which was a good exercise. Here is what I wrote:

Although it has not yet met its potential, HIT has created the ability for patients to have the following:
- Widespread health-based communities to develop online, supporting research, care, education and social support
- Online management of health, from ordering medications to tracking blood pressure, to communicating with your physician
- Transparency with respect to quality, cost, and other metrics

For physicians, the age of Electronic medical records is upon us and have an increasingly profound impact on how we as physicians manage patient care. Although not fully adopted yet, there are pockets of excellent use creating improved quality and efficiency – via a combination of better access, improved legibility, point of care decision support and the ability to do retrospective data analysis to support process improvement projects. But there is a long way to go, as robust adoption is still under 10% of physicians, and many implementations still do not show significant care improvements. Future systems need to be easier to use, cheaper to implement, and they need to truly meet the needs of the end-users.
______________________

Let's hope the new year and decade brings with it the full potential of all HIT can do!

FYI- Here is the eventual article that was published about these advances. Besides HIT, the other nine were: Human Genome Decoded, Anti-Smoking Laws, Heart Disease drops by 40%, Stem Cell Research, Targeted Cancer Therapies (eg HER-2), HIV Therapy, Minimally Invasive Surgical Techniques, HRT Controversy, and Functional Brain MRIs.

The Inflection Navigator Project

2009-12-16T23:16:00.005-06:00

A lot of my effort in the past 1-2 years with the Szollosi Healthcare Innovation Program (www.TheSHIPHome.org) has focused on making the experience easier and better for patients dealing with an "acute inflection point" in their healthcare, such as the new diagnosis of cancer or a heart problem. Working with a great team at Northwestern University and Northwestern Memorial Hospital, we created "The Inflection Navigator" project, which brings together physician-friendly ordering workflows, system level protocols, care coordinators ("Navigators") and a web-based tool we developed to tie it all together.

We went live in April with a Hematuria Pathway, and then launched the Atrial Fibrillation Pathway in June, and finally the Cancer Pathway in September. We believe this combination of people, process and technology improves both the quality and efficiency of these situations, and does so in a cost-effective manner.

This recent article further explains our system and how we developed a web tool called "iNav", working with Northwestern University Biomedical Informatics Center (NUBIC):
http://cabig.cancer.gov/resources/newsletter/issueXXV/action.asp

Mike Gurley led the software development of iNav. Since it as based on open source code already developed for the cancer Biomedical Informatics Grid (caBIG), he posted the code and architecture online: http://github.com/mgurley/inav
Enjoy!

More Money for Early EMR Adopters

2009-12-06T22:21:00.004-06:00

More Money for Early EMR Adopters (appropriately so)
ONCHIT Czar Dr. David Blumenthal announced a new round of HIT monies for those who are successfully using EMRs: http://healthit.hhs.gov/blog/onc/index.php/2009/12/02/beacon-communities-a-proving-ground-for-health-it/

I am a fan since I do think that early adopters should get some credit, and the government thinking and reasoning on this appears very sound. Of course, they are not just giving the money away - they are providing it to those EMR adopters who will use it to show specific benefits or integration abilities. Here is what they specifically said:

"Why invest in health communities that are already well ahead in their adoption and use of health IT, when we still have so many communities that are just getting started? Simply put, because it’s sound planning and program management. Together with the Medicare and Medicaid program, we are investing billions of dollars in creating a nationwide interoperable private and secure health information system across all communities. We recognize that throughout our country we have different levels of health IT adoption and varied capabilities to establish EHR systems. Because of this diversity in adoption levels and capabilities, we want an opportunity to peer into the future, to demonstrate the benefits of health IT concretely, and to learn valuable lessons about how American communities can transform their health systems through the use of health IT. Given the pressure to improve our health system, we want to learn these lessons quickly – in a few years if possible – and we think the best way to do that is to accelerate the progress of diverse communities that are leading the way."

Can't wait to see who they choose for this!

Patient Safety: Slow but Steady Progress

2009-12-03T23:31:00.004-06:00

Dr. Robert Wachter is a UCSF "hospitalist expert" who has a great blog talking about quality, safety, and health policy.

He recently published an article in Health Affairs:
"Patient Safety At Ten: Unmistakable Progress, Troubling Gaps", which reviews how well (or not so well) we have done in improving patient safety since the famous IOM report ten years ago. Although not IT/EMR specific, it does stand in contrast to recent papers saying that EMRs have not improved quality significantly. This parallels increasing thoughts around the fact that process innovation is more important than product innovation. It is well worth a read.

ABSTRACT
December 1, 2009, marks the tenth anniversary of the Institute of Medicine report on medical errors, To Err Is Human, which arguably launched the modern patient-safety movement. Over the past decade, a variety of pressures (such as more robust accreditation standards and increasing error-reporting requirements) have created a stronger business case for hospitals to focus on patient safety. Relatively few health care systems have fully implemented information technology, and we are
finally grappling with balancing “no blame” and accountability. The research pipeline is maturing, but funding remains inadequate. Our limited ability to measure progress in safety is a substantial impediment. Overall, I give our safety efforts a grade of B−, a modest improvement since 2004.

"What health care needs is process innovation, not product innovation."

2009-11-23T22:00:00.003-06:00

Wow- I love it, this is a simple but great explanation of where we should focus on innovation in healthcare (from Dr. Devi Shetty, a cardiac surgeon and efficiency expert in India). To clarify further: we actually know how to do a lot of things very well (e.g. prevent infections, manage diabetes, cure many cancers)... but instead of trying to make sure we follow these processes 100% of the time, we seem more intent on coming up with the newest product or service that will only be incrementally better than the last one (and which may actually be used by less patients because it is more expensive)!

