Niam Yarhagi’s THCB piece, Congress Can’t Solve the EHR Interoperability Problem (March 21, 2015) raises excellent points with which I mainly agree. So why write a responding blog? Because I don’t agree with his solution.
To review: Dr. Yarhagi discusses a draft congressional bill that calls for the creation of a “Charter Organization” that “shall consist of one member from each of the standard development organizations accredited by the American National Standards Institute and representatives that include healthcare providers, EHR vendors, and health insurers.”
Four agreements: I agree with Dr. Yarhagi’s conclusion that the proposed charter organization will not succeed; I agree with his prediction that it won’t be able to develop useful interoperability measures (hint: these are the same vendors that have refused to cooperate for the past 30 years); I agree that the ONC or CMS will not decertify an EHR vendor that has over 50% of all American patients and providers; and I agree that there are some medical providers who intentionally refuse to share patient information (because they think it gives them a competitive advantage over their local rivals).
One disagreement: But I disagree strongly with Dr. Yarhagi’s faith in the market to ensure that healthcare information technology (HIT) vendors will be obliged to “develop sustainable revenue stream through reasonable exchange fees negotiated with the medical providers.” That is, he asserts that if there were a real market without federal subsidies and requirements that all healthcare providers buy the HIT, then providers and the HIT vendors would agree on reasonable fees for exchanging patient records.Continue reading…
The growth in business cases for new models of healthcare delivery and integration of digital health technology is reaching the point of convergence — creating powerful synergies where there was once only data silos and skepticism.
We have not quite achieved this synergy yet, but opportunities emerging in 2015 will move the industry much closer to the long-awaited initiatives in connected, value-based care.
Individuals are constantly hyper-connected to a variety of technology networks and devices. Wearables will continue to enter the market, but their features and focus will go well beyond fitness. Even the devices entering the market now are more sophisticated than ever before. Some are now equipped with tools like muscle activity tracking, EEG, breath monitoring, and UV light measurement.
It will be fascinating to watch how consumer electronics, wearables, and clinical devices continue to merge and take new forms. Some particularly interesting examples will be in the categories of digital tattoos, implantable devices, and smart lenses.
As the adoption of wearables continues to grow, we will continue to see more value placed on accessing digital health data by healthcare and wellness organizations. This will be especially important as healthcare shifts towards value-based models of care. The need to gain access to the actionable data on connected devices will only grow as innovation creates more complex technologies in the market.
While the electronic medical record (EMR) has advantages, it also has introduced liability risks. EMRs can lead to lawsuits or result in a weak defense by casting the physician in an unfavorable light.
EMRs can increase malpractice risk in documentation of clinical findings—copying and pasting previously entered information can perpetuate any prior mistakes or fail to document a changing clinical situation.1 In a study by The Doctors Company of 97 EMR-related closed claims from 2007 to 2014, 13 percent of cases involved prepopulating/copy-and-paste as a contributing factor.2 Copy-and-paste is a necessary evil to save time during documentation of daily notes, but whatever is pasted must also be edited to reflect the current situation. Too often the note makes reference to something that happened “yesterday.”
Checkboxes, particularly those that prepopulate, can be a physician’s nemesis. EMRs have been presented in court that show, through checkboxes, daily breast exams on comatose patients in the ICU, detailed daily neurological exams done by cardiologists, and a complete review of systems done by multiple treating physicians on comatose patients. Questioning in court as to how long it takes to do a review of systems and a physical examination, the patient load of the physician for that day, and how many hours the physician was at work cast doubt on the truthfulness of the testifying physician. A time analysis showed there was no way the physician could have accomplished all that was charted that day, leading to the loss of credibility of that physician in court.
The U.S. Senate has an opportunity next week to hammer the final nail in the coffin of the failed “sustainable growth rate” (SGR) formula for Medicare physician payment. At the same time, it can move the U.S. closer to a system that pays doctors for the quality of care they deliver, not the quantity.
Bear in mind that Medicare pays about a third of the tab each year for all physician services in the U.S.
For those who have not been following this issue (and I don’t blame you, it’s convoluted, even tortuous), here’s a quick recap:
The House in a rare bipartisan vote (392-37) voted on Thursday, March 26 to repeal the SGR formula, which has been in place since 1998. The formula, part of the Balanced Budget Act of 1997, was intended to constrain Medicare spending by pegging annual physician fee updates to a target based on the growth in overall physician spending and the gross domestic product.
The formula never worked. I’ll spare you the details on that. Suffice is to say that the disparities between the growth in physician costs and GDP over the period 2002-2013 were such that reducing physician fees each year by the amount the formula dictated were—well, let’s just say they were very politically distasteful. Continue reading…
Epic Systems, the market leader in electronic health record software (EHR), recently made a quiet but potentially transformative announcement that may finally shake the healthcare industry out of its technological doldrums.
