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

Labs/Studies 
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.

HPI/Impression/Plan 
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.

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 http://www.clinical-innovation.com/topics/practice-management/we-don%E2%80%99t-have-shortage-pcps-we-have-shortage-using-them-efficiently

ADDENDUM
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.

* What Doctor Shortage?  Published in Medical Economics (Jan, 2023) - I revisited this topic 10 years after the original post and talk more about the execution of expanding panel size via a combination of technology and virtual team-based care.  This is playing out in real life with my new company  KeyCare (where we provide health systems access to a tech-enabled virtual care workforce practicing on an Epic platform optimized for telehealth).

Saving Primary Care: Team-Based Delegation Software may be our Best Chance!

This new article by Bodenheimer, et al. points out that our current system (making docs do everything) is absolutely not sustainable.  So what can we do?  It turns out the critical solution to make our system sustainable is to start delegating certain activities to the physician's team using protocols!  

But now I'll ask the more tactical question - does anyone expect us to use paper based protocols???  We all know those are hard to maintain and no one actually looks at them.  So what if there was a new type of healthcare IT software which could hold all these protocols in "the cloud", and then apply them against the data stored in EMRs, and then send back specific messages into the EMR - pushing the right information to the right person on the team.  In other words, automating the process so everyone works "to the height of their license".

Is there an app for that?   YEP!! I've been working with the great team at healthfinch the past two years to develop this type of "Team-based Delegation Software" which uses a cloud-based protocol system (all protocols are held and edited in the cloud) integrated with a variety of EMRs to produce a "team-based decision support and workflow tool" that saves physicians time, while also ensuring high quality care is delivered in a consistent and documented way by their team.  

We have RefillWizard for medication renewal requests (this alone saves docs 30 minutes a day)… and we plan to keep making more on the electronic delegation platform that has been developed. We seem to be in the RIGHT space at the RIGHT time! :)

For more info, here is a summary of the Bodenheimer article from a Medical Economics story:

Study: PCPs must delegate some preventive, chronic care

Publish date: Oct 25, 2012

There is one primary care physician per 1,500 Americans, yet most PCPs have panel sizes in excess of 2,000 patients. With no surge in PCP numbers expected anytime soon, a new report suggests a shift from physician-based care to team-based care, with PCPs delegating up to 77% of preventive services to non-clinicians.

“Our nation will need to implement models that reengineer the delivery of primary care and deploy our physician supply in a more efficient manner,” say researchers from the University of California at San Francisco in a new paper titled, “Estimating a Reasonable Patient Panel Size for Primary Care Physicians with Team-Based Task Delegation.” The paper was published in the Annals of Family Medicine in the September/October 2012 issue.

The average PCPs panel size is too large to deliver consistently high quality care, according to the report. Researchers estimated that it would take a PCP nearly 22 hours a day to provide all the recommended care for the average 2,300-patient panel. But decreasing PCPs means panel sizes will continue to rise, especially considering about half of all Americans have at least one chronic condition.

The study highlights two alternative practice models that might hold the key to solving this dilemma. The first model is to reduce panel sizes so physicians can provide comprehensive patient care. Concierge medicine, for example, utilizes panel sizes of 200 to 600 patients. However, without enough PCPs to go around using this type of model, the study determines this model would leave many patients without primary care.

The alternative model, the Organized Team Model, advocates building primary care teams that delegate patient care responsibilities among a healthcare team, allowing the physician to practice high-quality care without a large, but manageable panel size. Screening and performing certain tests should be left to the physician, according to the report, but tasks such as administering immunizations could be delegated to non-clinicians—with the clinicians explaining the services to their patients. All routine preventive counseling could be delegated, the report authors note, freeing up too three-quarters of a PCP’s time.

For chronic disease management, the report recommends that PCPs could delegate 75% of the time spent on chronic cases in good control and 33% of the time spent on patients in poor control. Non-clinicians could provide most of the routine chronic services such as patient education, behavior-change counseling, medication adherence counseling and protocol-based services delivered under standing physician orders.

