Tag: EHR

Lessons Learned from China

Nov 1, 2018

By John Halamka, MD

On Sunday I returned from a week in Shanghai and Hangzhou. A remarkable trip that included daily meetings with government, academic, and clinical leaders. What did I learn?

In China, about 5% of the GDP is spent on healthcare per year compared to 16% in the US. Although there is wide variation in lifespan and other population health measures between rural and urban settings, there are few interesting observations about Chinese healthcare:

*It’s a single payer, publicly funded system that provides universal healthcare via a 14% payroll tax.

*There is a single national set of regulations and policies applied to all hospitals, clinics, and doctors

*There is a single set of national privacy laws

*Immunization is mandatory for the entire population

*There’s a single national healthcare identifier

EHRs are widely used in China, however they are optimized for episodes of care, using templates for capture of selected data elements specific to a disease i.e. hypertension, hepatitis, diabetes. The volume of patients is overwhelming – in one hospital I visited (Huashan), the dermatology clinic sees 4000 patients per day. The Chinese EHR enables clinics to document the basics of a problem specific encounter, facilitating extremely fast throughput. The downside of this is that there is not a longitudinal problem list, medication reconciliation, or coordination of care to avoid repeat testing.

Uber-Tech

Nov 1, 2018

By Dinosaur, MD

As I have said many times before, I am no Luddite. I neither hate nor fear technology. My longstanding aversion to the adoption of an electronic medical record was entirely rational, based on the reality that an EMR is a tool. Until I had need for it (at a price I was willing to pay), I had no reason to go electronic.

Circumstances have changed, as they are wont to do, and I have changed along with them. My office now sports an electronic medical record, internet-based practice management system, and document scanners. I continue to make do with my positively antediluvian two-year-old iPod touch and my dumb phone, but have made impressive headway against the paper tide.

One feature of my EMR is a secure patient portal, which enables patients to access portions of their medical record online. Everyone who signs up for it loves it. The enrollment process is electronic, of course, except for one last piece of paper: after the system sends the patient an email with instructions on how to log in, the patient is supposed to enter a unique temporary PIN code that I’ve generated for him in the office. This produces a document. Usually I print it out and hand it to the patient, acutely cognizant of the irony of creating paper to enable paperlessness. At times, I’ve been known to jot it down on a note pad or sticky note, at least cutting down the size of the paper involved. Once or twice, patients have asked me to print the document as a PDF and attach it to an email. I’m happy to do that, but I think part of the idea is to have verification separate from the email.

Last week, though, I came face-to-face with the face of the Uber-Tech.

A tech-savvy patient eagerly agreed to enroll in the portal. The system generated the PIN document as usual, complete with the little rectangular “Print” button sitting patiently there in the upper right hand corner of the screen.

“How would you like me to print this out for you?” I asked my patient.

“Oh, don’t bother,” he replied.

He got up, took his (smart) phone out of his pocket, turned it on, stepped over next to me, and used it to take a picture of the section of my computer screen that contained the required information.

Ingenious!

Dinosaur, MD (aka, Lucy E. Hornstein, MD) is a solo-practitioner in Family Medicine. She is also a book author (Declarations of a Dinosaur) and posts frequently at her blog, Musings of a Dinosaur, where this post first appeared.

Separating Professional and Hospital Records

Nov 1, 2018

By John Halamka, MD

As Patient Centered Medical Homes and Accountable Care Organizations form, the lines between professional and hospital practice become increasingly murky.

CMS has long required that hospital and professional records be separable, so that in the case of audits or subpoenas, it is clear who recorded what.

Today, the BIDMC ACO continues to expand into the community, adding owned hospitals, affiliated hospitals, owned practices, and affiliated practices.

Our strategy to date has been to use our home-built inpatient and ambulatory systems at the academic medical center, Meditech in the community hospitals, and eClinicalWorks in private ambulatory practices which are part of our ACO.

We share data among these applications via private and public HIE transactions – viewing, pushing, and pulling.

The challenge with emerging ACOs is that professionals are likely to work in a variety of locations, each of which may have different IT systems and each of which serves as a separate steward of the medical record from a CMS point of view.

Our clinicians are asking the interesting question – can I use a single EHR for all patients I see regardless of the location I see them?

Our legal experts are studying this question.

Meaningful Use — A Pinch of 3 and a Dash of 4

Oct 1, 2018

By Margalit Gur-Arie

While most folks are busy trying to keep up with Meaningful Use Stage 1, and Meaningful Use Stage 2 only recently emerged from the customary rulemaking process, those who plan for distant futures are providing us a glimpse of what is being considered for Meaningful Use Stage 3 and here and there a hint at the possibility of a never before mentioned Stage 4 and beyond. Since Stage 2 is still somewhat theoretical, there is little value to enumerating the proposed measures of Stage 3, which is not due to take effect until 2016, but it may prove instructive to take a general look at the overall direction that seems to be favored by policy makers for future design and use of EHR technologies. To that end, several new proposed measures seem most enlightening.

The New US Census Bureau

Stage 1 of Meaningful Use added language, race and ethnicity to the customary demographic information collected from patients, such as name, address, date of birth, gender, etc. Stage 2 proposes to add language, race and ethnicity to clinical summaries provided to patients or sent to other providers of care. So the patient header of a Stage 2 clinical summary might look something like this:

Do Computers Really Come Between Doctors and Patients?

Sep 1, 2018

Davis Liu, MD

One of my favorite movies is Back to the Future starring Michael J. Fox. I must admit after reading this New York Times piece, titled “When Computers Come Between Doctors and Patients” I have to wonder.

Am I fortunate to be coming from the future? Because I completely disagree with Dr. Danielle Ofri, again.

I’ve had the privilege and opportunity to work in a medical group which has deployed the world’s largest civilian electronic medical record and have been using it since the spring of 2006. I don’t see the issue quite as much as Dr. Ofri did. It is possible that she examined patients in her office with a desk rather than an examination room.

If placed and mounted correctly in the exam room, the computer actually is an asset and can improve the doctor patient relationship. It is part of the office visit. The flat screen monitor can be rotated to begin a meaningful dialogue between the patient and I. We review the lab work together as well as the trends. Look at xrays. Who needs anatomy flip charts when I can Google any image instantly? Patient friendly information to reinforce our discussion is a click away.

Cats & Dogs: Can We Find Unity on Health Care IT Change?

Aug 15, 2018• 4

By MATTHEW HOLT

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.

Apple’s EHR: Why Health Records on Your iPhone is Just the Beginning

Feb 27, 2018• 11

BY RYAN MARLING

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.

This EHR Mess We’re In

Jul 27, 2017• 5

MICHAEL CHEN, MD

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
Interoperability

Government Pipedream?

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.

Electronic Medical Records 2017: Science Ignored, Opportunity Lost

May 8, 2017• 5

By KENNETH BARTHOLOMEW, MD

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.

My Ideal EHR

Aug 23, 2016• 19

By NIRAN AL-AGBA

flying cadeucii 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.