The recent history of electronic medical records in ambulatory care, or what we now call EHR (electronic health record) technology, can be divided roughly into three phases. Phase I, which lasted approximately 20 years, from about 1980 to the early 2000’s, was an era of exploration and early adaptation of computers to outpatient medicine. It coincided with the availability of PCs that were cheap enough to be owned by many doctors, and with the increased capacity of off-the-shelf software programs, mainly spreadsheet and database management systems such as Lotus, Excel, Access, and Microsoft’s SQL, to lend themselves to computerized capture of health data and information. Phase II coincided roughly with the American Academy of Family Physician’s (AAFP’s) commitment to health IT as a core competency of the organization, and with its support/promotion of the early commercial vendors in the Partners for Patients program, a national educational campaign inaugurated in 2002 which involved joint venturing with vendors that included Practice Partners, MedicaLogic, eClinicalWorks, and eMDs, among others. Several other physician membership organizations joined this effort to popularize EMRs, or crafted their own education programs for their members based on the AAFP’s model. The most popular Phase II products were, and still are for the most part, client-server software applications that run on local networks and PCs within the four walls of a practice, and tend to use very similar programming development tools, back-end databases, and support for peripherals such as printers. The industry grew, albeit sluggishly, from roughly 2002-present in an unregulated environment, with increasing support from quasi-official industry groups like HIMSS and CCHIT, and with the blessing of many professional organizations, including the AAFP, ACP, AOA, and the AAP. Best estimates are that the numbers of physicians using EHR technology from a commercial vendor roughly tripled during this period, from about 5% of physicians to about 15%. The Bush administration gave moral support to the industry, but did not provide funding or payment incentives, and mostly left the industry to itself to sort out the rules, including certification. The industry is now entering a new phase, one we predict will significantly depart from the previous two eras.Continue reading…
If you hate HIPAA, it’s your lucky day. Paul Ohm is handing you ammunition in his article, “Broken Promises of Privacy: Responding to the Surprising Failure of Anonymization.” His argument: our current information privacy structure is a house built on sand.
“Computer scientists…have demonstrated they can often ‘reidentify’ or ‘deanonymize’ individuals hidden in anonymized data with astonishing ease.”
Ohm’s article describes HIPAA, in particular, as a fig leaf – or worse, as kudzu choking off the free flow of information.
“[I]t is hard to imagine another privacy problem with such starkly presented benefits and costs. On the one hand, when medical researchers can freely trade information, they can develop treatments to ease human suffering and save lives. On the other hand, our medical secrets are among the most sensitive we hold.”
Recently, Steve posted about the idea, floated by Ken Mandl and Zak Kohane, that EHRs (or health IT more broadly) could move to a model of competitive, substitutable applications running off a platform that would provide secure medical record storage. In other words, the iPhone app model, but, for example, you could have an e-prescribing app that runs over an EHR instead of the Yelp restaurant review app on your iPhone. We’re thinking about the provider side of the market here, as Google Health and Microsoft HealthVault are already doing this on the consumer side.
It’s nice to ponder these “what ifs,” but we’re a bit more action-oriented here and we’ve turned our attention to asking what it would take to make this happen. It seems that there are two things that are needed. First, we need the platform. Some of the most notable platforms started out as proprietary that were then opened up. The IBM PC comes to mind as an example. Some were designed from the beginning to be open platforms with limited functionality until the market started developing applications. A recent example is the development of iGoogle and the tons of applications that are available for free. Finally, there was the purely public domain development from the beginning to end that we’ve seen in the Linux world. Or perhaps we don’t need a common platform and maybe what is needed is to stimulate the market for health IT products that have open application programming interfaces (APIs) that allow for third-party application development? Several ideas come to mind.Continue reading…
This post is aimed at serving as an interlude to the “public option/death panels” discussions. No matter what healthcare reform bill, if any, is passed this fall, HIT will be part of the program. Four short years ago I was involved in the creation of a comprehensive, some would say monolithic, EMR/Practice Management/Billing system. This new product was built in reaction to the very large, very expensive and very clunky systems already on the market.
Remembrance of Things Past – The driving design considerations four years ago
- The problem – Paper charts are causing inefficient workflows in physician offices. It is hard to find pertinent information in a big chart and it is hard to analyze that information. Charts can only be accessed by one person at a time and cannot be accessed from outside the office. Charts are sometimes misplaced and may be lost during a fire or natural disaster. Every new chart costs money to create, store, pull and maintain.
