We continue to see progress in improving the nation’s health care system, and a key tool to helping achieve that goal is the increased use of electronic health records by the nation’s doctors, hospitals, and other health care providers. These electronic tools serve as the infrastructure to implementing reforms that improve care – many of which are part of the Affordable Care Act.
Doctors and hospitals are using these tools to reduce mistakes and hospital readmissions, provide patients with more information that enable them to stay healthy, and allow for rewarding health care providers for delivering quality, not quantity, of care.
The adoption of those tools is reflected today in a release from the Centers for Disease Control and Prevention’s National Center for Health Statistics which provides a view of the Medicare and Medicaid EHR Incentive Program and indicates the program is healthy and growing steadily.
The 2013 data from the annual National Ambulatory Medical Care Survey are encouraging:
- Nearly 80% of office-based physicians used some type of electronic health record system, an increase of 60 percentage points since 2001 and nearly double the percent in 2008 (42%), the year before the Health Information Technology and Economic and Clinical Health Act passed as part of the Recovery Act in 2009.
- About half of office-based physicians surveyed said they use a system that qualifies as a “basic system,” up from just 11% in 2006.
- Almost 70% of office-based physicians noted their intent to participate in the EHR incentive program.
Figure 1. Percentage of office-based physicians with EHR systems: United States, 2001-2013
The report also noted that 13% of physicians who responded said they both intended to participate in the incentive program and had a system that could support 14 of the Meaningful Use Stage 2 “core set of objectives,” ahead of target dates. This survey was performed in early 2013 – before 2014 certified products were even available.
The deadline to begin attesting for Meaningful Use Stage 2 is October 2014 for the earliest adopters of Meaningful Use Stage 1, so more than one in ten physicians decided on their own to participate Meaningful Use Stage 2 capabilities more than a year earlier than necessary. These are early adopters who recognize the benefits of EHRs.
“From 2010 through 2013, physician adoption of 7 of the 17 capabilities required for Stage 2 core objectives for meaningful use increased significantly,” according to National Center for Health Statistics health-policy researcher and lead author Chun-Ju Hsiao, PhD. Electronic prescribing through an EHR and adverse drug event/contraindication alerts had the largest increase among the stage 2 capabilities, Hsiao wrote.
In 2013, Meaningful Use related functionalities with the highest adoption rates included capabilities for recording key patient health information and functionalities related to medication management and safety. About three-quarters or more of physicians had these types of computerized capabilities.
Notably, physician respondents to another national survey also noted the clinical benefits in using EHRs, including that they helped physicians access records remotely (81%), and alerted providers of a critical lab value (62%). Most importantly, 78% of respondents said that EHRs “overall, enhanced patient care”.
Overall, we are encouraged to see that physician adoption of EHRs meeting Meaningful Use Stage 2 is increasing significantly and that physicians are recognizing the value of EHRs in the care setting. The report does also tell us there is more to do and we agree. Fewer than one in three respondents (30%) said their EHR facilitated a communication with a patient via e-mail/secure instant messaging.
At ONC we look forward to continuing to work on key issues such as usability and improving functionalities so we can all see the promise of EHRs and health IT to improve care and eventually health.
Figure 2: Percent of physicians with selected computerized capabilities related to Meaningful Use objectives, 2013
Data Source: CDC/NCHS, National Ambulatory Medical Care Survey, Electronic Health Record Survey. Notes: VDT is “view online, download or transmit”. Data represent non-federal office-based physicians providing direct patient care in the 50 states and the District of Columbia, excluding radiologists, anesthesiologists, and pathologists.
Karen DeSalvo, MD, MPH, MSc. is the National Coordinator for Health Information Technology at the U.S. Department of Health and Human Services. More information about the Office of the National Coordinator for Health IT and health information technology can be found at www.HealthIT.gov
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Yes, the EHR incentive program is “on track”. Yet, this doesn’t really mean much.
Computerizing something doesn’t magically fix it.
Giving more info to patients should be a good thing, but then the patients have to actually care about the information and do something with it…this is where the real challenge comes in.
Also, for those who thing MU helps usability…where does this come from?
Ask any end user and they’ll complain about how many times they have to click is different areas just to get one MU “counter”.
what is PracticeFusion and pharmas doing together? Have you seen their recent press release. http://www.forbes.com/sites/kashmirhill/2013/10/24/practice-fusion-reviews-whoops/
My response to this post: http://www.emrandhipaa.com/emr-and-hipaa/2014/01/22/meaningful-use-program-a-success-depending-on-how-you-measure-success/
Needless to say, we all measure success very differently.
“Given the recent Robert Wood Johnson Foundation report (Time to Act: —), it appears that the best way to reduce the cost of healthcare is not to invest in HIT but to invest in our communities so as to prevent disease before it happens.”
In other words- our prioritization of investing in physicians, their institutions, and the whole medical model is also misguided. Or do we not like that uncomfortable reading of the data?
See http://tinyurl.com/l6vsxly
Agreed that policy wonks often focus on the wrong things, though depending on where that wonk sits in the political system they are probably legally bound to base what they focus on on public input, as somebody mentioned earlier in this thread. This really does seem to be the least understood aspect of the American political system- legislators are the only ones who get to just make stuff up. Regulators have highly defined rules for public comment and rule-making within the parameters of a given piece of legislation.
Aside from civics class- I’d say us physicians also pay little more than lip service to this idea of prevention and the creation of healthier communities. Usually that means I want to be reimbursed for counseling on weight loss and exercise, not I think you shouldn’t pay me for that at all and instead should fund easy access to fresh produce and safe environments for everyone to get outside.
