EMR and EHR

An EMR Point of Differentiation – Watson

John — Thu, 17 May 2012 19:08:46 +0000

Michael Dale has an interesting post I came across discussing IBM’s Watson in healthcare. Here’s one piece of the post:

You may know Watson best for its performance on the Jeopardy game show. Watson demonstrated swift decision making after indexing over 200 million pages of data. Watson would only answer if the system crossed a certain confidence threshold. The confidence threshold was a predefined percentage set inside the system. When Watson referenced the data, it determined the percentage to which it was sure the top three answers were correct. If the percentage of the top answer crossed the confidence threshold, Watson would signal for the answer. The IBM machine proved itself successful against two humans competing in the game show by winning both rounds.

Certainly physicians and members have much to gain from the assistance of a machine that can reference millions of pages of data to ascertain a diagnosis or treatment. While physicians may always hold the upper hand to interpret the context of the situation for a presenting patient, Watson’s assistance can certainly supplement any decision using vast amounts of data in a quicker time frame.

My immediate reaction to reading this post was the following:

Reading what you wrote made me wonder if the Watson like technology could become a strong differentiation between EHR vendors. It has been extremely challenging lately to differentiate between the various EHR vendor offerings. It seems like having a Watson like brain assisting you in the process could become a differentiation point.

So many physicians are trying to sift through the overwhelming number of EHR companies, that they are looking and wanting for some sort of major EHR differentiation. I wonder if some smart Watson like technology would be amazing enough to blow physicians away so they start saying, I have to have that.

Michael Dale also discusses in the post how Watson would essentially use an EHR to access the data. Sounds a lot like my comments about EHR Being the Database of Healthcare.

Healthcare IT’s Success is Truly in the Eye of the Beholder

Jennifer Dennard — Wed, 16 May 2012 14:20:08 +0000

I’ve come across few articles recently that really validate the notion that the success of healthcare IT is really in the eye of the beholder, or in some cases, the editorialized results of a study.

Take, for example, the following headlines:

“EHR Use Not Linked to Improved Diabetes Care Quality, Study Finds”
and
“App Improves Diabetes Management Among Teenagers, Study Finds”

I find it hard to believe that if formally connected, the second study couldn’t somehow influence the first. In other words, if a mobile health app can improve diabetes management among teenagers, shouldn’t whatever data that app is capturing transmit successfully to the teen patients’ EHRs for easy access by their doctors? And then couldn’t that doctor digest that information, picking out patterns in the patient’s behavior that is either positively or negatively impacting their diabetic condition and overall health, to better inform care protocols?

I’m taking big leaps of logic here, since the first study found that not only was there no correlation between the use of an EHR and “increased adherence to clinical guidelines for care processes and treatments,” but there was actually a “higher probability of meeting certain targets for blood pressure and A lc levels after two years” at practices without such systems. (Seems like these outcomes might be due more to end-user experience than the technology itself.)

The second study doesn’t even mention EHRs, but I wonder how many of the 20 teens participating in the study see doctors who have this type of technology, how many of those doctors know their patients are participating in the study (all I’d assume), and how many are feeding the app’s info into an EHR.

Surely if a smartphone app is helping a diabetic teenager better adhere to medication regimens, then the EHR their doctor could potentially be using would somehow tie in to better clinical outcomes. Another study to start, perhaps?

The second set of headlines that gives me pause (and kinda makes me chuckle) includes:

“Physician Use of Tablets has Nearly Doubled Since 2011”
and
“Not all Doctors and Nurses are Happy with an iPad in the Hospital Setting”

Neither headline surprises me. We all know that adoption of mobile health tools is growing, if not by leaps and bounds then at least steadily. It would make sense that providers are adopting tablets in relation to this. Every technology has its detractors, so of course not everyone is going to be happy with how an iPad works in a clinical setting, just as not every provider is going to want to install an EHR. I do wonder, though, how the same set of users mentioned in the second article would rate a different kind of tablet if given the opportunity to use one.

I find the first sentence to be kind of hard to believe: “It looks as if most doctors and nurses would rather not touch the iPad at work (or deal with any other kind of tablet computing).” If “most” doctors and nurses would rather have nothing to do with tablets at work, than how can physician use of tablets have doubled since last year?

