NEW @ THCB PRESS: Surviving Workplace Wellness. Spring 2014. Al Lewis and Vik Khanna. e-book edition. # LIGHTHOUSE Healthcare. Illuminated.

EHR

A common and somewhat unique aspect to EHR vendor contracts is that the EHR vendor lays claim to the data entered into their system. Rob and I, who co-authored this post, have worked in many industries as analysts. Nowhere, in our collective experience, have we seen such a thing. Manufacturers, retailers, financial institutions, etc. would never think of relinquishing their data to their enterprise software vendor of choice.

It confounds us as to why healthcare organizations let their vendors of choice get away with this and frankly, in this day of increasing concerns about patient privacy, why is this practice allowed in the first place?

The Office of the National Coordinator for Health Information Technology (ONC) released a report this summer defining EHR contract terms and lending some advice on what should and should not be in your EHR vendor’s contract.

The ONC recommendations are good but incomplete and come from a legal perspective.

As we approach the 3-5 year anniversary of the beginning of the upsurge in EHR purchasing via the HITECH Act, cracks are beginning to show. Roughly a third of healthcare organizations are now looking to replace their EHR. To assist HCO clients we wrote an article published in our recent October Monthly Update for CAS clients expanding on some of the points made by the ONC, and adding a few more critical considerations for HCOs trying to lower EHR costs and reduce risk.

The one item in many EHR contracts that is most troubling is the notion the patient data HCOs enter into their EHR is becomes the property in whole, or in-part, of the EHR vendor.

It’s Your Data. Act Like it.

Prior to the internet-age the concept that any data input into software either on the desktop, on-premise or in the cloud (AKA hosted or time sharing) was not owned entirely by the users was unheard of. But with the emergence of search engines and social media, the rights to data have slowly eroded away from the user in favor of the software/service provider.

Facebook is notorious for making subtle changes to its data privacy agreements that raise the ire of privacy rights advocates.

Continue reading “Whose Data Is It Anyway?”

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OMG-to-WTF spectrum

So I was at TechfestNW earlier this fall and I had the opportunity to hear James Keller at WalmartLabs speak about the importance of having a minimum valuable (versus viable) product that is tied into the user experience.  It is how the user’s emotional response to the application’s interface, which is so important to have, that gives a product meaning.

And this concept (although I admit I completely stumbled upon it) is at the very heart of what makes NOSH ChartingSystem so different.   As I have stated on my blogs before and on my Indiegogo campaign site, I wanted to have an EHR that was both intuitive to use AS WELL AS having an interface that was calming and meaningful at the same time.  So as an example from the medical world, having a pain scale is pretty good indicator of how user-friendly your application is.

Pain Scale

An analogous concept is the OMG-to-WTF scale (see above).

Where does your EMR stand on the scale?

Continue reading “The OMG to WTF? EMR Pain Scale”

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Remember the Ford Pinto and the AMC Pacer, aka the Pregnant Pinto?

Both serve as reminders of an in era in which the American auto industry lost its way and assumed drivers would buy whatever they put on the lot. Foreign competition, primarily from Japan, filled the void created by American apathy for quality and design, and the industry has never been the same.

Admittedly, the comparison of cars and EHRs is less than apt, but health IT also assumes healthcare will buy what we’re selling because the feds are paying them to. And, like the Pinto, what we’re selling inspires something less than awe. In short, we are failing our clinical users.

Why? Because we’re cramming for the exam, not trying to actually learn anything.

Myopic efforts to meet certification and compliance requirements have added functionality and effort tangential to the care of the patient. Clinicians feel like they are working for the system instead of it working for them. The best EHRs are focused on helping physicians take care of patients, with Meaningful Use and ICD-10 derivative of patient care and documentation.

I recently had dinner with a medical school colleague who gave me insight into what it’s like to practice in the new healthcare era. A urologist in a very busy Massachusetts private practice, he is privileged to use what most consider “the best EHR.”

Arriving from his office for a 7 PM dinner, he looked exhausted, explaining that he changed EHRs last year and it’s killing him. His day starts at 7 AM and he’s in surgery till noon. Often double or triple booked, he sees 24 patients in the afternoon, scribbling notes on paper throughout as he has no time for the EHR. After dinner he spends 1.5 to 2 hours going over patient charts, dictating and entering charges. What used to take 1 hour now requires much more with the need to enter Meaningful Use data and ICD coding into the EHR.  He says he is “on a treadmill,” that it should be called “Meaningless Use,” and he can’t imagine what it will be like “when ICD-10 hits.”

My friend’s experience is representative, not anecdotal. A recent survey by the American College of Physicians and American EHR Partners provides insight into perceptions of Meaningful Use among clinicians.

