Tag: Margalit Gur-Arie

New and Improved Meaningful Use

Jul 14, 2010• 9

By MARGALIT GUR-ARIE

The long anticipated final rule on Meaningful Use was unveiled yesterday with much pomp and circumstance in a rather unusual ceremony which, interestingly, also marked the first public appearance of Dr. Berwick as CMS Administrator. The Final Rule is contained in an 846 page document. Accompanying the CMS ruling is the 228 pages final EHR certification rule issued simultaneously by ONC. Fortunately for all of us scrambling to figure out what has changed, Dr. Blumenthal released a synopsis in NEJM (recommended). Already many articles and dissertations have appeared and indubitably many, many more will be written in the next few days and weeks analyzing every change and every nuance of the new, and now binding, Meaningful Use. For those who don’t care much about nuances, preferring a bigger and lower resolution picture, here are the major changes to the old version of Meaningful Use.

The Good

By far the biggest relaxation was to divide the original 25 measures (23 for hospitals) into two groups – 15 mandatory measures and 10 optional measures of which only 5 need to be fulfilled, per provider choice. This is in effect a 20% reduction of the Meaningful Use burden.
They added back a requirement for hospitals to record advanced directives. It is listed in the optional group, which means that some hospitals could choose not to implement it, but one must be grateful for having it back on the list.Continue reading…

Leapfrogging CPOE

Jul 7, 2010• 11

By MARGALIT GUR-ARIE

Last week, yet another alarming Computerized Physician Order Entry
(CPOE) study made headlines. According to Healthcare IT News, The Leapfrog Group, a
staunch advocate of CPOE, is now “sounding
the alarm on untested CPOE” as their new study “points
to jeopardy to patients when using health IT”. Up until now we had
inconclusive studies pointing to increased and also decreased mortality
in one hospital or another following CPOE implementation, but never an
alarm from a non-profit group who made it its business to improve
quality in hospitals by encouraging CPOE adoption, and this time the
study involved 214 hospitals using a special CPOE evaluation tool over a
period of a year and a half.

According to the brief Leapfrog
report, 52% of medication errors and 32.8% of potentially fatal
errors in adult hospitals did not receive appropriate warnings (42.1%
and 33.9% accordingly, for pediatrics). A similar study published in the
April edition of Health
Affairs (subscription required), using the same Leapfrog CPOE
evaluation tool, but only 62 hospitals, provides some more insights into
the results. The hospitals in this study are using 7 commercial vendors
and one home grown system (not identified), and most interestingly, the
CPOE vendor had very little to do with the system’s ability to provide
appropriate warnings. For basic adverse events, such as drug-to-drug or
drug-to-allergy, an average of 61% of events across all systems
generated appropriate warnings. For more complex events, such as
drug-to-diagnosis or dosing, appropriate alerts were generated less that
25% of the time. The results varied significantly amongst hospitals,
including hospitals using the same product. To understand the
implications of these studies we must first understand the Leapfrog CPOE evaluation tool,
or “flight simulator” as it is sometimes referred to.

Do Physicians Have a Right to Privacy?

Jun 25, 2010• 20

By MARGALIT GUR-ARIE

As we move to Electronic Health Records (EHR), the debates over security and privacy are becoming more frequent and more poignant. We of course have HIPAA laws on the books and ONC has a Tiger team assembled to recommend privacy and security policies to Secretary Sebelius. CIOs and entire IT departments are all focused on protecting the privacy of patients and their Personal Health Information (PHI). This is, of course, as it should be, but how about privacy of those taking care of patients? Do physicians have a right to privacy too?

As EHRs become more prevalent and interconnected, increasing amounts of clinical and administrative data will be flowing out of doctors’ offices and into the great beyond. Most of this data is indeed patient data, but some of it could be combined, sliced and diced to derive pretty extensive information about doctors. For example, and in no particular order:

Prescribing patterns – Prescription data has been collected and sold to pharmaceutical companies for decades. EHRs will make this much easier to accomplish and the data will become richer and more granular, since it will contain the exact nature of the visit where a particular drug was prescribed or discontinued, including physician notes on the subject. Of course, such information finding its way to public websites would present a novel difficulty if, say, we can look up Dr. X and see that she wrote 30 prescriptions for contraceptives last month, half of which were for girls under 16 years of age.Continue reading…