We especially don’t like any suggestions that such outreach and services would take place without a physician in charge. God forbid for example we use midwives in a community prenatal and birthing model the way countries with the lowest maternal mortality and morbidity rates do. As if we are taught anything about building a healthy community in medical school beyond hearing the sad statistics, or at best doing a one year fast track MPH.
Thanks. Great comment.
These entrepeneurial programs are a direct result of the government’s ill conceived rules and laws to control costs: http://www.nytimes.com/2014/01/19/health/patients-costs-skyrocket-specialists-incomes-soar.html?_r=0
Gee whiz, do ya think that doctors are willing to be data clerks and clickers and do windows for the likes of J . Faulkner and N. Patterson, who have sold poorly usable medical devices endorsed by the likes of K. DeSalvo, F. Mostashvitz, and K. Sebelius, under the guise of Meaningful Use?
The programme of HITECH and the embellishments of ONC are ill conceived and cloaked with vendor financial influence, and undoubtedly will have formidable unintended consequences.
url correction, I think.
Try this to see commercial uses of feral, escaped, medical data:
To see the commercial uses of escaped medical data read the registration statement–Form S-1–of IMS Health Holdings,Inc. filed with the SEC, Jan. 2, 2014: http://www.sec.gov/Archives/Edgar/data/1595262/000119312514000659/d628679ds1.htm
Once digital always public.
@kdesalvo
Hello Karen:
What are your thoughts about the multi million dollar industry for EHR scribes needed because the EHR tools are poorly usable?
http://www.nytimes.com/2014/01/21/health/an-outdated-solution.html?emc=edit_tnt_20140120&tntemail0=y
TO THE EDITOR:
Re “A Busy Doctor’s Right Hand” (Jan. 14): I wholeheartedly agree that scribes could alleviate physician dissatisfaction and let physicians do “the work they went into medicine for in the first place.” But scribes are an expensive and misguided 20th-century solution to a 21st-century problem. The fact that there is such a market for them shows that systems have not been tested adequately for usability.
Electronic health records in their current form are not designed for the workflow of the end user, the physician. Instead of creating a new work force of scribes, health technology vendors should design interfaces that are easy to use and reduce cognitive demands on physicians.
Edward R. Melnick, M.D.
New Haven
__
“health technology vendors should design interfaces that are easy to use and reduce cognitive demands on physicians.”
Well, yeah. That IS what is needed. Everyone knows that. But, a huge part of the problem is the paradigmatic 15 minute office visit. Entering, editing, or just traversing hundreds of data elements comprising FH, SH, PMH, CC, HPI, vitals, active meds list, active problems list, labs, referral reports, ROS etc — all leading to an effective SOAP and accurate coding.
It’s just too much. Productivity treadmill / assembly line medicine.
I think docs should be paid like lawyers, hourly. And paid well, like lawyers — the good docs. When I did the Guardianship I needed on my now-late dementia-addled dad, the attorney was $300/hr (that’s cheap any more). However long it took to assessment the estate financial health and devise an effective “plan,” well, that’s what it took. The whole thing cost me about 4 grand. Had to have it.
@kdesalvo
*******delivering quality, not quantity, of care******
Has she not read about using the EHR tools to construct 7 page progress notes? Has she not read notes of dermatologists’ cardiac exams, constructed to bill the max? just wonderin
Zero evidence that EHRs improve quality, outcomes, or costs.
If quality includes intreating with patients, it is deteriorating. Doctors and nurses now interact with EHR tools while patients lay in neglect.
Let’s hear from K. DeSalvo on the evidence backing up her statements. Mr. Gladd, I am glad to read what you say, but you seem highly committed, almost biased.
Whatsen, I am not an IT geek, nor am I shilling for any Health IT vendors. I am an experienced data analyst, foremost.
When I worked for the REC, I routinely called bullshit on the stupid stuff at every turn (much to the irritation of my then- REC Executive Director, who berated me openly in the company for my blog and “exceeding your scope.” [bleep] her; I just kept right on). My interests are in process improvement, and obviously clinical outcomes improvement.
http://tinyurl.com/9ombbgs
I hope to get some face time with Dr. DeSalvo this week at the ONC conference in DC to probe her on some of these issues. I am going there on my own dime. I take no funding from anyone, and my blog is strictly independent and not-for-profit.
I AM in fact biased in favor of appropriate information technology, in any field.
But, see my “Clinic Monkey” spoof site and ask, “is this guy a HIT Kool-Aid Drinker”?
Seriously?
Peter1 says:
“Legacy, are you saying there is really NO advantage and we would be better off using the phone and the mail – other technologies which needed implementation over time?”
No. I believe a well designed EMR can be helpful to patients and physicians. However, EMRs are designed for the benefit of the Government, Hospitals, Billing Departments, etc. NOT for the benefit of patients or physicians.
The best example of physicians hunger for GOOD electronic medical records is what happened recently at the U of Oregon. The residents, frustrated by the cumbersome, user unfriendly, EMR chosen by the hospital system put together their own EMR based on a spreadsheet and posted it on Google Groups.
Of course everyone was aghast at all the HIPAA violations this entailed but think about what it really meant:
1) Physicians (residents in this case) want an electronic medical record and will embrace one that is useful and reasonably easy to use.
2) The hospital EMR (approved by the government and insurance companies) was so bad, they felt it necessary to create their own instead.
