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Tag: EHR

More Work Is Needed on the Safety and Efficacy of Healthcare Information Technology

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By Stephen Soumerai & Ross Koppel

If one were writing about the improvement of gastronomy in America, one would probably not celebrate “over 300 billion hamburgers served.”  But that’s very much the type of success Dr. Ashish Jha is celebrating in last week’s piece on recent US healthcare IT sales. Unfortunately, the proliferation of Big Macs does not reflect superior cuisine, and healthcare IT (HIT) sales do not equate with better healthcare or with better health. Quantity does not equal quality of care.

To be sure, Dr. Jha acknowledges the challenges of rolling out HIT throughout US hospitals. And he should be strongly commended for his admission that HIT doesn’t capture care by many specialists and doesn’t save money. In addition, Dr. Jha points to the general inability of hospitals, outpatient physicians and laboratories to transfer data among themselves as a reason for HIT’s meager results.

But this is a circular argument and not an excuse. It is the vendors’ insistence on isolated proprietary systems (and the government’s acquiescence to the vendors) that created this lack of communication (non-interoperability) which so limits one of HIT’s most valuable benefits.

In our opinion, the major concern is that the blog post fails to answer the question we ask our PhD students:

So what? What is the outcome?

This entire effort is fueled by $29 billion in government subsidies and incentives, and by trillions of dollars spent and to be spent by hospitals, doctors and others [1].

So where is the evidence to back up the government’s and industry’s promises of lower mortality, improved health and lower health care costs?

Single studies tell us little. Sadly, as many as 90% of health IT studies fail the minimal criteria of the respected international literature syntheses conducted by the Cochrane Collaboration.

In other words, studies with weak methodology or sweetheart evaluation arrangements just don’t count as evidence.
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Really Meaningful Use

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By Rob Lamberts, MD

It has been nearly 6 months since I started my new practice, since I took the jump (or, more accurately, was pushed off the ledge) into a brave new world.  It seems very distant, like I should get Shirley MacLaine or Gwyneth Paltrow to help me channel my old sad self.  It is tempting.

I have a vague recollection, a memory shrouded in mist, where I pondered what seemed like a radical question: What would a health record look like if my only concern was patient care? This was a radical question because in my previous life I was an electronic health record aficionado.  I was good at EMR, which meant that I was really good at finding work-arounds:

  • How can I work around the requirements for bloated documents and produce records that are actually useful?  The goal of records in that previous life was to justify billing, not for patient care.
  • How can I work around the financial necessity to keep my schedule unreasonably full and keep my visits unreasonably short and still give good care?
  • How can I work around the fact that I am paid better when people are sick and still try to keep them healthy?
  • How can I work around the increased amount of my time devoted to qualifying for “meaningful use” and still give care that is meaningful?

Computers were all about automating the drudgery, organizing the chaos, and carving out a sliver of time so I could spend the extra minutes needed to give the care I wanted to give.  I was using them to give good care despite the real nature of the medical record: a vehicle for billing.

But that was my past life. Now I no longer have to worry about a Medicare audit (and the looming threat of an accusation of “fraud” for simply not obeying the impossible documentation rules).  I no longer have to keep my office full and my patients sick enough to pay the bills.  I am actually rewarded for handing problems early, for communicating well, and for keeping patients healthy and happy, as it keeps them paying the monthly subscription fee.

Ironically, in asking the question, what would a health record look like  if my only concern was patient care,  I was really asking the question: What does “meaningful use” of the record really look like?

Now this question is no longer a hypothetical; it is real.
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As the Debate Over Obamacare Implementation Rages, a Success on the IT Front

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By Ashish Jha, MD

Just a little over four years ago, President Obama, in his inaugural address, challenged us as a nation to “wield technology’s wonders to raise health care’s quality and lower its costs.”  This was an awe-inspiring, “we will go to the moon” moment for the healthcare delivery system.  But the next thought that ran through the minds of so many of us who work on health IT issues was this: how were we going to get there?