According to the survey, between 2010 and 2012, general user satisfaction fell 12 percent and very dissatisfied users increased by 10 percent.

Continue reading “Darwinian Health IT: Only Well-Designed EHRs Will Survive”

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Chicago Cubs fans of a certain vintage will never forget broadcaster Harry Carey’s signature line, “Holy cow!”  Some have speculated that the exclamation may have originated in Hinduism, one of the world’s major religions, whose adherents worldwide number approximately one billion.  Hindus regard cows as maternal, caring figures, symbols of selfless giving in the form of milk, curds, butter, and other important products.

One of the most important figures in the faith, Krishna, is said to have been a cowherd, and one of his names, Govinda, means protector of cows.  In short, cows are sacred to Hindus, and their slaughter is banned in virtually all Indian states.

Medicine, too, has its sacred cows, which are well known to physicians, nurses, and patients visited by medical teams on their hospital rounds.  In this case, the cow is not an animal but a machine.  In particular, it is the computer on wheels, or COW, a contraption that usually consists of a laptop computer mounted on a height-adjustable pole with a rolling base.  It is used to enter, store and retrieve medical information, including patients’ diagnoses, vital signs, medications, and laboratory results, as well as to record new orders.

As the team moves from room to room and floor to floor, the COW is pushed right along. The COW is often treated with a degree of deference seemingly bordering on reverence.  For one thing, people in hallways and patients’ rooms are constantly making way for the COW.  As an expensive and essential piece of equipment, it is handled gingerly.  Often only the senior member of the medical team or his or her lieutenant touches the COW.

Others know that they have said something important when they see the chief keyboarding the information into the COW.  Sometimes it plays an almost oracular role. When questions arise to which no one knows the answer, such as the date of a patient’s admission or the time course of a fever, they often consult the COW. Just as cows wandering the streets of Indian cities often obstruct traffic, so healthcare’s COWS can and often do get in the way of good medicine. Continue reading “Should We Sacrifice Medicine’s Sacred COW?”

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The U.S. government shutdown continues to claim victims.

The latest is HealthIT.gov, the website designed to help doctors and hospitals make the transition to electronic and make better use of health information technology – a key component of Obamacare’s drive to transform healthcare.

The Health Information Technology Office of the National Coordinator posted a brief announcement on the site informing visitors to HealthIT.gov that “information … may not be up to date, transactions submitted via the website may not be processed and the agency may not be able to respond to inquiries until appropriations have been enacted.”

Officials also sent a tweet saying that the ONC regrets to inform us that while the shutdown continues it will “not tweet or respond to tweets.”

This struck THCBist as slightly odd.

After all, if you’re looking for an inexpensive way to communicate with the public in a pinch, Twitter seems like the perfect choice.  We get that government websites are ridiculously expensive things to run. Blogs are considerably cheaper.  Operating a Twitter account — on the other hand — is almost free.  Our brains were flooded with scenarios.  How much could the ONC possibly be spending on Twitter? And for that matter, didn’t the Department of Defense originally invent the Internet to allow for  emergency communication during times of national crisis? Doesn’t a fiscal insurrection by cranky Republicans qualify?

Fallout for the National Health IT Program

While federal officials have issued repeated assurances that the shutdown will not impact the Obamacare rollout, it does look as though there will be a fairly serious impact on the administration’s health IT program.  If HHS sticks to script, only 4 of 184 ONC employees will remain on duty during the shutdown. That makes it sound like activities are going to have to be scaled back just a bit.

If you’re counting on getting an incentive payment from the government for participation in the electronic medical records program, you may be in trouble — at least until the stalemate is settled.  Although ONC has not yet made an official statement,  presumably because the aforementioned Twitter channel has been disabled, leaving the agency unable to speak to or otherwise communicate with the public, going by the available information in the thirteen-page contingency plan drafted by strategists at HHS, it is unclear where the money will come from.

This could be bad news for electronic medical records vendors counting on the incentive program to drive sales as the Obamacare rollout gets officially underway.

Continue reading “Washington In Crisis: ONC Announces That It Will Not Tweet Or Respond to Tweets During Shutdown”

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Now that Labor Day has come and gone,  I’ve thought about the months ahead and the major challenges I’ll face.

1.  Mergers and Acquisitions

Healthcare in the US is not a system of care, it’s a disconnected collection of hospitals, clinics, pharmacies, labs, and imaging centers.  As the Affordable Care Act rolls out, many accountable care organizations are realizing that the only way to survive is to create “systemness” through mergers, acquisitions, and affiliations. The workflow to support systemness may require different IT approaches than we’ve used in the past. We’ve been successful  to date by leaving existing applications in place and building bidirectional clinical sharing interfaces via  ”magic button” viewing and state HIE summary exchange. Interfacing is great for many purposes.  Integration is better for others, such as enterprise appointment scheduling and care management. Requirements for systemness have not yet been defined, but there could be significant future work ahead to replace existing systems with a single integrated application.