Deobfuscating HITECH

Jun 21, 2010

By MARGALIT GUR-ARIE

Software developers sometimes use a technique called obfuscation to
protect their intellectual property. They use tools to add, remove and
displace the original flow of the code until no human can understand
what it does or how it does anything. Judging by the ample confusion
expressed by large numbers of physicians, it almost looks like a giant
obfuscator has been applied to the HITECH act leaving the medical
community to wonder what to do, why do it and how to proceed. The
prevailing wisdom is that, for some misguided reason, the Government is
paying for EHRs, but there are so many strings attached that it is very
unlikely anybody will ever see a dime of the much advertised $44,000.

First we should figure out what these EHRs can do, or more accurately,
will one day be able to do.

Store all your paper records electronically in a computer and
make them accessible to many other providers of care, including
patients. EHRs, if allowed, can also make all your records available to
insurers, Government and any other agencies or corporations who manage
to obtain access. There will of course be laws and regulations, consents
and all sorts of policies in place to prevent or punish unauthorized
access. Electronic data is much more liquid than paper based data,
leading to better collaboration, better visibility and like all liquids,
has better chances of leakage.

EHRs can slice and dice your data and present you with flowsheets
for an individual patient and many reports across your entire panel of
patients. You could see how your patients are doing, which ones need to
be reminded to come in, or schedule screening tests. It’s hard to do
that on paper.

Just like your data is available to others, theirs is available to
you. You can see medication lists, specialist notes or PCP histories,
hospital records, test results and even home monitoring devices input in
real time. Coordination of care should become less time consuming.

EHRs can help you directly communicate with patients (and other
doctors) via secure email or even secure teleconference. It can automate
making appointments, paying bills, obtaining pre-authorizations and
even the entire check-in/check-out process.

EHRs can provide you the latest guidelines and evidence, in a
patient specific context. Perhaps even CMEs. Computers are supposedly
better at calculations and cross checking large amounts of data, hence
they could alert you when an error is about to occur or present you with
the latest checklists.

No, all these things are not there now. Some of the simplest ones
are, and the rest should become reality after enough physicians start
using EHRs and enough EHRs get interconnected to form a critical mass
necessary for progress.

OK, so where is the catch? Truth being said, there is more than one
catch.

You have to feed the beast. Computers cannot deliver any of the
wonderful, or less wonderful, things above, unless somebody enters data
into the EHR to start with. While most data can be entered by staff,
lare portions will have to be collected by the physician.

Computers are intrusive. The EHR will make its presence felt in the
exam room. It will alter your interaction with your patients. There are
tips and tricks to minimize the change, but it cannot be eliminated
altogether.

EHRs are not a finished product. When you “adopt” one, you become
part of a learning effort on how to computerize medical records. EHRs
have “glitches”. The Internet and broadband have “glitches”. Computers
in general have “glitches”. People have many “glitches” too. Nobody
invented the perfect method for documenting encounters, for viewing
longitudinal records, for ordering tests and most important, EHRs are
not yet able to communicate with one another on a large scale.

The Government will have easy access to your records. Your
performance may be judged (perhaps inappropriately) and reimbursement
may be affected. Patients (and their attorneys) will have unfettered
access to your records. Mistakes will be found. Little notes you made
just for yourself in the paper chart, are not just for yourself anymore.

EHRs can be expensive. They don’t have to be, but they can be.
Picking the wrong piece of software, not getting proper training, not
managing the implementation process correctly and failing to
continuously manage change may cost you a small fortune, mainly in lost
productivity. There are no “lemon laws” for EHRs.

My first cell phone weighed over a pound and had huge buttons and a
very ugly antenna. My second cell phone was a flip phone and my third
one was Java enabled. I now have an iPhone. My first computer was a main
frame IBM 370. I was madly in love with the power of that machine. My
second computer was an IBM PC. I named him and took him with me on a
long vacation overseas and back. I now have a thin and much more
powerful Sony Vaio. I could have sat this whole thing out waiting for
the iPhone and the Vaio to be perfect, which they still are not, but I
would have been left behind I think. I would have certainly avoided the
embarrassment of dragging a 30 lb computer through several airports and
the excruciating wait for the modem to connect, or the inconvenience of
dropped calls every time I drove by an electricity pole. But I would
have also missed the ability to help a Hospital keep receiving lab
reports on a Friday night and the opportunity to walk a technician
through an entire database restoration from a mountain lodge in the
middle of nowhere.

