Amazon has transformed the way we read books, shop online, host websites, do cloud computing, and watch TV. Can they apply their successes in all these other areas to healthcare?
Just last week, Amazon announcedComprehend Medical, machine learning software that digitizes and processes medical records. “The process of developing clinical trials and connecting them with the right patients requires research teams to sift through and label mountains of unstructured clinical record data,” Fred Hutchinson CIO Matthew Trunnell is quoted saying in a MedCity News article. “Amazon Comprehend Medical will reduce this time burden from hours to seconds. This is a vital step toward getting researchers rapid access to the information they need when they need it so they can find actionable insights to advance life-saving therapies for patients.”
Deriving insights from data and making those available in a user-friendly way to patients and clinicians is just what we need from technology innovators. But these tools are useless without data. If an oncology patient is hospitalized, her provider may not be informed of her hospitalization for days or even weeks (or ever). And the situation is repeated for that same patient receiving care from cardiologists, endocrinologists, and other providers outside of her oncology clinic. When it comes to personalized health and medicine, both the quantity and quality of data matter. Providers need access to comprehensive patient health data so they can accurately and efficiently diagnose and treat patients and make use of technology that helps them identify “actionable insights.”
Today we have a humming economy and insane politics. In early 2009 we were in economic meltdown and were about one week into the sanest, soberist Administration and even Congress over many recent decades. In February 2009 they passed a stimulus bill that had a huge impact on the health IT market (and still does). At that time there was much debate on THCB about what the future of health IT policy should look like and how the stimulus “Meaningful Use” money should be spent. My January 2009 summary of that whole debate introduced the notion of “Cats and Dogs in health IT”. They’re still around today. We’re reprinting it here as part of our 15-year THCB birthday party–Matthew Holt
Those of you paying attention for the past few days might have noticed on the one hand a sense of optimism and unity as Barrack H. Obama, somewhat somberly, began his presidency.
Meanwhile, over the past few weeks the fur has been flying among the electrons on THCB while some very knowledgeable and opinionated health care wonks and geeks have been battling it out about what exactly we should be doing in terms of federal health care IT spending.
Given that even among you smart THCB readers this may be all a little perplexing, I’m going to try to try to make what I hope are some elucidating comments to put this argument in context. I’m doing this partly because I’m perplexed too, but also because I think that there is some hope for a middle road.
First the basics: As sometime THCB contributor & uber-CIO John Halamka makes clear in this excellent post about The Greatest Healthcare IT Generation, some $20 billion of the soon to be passed “spend it as fast as you can” stimulus package is going to be targeted towards health care IT. Now, that’s by no means the biggest part of the $800 billion or so package, and it’s not even the biggest part of the health care spending in the bill. Nearly $87 billion or so is going to support Medicaid, although that will mostly will be replacing cuts being forced on states.
Americans on average will visit a care provider about 300 times over the course of their lives. That’s hundreds of blood pressure readings, numerous diagnoses, and hundreds of entries into a patient’s medical record—and that’s potentially with dozens of different doctors. So it’s understandable, inevitable even, that patients would struggle to keep every provider up-to-date on their medical history.
This issue is compounded by much of our healthcare information being fragmented among multiple, incompatible health systems’ electronic health records. The majority of these systems store and exchange health information in unique, often proprietary ways—and thus don’t effectively talk with one another.
Fortunately, recent news from Apple points to a reprieve for patients struggling to keep all of their providers up-to-date. Apple has teamed with roughly a dozen hospitals across the country, including the likes of Geisinger Health, Johns Hopkins Medicine, and Cedars-Sinai Medical Center, to make patient’s medical history available to them on their phone. Patients can bring their phone with them to participating health systems and provide caregivers with an up-to-date medical history.
Empowering patients with the ability to carry their health records on their phone is great, and will surely help them overcome the issue of fragmented healthcare records. Yet the underlying standardization of how healthcare data is exchanged that has made this possible is the real feat. In fact, this standardization may potentially pave the way for innovation and rapid expansion of the health information technology (HIT) industry.
Dr. Matthew Hahn blogs about the current state of today’s EHR’s and rightly points out many of the same reasons that I have identified in my previous posts:
The negative impact of Meaningful Use (MU) since 2009
Poor usability of EHR’s
There are several other important concerns that have been left unanswered by our current Health IT offerings.
Patient privacy and control of their health records
The solution Dr. Hahn proposed is one that hinges on the hope that government will abandon MU (unlikely given this political climate), and create a whole new EHR development program based on a national competition and then for the government to subsidize the cost of that winner EHR for physicians to use.
Subsequently, this national competition will engage physicians so that they have control over their destinies in designing the EHR of their dreams. But is it realistic to hope that government will support such an endeavor? Although I’m a believer that government should and ought to play a role in setting fair rules and be accountable to the public (for the many and not the few) and not to be overrun by lobbyists and those with the most money and influence who can rig the system, I doubt this solution will see the light of day with our currently polarized politics and the continued, large influence of big money interests in government today.
Movements as Inspiration
Here is my proposal that leverages existing platforms and technologies (but that most physicians may not be aware of) without hoping for the government to intervene today (or yesterday). Only until a community of patients, physicians, and developers that have a common goal of creating an EHR that works for both physicians and patients, that we ultimately compel the government to support (financially) the further development and adoption of this type of system. Those who have studied previous movements (such as the LGBT social movement, thee Civil Rights movement, and the women’s suffrage movement) took a group of like-minded individuals from different walks of life who struggle together, make their voices heard, participate, and ultimately control the cultural narrative to the point that government had no choice but to abide to the sea change that has already taken place. This is where physicians and patients have to start. And we have the tools to start the change as we see fit.