I think that incident says more about the usefulness of EMRs to physicians and patients than anything that comes from Karen DeSalvo or any of the other apologists for EMR that post on this blog.
Legacy, Is it buyer beware?
Is this better/different?
http://www.epic.com/about-index.php
“How we’re different:
Epic’s on-time, on-budget track record is one of the best in healthcare, as rated by independent reviewers. Epic software is quick to implement, easy to use and highly interoperable through industry standards. Information is shared securely in two ways: Care Everywhere, where the doctor controls the flow of data across organizations, and the Lucy PHR, where patients control their own health information.”
“Why we’re different:
Founded in 1979, Epic is private and employee-owned. We develop, install and support all our applications in-house. Epic’s leadership team includes clinicians, developers and process experts – people deeply experienced in patient care and healthcare technology.”
Being installed at my wife’s hospital. I can let you know what she thinks.
EPIC is much unloved in many quarters. Their CEO is on the ONC Health IT Policy Committee, a glaring conflict of interest to many. The Meaningful Use initiative is seen by some as The Judy Faulkner Corporate Welfare Act.
http://www.forbes.com/sites/zinamoukheiber/2013/05/15/a-chat-with-epic-systems-ceo-judy-faulkner/
Is your wife a Physician?
How she likes Epic depends on what she does. If she is an Administrator, she will love it. If she is in the billing department she will love it.
If she has to enter data into it – not so much.
As Bobby Gladd says most physicians don’t like it and find that it increases their workload and slows them down.
Wife is nurse manager, but has to learn Epic to be launched April. Docs are helping to design it. When she was at Presence Hospital in Chicago the admitting nurse liked it. Physicians don’t like anything they can’t pass off to someone else.
I don’t know how any hospital would be able to operate without a computer. Maybe you should start Luddite Hospital.
Peter1,
You will note that I never advocated not having computers, but merely well designed software.
“Physicians don’t like anything they can’t pass off to someone else.”
Written like a nurse manager. And as usual, your charm shines through.
@Peter1 says:
“…people don’t insist enough that the technology work for the user and not visa/versa, and that too many software venders mislead buyers . Since Bobby Gladd is a vender [sic] maybe he can expand on that.”
__
I’ll have my Director of Marketing get back to you.
http://ClinicMonkey.blogspot.com
😉
“These electronic tools serve as the infrastructure to implementing reforms that improve care”_DeSalvo
I am not aware of any data showing improved outcomes or reduced costs from HIT. Are not “electronic tools” medical devices as device by the F D and C Act?
“Are not “electronic tools” medical devices as device by the F D and C Act?”
__
No.
Delete my post if you feel that’s indicated.
I’ll just point out that there was nothing personal or ad hominem in it, only a blunt critique of the quality of thought and analysis in the original post.
@karen_desalvo
Please explain why these instruments of care have been promoted and sold for more than a decade and have not undergone FDA approval as being safe and effective, let alone usable?
And now, you put out the SAFER Guidelines, which ignored the recommendations of the IOM. Why was the IOM ignored?
@Bobby-You are incorrect. We do read your comments. We do moderate. Please do not speak for us.
@Hayward-Thank you for taking the subject seriously enough to hold yourself to the high standards of decorum we appreciate.
@Granpappy: Hayward is correct. That sort of attack is uncalled for and inapppropriate. Consider yourself warned.
Your comments–and this portion of the thread–will be deleted shortly.
You “moderate” post hoc, not going in. That’s what I meant, and that is indeed the case.
Yes, you are absolutely correct, and that is why sites that have a lot of politics or other issues of intense debate by hyper partisan or extremist zealots should moderated. I do at mine, which is a health care site that at other similar sites have antiphysician trolls who gleefully write garbage when such other sites allow immediate gratification.
I hope the editors here think about the erosion of decency in discussions here on the net in considering moderation. I accept that as a limit on me.
I wonder about the EHR. Without a standardized vocabulary and maybe even an OS, can it live up to its interoperability promises? Does it actually carry as much information? …cf a handwritten chart (which actually is a sort of scrapbook and includes things the patient might have brought in like newspaper articles and specimens …”this was stuck in my ear, doc”.) There is also a lot of unwritten meaning in a handwritten chart: Bold writing. Weak writing. Unfinished sentences. Colorful pens and pencils. Circles around words. Writing also reminds the reviewer of moods and feelings that one might have had whilst writing the original. Was I laughing at the patient? Or distrustful? Or incredulous? All this is added information. The rapidity with which we can assimulate meanings when we see our own handwriting compared to when we are reviewing sterile printed text seems obvious. We are more efficient, therefore, when we review old charts.
It may be, however, that the sine qua non of handwriting advantages lies in security and HIPAA. Once digital, forever public. It could well be that future patients will demand that their health care information be in handwriting (or encoded).
“The activities and entanglements of the various MDs who participated in the public input for the MU program ran the gamut. There’s a public record there.”
An excellent non- answer.
It’s all there for you. I’m not your gofer.
That was harsh. Sorry.
Bobby,
Normally when people make statements like “it’s all there for you” they include some type of reference. You have not done so and I don’t know where “there” is. (Admittedly, if I was more dedicated or didn’t have a job and other interests I could hunt try to hunt down the information. I have better things to do with my time – like watch football)
Secondly, to say that there were many comments made by practicing physicians, doesn’t mean that any attention was paid to those comments. And if no attention is paid to comments, there is no true “input”. Its a little bit like the old western joke:
“Are you going to hang me?”
“No, first we are going to have a trial, then we will hang you”
Translation: It doesn’t matter what you say, we have decided what to do.