As it turns out, much of the time, all we need to do are create some easy and cheap process improvements which simply enforce the standards of care we all accept- and we would get much better bang for our buck than any new medication or device! This was highlighted by Dr. Atul Gawande in "The Checklist", an article about Dr. Peter Provonost's simple checklist procedure to prevent line infections in the ICU - which saved a significant amount of lives and money... and yet which has not yet been widely accepted because that is not how American's like their innovations! As Dr. Gawande describes:

The still limited response to Pronovost’s work may be easy to explain, but it is hard to justify. If someone found a new drug that could wipe out infections with anything remotely like the effectiveness of Pronovost’s lists, there would be television ads with Robert Jarvik extolling its virtues, detail men offering free lunches to get doctors to make it part of their practice, government programs to research it, and competitors jumping in to make a newer, better version. That’s what happened when manufacturers marketed central-line catheters coated with silver or other antimicrobials; they cost a third more, and reduced infections only slightly—and hospitals have spent tens of millions of dollars on them.

A more recent WSJ article reviews Dr. Shetty's experience and philosophy about how increasing volume can save money and improve quality:

The approach has transformed health care in India through a simple premise that works in other industries: economies of scale. By driving huge volumes, even of procedures as sophisticated, delicate and dangerous as heart surgery, Dr. Shetty has managed to drive down the cost of health care in his nation of one billion.

His model offers insights for countries worldwide that are struggling with soaring medical costs, including the U.S. as it debates major health-care overhaul. "Japanese companies reinvented the process of making cars. That's what we're doing in health care," Dr. Shetty says. "What health care needs is process innovation, not product innovation."

In the healthcare innovation program I help lead (the Szollosi Healthcare Innovation Program), we have used a similar philosophy to come up with some simple process improvements which have started making a difference. The ExpectED project created a web-based tool which formalized the hand-off from outpatient physician to the Emergency Department. Further evolutions of this project have moved this formalization into our EMR system.

Meanwhile, the Inflection Navigator system allows physicians to send a single order which then triggers a cascade of processes related to one of the defined "inflection points" we are studying (Cancer, Hematuria, Atrial Fibrillation). These processes (including radiology orders, specialist consults and patient education) are carried out by a team of people knowledgeable about each of their separate duties. The result is a more efficient and more consistent process for both patients and physicians.

So as Thanksgiving rolls around, let's rejoice in the fact that there is plenty of innovation left to do in healthcare... much of it right before our eyes!

If HITECH Does Not Work, What are the Options to help with EMR Adoption?

2009-11-15T19:58:00.008-06:00

The HITECH incentive plan (estimated at around $38 billon) was established to provide up to $44,000 to every outpatient physician who uses a "certified" EMR in a "meaningful" way (as well as $2-$3 million to each hospital). While its spirit has good intentions, I don't believe they will create a significant amount of new adoption in the outpatient arena because
- The amounts are too low (most systems cost much more to implement).
- There are severe shortages of qualified staff to help physicians convert from a paper to computerized system - a challenging task that includes IT knowledge, workflow redesign and general change management skills.
- The EMR systems are just not very good - both in form and function. See earlier blogs of mine about poor EMR Usability, from April and August, as well as a nice report by Dr. Peter Basch on the problems with current systems. Also check out a new podcast on EMR Usability in which I, and an IT Usability expert, discuss this topic in detail. Finally, here is the HIMSS WhitePaper on EMR Usability: http://www.himss.org/content/files/HIMSS_DefiningandTestingEMRUsability.pdf

So let's review two reasonable options - which are not mutually exclusive:

Change the Underlying Healthcare Reimbursement System
The government could forget the "on-time incentive" idea, and instead focus on long-term reimbursement changes that support quality and efficiency. As we know, our current reimbursement system mainly pays for the volume of "face-to-face visits". EMRs usually slow providers down, although can help them increase their coding levels for higher reimbursement. At best, it's a draw. What if the reimbursement system were instead based on quality (e.g. Pay for Performance) and efficiency (e.g. take care of patients, whether face to face, email or phone)? An EMR has much more potential to help here - by using decision support, establishing registries, and allowing for easy electronic communications. In other words, the government can just help set the reimbursement guidelines to focus on quality and efficiency, and then let the market work on optimizing care in line with that.

Create a Single Healthcare Data Platform
For a fraction of that same $39 billion dollars, the government could rather easily create a single data model and warehouse upon which all other applications can reside - thus solving standards and interoperability issues, increasing adoption, and creating a free market for the "best applications" out there. In fact, a conspiracy theorist might even suggest that the government assumes the current HITECH plan will fail...and thus they put a clause in the plan that says if there is not significant adoption by 2015 - the government can release some type of universal EMR...maybe the universal health database is what makes the most sense?

Several of us have been talking about this "iPhone" like platform in the past year, and here is a link to an interesting meeting that happened in May 2009, which resulted in the following: Ten Principles for Fostering Development of an “iPhone-like” Platform for Healthcare Information Technology
http://knol.google.com/k/kenneth-mandl/ten-principles-for-fostering/9x9jzgucudo6/2# .

And here are some videos from this meeting:
http://www.itdothealth.org/multimedia/2009-hit-platform/#videos

Pulling Forward the Benefits of HIT - Federal Comments

2009-11-03T09:48:00.005-06:00

The government is asking for "the public's" input on how to "Pull Forward the Benefits of HIT". I'm a bit confused as to how much they want input on that general topic vs. just how Standards play into it; as well as whether to just post a comment or do something elsewhere... so, I just posted a comment and we'll see if this changes their mind completely :)

Comment Posted to their site 11/03/09
My perspective comes as a practicing PCP (Internist) who has used an EMR since 2002, as Medical Director of Clinical Information Systems for a large primary care group, as a past Medical Director for an EMR company, and active consultant in the EMR space.