We were essentially starting from scratch.  Less than 1 in 10 hospitals had an electronic health record, and for ambulatory care physicians, the numbers weren’t much better – about 1 in 6 had an EHR.  Hospitals and physicians reported an array of challenges that were holding them back.  No nation our size with a healthcare system as complex as ours had even come close to universal EHR use.  Yet, the President was calling for this by just 2014.

And it was clear why.  The promise of EHRs was enormous and we knew that paper-based records were a disaster.  They lead to lots of errors and a lot of waste.  I have cared for patients using paper-based records and using electronic records – and I’m a much better clinician when I’m using an EHR.  In the weeks that followed Obama’s inaugural address, the U.S. Congress passed, and the President signed the Health Information Technology for Economic and Clinical Health Act, which contained a series of incentives and tools to drive adoption and “meaningful use” of EHRs. None of us knew whether the policy tools just handed to the Obama administration were going to be enough to climb the mountain to universal EHR use.  We were starting at sea level and had a long climb ahead.
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Building Cost and Quality Into the Electronic Medical Record

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By Hayward K. Zwerling, MD

Trends in US healthcare expenditures are financially unsustainable (1). I would like to propose two tweaks of the healthcare delivery process that may, in a small way, help rectify this problem.

Although there is a widespread impression that health information technology (HIT) will eventually “bend” the cost curve and put healthcare spending on a sustainable course, there is, as of yet, little data that convincingly supports this hypothesis (2).

Kaiser Permanente is a large, integrated healthcare delivery system which has invested heavily in HIT. George C. Halvorson, the chairman and CEO of Kaiser Permanente appears to have concluded that this investment will not solve the healthcare cost issue, when he was quoted in the New York Times (3/20/13) as stating “We think the future of health care is going to be rationing or re-engineering.”

Because HIT, as currently implemented, will probably not solve the healthcare cost problem, I would like to suggest a minor “re-engineering” of the electronic health record user interface which may help bend the cost curve.

At every office visit, the physician must make a myriad of decisions which incrementally effect the nation’s total healthcare expenditures. For example, the physician will have to decide which medicine to prescribe, and which radiology study or laboratory test to order.

In many situations, there is more than one acceptable choice. The physician’s ultimate decision will integrate their understanding of the disease process, the treatment’s side effect profile, their familiarity with the treatment options, patient preferences and many other variables.

I would suggest that every time a physician is about to order a test or a prescription, the cost of the test or prescription should be displayed to the physician. In the same vein, whenever a computer displays a test result, the cost of the test is immediately available to the reader. This information could then become an additional factor that the physician may choose to integrate (or ignore) at the moment when he/she is about to commit the patient and society (which is now paying >50% of all healthcare bills) to another healthcare expenditure. In terms of a risk/benefit analysis, I can see little downside to providing this cost information to physicians.

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Chapter Nine: In Which Dr. Watson Discovers Med School Is Slightly Tougher Than He Had Been Led to Believe

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By William Hersh, MD

One of the computer applications that has received the most attention in healthcare is Watson, the IBM system that achieved fame by beating humans at the television game show, Jeopardy!. Sometimes it seems there is such hype around Watson that people do not realize what the system actually does. Watson is a type of computer application known as a “question-answering system.” It works similarly to a search engine, but instead of retrieving “documents” (e.g., articles, Web pages, images, etc.), it outputs “answers” (or at least short snippets of text that are likely to contain answers to questions posed to it).

As one who has done research in information retrieval (IR, also sometimes called “search”) for over two decades, I am interested in how Watson works and how well it performs on the tasks for which it is used. As someone also interested in IR applied to health and biomedicine, I am even more curious about its healthcare applications. Since winning at Jeopardy!, Watson has “graduated medical school” and “started its medical career”. The latter reference touts Watson as an alternative to the “meaningful use” program providing incentives for electronic health record (EHR) adoption, but I see Watson as a very different application, and one potentially benefitting from the growing quantity of clinical data, especially the standards-based data we will hopefully see in Stage 2 of the program. (I also have skepticism for some of these proposed uses of Watson, such as its “crunching” through EHR data to “learn” medicine. Those advocating Watson performing this task need to understand the limits to observational studies in medicine.)