If I were a physician in a small private practice today, I would do my
research and locate the cheapest EHR that can do what needs to be done
relatively well. I would “adopt” the contraption, regardless of the
promised $44,000, probably name it Lucifer and keep an eye on it to make
sure it behaves itself. And I would try my hardest to become part of
the future and part of the solution, because folks, whether we like it
or not, paper is over.

Margalit
Gur-Arie blogs frequently at her website, On Healthcare Technology. She was COO at
GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing
services for physicians. Prior to GenesysMD, Margalit was Director of Product
Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large
non-profit hospital organization.

EHR & The Art, Science and Business of Medicine

Feb 10, 2010• 5

By MARGALIT GUR-ARIE

“The practice of medicine is an art, not a trade; a calling, not a business…”

– William Osler

Dr. Osler was a great physician and a great man. However, in America today medicine may be a calling and may be partly art, but it is also increasingly part science and, for many physicians in private practice, it must also be part business.

This article will attempt to examine the role of Healthcare Information Technology (HIT), and Electronic Medical Records (EMR or EHR) in particular, in the art, science and business of medicine as practiced today, whether by choice or due to political and economic circumstances in 21st century America.Continue reading…

Urgently Needed: Useful Meaning of Meaningful Use

Jan 11, 2010• 19

By MARGALIT GUR-ARIE

One day before 2009 passed into history, the much anticipated final definition of “meaningful use” was released by CMS and ONC, 556 pages and 136 pages, respectively. The blogosphere experts rushed to summarize the contents, some accurate and some less so, and just like everything that has to do with health care reform, for every rule making there are a dozen new questions being raised by the already thoroughly confused stakeholders at large.

Just so that THCB is not left out, here is a quick qualitative summary of the contents:

Requirements:

1. Data Collection – The following structured data elements will need to be collected by the software: Demographics, Vitals (plus Smoking status), Electronic Lab Results, Problem Lists, Medications and Allergies. The important thing to note here is that the requirement to record Advanced Directives has been dropped in the final ruling.

2. Medical Records for Patients – Providers will need to provide patients with electronic copies of Visit Summaries, Care Summaries, Discharge Summaries and Complete Medical Records upon request. In addition, continuous on-line access to medical records is also to be provided.

We the Consumers

Nov 7, 2009• 32

By MARGALIT GUR-ARIE

There has been much talk lately about the Consumer movement in health care. The health insurance industry has given us the Consumer Driven Health Care (CDHC), which has gained much traction in the marketplace in the form of high deductible insurance plans, where the Consumer, having “skin in the game” now, is expected to make informed decisions on how to spend his or her money on health care services. The Consumer is empowered and in control of health care expenditures.

And then there are the various Consumer advocacy groups demanding an end to the paternalistic approach to the practice of medicine. Doctors should relinquish control to the Consumer. Consumers should actively manage their care by obtaining and controlling their medical records. Consumers should be informed by the medical establishment of the latest evidence-based best practices, timely research and costs of treatment. The Consumers will then make an informed decision aided by a myriad of peer and professional information available on the internet.

That’s a lot of new responsibilities for most of us who have no idea how much a visit to the doctor costs and even less of an idea whether or not we need that stent, assuming that we even know what a stent really is. Well, since we are Consumers now, not just passive patients, let’s see how we stack up to our brand new responsibilities.Continue reading…

The Long Tail of the EMR

Oct 7, 2009• 14

By MARGALIT GUR-ARIE

In the fall of 2008 I had the opportunity to do some research on the, then dormant, EMR marketplace. The results came as no surprise. Most physicians did not have an EMR and were not interested in adopting an EMR due to cost and usability barriers.