I’m all for using EMRs meaningfully, and second, I’m all for rewarding physicians! However, I believe (as many do) that our current crop of EMRs are far from perfect and I have to question whether we could spend that $36 billion a better way than by rewarding mediocre vendors whose products are poorly adopted and poorly used (see the National Research Council’s recent report via this short press release, and this full PDF of the report: http://books.nap.edu/openbook.php?record_id=12572&page=R1). Rather, for a fraction of that money, perhaps we should consider creating a national EMR framework upon which vendors could build their applications (yes- sort of like the iPhone). This then solves interoperability immediately, and lets the vendor compete on applications and user interfaces rather than on all wasting time/money trying to replicate databases which limit their ability and creativity in building what we really need. More thoughts on this topic: http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20090430/REG/304309994/1029&nocache=1#

However, if we do keep the current definitions of Meaningful Use, then my three main talking points would be:
1. E-Prescribing: make this definition broad enough to reward providers who use their EMR to create and print out scripts, don’t limit to just electronic transmission to the pharmacies, as that is not yet a perfect science.
2. Interoperability: reward based on ability to share data in a group or with a hospital, but don’t require regional or national sharing at this point, that is way beyond the means of most providers and vendors.
3. Data reporting: reward based on producing the reports, whether from the EMR, an EDW (Enterprise Data Warehouse) or similar. Most EMRs are bad at report writing, and other tools are needed.
More details on all three at: http://www.histalkpractice.com/2009/08/25/drlyles-meaningful-discussion-about-meaningful-use-82609/

Health 2.0 Conference - Review

2009-10-12T23:08:00.006-05:00

I wrote up a summary about my day at Health 2.0 last week, posted on HISTalk:
http://histalk2.com/2009/10/12/readers-write-101209/

Talked about three main things:
1. Learned about what the big 3 are doing (Google, MS, WebMD)... all seem to want to own a patient's data.
2. Some cool new startups
3. Keas review

Hoping to go to the next Health 2.0 in April in Paris...

Speech Recognition and EMRs (and the holy grail of user interfaces)

2009-10-11T17:15:00.006-05:00

I was asked recently about Speech Recognition and EMRs, since the technology has improved in the past few years. Here are my thoughts:

Assuming it works well, the important question then becomes “How are you using it”? We are now seeing two main areas where it can be used in an EMR, and we can make some interesting predictions about the future.

The first option is to simply dictate a note after the visit or procedure. This saves on dictation costs, but one would lose out on (1) The value an EMR can bring with respect to decision support at the time of care and (2) The efficiency of copy/paste when documenting chronic care over many visits. Therefore, this option may be appropriate for things like
- Documenting procedures (eg colonoscopy)
- Specialists or ER doctors whom may just see a pateint once
- Creating a letter to send to a colleague
- EMR systems which really are just note repositories (ie ones that do not have electronic prescribing or other ordering, and thus decision support is not easily integrated).

A second and growing option is to integrate “hot spot” dictation into an EMR workflow by using it just for highly complex parts of the note, such as describing details in a patient’s “History of the Present Illness” (HPI). More and more EMRs allow for these “hot spots”, which can be done either during the visit or afterwards. Some rely on speech recognition, others send it to a live transcriptionist to type in, and others use a combination – starting with speech recognition and then sending to a human “correctionist” to make sure it was done right. The final product then needs to be “signed off” by the doctor.

However, the more interesting issue is what the future might hold as these systems improve. I predict that within 10-20 years, and maybe sooner, a computer with speech recognition could become an interactive part of the visit experience, and in fact serve as an “assistant” to the physician. Imagine a situation where the doctor could “tell” a computer that he wants to order a chemistry panel and start lisinoprol on a patient newly diagnosed with hypertension. The system would warn if there were any drug interactions, and could then input the orders into the correct place, send the prescription to the pharmacy and even offer to print up extra information about the drug and hypertension... all with no typing by the doctor. Even further down the road, perhaps the computer can listen to the doctor and patient talking about the history and create the note based on that input. The future of speech recognition paired with artificial intelligence may indeed by the holy grail for user interfaces.

The Mayo Innovation Conference

2009-10-03T17:14:00.002-05:00

Mayo had a recent conference on innovation. It was called "Transform: A Collaborative Symposium on Innovations in Health Care Experience and Delivery".
Their web site (http://centerforinnovation.mayo.edu/transform) actually has videos from the whole conference... wish I was there, or that I had a day to sit and watch all these (although nothing beats really being there in person!). I'm definitely planning to go next year.

Reinventing Health Care Delivery: Innovation and Improvement Behind the Scenes

2009-09-26T01:23:00.004-05:00

The California Healthcare Foundation (CHCF) just put out a new paper on Innovation Centers- it’s a nice overview of what is happening out there formally, and ideas on how they can be expanded. The paper highlights 9 innovation centers/organizations across the nation:
- Kaiser's Garfield Health Care Innovation Center
- Vanderbilt's Center for Better Health
- Mass General's Stoeckle Center for Primary Care Innovation
- Mayo Clinic's Center for Innovation
- Johns Hopkins Center for Innovation in Quality Patient Care
- Ascension Health
- Alegent Health
- Geisinger/Geisinger Ventures
...and the one I help lead: The Szollosi Healthcare Innovation Program (www.TheSHIPHome.org).

Intro is below, full paper is online: http://www.chcf.org/topics/view.cfm?itemid=134067

Reinventing Health Care Delivery: Innovation and Improvement Behind the Scenes
by Bonar Menninger
September 2009

Hamstrung by an increasingly complex, costly, and disorganized system of care, health care organizations are following the lead of the corporate world and embracing innovation as a way to overcome the seemingly intractable problems that have undermined U.S. health care delivery for decades.

