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
Sunday, August 16, 2009
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.
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":
http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10741_876940_0_0_18/Meaningful%20Use%20Matrix%2007162009.pdf
Some of the clarifications they note:
1 The HIT Policy Committee recommends that incentives be paid according to an “adoption year” timeframe rather than a calendar year timeframe. Under this scenario, qualifying for the first-year incentive payment would be assessed using the “2011 Measures.” The payment rate and phaseout of payments would follow the calendar dates in the statute, but qualifying for incentives would use the “adoption-year” approach. [Extra info: a ppt slide clarifies latest year to start adoption is 2014, and in that case, max amount of incentive would be $24,000 rather than $44,000].
2 CPOE requires computer-based entry by providers of orders (medication, laboratory, procedure, diagnostic imaging, immunization, referral) but electronic interfaces to receiving entities are not required in 2011
3 Race and ethnicity codes should follow federal guidelines (see Census Bureau)
Things I like
- Implement one clinical decision rule relevant to high clinical priority: That provides value, is realistic with most EMRs, and ideally "gets the ball rolling". Of course, this depends on what they allow as a "clinical decision rule"
Things that worry me:
- Provide patient access to electronic health information: very few EMRs do that now, and yet they moved it up to 2011 ("Year One" measures) - that seems to be wishful thinking.
- % of all medications entered into EHR as generic, when generic options exist in the relevant drug class: I have no idea how one would measure that, and furthermore- it is not very realistic. For example, I presribe a lot of meds with their brand name, but check off "may substitute" - so the patient can make the final choice as to whether they want the generic. Also, to be honest- it's a lot easier to manage a med list made up of brnad names than generic ones!
- Does ePrescribing mean prescriptions transmitted electronically?: I continue to be baffled as to whether this will truly be a requirement as compared to just creating the Rx via an EMR. Specifically, if I create a prescription online (which implies it is electronic and I do get clinical decision support/alerts) and then print it for the patient - shouldn't that be good enough at least to start with? Why insiste that I also have to send it via EDI to a pharmacy - especially in a world where patients don't always know where they want it sent, and not all pharmacies support this process yet. I do some occasional eRx transmittals, and I've gotten upset calls from some patients because the pharmacy truly does not understand the concept (usually, they have the IT, they don't have the training).
_______________
Link to full text of HITECH bill:
http://www.opencongress.org/bill/111-s350/text
http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10741_876940_0_0_18/Meaningful%20Use%20Matrix%2007162009.pdf
Some of the clarifications they note:
1 The HIT Policy Committee recommends that incentives be paid according to an “adoption year” timeframe rather than a calendar year timeframe. Under this scenario, qualifying for the first-year incentive payment would be assessed using the “2011 Measures.” The payment rate and phaseout of payments would follow the calendar dates in the statute, but qualifying for incentives would use the “adoption-year” approach. [Extra info: a ppt slide clarifies latest year to start adoption is 2014, and in that case, max amount of incentive would be $24,000 rather than $44,000].
2 CPOE requires computer-based entry by providers of orders (medication, laboratory, procedure, diagnostic imaging, immunization, referral) but electronic interfaces to receiving entities are not required in 2011
3 Race and ethnicity codes should follow federal guidelines (see Census Bureau)
Things I like
- Implement one clinical decision rule relevant to high clinical priority: That provides value, is realistic with most EMRs, and ideally "gets the ball rolling". Of course, this depends on what they allow as a "clinical decision rule"
Things that worry me:
- Provide patient access to electronic health information: very few EMRs do that now, and yet they moved it up to 2011 ("Year One" measures) - that seems to be wishful thinking.
- % of all medications entered into EHR as generic, when generic options exist in the relevant drug class: I have no idea how one would measure that, and furthermore- it is not very realistic. For example, I presribe a lot of meds with their brand name, but check off "may substitute" - so the patient can make the final choice as to whether they want the generic. Also, to be honest- it's a lot easier to manage a med list made up of brnad names than generic ones!
- Does ePrescribing mean prescriptions transmitted electronically?: I continue to be baffled as to whether this will truly be a requirement as compared to just creating the Rx via an EMR. Specifically, if I create a prescription online (which implies it is electronic and I do get clinical decision support/alerts) and then print it for the patient - shouldn't that be good enough at least to start with? Why insiste that I also have to send it via EDI to a pharmacy - especially in a world where patients don't always know where they want it sent, and not all pharmacies support this process yet. I do some occasional eRx transmittals, and I've gotten upset calls from some patients because the pharmacy truly does not understand the concept (usually, they have the IT, they don't have the training).
_______________
Link to full text of HITECH bill:
http://www.opencongress.org/bill/111-s350/text
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?