Epic said it is prepared to support the creation of a more open interoperability platform for integration with other diversified healthcare applications. This will attract substantial investment to create software that operates, hopefully seamlessly, within the Epic EHR infrastructure. Expect Epic’s competitors to follow suit, eventually opening up the marketplace of installed EHRs to third-party software developers and the efficiencies of modern, post-EHR technology ecosystem.
Epic’s critics have often denounced the company for selling a mostly closed technology, dampening hopes for the creation of an ecosystem of best-of-breed applications that work together with the EHR to automate much of the care delivery infrastructure beyond patient intake and billing. The value of such an infrastructure is extremely compelling and so the company is under enormous pressure from its customers to become more open.
Dr. Samuels’ day-long training experience is unfortunate, but it’s only the opening chords of a much longer symphony of time commitments required by electronic medical records (EHRs). Many studies document the extra time that EHRs impose on doctors and patients. Research in U.S. hospitals and medical offices suggest that these systems can add a half-hour or much more time to a day. A study by McDonald et al (2013 JAMA Internal Medicine) found EHRs added 48 minutes/day to ambulatory physicians, and Hill et al found that in a large community hospital emergency room 43% of all physician time was spent entering data into the EHR. This almost doubled the time spent caring for patients, and tripled the time needed to interpret tests and records. (Annals of Emergency Medicine, 2014).
Some of that extra time is spent with clunky interfaces and hide-n-go seeking for information that should be immediately available, such as arbitrary or unexpected presentations of data, e.g., having to find a patient’s history by clicking on her current room number, or lab reports that may be arranged by chronology, by reverse chronology, by the lab company, by the organ system, by who ordered them, or by some informal heading, such as “blood work” or “tests” or “labs.” Then there’s the constant box clicking (or what clinicians call “clickarrhea”). EHRs also send thousands of usually irrelevant alerts that desensitize doctors to legitimate clinical recommendations.
The focus on design for health IT at the HxRefactored conference on March 31 raised several tough questions about the hazard-strewn path app developers must travel in that field. My sampling of introductory workshops and afternoon sessions (I unfortunately had the chance to attend only the first day of the two-day conference) brought up many fine design principles, but most of the presenters were general-purpose designers having limited experience in health care. Still, some important distinctions to recognize when entering health IT came up.
One factor making design is so difficult in health care is the vast variety of tasks health care professionals perform. If you’re designing an app to reserve a restaurant table or buy a sweater, how many pathways can a user take? Probably at most a dozen or two. Now think of a hospital ward: one patient whose heart has to be monitored constantly, another who needs regular injections, and yet another whose medication has put her in a delirium that leads her to jump out of bed and wander. Truly, the pathways that a doctor or nurse can take through the health care application verges on the infinite.
Criteria for Stage 3 of meaningful use of EHRs were released recently and there is lots of controversy, as would have been predicted. One set of recommendations that is raising eyebrows is around patient engagement.
The recommendations include three measures of engagement, and providers would have to report on all three of them, but successfully meet thresholds on two.
Following on the Stage 2 measure of getting patients to view, download, and transmit their personal health data, the Office of the National Coordinator (ONC) has proposed an increase from five to 25 percent.
The second measure requires that more than 35 percent of all patients seen by the provider or discharged from the hospital receive a secure message using the electronic health record’s (EHR) electronic messaging function or in response to a secure message sent by the patient (or the patient’s authorized representative).
The third measure calls for more than 15 percent of patients to contribute patient-generated health data or data from a non-clinical setting, to the EHR.
To his credit, Mark Cuban, engaged on Twitter in response to my post.
Mark, I’m sorry I had to leave Twitter abruptly. My wife threatened to kill me and then divorce me – in that order – if I didn’t get off Twitter instantly and get the groceries.
However, I caught the tail end of the Tweets. I’ll do my best to respond.
1. “Why is this contingency all radiologists?”
Mark wondered why everyone on a thread about overtesting were radiologists. It would be a great question if radiologists, who deal with testing, overtesting, limitations of testing, harms of testing, benefits of testing, appropriateness of testing, in other words the science of testing, would be offering advice on financial planning or offering the White House advice on their ISIS policy.
I can do no better than quote @jeffware.
“Exactly Mark – why are the Drs. who specialize in testing trying to explain the dangers of overtesting?”
That was a rhetorical question. But there are some entrepreneurial radiologists who are licking their lips at the epidemic of overtesting. I can hear them say “Mark and acolytes, bring it on.”
To wit, overtesting is better business for us. So our objection is not financially motivated. Let me make this even clearer. The more blood tests and genomic tests the “must prove that I’m healthy” brigade have, more $$$ for radiologists.