One concern I have had about Watson is that the publicity around it has been mostly news articles and press releases. As an evidence-based informatician, I would like to see more scientific analysis, i.e., what does Watson do to improve healthcare and how successful is it at doing so? I was therefore pleased to come across a journal article evaluating Watson [1]. In this first evaluation in the medical domain, Watson was trained using several resources from internal medicine, such as ACP Medicine, PIER, Merck Manual, and MKSAP. Watson was applied, and further trained with 5000 questions, in Doctor’s Dilemma, a competition somewhat like Jeopardy! that is run by American College of Physicians and in which medical trainees participate each year. A sample question from the paper is, Familial adenomatous polyposis is caused by mutations of this gene, with the answer being, APC Gene. (Googling the text of the question gives the correct answer at the top of its ranking to this and the two other sample questions provided in the paper).

Watson was evaluated on an additional 188 unseen questions [1]. The primary outcome measure was recall (number of correct answers) at 10 results shown, and performance varied from 0.49 for the baseline system to 0.77 for the fully adapted and trained system. In other words, looking at the top ten answers for these 188 questions, 77% of those Watson provided were correct.

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60% of Massachusetts Doctors Will Not Meet State Electronic Record Mandate

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By Josh Archambault

Putting aside a lengthy discussion over the merits of and cost saving potential of EMRs for a minute, comes this gem from the land of not so well thought out policy making…

In 2010, the Massachusetts Legislature passed a law requiring that, as a condition of licensure starting in 2015, Massachusetts physicians must demonstrate proficiency in the use of electronic health records, computerized order entry, e-prescribing, and other forms of health information technology.

Last year [ in chapter 224], the Legislature amended that statute to state that physicians must “demonstrate the skills to comply with the ‘meaningful use’ requirements.” There was no further language to explain the intent or scope of that amendment.

Given that even the most optimistic forecast holds that only 12,000 eligible providers in Massachusetts would achieve Meaningful Use certification by 2015 (more than 30,000 physicians hold a Massachusetts license), the MMS is committed to ensuring that the statute is interpreted broadly, and does not unintentionally disenfranchise thousands of physicians, thereby creating an extreme health care access issue.

-Massachusetts Medical Society

So 60% of doctors are projected to be non-compliant?!? I guess a doctor shortage will take on a whole new meaning in the state.

This is what happens when you pass major policy bills in  14 hours without anyone reading the whole thing first, but I digress…

This issue prompted a recent call to action from a local doctor in North Chelmsford, Dr. Hayward Zwerling.

Josh Archambault is director of health care policy at the Pioneer Institute in Boston (www.pioneerinstitute.org), publisher of “The Great Experiment: The States, The Feds and Your Health Care.”

From the Case Files of the Robert Wood Johnson University Hospital, Dec 2015

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By James Salwitz, MD

May 30-8:12pm: 27 yo teacher, Pam S., is out for her evening run. The delicious evening air fills her nose and lungs. She feels strong, healthy, and alive.

May 30-8:13pm: Pam pushes up a gentle hill. She feels sudden and severe pain, as if stabbed deep by a flaming splinter.  Pam stops, almost falling.  She struggles the mile home. The searing throb begins to fade. A long hot shower gives some relief.

June 3-5:45am: The torment progressed through the weekend and curled around pillows, drenched in sweat, she has not slept all night.  As traces of sunrise light frame her bedroom window, she decides to get medical care.

June 3-9:22am: Pam tells her story to her Primary Medical Doctor (PMD) and is examined.  Her pain is intense with any movement and he is worried. He orders blood work, pain medication and calls an orthopedic surgeon. The PMD completes his history and physical report, as well as his differential, in his Electronic Medical Record (EMR).  The note is transmitted instantly to the surgeon.

June 3-9:59am: STAT blood work is drawn at a lab down the street.

June 3-10:37am: Pam picks up the pain medication.

June 3-11:25am: The orthopedic surgeon reads the PMD’s note, listens to Pam’s story and examines her.  He orders an emergency MRI.