It is the sense of many physicians that most EMRs were designed according to the following criteria:
1) What is easiest and more profitable for the EMR company.
2) What the government wants
3) What the insurance companies want
……………….
47) What is best for the patient
48) What is easiest for the Physician to use
As many people have already pointed out, the fact that EMRs are being adopted has everything to do with the power of government, insurance and hospital bureaucracy and little to do with the benefits of EMRs to patients and physicians.
Peyton Manning to embarrass Seattle in 2 weeks.
Amen to Legacy.
Nice touch with listing patients and doctors at #’s 48 and 49!
http://www.healthit.gov/buzz-blog/ehr-case-studies/meaningful-ehr-ehr-preventing-hospital-readmissions/
“All of the above would not have been possible without the Riverdale Family Practice’s commitment to its electronic health record system.”
“little to do with the benefits of EMRs to patients and physicians”
Legacy, are you saying there is really NO advantage and we would be better off using the phone and the mail – other technologies which needed implementation over time?
I agree though that people don’t insist enough that the technology work for the user and not visa/versa, and that too many software venders mislead buyers . Since Bobby Gladd is a vender maybe he can expand on that.
Peter1:
To imply that it’s impossible to get a discharge summary promptly without an EHR and MU is just total baloney, and just goes to show how the boosters are clutching at straws.
And how would you like to be a patient of that doc who apparently schedules them every 10-12 minutes?!
No one who is genuinely concerned about health care first and foremost supported the development of “let’s pass this bull, er, bill and find out what’s in it later” Obamacare. But, again, facts and transparency aren’t traits of this administration, eh?
Just like what the EHR/EMR is about too?
Bobby Gladd,
“Anyone familiar … this program … knows that there was heavy and sustained public input from all stakeholder segments … including many, many practicing physicians.”
I am surprised by this statement. Some questions:
– Were they really practicing, or were they academic docs and MD MPHs?
– Were they employed or did they accept money from the EHR companies?
– Was their input listened to/acted upon or were they ignored?
I am a practicing physician and I am familiar with the process of “giving input”. Sometimes your input actually makes a difference. Sometimes your input is ignored.
“Sometimes your input actually makes a difference. Sometimes your input is ignored.”
__
That’s just life in general.
The activities and entanglements of the various MDs who participated in the public input for the MU program ran the gamut. There’s a public record there.
Against incredibly stiff competition, the original post is the biggest piece of bullshit ever to show up on THCB.
You haven’t read old posts by Maggie Mahar here, but I guess for current posts, you probably are correct. Oh, but the editors do reveal their agenda by including Rob Reich of The NY Slimes. You should catch the video of Newt Gingrich putting Reich in his place when Reich tried to pin the hopeless War on Poverty on the Republicans!
“You should catch the video of Newt Gingrich putting Reich in his place when Reich tried to pin the hopeless War on Poverty on the Republicans!”
http://www.politifact.com/punditfact/statements/2013/dec/15/newt-gingrich/new-gingrich-says-poverty-problems-are-tied-democr/
“The poorest states, based on per capita income, are, from first to last: Mississippi, Arkansas, Tennessee, West Virginia, Louisiana, Montana, South Carolina, Kentucky, Alabama, and North Carolina. Of these, exactly half—Arkansas, Kentucky, Montana, North Carolina, and West Virginia—have Democratic governors and three have Democratic majorities in the lower house of their legislature…”
You’re an idiot.
No, the point of the comment was the fact that most poverty is in major cities, fairly much all run by Democrat mayors and legislatures in those cities. For 50 years in many of those cities, Baltimore one I know well.
So, who is the idiot, one who cherry picks some stats, or, what are equally facts that show a party that talks a great game, but then sacrifices those they use for votes, for decades.
Oh, and my allegiance is to the public, neither party that rule America. Thanks for illustrating the partisan agenda I know is prevalent at these blog threads.
http://en.wikipedia.org/wiki/List_of_the_poorest_places_in_the_United_States
You have your resources and stats, P#1, and I have mine.
Let readers decide by researching all the info on their own who is honestly fighting for people who are struggling, and who is just putting on a show for votes each election year.
here is my last reply on this matter,
http://www.wbal.com/article/104941/12/violent-crime-in-baltimore-city-is-acceptable-what
It is what the Police Commissioner said last week, as readers can google “Baltimore City Commissioner and acceptance of murder & Baltimore Sun & 2014” and read more, just for here alone, a bastion of Democrat RULE for 50 years plus now.
Yeah, I am glad I am not in Mississippi, but I bet the Republican leadership there is a bit honest about what they will and won’t do; the Democrats, who by the way were AGAINST desegregation in the South up into the mid 1960s, well, they have suppressed that lie for decades longer, eh? Why did they quit that attitude, or perhaps the better question is, how did they reframe it and get the black vote?
The African American culture is so much improved with Barack Obama in office for 5 years now, eh? Those unemployment numbers alone for males are inspiring, true, P#1?
George Carlin said it best before he died, “the real rulers of this country don’t want an educated, informed public.” And all you apologists and defenders of said rulers continue the spin machine.
And the general public sucks it up!
The computer has been down since Tuesday night. Back to paper.
Ahhh! What a refreshing development. Giving verbal orders instead of CPOE. Writing orders on a chart anywhere in the department instead of going back to the computer at the far end of the dept. Dictating for a transcriptionist instead of Dragon which is really a bad system attached to Meditech.
Things are getting done much faster. Patient stays are shorter. Room assignments for admission are quicker and patients go to their rooms in a shorter period of time.