Today's innovation centers — most of which are affiliated with large hospitals or health systems — range in scope from modest internal programs to large, formalized organizations with dedicated physical space, sizable staffs, and external clients. Key areas of emphasis include facility design, operational efficiency, optimized information technologies, improvements in the patient experience, and care quality.

Leaders at health care innovation organizations nationwide were interviewed to learn more about how the centers operate, the objectives they are pursuing, and some of the challenges they face.

The complete issue brief is available under Document Downloads below. Also available is a video presentation on the Garfield Health Care Innovation Center at Kaiser through the External Link below.

Joe Flower's "How to Mayo Up" and Innovation in business models

2009-09-15T23:30:00.005-05:00

Joe Flower is a "healthcare futurist" and writes some great articles to promote and provoke thinking about what is ahead. In his recent article "How to Mayo Up" he postulates that a key success factor in creating value based healthcare is having an "integrated system" (ala Mayo, Kaiser, Geisenger, Group Health, etc) - by having both the health plans and physicians working together, they can create the right reimbursement models to align incentives with quality and efficiency... and foster oodles of innovation!

A segment of his article summarizes Clay Christensen's recent book, The Innovator's Prescription, extremely well. I think Christensen's idea are both logical and innovative, and this summary by Joe Flowers is as good as it gets:

Innovation in business models.
In The Innovator's Prescription, Clayton Christensen and his co-authors make a compelling argument that what is holding health care back from true innovation is a confusion of different business models within single institutions.

Porter and Teisberg, and Herzlinger, make similar arguments: Competition does not work in health care because of a confusion of business models. Put two health care systems in direct competition, and what they do is add services that are reimbursed well enough to make money, add specialists, jack up utilization as much as possible and avoid as much uncompensated service as possible. Done this way, competition between general hospitals and comprehensive medical systems helps drive the cost of health care up, not down.

Medicine comes in different flavors, Christensen et al. argue. Some diagnoses and some therapies have no settled pathway, and truly call for the intuition, experience and judgment of the best clinicians, ideally working in teams that bring different skill sets to bear on the same problem. Think migraines, depression, multiple sclerosis and most types of cancer. Call this "intuitive medicine." On the other hand, there are broken bones, strep throat, Type 1 diabetes, cataracts, and hip and knee replacements— conditions for which the diagnosis is certain and the clinical pathway quite clear. Call this "precision medicine."

These two types of medicine have completely different pathways to value, so we will never be able to find that value until we separate them, each with their own business model. Intuitive medicine calls for a "solution shop" model, in which the right resources are gathered to look at your particular problem. Examples are M.D. Anderson for cancer; National Jewish in Denver for pulmonary disease, particularly asthma; the Texas Heart Institute; or the heart and vascular institute and the neurological institutes of the Cleveland Clinic. Intuitive medicine must always be billed as "fee for service," as both the level of resources needed and the outcome are unpredictable.

Precision medicine, on the other hand, calls for a "value-added process" model, much like a factory. You do one thing over and over and get really good at it. The project is well-defined, the outcomes highly expectable, the variations well managed. Such processes can be bundled into products—from diagnosis through rehab, including imaging, pharmaceuticals and counseling—and given a price tag and warranty. They can be billed on a "fee for outcome" basis, as the outcome is fairly certain. On such a targeted basis, you can get rapid improvement and lower costs.

Christensen et al. cite Ontario's Shouldice Hospital, which is dedicated to hernia repair and does it as a four-day, inpatient process on a country-club-style campus—and still charges 30 percent less than the U.S. CPT 49560 outpatient hernia repair reimbursement. And U.S. hernia repairs average 10 to 20 times the Shouldice's 0.5 percent complication rate.

Examples of how EMR User Interfaces may look in the future

2009-09-15T15:37:00.004-05:00

As I was putting up the post about "The Medical Record as Nutrition labels" - it reminded me of the "new" EMR User Interfaces I put together a few months ago (with the help of some very talented graphical designers).

First is a way to think of the problem list as a series of circles or boxes whose color and size each had meaning, and whose relationship to one another was made obvious. Here are two examples:

The next is a problem list that is even more fanciful in using graphical visualization to represent each diagnosis and its acuity and importance:

And finally, here are two views of how to pull all the data together to explain a patient with respect to their diagnosis of hypertension (i.e. one page that brings together meds, labs, tests, history, physical, and plan about a single disease entitity):

What if the Medical Record looked like a Nutrition Label?

2009-09-13T23:21:00.006-05:00

In one of my first posts, I talk about inadequacies of the EMR's user interface - a paper based approach that does not take advantage of either the power of the computer nor the artistry of information visualization. Around that time, my friend and colleague Dr. Ted Eyton (http://www.tedeytan.com) told me about someone he had started following who was doing some cool stuff in this area. And she was not some high brow informatics type, simply an artist with a passion. Here is her story:

What if your spouse had a complex medical history and you knew that the standard "medical record" (whether paper or electronic) was simply inept at helping your healthcare providers get the full and complete picture of his/her health. What if you knew that it was full of an overwhelming amount of numbers and facts, was disorganized and inconsistent in its presentation and had many errors scattered throughout. What would you do?

If you are Regina Holiday (http://reginaholliday.blogspot.com), an artist with a husband dying of kidney cancer, you use your talents to help others understand that there may be better ways to visualize medical information. Relatively easy ways to organize data and present it in a graphically pleasing and consistent manner such that the key medical facts are obvious to any healthcare provider (or even to any family member).