So you see, the “success” of healthcare IT seems to depend on whose writing about it. I have a feeling the American Forest and Paper Association might be behind the very first one.

Health 2.0 Boston

John — Tue, 15 May 2012 15:07:51 +0000

I’m in Boston enjoying meeting with a lot of really smart people at Health 2.0. As usual, the biggest value of the conference is the people you meet and the hallway conversations you have with those people. I’ll certainly be doing posts over the next couple weeks related to those conversations.

The other highlight of Health 2.0 was hearing Jonathan Bush speak. He was in true Jonathan Bush form and he’s great because you can guarantee that he’ll never give the same speech twice. As one person said in the hallway, the connection between him thinking it and him saying it is very short. It’s so short that it has no filter. My biggest complaint with Jonathan Bush’s talk was that they only gave him 20 minutes on stage. Not nearly enough.

For those who couldn’t make it, here’s the main points that Jonathan Bush provided:
1. “Don’t bite off more than you can chew.”
2. “You need your partner’s ‘id’ as well as their signature.”
3. “Culture trumps capability.”

This is all really good advice for healthcare startup companies. One other thought from Jonathan Bush:

.@Jonathan_Bush compares entrepreneurial survival to paramedics’ attention to the ABCs…focus on first things first. #health2con #EMS

— Carissa O’Brien (@CarissaO) May 15, 2012

Here are some other good takeaways from Health 2.0 Boston that were tweeted out:

Steve Krein: Introductions are easy, being prepared for the meeting and what follows is hard #health2con

— Matthew Holt (@boltyboy) May 15, 2012

Very good advice and appropriate at Health 2.0 Boston since the focus of it is about partnerships.

The core problem is “uncompensated care.”#health2con

— EMR, EHR and HIT(@ehrandhit) May 15, 2012

There’s a compelling story if you look at how much uncompensated care physicians provide.

Affordable Care Act and Employee Health

Priya Ramachandran — Mon, 14 May 2012 17:41:02 +0000

Over at healthaffairs.org, there was a super interesting brief on Affordable Care Act and its forthcoming changes regarding employee health. Starting in 2014, employers will be able to offer incentives to employees regarding their enrollment in employee wellness programs. Employers can offer incentives such as monetary rewards for positive employee behavior like enrolling in a smoking cessation program, or joining a gym at discounted rates. Or these can work like the proverbial stick, by imposing penalties on non-compliant employees, e.g. increasing the cost of participating in an employer health plan by $1000 for employees who say they have smoked in the last year.

Now all those good components of the ACA will still be applicable i.e insurance companies will not be able to refuse patients based on prior medical history. But I can’t help but notice the irony of the ACA being used to discriminate between a healthy employee and a sick one.

One of the examples cited in the brief is that it will be legal for an employer to offer a health plan to employees who fulfil certain wellness criteria such as enrolling in a gym in addition to the other health plan options available to its other employees. The cost of the other health plan options to a truly unwell employee could well be so exorbitant as to make it impossible for him/her to enroll in it. Options for such employees could be to enroll through a spouse’s plan or purchase private insurance through the health information exchanges. The brief says that there are plugs for these sorts of employer excesses, such as companies with over 50 employees will be penalized even if one employee enrolls in a subsidized state insurance program in lieu of the company sponsored one.

I’m also wondering if there will be any kind of guidelines for companies to design their incentive/penalty programs. Health and wellness are incredibly nuanced issues. For every person who can exercise a half hour a day and lose a pound a week, there are those who seemingly subsist on air and water and barely make a dent in their BMI. Genes determine plenty of factors in a person’s helath profile, including weight, propensity to develop certain conditions and so on. It makes me wonder if we’re oversimplifying things by gauging employee wellness based on criteria such as gym enrollment.

Plus what if you have lots of people like me who might enroll in a gym and never see the inside of it beyond the first few days? Simple enrollment might not be enough. But, to my mind at least, tying enrollment to outcomes has the unfortunate whiff of a mini nanny state in the making. Who wants to be the person at the company weigh-in whose BMI has come down by .1 while the muscled, rippled company health club employee looks at you quizzically? Not me.