PACS, the best piece of technology for the clinician, still works.
What was it we were on track for with EHR? Whatever it is (was), it’s not patient care.
Nice point here, what happens WHEN the system crashes? Does care freeze? Or do clinicians just turn to a dart board to make decisions?
Us 30+ year docs just do what we have always done…provide great care. With no computer I have much more time for either the paitent or for more patients.
If what I do needs to be injected into a computer, someone else who cannot do what I do needs to put it in.
What happens when the power in your office goes out?
Do you demand access to your tinderbox and oil lamp?
No, you turn to your backup.
Do you have one?
Love it.
Typical, have to buy more IT products because we have to expect these wonderful technological advancements are going to fail.
Gee, really refutes my earlier comment about HIT being today’s snake oil salesmen. Fits perfectly with working for Obummer.
What happens when the power in your office goes out?
Do you demand access to your tinderbox and oil lamp?
No, you turn to your backup.
Do you have one?
Wow – missed the point entirely. Why would you want a backup when things run so much better when it crashes?
Karen DeSalvo, MD, MPH, MSc. is the National Coordinator for Health Information Technology at the U.S. Department of Health and Human Services.
That should’ve been at the beginning, not the end of the article, as a warning. Kinda like, “Abandon all hope of finding meaning, ye who read here.”
Dr. DeSalvo is serving up the KoolAid.
Drink as much as you like!
Dr. DeSalvo is defending a program that was put in place by her predecessors. The notion of meaningful use may be a misguided one designed by academics who don’t understand the realities of the system, but that doesn’t make the goal of EHR adoption a bad one. You’re confusing poor execution with a poor goal.
If ONC wants to win this fight they will
A. take steps to prevent EHRs from being turned into high tech torture instruments by reducing unneeded bureaucracy (oxymoron alert: “digital paperwork”) Until they respond to critics, the attacks will only intensify. By saying nothing they will appear clueless and complicit. B. Open up the system to competition by making it possible for new competitors to enter, encouraging solutions to the design problems and sloppy work we’re seeing on the part of vendors. C. Develop safety and regulatory regimes that address some of the early problems we’re seeing. This is not optional. It is necessary. D. Work with Congress and the White house, to develop data portability and compatibility rules that allow information to flow freely. This is as important as net neutrality but completely misunderstood. E. Develop privacy rules that balance the needs of commerce, science and the consumer. Doing A-E will involve paying a political price. Otherwise we get what we pay for.
Nice comment. But
“designed by academics”
__
Not true.
Anyone familiar with the way this program was rolled out knows that there was heavy and sustained public input from all stakeholder segments at EVERY step along the way — including many, many practicing physicians.
“develop data portability and compatibility rules that allow information to flow freely”
__
One Comprehensive Data Dictionary Standard. Problem largely solved. From my REC blog:
__
One.Single.Core.Comphrehensive.Data.Dictionary.Standard
One. Then stand back and watch the Market Work Its Magic in terms of features, functionality, and usability. Let a Thousand RDBMS Schema and Workflow Logic Paths Bloom. Let a Thousand Certified Health IT Systems compete to survive. You need not specify by federal regulation any additional substantive “regulation” of the “means” for achieving the ends that we all agree are desirable and necessary. There are, after all, only three fundamental data types at issue: text (structured, e.g., ICD9, and unstructured, e,g., open-ended SOAP note narrative), numbers (integer and floating-point decimal), and images. All things above that are mere “representations” of the basic data (e.g., text lengths, datetime formats, logical, .tiffs, .jpegs etc). You can’t tell me that a world that can live with, e.g., 10,000 ICD-9 codes (going up soon by a factor of 5 or so with the migration to ICD-10) would melt into a puddle on the floor at the prospect of a standard data dictionary comprised of perhaps a similar number of metadata-standardized data elements spanning the gamut of administrative and clinical data definitions cutting across ambulatory and inpatient settings and the numerous medical specialties. We’re probably already a good bit of the way there given the certain overlap across systems, just not in any organized fashion.
Think about it.
Why don’t we do this? Well, no one wants to have to “re-map” their myriad proprietary RDBMS schema to link back to a single data hub dictionary standard. And, apparently the IT industry doesn’t come equipped with any lessons-learned rear view mirrors.
That’s pretty understandable, I have to admit. In the parlance, it goes to opaque data silos, “vendor lock,” etc. But, such is fundamentally anathema to efficient and accurate data interchange (the “interoperability” misnomer).
Yet, the alternative to a data dictionary standard is our old-news, frustratingly entrenched, Clunkitude-on-Steroids Nibble-Endlessly-Around-the-Edges Outside-In workaround — albeit one that keeps armies of Health IT geeks employed starting and putting out fires.
Money better spent on actual clinical care.
I’m still awaiting substantive pushback. There are conceptually really only two alternatives: [1] n-dimensional point-to-point data mapping, from EHR 1 to EHRs 2-n, or [2] a central data mapping/routing “hub,” into which EHRs 1-n send their data for translation for the receiving EHR.
CODA to that thought, also from my blog:
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True interoperability requires a comprehensive data dictionary standard. Without it, information can become “garbled.” That is, altered during sequential transmissions. For example, what if you took these sentences and ran them through Google Translate from one language to another — say, [1] from English to Spanish, [2] then from Spanish to French, [3] then from French to German, [4] then from German to Greek, [5] then from Greek to Swedish, [6] then from Swedish to Portuguese, and [7] then back to English?
