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The “Enthusiasm Gap” in Health IT

My next piece is published at Townhall.com:

 

Despite the success of information technology (IT) in transforming many parts of the economy, the health care sector has proven itself immune to the seduction of smart phones and iPads.  This is puzzling at first glance.  It is certainly not due to any shortage of health IT products.  The problem appears to be on the demand side.

A recent article by Olga Khazan in The Washington Post provides some explanation. She reports on the third annual mHealth Summit, held earlier this month in Washington D.C.  The event has attracted such notables as Bill Gates and Ted Turner, according to the mHealth website.  The piece laments the “enthusiasm gap” between Health IT startup companies offering dozens of miracle products and those darn stick-in-the-mud physicians who just can’t get with the program.   But meetings like the mHealth Summit actually hurt the movement of Health IT that they profess to support.

The poster child for Ms. Khazan’s article is Dr. Eric Topol, one of the Summit’s keynote speakers.  HHS Secretary Kathleen Sebelius joined Dr. Topol behind the podium.  Together they offered Health IT Utopia – where “you can take a video of a rash on your foot and get a diagnosis…without making a doctor’s appointment.”  Then they criticized practicing physicians using the same old Obamacare propaganda.  Ms. Sebelius continued, “Americans still live sicker and die sooner than many of the people in other nations…Healthcare has stubbornly held on to its cabinet and hanging files.”  Dr. Topol called the medical community “ossified” regarding the adoption of health information technology.  The author starts the online post-article comment thread herself with the question, “How do we encourage doctors to be more open to these technologies?”

This kind of meeting is common in the Health IT (HIT) community.  A bunch of self-described HIT experts get together, pump each other up about the absolute perfection of their products, and then start bashing physicians because – literally and figuratively – we aren’t buying it.  At similar meetings I have heard HIT people brag about walking out on their doctor the minute he pulled out a paper prescription pad.  Doctors are called fearful, stupid, or rich fat-cats protecting their turf.  Now thanks to our “colleague” Dr. Topol we can add, “ossified” to the list of unflattering terms.  It comes as no surprise that the government is happy to join in the sing-along.  It is a free opportunity to serve Obamacare Kool-Aid.

I am a dedicated supporter of HIT.   Our practice’s EMR implementation reached a reasonable level of maturity long before Obamacare, HITECH incentives, and Ms. Sebelius came along.  We became Meaningful Use – compliant the first of October.  I believe in the potential of HIT to revolutionize the practice of medicine by reducing costs and improving efficiency and quality of care.  But I do not believe the HIT community is on a course that will take us to that vision.

Read the rest of the article here at Townhall.com

January 5, 2012 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

The Nitty-Gritty of Meaningful Use – Part 2

This is the second in the series of how our practice is getting the work of MU done.  The first of the series can be found here.

Starting with Core Set Item #7:

7.   Record demographics as structured data.  We have been doing this for a long time but MU requires us to add race and “ethnicity.”  Isn’t ethnicity the same as race but more specific?  If you have the latter you don’t need the former.  Furthermore we have had patients push back on asking this question.  Some find this question offensive.  They shouldn’t; since many diseases are race / ethnicity – specific the question is medically appropriate.  Fortunately MU considers the term “undetermined” as acceptable for this data point.

8.  Record vital signs as structured data.  This conflicts with lower level CPT E/M coding with does not require vital signs.  Once again the left hand of government doesn’t know what the right is doing.  Nobody thought it through.

9.  Record smoking status.   No problem here.  Medically appropriate for all specialties.

10.  Quality measures.  These are poorly designed and confusing.  There are 2 redundant measures both dealing with tobacco use and cessation, and these are both redundant (but not identical) to core set #9.  Weight screening is reasonable enough but the follow-up requirements are ambiguous and burdensome.  Are we really supposed to bombard our local dietician with weight loss consultations?

11.  Decision support rule.  We will configure our EMR to prompt for hearing loss screenings in patients over 50 years old.  Fair enough.

