Sunday, April 29, 2012

EMR Apps Taking Off, Starting with Refill Requests

About ten days ago, the new Technology Editor for Healthleaders magazine (Scott Mace) interviewed me about a range of healthcare information technology topics, and within a week he put out an article - these writers are getting quick!   He was especially intrigued about healthfinch, the company I helped co-found last year to build HIT tools which, "make life easier for physicians, and better for patients".  We talked a lot about our first product, RefillWizard, which is an "EMR Extender Tool" that uses the new concept of "team-based decision support" to help improve efficiency (by task-shifting work away from physicians and towards their team) AND quality (by increasing compliance with protocols).

I've talked about these ideas in previous posts (Rise of the EMR Extenders, Need for New Clinical Workflows and EMR Usability Update), and have hinted that I was working on putting these ideas into reality... I guess now the cat is out of the bag!   So if you have an EMR in place and want to implement tools which actually decrease the amount of work your physicians have to perform (while improving quality and documentation), then check out what we are doing!

Of note, Scott did a great job of explaining our philosophy and I liked how he stressed the importance of getting clinically active physicians more involved in these types of companies.  He even says at the end that if someone like DrLyle can do this - then anyone can!!!  That's OK - I know what he meant :)

Here is the article, with a few addendum from me in brackets:

EMR Apps Taking Off, Starting with Refill Requests

Scott Mace, for HealthLeaders Media , April 24, 2012

Lyle Berkowitz, MD, has graced the pages of HealthLeaders Media before, but with the new twist his story is taking, healthcare technology leaders everywhere should take notice.

Berkowitz was one of the HealthLeaders 20 in 2008—"20 people who make healthcare better."  [At that time], Berkowitz had recently founded the Szollosi Healthcare Innovation Program while continuing his primary care practice at Northwestern Memorial Physicians Group, the largest primary care group in the city of Chicago.

Now, in addition to these ongoing duties, add entrepreneur to his CV. In the process, he's using more technology to disrupt current healthcare best practices.

"I'd argue that primary care physicians should never have to be directly responsible for preventive care measures," Berkowitz says. "When I say that, people gasp. But when you look at the most efficient clinics and some of the highest-quality clinics, they actually have shifted a lot of that work to nurses who are very focused on that particular issue."

Back in 2010, Berkowitz was speaking on this very topic at the Mayo Clinic's invitation on how EMRs could make doctors' lives easier. In the audience were two young aspiring consultants who got so excited about a mock-up Berkowitz was showing, they proposed a new company to put actions behind Berkowitz's philosophy and inspiration. Thus was born Healthfinch. Berkowitz is chairman and chief medical officer and leaves the day-to-day operation to his partners.

Today, Healthfinch ties into most popular EMRs and runs prescription refill requests through a Web service, making it simple for physicians to delegate those refill requests to nurses and other medical office support staff.

At Elmhurst Clinic, based in nearby Elmhurst, Ill., one physician using the Healthfinch service is seeing real productivity gains. He sees less than half the refill request messages he used to see, according to Elmhurst Clinic CEO Donald Lurye, MD, MMM, CPE.  [To clarify, it was one physician interviewed, but their group actually has over 50 doctors using the system and they are each saving around 15-30 minutes a day!]

"The management of refills is a major activity, particularly in primary care where you're dealing with a lot of people with multiple chronic illnesses, that can have complicated prescription regimens and necessarily so," Lurye tells HealthLeaders Media.

"Dealing with refill requests sounds simple but it isn't. Many times, there's a need for a physician taking a look at a chart to decide whether a refill is appropriate. It can involve checking to see whether various types of follow-up have occurred, or whether certain lab tests have been done in a timely manner, that either just need to be done for monitoring or should be there to guide the therapy."

Healthfinch's rules-based engine, configurable by the Healthfinch staff in collaboration with customers such as Elmurst, automates the decision-making and offloads it from doctors.

When I first heard of this concept, I figured there might always be some super-cautious, belt-and-suspenders type physicians who would still insist on checking every detail.

"First of all, the protocols that Lyle presented to us initially were very conservative, and correctly so," Lurye says. "In fact, in his own personal use, he was still looking at every refill request. He just wanted to see, 'Okay, these are the things I think can be done automated. Now let's see if I actually agree with myself.' And we did the same thing here. And we've kept it fairly conservative. So that's one answer.

"And again, if we ever needed to they're fairly easy to adjust."