1. Verdadero interoperabilidad requiere un amplio diccionario de datos estándar. Sin ella, la información puede llegar a ser “confusa”. Esto es, alterado durante las transmisiones secuenciales. Por ejemplo, ¿qué pasa si usted tomó estas frases y las pasó por Google traducir de un idioma a otro – por ejemplo, del Inglés al Español, a continuación, del español al francés, después del francés al alemán, después del alemán al griego, luego del griego al sueco, luego del sueco al portugués, y luego de nuevo a Inglés?
2. Véritable interopérabilité requiert une vaste série de dictionnaire de données. Sans elle, l’information peut devenir “confus”. C’est, séquentielle modifié pendant la transmission. Par exemple, si vous avez pris ces mots et a traversé Google traduire d’une langue à l’autre – par exemple, de l’anglais à l’espagnol, puis l’espagnol vers le français, puis du français en allemand, puis de l’allemand vers grec , puis du grec au Suédois Suédois Portugais après, puis revenir à l’anglais?
3. Echte Interoperabilität erfordert eine breite Palette von Data-Dictionary. Ohne sie können die Informationen zu “verwirrt”. Dies wird sequenziell während der Übertragung verändert. Zum Beispiel, wenn Sie mir das Wort und ging durch Google übersetzen von einer Sprache in die andere – zum Beispiel aus dem Englischen ins Spanische und Spanisch in Französisch und von Französisch ins Deutsche und Deutsch auf Griechisch, dann aus dem Griechischen ins Schwedisch Portugiesisch nach dann wieder auf Englisch?
4. True διαλειτουργικότητα απαιτεί ένα ευρύ φάσμα του λεξικού δεδομένων. Χωρίς αυτά τα στοιχεία για να “σύγχυση”. Αυτό είναι διαδοχικά αλλαχτούν κατά τη μεταφορά. Για παράδειγμα, αν η λέξη και μου περπάτησε μέσα από το Google μετάφραση από τη μία γλώσσα στην άλλη – για παράδειγμα, από τα αγγλικά στα ισπανικά και ισπανικά στα γαλλικά και από Γαλλικά σε Γερμανικά και Γερμανικά σε Ελληνικά, στη συνέχεια, από τα ελληνικά στα Σουηδικά Πορτογαλικά σε συνέχεια πίσω στα Αγγλικά;
Verklig driftskompatibilitet kräver ett brett spektrum av data dictionary. Utan denna information till “förvirring.” Detta successivt förändras under transporten. Till exempel, om ordet och promenerade mig genom Google översättning från ett språk till ett annat – till exempel från engelska till spanska och spanska till franska och från franska till tyska och tyska till grekiska, sedan från grekiska till Svenska Portugisiska in sedan tillbaka till engelska?
5. Plena interoperabilidade exige uma ampla gama de dicionário de dados. Sem esta informação a “confusão”. Isso mudou gradualmente em trânsito. Por exemplo, se a palavra e me atravessou tradução do Google a partir de uma língua para outra – por exemplo, de Inglês para Espanhol e Espanhol para Francês e de Francês para Alemão e Alemão para o grego, depois do grego para o Português Sueco em seguida, de volta para Inglês?
6. Full interoperability requires a broad range of data dictionary. Without this information to “confusion.” This gradually changed in transit. For example, if the word and I went through Google translation from one language to another – for example, from English to Spanish and Spanish to French and from French to German and German to Greek, then from Greek to Portuguese Swedish in then back to English?
Ouch.
Pull up Google Translate, try it yourself. Pick additional languages. The results can often be quite amusing.
Missed numbering one above. Wish we had “edit” functionality.
“Verklig driftskompatibilitet kräver ett brett spektrum ”
Should have been #5
Um, some clarification from you, sir, don’t you sell or represent EHR materials?
You could find out in a heartbeat. I blog about Health IT. Independently and with an unsparing critical eye. Google “REC Blog”
I am a statistician by training and long experience, not an IT geek.
But, in fairness, I DO own an EHR company.
http://ClinicMonkey.blogspot.com
🙂
well thank you! But, you have a personal gain here to some degree, eh? You could retort that I do too, but, it isn’t about profit or personal gain for me, but, making sure the health care process is allowed to provide care, not minimize cost to provide profit elsewhere outside the health care process.
Tell us your opinion about the part of bailing out the insurance industry as part of the bill not read until the last few months. Or, does that benefit you as well???
Joel, I was not a big fan of “AHIPcare” as I call it. See my post “Public Optional.”
http://bgladd.blogspot.com/2009/08/public-optional.html
“you have a personal gain here to some degree”
Not by distorting any conclusions I might come to in order to make a buck. No, not at all. My interest is in science.
“You’re confusing poor execution with a poor goal.”
But what is the goal? Most physicians have realized that it’s not better, more efficient medical care. Ir’s data collection, and in terms of my patients and my practice, that is a poor goal.
Do you think there is even the slimmest chance of A-E being achieved? The idea of ONC working to reduce the digital paperwork seems pretty fantastical. It seems much more likely that physicians will be stuck with these high tech ( actually pretty low tech by current standards) torture instruments for a long, long time.
“Doctors and hospitals are using these tools [EHRs] to reduce mistakes”
I laughed when I read this. Having been a victim of a medical error CAUSED by an electronic medical record system (the system would not allow the human nurses to administer pain meds to me after surgery), needless to say I am skeptical of this promise. But then, I’m just a study of n=1.
@policywonk
Details please. Without naming names, what happened?
