Sunday, August 18, 2013

Defining Healthcare Innovation

In my recent post at Clinical Innovation + Technology, I tackled the issue of defining "Healthcare Innovation".  I decided to do it by answering the typical questions I often hear, and so hope this helps you in explaining to others!  Below are my answers, with a bonus answer for my blog :)

One of the most common questions asked these days is “What is healthcare innovation?” Like the story of the blind men touching different sides of an elephant and each describing something separate, you will hear a wide variety of answers to this question based on whom you ask.
The following is a way to address the common questions on this topic so you can start organizing innovation in your mind and within your organization.
First, should the focus of innovation be on innovative information technologies, devices, workflow processes, care models or business models? Obviously, it can be any or all of the above. In the past, it is fair to say the majority of innovation work was in the devices arena since there was a clear financial return to the organization if a new device was widely adopted.  However, in a world changing to value-based reimbursement, we are seeing that process and care model innovations will likely be leading the charge, with information technology being an enabler of those innovations.
Second, how is an innovation project different than an improvement project? The short answer is that an improvement project is done to improve something, while an innovation project is done to blow up the current process or tool and create a new one. A classic example of this is polio: improvement experts would focus on designing a better iron lung, while innovation experts would consider how they might create a vaccine to stop this disease in the first place.
Third, is there a science or methodology to doing innovation well? Yes, similar to how improvement projects may use techniques like Lean and Six Sigma, the world of innovation relies on the concept of “Design Thinking” which has a different set of methodologies. The typical innovation project involves three main phases: discovery, incubation and acceleration. In the discovery phase, a problem is studied and observed and then various brainstorming techniques are used to create potential solutions. In the incubation stage, rapid cycle prototyping and piloting are done to quickly and cheaply find what fails and what works. In the acceleration phase, the successful pilot is spread using a variety of educational and other techniques.
Fourth, do all innovators need to use this formal science of innovation to succeed? It’s fair to say that many of the innovations we see in healthcare were done without formal innovation methods.  Rather, innovation started with a passionate individual or team trying to solve a problem with which they had a deep understanding. They would try various iterations until they got something that worked and then maybe spread it to others. However, the creation of an innovation culture and infrastructure to support a formal process of design thinking is likely to help identify more of these projects and make them more successful.
Fifth, what helps make up a successful healthcare innovation? First, it always starts with a passion for making something better plus some time and resources to focus on the project.  Second, it needs to have a real-world business model to keep the innovation sustainable. Third, the innovation needs to be well integrated into information technologies and clinical workflows so that it can be easily spread. Not surprisingly, it is this last part which is always one of the hardest and yet most important pieces. And it is why this intersection of information technology and innovation remains critical to the success of evolving our healthcare system to meet its potential.
Bonus question: What is the difference between a sustainable and a disruptive innovation? Sustainable innovations are those which sustain the current business model (e.g. things that promote volume in a FFS environment) and/or which add on features/functions with an increasing cost (e.g. the new MRI machine). Disruptive innovations are going to change the business model, often by offering same or less features, but at a much lower cost (e.g. TeleDerm visits, Nurse-managed protocols for Diabetics, a hand-held cardiac ultrasound which gives you just the heart information you need to make a clinical decision).  A recent article from the Clay Christenson Institute reviews Why EHRs are Not (yet) Disruptive.

Clinical Innovation & Technology Article Link: Defining Healthcare Innovation

Monday, July 01, 2013

The Hat Trick: Physician + Informatics + Innovation

Looks like June is Q&A month for me!
Here are three recent interviews and articles where I answer questions about Healthcare IT and Innovation:

When Health IT Meets Innovation: Q&A With Dr. Lyle Berkowitz of Northwestern Memorial Hospital (Becker's Hospital Review)
This interview focuses on lessons learned from my book (Innovation with Information Technology in Healthcare) - so I review the history of the book, mention a few of the stories, discuss the biggest "takeaway" (get inspired by others, but modify innovations for your own organization), and explain how to start innovating right now!

5 Questions For… Dr. Lyle Berkowitz (The Intel Health Blog)
This interview is more broad-based and we talk about how to change an organization's culture towards innovation, more lessons learned from my book, where healthcare innovation is heading in the coming years, and What is the Szollosi Healthcare Innovation Program.

The Hat Trick: Physician + Informatics + Innovation (Clinical Innovation and Technology)
This is my monthly article as "Innovator in Chief", and I talk about one of the most common questions I am asked - how to balance clinical care, informatics and innovation.  Full text is below:

I am a practicing physician with extra responsibility for informatics and innovation. I love being able to do multiple things in my day, but I do often hear “How do you juggle all those roles?”  The simple answer is that I truly treat them as synergistic—they feed and support each other. My first love is being a primary care physician and taking care of my patients. Yet I also am constantly thinking about how I might do my job easier and better.
Sometimes there is an informatics answer, such as creating new content, alerts or reports within our EMR. Other times there are more innovative answers, such as creating a new process which helps delegate work across my team. But increasingly, there is a combined answer, such as creating a new workflow within our EMR or finding an innovative IT tool and figuring out how it fits into our system’s infrastructure.
Physician informaticists also ask me is how they can be more innovative. The good news is that most informatics doctors are perfectly set up to expand into the innovation space. They already have an appropriate skill set, such as an interest in new technologies and workflows, excellent problem-solving talents, an ability to work with a wide range of personnel, and an innate desire to constantly improve the current system. The trick is whether they have the time and resources to make these changes happen, so here are some thoughts to help you blaze this trail at your organization.
First, start small and let things evolve. In fact, a well-known innovation mantra is “Fail Fast, Fail Cheap, and Fail Often.” In other words, you should embrace piloting and the concept of an “n of 1,” often where you can and should be your own guinea pig and ground zero for your innovations. This means signing up for the many new apps, websites and technologies you see out there, healthcare related or not. Try them all for a little to see what they feel like and think about how they might apply to healthcare. Maybe come back to them at another time if you don’t see the value at first. Be the first to try new EMR functions to determine how well they might work in your system’s current workflow, or if they warrant a new workflow.
You will fail. A lot. That is okay, because each mistake is a golden piece of information which will help lead you to a better place. By starting small, you don’t need a lot of time, resources or permission to try something new.
Second, always make time to observe. Just watching your colleagues and staff in their day to day lives will help you quickly see bottlenecks and gaps. For example, I was approached by our hospital nursing executives recently as they were trying to be innovative with the discharge process. We formed two teams of three people each and went to the floors to observe and talk to the frontline staff—the nurses and other caregivers on the floor. We used a classic innovation method called “Love/Wish,” where we ask folks what they love about a process and what they wish would change to make it better. An hour later our two groups met and found we had a robust list of opportunities that involved improvements and innovations to both workflow and IT utilization.  
Being a physician informaticist gives you a unique platform upon which to innovate, so keep your eyes and mind open and help make a better system for all of us.

Tuesday, May 28, 2013

A Call to Action for HC Innovators: Do the Easy First (and then Google Glass)

At HIMSS in March, I loved hearing Dr. Eric Topol's keynote talk about the Creative Destruction of Medicine, and how future technologies like genomics and nanotechnology will make diagnosis and treatment so much better and easier.  And then last month, I read Travis Good's HISTalk story about "The Power and Hype of Google Glass", and searching online, I found many more:

It got me to thinking that there are so many cool and futuristic things we can (and should) be doing in healthcare.  However, if all the best thinkers are focusing on the "future" - who will be focusing on the present?  By always coming out with new technologies, we seem to have created a "time-shift brain drain", which means we may not be focusing on how to improve or innovate with the stuff we have RIGHT NOW.  It might not be as fun to optimize the slow, clunky "EMR 1.0" we use today, but it is important, and will help free up time for doctors and others to actually take a breath and do what they are good at (e.g. higher order thinking) rather than the rote, repeatable tasks which have to be done every day (e.g. med refills, reviewing every single lab, documenting every single action...)!  And this is especially important as a new study illustrates how "time constraints make it harder for physicians to solve the medical mysteries that confront them".

So it led me to write my May "Innovator at Large" column in Clinical Innovation + Technology, it's called "Do The Easy First"... which is a "Call to Action" for healthcare innovators everywhere to start thinking about both the present and the future... as it will be much easier to evolve our healthcare system if we make sure it does not go extinct first!

Do the Easy First (April 24, 2013)

I love reading about advanced technologies that have the potential to help with our most complex patients. It will be a fantastic future where natural language processing mixed with big data analytics will help diagnose difficult cases and suggest novel management strategies.
A future where Google Glass will help doctors more easily recognize dermatological manifestations of systemic diseases while also providing patients with a video of their visit to the physician. And where a nanotechnology sensor floating in the bloodstream can identify DNA changes related to early cancer or heart disease and send an alert to let patients and their providers know to start intervention quickly.  
However, I am also a pragmatic physician and know that while all of this may eventually happen, I have to live in the here and now of technical and financial limitations. Currently, we still struggle to get reasonably accurate data into EMR systems, doctors are not paid extra to identify anything early and most physicians feel they are running out of steam as they spend half their time doing non-clinical, or certainly non-advanced, duties.  
I believe some innovators need a wake-up call. Instead of focusing all your time trying to figure out the hardest and most complex issues, how about figuring out the easy stuff first? For example, many physicians spend a big chunk of their day documenting what they just did, filling out administrative paperwork, trying to keep everyone up to date on preventive care and disease management protocols, and answering the same questions over and over again.
In other words, physicians are not being used at the highest level of their abilities and, thus, we have created an artificial shortage of doctors. Furthermore, physicians are not great at taking care of all this routine care and administrative paperwork, resulting in decreased quality and patient satisfaction. It’s no wonder our healthcare system is the costliest and not the most effective in the world.

But who says doctors should be doing all this work? State laws on scope of service need to be respected (or at some point reviewed for best practice). But ironically, the current use of IT has often shifted more work onto the physicians than ever before due to poorly created IT systems which were built for a physician-centric setting rather than a team-based setting.  
What if we started applying our innovative technologies and thinking to help streamline the routine and repeatable workflows which clog up a physician’s time? What if we could use automation to cut down on the unglamorous paperwork chores which are slowly strangling our physicians? What if we used HIT to empower a physician’s team to manage a large chunk of their stable patients remotely based on the doctor’s electronic care plan? What if we saved physicians one, two, even four hours a day of this drudgery so they could spend that time focusing on their truly complex patients? What if we could have a future where care could be delivered in a safer, cheaper and more efficient manner and doctors could focus their time on tasks for which their abilities are best matched?
Maybe they’d even have some time to try out that new Google Glass!

Monday, April 15, 2013

Population Health or Bust!

