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!]

View Online at: http://www.healthleadersmedia.com/print/TEC-279324/EMR-Apps-Taking-Off-Starting-with-Refill-Requests

And here was a summary from another HIT blogger who picked it up the next day: http://www.hospitalemrandehr.com/2012/04/27/will-next-generation-emrs-be-platform-stack-of-apps/

EMR's and Typewriters: They both have potential

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

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

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

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

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

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

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

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

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

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

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

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