2.  Regulatory uncertainty

Will ICD10 proceed on the October 1, 2014 timeline?  All indications in Washington are that deadlines will not be changed. Yet, I’m concerned that payers, providers and government will not be ready to support the workflow changes required for successful ICD10 implementation.    Will all aspects of the new HIPAA Omnibus rule be enforced including the “self pay” provision which restricts information flow to payers?  Hospitals nationwide are not sure how to comply with the new requirements.   Will Meaningful Use Stage 2 proceed on the current aggressive timeline?  Products to support MU2 are still being certified yet hospitals are expected to begin attestation reporting periods as early as October 1.   With Farzad Mostashari’s departure from ONC, the new national coordinator will have to address these challenging implementation questions against a backdrop of a Congress which wants to see the national HIT program move faster.

3.  Meaningful Use Stage 2 challenges

Although attestation criteria are very clear (and achievable), certification is quite complex, especially for a small self development shop like mine.   One of my colleagues at a healthcare institution in another state noted that 50 developers and 4 full analysts are hard at work at certification for their self built systems.   I have 25 developers and a part time analyst available for the task.   I’ve read every script and there are numerous areas in certification which go beyond the functionality needed for attestation.    Many EHR vendors have described their certification burden to me. I am hopeful that ONC re-examines the certification process and does two things – removes those sections that add unnecessary complexity and makes certification clinically relevant by using scenarios that demonstrate a real world workflow supporting the functionality needed for attestation.

Continue reading “What Keeps Me Up At Night – 2013 Edition”

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So, the question has been raised: why am I doing this?  Why re-invent the EMR wheel?  What is so different about what I am doing that makes it necessary to go through such a painful venture?  I ask myself this same question, actually.

Here’s my answer to that question:

What medical records offer:
High focus on capturing billing codes so physicians can be paid maximum for the minimum amount of work.

What I need:
No focus on billing codes, instead a focus on work-flow.

What medical records offer:
Complex documentation to satisfy the E/M coding rules put forth by CMS.This assures physicians are not at risk of fraud allegation should there be an audit.  It results in massive over-documentation and obfuscation of pertinent information.

What I need:
Documentation should only be for the sake of patient care. I need to know what went on and what the patient’s story is at any given time.

What medical records offer:
Focus on acute care and reminders centered around the patient in the office (which is the place where the majority of the care happens, since that is the only place it is reimbursed)

What I need:
Focus on chronic care, communication tools, and patient reminders for all patients, regardless of whether they are in the office or not. My goal is to keep them out of the office because they are healthy.

What medical records offer:
Patient access to information is fully at the physician’s discretion through the use of a “portal,” where patients are given access to limited to what the doctor actively sends them.

Continue reading “What I Need”

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The original Hipoocratic Oath states:

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

One modern version reads:

I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.

The idea here is that a doctor needs to recognize when another practitioner has a skill that they do not, and that they must refrain from “practice” when another person has demonstrable expertise in that area of practice.

It is now 2013. It is time for doctors to stop “writing their own EHR” from scratch. They need to bow out of this in favor of people who have developed expertise in the area.

I just found out about another doctor who has decided to write his own EHR, because he has not been able to find one that supports his new direct pay business model adequately. In the distant past I encountered a doctor who believed that his “Microsoft Word Templates” qualified as an EHR system. This is a letter to any doctor who feels like they are comfortable starting from-scratch software development for an EHR in 2013 or later.

You might believe yourself to be an EHR expert.

Are you sure about that? Are you sure that you are not just an EHR expert user?

This difference is not unlike your relationship with your favorite thoracic surgeon. Or for that matter, your relationship with the person who built your car. The fact that you are capable of expertly evaluating and using EHR products does not mean you are qualified to build one. Just like the fact that you are qualified to treat a patient who has recently had heart surgery or to discern when a patient might need heart surgery does not make you qualified to perform that heart surgery. Similarly, the fact that you can drive, or even repair your automobile, does not provide you with the expertise you need to build a car from scratch.

The ethical situation that you are putting yourself in by developing your own EHR is fairly tenuous. Performing heart surgery without being a heart surgeon, building and driving your own car without being an automotive engineer and a doctor coding their own EHR system from scratch all have the same fundamental problem: You might be smart enough to pull it off, but if you don’t you can really mess up another person’s life. Make no mistake, you can kill someone with a shoddy EHR just as easily as by performing medical procedures that you are not qualified for or by driving a car that is not road-safe.