My April editorial post for Clinical Innovation + Technology is called "Population Health or Bust!".   The premise is that we know reimbursement models are changing from "Volume-Based to "Value-Based care", which may range from gain-sharing to bundled payments to full capitation... And thus we need certain types of tools to better manage our populations of patients.  So I defined what these population management tools should do and what to consider when purchasing them:

First, population health management means that you (1) define a specific population and (2) manage that population in the most efficient, cost-effective and highest quality manner possible.  In other words, instead of treating everyone the same, you provide the right care to the right people in the right time and in the right format. This helps to ensure that we focus our limited resources on the people who need them most, while using innovative strategies and technologies to leverage care for others.
Second, be on the lookout for some key functionalities when choosing your population management tools. These include risk stratification, impactability analysis, care gap identification, outreach capabilities, care coordination dashboard, patient engagement systems and analytics reporting.
Third, population health tools are everywhere right now, including offerings from your EHR vendor, your insurance companies and various third parties. Factors to help guide your decision will include not just the strength of their offering, but their ability to integrate into your workflow, their ability to work with multiple data sources, and their future visions. Additionally, we are starting to see interesting gain-sharing business models that may make initial investments free or cheap.
I ended my post explaining why I believe that when dividing populations into "Low, Medium, and High" risk, that the really cool innovations (e.g. mobile monitoring, telehealth, automated care) will be in the Low and Medium categories, rather than the High risk ones.  And furthermore, that this will hopefully open up more free time for physicians to spend with the "High risk" patients who needs more of the face to face care we consider traditional right now.  Said another way... let's automate the easier stuff so we can allow for more time, critical thinking and compassion for the tougher stuff! 
Companies in the Population Health Space (at least a partial list)
·         Advisory Board Company:
·         CareMerge (focus on elderly):
·         Care Team Connect:
·         Clairvia http:
·         Click4Care:
·         Clinigence:
·         Curaspan (SAAS – Handoffs):
·         Essence HC:
·         EvolentHealth (UPMC + ABC):
·         GSI Health (Lori Evans) (CC Platform):
·         Healarium (Mobile Pt Activation Apps):
·         Humedica (bought by Optum 1/13):
·         Intelligent Healthcare:
·         Lumeris (ACO for hospitals):
·         Medventive (bought by HBOC 2012):
·         Outcome Advantage:
·         Patient Point:
·         Pharos (Dz mgt, Randy Williams):
·         Phytel:
·         RipRoad:
·         See Change (Insurance and Systems for Employers):
·         Symphony (ACO Software):
·         TCS:
·         US Health Centric (Dx/Wellness mgt):
·         Valence Health:
·         Vital Health:
· (Checklist based Workflows for Discharges):
·         Wellcentive:
·         xG Health Solutions (Geisinger Spin-off): 

I will edit this list over time - but it gives one a sense of how many companies are already in the space in one form or another (and this does not even include all the EMR vendors and their offerings).

Wednesday, April 03, 2013

HIMSS 2013 Review

Some thoughts on the HIMSS 2013 Conference in New Orleans (March 3-7)

Pre-Conference Advice
I wrote a short column on "Innovators at HIMSS" - my advice on how to Find, Share or Sell Innovation - by breaking down the conference into three chunks:  Educational Sessions, the Exhibit Hall and Networking.

Overall Impression of the Conference
I still love New Orleans as a city and as a convention spot (not an opinion shared by everyone)!  Of course I did have a hotel within walking distance.  I also liked that the "exhibit floor" was constrained and thus the vendors had smaller booths… but it seemed they all had plenty of room.  With that said, I felt more rushed than ever trying to see everything on the vendor floor, and for the first year ever, I didn't even have time to attend many of the educational sessions.  Is HIMSS becoming more vendor fair than educational?  Not necessarily, when you have 35,000 people - there are different needs and I still think the educational sessions are important for different people in different roles in different stages.  But this year, my role was more about exploring - especially in the population health arena, of which EVERYONE seemed to have an answer.

Personal Highlight
Getting to meet and talk with Dr. Larry Weed, who gave a brilliant closing keynote at the Physician Symposium on Sunday... he is a hero and legend to many of us in the healthcare informatics field.  He developed the concept of organizing the medical record in the SOAP format, created one of the first computerized medical record systems, and has been a long-time voice in helping doctors learn how to "think better" in taking care of our patients.  I plan to write an expanded blog on his talk in the near future, but here is what I've said in the past.

Hot Topics
I think there were two clear camps:  (1) Meaningful Use: finishing up stage 1, getting ready for stage 2; and (2) Population Health tools: understanding who were the players, what do they do, what are the business models, etc.

Population Health Companies
Here are some I saw and/or I think have good relevance in this space (and it is far from complete):

Some Assorted Cool Things I Saw
HealthCatalyst:  An analytics company with a really good story of what they do… They start with an analysis of high cost and high volume activities which also have a high variance in your health system.  After mutually agreeing on where to focus and how much money might be saved by reducing variance closer to the mean scores, they help you determine why the variance is high (via more in-depth analytics) so you can correct it.  Concept is simple, but the execution is the critical part and they seem to have captured some secret sauce that makes them very good at this.  And they've got some great people, including all start CIO Dale Sanders.  An interesting "telemedicine in a box" concept... where they will build a self-contained telemedicine "box" wherever you want it (e.g. a pharmacy, a company's warehouse, an underserved youth center, etc.).  A patient goes in the box, fills out some computerized forms, and they then have a live video feed with a doctor.  But the key is that they also have access to a variety of "tools" which they can use on themselves to show the doctor everything they need to see - including a stethoscope, and devices to look at eyes, ears and skin at visual magnifications greater than one could even get in the office!  A medical assistant staff person can help if there is confusion.  The MA also does basic clean-up, and there is some automated UV-light cleansing as well.  Is this better than Skype and buying the tools separately... not sure, but it's something to consider. 
ReadyDock:  A simple little "iPad Dishwasher" which stores, charges and sterilizes handheld computers, such as the iPad.  I think we will be seeing more iPad use in hospitals, by both providers and patients… so this could be a really good idea.  I do wonder if just having a plastic "cleanable" cover over these iPads might be a simpler, cheaper idea... this is something that has to be tested out.