12.  Provide an electronic copy of health information to the patient upon request.  Who are they kidding?  This should have been delayed to Phase two.  Qualified EMRs can do this easily enough but the product is exported to your remote server desktop; it is cumbersome to copy from there.  We have had few such requests from patients; I wonder if those few are asking just to prove a point.  I don’t know that for sure.

13.  Provide clinical visit summaries.  Again should have been delayed to Phase two.

14.  Exchange key clinical information between systems.  This one is unbelievable.  Fortunately, as I understand it, you only have to do it once.  You are supposed to upload all or part of someone’s chart (or perhaps a test chart or other hypothetical data) to portable media, go to someone else’s EMR and try to upload the data.  Doesn’t matter if you succeed or not.  Am I misunderstanding this one?  If anybody has a better handle on this one please leave a comment.

15.  HIPAA security risk analysis.  Although I hate paying for it I must admit that is a good idea.

 

The last installment will cover the Menu Set Measures.

September 18, 2011 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

The Nitty-Gritty of Meaningful Use – Part 1

To this point I have contemplating Meaningful Use from 10,000 feet above the landscape.  I have done my reading, been to meetings, and met with our EMR vendor…all the usual things.  But this week it was time to roll up our sleeves and go down from 10,000 feet to cut through the jungle at ground level and bring MU to our practice of 19 physicians.

We faced the maddening task of reviewing 15 Core Set Measures and choosing 5 out of 10 Menu Set Measures, and then getting them done.  I have to admit that some parts of meaningful use are not too bad.  But there are other parts that are confusing, redundant or totally ridiculous.

Regarding the first 6 of the 15 Core Measures:

CPOE for Medication orders.   The concept is fine but the requirement is not structured well.  It reads, “More the 30% of all unique patients with at least one medication in their medication list seen by the EP (eligible provider) have at least one medication entered using CPOE.”  Read it carefully.  It says if a patient walks in my door and reports to be on any medication, I have to prescribe another medication whether the patient needs one or not.  Most doctors write enough prescriptions that by luck of the draw this won’t be a problem.  But we have 2 docs that don’t write a lot of prescriptions and they are currently don’t meet this measure even though they rarely, if ever, write a paper prescription.

Drug-Drug interactions and Drug-Allergy Interactions.  No problems here.

Maintaining a Structured Problem List.  Certified EMRs do this automatically and this function is essential to quality measurement and outcomes research.  Some of us (me included) need to change our documentation habits to get the proper data capture.   By personal habit I prefer writing unstructured paragraphs instead of distilling a patient visit down to a bunch of ICD-9 codes.  I’ll get over it.

 E-Prescribing.  Obviously an appropriate requirement.  But it sets the bar higher than the CPOE for Meds requirement (see #1 above), so why bother having the CPOE requirement at all?

 Maintain structured active medication and allergy lists.  Also a reasonable requirement.  This has always been a part of the physician’s visit routine.  The only problem is that the EMR requires the doc to check a box for each of these requirements.  I am going to try to modify our existing templates to make that task as painless as possible.

 

In future installments on this topic I will cover how we are handing the remainder of the MU requirements.  Stay tuned.

 

 

August 11, 2011 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

Lessons Learned from Anesthesia EMRs

Several years ago one of the hospitals where I operate spent 6 figures on an anesthesia EMR system.  After several months and a huge amount of money the whole thing was scrapped because it was so cumbersome to use.  They have not tried again.

A few weeks ago the anesthesia group that covers our surgery center got an EMR.  The product is called Anescan and apparently has many successful installs.  It runs on Windows 7 tablets that communicate with a central server.  Needless to say I was curious to see how this system differed from the failed system I had seen years ago.  What I learned was very interesting.

Medical record keeping in anesthesia is different from all other medical specialties.  The job includes monitoring vital signs constantly and documenting them in the anesthesia record every few minutes.  It is a task that begs to be automated.  Such technology would presumably free the anesthesiologist from mundane repetitive documentation, allowing more efficient and effective monitoring of the patient.   The necessary technology has been available for years and was used in the failed hospital system from years ago.