Regina has created a mural of her husband’s medical record that resembles the “Nutrition labels” we see on most things we buy in a grocery store. It is a great way to shock our systems in thinking that medical records don’t have to simply be a problem list or a free text narrative of what happened on one day from one viewpoint… take a look below and think how your own medical records might benefit from this type of thinking. Regina's husband Fred died this past summer, but her fight goes on.

Here is a video of Regina painting and talking about the mural and its meaning (note: it goes black after 3 minutes, nothing else comes on):

Key Websites for Meaningful Use

2009-09-03T23:09:00.003-05:00

CMS - HIT Overview
http://www.cms.hhs.gov/Recovery/11_HealthIT.asp

HHS - Meaningful Use Overview
http://healthit.hhs.gov/portal/server.pt?open=512&objID=1325&parentname=CommunityPage&parentid=1&mode=2

HHS - Meaningful Use Matrix
http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10741_876940_0_0_18/Meaningful%20Use%20Matrix%2007162009.pdf

AMDIS Overview Site
http://www.meaningfuluse.org/

Meaningful discussion on Meaningful Use

2009-09-01T00:59:00.002-05:00

I've been wanting to expand my comments on the meaningful use criteria for awhile, and has this piece posted last week on the HISTalk Blog:
http://www.histalkpractice.com/2009/08/25/drlyles-meaningful-discussion-about-meaningful-use-82609/

Basically, it's my view of the criteria and proposed definitions - with some suggestions on how to help ensure the intent in a more realistic manner.

“Good software includes superb usability”

2009-08-16T23:07:00.003-05:00

HISTalk just published a fantastic interview with Ross Koppel, PhD, a sociologist who has researched and published on the problems with HIT systems – focusing mostly on errors with CPOE, but can be easily applied to ambulatory EHRs as well.

At the beginning of the interview, he says something that needs to be better understood in the marketplace: “Vendors seek market penetration ASAP because user implementation costs prevent reconsideration of other options once a hospital or even medical practice is committed. But vendor product cycles do not allow the ongoing feedback and adjustments that allow rapid improvements. The vendors are eager to roll out new iterations while the industry structure does not encourage patient safety or the actual needs of hospitals and clinicians.” In other words - be careful with your first choice... it's a very long relationship and you better know what you are getting into!

He further elucidates that non-disclosure agreements (and/or other company policies) mean that when the vendors get feedback about problems, they are neither sharing them amongst all users nor are they prioritizing them based on true clinical needs. Specifically he says that “…the vendor picks and chooses on the basis of a market model and a marketing strategy, not on the basis of what is greatest for the greatest number of patients and clinicians. Now, if that were transparent and we could see that there are, of the 1,500 complaints, there have been 10,000 dealing with — those are categories of complaints — I don’t know, the impossibility of entering allergies, or when you enter an allergy, it wipes out the previous allergy. So if the first allergy was anaphylactic shock and the second was a mild rash to latex, anaphylaxis dies, disappears, and you get the mild rash to latex coming up.” In other words, do your best to make sure your vendor shares all the feedback they receive, and that the current customers have a strong say in prioritizing what gets fixed.

And I love this quote near the end: “Now, why do clinicians accept this? It’s because they didn’t go to law school. And by the way, I’m speaking very soon to a group of healthcare lawyers and the like. The CMIOs come to me and say, “Look at this, we bought this and now we can’t address this,” and the lawyers for the hospitals say, “Schmuck. People come to me with a $5,000 contract to make sure it’s passing muster. You signed a $100-million contract, and now you come to me now that you’re stuck”. Enough said.

And when asked what he would change, Dr. Koppel wishes there was simply better software to do what we all want, and intones the universal chant we are hearing more and more… “Good software includes superb usability”.

Bottom line, this interview should be required reading material for all CIOs and CMIOs working with any HIT vendors!

Also check out: The HIMSS WhitePaper on EMR Usability

Why I'm optimistic healthcare reform will pass this year

2009-07-25T23:10:00.003-05:00

I have been optimistic about healthcare reform since a few years ago when I met a then state Senator Obama as he was running for US Senator. His passion about the issue struck me even then... and I was on his bandwagon early. My friends who ask me what I think of "The Plan" hear the following from me - it's not about the specifics (which we really don't know yet), it's about acknowledging the failure of our current system to create a sustainable system that takes care of everyone, and the potential to improve in so many ways by aligning incentives and allowing enough freedom to system create innovations that work.

And when I hear the pessimists say it won't pass, I truly believe that many more people want it to pass than do not. This recent article provides a good analysis of that subject:
Lobbyists the silver lining in health care storm?

A few crucial snippets:
__________
The drug industry, the American Medical Association, hospital groups and the insurance lobby are all saying Congress must make major changes this year. Television ads paid for by drug companies and insurers continued to emphasize the benefits of a health care overhaul — not the groups' objections to some of the proposals.

"My gut is telling me that something major can pass because all the people who could kill it are still at the table," said Ken Thorpe, chairman of health policy at Emory University in Atlanta. "Everybody has issues with bits and pieces of it, but all these groups want to get something done this year." As a senior official at the Health and Human Services department in the 1990s, Thorpe was deeply involved in the Clinton administration's failed effort.
___________

And as much as these forces were against change in the past, their strength will be one of the reasons we will be able to move forward in the future.