My big brother Bill, may he rest in peace, taught me a valuable lesson four decades ago. We were gearing up for an extended Alaskan wilderness trip and were having trouble with a piece of equipment. When we finally rigged up a solution, I said “that was harder than it should have been” and he quipped in his wry monotone delivery, “There are no hard jobs, only the wrong tools.”
That lesson has stuck in my mind all these years because, as simple as it seems, it carries a large truth. It rings of Archimedes when he was speaking about the simple tool known as the lever: “Give me but one firm spot on which to stand, and I will move the earth.”
Enter the Electronic Medical or Health Record (EMR or EHR) as it exists in most forms today. As information tools for clinicians, most EMRs have been purchased by administrators who know nothing of patient care or workflow, and most of these EMRs have been reverse engineered from billing and collection systems, because the dollar drives all.
Give me technology which improves my life and that of my patients, or give me death. Medical records must be informative, efficient, and flexible; like the physicians they serve. For me, a medical record does not contain just a collection of problem lists, prescribed medications, and immunizations; it is a noteworthy account of the health care provided to another human being over a lifetime.
Recently, I attended a baby shower of a patient who is now an adult. (I am a pediatrician.) I brought her medical chart wrapped with a satin bow as one of her gifts. I was her physician for many years; my father had taken care of both her and her mother as children. Her growth, development, immunizations, and illnesses were all recorded; but so were 25 years of life experiences, trials, triumphs, and tribulations. The back section contains drawings she had given me, newspaper articles of her achievements, graduation announcements, and her wedding invitation. Obviously, medical records register growth parameters, vital signs, and sick visits; but they also encompass my relationship with my patients.
It is very early. I am running to the ‘clinical decision unit’ (CDU) to see a patient of mine sent in the night before from a local skilled nursing facility. Also known as clinical observation units, ‘obs’ units, or short stay observation units, these units were designed to help decompress busy emergency rooms and divert unnecessary, expensive inpatient admissions. The units are typically adjacent to emergency departments, and usually are run by emergency physicians.
My particular patient was admitted due to an episode of chest pain at her facility. A brief conversation the prior night with the emergency room staff revealed chest pain that clinically was not typical for any of the feared diagnoses of a heart attack, pulmonary embolism or an aortic dissection. An electrocardiogram and cardiac enzymes were also initially unremarkable. Regardless, the patient was elderly and had multiple other comorbidities, and was somewhat confused. I recommended a short stay to allow anything malignant to declare itself.
And so, here I was, at the observation unit, digging through pages upon pages of printed gibberish that clearly had achieved the nirvana stage of meaningful use (for those wondering, that’s after stage 3). Ironically, the most useful piece of information lay in a handwritten progress note describing the episode. I could see why the patient had been brought here to be further evaluated, but after 18 hours of negative biomarkers, electrocardiograms, and no recurrence of symptoms, I felt comfortable letting her go back to where she came from. I told the ER staff… who cancelled her stress test. A stress test? Yes, a stress test had been ordered prophylactically. We practice in a climate where every bad outcome has the potential for litigation – malpractice lawyers would have a field day with the case of anyone going to the ER, being discharged without some type of cardiac imaging study, and having a heart attack. My recommendation to discharge the patient shifts the liability of an adverse outcome from the ER squarely on to my shoulders, and thus, poof goes the stress test.
The electronic health record (EHR) is now used by the majority of physicians during every patient encounter. The EHR has become the most important tool in our “black bag” and precisely for that reason, the EHR must be highly accurate and free of bias. As our most heavily utilized tool, the EHR must also be flexible and highly optimized so as to ensure it does not adversely impact the delivery of healthcare. Unfortunately, numerous surveys have found widespread physician dissatisfaction with EHR design.
The fact that EHR programming code is shielded from objective scrutiny by independent evaluators increases the risk that the EHR will contain errors and bias which could adversely impact our patient’s health, hinder our ability to deliver healthcare, “warp” the design of the healthcare system and drain financial resources from our patients and society.
EHR “errors” are well documented in the literature and are referred to as “e-iatrogenesis” or “technology induced” errors. “Bias” in EHR programming code is not discussed in the literature.
I am an IT geek physician. I have my an EHR which I created and control.
Today, I wanted to understand my diabetic practice a little more, so I dumped all my HbA1c data out of my EHR and into a spreadsheet where I was able to manipulate the data and learn a few things about my practice.
I learned that:
If my patient had a HbA1c ≥ 8, the likelihood that the HbA1c would be < 8 at the next visit is 68%.
If my patient had a HbA1c ≥ 8, the likelihood the HbA1c would be even higher at the subsequent visit is 29%.
If my patient had a HbA1c ≥ 8, the average change in the HbA1c at the next visit was -0.7.
If my patient had a HbA1c < 8, the likelihood that HbA1c at the subsequent visit would exceed 8% would be 15%.
Over the last few years, we have seen large EHR vendors purchase the moderate size EHR vendors, while moderate-size EHR vendors acquire smaller EHR vendors. We can expect to see a further decline in the number and diversity of EHRs as the IT mandates of Meaningful Use 2 and 3 are technically unachievable for all but the most well-endowed EHR vendors.
Along with the decreasing diversity of EHR options, an increasing number of physicians have lost the ability to choose the most important tool in their black-bag, their EHR, as many are now employed by large organizations which tell the physicians which EHR/HIT tools they are allowed to use.
If there was data that “Certified” EHRs, “Meaningful Use,” ICD10 and PQRS mandates had an impact on the cost or quality of healthcare which was commensurate with the IT costs and logistical disruptions, I would be the first to encourage physicians to use the new and proven technology. Unfortunately, we still do not know if “more” HIT is good for the healthcare system and society in general, or if it is only good for the IT industry.