Overall, this model would allow 77% of preventive care and 47% of chronic care to be delegated to non-clinical staff. All acute care would be provided by physicians, the authors note.  The study does not address the additional staff training that would be needed to prepare non-clinicians to handle additional tasks, or the payment reform that would be needed.   

“Such an unprecedented change in both the culture and structure of primary care practice can be accomplished only through a change in clinical mindset, the training on non-clinician team members, the mapping of workflows and tasks, the creation of standing orders that empower non-clinicians to share the care, the education of patients about team-based care, and the reform of primary care payment,” the study authors conclude. 

Why the next wave of health IT innovation will build on EMRs, cater to “physician happiness”

I am always impressed when a reporter can ask a few questions, listen to me talk for 30 minutes, and then assemble it into a great article which really explains my thoughts well... and I am even more amazed when they can do it in 24 hours!  Thanks to reporter Deanna Pogorelc from MedCityNews for doing such a great job - and I love the title too: Why the next wave of health IT innovation will build on EMRs, cater to “physician happiness”... Here it is (with a few bolds and comments in brackets from me):

There’s no shortage of primary physicians, but rather a shortage of primary physicians who are able to use their time efficiently in today’s healthcare environment.  That’s why the industry is moving away from the first version of the EMR, according to Dr. Lyle Berkowitz, the associate chief medical officer of innovation at Northwestern Memorial Hospital and Medical Director of IT & Innovation at for Northwest Memorial Physicians Group in Chicago. 

The inaugural EMRs are basically computerized versions of paper records that weren't necessarily designed with usability in mind, he noted. So rather than saving time and making administrative processes easier, they’re in some cases adding to doctors’ workloads.
[Or as many say - they focused on just documentation and billing, not clinical workflow] 

Enter the next wave of health IT innovators, who are taking EMR data and using it elsewhere to improve workflow. “(EMR vendors) are kind of stuck to Meaningful Use and creating a standardized format to make sure everybody is at the first-base level,” Berkowitz said. “That’s a good start, but we have to start building tools that can fit on top of these. A whole ecosystem is going to build up on top of EMR systems to make them easier and faster to use.”
[Check out the ONC Standards Hub to see how Meaningful Use Part 2 will require all EMR vendors to adhere to certain standards which will make it even easier for 3rd party vendors to work with them]

And, it seems that EMR companies are getting on board with that as well. “They buy into this idea that innovation comes from the outside by saying, we’re going to open up our system and let others build on it,” he said. “AllScripts I think is leadingthe charge. Athenahealth is moving that way, and some others. EMR vendors are going to be end up being able to provide more and more solutions to their users this way.”

EMR extender companies have been around for a while; business intelligence and data analytics are well-established industries. But we’re seeing the dawn of a new category of innovation focused on workflow tools to make doctors more productive and efficient – what Berkowitz calls “physician happiness.”

There’s evidence of that, in the form of companies like Modernizing Medicine, which makes a touch-based “electronicmedical assistant” for specialists, and SchedFull, which is working on a way to help physiciansfill canceled appointments that it hopes to integrate with web-based EMRs.

There’s also healthfinch, the company Berkowitz co-founded with designer Jonathan Baran and programmer Ash Gupta in 2010. It’s focused on making the practice of medicine more enjoyable for physicians by letting them focus on the higher-order thinking they’re good at, rather than spending their time on paperwork. (He compared this to the process of making a new car, and the absurdity of the idea that the people who design technology for the cars would spend part of their time working on the assembly line.)
[What I was trying to say is that a car company knows that their smart car engineers should spend time on solving problems and designing cars, not on screwing in car seats… let them focus on the higher order stuff, and delegate the assembly line work to the people on the floor… another analogy would be that you don't walk into a bank and ask the VP to withdraw $200 - you go to the teller, or the ATM!]

The place where doctors can best apply their skills is the 10 to 20 percent of very sick, complex patients they see, Berkowitz said. That’s precisely why healthfinch focuses on the other 80 percent of patients who might be fairly stable. By creating protocols and automated processes for meeting the needs of these stable patients, other staff members can work together to take care of them, and the doctor has more time to spend with sicker patients.