I also worry about the unwell employee who feels pressured into signing up for risky activities (from his/her health perspective), simply in order to get the rewards offered or to avoid the penalties. S/he might have something truly tangible to lose both ways.

I would love to see how ACA transforms in the next couple of years but right now I think I have way too many unanswered questions.

EHSD, Computing In Front of Patients, EMR Workflow, and more – This Week in HealthCare Scene

Katie — Mon, 14 May 2012 00:07:31 +0000

Didn’t have a chance to read everything that other HealthCareScene.com websites had to offer this week? Here is a round-up of some of the best articles this week

EMR and HIPAA

EHSD – EHR Hunt Stress Disorder

Are you “worn out, drug out, and generally pooped” about the search for the perfect EMR? If so, the diagnosis might be what Dr. Gregg describes as EHSD — the EHR Hunt Stress Disorder. Sometimes it is hard to know which EHR company to go with, with over 600 out there. Knowing how to narrow the options down quickly might make the decision a little bit easier, and EHSD less severe.

The Happy EMR Doctor

Readers Speak About Computing in Front of Patients

Should not only use, but discuss, EMR in front of patients? Dr. Michael West recently wrote about computing in front of patients. Readers responded about their thoughts on it and hardly any had negative feelings. In this post, Dr. West responds to the comments readers left and how he feels that EMR is here to stay.

Wired EMR Doctor

EMR Workflow Continues to Evolve

Over the last seven years, Dr. Michael Koriwchak has implemented electronic medical records into his practice. While there has been some trial-and-error involved, the skills his staff and him have concerning EMR continually become more fine-tuned. Dr. Koriwchak talks about two different types of workflow, and which one he prefers. He reflects on how the combination of “successful web portal with a sophisticated workflow engine operated by staff” allows a practice to use EMR even more efficiently.

Smartphone Healthcare

New Friend Request . . . From the Family Doctor?

Social Media is becoming more and more popular, so doctors and hospitals everywhere are jumping on the bandwagon. Would you follow your doctor on Twitter or Facebook, or is that crossing the line for a patient-doctor relationship? The pros and cons of the growing trend for medical professionals going virtual are discussed.

Hospital EMR and EHR

Issues to Consider When Offering Hospital-Subsidized EMRS

Hospitals have started offering subsidized EMRs recently to physicians. While these might be tempting to accept, a physician must be careful about the conditions on which the EMR is accepted. Before accepting a hospital-EMR deal, be sure to read this list of questions to ask the hospital offering it.

EHR and EMR Videos

Smoking Cessation With the Waiting Room Solutions EMR System

There are quite a few preventative measurements required for EHR Incentive Meaningful Use and CQM Compliance. A video from Waiting Room Solutions provides a “how-to” video on how to use the Web-based EMR system for Smoking Cessation.

Doctor Describes 15+- Year EMR Integration Project

Anne Zieger — Fri, 11 May 2012 18:46:51 +0000

Wouldn’t it be great if you rolled your EMR and, bam, all of the problems you hoped to solve were solved, just like that? Sure, but in most cases the technical rollout will do little to solve workflow problems unless you have them analyzed in advance, according to one doctor who’s taken part in a long, slow rollout. Here’s a quick overview of his organization’s progress: see what you think.

Going live is a far cry from having truly adopted an EMR, and getting to adoption is a very long, drawn-out process, said Dr. Fred M. Kusumoto, who spoke at a recent meeting of the Heart Rhythm Society.

Dr. Kusumoto, who’s with the Mayo Clinic Jacksonville Electrophysiology and Pacing Services, conceded that EMRs can help smooth communication between systems. The thing is, he noted, integrating systems won’t happen over night. After all, the workflow of doing integration is very complex, so much so that years hardly suffice. His organization began serving as “guinea pig” for its EMR vendor in 1996 and will as of 2013, will have one database using structured data, he said.

So, the million-dollar question is this: Has all of this effort been worthwhile? Dr. Kusumoto actually didn’t say, if the CMIO article I reviewed is accurate. Interesting. But he’s clearly learned a great deal, regardless of whether his rollout works out for Mayo. Here’s some of his suggestions on how to improve returns from your maturing EMR:

* Make sure all stakeholders are involved as the EMR migration, including administrators and IT staffers.

