Wednesday, December 30, 2009

Meaningful Use Final Matrix Posted

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:

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:

* MU summary from Mr. HISTalk:

* An MU Excel Spreadsheet created by Mr. HISTalk:

* Dr. John Halamka's MU Summary:

* Matrix of Numerators and Denominators

Top Medical Advances of the Decade

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.

Wednesday, December 16, 2009

The Inflection Navigator Project

A lot of my effort in the past 1-2 years with the Szollosi Healthcare Innovation Program ( 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):

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:

Sunday, December 06, 2009

More Money for Early EMR Adopters

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:

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!

Thursday, December 03, 2009

Patient Safety: Slow but Steady Progress

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.

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.

Monday, November 23, 2009

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

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!

Sunday, November 15, 2009

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

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:

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 .

And here are some videos from this meeting:

Tuesday, November 03, 2009

Pulling Forward the Benefits of HIT - Federal Comments

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: 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:

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:

Monday, October 12, 2009

Health 2.0 Conference - Review

I wrote up a summary about my day at Health 2.0 last week, posted on HISTalk:

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...

Sunday, October 11, 2009

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

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.

Saturday, October 03, 2009

The Mayo Innovation Conference

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 ( 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.

Saturday, September 26, 2009

Reinventing Health Care Delivery: Innovation and Improvement Behind the Scenes

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 (

Intro is below, full paper is online:

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.

Tuesday, September 15, 2009

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

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

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):

Sunday, September 13, 2009

What if the Medical Record looked like a Nutrition Label?

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 ( 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 (, 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):

Tuesday, September 01, 2009

Meaningful discussion on Meaningful Use

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:

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.

Sunday, August 16, 2009

“Good software includes superb usability”

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

Saturday, July 25, 2009

Why I'm optimistic healthcare reform will pass this year

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.

Friday, July 17, 2009

Meaningful Use Definition - Updated

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":

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:

Monday, June 29, 2009

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

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?

Wednesday, June 17, 2009

Meaningful Use - The Start

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, with the subject line "Meaningful Use."

Tuesday, June 16, 2009

Thoughts on the President’s AMA Speech

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:

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!

Monday, May 25, 2009

Optimism, opportunity abound via cash for EHR fixes

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.

Tuesday, May 19, 2009

A Historic Opportunity

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:

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!

Tuesday, May 12, 2009

"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 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.

Friday, May 01, 2009

How should we use $36 billion to promote EMRs?

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!

Thursday, April 30, 2009

Information Overload: Don't over-encourage national interoperability

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

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

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

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

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

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

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

Wednesday, April 29, 2009

Meaningful Use Committee meetings

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

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

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

Sunday, April 19, 2009

Improving EMRs: Usability, Usability, Usability

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

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

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

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

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

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

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

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

The Change Doctor

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