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Tag: EHR

The Napsterization of Health Care


Two weeks ago I had the good fortune to be invited back to the South by Southwest Conference (SXSW) to participate as a judge of a digital healthcare start-up competition. SXSW, which takes place in Austin, TX, is historically an indie music gathering that has evolved into a massive mainstream music conference as well as a monumentally huge film festival, like Sundance times twenty. There are literally hundreds of bands and films featured around town. There has now evolved alongside this a conference called Interactive that draws more than 25,000 people and focuses on technology, particular mobile, digital, and Internet.

In other words, SXSW has become one of the world’s largest gatherings of hoodie-sporting, gadget-toting nerd geniuses that are way too square to be hip but no one has bothered to tell them. Imagine you are sitting at a Starbucks in Palo Alto, CA among 25,000 people who cannot possibly imagine that the rest of the world still thinks the Internet is that newfangled thing used mainly for email and porn. SXSW is a cacophonous melting pot of brilliance, creativity, futuristic thinking, arrogance, self-importance, ironic retro rock and roll t-shirts and technology worship. One small example: very hard to get your hands on a charger for anything other than an iPhone 5 because, seriously, who would have anything else?

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The #CommonWell Open Discussion Forum

The EHR vendor lock-in business model is under attack by frustrated physicians and patients and the reality that health care cost and quality are more opaque than ever. Doug Fridsma of ONC politely talks of the need to move from vertical integration of health care services to horizontal integration where patients can choose with their feet. Farzad Mostashari calls for moral behavior and price transparency. The Society for Participatory Medicine says “Gimme My DAM Data” and Patient Privacy Rights asks HHS to allow physicians to prescribe health IT without interference from the institution or the vendor.

The vendors’ response is a charm offensive called CommonWell Health Alliance with a pastel .org website. The website is presumably the official source of information about CommonWell and it lays out the members’ strategy to preserve the vendor lock-in business model for a few $Billion more. Ok, maybe more than a few.

The core of the CommonWell strategy is to avoid giving patients their data in a timely and convenient way.

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A Time Out For Health IT?

A recent RAND(1) study has concluded that the implementation of health information technology (HIT) has neither effected a reduction in the cost of healthcare nor an improvement in the quality of healthcare. The RAND authors confidently predicted that the widespread adoption of HIT will eventually achieve these goals if certain “conditions” were implemented. I do not believe that there is sufficient scientific data to support the authors’ conclusion nor validate the Federal Government’s decision to encourage the universal installation of “certified” electronic medical records (EMRs.)

As a “geek” physician who runs a solo, private practice and the creator of one of the older EMRs, I believe that I can provide a somewhat unique perspective on the HIT debate which will resonate with a large fraction of private practitioners.

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Beyond HIT Operability: Open Platforms Are Key

I want to begin by sharing well-known information for the sake of comparison. Both the Apple and Google Android platforms welcome the introduction of new and (sometimes) highly valuable functionality through plug-n-play applications built by completely different companies.

You know that already.

Healthcare IT companies welcome you to pay them great sums of money for enhancements to their closed systems. This is on top of substantial maintenance fees that may or may not lead to hoped-for updates in a timely fashion. (With all due respect to the just-announced CommonWell Health Alliance, Meaningful Use does mandate interoperability. The participants are, in effect, marketing what they have to do anyway to try to differentiate themselves from Epic.)

The respective results of these two divergent approaches are probably also familiar to you.

Consumer technology has taken over the planet and altered almost every aspect of our lives. These companies and industries have flourished by knowing what customers will want before those same customers feel even a faint whiff of desire. We are both witnesses to and beneficiaries of dazzling speed-to-solution successes.

Back on planet health IT, the American College of Physicians reports that the percentage of doctors who are “very dissatisfied” with their EHRs has risen by 15 percent since 2010; in a poll, 39 percent said they would not recommend their EHR to colleagues and 38 percent said they would not buy the same system again.

I will argue that the difference between health IT and every other progressive, mature industry is the application of open source, open standards and, most importantly, open platforms. These platforms supporting interoperability and substitutability have enabled Apple and Google—and NOAA weather data, the Facebook Developer Platform, Amazon Web Services, Salesforce, Twitter, eBay, etc.—to drive innovation and competition instead of stifling it. They have created markets where everyone wins—the client, the application developer and the platform company.

The keys to open platforms are application programming interfaces (APIs) through which a platform-building company (i.e., Apple, Google) welcomes the contributions of clients and other companies. The more elegant the API, the more it can support true interoperability.

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Why Haven’t Electronic Health Records Made Us Any Healthier?

Almost 20 years ago close to 4,000 people from 200 companies gathered in San Diego for a conference to discuss the future of health-care information technology. This was before the Web. This was back when computers in physicians’ offices, to the extent they were present at all, were used only for scheduling and billing patients. Paper charts bulged out of huge filing cabinets.