I was surprised to learn that Anescan avoids that technology.  A conversation with the Anescan rep revealed that is was precisely that technology which caused earlier systems to fail.  It’s easy to measure blood pressure, heart rate, respiratory rate, and blood oxygen level and push that data to an EMR.  The problem is that the data are often riddled with artifact.  If an EKG lead or pulse oximeter comes loose, or if the surgeon leans on the arm-mounted blood pressure cuff, it is not unusual to get an automated pulse or blood pressure of zero.  The anesthesiologist / anesthetist can easily recognize what is happening, fix the monitors and record accurate vital signs.  This often happens several times during a case and is no big deal.

The automated system makes it much worse.  By the time the bad data are recognized the automated system has already pushed that zero pulse and BP to your EMR.  Now the anesthesiologist / anesthetist has to open some kind of editing function in the EMR and delete, edit, or explain away the false readings…AND at the same time troubleshoot the monitors that sent the bad data in the first place…AND by the way your patient is still asleep and you can’t stop watching him.  AND you only have a couple of minutes to get caught up before the monitors send the next the next set of (? bad) vital signs to the EMR.  The potential downward spiral is easy to see.

Anescan avoids this problem.  The tablet PC presents an image of a standard anesthesia paper record with the patient demographics and other data already in place as structured data.  Vital signs are recorded with “digital ink.”   Use the stylus to record vital signs on the form, on the tablet.  When the case is complete the form images are sent to the server for centralized record keeping and billing.   A paper copy is printed for the surgery center chart.  This is an elegant solution that automates only those parts of record keeping where it is practical.

Someday the artifact problem will be solved either through better monitors or better error recognition within the EMR.  But today this serves as yet another example of too much IT and automation in health care causing more problems than it solves.

July 24, 2011 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

Our Disaster Recovery “Fire Drill”

Last Friday our practice had an opportunity to practice our disaster recovery protocol.  This was actually good news; we are replacing our 6 year old servers with virtual servers and a storage area network (SAN).  The implementation plan required more down time than a weekend would provide so we added a Friday to it.

Unlike a real disaster we had the opportunity to prepare immediately before, knowing exactly when the system was going down.  We printed our clinic schedules and printed the clinic note from the last visit for patients who had appointments.  We did not cancel appointments or reduce the number of patients seen.  For appointments requiring other documentation (i.e., pathology reports for post-surgery visits) we printed those.  We also printed a generous number of our most common handouts and got our paper prescription pads ready.

The day was free of major problems and the staff performed very well.  The experience was very interesting:

  1. My description above is a little too rosy.  We ended up searching for some documents at the last minute.  We ran behind schedule and there was a mild degree of disorganization throughout the day.
  2. Patients were very understanding about the delay and about our EMR being down.  Everyone understands that computers go down and I was thankful to see that our patients remembered that.  In some cases I had to ask patients to refresh my memory regarding prior visits since I didn’t have the entire chart available.  No one seemed to mind.
  3. I was still able to use my PC and Dragon Speech. Dragon runs locally on my desktop.  I dictated notes in Notepad and saved a separate note for each patient.  On Monday, my assistant will create Friday’s chart notes in the EMR, enter their data (vital signs etc.) and route the notes to my desktop.  Then I will copy / paste my notes into the EMR chart.
  4. Dictating unstructured chart notes into my PC was refreshing.  It was also an impressive reminder of how much garbage CPT forces us to add to our notes.  Even for complicated, new patients I was able to record everything relevant in less than two-thirds of a page.  Adding the CPT-required material almost doubles the size of the note without adding any relevant, useful data.
  5. With the system down the front office could focus on patient service without having to obsess over data entry.
  6. With all the extra paper floating around the back office was a mess.  I can’t imagine going back to paper charts.
  7. We were still compromised operationally when we had a patient who needed to schedule surgery.  Without the EMR workflow engine we could not print customized surgical packets.  Handwriting surgical consents is not acceptable.  We will have to catch up on this workflow next week.

Take home lessons:

We need to improve our disaster readiness, but at the moment our readiness is not too bad.  Our new SAN is configured to perform incremental backups every night and full backups every weekend.  The virtual servers and SAN will allow us to redirect workload in the event of a server or hard drive failure.  For a network failure we can follow the protocol we just rehearsed, but we should take the time to update our hard copies of handouts and surgical consents.  This is interesting because on more than one occasion we have had IT vendors try to push their way in to our practice using our presumed lack of disaster readiness as their excuse.