As for the rest of the care team, "it really makes them feel much more like participants," Lurye says. Refill requests can be "opportunities for patient education and encouraging people to come back in for necessary care."  [It turns out that the Nurses and staff like it more than we initially would have thought - they love being able to answer patients more quickly rather than playing EMR message-tag with their doctors.]

Deployed initially in primary care, the Healthfinch service will find its way into Elmhurst's specialty practices, Lurye says.
Healthfinch is extracting info from the NextGen EMR in use at Elmhurst. I was surprised that existing EMRs don't yet have the refill-request-delegation features built into them.

"The evolution of EMRs didn't really come from the clinical side so much," Lurye says. "The real return on investment on EMRs initially was that they helped to do charge capture better and meet coding criteria for various types of visits. They've become over time much, much more clinically oriented, and that's great."

Berkowitz sees EMRs as a platform on which a multitude of apps can be built, much as apps now get built on mobile platforms such as Apple's iOS or Google's Android.

"EMR vendors are pretty much focused on Meaningful Use right now," he says. "Nothing in Meaningful Use really says, 'Make a tool that makes the doctor more efficient.' Our tool doesn't help Meaningful Use. It simply helps the doctor be more efficient and provide higher-quality care."  [I love this line!]

EMR vendors are beginning to open up their platforms to allow third-party vendors to build these apps. "Allscripts and Greenway are leading the charge," Berkowitz says. Others will follow. For now, that means apps such as Healthfinch have to find more cumbersome ways to extract and use data.  [We have built our systems in a way which actually makes it now so hard to get the data we need from EMRs.]

But clearly this notion of EMR apps is going to be much, much bigger than just delegating refill requests. The healthcare ecosystem, ranging from payers to caregivers and encompassing financial analysts, quality mavens, and researchers, is starting to tap vast quantities of patient data that will accelerate the pace of innovation in healthcare technology by leaps and bounds.

To me it's very encouraging that there are physician-leaders such as Berkowitz who, while keeping their day jobs, have found ways in their spare time to advance this ball. The message is clear to healthcare technology vendors: If the Lyle Berkowitzes of the world can get this done, you should, too—and more.  [Well... I've been waiting long enough - glad my hat is in the ring now!]

And here was a summary from another HIT blogger who picked it up the next day:

Tuesday, April 03, 2012

The Future of Physicians

My friend, CIO Extraordinaire and fellow blogger Dale Sanders, thought I might want to respond to the following... he was right!   This past week, Ezekiel J. Emanuel, MD posted an editorial in JAMA entitled, "Shortening Medical Training by 30%", in which he argues that we should spend less time and money on training doctors: "there is substantial waste in the education and training of US physicians. Years of training have been added without evidence that they enhance clinical skills or the quality of care. This waste adds to the financial burden of young physicians and increases health care costs. The average length of medical training could be reduced by about 30% without compromising physician competence or quality of care."

The well known KevinMD blog posted a response from Karen Sibert, MD, a professor at Cedars Sinai, Reducing training will diminish the status of physicians, in which she argues the dangers of this option and that the real motive is to be able to pay physicians less long-term by lessening what they do.  She says, "The Emanuel prescription for cutting [training] by 30 percent would downgrade the profession of medicine.  Instead, the prescription should be to support medical education at every level, and uphold the practice of medicine so that the brightest young students will always aspire to be physicians."  

I would even argue a more extreme reversal to Dr. Emanuel's theory and suggest that we actually spend more time and money to make sure physicians are trained VERY WELL... to take care of patients directly, but also to lead a team in the world that will be tomorrow's healthcare system.  But the catch is that we ALSO have to train a lower level of physician extenders to staff that team. In other words, the key is not to simply cut training costs nor to even increase the number of physicians by 10-20%, but to make the physicians we have 100-200% more productive by giving them well designed HIT systems which allow them, empowered by their teams, to take care of a greater number of patients in a much more consistent manner.  

The future of healthcare should see physicians doing less of the structured/mundane/checklist type work (which includes both indirect and direct patient care), and more of the higher ordered care - mainly direct contact with a smaller number of complex patients who really need that level of attention.  Studies have found that this high level of attention on the most complex patients improves care and saves money, while other research has shown that nurses and other paramedical personnel actually do better at handling preventive care and treating stable patients with chronic illness.  So let's free up our doctors to do the hard stuff where they can add the most value (and make sure we train them well to do so)!