Its first product focuses on using data to design a protocol for handling medication refills. Doctors receive many refill requests every day, many of which require them to review charts to ensure patients have completed follow-ups or lab tests. Some of this work could be delegated to the nursing staff or medical assistants. To make that happen, RefillWizard leverages EMRs to help practices manage prescriptions more efficiently.
[By using their rules based workflow software to allow for safe and easy delegation of tasks away from docs and towards their team]

Healthfinch plans on using the same technology and philosophy to continue developing products that will save doctors more time by using every person on the staff to the highest level of his or her licensure.  “I’m always on the lookout for things I do repetitively, to see if they can be automated,”Berkowitz added, in illustrating what inspires his innovation. “I’m always trying to figure out how to take something I do in 20 steps and cut it down to five steps or, even better, zero steps.”  [That's one of our new slogans - "The Power of Zero"!]

Abuse of EMRs? Really - Let's Take a Closer Look!

The New York Times recently published an article called "Abuse of Electronic Medical Records", in which they started off by saying "The Obama administration has issued a strong and much-needed warning to hospitals and doctors about the fraudulent use of electronic medical records to illegally inflate their billings to Medicare."

REALLY?!?!   Let's take a closer look:  First, the evidence is that billings and coding has gone up over the past 5 - 10 years, and EMR vendors tout better billing as one of their benefits.   Hmmm... that's not exactly a smoking gun.

But fair enough, so let's review why we might get increasing billings and coding:

1. The EMR makes it easier to code appropriately.  I hate when they say "upcode", which implies fraud.  Rather, I think that many doctors (especially primary care and other non-proceduralists) have undercoded for years... and the EMR actually allows them to document all the "thought work" they have been doing for a long time.  The E/M system was designed to help value "thinking doctors" - and it's starting to work!  Let's applaud that, not try and make it sound like fraud.

2. The EMR allows docs to do more at a single visit.  I think this is an often overlooked reason to explain what has happened.  I know in my practice that having an EMR allows me to get to more things in a single visit than in a paper-based system.  So without an EMR, if a patient came in for a sprained ankle - I might just take care of that and told them to come back for their other issues.  With an EMR, it makes it easier to see everything at once and manage multiple issues.  This is an incredibly GOOD thing for the patient, and for the system - since one "bigger visit" (e.g. "Level 4") is cheaper and more efficient than two "smaller visits" (e.g. Level 3).   So maybe the government should not just look at billings, but also at the total number of visits a patient had - and see if that decreased over the past 5 - 10 years... maybe because docs were doing more work in less visits!

Oh wait, they did do this!?  One of my favorite blogs (HISTalk) actually ran this snippet of info today: The Census Bureau says adults under age 65 made an average of 3.9 visits to physicians in 2010, down from 4.8 visits in 2001. Possible explanations: more uninsured, fewer physicians, higher patient costs, innovation that allows providers to accomplish more in a single visit, and more meds available without a prescription.  So maybe the attorney general and HHS could talk to their own colleagues a bit more before throwing around accusations slandering docs who use EMRs?

3. Docs are using EMRs to defraud the government.  Obviously, there will always be some small amount of doctors who commit fraud - whether that is on paper or EMRs... but I certainly don't think that using an EMR all of a sudden makes doctors more fraudulent.  And by the way, since this fraud is happening in both paper and IT systems... I'd appreciate if our government didn't just pick on EMRs, and said something like this instead:   "We know most doctors are outstanding citizens who give of their time to help others, but there are a few who commit fraud... and whether they do so on paper or EMRs - we will find them and prosecute them!  And while healthcare IT may make it easier for some to perform some fraud, it also makes it easier for us to catch them - so watch out bad guys!" 

Addendum

• Coding: Up, Down or Around? I'm quoted in this HDM article - basically saying EMRs make us more efficient docs and better coders (in contrast to the HHS report trying to make EMRs sound like fraud machines)!

Reducing ReAdmissions... Another Obvious Thing We Need To Do!

Reducing readmissions is a very hot topic now since the government and other payors are starting to create an incentive system which punishes hospitals who have high readmission rates (at least for some of the top categories like CHF and Pneumonia), they do this by basically saying they will not pay if the patient is readmitted within 30 - days of discharge. So I do like the idea of creating well aligned incentives... as long as there is also upside to doing things well.