* Bear in mind that EMR rollouts are at their most flexible in the first few years, so don’t miss your chance to get involved early.

* EMR implementations (typically) involve a scanning phase where the institution captures written records and plans for turning the records into structured data. Make sure you leave enough time to do this right.

Giving Up on Digital Patient Engagement

Jennifer Dennard — Thu, 10 May 2012 15:59:56 +0000

I’ve been a big fan of the “engaged patient” for about as long as I’ve known what the term meant, but until earlier this week, I hadn’t given much thought to the burden Meaningful Use requirements potentially place on providers to create these types of folks.

As I’m sure most readers know, comments on proposed Meaningful Use Stage 2 requirements were due to CMS this past Monday. Many organizations not only turned in comments, but released summaries of those comments to various media outlets as well.

Lynn Scheps, Vice President of Government Affairs at SRSsoft, has done a nice job of drawing out a few major themes from comments submitted over the 60-day period. In her most recent Meaningful Use Monday blog, she points out that:

“While increased patient engagement is recognized as an important goal, providers are expressing concern about having their incentives be dependent on actions by patients—actions over which they have no real control. For example, one proposed measure would require that 10% of patients access their information on the physician’s portal, and another that 10% of patients send a secure e-mail message to their physician.”

Now, as I’ve written (or tweeted) about before, I’ve tried to get into using a personal health record, and just found it to be too much trouble, too time consuming. If I, a fairly digitally savvy healthcare consumer (and thankfully a fairly healthy one), can’t keep up with a PHR, how likely is it that patients who don’t even have an email address will immediately jump onto their physician’s portal or send e-mail messages to their physician.

And it should probably be pointed out that those who make up the bulk of healthcare costs in America – the chronically ill and/or obese – most likely consist of patients in underserved communities, people who don’t have consistent access to the Internet. It’s a systemic problem that I could write at length about, but I’ll save that for another blog altogether.

On the flip side, the Robert Wood Johnson Foundation, in its Stage 2 comments to CMS, called for the criteria around patient engagement to be either maintained or enhanced. Its views on doubling the 10-percent threshold of patients viewing, downloading or transmitting their health information seems fairly indicative of their stance on the criteria as a whole:

“This change would provide an incentive to health professionals to adopt patient-facing platforms that have the potential to increase patient engagement and self-care.”

Needless to say, it will be interesting to see what route CMS takes when it issues a final rule sometime in August. I do hope that it errs on the side of conservative optimism, and keeps its proposed patient engagement criteria, rather than decreasing or banishing them altogether. Hopefully this can help healthcare overcome its bad habit of protracted procrastination and, with the tiniest of baby steps, help physicians get over the hump of getting themselves, and their patients, on the digital bandwagon.

Are Large EHR Vendors More Likely to Shut Down an EHR Than Small EHR?

John — Wed, 09 May 2012 14:28:49 +0000

As most people who have read this blog for a while, you know that I try to bring you raw perspectives on things that a lot of people don’t want to talk about. Plus, I don’t mind arguing the other side of topics in order to provide a more well rounded view of an important topic. One of my main goals is to provide the information necessary for doctors to make great decisions.

I recently got into a lengthy discussion with someone about EHR vendor selection. They suggested that doctors should look to the 5 EHR market leaders in their EHR selection process (I believe he sold one of those EHR market leaders). He made some very good points about the market leaders ability to support all stages of meaningful use, that they have a solid business model that will support doctors for the long term, and that they have the resources to support an EHR software for the long run. He also provided some reasonable cautions around small EHR vendors with skeptical business models that might not be around a few years from now.

Certainly the points he makes have merit and are worthy of consideration. Although, unlike this person, I’m not so ready to throw the rest of the non-top 5 EHR vendors out and I think it’s a mistake for a doctor or practice manager to do so as well.

As I considered on this discussion, I realized that over the past 5-7 years, it’s many of the big EHR vendors that have closed up their EHR software. Possibly even more than the various startup EHR companies. Here are just a few examples of large companies shuttering their EHR: Misys (billion dollar company if I remember right), Epocrates and GE Centricity Advance (one of GE’s suite of EHR). Of course, Misys merged with Allscripts (if you call it a merger since they were going bankrupt), but I know a lot of unhappy Misys users that don’t know what to do now. GE has many other Centricity products as well and seems to have made a smoother transition for their Centricity Advance users. At least that’s within the same company. Epocrates is a large company, but didn’t have many EHR users.