This does not sound like a medical error, it sounds like a bad policy. I’m curious to know, how did this story end? Did the nurses refuse to provide pain meds? Were you sent home screaming in agony? Or was there simply a delay in treatment?
Spending the HIT/EMR money to instead send public health nurses into impoverished areas would do more to reduce medical spending – I’m thinking.
This a people business, not a technology business.
Usability is a big part of the MU2 incentive program. Many EHR vendors are eager to achieve the “Complete EHR Ambulatory” certification from a certified ONC-ATCB, such as Drummond, or CCHIT, authorized to conduct complete and modular EHR testing and certification in accordance with the applicable certification criteria adopted by the Secretary of Health and Human Services.
To be able to obtain the ONC certification (and meaningful use funding for their clients) EHR vendors must follow a formal User Centered Design (UCD) process and perform and report summative usability tests of specific areas of their EHR product to an ONC-ATCB.
We have been in contact with a number of EHR vendors that have reached out to the certification bodies, and are currently preparing their submission. In preparing their submission they have discovered that they are missing the usability evaluation portion for the Safety-enhanced design criteria.
Usability testing cannot happen overnight, and it is important that you reach out to your usability partner early so that the required testing can be completed in time for your appointment with the ONC-ATCB.
We recommend that you allow at least 3-4 weeks in your submission timeline for the preparation, conducting and reporting of a summative usability test for EHR 2014 Certification.
Visit out blog site for info and discussion of Usability in Healthcare, http://www.HealthcareUsability.com
just remember there is a big difference between “monitoring outcomes and improving outcomes” Monitoring outcomes are for someone elses benefit ie insurance etc and improving outcomes are for the patients benefit.
“Health IT experts brainstorm with ONC on clinical quality measures”
“Informaticists joined clinical quality experts in a brain storming session this week with new ONC chief Karen DeSalvo, exchanging ideas on developing the “next generation” of quality measures.
Charged with developing new e-clinical quality measures that can work in tandem with accountable care measures, the HIT Policy Committee’s Quality Measures Workgroup offered recommendations to Karen DeSalvo at her first policy meeting…”
http://www.healthcareitnews.com/news/health-it-experts-brainstorm-onc-clinical-quality-measures?topic=29
Should there be ANY outside 3rd party assessment mechanisms? Are “clinical quality measures” feeble (or irrelevant) proxies for health care “quality”?
“Should there be ANY outside 3rd party assessment mechanisms? Are “clinical quality measures” feeble (or irrelevant) proxies for health care “quality”?”
feeble, irrelevant, harmful they are.
Here’s some more info (from a recent THCB post) on what true quality is about:
https://thehealthcareblog.com/blog/2014/01/15/fee-for-service-vs-fee-for-serving/
Checking my pulse. Breathing into paper bag. OK, I can write now.
Adoption of an EMR system centered around using a broken system in a more efficient manner, then reporting “success” by obvious measures (remote access, adoption rates) DOES NOT constitute proof that “meaningful use” works. Obviously doctors will adopt EMR more because we are holding a gun at their head (with “incentives” for adoptions followed by significant penalties for those who don’t).
Having stepped out of the problem-oriented, sickness rewarding, procedure promoting system into a world where healthy patients are better for business, I can say that EMR systems are very far from being good tools for improving care. They have been corrupted by the payment system and by the “meaningful use” criteria. Why do I say this? I tried using them outside of the payment system we are being crushed by and found very little left when there wasn’t need for note-generation, code submission, and meaningful use compliance. There is little left for real patient care. EMR systems have become a vehicle for communication between doctors and those who pay doctors (insurance companies and the government).
OK. I’ve got to pick up the paper bag again.
If only we could stop all the “perverse incentives” that HHS continues to design, physicians might be able to improve care. Now that Godzilla has an iPad, things will certainly improve for those being crushed under his rampage. I cant wait to see how much ICD-10 and MU27 improve patient outcomes.
ICD-10 conversion alone is gonna be a CusterFluck.
Not all of us have opted out of our ethical obligation as doctors and opened up direct pay practices with 1000 patients and then toss bombs over the wall at the rest..
Your solution isn’t scalable but yes we all know it is good for your paycheck to no longer treat the most vulnerable in a practice. (how many medicare or medicaid patients do you see? what happened to the other 1000 in your old practice? who picked up the slack for you)
Honestly what EHR did you use? Most of us don’t find it difficult to type (we dictate the clinical encounter and it blows into the chart in a few hours) so it is just the patient instructions usually.
So please stop accusing anyone of being “Corrupted by the payment model” when we all know your goal was to increasing your income by opting out? (Why not go on salary instead like many of us at academic teaching facilities) or work at someplace like Kaiser – no external billing.
Head in a bag or in the sand?
Eric:
18 years in practice being paid for Medicare/Medicaid at their rates and doing far less for patients than I am now. As of the first year in my practice, I continue seeing both medicare and Medicaid patients, and I estimate I’ve saved the government at least $500,000 by giving patients access to me so they can get my input on whether or not they need to go to the ER, or as I have followed their daily weights, BP, and other vitals and have kept them out of the hospital. These are things I never had time to do because of the perverse payment model that “encourages” me to give better care by paying me less. In this past year, by the way, I am not yet anywhere near my salary when I worked in the hamster wheel of our payment system.