It was one of the first big conferences held by the Healthcare Information and Management Systems Society (HIMSS). I was among a grab bag of physicians, technologists, visionaries, engineers and entrepreneurs who shared one idealistic goal: to use information systems and technology to fundamentally change health care.

We didn’t just want to upgrade those old systems. We imagined a future that looked a lot like what we were being promised throughout the economy as it sped into the Internet era. Computers would enable improvements in the practice of medicine—and make it safer, higher quality, more affordable and more efficient—all at the same time. We wanted people to be healthier.

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Moving Toward An Identity and Patient Records Locator

Last week, five health IT vendors came together to announce the CommonWell Health Alliance, a nonprofit focused on developing a national secure network and standards that will:

  1. Unambiguously identify patients
  2. Provide a national, secure record locator service. For treatment purposes, providers can know where a patient’s records are located.
  3. Enable peer-to-peer sharing of patient records requested via a targeted (or directed) query
  4. Enable patients and consumers to withhold consent / authorization for participation in the network

Unambiguous patient identity matters

In banking, without certainty about identity, ATM machines would not give out cash.  And in healthcare without certainty about identity, physicians are working with one hand tied behind their backs.

This problem will never be solved by the Feds. In fact, Congress has restricted any spending on it by the government at all.  Industry working together may be the only practical alternative.

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Paging Dr. Google

For the record: I am a geek. I love technology. I adopted EMR when all the cool kids were using paper. Instead of loitering in the “in” doctors lounge making eyes at the nurses, I was writing clinical content and making my care more efficient. I was getting “meaningful use” out of my EMR even when nobody paid me to do it.

But now who’s laughing? While they are slaving away trying to get their “meaningful use” checks, I’ve moved on to greener pastures, laughing at their sorry butts! It’s just like my mom promised it would be. Thanks mom.

Really, for the record, I am not so much a technology fan as a “systems” guy. I like finding the right tool for the job, building systems that make it easier to do what I want, and technology is perfect for that job. I am not so much a fan of technology, but what technology can do. Technology is not the goal, it is the best tool to reach many of my goals. There are two things that measure the effectiveness of a tool:

1. Is the tool the right one for the job?
2. Is the person using the tool properly?

So, when answering the question I posed at the end of my last post, what constitutes a “good” EMR, I have to use these criteria.

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The Health IT Scandal the NY Times Didn’t Cover

In case you missed it, the shocking news was that health IT companies that stood to profit from billions of dollars in federal subsidies to potential customers poured in ­– well, actually, poured in not that much money at all when you think about it ­– lobbying for passage of the HITECH Act in 2009. This, putatively, explains why electronic health records (EHRs) have thus far failed to dramatically improve quality and lower cost, with a secondary explanation from athenahealth CEO Jonathan Bush that everything would be much better if the HITECH rules had been written by Jonathan Bush of athenahealth.

Next up: corporate lobbying for passage of the 1862 Pacific Railroad Bill is blamed for Amtrak’s dismal on-time record in 2013.

The actual scandal is more complicated and scary. It has to do with the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence. Way back in 1971, for example, when Intel was a mere fledgling and Microsoft and Apple weren’t even gleams in their founders’ eyes, a study in a high-profile medical journal found that doctors missed up to 35 percent of the data in a paper chart. Thirty-seven years later, when Intel, Microsoft and Apple were all corporate giants, a study in the same journal of severely ill coronary syndrome patients found virtually the same problem: “essential” elements to quality care missing in the paper record.

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Zen and the Art of Charting

One of the many challenges I face in my clinical work is keeping track of a patient’s multiple health issues, and staying on top of the plan for each issue.

As you might imagine, if I’m having trouble with this, then the patients and families probably are as well.

After all, I don’t just mean keeping up with the multiple recommendations that we clinicians easily generate during an encounter with an older patient.

I mean ensuring that we all keep up with *everything* on the medical problem list, so that symptoms are adequately managed, chronic diseases get followed up on correctly, appropriate preventive care is provided, and we close the loop on previous concerns raised.

This, I have found, is not so easy to do. In fact, I would say that the current norm is for health issues to frequently fall between the cracks, with only a small minority of PCPs able to consistently keep up with all health issues affecting a medically complex adult.

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HiMSS Countdown, with Matthew Holt


Early this week Greg Masters and Pat Salber chatted with me for a fun convo about EMRs, NOLA, HIMSS, and alot more. It’s part of their overall series for the HIBCtv (Health Innovation Broadcast Network Consortium). And be warned they are giving me keys to the car for 90 minutes at HIMSS next Weds! You should be able to click on the player above to hear. If not click to this.

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