Sunday, March 10, 2013

The HIT Productivity Paradox - It's Gonna Be OK!

The NY Times published another article recently with a negative vibe about EMRs... implying that spending money on EMRs is a waste since the benefits are not obvious, and questioning the ethics of EMR vendors for asking the government to help subsidize these systems.

Really?  It seems like that is incredibly backward thinking which was also likely used against the stethoscope, anti-sepsis, penicillin, cars, planes, TVs, computers and the Internet when they first started out. I get it, change is hard and technical progress is slow - but let's not throw the baby out with the bathwater, let's give it a chance to grow up!  And, of course, what is even more interesting is that like so many media cycles, the media happily built up how great healthcare IT would be, and then gladly tear it down when it does not happen right away.

Glen Tullman (HIT entrepreneur and former Allscripts CEO) had some great thoughts on this issue in a recent Forbes Editorial he wrote Why Haven't Electronic Health Records Made Us Healthier?  He essentially said that we are a lot further along than when we started, but certainly still have far to go.  I especially liked that he reminded us of Amara’s Law: “We tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run.”

SIDE NOTE:  I did a little research to find out that Roy Amara was a Stanford Systems Engineering PhD who was President of the Institute for the Future.  I also found that his law was one of Four Geeky Laws that Rule Our World, the four together are:
  • Amara's Law:  "We tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run."
  • Brooks' Law:  "Adding manpower to a late software project makes it later."
  • Thackara's Laws:  "If you put smart technology into a pointless product, the result will be a stupid product."
  • Reed's Law:  "The Value of a Network Increases Dramatically When People Form Subgroups for Collaborations and Sharing."

So I wrote a little reply to the NY Times article as well and the wonderful folks at HISTalk published my piece at: 
I actually received a lot of positive feedback on this - so here it is: 

Fair enough - are EMR's worth it, was MU worth it?
I've said before that I don't think I would have spent the $30-40 billion that way (remember, they use the $19 billion figure because they assume $10-20 billion in savings).  I would have focused on mandating standards and trying to push for a uniform data model platform upon which vendors could then build their more external facing products.  However, I will happily admit that MU has done it's job - it has stimulated the adoption of EMRs… it won't be the 80+% they were hoping, but it's still got a lot of people off their asses and moving.

So next question - Will they provide all the great things we are hoping for?   
Certainly we've got some issues - EMRs are still not mature, nor is our understanding on how to best use them. But no technology, from cars to computers, started out perfect.  I've been reading "The Signal and the Noise" - and very early on it reminds readers of "The productivity paradox" which helped explain why the early computer age (1970s-1990s) actually saw a LOWER productivity as everyone was figuring out how to build them well and how to use them!  Sound familiar?

From WikipediaThe productivity paradox was analyzed and popularized in a widely-cited article[1] by Erik Brynjolfsson, which noted the apparent contradiction between the remarkable advances in computer power and the relatively slow growth of productivity at the level of the whole economy, individual firms and many specific applications. The concept is sometimes referred to as the Solow computer paradox in reference to Robert Solow's 1987 quip, "You can see the computer age everywhere but in the productivity statistics."[2] The paradox has been defined as the “discrepancy between measures of investment in information technology and measures of output at the national level.”[3] It was widely believed that office automation was boosting labor productivity (or total factor productivity). However, the growth accounts didn't seem to confirm the idea. From the early 1970s to the early 1990s there was a massive slow-down in growth as the machines were becoming ubiquitous. (Other variables in country's economies were changing simultaneously; growth accounting separates out the improvement in production output using the same capital and labour resources as input by calculating growth in total factor productivity, AKA the "Solow residual".)

So if and how can this best be applied to healthcare IT?  
Well, it turns out that some smart authors actually addressed this exact issue in a June, 2012 NEJM article entitled: Unraveling the IT Productivity Paradox — Lessons for Health Care.   In this article, they explain that sure, we are seeing problems with HIT… but it is as expected - just like every other new industry has to evolve.  They conclude with the following paragraph:
The resolution of the original IT productivity paradox suggests that current conclusions about the value of health IT investments may be premature. Research suggests three lessons for physicians and health care leaders: invest in creating new measures of productivity that can reveal the quality and cost gains that arise from health IT, avoid impatience or overly optimistic expectations about return on investment and focus on the delivery reengineering needed to create a productivity payoff, and pay greater attention to measuring and improving IT usability. In the meantime, avoiding broad claims about overall value that are based on limited evidence may permit a clearer focus on the best ways of optimizing IT's use in health care. 

Clearly we are not at perfection - HIT can affect efficiency and quality in both good ways and bad.  But rather than try to create some artificial polarization that it is all good or all bad… let's continue doing our job (for the medical informatics professionals reading this) to keep making HIT better serve our providers and patients, while educating those who get freaked out every time a new stat or story comes out pointing out its imperfection.