Once our new servers and SAN are settled in I may look into an automated method of copying appointment schedules and recent chart notes for patients with appointments to a local PC in each office rather than wasting all that time and paper every day.

I understand that all that front office data entry is a necessary evil.  But I never realized how much it distracts the front office from tending to patients.  I am going to double my efforts to make it attractive for patients to enter their own data online in advance of the visit – or at least have them use the patient portal to enter their own data in the waiting room.  As much as we have tried so far, our patient portal still has not caught on with our patients in the waiting room, and there has been only moderate use from home.  I don’t think our web portal is good enough yet.

February 20, 2011 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

A Process for Replacing CPT Codes

Those of you who have been kind enough to read my blog know I criticize CPT coding on a regular basis.  Finally after my last tirade, a comment from John finally said what I have been dreading to hear:  “I’d love to hear more about what you think a good replacement to the current CPT system would look like.”

That is the question, isn’t it?   I’ve been criticizing long enough.  Time to put up or shut up.  A brief Internet search does not reveal any significant activity regarding a replacement for CPT except for vague “pay for performance” concepts that would pay for results rather than the care itself.  I must confess that despite thinking about CPT replacement for the past few months I don’t have any bright ideas either.

But since I raised the question in the first place I’m willing to take a shot at it.  Ignorance has never stopped me before…

I would like to begin a 4 step brainstorming process with you:

  1. Outline the shortcomings of CPT coding
  2. Translate those shortcomings into desired characteristics for a replacement system
  3. Explore applicable technologies that allow us to leverage the use of EMR to create an IT-based payment system with the desired characteristics
  4. Formulate proposals to replace CPT

I’m going to resist the urge to write my usual 1000 word post and stop here.  Please share your thoughts regarding the wisdom of this project and whether or not these 4 steps are the best way to approach the question of a replacement for CPT.

January 27, 2011 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

The Frightening Political Side of EMR

What truly frightens me about HITECH is that it demonstrates the government’s enthusiasm for juxtaposing itself into the EMR movement.  I am frightened, but obviously not surprised.  Like any powerful technology, EMR can be used for benefit or harm.  Used properly EMR can fulfill the promise of lower costs, improved efficiency and higher quality of care.  But if controlled by sinister forces, EMR will become a vehicle to undermine the doctor-patient relationship by limiting treatment choices and covertly monitoring /controlling doctor-patient behavior.  Make no mistake: there are elements within our government that have recognized the potential of EMR as an instrument to bring health care under their control.  If you think that notion is a bit paranoid, consider the words of the new director of CMS, Dr. Donald Berwick:  “It’s not a question of whether we will ration (health) care, it is whether we will ration with our eyes open.”  Regarding Britain’s National Health Service (NHS), which rations care to British citizens, Dr. Berwick says, “I am romantic about the National Health Service. I love it.”  The NHS limits spending on life-saving care to $44,000 per year.

It is not difficult to understand how a government EMR system could be used to control and ration care.  Remember the FDA’s recent withdrawal of its approval of the drug Avastin for breast cancer?  Although doctors are powerless to reverse this unfortunate decision, at least it was formally announced and subjected to public scrutiny and debate.  And Avastin is still available to use “off-label.”  If EMRs were government controlled, no announcements would be necessary.  The “Avastin button” would simply be removed from the physician’s treatment option screen.  And it would be easy to program a government-controlled EMR to enforce an NHS-type spending limit to extend life.  When a patient’s spending limit is reached, the system locks out that patient’s chart and no more care can be given.

Ridiculous, perhaps?  The HITECH program, through EMR certification, already has established a mechanism to force EMR vendors to make their products comply with government requirements.  It would be a simple regulatory step to “upgrade” those requirements to include a method of government “back door access” to any EMR. Such access would allow the government to establish and codify within EMRs methods of limiting and rationing care.  It would also allow the government to monitor physician-patient behavior and deliver sanctions if it so desired.