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 meaningfuluse@hhs.gov, with the subject line "Meaningful Use."
My initial thoughts were that the objectives were much too specific - they were defining the "means", not the "ends". However, with input from others, I then understood the gold is in the column titled "measures" - that is actually what will be defining whether someone gets their incentive bonus. At a high, strategic level- those seem closer to "ends" rather than "means" - which is satisfying since it allows for much more creativity and innovation in getting to those means.
On the other hand, I am not saying that they can all be done without many of the objectives- but hey, that is part of the cool thing about innovation – we don’t know yet what new ideas and technologies might pop up to better solve these problems. For example, instead of a doctor maintaining a med list at the point of care, perhaps a Data Warehouse collects all the billing codes, lab results, and meds from the pharmacies – and then uses some artificial intelligence to auto-create a problem list which can be used to create registries. In fact, that might be more accurate than relying on physician entered problem lists that are often pretty poor. In other words, there has to be some access somewhere to electronic data to make this work, but it does not all have to be physician entered into a single EMR…
So now we can dig into the details and ask some obvious questions:
- Are these the best measures, some are easily defined (eg % diabetics with HbA1C), but others do not have metrics captured in such an objective fashion (eg % smokers offered smoking cessation).
- We need more details about the format of these reports, and how we report them
- Will the government require all of them, or just a limited amount of the reports listed (similar to PQRS in which we only have to report 3 from a larger list).
I'll also make one suggestion - to include the concept of physician to physician messaging, both within an EMR, and across EMRs. I think that may be as or more important than sharing things like medication lists! But I did not see anything in any column in any year that talked about this really important functionality… they talked about access to shared data, but not about ability to send messages to doctors within your direct organization, or within your greater organization. I realize this may be looked at as more of a functionality, and thus contradicts my aversion to focusing on the “means” – but I hope somehow this is included.
Finally, the CCHIT folks have stated they will expand their defintions of certified EHR technologies- which is a good thing (assuming they set the standard to be used by HITECH). The result is that a variety of innovative approaches can then be taken to achieve meaningful use: Some docs will use a full functioning unified EMR, others might use a home grown system that patches together multiple components, and still others might just use HIT on the backend to reach the majority of the metrics required. In other words, it will be interesting to see how many of the measures could be achieved without requiring a physician to touch a keyboard at all (eg no data input). If we can accomplish that - then we may get both significant and meaninful use!
The HIT Policy Committee will accept public comment through June 26 on the just-released draft description of "meaningful use" of electronic health records. Comments should not exceed 2,000 words in length. Electronic comments are preferred and should be addressed to meaningfuluse@hhs.gov, with the subject line "Meaningful Use."
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:
http://www.histalkpractice.com/2009/06/16/drlyles-thoughts-on-the-presidents-ama-speech-61609
My ending comments were as follows:
I agree with President Obama - we can do better. It is quite clear that our current system is simply not sustainable long term, nor is it a “fair” system due to its inability to provide access to all Americans. So I hope we will be able to tell our children in ten years that we were part of the movement which allowed us to become a nation where we can provide the best healthcare to all Americans in the most convenient and cost-effective way possible. It is right financially, it is right morally, and it is right clinically. Now Mr. President, just make sure those words move into action.
I also responded to a comment about the concern around non-compliant patients:
My best comment is that there is no single answer, but if we create the RIGHT INCENTIVES - then let the market and providers be creative and innovative in figuring out how to deal most efficiently with both the doctors/patients who want to work together, as well as those who don’t. America has always been built on that concept - and it can be a double edged sword since the reimbursement system has to be well balanced for quality and cost, but I think we are much closer in a setting where we get “care coordination” PMPM fees vs. simple FFS fees.
...with the right incentives in place - it will be very interesting to see what people come up with - I still remember hearing about the pre-natal clinic which gave away lottery tickets to get all the economically disadvantaged mothers to come into the clinic - it worked well and created an enormous ROI by decreasing pre-term births. Hmmm… maybe that is the answer for the rest of America - see your doctor, be compliant, and get a national lottery ticket!
My full article was posted at the HISTalk site:
http://www.histalkpractice.com/2009/06/16/drlyles-thoughts-on-the-presidents-ama-speech-61609
My ending comments were as follows:
I agree with President Obama - we can do better. It is quite clear that our current system is simply not sustainable long term, nor is it a “fair” system due to its inability to provide access to all Americans. So I hope we will be able to tell our children in ten years that we were part of the movement which allowed us to become a nation where we can provide the best healthcare to all Americans in the most convenient and cost-effective way possible. It is right financially, it is right morally, and it is right clinically. Now Mr. President, just make sure those words move into action.