Saturday, February 02, 2013

The Healing Edge: At the Intersection of Innovation and HIT

Three years ago I was asked by Marion Ball, EdD (a well respected informaticist and long-time colleague) to write a book about the intersection of healthcare IT and innovation.  I was smart enough to initially say no, but she kept asking because she knew I had been combining my long background in informatics with a newer interest in the science of innovation as part of the Szollosi Healthcare Innovation Program, a charitable organization I established in 2007 with a mission to use creative thinking and diverse technologies to produce a better healthcare experience for patients, physicians and others associated with their care.  

After about 6 months I finally accepted the challenge, realizing that since I was an early pioneer in this world of HIT meets innovation - I might as well try and give the area a good book.   I was wise enough to quickly get a partner in this endeavor, the amazing Chris McCarthy, MPH, MBA.  Chris is a friend and my #1 innovation mentor, as well as the Director of the Innovation Learning Network and an Innovation Specialist with Kaiser Permanente’s Innovation Consultancy.  We liked the idea of storytelling and wanted to make the book an enjoyable read about the many awesome healthcare innovators who have used IT to make the healthcare system better, faster and/or cheaper.  We also realized that it would make sense to truly hear the "voice of the innovators" by having them each write their own stories within the framework we created.

The result is our book, Innovation with Information Technology in Healthcare, which describes the stories of over 20 organizations who have combined innovative thinking with information technologies to improve their processes of care and solve a need at their organizations.

The first chapter sets the stage, describing how this work should be viewed like a big cookbook of recipes, with sections on EMR Innovation, Telehealth Innovation, and Advanced Technology Innovation (e.g. analytics, portals, mobile and gaming).  The second chapter describes the science of innovation itself, including an assortment of methodologies which help move the innovation process from ideation to prototyping/piloting to spreading it across an organization.  The authors, from Kaiser's Innovation Consultancy, give examples from the very real work they have done over the past decade.

The rest of the chapters are the stories, written by the innovators themselves, about what they did, why they did it, how they succeeded, lessons learned, and their plans for the future.   It is especially fun to read about the origins of these innovations and peer into how an organization moves from a problem to an innovative new way of doing things. I wrote a short editorial on the "Big Lessons Learned" from these stories, including the following ideas:
  • Use What You Have:  Our first group of stories highlights how a lot of innovation can be made with the underlying HIT you already have in place, especially EMRs.  Examples include use of messaging to support care coordination, CDS tools to support delegation of preventive care and other duties to staff, and reporting tool to identify adverse events.
  • Innovation is More Than Technology.  For innovations to succeed, it's critical to also address culture issues, new business models, legal and political hurdles, and process change.  And, of course, it's often a good idea to be innovative in doing so!  The stories about telehealth give some great examples of this!
  • Look Around.  Learn from all the new technologies and companies appearing in every aspect of our life... from mobile apps to business intelligence to RFID tools to gaming systems.  The final section on Advanced Technologies provides many examples of this rule. 
  • Dream Big (and Wild)!  We all are faced with problems in our healthcare organizations, and while sometimes the answer is a small improvement in what we do, in other cases we truly need to innovate - to rethink how we do everything and at that time it's important to come up with wild and crazy ideas which can really make a difference.  Don't worry, there will be time later to mix in reality and pragmatism - but in brainstorming, don't be afraid to dream big!  

Finally, it's important to understand that we don't expect readers to follow the exact "recipes" in the book, but rather to be inspired and educated to innovate themselves!  Ideally, you will see what others have done and find the "essential innovation" in each story and be able to apply that to your organization.  It is truly meant to serve as both an educational platform for stimulating ideas in any organization, as well as an inspirational read to help you realize that you too can innovate.  Whether you are a CEO, a CIO, a department head, a clinic manager, a physician, a nurse, an empowered patient, an EHR vendor, an HIT consultant, or anyone else involved in the healthcare system, we hope this book helps you in your quest for The Healing Edge!

Reviews, Editorials, Interviews, Webinars...

Tuesday, January 29, 2013

In Defense of Copy-Forward!

The wonderful folks at HISTalk posted my thoughts "In Defense of Copy Forward" this week (full text below), and as usual - I've had additional thoughts on it... especially when one of my CMIO colleagues said that their auditing folks were actually asking him to look into plagiarism software!   Here was my response to that, as well as some ideas on how we might address the ugly side of Copy Forward (especially on the inpatient side):

Folks - our role as CMIOs is often to serve as the bridge between real-world clinicians and pie-in-the-sky (or at least non-clinically oriented) legal/admin/executives/IT/politicians, etc…   And one of our chief responsibilities is thus to bring everyone back to common sense when hysteria starts to set in.

So please, everyone take a breath - and repeat, "If I am asked to review plagiarism software for my organization, I will tell them they are off their freakin' rocker"… and make them write it down 100 times.   Or maybe I will make a deal, if we use it on medical records, then we can also use it on all their legal documents, managed care contracts, annual reports, etc... again, let's just use common sense!   We are supposed to be using standardized format and structure… so it is expected that notes should be 60-90% similar from visit to visit, or day to day in the hospital.   On the other hand, I know it can get bad - especially on the inpatient side, especially in an AMC where residents, students, fellows and attending are all writing notes!