So how can a hospital succeed here? CSC recently published a report about reducing readmissions. Key Points include:

• Hospital efforts to reduce readmissions have become more visible and important because of the financial stakes — disincentives being incorporated into payment reform — are now high enough to be noticeable in the bottom line.

• Variability in rates across hospitals and regions of the country suggests that significant reductions are possible if practices in better performing hospitals are adopted more uniformly.

• Current measures employed in Medicare incentives target acute care hospitals and high-risk patients defined as those with heart failure, pneumonia, or an acute myocardial infarction. Any re-hospitalization to any hospital within 30 days, for any condition, is counted.

• Preventing readmissions is very challenging because so many community and patient factors contribute to the problem, many of them outside of the direct control of the hospital.

• However, research, combined with practices in hospitals with a track record of reducing readmissions, shows that comprehensive discharge planning and post-discharge care and support during the transition period reduces readmissions in high-risk patients.

• The next scope of work will be to achieve a formal connection with organized care management for every patient covered by this type of program.

• As more high-risk patients are covered by these programs, this will decrease the role of the hospital in providing post-discharge care and support, but formally link patients back to organizations accountable for ongoing care.

• Key elements of the resulting model will be organizing and operating transitional care as a process in its own right, laying out each patient’s transition and hand-off in a time-limited transition clinical pathway, and new uses of health IT in patient tracking and transition care planning.


So the report states that one major key to reducing readmission rates is patient-centered discharge planning. That absolutely makes sense... but hey - it is certainly not a surprise! The real surprise is simply that it is not done more often (Why? Because payors don't pay for it - they pay for procedures over process or thinking). Like much of what we do, if you ask someone outside of healthcare if they thought we did this routinely - they would assume that of course we did it - it just makes sense to create a highly personalized and integrated discharge plan for a complex medical patient when they are discharged from the hospital.

Of course, times and incentives are changing, so clearly we will hear about more emphasis on this type of patient centered planning; on the other hand, we will see hospitals having to cut corners by firing discharge planners and asking RNs to do more of it themselves.

But assuming we are doing more of this, the next issue is "The Details"... will there be a secret sauce or consistent algorithm to make this easy, safe and cheap? Or is it simply about having a smart person use higher order thought processes to create a very personalized approach to each patient. I think it will be a bit of both; the more in the former category - the more likely we can spread this work and make it cost-effective and successful!

ER Visit Cost Reduction Theory; Patient "Web Searchers"

I get a lot of eNewsletters sent to me about healthcare IT and innovation - and there are often articles which catch my eye (AWCME).  They might talk about an interesting study or person, and when I read them I have some immediate thoughts because it resonates with my experiences or thinking in some way.  I'll sometimes do a quick post to FB or twitter so I can track the stories, but I've never been great about blogging on them since it takes extra time... but I'm going to try and get a little better at it.  So this will be the first edition of Articles Which Catch My Eye (AWCME)!  I will provide summaries of the article and then my "biased thoughts" (being a PCP, IT-savvy, Innovation promoting doc)!

A Novel Approach to Identifying Targets for Cost Reduction in the Emergency Department

(Link to the article in the Annals of Emergency Medicine)

A Modern Healthcare story on this article summarizes: "To maximize cost savings, hospitals and health systems should focus on reducing avoidable patient admissions to the hospital from the emergency department rather than on preventing non urgent emergency department visits… Researchers with Boston's Beth Israel Deaconess Medical Center and Harvard Medical School argue that more money can be saved by reducing the number of patients admitted to the hospital from the ED because there are no other good care options for them at the time or because a patient's complex chronic conditions were not treated properly. The researchers estimated that minor injuries and illnesses accounted for 12% to 40% of ED visits but only 0.4% to 1.6% of overall healthcare expenses, so even reducing these visits by 50% would result in savings of less than 1% of costs. On the other hand, patients with intermediate or complex conditions account for 31% to 57% of all ED visits.