Continue reading “Why Doctors Should Stay Out of the Business of Building EHRs”

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In the wake of the National Coordinator’s announcement that he is departing, there has been a flurry of tweets, blog posts, impromptu online polls, and conjecture about the most likely successor.  To date, none of these conversations has resulted in a thoughtful assessment of the set of characteristics that would represent the ideal candidate, nor has there been any thorough review of the most likely candidates in the context of these attributes.  The need for a rapid transition to a successor is well understood by all – yet there has been no indication that the Obama administration is in a hurry.  Let’s hope that we can evolve them toward a greater sense of urgency. The fragility of ONC – and the importance of its health – can’t be overlooked.

Let’s consider some history:

The first two National Coordinators, David Brailer and Rob Kolodner, were appointed before ARRA.  The agency was small, focused largely on certification (through CCHIT), standards (through HITSP) and policy.  When ARRA arrived, David Blumenthal, a thoughtful, deliberate, policy-savvy internal medicine physician from Boston was brought in to lead the rapid expansion of health IT that was facilitated by the HITECH Act.

ONC expanded under Blumenthal from a team of ~ 30 people to a team of >100 in the two years that he was at the helm, and the agency published the 2011 certification criteria regulations, and collaborated with CMS to publish the regulations that defined stage 1 of the Meaningful Use incentive program.  The policy foundation was that the three-stage program – to be implemented over six years – would evolve the nation’s care delivery system by causing adoption of EHR technology (stage 1) and then exchange of clinical information electronically (stage 2) and finally improved clinical outcomes (stage 3).

Farzad Mostashari, who joined Blumenthal as the Deputy National Coordinator early in Dr Blumenthal’s tenure, was quickly named as Blumenthal’s successor when Blumenthal announced his resignation in the Spring of 2011.  Both Mostashari and Blumenthal pushed hard for Mostashari’s appointment – so that the consistency, focus and forward momentum of the organization could be maintained.

And so it was.  Under ARRA, adoption of EHRs has skyrocketed.  The CMS MU Stage 2 regulations and the ONC 2014 certification regulations were published, and the size of the agency has doubled to over 150 people.  Recognizing the need for experienced partners to assist him in leading a larger agency – and growing national reliance on health IT and an essential component of the care delivery ecosystem – Mostashari hired David Muntz as the “Principal Deputy” (essentially the COO of the agency), Jacob Reider as Chief Medical Officer (leading a team of clinicians focused on quality and safety) and Judy Murphy as the Deputy National Coordinator for Programs and Policy (adding internal coordination support for ONC programs).

Continue reading “Replacing Farzad”

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In Shirie Leng’s excellent post, “The Email I Want to Send To Our Tech Guys But Keep Deleting, Dr. Leng lists a series of problem areas which plague software development in healthcare. Making things better requires taking a closer look at the specs we use. The new-age consumer-focused software companies can build products with outstanding usability because they start and end with the specs.

I have spent time at several academic medical institutions, and their software solutions are very much the same. At one, I was given this five-page table of portals and documentation systems with instructions on how to log in.


The punchline: I’m asked to have a different username and password for each of them.

I give much credit to the physicians who navigate these software applications, including the one that compiled the list I showed above. But physicians have allowed poor design of their technological solutions for too long, and have neglected to demand interoperability from software vendors.

The number of required training hours is a good indicator of usability. (And many of the items on the list come with long training hours.) While physicians have accepted these courses as part of their jobs for years, why should formal training be necessary to operate an EMR? Most of the tasks of ordering and documentation are no more complicated than paying your credit card bill or shopping online.

I’ll only scratch the surface of this usability problem by highlighting several notably poor implementations. I won’t even get into the inefficiencies in ordering and documentation.

My first example is an EMR system that is used to order medications and communicate data with nurses [below]. At a glance, there are no fewer than seven distinct menus on the screen at the same time. In my experience using this EMR, I’ve clicked ten percent of these buttons (and I would estimate that 90% of the work occurs in 5% of the buttons). The poor organization of information leads to lengthy searches for the right information, and often, the unawareness of critical information that is hiding under a nondescript label.

Lesson: Menus should have clear hierarchy.

My second example is a shift-scheduling application [below]. Here is an example of of how applications can invent interfaces rather than using the ones familiar to us. The primary menu is on the left-hand side. Upon clicking on one of these options, the secondary menu is displayed right below the header. The tertiary menu, however, goes back to the left-hand side. The issue here is a lack of consistency and predictability.

Continue reading “How Programmers Think: A Doctor’s Guide to Building a Better EMR”

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MASTHEAD


Matthew Holt
Founder & Publisher

John Irvine
Executive Editor

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Editor

Alex Epstein
Director of Digital Media

Munia Mitra, MD
Chief Medical Officer

Vikram Khanna
Editor-At-Large, Wellness

Maithri Vangala
Associate Editor

Michael Millenson
Contributing Editor










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