- The solution – Application software that provides a computerized version of the paper chart – an Electronic Medical Record. Computers are great at storing and arranging data in all sorts of ways and formats. Computers can analyze, graph and report on enormous amounts of data. The software should be web based so it can be easily accessed from anywhere by multiple users simultaneously. No more misplaced charts and no more wasted office space and a SaaS solution would make sure the records are disaster proof.Continue reading…
Before the Obama administration set aside billions to accelerate the dissemination of EHRs, providers were slow to adopt them. As recently as 2 years ago for example, a study published in the NEJM revealed that only 4% of non-hospital based providers had fully implemented an EHR, and only 13% more had a partial installation.
By contrast, the growth of social media including Facebook, Twitter, YouTube, blogs and virtual communities like Sermo and Physician Connect, has been explosive.Enterprising providers have already deployed sophisticated social media strategies to extend their brand around the world. The Mayo Clinic for example, maintains several blogs, a Facebook fan page (which has 8,800 fans), a library of YouTube videos and a Twitter page (7,120 followers).Continue reading…
On August 20th, HHS Secretary Kathleen Sebelius and ONC head David Blumenthal announced $598 million in grants to set up about 70 “regional extension centers” (RECs) that will help physicians select and implement EHR technologies. Another $564 million will be dedicated to developing a nationwide system of health information networks.
The RECs are based on the example of agricultural extension offices, established over 100 years ago by Congress, which offered rural outreach and educational services across the country. These extension services made America’s agricultural revolution possible, dramatically increasing farm productivity. By analogy, the Administration hopes that on-the-ground health IT trainers and implementation experts can facilitate small medical practices’ adoption of EHR technologies, especially in rural and under-served areas, enhancing care quality and efficiency around the US.
The comparison between RECs and agricultural extension offices is probably a good one, and we applaud this effort. But there are some striking differences between agriculture and health IT. For one thing, many best farming practices were well known by the early days of agricultural extension services. The road map under ARRA/HITECH for successful small medical practice health IT acquisition and use is still under development, and remains full of tough questions and unknowns.
In fact, under Dr. Blumenthal’s leadership, the government is now crafting specifications for Meaningful Use, HHS Certification, security, and interoperability. It’s not yet clear what “meaningful use of certified EHR technology” means. So we could be in a cart-before-the-horse situation. It might be a little premature to set up technical assistance programs if we can’t provide specific guidance on how to assist. Even fully CCHIT-certified comprehensive EHRs can’t meet the Meaningful Use criteria today, so the REC’s geek squads will have their work cut out for them.
However, a body of knowledge and experience already exists about successful health IT system implementation in small primary care and specialty practices. For several years, one of us (DCK) worked under the auspices of the American Academy of Family Physicians (AAFP), helping family physicians’ practices prepare, select, implement, and maintain information technology offered by EMR and EHR vendors. The AAFP’s current Center for HIT staff has expanded this effort, assembling an impressive body of resources and tools. It was augmented as well by the work of the Quality Improvement Organizations (QIOs) that participated in the Doctors Office Quality-Information Technology (DOQ-IT) programs between 2006-2008.
Some of this knowledge is anecdotal, and should certainly be revised in light of the definitions and specifications that the ONC will issue later this year and likely finalize by spring of 2010, according to Dr. Blumenthal. But the AAFP’s and QIO’s hard-won lessons may be useful to those who are planning the new effort.
Here’s some broad guidance for state planners who are applying for these grants and who hope to set up their RECs by early 2010.
- Keep your advisory services simple and targeted on solving actual problems. Hire people with hands-on medical practice experience, who will carefully listen to what physicians and practice managers want the EHR technology to do for them and their patients. Physicians in small practices generally will use EHRs in caring for patients and for managing office accounts. Overwhelming change won’t be welcomed. Instead, focus on incremental implementations that try to solve information management problems without interrupting work flows.Start with one system or workflow area, gaining success and then moving on to another. For example, some practices may be ready to implement ePrescribing, but are not ready to replace paper records with an electronic documentation system. Many practices have found that Web portals facilitating patient communications are a good EHR starting point, because they let doctors and patients exchange information online and asynchronously, easing telephone line congestion.
- One size does not fit all. General IT skills are useful. New rules will soon specify how physicians and hospitals can qualify for the HITECH incentive payments and which products will be certified. Even so, there may be many different routes to successful EHR use. A flexible perspective is paramount. Favor advisers with generalized health IT system knowledge, rather than expertise with a particular vendor’s product.Some medical practices will choose a single-vendor EHR with all the added features, but others will mix and match modular applications that together create can minimum system capability needed for HITECH meaningful user status and incentive payments.
Similarly, some practices will prefer to locate data servers inside their practices or at the community hospital. Others will opt for Clinical Groupware, web-based and remote services EHR technologies that offer less hassle and expense for maintenance and security. Recognizing and differentiating between EHR technology offerings is going to be a major challenge for REC personnel in the near future.