MY THOUGHTS:  One on hand, I love that they did this relatively logical analysis on the stats (and it's amazing how rarely this is done in healthcare - other industries live and die by these types of stats, of course they also have an incentive system which is more consistent than our hodgepodge).  And their findings make sense: that even if the "low acuity visits" are high volume, they don't cost that much - so don't worry about them - just focus more on the high acuity visits.  However, this is where I think they missed the big picture.  IF we actually spent a bit more time figuring out how to deal with the low acuity visits (e.g. a free Primary care clinic next to the ER; or even machines which dispense antibiotics based on a few questions) - then we'd actually have much more time to spend on the high acuity patients, making it more likely they won't get admitted.  In other words, instead of thinking about absolute value, we need to look at this equation with the understanding that a given physician or ER has a limited amount of time and "cognitive load" they can use... so let's create a system where the top people (doctors) are focusing on the sickest people, and we create a system which automates or appropriately delegates lower acuity visits to other members of their health team. 

The Prepared Patient: Information Seeking of Online Support Group Members Before Their Medical Appointments

(Link to the article in the Journal of Health Communication)

Abstract: The authors examined online support group members’ reliance on their Internet community and other online and offline health resources as they prepare for a scheduled medical appointment. Adult members of an online support group (N = 505) with an upcoming medical appointment completed an online questionnaire that included measures of illness perceptions, control preference, trust in the physician, and eHealth literacy; a checklist of actions one could take to acquire health information; and demographic questions. A factor analysis identified 4 types of information seeking: reliance on the online support group, use of other online health resources, use of offline health resources, and personal network contacts. Pre-visit information seeking on the Internet was extensive and typically augmented with offline information. Use of online health resources was highest among those who believed they had control over their illness, who attributed many symptoms and negative emotions to it, and who were more eHealth literate. Reliance on the online support group was highest among those who believed they had personal control over their illness, expected their condition to persist, and attributed negative emotions to it. Trust in the physician and preferences for involvement in decision making were unrelated to online information seeking. Most respondents intended to ask their physician questions and request clinical resources based on online information.

An iHealthBeat story on this article summarizes as follows:

Researchers found that patients were more likely to look for health information online if they (1) Believed their medical conditions were long-term; (2) Felt they had some degree of personal control over their illness; or (3) Were distressed about their medical condition.  Researchers also found that: 70% of study participants said they planned to ask their doctor questions about information found online; More than 50% planned to make a request of their doctor based on information found online; and 40% printed information from the Internet to bring to their doctor's appointment. 

MY THOUGHTS: Most of this is consistent with what I've seen - that many patients will find info online and share it with me and ask questions (although not close to 40% would print it out ahead of time).   I generally find that the online patients fall into three categories: 

1. The Worried Well: They will look online anytime they have any symptoms, and find something scary, and then make an appointment to be reassured.  This is usually the largest group, and their web activities usually drive up the volume of business.  Which may be an ironic twist as there once was an assumption that having information online would avoid visits - but that is the exception - there is often just too much information for a consumer to fully understand.  These are usually quick and easy discussions - most of these patients know they over-reacted, and just need the reassurance from their physicians. 

2. The Savvy Searcher: Someone who knows what they have and does the research to help either diagnose or manage their care better.  An example might be if I tell a patient they have high cholesterol, and they use the web to find better diets for them; or patients with a "strange problem" who identifies a possible diagnosis or new medicine to try.  These folks are very much partners in the process - and I love working with them. 

3. The Truly Tragic: People who have a very bad diagnosis (e.g. Cancer, Lou Gehrig's disease...) and then obsess about it - and look at every website they can... to the point where they often drive themselves crazy because of the immense information overload.  And the worst case scenario is that if you look hard enough, they can almost always find what they want to find - such as the side effect to a drug, or that some obscure tree root is the cure which is being hidden by the establishment.  It is important that we let these patients know they should keep us in the loop because they sometimes can go on dangerous tangents if they think everything they find online is true.  

Dr. Larry Weed is The Oracle: Medical Records Should Guide and Teach!

Dr. Larry Weed was an amazing visionary physician.  Let me start by summarizing what he started saying in the 1960s:  "We need to better organize our records, better utilize paramedical personnel and appropriately use computers" - over 40 years later, and we still haven't followed his advice very well!  But we know it's true more than ever now, and we better start moving in that direction quickly!