So what can we do?  Telling docs to not use a key functionality doesn't make sense and is very much the "bad apple" approach of punishing everyone because a few abuse the system.  We need to think about big picture innovations we can do to improve the system for everyone.  I think there are two core issues we need to figure out:
(1) Multiple authors:  For this issue, I'd suggest rethinking how notes are created, and consider a multi-contributed note… similar to a Wiki, but would need to meet the legal standards.   I believe some EMR vendors are exploring the concept of a multi-contributed note, and I do think there is some balance here in making it both easy to use and higher quality than what we currently do… which is often like a mid-1990s version of MS Word.
(2) Poorly trained providers:  I'd put this issue on all of us (GME, Informatics, Clinicians)… I think we have not done nearly as good a job as we should in understanding how to document and then explaining that to those we teach.  And we certainly have not made them feel very responsible.  I think one way to "monitor/measure" this would be to have random chart audits looking for these type of issues, and present them in an "Morbidity & Mortality" style format that will make providers take documentation a bit more seriously… hmm, I actually like that idea!   I hope someone does this and will let me know what happens!

Full text of the original blog:
I’m part of the Association of Medical Directors of Clinical Information Systems (AMDIS), a group of 2,000+ physicians who are the experts in implementing and using EMRs. We have a pretty lively listserv discussion board, and I enjoy seeing what my colleagues are thinking, as well as posting my own thoughts. I especially enjoy posting when I feel like certain studies or comments by non-clinical researchers, administrators, or politicians make us start to question common sense.
One of my favorite topics recently came up — the fear and horror associated with actually reusing some of a previous note. This usually falls into the concept of "Copy-Forward" (when you copy forward the whole note and then edit for today’s visit), or "Copy-Paste" (when you select certain parts of a past note and just copy that part of it. I posted my reply and thought I’d share and expand a bit.
So as not to bury the lead, I think Copy-Forward of a note is a great tool and supports both efficiency and quality, when used appropriately. Turning it off is a classic throwing the baby out with the bathwater analogy. To clarify my biases, my thoughts and ideas are mainly from the perspective of an outpatient physician using Copy-Forward over the past decade, but much of this certainly can be applied to the inpatient world in various ways.
Also, the use of Copy-Paste has some similarities to Copy-Forward, but I agree Copy-Paste is not nearly as efficient and poses more quality issues since it does not have the automatic updating features you might see with Copy-Forward. Here are the points I would suggest we consider.
First, I am sick of these reports which say that things like, "We used plagiarism software to show that 60-80 percent of a doctor’s note is the same as their last one." Um, of course! Since when did progress notes become creative writing endeavors about coming up with different ways to document diabetes, hypertension, and obesity in the same patient visit after visit?
The creative parts of doctoring should involve being "House": figuring out the diagnosis, figuring out the best treatment plan, and artfully explaining it all to the patient. It should not be writing Edgar Allen Poe-like short stories to amuse our auditors or confuse our colleagues. Although, it could be fun, hmmm… what if I described a diabetic’s problems with hypoglycemia in Poe’s style: "Arousing from the most profound of slumbers (due to a glucose of 45), the patient states he feels as if he was in a gossamer web of some dream. Yet in a second afterward, so frail may that web have been, he claims to not remember that which he was dreaming."
Second, there are obvious efficiency benefits to Copy-Forward, but there are very real quality benefits as well. The most obvious is that this type of workflow makes it less likely that important diagnoses will be missed or forgotten over time. Additionally, many systems update certain pieces of data during the Copy-Forward process, so that you can see the most recent results (discussed more below). Obviously incorrect information can be duplicated, especially when a note is being authored by multiple providers over time, but this is where good training and leadership are needed to ensure every provider feels fully responsible for everything in their notes.
Third, getting rid of Copy-Forward or even Copy-Paste is certainly overkill, but we do need to use some common sense in designing technology, workflows, and processes that make it easy to do the right thing when documenting. In the ideal system, much of the critical data would either be updated automatically (e.g. the most recent lab would appear when a note is copied forward), or the system would date entries so it is clear what was done in the past versus today. To clarify, let me break down how an ideal progress note might look like when Copy-Forward is used:
Allergies, Meds, Problems 
These update automatically, which is great, and means the note has the most recent data. I would hope all EMRs have this functionality already.
Past Histories (Social, Surgical, Family) 
These copy forward and allow for easy editing in the note. Ideally, they could be managed in a widget external to the note and have them update from those profiles as well.
Physical Exam 
Want to ideally be able to view old physical exams, and even reuse them when desired (except for vitals). In my current system, the full exam (sans vitals) does copy forward. So I usually just delete it and drop in a new macro and edit that. However, some patients have findings I want to compare from last time (e.g. size of a rash), or consistent findings (e.g. murmur) which I want to be reminded about
For labs (e.g. CBC, chem, chol profile) and certain studies (e.g. mammogram results, last ECG), we use macros which "auto-updatem" so when a note is copied forward, they update automatically to the most recent dates and values.
As some have heard me detail before, I use a form of "problem-oriented charting" in which I type out the history, impression, and plan for a diagnosis (e.g. diabetes) or system/problem area (e.g. "GI issues") all on one line. I also use a macro which includes the date of the entry and my initials.
  • Example for a diabetic patient. "01/19/13(LLB): Stable on Metformin 500bid, CS 100-120s before meals, no med side effects or other complaints. Impr: Stable DM, PLAN: CPM, labs, rtc 4 mos". No flourish is needed. The result is that when copied forward I can see the last time I addressed the DM and if I made any changes. In the same "area" for the problem, I would also have a list of relevant meds, labs, and testing results (e.g. ECGs and ECHOs for hypertension). This way I can see everything I need about a problem all in one place – which means I can make quicker and more accurate decisions.
  • Summarizing old entries over time. I will either retain the old entry, or can summarize over time (e.g. I might take four entries from 2012 and summarize into one line such as, "2012: Dx with DM 4/12, added Metformin 500qd, 6/12 incr to 500 bid and did well").
  • Multiple issues. Since I often address multiple issues in a given visit, I created a line which reads, "Problems below not addressed this visit" so that I can clearly demarcate what I did and did not address on a certain day. I think this method is extremely efficient and higher quality than the method of trying to document all the HPI about multiple issues at the top of a note, and then separating out the Impr/Plan at the bottom.
  • What is a SOAP note? Larry Weed, MD devised the concept of problem-oriented charting 50 years ago, but I think it’s fair to say we have over-complicated it over time. The SOAP note is supposed to be based around a problem. In other words, each problem should have a documentation area for Subjective, Objective, Assessment and Plan. Instead, we create one large SOAP note where we break away all the Subjectives into their own paragraph ("HPI"), thereby distancing your thinking about the complaint and what we are going to do about it. I hope we will soon see more EMRs going "back to the future" by embracing the true problem oriented charting philosophy.
Fourth, the outpatient world is different from inpatient, but there are similarities. I understand that inpatient notes can be more difficult to manage due to quickly changing problems, and especially multiple authors. Personally, I hope we put some more thought into the concept of an "Inpatient Wiki," a single type of inpatient note that can automatically pull in the relevant information for each specialty (e.g. different for medicine, OB, and various types of surgery). Then each author could see what they need to see – it would pull in the labs, tests, consult suggestions, or a nursing note – why make the doctor repeat this themselves every time?
The care provider would then be prompted to write what they are supposed to add, and the note would be a living document which flexes to the individual, but can be time-stamped for medico-legal purposes as well. It could have clear sections (similar to above), as well as an organ or system based areas (e.g. Cardiology issues, GI Issues, Neuro Issues, F/E/N issues) for documenting the SOAP note .
In summary, I would go as far as to say that we need to change our paradigm to "The Note is the Chart." The chart should no longer be a collection of distinct and incomplete notes, but rather the last note can really be the complete chart which contains everything a provider needs. If we do this, then we can reframe our expected workflow from, "You need to read every note ever written to understand the full patient" to, "You just need to read the last note".
The result: when a patient goes to the ER or sees another doc, those providers will find that the most recent note in the system will have all the info they need, so they won’t need to try and dig through 48 notes over 10 years (and let’s face it, they never do that anyway). Granted, the paper record allowed for a much easier way to flip thru past notes, but sooner or later we have to acknowledge that computerized systems have different attributes than paper. We can either keep trying to force the computer to act like paper, which never works out well, or we can start embracing the differences and truly take advantage of them.