I also responded to a comment about the concern around non-compliant patients:
My best comment is that there is no single answer, but if we create the RIGHT INCENTIVES - then let the market and providers be creative and innovative in figuring out how to deal most efficiently with both the doctors/patients who want to work together, as well as those who don’t. America has always been built on that concept - and it can be a double edged sword since the reimbursement system has to be well balanced for quality and cost, but I think we are much closer in a setting where we get “care coordination” PMPM fees vs. simple FFS fees.
...with the right incentives in place - it will be very interesting to see what people come up with - I still remember hearing about the pre-natal clinic which gave away lottery tickets to get all the economically disadvantaged mothers to come into the clinic - it worked well and created an enormous ROI by decreasing pre-term births. Hmmm… maybe that is the answer for the rest of America - see your doctor, be compliant, and get a national lottery ticket!
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.
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:
http://www.americanprogress.org/issues/2009/05/health_it.html
Peter said the publishers of the paper, the Center for American Progress, will use this in their discussions with key Congressional staff, to attempt to have payment reform made part of the fabric of upcoming healthcare reform. I certainly hope this has some influence- I agree that if HITECH wants to use $36 billion to promote EMRs… it is much better off using that money to update our failed volume based reimbursement system to promote quality and efficiency, as compared to giving the money to doctors to simply use EMRs of dubious effectiveness. Pay us to change and improve our systems – and let us figure out the best way to do it…
And most importantly, make this a long-term reimbursement change – not a one time “bonus”.
Also, let’s start more consistently using the $36 billion amount rather than the $19 billion amount – as the $19 billion is actually what the govt considers “total cost” – they plan to give $36 billion in incentives, but they assume there will be $17 billion in money saved, so the total cost to the govt is “only” $19 billion – let’s ride with it!
http://www.americanprogress.org/issues/2009/05/health_it.html
Peter said the publishers of the paper, the Center for American Progress, will use this in their discussions with key Congressional staff, to attempt to have payment reform made part of the fabric of upcoming healthcare reform. I certainly hope this has some influence- I agree that if HITECH wants to use $36 billion to promote EMRs… it is much better off using that money to update our failed volume based reimbursement system to promote quality and efficiency, as compared to giving the money to doctors to simply use EMRs of dubious effectiveness. Pay us to change and improve our systems – and let us figure out the best way to do it…
And most importantly, make this a long-term reimbursement change – not a one time “bonus”.
Also, let’s start more consistently using the $36 billion amount rather than the $19 billion amount – as the $19 billion is actually what the govt considers “total cost” – they plan to give $36 billion in incentives, but they assume there will be $17 billion in money saved, so the total cost to the govt is “only” $19 billion – let’s ride with it!
Tuesday, May 12, 2009
MeaningfulUse.org
"May 12, 2009--Compuware Corporation (NASDAQ: CPWR) and the Association of Medical Directors of Information Systems (AMDIS) today announced that they have joined forces to launch www.meaningfuluse.org. This collaborative web site will promote and advance the national dialogue and education around “meaningful use.” The new site gives the healthcare information technology (HIT) community a single, central location to access resources, collaborate, influence and discuss the definition of “meaningful use” and to learn how to take advantage of the HITECH Stimulus funds."
There may not be two more important words in the english language right now. How they are defined will affect if/how EMRs are fully adopted and whether they are used in a way that truly makes a difference... In other words, the very fate of our healthcare system may rely on how this is defined in the weeks and months ahead.
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!
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.
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
NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS
EXECUTIVE SUBCOMMITTEE
Hearing on "Meaninful Use" of Health Information Technology
April 28 - 29, 2009
http://www.ncvhs.hhs.gov/090428ag.htm
This is really an important time for EMR vendors and users... starting to define "Meaningful Use" - there will be immediate implications for the HITECH bill, but even more resounding implications for the future of EMRs in so many ways. My fear is that they focus on adoption of certain technologies and workflows (e.g. "Physicians must personally use electronic prescribing"). My hope is they focus on realistic outcomes (e.g. risk adjusted ER visits, hospitalizations, and specialty visits; and/or standard metrics like preventive care guidelines, lab results, etc...).
I don't think we need to mandate physicians directly using EMRs, we need to reward effective use of systems that improve quality in whatever manner works. This will invariably mean use of IT, but it can be in many different ways. Keep the eye on the outcomes, not the means...