Thanks to the internet, much of his original work exists, and it should be mandatory reading (and viewing) by anyone developing healthcare IT software or trying to change the system in any way.  Here are some of his papers:

• Medical Records that Guide and Teach: His original 1968 paper in the NEJM explained the Problem-Oriented Medical Record (POMR) - which has since become the standard of documentation across the globe.   NOTE: Unfortunately, this system has often been incorrectly thought to mean the whole note should be in SOAP format (Subjective, Objective, Assessment, Plan) vs. having a SOAP component for each individual problem.  The result is that many notes are harder to create and read since they don't group relevant information together.  
• Managing Medicine: His 1983 book which: "Contains the best of previously-published materials on Problem-Oriented Medical Records, and explains the Knowledge Couplers which have occupied Dr. Weed up to the year 2000. Much of this material is transcribed from lectures and conversations, so it preserves the candid tone, energy, and eloquence of Dr. Weed that can usually only be experienced in person or on videotape. Illustrated, with highlights captioned throughout." (per Amazon description).
• Interview with Dr. Weed: A 2009 article written by a former student who says, "We discussed when he first was alerted to the nonscientific approach clinicians use to make decisions on patients. The rest of the interview time was spent with Dr Weed teaching me about the solution that he has spent the last 30 years designing and implementing."
• Medicine in Denial (2011) According to Dr. George Lundberg's commentary, "In 267 pages, they sharply dissect virtually every sphere of medical education and medical practice. The tenet is familiar; the need to couple patient data with medical knowledge. This is not just a critical rant; it is a detailed "how to" fix the broken system.  Specifics such as "Changing medical education from a knowledge-based to a skills-based approach" and "Information processing, clinical judgment, and the two stages of decision-making" are good examples of the original 1970s premise still awaiting mass application in this century."  You can get a PDF overview here.
• Other: "Medical Records, Patient Care and Medical Education" (1964), his first paper on the topic, and in a later paper he explains, "The Problem-Oriented System, Problem-Knowledge Coupling, and Clinical Decision Making" (1989).

Finally, I especially enjoyed this video of his 1971 Grand Rounds at Emory University (see below).  Some key takeaways from his presentation include:

• Physicians need to be guidance systems, not oracles.  
• The medical record provides the data needed to be a successful guidance system, and is critical for the best Education, Care and Research. 
• Every patient and their problems are unique - just like there are 88 keys on the piano, but millions of symphonies can be played.  
• Treating a sick patient is like a Chess game... you make your move, Nature plays her move, and then back to you.

The EMR Race is Over, Long Live EMR Extender Tools!

I've been increasingly talking about the concept that the EMR race is over, and that EMRs now serve as the infrastructure and platform upon which innovative companies will develop "EMR Extender Tools", in areas such as: Physician Productivity (e.g. healthfinch), Decision Support (e.g. Zynx), Business Intelligence (e.g. DrEvidence), and Patient Outreach (e.g. Healthloop).  This seems to resonate well with mature EMR users since they often feel like the EMRs they have are rather stagnant - and the vendors will be focusing for years on just getting basic things right and fulfilling Meaningful Use, and thus has no ability to add innovative features.

This is particularly relevant as a recent article came out asking, "What is the future of healthcare innovation now that Epic has become the dominant EMR player?"  The author offered a variety of scenarios, but I think Mr. HISTalk had the best analysis when he said:  "Companies should stop fixating about mounting a full frontal attack on Epic that’s sure to fail and instead innovate on building products and services for Epic’s large client base just like the companies that coexist successfully with Meditech."

Oh yeah!  Now we are talking about an ecosystem that will really let innovation flourish (I think it will be Epic and a few others).  Big Kudos to Allscripts and Greenway for walking the walk and being the first to launch official "platforms" for allowing third parties to build tools upon them.  And nod of the hat to other EMR vendors who are at least talking the talk - even if their "Platforms" are not quite launched yet... such as GE, NextGen, AthenaHealth.  And here is hoping that Epic and ECW will eventually come around and create official platforms to encourage innovation... I think they will eventually move to this, and/or their customers will do it for them.  Finally, I'll be closely following a few other companies trying to build "Uber-Platforms" in this space, including Optum, Aetna's Medicity and the GE/MS spinoff Caradigm.