Sunday, January 06, 2013

We Don’t Have a Shortage of PCPs, We Have a Shortage of Using Them Efficiently

I've been asked to serve as the "Innovator-at-Large" (aka Editor-at-Large) for the magazine "Clinical Innovation and Technology"... which I was happy to accept as it's the perfect intersection of my worlds!.   In my first post, I've expanded on a phrase I've been using for several years - that "We Don’t Have a Shortage of PCPs, We Have a Shortage of Using Them Efficiently".   I go on to describe the future of healthcare in a world where innovation and IT are being used to their potential to make life easier for physicians and better for patients (of course assuming our reimbursement system equally evolves).  I hope it inspires you!

We Don’t Have a Shortage of PCPs, We Have a Shortage of Using Them Efficiently

Every few months another study warns of a severe shortage of primary care physicians (PCPs) in the future. A recent report published in the Annals of Family Medicine explained how we will require 52,000 more PCPs by 2025 due to population growth, aging demographics and insurance expansion (Reference: 1. Ann Fam Med  2012;10(6):503-509).

Fortunately, both clinical IT and innovation will deeply change medicine over the next decade, resulting in a new paradigm with the potential to improve both efficiency and quality of care. In this paradigm, software will be able to automate or delegate much of the routine care usually provided by physicians. If automated systems and empowered staff members manage stable patients according to evidence-based protocols, physicians can focus on more complex patients who truly require their attention. Individual physicians will actually see fewer patients, but oversee a team who will care for more patients. Thus, we won’t need more physicians; we will just need a better system to help most appropriately leverage physicians, staff and IT.

A typical physician’s office in 2025 might look something like this: Dr. Blake Willoca arrives around 9a.m. and sits in front of a bank of computers and video screens. Dashboards provide real-time analysis of the status of his panel of 5,000 patients. Patients in the Green Zone will be managed mainly by computerized systems which check on patients virtually to provide positive feedback and ensure they stay on track. Meanwhile, patients in the Yellow Zone will be visited by the physician’s care team at home or work, or perhaps have a virtual conference with the physician to answer their questions. Finally, those patients in the Red Zone will be seen in the office or home for longer sessions with the physician and his or her care team to help determine what is going on and how to get it under control. Today, Dr. Willoca will spend an hour with each of these four Red Zone patients in his office, he will do five-minute video conferences with staff members taking care of 20 Yellow Zone patients, and he will spend some time in a virtual reality game teaching med students about how this new system works. As Dr. Willoca leaves his office at 5p.m., he knows he’s helped the patients who most needed it today in a relaxed and livable manner, and he knows that his IT tools and care teams will continue to monitor and help manage his patients 24 hours a day.   