Meaningful Use Definition - Updated

2009-07-17T00:56:00.007-05:00

Congrats to the committee for quickly getting input and continuing to evolve this hotly debated area. Here is the link to the updated matrix on "Meaningful Use Definition":
http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10741_876940_0_0_18/Meaningful%20Use%20Matrix%2007162009.pdf

Some of the clarifications they note:
1 The HIT Policy Committee recommends that incentives be paid according to an “adoption year” timeframe rather than a calendar year timeframe. Under this scenario, qualifying for the first-year incentive payment would be assessed using the “2011 Measures.” The payment rate and phaseout of payments would follow the calendar dates in the statute, but qualifying for incentives would use the “adoption-year” approach. [Extra info: a ppt slide clarifies latest year to start adoption is 2014, and in that case, max amount of incentive would be $24,000 rather than $44,000].

2 CPOE requires computer-based entry by providers of orders (medication, laboratory, procedure, diagnostic imaging, immunization, referral) but electronic interfaces to receiving entities are not required in 2011

3 Race and ethnicity codes should follow federal guidelines (see Census Bureau)

Things I like
- Implement one clinical decision rule relevant to high clinical priority: That provides value, is realistic with most EMRs, and ideally "gets the ball rolling". Of course, this depends on what they allow as a "clinical decision rule"

Things that worry me:
- Provide patient access to electronic health information: very few EMRs do that now, and yet they moved it up to 2011 ("Year One" measures) - that seems to be wishful thinking.
- % of all medications entered into EHR as generic, when generic options exist in the relevant drug class: I have no idea how one would measure that, and furthermore- it is not very realistic. For example, I presribe a lot of meds with their brand name, but check off "may substitute" - so the patient can make the final choice as to whether they want the generic. Also, to be honest- it's a lot easier to manage a med list made up of brnad names than generic ones!
- Does ePrescribing mean prescriptions transmitted electronically?: I continue to be baffled as to whether this will truly be a requirement as compared to just creating the Rx via an EMR. Specifically, if I create a prescription online (which implies it is electronic and I do get clinical decision support/alerts) and then print it for the patient - shouldn't that be good enough at least to start with? Why insiste that I also have to send it via EDI to a pharmacy - especially in a world where patients don't always know where they want it sent, and not all pharmacies support this process yet. I do some occasional eRx transmittals, and I've gotten upset calls from some patients because the pharmacy truly does not understand the concept (usually, they have the IT, they don't have the training).
_______________
Link to full text of HITECH bill:
http://www.opencongress.org/bill/111-s350/text

How Doctors feel about EMR vendors too much of the time...

2009-06-29T23:21:00.005-05:00

I tried to post a specific Dilbert comic from last week, but the app seems to automatically move to the current cartoon. Fortunately, I think the text is all one needs...
Pointy-haired Boss: We can only afford to fix the high priority bugs
Dilbert: If we don’t fix 100% of the bugs, the software will be 100% useless
Dilbert: So our plan is to fail?
Pointy-haired Boss: More slowly.

Yep - I can't imagine any other executive in any other business putting up with the software physicians are expected to use: clunky, non-intuitive design backed by slow and error-prone technology. Would a bank VP be satisfied with software that required them to use 25 clicks and scrolls to find and document a single transaction? Would an air traffic controller settle for a system that only allowed them to view 1 airplane at a time and which "blew up" 3 times a day?

So why are we having such problems? Likely a combination of:
1. Not getting input from "true" users (do we think the people who created air traffic control software just designed it in-house and then sold it "as is"?).
2. A poorly aligned reimbursement system which provides minimal reason for doctors to use these systems. The potential meaningful use bonus, we be a start - but we still need a more comprehensive reimbursement adjustment to reward efficiency and quality.
3. Lack of standards: I hate to say it, but we are part of our own problem - every time we allow multiple EMR vendors on the same campus or over-customize the software we buy, we make it harder for there to be consistency over time. I think we really need to look at models where there is some consistent framework across the nation, and then there is the ability to add on feature/apps as an option- the "iPhone" model. Examples might include ATM machines, law databases, and again- the air traffic control software (but I'm not sure- feel free to enlighten me).

Finally, there was a recent article which suggested the real problem with EMR adoption is that medical providers are worried that EMRs will "reveal" too many financial secrets- wow, that guy was out of touch. Most docs would love a good system - but it has to be really helfpul to their daily lives. How would that writer like it if his Word processing software required him to click on 5 things to get a capital letter, and 6 to start a new paragraph? And what if he could get paid more for handwriting his columns because it was faster for him?

Meaningful Use - The Start

2009-06-17T02:11:00.005-05:00

The initial suggestions for Meaningful Use (MU) definitions have begun. This Matrix reviews the different categories and the Goals, Objectives and Measures in each one.

My initial thoughts were that the objectives were much too specific - they were defining the "means", not the "ends". However, with input from others, I then understood the gold is in the column titled "measures" - that is actually what will be defining whether someone gets their incentive bonus. At a high, strategic level- those seem closer to "ends" rather than "means" - which is satisfying since it allows for much more creativity and innovation in getting to those means.

On the other hand, I am not saying that they can all be done without many of the objectives- but hey, that is part of the cool thing about innovation – we don’t know yet what new ideas and technologies might pop up to better solve these problems. For example, instead of a doctor maintaining a med list at the point of care, perhaps a Data Warehouse collects all the billing codes, lab results, and meds from the pharmacies – and then uses some artificial intelligence to auto-create a problem list which can be used to create registries. In fact, that might be more accurate than relying on physician entered problem lists that are often pretty poor. In other words, there has to be some access somewhere to electronic data to make this work, but it does not all have to be physician entered into a single EMR…

So now we can dig into the details and ask some obvious questions:
- Are these the best measures, some are easily defined (eg % diabetics with HbA1C), but others do not have metrics captured in such an objective fashion (eg % smokers offered smoking cessation).
- We need more details about the format of these reports, and how we report them
- Will the government require all of them, or just a limited amount of the reports listed (similar to PQRS in which we only have to report 3 from a larger list).