- Skate to where the puck will be. The old paradigm of health data management tried to collect a patient’s complete data in a single database application, owned, maintained and controlled by a particular organization. However, throughout other disciplines, information management has become Web-centric and based on meta-data searches augmented by real-time communications and shared group activities. Think Wikipedia, Google docs, Microsoft Sharepoint, the Apple iPhone, and, yes, even Facebook, as representative of where health IT is migrating over the next few years.Eric Schmidt, CEO of Google, and a member of the President’s Council on Science and Technology, PCAST, recently urged President Obama and David Blumenthal to consider Web-based technologies as the basis of the national health information network. He warned that “the current national health IT system planned by the administration will result in hospitals and doctors using an outdated system of databases in what is becoming an increasingly Web-focused world. The approach will stifle innovation.” Mr. Schmidt’s advice, and similar advice from Craig Mundie of Microsoft, is coming from within the Administration, not from outside it. In other words, it’s much more likely to be heeded than if were it coming from the opposition.
We hope that ONC’s specifications, issued as guidance to the RECs by mid-2010, reflect market-driven innovations that can reduce the cost and complexity of EHR technology acquisition and use. Otherwise we’re in for a national exercise in chaos.
- Don’t waste time re-inventing the wheel. Every REC should network with every other REC, regardless of location or stage of development, to share lessons and experience, and to avoid wasted effort. In the past, for example, regional helper organizations – some QIOs and medical societies – independently formed exclusive contracts with one or two EHRs vendors, hoping these arrangements would simplify choices and implementation. These proprietary relationships were invariably unsuccessful for the helper organization and for the practices.Physicians and their organizations want to make health IT selections based on their own situations and needs. But almost always, they will seek the same kinds of IT support during implementation: e.g. networking, set up, Internet connectivity, security, and basic computer skills training for staff and physicians alike.
RECs should collaborate on tools and instruction kits where ever possible: each REC doesn’t need to develop its own HIPAA privacy and security guide book, for instance. Remember that peripheral devices, such as printers, fax machines, and modems, are part of every office’s set up, and that these items can be troublesome to set up and use.
- Come to the task understanding that successful HIT implementation requires fundamental process re-design. We’ve learned this the hard way. Unless health IT helps re-design practice work and information flow processes so they can be more efficient and quality-promoting, then the IT is simply an expensive appliance. Process re-design also can determine whether the EHR technology deployment produces a return on investment (ROI). For example, re-designing the documentation process to reduce or eliminate dictation transcription services, relying instead on EHR data entry by office staff and the physicians themselves, can save money and lead to an ROI within 12-24 months. We have seen this occur frequently. On the other hand, practices that continue dictation at the old levels are simply adding new data capture expense, making it harder to justify the investment.
States are hurrying to get access to this stimulus money. Many organizations aspiring to be RECs are focused on the rapid grant/award cycles. But its critical for planners to focus on what it will take to get the job done, and setting the groundwork for effective regional centers that can offer thousands of practices the help they need.
David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on healthcare professional and consumer technologies. Brian Klepper PhD is a health care market analyst.
By GLENN LAFFEL
Author’s Note: This the second of a 5-part series whose purpose it is to make the case for implementing a widespread, systematic approach to HIT education in medical schools and continuing medical education programs for physicians. A previous post reviewed challenges posed by the HIT Deluge.
Countries around the world are racing to digitize patient medical records. In the US for example, the American Recovery and Reinvestment Act allocated $21 billion to an incentive program designed to encourage the “meaningful use” of such systems.
The Federal government’s largesse is based on the premise that EHRs will improve the quality of care and reduce its costs, but the move will impact the health care system in many other ways as well. One area sure to be impacted is the education and training process for new physicians.
What kind of impact can we expect? In some ways, EHRs appear to enhance medical education, but there are as many or more instances in which the impact appears to be negative. Thankfully, careful planning can mitigate most of the collateral damage, a topic to be covered in this series’ next installment. For now, we’ll settle for a review of the good, the bad and the ugly.
There was a time–not too long ago, in fact– when it seemed safe and reasonable to define health information technology narrowly: the acronym encompassed the management of health information and its secure exchange between patients, providers, and insurers.
For many providers, the definition seemed to compartmentalize HIT. It was for someone else, perhaps the Ivory Tower crowd, but not for me. The nearly 90% of practicing physicians in the US that don’t use an EHR for example, might have sensed that someday they’d have to log on, but not any time soon.
And as for all that stuff about telemedicine and consumer driven health care, that made good topics for CME courses, but again, it wasn’t immediately relevant.
That began to change 15 years ago when nascent quality reporting initiatives began forcing physicians to deal with clinical performance data and the systems used to collect, analyze and display it.