This might all seem like a PCP’s dream, but we need to recognize and accept that we are the generation who will make this happen. There is much to do in healthcare, and there could not be two greater tools to use than clinical innovation and IT.

Online at

As questions come up on this article and topic, I'll make sure to post answers here.

* Barriers: Someone asked why we don't see more of this type of attitude from doctors?  My answer: I think there are two main barriers we need to overcome to increase the spread of this type of "team-based CDS" which automates and delegates clinical work:  First, we need to continue to better align incentives (i.e. Value-based vs. Volume-based reimbursement and legal systems)... How can we expect doctors to delegate work if they are not protected financially or legally from doing just that?  Second, we need to make CDS easy and intuitive to use and ideally integrate them fully and elegantly into our EMR systems (see examples below of companies working on these types of tools).

* Speed: Someone asked why this can't happen sooner (i.e. why did I say 2025 instead of 2015).  It's a good point, as I think it is technically feasible today.  I used 2025 because (1) It was the year used in the article I initially quoted about MD deficits, and (2) I did want to describe a future world where this vision of team-based care and HIT would be completely common and routine, not simply possible.  I think there are financial and legal issues which will slow it down, but I also think that we will be seeing more and more of this happening in the near term as well - just not as widespread and pervasive as we'd like for another 10 years or so.

* Risk Stratification: Someone asked how many patients would fall into the Green/Yellow/Red zones.  Studies have shown that 1% of the population accounts for 20 - 30% of the cost, and 5% account for 50%, whereas the healthiest 50% account for just 3% of the total cost.   So I'd suggest the "Red Zone" is about 5% (e.g. 250 patients in a panel size of 5000), the Yellow Zone would be around 20% (1000 in a panel size of 5000), and then the other 75% in the green zone.  Using another way to measure it, today's typical panel size is 2500, which requires a PCP to see about 25 of these patients in a given day.  If the panel size were 5000, the old system would require them to see 50 patients a day.  In the "new" system, I'd suggest they will need to see about 5 "Red Zone" patients a day in the office while interacting with another 20 "Yellow Zone" patients (or answer questions for their staff members) - which could take anywhere between 1-5 minutes.   The reason that this number stays relatively high is that the Red and Yellow patients do need to be actively managed on an ongoing basis - some will eventually move into Green territory, but others simply have too many interacting or unique problems and medications which are beyond the scope of even advanced protocols and is where the cognitive skills of physicians will shine.  Of course, when artificial intelligence gets good enough to figure all these things and how to communicate it all to patients - then we may see even more automation in healthcare... but if/when computers have gotten that good - we will likely see automation in every other professional career as well - from lawyers and judges, to politicians and marketers, to stockbrokers and Venture Capitalists.  In other words, while I agree with Vinod Khosla's assessment that we will see HIT further automating healthcare... I don't think it will "replace 80% of doctors" - but it will allow us to effectively leverage the current amounts of physicians.

Companies Making "Physician Efficiency Apps" (or "Doctor Happiness Tools" as I like to call them)
* healthfinch: A cloud-based decision support system which integrates with EMRs to automate and delegate repeatable work away from physicians and towards their staff in a safe and consistent manner (e.g. Medication Refills).  I founded this company in 2011 with two very smart HIT experts focused on human-centered design, and have mentioned in some past blogs about "Saving Primary Care with Team-based Delegation Software" and another about "EMR Extender Tools creating Doctor Happiness".  The first product, RefillWizard, which integrates with some of the main outpatient EMRs to help decrease the amount of time doctors must spend approving medication renewal requests, saving them up to 30 minutes daily. If we apply that 30 minutes of savings to the 400,000 primary care physicians in the US, we can effectively "create" 25,000 new physicians—half the expected shortfall in physicians caused by population growth, aging demographics and insurance expansion!  Now just create a few more of these and we save the healthcare system!
* healthloop: Automates the "follow-up" process to check on patients after their in-person visits.  Founded by Dr. Jordan Shlain, another of the rare but growing breed of working PCPs who understands how HIT can help make life easier for docs and patients and is building tools to fulfill that vision.

Other Relevant Articles
Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication, Health Affairs, Jan, 2013 (vol. 32, no 1): 11-19.   Says that there will not be a doctor shortage as long as we optimally utilize team-based care and HIT.
Estimating a reasonable patient panel size for primary care physicians with team-based task delegation.  Altschuler J, Margolius D, Bodenheimer T, Grumbach K. Ann Fam Med. 2012 Sep-Oct;10(5): 396-400. doi: 10.1370/afm.1400.  Estimates how much care can be delegated in a team-based model, and thus what an optimal panel size could be to do perfect care.
* Project Doc Shortage is Real, Experts Say.  Modern Healthcare, Jan, 2012.   Discusses that while team-based care and HIT will improve efficiency, we will still have some need for more PCPs - especially in underserved areas.
* Doctor Shortage Getting Worse.  A CNBC article (Mar 13, 2013) where they use the usual claims (again, based on the current model of care) and I appear to be the "poster doc" for the concept of using IT to improve efficiency and save time.  My section: And one expert says it's not so much a scarcity of physicians but of using them in the right way.  "We don't need more physicians, but rather better "team-based workflow tools" to ensure that everyone on the team can work to the highest level of their ability in a safe and efficient manner every day," said Dr. Lyle Berkowitz, Associate Chief Medical Officer of Innovation for Northwestern Memorial Hospital.  "That means using information technology and freeing physicians to spend their time on more complex patients," Berkowitz added.