I am not suggesting we storm Dr. Berwick’s office with torches and pitchforks.  But I would like to offer some thoughts to serve as a “moral compass” as we continue our work on the EMR movement:

  1. EMR should only be used in a manner that supports the doctor-patient relationship.  EMR should be used to reduce costs, improve efficiency, improve quality of care, enhance doctor-patient communication and protect the physician’s ability to properly practice medicine.  EMR and related technologies, such as health information exchanges, should be used to efficiently move data among providers and to automate those parts of health care workflow that are appropriate for automation.
  2. It is inappropriate to use EMR as a vehicle for the government or any third party payer to force itself into the practice of medicine and into the doctor-patient relationship. EMR must not be used to enforce any restriction of treatment choices.  It is improper to use EMR as a tool for the government or any third party payer to covertly monitor physician / patient behavior.
  3. The HITECH incentives are a mixed blessing. While the incentives certainly encourage EMR adoption they may also deprive the medical culture of the necessary time to make a stable, controlled cultural change to an information technology environment.  This increases the risk of failure and may paradoxically increase the time and resources that are ultimately required to complete the cultural transition.   It will take extra time and money for some medical practices to recover from poor decisions made in haste.
  4. The HITECH incentives are also harmful because they create a paradigm in which government sets the goals and the medical and IT cultures follow.  The result could be a health care IT system that serves the whims of politicians, not the needs of patients.  This is unacceptable.
  5. Let’s start thinking about a better physician payment system than CPT. The CPT coding system was created by the American Medical Association (AMA) over 40 years ago and has become an antiquated, overly burdensome set of documentation requirements.  The coding compliance industry must siphon billions of health care dollars away from patient care to help physicians comply with these incredibly complex guidelines.  The AMA profits approximately 50 million dollars a year selling CPT and ICD-9 materials to physicians.  Their support of CPT is not objective and cannot be trusted.  The CPT coding system assumes paper-based documentation.  Through EMR we have learned that a fully CPT-compliant chart note is almost useless to the clinician.  The relevant data are buried in a sea of white noise: patient demographics, irrelevant historical data, normal physical findings, and diagnosis / billing codes.  The result is lengthy documentation that is dedicated to CPT compliance rather than to communicating useful health care information. EMR gives us the opportunity to replace CPT with a new physician payment system based on information technology instead of paper charts.  Such a system will allow us to re-direct limited health resources from regulatory compliance back into patient care.
  6. Technology always brings unintended consequences.  Health information technology will certainly bring unintended consequences, including unintended and undesirable de facto changes to the standard of care.  We must watch carefully for these changes and protect physicians from these unplanned changes in the standard of care until they are examined, modified if necessary and formally recognized.

Recent political events clearly demonstrate a significant change in the relationship between America’s government and her citizens.  Those who work in health care information technology must be aware that EMR technology could be utilized as a government instrument to covertly take control of our health care system in the name of “social justice” and cost containment.

January 17, 2011 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

Busting the Myths about EMR Implementation

I am still crazy over the ridiculous EMR cost study recently published by CDW.  This regrettable study was obviously put together by a bunch of newbies that had no idea what they were doing.  A few weeks ago, during a rant on a previous post on this topic I promised I would review our practice’s implementation strategy.  It’s time to live up to that promise.

The CDW group assumed, as I imagine many still do, that EMR should be implemented as quickly as possible minimize the financial impact of decreased patient volume.  In our practice we took the opposite approach, realizing that if we brought in EMR slowly enough we wouldn’t have to decrease patient volume at all.  We overcame both the cultural and the financial barriers to EMR by creating an approach that was different from the prevailing wisdom at the time. Conventional project management principles don’t work in the physician practice setting.