I'll also make one suggestion - to include the concept of physician to physician messaging, both within an EMR, and across EMRs. I think that may be as or more important than sharing things like medication lists! But I did not see anything in any column in any year that talked about this really important functionality… they talked about access to shared data, but not about ability to send messages to doctors within your direct organization, or within your greater organization. I realize this may be looked at as more of a functionality, and thus contradicts my aversion to focusing on the “means” – but I hope somehow this is included.

Finally, the CCHIT folks have stated they will expand their defintions of certified EHR technologies- which is a good thing (assuming they set the standard to be used by HITECH). The result is that a variety of innovative approaches can then be taken to achieve meaningful use: Some docs will use a full functioning unified EMR, others might use a home grown system that patches together multiple components, and still others might just use HIT on the backend to reach the majority of the metrics required. In other words, it will be interesting to see how many of the measures could be achieved without requiring a physician to touch a keyboard at all (eg no data input). If we can accomplish that - then we may get both significant and meaninful use!

The HIT Policy Committee will accept public comment through June 26 on the just-released draft description of "meaningful use" of electronic health records. Comments should not exceed 2,000 words in length. Electronic comments are preferred and should be addressed to meaningfuluse@hhs.gov, with the subject line "Meaningful Use."

Thoughts on the President’s AMA Speech

2009-06-16T13:02:00.003-05:00

President Obama spoke this week in front of the AMA, and gave a great speech about how we need to really improve how we deliver healthcare. He noted that we won't get there by simply implementing electronic medical records or enouraging preventive care. He understands and said clearly that we need to improve our payment system so that it encourages quality and efficiency, thus resulting in lower costs and happier patients.

My full article was posted at the HISTalk site:
http://www.histalkpractice.com/2009/06/16/drlyles-thoughts-on-the-presidents-ama-speech-61609

My ending comments were as follows:
I agree with President Obama - we can do better. It is quite clear that our current system is simply not sustainable long term, nor is it a “fair” system due to its inability to provide access to all Americans. So I hope we will be able to tell our children in ten years that we were part of the movement which allowed us to become a nation where we can provide the best healthcare to all Americans in the most convenient and cost-effective way possible. It is right financially, it is right morally, and it is right clinically. Now Mr. President, just make sure those words move into action.

I also responded to a comment about the concern around non-compliant patients:
My best comment is that there is no single answer, but if we create the RIGHT INCENTIVES - then let the market and providers be creative and innovative in figuring out how to deal most efficiently with both the doctors/patients who want to work together, as well as those who don’t. America has always been built on that concept - and it can be a double edged sword since the reimbursement system has to be well balanced for quality and cost, but I think we are much closer in a setting where we get “care coordination” PMPM fees vs. simple FFS fees.

...with the right incentives in place - it will be very interesting to see what people come up with - I still remember hearing about the pre-natal clinic which gave away lottery tickets to get all the economically disadvantaged mothers to come into the clinic - it worked well and created an enormous ROI by decreasing pre-term births. Hmmm… maybe that is the answer for the rest of America - see your doctor, be compliant, and get a national lottery ticket!

Optimism, opportunity abound via cash for EHR fixes

2009-05-25T15:34:00.006-05:00

The Modern Healthcare article I mentioned in a previous post quoted me as saying that for $36 billion of incentives, the government better make sure they are paying for improved quality and value, not simply for the use of present-day EMRs which do not automatically equate with clinical improvements. There were many letters to the editor about that article- most agreeing with this underlying premise.

Of course, there was one confused writer who actually said that EMRs must be fine since the vendors employ physicians... well, it is a nice thought, but basically that's the same as saying the banking industry must be fine since they employ MBAs - and we know that's not the case! The reality is that there are two flaws with this arrangement:

1. The physicians are not IT/Informatics savvy and/or the IT people are not clinical savvy. The problem is that the vision is wrong (eg "let's try and create an EMR that looks/acts like paper"), or the interpretation of the vision is wrong (we can't expect 20somthing year old IT programmers to understand how to model complex healthcare workflows without very deep guidance).

2. Even if you have a sophisticated informatics, future thinking Physician Executive who figures it all out - the marketing/sales team at the EMR vendor usually has a bigger say in development. Why? Because they are more concerned with selling to the "new customer" - and the "new customer" is usually naive about EMRs and thus they want a demo that looks/acts like the paper based system they currently use. It's definitely a catch-22...

So, here is the "reply" I sent in to clarify and expand on some of the things I said earlier:

Optimism, opportunity abound via cash for EHR fixes
In response to reader commentary on Joseph Conn’s “Rush for EHRs could ‘stick docs with bad systems’ ":

I am certainly pleased to see that this article has sparked so many great comments and responses. Of course, it is interesting to observe how different people have interpreted it through their own lenses, so I thought I would add a few more thoughts to the discussion.

First, I certainly think the American Recovery and Reinvestment Act of 2009 incentives for electronic health records are a good idea. I simply expressed my hope about how those monies would be distributed—specifically, that the government would define “meaningful use” based upon improvements in quality and efficiency (and not on just using a keyboard in an exam room). As it turns out, it appears that things are headed that way, and so I hope it continues in that direction.

Second, I’ll put on my primary-care physician hat and point out that while the incentives are a nice start, they are not enough. The government (and other payers) really need to change the whole healthcare reimbursement model to reward quality and value over quantity and volume. Once that occurs, we will see some true innovation in healthcare process and delivery that will certainly include robust adoption of EHR systems as an important tool to improve quality and value.