Much has changed in one short year. Spurred by ARRA and its HITECH portion, there is a renewed interest for technology in the physician community. Some of it came from the promise of stimulus funds and some stems from the perceived inevitability of the need to have technology in one’s office. There is no feverish anticipation of the great things an EMR will bring to a medical practice. Instead, there seems to be a somber resignation to the upcoming demise of a trusted friend: the paper chart.Continue reading…

The End of Dr. Marcus Welby

May 4, 2009• 14

By MARGALIT GUR-ARIE

Marcus Welby hard at work For most of us the term “Family Doctor” brings up images of Dr. Marcus Welby, the quintessential family doctor. There are almost no Marcus Welbys left out there, but there are thousands of family doctors in small practices that still have personal relationships with their patients and their families. Most of these physicians chose medicine for all the right reasons and most are frustrated with a system that seems to perversely sabotage their desire to provide quality care to the families in their charge. These days we are witnessing what could be the beginnings of major healthcare reform in this country. Will this also inadvertently be the beginning of the Industrial Revolution for primary care? Are we looking at Institutions of Primary Care replacing the solo family practitioner? At first glance it seems that in the name of efficiency and cost cutting these institutions, or mega-clinics, make perfect sense. After all, no one can dispute the achievements of the Mayo Clinic. Similar consolidation occurred in almost every sector of the economy in one form or another. The corner bookstores are all but extinct and the same is true for mom-and-pop grocery stores and pharmacies. It usually starts in the city and then Wal-Mart completes the process in small-town America.

There is much talk these days about medical homes. At first I thought that Marcus Welby was the perfect medical home. He was accessible to his patients day and night. He was there when the babies came and when it was time to accept the inevitable end of life, providing hope and comfort and sound medical advice devoid of unnecessary expensive tests and heroic measures. His patients trusted him and they were very likely to accept his prescriptions for changes in lifestyle. He coordinated all their care with hospitals and specialists. Sounds like a medical home to me. However when you begin reading today’s definition of a medical home, you quickly realize that Dr. Welby would not qualify. He simply didn’t have enough staff. The solo doc in rural Nebraska of today will not qualify either. And then there’s the technology question. Dr. Welby’s definition of technology was a stethoscope. Today’s medical home requires technology beyond Dr. Welby’s wildest imagination. For over a decade, HIT vendors peddled EMRs at exorbitant prices and failed to convince doctors in small practices to purchase anything. Maybe because the value proposition to the physician was nonexistent. Today we are about to make these certified, overpriced and, by and large, unusable products mandatory for medical homes and the practice of medicine in general. The solo doc in Nebraska cannot afford these products even if the government is proposing to eventually bear some of the financial burden.Are we saying that a medical home should by definition be a mega-clinic with deep enough pockets to bear the costs of arbitrarily imposed staffing models and dubious software purchases? Shouldn’t the choice of tools, whether staffing or technology, be left to the physician? Is anybody consulting America’s practicing physicians on how best to practice medicine? Are we absolutely certain that large institutions will provide all around better quality of care? I fear that the independent family doctor is going to go the way the corner bookstore went, and be replaced by the cold, impersonal, shiny mega-clinic chain in the city. It won’t be long after that before Wal-Mart sets up the Wal-Health clinics in rural America. Any young kids out there planning on going to medical school and hoping for an illustrious career with Wal-Mart?

Margalit Gur-Arie is COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization.

For whom the HITECH Bill Tolls?

Mar 17, 2009• 18

By MARGALIT GUR-ARIE

As part of a sweeping effort to address the woes of the current US economy, the government has placed $19 billion on the table for HIT, aimed at containing healthcare costs and creating new jobs. The ultimate instruments for implementing this HITECH bill are America’s physicians and there is much confusion and apprehension in the physician community regarding the net effects of this bill on doctors in particular and healthcare in general. The HIT stimulus effort will not reach its stated objectives without voluntary adoption by our doctors. The government and the HIT community must find a way to draw physicians all over this country into the process of defining and implementing the stimulus package.

In very broad terms, interoperability standards will be defined, Electronic Health Records (EHR) technologies will certify compliance with the standards and physicians will be provided financial incentives to acquire, and meaningfully use, those EHR technologies. The assumptions are that use of these standardized EHRs will reduce costs by reducing medical errors, reducing duplication of tests, improving quality of care and encouraging evidence based clinical decisions. Jobs will be created as the EHRs are deployed across the nation. Experts are already at work “on the Hill”, in the White House, in the boardrooms of HITSP, NIST, CCHIT and other acronym organizations. Technology vendors are feverishly doing their part, from creating websites devoted to the HITECH bill, to making products available at Wal-Mart, to sudden revelations that HIT is really their main business. Everybody is actively involved in making this bill a success. Well, maybe not everybody.