Liquid Vapor

For the uninitiated, every year HIMSS runs a big huge trade show for EHR and HIT vendors, which is to the HIT industry what Oscar night is to Hollywood. No, HIMSS does not award any prizes or trophies, but it occasions the same breath taking congregation of all industry glitterati in one place, complete with clever little parties and big extravagant shows. There were well over 30,000 people at this year’s HIMSS11 conference, and although I wasn’t one of them, I made sure to follow the events through the steady Twitter stream and many excellent blogs, reports and interviews, because what happens at HIMSS is good indication for what the HIT industry is doing and where it is going. So to summarize all the excitement, the established HIT folks are doing Meaningful Use, which has become yesterday’s news, with HIE being the next project on the books. Everything is being pushed to tablets and the cutting edge innovations are all about a myriad of small Mobile Health (mHealth) applications. Analytics and business intelligence is looming large on a horizon filled with provider consolidation, capitation and value-based medicine.

On the surface, this seems a very logical succession of events. Meaningful Use is collecting data, HIE will make it liquid and, as predicted, 1000 flowers of innovative mobile applications will eventually be blooming to bring the liquid data to consumers and innovators who will slice and dice it to provide us all with unimaginable medical utility. However, in the excitement of anticipation on those balmy Florida nights, it is easy to overlook the fact that this entire chain of events is based on one assumption: somewhere, somehow, someone will have to enter data into the system, consistently, accurately and in minute detail. For free. Is there a problem here?

Well, it depends on who you ask. The Meaningful Use regulators, encouraged by the stated intentions of many physicians and hospitals to seek Meaningful Use incentives, are probably assuming that data will be dutifully entered into HIT systems. HIT vendors seem even more certain in their assumption that data will accumulate in their systems, since very few, if any, are doing anything about data entry user interfaces. The same forms and templates sold four, five years ago remain unchanged in the Meaningful Use certified, and iPad enabled EHR versions of today. If you ask physicians and nurses, they will invariably tell you that they resent being turned into “data entry” clerks. And, yes, unlike other industries where computerization of records seemed to have worked wonders, in health care data entry must be done by the scarcest and most expensive resource in the system. Some of those expensive resources decided to do what highly paid executives have done decades ago: hire a stenographer, or in health care parlance, a scribe; interesting idea, but a partial solution at best, and a new source of errors and inaccuracy, at worst. So, how is it that 41% of physicians and 81% of hospitals believe that they can achieve Meaningful Use, which comes with rather prescriptive data collection requirements?

One answer would be that doctors and nurses everywhere are just fine with clicking on as many boxes as needed to qualify for government incentive funds. Clicking 4 Dollars may turn out to be a successful strategy. Another possibility would be that data collection requirements embedded in Meaningful Use are not so obvious to the naked eye. The place to look is the long list of Clinical Quality Measures. For example, a simple measure such as Adult Weight Screening and Follow-Up (NQF 0421), has the following description: “Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside parameters, a follow-up plan is documented.” Sounds simple; the nurse weights everybody anyway, and the EHR calculates BMI on the fly, so no problems here. Or are there?

What is the meaning of “a follow-up plan is documented”? Does it mean that you type into the Plan section something like: “recommend 30 minutes walks every day and low fat diet”? Eh, not good enough. First the EHR needs structured data fields to perform calculations and your free text is unusable. Second, this is not a follow-up plan. A follow up plan would involve gastric surgery, referral to dietician, referral to exercise classes or at the very least a V65.3 added to a visit. All the sanctioned CPTs for these activities are provided by NQF (not sure how they end up in your chart though). Just a few more clicks, but we’re not done yet. Like most measures, this one has exclusion criteria, i.e. patients for whom you need not document a follow-up plan. So if you don’t document one, you must specify the reason. Did the patient refuse to discuss such plan, or was there a medical reason not to have a plan, or perhaps the patient suffers from a terminal illness? Need a couple more clicks here to complete this one measure. Does your certified EHR have all those boxes for you to click on?

This was one of the simpler quality measures. If you are interested in hospitals, you may want to look at this CSC report which uses VTE prophylaxis as an example of the mind numbing complexity of data elements required for accurate reporting. As far as Meaningful Use is concerned, if you don’t collect all data elements and your quality measures numbers are less than stellar, there is no harm done. The incentives are not dependent on perceived quality. However, if you’re a physician, maybe not today, maybe not tomorrow, but soon, your paycheck will be dependent on little else. And whether you are an EHR vendor, an HIE vendor, a data analytics middleman or a brand new mHealth vendor, your financial success will be inextricably tied to the amount and accuracy of data entered by clinicians at the point of care. You cannot make liquid that which does not exist.

Solutions? We could continue to apply pressure to practicing clinicians in the hope that the vapors will condense into droplets of liquid data. We could also look for objective liquid data somewhere else, but for some reason I am starting to think that those who want data, are more interested in patient and physician generated data, perhaps because of its inherent richness of intimate details. We could also create EHRs which will allow one-click documentation-by-exception of “normal” quality measure elements, similar to what we did for CMS reimbursement required data elements, and with similar results, i.e. 12 pages of irrelevant visit notes (Bingo!!). Or we could look for true innovation in human computer interaction which will make data collection a transparent byproduct of the practice of medicine. Until then, all the Internet pipes and all the tagged and untagged content flowing through them and all the master patient repositories and all massive provider directories will provide only incrementally better clinical utility than electronic faxing.