Of course, how cool would it be if we had one platform upon which any third party vendor could integrate their tool... and it would magically work with any EMR?  Oh wait, we actually do have the government sponsored SMARTPlatform... now we just have to get the vendors to agree to work with it!  The geniuses behind this platform (Kenneth D. Mandl, M.D., M.P.H., and Isaac S. Kohane, M.D., Ph.D.) just wrote another NEJM article (Escaping the EHR Trap — The Future of Health IT), if you are interested in hearing what they think the future should look like.  Here are a few good quotes from their article:

• “[T]here’s a clear path toward better, safer, cheaper and nimbler tools for managing healthcare's complex tasks.”
• “Programs should not be held hostage to EHRs that reduce their efficiency and strangle innovation,” the authors concluded. “New companies will offer bundled, best-of-breed, interoperable, substitutable technologies … that can be optimized for use in healthcare improvement. Properly nurtured, these products will rapidly reach the market, effectively addressing the goals of ‘meaningful use,’ signaling the post-EHR era, and returning to the innovative spirit of EHR pioneers.”

Getting back to reality (meaning we don't have seamless platforms to do all this yet)... I do think we are seeing an explosion of small companies creating great niche products and figuring out how to work with EMRs.  So whether there is an official platform or not, the EMR Extender Tools are here to stay and they are only going to grow bigger and better!

Past Blogs on this topic
* Rise of the EMR Extenders (March, 2011)
* EMR Apps Taking Off (April, 2012)

Six Steps to Saving the Country with Preventive Care

Joe Flower is one of the best healthcare futurists an authors out there… which is why I quote him so often!  In his recent article, "Save the Country with Preventive Care", he explains how we can save the healthcare system by focusing on the treasure in plain sight: "It is those thousands and millions of patients with poorly treated and untracked chronic disease that flood our EDs every day. We can mine those cases to reduce health care costs drastically, put our hospitals and health systems on a sound economic footing, make people healthier and, by the way, save the country."

He then goes on to describe the SIX WAYS to do this, which I will help summarize:

1.      Coverage. Everyone needs to be covered, even illegals and those who won't pay for it - because otherwise they just cost everyone more later on.  He notes, "If they are covered, it is much easier to fashion preventive and outreach programs to keep them from your door."

2.      Shift in risk. He explains this well, "Shift from the standard model (fee-for-service, with all financial risk in the payer) to various models in which the provider takes on some risks (as with bundles, warranties, capitation, minicaps, alternative quality contracts and other models) and the patients take on some risk for making a good decision (going to a clinic or an urgent care provider instead of the ED with a minor matter).

3.      Incentivized wellness. These types of programs "give people financial rewards (such as lower premiums) when they participate and meet simple goals. Correctly done, these programs reduce the actual costs for covering the whole population (including those who do not participate) by 10 percent or more."

4.      Targeting. "Find and go after that 5 percent, that 1 percent who are costing the most money. Some of the cost will be recoverable, some will not; but go after them anyway, because the costs spiral out of control once they cross your threshold."  This includes putting in more clinics in high risk sections of town, as well as "HotSpotting" individuals, as popularized by Dr. Atul Gawande.  There is a lot of energy and momentum to do this - which is a good thing.  I'd just point out at the same time we pour resources into these folks, we need to efficiently take care of the other 95% to make sure they stay stable and healthy (which is a focus of a lot of my recent work).

5.      Public health. Consider how you can better work with your federal, state and local public health officials to address the health needs in your community.

6.      Healthy Communities. "Finally, at the furthest remove from your ED threshold is the Healthy Communities movement. There are local groups in most places across the country, supporting programs dealing with everything from effluents to traffic to education to AIDS awareness. The return on investment is always large because the investment is so small compared with the ED visits, surgeries, premature births, and NICU and ICU use that they eventually prevent."

He finishes with:  "We will save much more money, shore up our finances and help solve the deficit problem when we stop waiting passively for people to cross our threshold and begin aggressively exporting health to those who need it the most."

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/

The Future of Physicians

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

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

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

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