My point of course is that even EHR software from large EHR vendors aren’t safe from possible future issues. In fact, I could make a reasonable case for why a smaller EHR vendor that’s grown in a sustainable way over a long period of time is in a better financial position than a HUGE company with a lot of overhead. Plus, I know personally A LOT of these small EHR vendor CEOs. They love what they’re doing and they’re in this for the long haul.

Now with 600+ EHR vendors out there, I’m certainly not saying that all of them have great business models. I was blown away when I met one at MGMA who had 1 doctor using their system. I hope whoever they sign up second is aware of the situation and is going in with both eyes open. There are certainly risks associated with being the second doctor on an EHR software, but there are also plenty of benefits as well. When you suggest something be changed, there’s a good chance you’ll get that change.

Conclusion
There are good small EHR companies.
There are good large EHR companies.
There are bad small EHR companies.
There are bad large EHR companies.

I guess what I’m saying is that size doesn’t matter in EHR selection. There are much more important factors to consider.

Use Of E-Health Technologies Growing Internationally

Anne Zieger — Tue, 08 May 2012 19:31:29 +0000

While much of the discussion in Twitter forums and the like focuses on U.S.-based e-health use, here and there stories crop up of intriguing ways e-health technologies can help transform healthcare in developing nations. This week, we got a more comprehensive look at the global picture.

The World Health Organization has just issued a report outlining the rapid pace at which mobile health use is expanding in low- and medium-income countries around the world. In many of these nations, mobile health programs are emerging, in part because public use of computers and mobile phones is increasing, the WHO notes.

The WHO report focuses on privately-funded programs, as reliable government data is difficult to obtain. The private data WHO uses comes from the Center for Health Market Innovations, which has been collecting data on public health programs in developing nations since 2007.

By U.S. standards, mhealth programs in developing countries are still in their infancy. Only 176 of the 657 the public health programs WHO looked at in Bangladesh, Bolivia, Brazil, Cambodia, Ecuador, India, Indonesia, Kenya, Pakistan, Peru, the Philippines, Rwanda, South Africa, Uganda, the United Republic of Tanzania and VietNam were using communications tech to improve healthcare.

Among the main technologies providers used were telehealth-related, given that in many cases patients were a long distance away from any form of direct care. For example, “video chat” programs and phone hotlines offering access to doctors are emerging quickly. Key conditions addressed by telehealth programs are emergency care, tuberculosis, mental health, malaria, general primary care, maternal and child health and HIV/AIDS.

While these programs show promise, there’s one roadblock which isn’t likely to go away quickly — money. Apparently, about half of the mhealth activity tracked by the report is funded by private sources, which limits their growth. Also, text-driven programs which have worked well in the U.S. and other industrialized nations aren’t nearly as effective, as many residents of these countries are illiterate.

A Rosa Parks for EMRs

Priya Ramachandran — Mon, 07 May 2012 21:56:03 +0000

From the Healthcare blog, this week there’s a super interesting post on Regina Holliday, a widow turned patient rights advocate.

First some background about Holliday: She’s a widow with young kids, her husband Fred died after weeks of suffering from from cancer. She is now taking her patients’ rights advocacy before the American Heart Association by protesting the lag in how soon patients can see their medical records. Holliday’s personal experiences inform her protest.

From the post:

When [Hollidays] sought access to [Fred's] electronic medical record, the hospital responded by saying “we must wait 21 days and pay 73 cents per page to see the story of his care. Then they told us we could go home to die.”

Per Meaningful Use Stage 1 guidelines, patient records must be made available within 4 days. Holliday is asking for access within 24 hours. American Hospital Association (AHA) in all its wisdom is asking for 30 day lag.

The one issue I don’t see addressed either by Holliday nor by Michael Millenson in his post is the question of cost. Who will bear the cost of making records available immediately? Will it roll downhill to the patient, or become a shared cost between patient and provider? Still I hope Holliday succeeds, it is a radical idea worth pondering over.