  1. We recognized that EMR was not a project with a defined end point – it would instead be an ongoing “work in progress.”
  2. We avoided big “go-live” dates and hard deadlines for abandoning paper charts.  Paper charts were eliminated gradually, via attrition, over 2-3 years.   Docs are already uptight and uneasy about EMR; deadlines only make it worse.
  3. We rejected the notion that we would have to decrease patient volume and lose revenue, even temporarily, to get EMR implemented.  Don’t even think about suggesting to a doc that (s)he will have to decrease patient volume.  We can’t tolerate it financially.
  4. Every office and every physician was allowed to progress along its own timeline.  Every office has its own set of assets and liabilities – its own subculture.  It made no sense to force the same timeline on everyone.  We also offered (and continue to offer) each office / physician a fair amount of latitude on exactly how the EMR is used.  Some docs use speech recognition, some don’t.  Some offices didn’t scan outside records at first.  In the early days we didn’t care if docs wrote paper prescriptions.  The script pad is one of the hardest cultural icons for the physician to let go.

We had one physician who resisted EMR for almost a year.  I was approached several times to pressure this doc to “give in.”  I declined.  Then one day he discovered Dragon Speech and started EMR almost overnight.  We docs are self-selected fiercely independent souls; our training reinforces those characteristics.  I know this physician well; he had to do EMR on his timing and his terms.  If I had pressured him it would have backfired badly.  I probably would have behaved similarly.

To accommodate the physician’s need for independence the EMR adoption process was broken down into a large number of incremental steps.  After a short teaching session each physician had a training version of the EMR, complete with fictitious doctors and patients, installed on his/her laptop.  Over a few evenings the physician would work with the program to get used to the basic operations and functions.  Once the physician was comfortable we put the server communication software on the doc’s PC and showed him/her how to log in and use the same training EMR program on the server.  The training EMR on the server was configured with our custom templates.   The physician was then instructed how to create chart notes using our templates.  Then he/she could spend more time practicing at home, logging onto the server from there.

Then it was time to use the “real” EMR program on real patients.  But not all at once. Start with only one patient, the last patient of the day. Those first few notes took forever to complete.  But with our approach that was no problem.  For a while many of the docs printed out the completed EMR note and put it in the paper chart.  Why bother doing that?  It was a cultural trust issue.  With time, trust in the EMR increased and the practice disappeared naturally.

We advanced each doctor at his/her own pace.  Do EMR for the last 2 patients of the day, then the last 3, etc.  When ready, take on a half day of patients, then an entire day.  If there is a problem, back off.  Get the issues resolved and try again.   There were no deadlines and no pressure.  After getting settled with documentation move on to workflows such as prescriptions, ordering tests and imaging.  Then finally learn CPT/ ICD-9 charge code entry.

This process serves 2 goals.  First it allows the cultural change to an IT setting to progress at an acceptable, sustainable rate.  It also allows EMR to come in without decreasing patient volume.  It took almost a year to get 20 physicians in 15 offices implemented with basic EMR functions – but there was no panic, only modest chaos and no loss of patient volume.  We had our frustrating moments, but I am convinced that they would have been far worse with a conventional implementation plan.

January 11, 2011 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

Over-Automation of EMR Note Creation Encourages Missed Diagnosis and Incurs Medical-Legal Risk

Over the past several months I have read several online discussions and comment threads on the medical-legal issues raised by EMR, including an HIMSS brochure on the subject.  Most of these discussions miss what I consider to be most important legal weaknesses of an electronic medical record. I finally came across an online discussion that comes closer to covering what I consider to be the most important medical-legal issues.

When we were setting up our EMR about 6 years ago many of our docs came to me with the same request:  “I want to create a chart note with a single button click.”  Although that was obviously a bad idea, their desire for it was understandable, given our inexperience at that time.  Templates are widely recognized as an effective method of documenting care and complying with CPT coding requirements.

For many common diagnoses physicians have been using “mental templates” long before EMR existed.  For example, a pediatrician refers an otherwise healthy 4 year old child to an ENT doctor for recurrent middle ear infections.  Because pediatricians are capable of utilizing all conservative treatment options for middle ear infections, the pediatrician will usually not refer the child until he needs ear tubes.  This is one of our most common operations.  The ENT doctor’s mental template is thus geared towards documenting indications for ear tubes.  The template includes quality and duration of ear symptoms, number of doctor visits for ear infections, and the antibiotics that have been tried so far.  Also included would be the appearance of the eardrums and the results of testing performed in the office.