Third, I stand by my premise that current EHR systems need to do better with a lot of emphasis on improving their user interfaces, which need to be more intuitive and workflow-savvy. This problem with EHRs has been confirmed by recent studies showing both poor adoption rates as well as poor benefit realization in healthcare systems with mature EHR implementations. And while there are also some excellent implementations of EHRs throughout the nation, they usually require a huge amount of time, effort and money, factors we honestly can’t count on in the majority of locations.

Fourth, I am not saying to throw the baby out with the bathwater, but that baby has to start growing up. So how can EHRs improve? I think there are two critical components: incentives and usability. The more healthcare reimbursement incentives reflects the importance of features like quality reporting, registries, chronic disease management and virtual care, the more EHRs will move in that direction.

But that has to be paired with better usability that is very dependent on obtaining better physician input. While having physicians employed by vendors is a nice start, experience shows us that is certainly not enough. Rather, vendors need to start spending a lot more time with their actual users—physicians and other clinicians in the trenches. They should make their programmers go out and observe physicians using the systems they are creating, as well as use formal usability techniques to better understand how to improve their systems—the synergies and learning will be critical all the way around.

But be aware, if EHR vendors don’t start improving, and if there is not better adoption and better care, then the government may wind up using that money to instead create their own “iEHR” platform, which allows developers all over the world to create apps and widgets that meet every niche physicians’ need.

Finally, the title of the article was a warning, but one that can hopefully be averted—the overall message should be viewed as one of optimism and potential. At this moment of time, we have a very big opportunity, but with that comes a responsibility to make sure the physician’s voice is heard loud and clear as we move forward. Fortunately, we just have a very simple message: “Give us highly usable EHR systems paired with well-aligned reimbursement philosophies, and we will give you the best healthcare system ever.” - Lyle Berkowitz, M.D.

A Historic Opportunity

2009-05-19T10:15:00.004-05:00

A Historic Opportunity: The new paper by Todd Park and Dr. Peter Basch is a fantastic summary of the potential benefits we can achieve with practice innovations and appropriate use of healthcare IT, as well as the importance of changing reimbursement systems to promote both:
http://www.americanprogress.org/issues/2009/05/health_it.html

Peter said the publishers of the paper, the Center for American Progress, will use this in their discussions with key Congressional staff, to attempt to have payment reform made part of the fabric of upcoming healthcare reform. I certainly hope this has some influence- I agree that if HITECH wants to use $36 billion to promote EMRs… it is much better off using that money to update our failed volume based reimbursement system to promote quality and efficiency, as compared to giving the money to doctors to simply use EMRs of dubious effectiveness. Pay us to change and improve our systems – and let us figure out the best way to do it…
And most importantly, make this a long-term reimbursement change – not a one time “bonus”.

Also, let’s start more consistently using the $36 billion amount rather than the $19 billion amount – as the $19 billion is actually what the govt considers “total cost” – they plan to give $36 billion in incentives, but they assume there will be $17 billion in money saved, so the total cost to the govt is “only” $19 billion – let’s ride with it!

MeaningfulUse.org

2009-05-12T23:35:00.008-05:00

"May 12, 2009--Compuware Corporation (NASDAQ: CPWR) and the Association of Medical Directors of Information Systems (AMDIS) today announced that they have joined forces to launch www.meaningfuluse.org. This collaborative web site will promote and advance the national dialogue and education around “meaningful use.” The new site gives the healthcare information technology (HIT) community a single, central location to access resources, collaborate, influence and discuss the definition of “meaningful use” and to learn how to take advantage of the HITECH Stimulus funds."

There may not be two more important words in the english language right now. How they are defined will affect if/how EMRs are fully adopted and whether they are used in a way that truly makes a difference... In other words, the very fate of our healthcare system may rely on how this is defined in the weeks and months ahead.

How should we use $36 billion to promote EMRs?

2009-05-01T00:05:00.006-05:00

Journalist Joe Conn is one of my all time favorite HIT writers - especially because he has the talent to take my ramblings and put them into excellent articles, like this one he just published at the Modern Healthcare web site... or if that does not open, you can find it on my DrLyle website.

I was talking about the government plan to reward doctors with $36 billion in incentive bonuses for using EMRs in a "meaningful manner" - first, I'm all for using EMRs meaningfully, and second, I'm all for rewarding physicians! However, I was warning that our current crop of EMRs are far from perfect and was saying to make sure that we reward the right thing (quality and efficiency, not simply use of IT). I like how John Halamka, M.D. and CIO at CareGroup Health System in Boston defined "meaningful use" during the recent DC Hearings on this topic: “Processes and workflow that facilitate improved quality and increased efficiency.”
Additionally, I was questioning whether we could spend that $36 billion a better way- perhaps by creating a national EMR framework upon which vendors could build their applications (yeah- sort of like the iPhone). Hell- for $36 billion, the government could buy up the EMR divisions of Cerner, GE, Allscripts, and many others and then get everyone on one system!

Information Overload: Don't over-encourage national interoperability

2009-04-30T23:21:00.007-05:00

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

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

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

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

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

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

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

Meaningful Use Committee meetings

2009-04-29T02:57:00.004-05:00

NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS
EXECUTIVE SUBCOMMITTEE
Hearing on "Meaninful Use" of Health Information Technology
April 28 - 29, 2009
http://www.ncvhs.hhs.gov/090428ag.htm

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

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

Improving EMRs: Usability, Usability, Usability

2009-04-19T18:53:00.010-05:00

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

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

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

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

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

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

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

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

Improving EMRs 2009

View more presentations from Lyle Berkowitz, md.

Post-Blog stories of interest
Wired magazine "re-imagines" lab reports: http://www.wired.com/magazine/2010/11/ff_bloodwork/all/1

The Change Doctor

2009-04-19T15:50:00.000-05:00

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