In my old practice I was only paid when people were sick. Now I am rewarded for an empty waiting room and healthy patients. In my old practice I was rewarded for patients with more serious problems. Now I am rewarded when I keep them small. In reality, the ratio of Medicare patients in my practice is fairly close to that in my old one. True, I have a smaller patient base for now, but I am working to grow it to where the two are comparable in size. Will I be ashamed if I make more money doing it this way? Why should I be? My patients choose to pay me to keep them well and can leave my practice any time they want (I require no commitment). I give them value they can’t find anywhere in the kind of practice I am accuse of “abandoning.” My goal was never to escape the old system; it was to build a legitimate alternative that no longer encouraged spending, sickness, and terrible customer service.d
Shame on me for that.
“Doctors and hospitals are using these tools to reduce mistakes and hospital readmissions, provide patients with more information that enable them to stay healthy, and allow for rewarding health care providers for delivering quality, not quantity, of care.”
Really? I would like a little more data on this one? I am skeptical when it comes to data given to me by drug companies concerning there drugs and i am skeptical when it comes to data regarding quality and cost when it come from HIT/govt sources.
Agree that quote is completely unsubstantiated. Medical errors may be up, no one is measuring honestly. Of course EHR is moving forward, HHS sanctions are working.
Have errors ever been measured honestly? In any industry?
When you get down to it, are critics measurements any more honest?
In some health care systems like Group Health Cooperative (has had an EHR since 2006 and is owned by its members – employs 900 docs). they have the highest quality at the lowest cost in the region (puget sound health alliance community check-up). google them lots of published research – health affairs and elsewhere
The key wasn’t the EHR on its own but using healthIT to implement the medical home model.. Their payment structure (salaried docs) also allows up to 30% of all primary care encounters to happen via email or scheduled phone encounters.
None of their data goes to a drug company nor do they allow drug companies to deliver ads on the doctors screens like some of the “free” ehrs do.
i have always been interested in how they do it, last i read was they have big subsidies and docs see less then 16 per day and make less then 200K. Not feasible in real work medicine unless you work at the VA
“Given the recent Robert Wood Johnson Foundation report (Time to Act: Investing in the Health of Our Children and Communities, Robert Wood Johnson Foundation Commission to Build a Healthier America), it appears that the best way to reduce the cost of healthcare is not to invest in HIT but to invest in our communities so as to prevent disease before it happens.”
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Yeah, see http://theincidentaleconomist.com/wordpress/poverty-homelessness-and-the-social-determinants-of-health/
“Policy wonks have a terrible habit of focusing on insurance and health system design… This gives short shrift to the “social determinants” of health—upstream factors related to lifestyle, environment, and socioeconomic status—that cannot be corrected by medical interventions. We’re fond of highlighting how much more the United States spends on health services, but an idiosyncrasy that receives less attention is how much less we spend on other social services.”
Perhaps investing in healthIT will give you the data you need to show where we need to invest. Places like Theda Care rely on both – data to drive interventions at the personal social level and hotspotters also use data to drive change..
It is startling to see how much wider our ratio or medical vs social spending is verus most of the developed world and how much better their outcomes are.. Perhaps health IT can start to include those organizations as partners as well like they are experimenting with in Oregon via their Community Care Organizations (sort of medical home Plus social services)
While it would be rational to conclude HIT will improve healthcare, the data to-date does not allow one to conclude that HIT will substantial decrease the cost of healthcare or improve quality. There are studies showing CPOE and CDS has merit, but the remainder of the HIT initiate is more of a pipe dream, at this time. See: What It Will Take To Achieve The As-Yet-Unfulfilled Promises Of Health Information Technology. Health Aff January 2013vol. 32 no. 1 63-68 and Health Information Technology: An Updated Systematic Review With a Focus on Meaningful Use Ann Intern Med. 2014;160(1):48-54-54
Given the recent Robert Wood Johnson Foundation report (Time to Act: Investing in the Health of Our Children and Communities, Robert Wood Johnson Foundation Commission to Build a Healthier America), it appears that the best way to reduce the cost of healthcare is not to invest in HIT but to invest in our communities so as to prevent disease before it happens.
As there are limited resources, we should prioritize interventions that have been proven to work, rather than those that we “think” will work. As most physicians are well aware, that vast majority of new interventions in healthcare usually, (after scientific studies), turn out to be either ineffective or dangerous. Clearly, evidence based medicine should be the standard used throughout the healthcare industry, and it should apply to HIT as well.
Unfortunately, the snowball is rolling downhill and is being pushed ever faster by the politically unstoppable HIT industry. While the HIT proponents espouse a commitment to better/cost effective healthcare, their actions demonstrate that their priority is to their own market share, control of HIT and the bottom line. I fear the battle is already lost.
It is interesting we never ask is their an ROI on using a phone in health care or even perhaps an exam table.. Wouldn’t it be cheaper to eliminate beds in hospitals? What study has ever shown they add any value? How about hospital administrators now that we are looking at ROI? (joking)
Like HealthIT they are simply the infrastructure that give you the ability to manage your practice and meet your patients needs.. Email and online questions are huge time savers for the patients and increase loyalty. Registries help you find patients who aren’t getting their needs met.. EHR’s allow you to quickly contact of patients when an RX is recalled.
The ability to see and then manage your cases at a population level. There will always be early adopters and laggards in any organizational change and you are correct public health actually is the best ROI we have but there is little profit to be made there so very little investment.
So perhaps it isn’t a battle and an unintended secondary consequence of big companies building market share will be a backbone of data that will give us all the information we need to know where to focus our efforts?
“These electronic tools serve as the infrastructure to implementing reforms that improve care – many of which are part of the Affordable Care Act.”
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While this is true, I’m sure a lot of critics will point to this as a negative. I’d be touting HIT on its own merits.