EXECUTIVE SUBCOMMITTEE
Hearing on "Meaninful Use" of Health Information Technology
April 28 - 29, 2009
http://www.ncvhs.hhs.gov/090428ag.htm
This is really an important time for EMR vendors and users... starting to define "Meaningful Use" - there will be immediate implications for the HITECH bill, but even more resounding implications for the future of EMRs in so many ways. My fear is that they focus on adoption of certain technologies and workflows (e.g. "Physicians must personally use electronic prescribing"). My hope is they focus on realistic outcomes (e.g. risk adjusted ER visits, hospitalizations, and specialty visits; and/or standard metrics like preventive care guidelines, lab results, etc...).
I don't think we need to mandate physicians directly using EMRs, we need to reward effective use of systems that improve quality in whatever manner works. This will invariably mean use of IT, but it can be in many different ways. Keep the eye on the outcomes, not the means...
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 (http://www.theshiphome.org/).
I think this topic of Physician Adoption of EMRs is particularly relevent due to the recent Health Information Technology for Economic and Clinical Health Act (HITECH) bill for funding "meaningful use" of EMRs in an environment which has not yet seen much adoption, as evidenced by a Fall, 2008 NEJM article which found just 4% of US doctors using a "fully functional" EMR in the outpatient environment, and only 15% using a "basic one" (NEJM, July, 2008: Electronic Health Records in Ambulatory Care — A National Survey of Physicians).
So while adoption has many mothers, I'm going to suggest we are wise to focus on the "Three I's" to understand how to improve adoption:
(1) Interoperability: What a bugaboo. While many say that we don't have enough, I'd actually argue that we are so obsessed with this issue that we are losing the forest for the trees. In other words, let's get doctors using systems first, and worry about interoperability later. I realize that is a bit heretical, but the truth is that the majority of healthcare is local - and what we really care about is making sure that our EMR interfaces with our local PM system, lab, Xray facility, etc... rather than worrying about some regional or national sharing. The latter is still important, and there are always great anectdotes about having access to an ECG when on vacation, but let's start shifting some of the interoperability obsession to usability obsession (which I understand CCHIT is doing - and I approve!). Meanwhile - tell your patients (at least the sick ones) to keep a piece of paper in their wallet with: allergies, meds, problems, the names of their doctors and perhaps a copy of their ECG. I guarantee that one of the first thing paramedics do is go through someone's wallet or purse to look for this type of info.
(2) Incentives: No surprises here - we all know a system gets what it is designed to get, and right now, our healthcare system reimburses based on volume over value, and quantity over quality... and the former is pretty much what it gets. So clearly we need to create a reimbursement system that rewards physicians for value and quality... and if they achieve these things, they should get those rewards whether they use EMRs or not (but I suspect it will be easier to do this with EMRs than without). I think the HITECH bill is a positive step and truly a "stimulus", but we still need to figure out how to improve long term, day to day reimbursement to make sure doctors are rewarded for doing the right thing.
(3) Interface ("User interface" or "Usability"): This third point has always held great interest for me, since I have often had to use the systems I build. So I feel the pain when it takes 25 clicks to refill a med because EMR vendors still don't seem to understand that for me to refill a med, there is a ton of contextual data needed. For example, I need to know: what I was thinking at the last appointment (e.g. did I tell the patient to return in 3 months, and it has now been 5 months without a return), do they have an upcoming appointment, did the labs from the last visit alter my thinking on their follow-up, or has anything happened in the interval. In a typical EMR, I need to click all over the place to find this information - how come it can't just bring it all to me (answer- technically it is possible, but the EMR vendors just don't seem to get it).
This idea that the EMR needs to pull together and present "what we need to know and what we can do" is a recurring theme in my diatribe on Usability - the screen shots for specific workflows (e.g. med refill, lab review, phone message, office visit) should consolidate all the information I would likely need to review to complete that workflow (e.g. meds, labs, visit dates, notes) - ideally in a manner that is easy and quick to read: "Data visualization" may include graphics or other data manipulation (e.g. calculate the anion gap, or the Total/HDL values for me). Furthermore, the EMR should predict what I might want to do next and offer up those options to me (e.g. refill a med, order another potassium test, etc...). The result is LESS CLICKS - I don't need to go looking everywhere for data or orders- the EMR has brought them to me!!!
I talked in depth on this topic at the recent HIMSS conference and hired several graphic designers to actually build out some of these concepts as either screen shots or flash animation - these are by no means perfect, but they give some sense of interfaces that take advantage of how an EMR can make workflows easier. They will hopefully stimulate more thought and ideas in this area. The PPT below provides a summary of this talk (although I could not figure out how to upload the flash applications - so it will all be static screen shot here). I used SlideShare to upload the PPT and embed into Blogger:
Post-Blog stories of interest
Wired magazine "re-imagines" lab reports: http://www.wired.com/magazine/2010/11/ff_bloodwork/all/1
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: http://www.wired.com/magazine/2010/11/ff_bloodwork/all/1
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!
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