Margalit Gur-Arie was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization. She shares her thoughts about HIT topics and issues at her blog, On Healthcare Technology.

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14 replies »

  1. It’s hard to put into words how discouraged this post and the one by Mr. Moore make me feel. So much money being siphoned away from true healthcare reform to be spent on products that don’t seem to do anything worthwhile.

  2. Brad, to be honest, as long as data entry is assumed to occur through keyboards, mice, touch, etc., and information extraction is assumed to occur the same way, there will be only limited improvement to what you see.
    That being said, I do believe that, for the short term, usability work can be successfully done to significantly improve what is out there now. Putting pressure on physicians to use products, in their current state, is a big disincentive to investment in usability, which would occur if market forces were allowed to operate freely.
    I am also very skeptical of having the government “certify” usability, which seems to be the latest idea floating out there,

  3. Never have I used such dangerous and rigid devices for medical care as is CPOE. EHRs promote cut and paste meaningful mindlessness. The reports and progress notes are vapid billing statements.

    Patients are suffering while doctors and nurses are clicking and billing. HIMSS has dead patient’s blood on its hands. CCHIT is an accessory to the fraud.

  4. Margalit,
    Got it, but a bit overly near term optimistic, dont you think?. We’ll get there eventually, but folks have to plan for the next 5-10 years, and work flow consideration and EMR design can only move so fast. I dont see anything on the horizon to meet my, and the needs of other providers for the next few years.

    I should add, I dont like current EMR designs, and yes, they are all conceived on a platform to adhere to payment and administrative ideals, not what we need to do our work.

    We will wait.


  5. Jonathan, if we are going to expand beyond pure technology, and we should, I think they ought to get rid of those 1995 and 1997 E&M guidelines. Perhaps replace the number of organs and systems with just plain time spent with patients, so 30 or 45 minutes would be a level 5 and downwards from there.
    The next thing on my wish list would be to significantly increase PCP payments. Such investment will probably pay for itself and then some, so no need to take anything away from specialists.
    If we do all this, we should probably have train additional primary care docs because if PCPs spend enough time with each patient to make a real difference, AND document properly (as they define “properly”), there will certainly not be enough trained physicians to go around.
    I never understood why we keep talking about shortage of doctors but do very little to graduate more.

  6. Margalit, I agree that a tighter integration of voice recognition with the structured data fields of EMRs, informed by a sophisticated understanding of workflow, should be included in the next generation of the technology.

    As you know, payment on a FFS basis is also a problem for documentation, because physicians are paid by volume and only enough documentation to get paid. So, clearly, basing payment in a significant way on documenting quality of care would help.

    Thinking big, I’d say another thing that would help 10 years down the road would be to train and hire another 100,000 primary care physicians. When this is combined with a job outlook focused on quality more than volume, it would help avoid the overbooked, rushed physicians who schedule 15 minute appointments but are only in the room with the patient for 10 minutes. Hard to do a lot of documentation in that circumstance.

    To pay for the extra PCPs, the ethical thing to do is to lower the pay of specialists so that the net cost is zero. Of course, politically that is a hard slog.

  7. MD as HELL, in spite of my affinity for technology, I do agree that there are more immediate issues in health care that need resolution, which should probably take precedence….

  8. Bobby and Brad,
    I am thinking about voice recognition tuned to perfection. I know people are working on natural language processing and voice recognition, but right now the quality, in my opinion, is nowhere near what is needed for medical purposes. I have a vision of the EHR “sitting” in the exam room and picking up on the ongoing dialog and documenting pertinent data. I suspect that we will need some sort of technology breakthrough to get IBM’s Watson to actually capture, process and “understand” things on the fly…. and by the same token, respond intelligently to verbal requests for information in plain English. I’m not holding my breath, but I think this is where it has to go.

  9. @BobbyG

    You literally took the words out of my mouth. With baited breath, I waited for the answer you are looking for as I continued reading the post. Did not arrive.

    Margarlit: Please enlighten, and be as specific as feasibly possible.


  10. My hospital’s computers crashed last night, as did the Dictophone. It took forever to get a patient transferred, not because of the computer, but because of the lack of incentive to accept the patient. Taking care of this insured but critically and acutely ill woman was not a great enough opportunity.

    The doctor accepted her promptly. the state owned hospital to its everloving sweet time assigning a bed. They had beds, but they had no indication they felt any urgency to get her a bed so we could get her moving to the ICU she needed.

    Seamlessly transferring information is hardly necessary until the patient can be beamed, too.

  11. I had no idea when I first started reading THCB, that the article authors and commenters were mostly the same people. Just commenting on one anothers blog posts. Very disappointing.

  12. “Or we could look for true innovation in human computer interaction which will make data collection a transparent byproduct of the practice of medicine.”

    What, in your view, might this look like? I am sympathetic to this entire problem faced by clinicians, given that it’s driven by the billing imperative.