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Datapalooza Report on Data Economics and a Call for Reciprocity

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By Adrian Gropper, MD

Uwe Reinhardt said it perfectly in a Tuesday plenary but I can only paraphrase his point: “health information is a public good that brings more wealth the more people use it.” Or, as Doc Searls puts it: personal data is worth more the more it is used. Datapalooza is certainly the largest meeting of the year focused on health data, and our Health and Human Services data liberation army was in full regalia. My assessment is: so far, so good but, as always, each data liberation maneuver also reveals the next fortified position just ahead. This post will highlight reciprocity as a new challenge to the data economy.

The economic value of health data is immense. Without our data it’s simply impossible to independently measure quality, get independent second opinions or control family health expenses. The US is wasting $750 Billion per year on health care which boils down to $3,000 per year that each man, woman and child is flushing down the drain.

Data liberation is a battle in the cloud and on the ground. In the cloud, we have waves of data releases from massive federal data arsenals. These are the essential roadmap or graph to guide our health policy decisions. I will say no more about this because I expect Fred Trotter (who is doing an amazing job of leading in this space) will cover the anonymous and statistical aspects of the data economy. Data in the cloud provides the basis for clinical decision support.
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Electronic Health Records. Are We There Yet? What’s Taking So Long?

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By Michael Painter, MD

I am a family physician, but one who doesn’t currently practice and importantly, one who isn’t slogging day after day through health care transformation. I do not want to be presumptuous here because the doctors and other health professionals who are doing this hard work are the heroes. They are caring for patients while at the same time facing tremendous pressure to transform their life’s work.  That includes overwhelming pressure to adopt and use new information technology.

This level of change is hard, difficult and confusing—with both forward progress and slips backward. Nevertheless, doctors take heart because you are making progress. It may be slow at times, but it’s substantial—and it’s impressive. Thank you.

The Annals of Internal Medicine today published a study (I was one of the authors) finding that more than 40 percent of U.S. physicians have adopted at least a basic electronic health record (EHR),  highlighting continued progress in the rate of national physician adoption of EHRs. The study, also found that a much smaller number, about 9.8 percent of physicians, are ready for meaningful use of this new technology.

Some might say, “Wake up, folks!”   Look at those small meaningful use numbers.  Change course, now.  After all of this time and tax-payer expense, less than 10 percent of doctors are actually ready to use these important tools meaningfully. What’s up with that?

To me, though, this study is good news. All who care about health care transformation should be heartened by the progress—but also impressed by the enormous challenge that our health professionals have undertaken.

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Unintended Financial Consequences

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By Edmund Billings, MD

A question: What is the opposite of health IT return on investment?

The answer: Unintended financial consequences, or UFCs, for short.

The scenario: A sophisticated medical center health system begins to roll out an expensive proprietary EHR and shortly thereafter sustains an operating loss, leaving no choice but to put the implementation on hold. The operating loss is attributed to “unintended financial consequences” directly related to buying a very expensive EHR system.

This is exactly the situation at MaineHealth, who selected Epic. As recently reported, a little while ago Maine Medical Center President and CEO Richard Peterson sent a memo to all employees saying the hospital …

… has suffered an operating loss of $13.4 million in the first half of its fiscal year. The rollout of MaineHealth’s estimated $160 million electronic health record system, which has resulted in charge capture issues that are being fixed, was among several reasons Maine Med’s CEO cited for the shortfall.

“Through March (six months of our fiscal year), Maine Medical Center experienced a negative financial position that it has not witnessed in recent memory,” Richard Peterson, president and CEO of the medical center, wrote in the memo to employees.

Peterson’s memo outlines the specific UFCs that explain, in part, MaineHealth’s operating loss:

  • Declines in patient volume because of efforts to reduce re-admissions and infections
  • Problems associated with being unable to accurately charge for services provided due to the EHR roll out
  • An increase in free care and bad debt cases
  • Continued declining reimbursement from Medicare and MaineCare, the state’s Medicaid program

These challenges are common to just about any medical system in the country, making MaineHealth potentially a harbinger of things to come for those hospitals and health systems that pay multi-millions of dollars for a health IT system.

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