It accelerated when patients began showing up in their offices with Internet-derived reprints of journal articles they hadn’t read themselves, and with pay for performance systems in which insurers tied a chunk of their income to the frequency with which they screened people for colon cancer and kept their diabetics’ HbA1c levels below 7.0.
But nothing in the past could have prepared physicians to deal with the overwhelming flood of HIT that inundates them on a daily basis today, a flood that threatens to sweep away long-established professional codes of conduct and disrupt the very processes by which care is rendered, doctors communicate with patients, and health systems interact.
The Obama administration’s push to disseminate EHRs via Medicare bonus payments for those who demonstrate “meaningful use” beginning in 2011, is but a tiny component of the Deluge.
Equally if not more important is the recent explosion of social media, a phenomenon whose unprecedented, indiscriminate growth has spared no sector of our society and taken health care by storm.
The newest generation of physicians has grown up with Facebook and Google, with Twitter and YouTube. They “get” the technology, but don’t always understand how its use affects their efforts to forge identities as medical professionals.
And for the rest of us, forget it. What in the world is all this stuff, and how dare we use it without getting burned by the fire?
Consider the following examples, which illustrate how the deluge affects physicians at every stage of their careers:
1) In his second week as a medical intern, Dr. Jain receives a “friend request” from an Erica Baxter on Facebook. Years ago, while he was a medical student, Jain helped deliver Baxter’s baby. Now she wants to reconnect. Is she simply a grateful patient interested in sharing news about her child, or does she have other motives? Jain clicks “confirm,” granting Ms. Baxter access to his network of friends, his personal photographs and blog, and the scrawls of others left on his wall.
2) Dr. Margolis, a middle-aged pulmonologist, receives about 120 emails per day. The assortment spans the range of her busy life. There’s an email from her oldest child who needs to be picked up at 6:30, not 5:30. Her dentist has an opening this afternoon and wants her to come in for a permanent fitting on her crown. Her secretary wants her to see a patient whose breathing difficulties have taken a turn for the worse.
And then there are emails from Dr. Margolis’ patients. Some are annoying, some can be handled by the nurse practitioner, and some reflect downright emergencies.
Problem is, Dr. Margolis is way too busy to read 120 emails per day. She’s lucky if she gets through half of them. She has a thousand unread emails in her inbox, many of which arrived weeks ago. She worries some may contain time-sensitive information regarding a patient.
3) Dr. Tapscott, in his late 60s and nearing the end of a satisfying career in family practice, is convinced by front-office personnel to begin using an electronic health record. “That $44,000 in bonus payments sure would help make ends meet,” he reasoned to himself at the time.
But the EHR implementation doesn’t go well. He has trouble getting the hang of the thing and believes the machine puts a barrier between himself and his patients. He expresses displeasure to his staff, one of whom leaves in a huff. Five months and tens of thousands of dollars later, he ditches the system.
Physicians have faced emerging ethical challenges before. Their struggle to develop professional identities is as old as the profession itself. And this isn’t the first time they’ve have had to incorporate new medical innovations into their daily lives, but the HIT deluge multiplies these challenges several fold, and creates myriad new ones, many of which remain vexing even to deep thinkers in the field.
Something has to be done to support physicians as they confront the HIT Deluge.
Thankfully, that’s possible and within our abilities to do so, at least for the most part. In subsequent posts of this series, we’ll explore the Deluge in detail and draw conclusions about what we need to do.
Glenn Laffel is a physician with a PhD in Health Policy from MIT and serves as Practice Fusion’s Senior VP, Clinical Affairs.
Americans are generally skeptical of words that otherwise intelligent and articulate people can’t pronounce. “Interoperability,” like nu-cu-lar, is one of these. After a while, these words can take on a mystique all their own.But interoperability is a hugely important word in the context of today’s ongoing debate about the use of EHR technology by physicians, hospitals, and patients too. The federal government is going to provide billions of dollars to encourage today’s fragmented health care providers to convert from mostly paper to mostly computerized information systems. It is critically important for these systems to talk with one another. We want health data to flow between and among these systems and to be, well, interoperable. And it isn’t now.
So how can this word be so difficult to put into action? Here’s a clue: a lot of people are confused about its meaning.Continue reading…
One of the best local talk shows anywhere is Michael Krasny’s Forum on 88.5 KQED, San Francisco’s establishment NPR station (SF of course has a rebel NPR station KALW which has had me on a couple of times but I’m too scruffy for KQED!).
At 10 am PST Forum has a show about health IT which has Robbie Pearle from the Permanente group and 2/3 of my old HIO project team at IFTF, Joe DeLuca and Jane Sarasohn-Kahn.
You can listen in here