So why not create a “one button click” template?  When this child comes to your office bring up the template, fill in the blanks and you are done.  Come to think of it, let’s save some money and have a nurse, nurse practitioner or a physician assistant do the entire visit.  Sounds like an ObamaCare Dream Come True.

There’s just one small problem.  Hidden among the dozens of children with straightforward ear infections are a few kids who look like they have chronic ear infections, but actually have something else going on.  It might be something benign like allergies or enlarged tonsils and adenoids, or it might be something rare and ominous like eosinophilic granuloma or malignancy.  It is the physician’s job to recognize these patients in the crowd of children with symptoms consistent with chronic ear infections.  To find these patients the physician uses an open diagnostic thought process.  In the physician’s mind, mental templates and open diagnostic thought coexist in a non-competitive, complimentary fashion.   A good clinician automatically uses the right thought process at the right time.

The same cannot be said of EMR.  EMR templates must be carefully designed to support the open diagnostic thought process that is essential to practice medicine well. EMR templates will subtly influence the physician’s thought process as they are used over and over.  Depending on the EMR template structure that influence can be positive or negative.  Templates that over-automate the note creation process emphasize template thinking at the expense of open diagnostic thought.  This increases the risk of a missed diagnosis and incurs medical legal exposure.  Such templates augment the already unfavorable influence of CPT coding requirements, which also force clinicians to focus on documentation of care rather than the care itself.  Among the worst examples of such templates are those that prompt the user to check a bunch of boxes and then create a narrative based on the user’s menu choices.  The result is awkward text that reads nothing like prose composed by a real person.

From a legal standpoint it is easy to read through the facade of automated detail and completeness to see the clinician’s lack of true diagnostic thought.  In the event of a bad outcome the legal exposure is just as severe, perhaps worse, than a sparsely completed paper chart note.  To avoid this hazard, those who design and customize EMRs must seek an optimal level of automation – one that leverages the advantages of EMR but still supports and documents the physician’s direct participation in care.  A properly designed template requires at least one “physician narrative”.  A physician narrative is a few sentences of prose composed totally by the physician with no IT automation involved.  In legal matters this narrative my be the only clear proof that the physician actually touched the patient him/her- self and gave that patient some thought.

January 6, 2011 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

Bedside Manner in the Information Age

In 2003 our practice had a rare opportunity to build EMR functionality into the floor plan of our new office.  I thought I had the perfect design for the EMR-based exam room.  The spring-loaded, cantilevered arms used to hold monitors and keyboards in ICU rooms would be perfect.  Fitting a touch screen monitor to a standard PC would allow the provider to work without a mouse.  I could turn the screen toward me or toward the patient, depending on what I was doing.  Could see it all in my mind’s eye, plain as day.  Fortunately my partners had more sense than I did; the group limited the idea to 2 of 8 exam rooms.  Six months after we moved into our new space the idea had been tried and had died, and the 2 arms now sit unused.

Shortly thereafter, the other member practices in our network were preparing to implement EMR.  Everyone wanted to know what kind of computers to buy and where to put them.  We considered many combinations of computers (desktops, laptops, tablets) and possible locations (exam rooms, back office, physician office).  Where inside the exam room should the computer be placed?  And where should the printers be installed?  I began to realize that behind these seemingly simple hardware questions lurked a much more challenging issue.

The introduction of information technology to the patient care environment fundamentally changes the physician’s interpersonal approach to the patient – one’s bedside manner.  If this change is not actively managed, the doctor-patient relationship will be adversely affected.  The computer competes with the patient for the doctor’s attention and can easily take over.  We must ensure that the patient always prevails over the machine.

To that end, we have learned some things over the past 5 years:

The e-scribe.  This is a very effective technique but is also the most expensive.  Because the physician almost never touches the computer, the patient has the doctor’s undivided attention.  But the scribe has a big pitfall- it’s very easy for the physician to avoid contact with the chart altogether.  This reduces the quality of documentation and raises the risk of medical errors.  Every chart note must have some documentation that came directly from the physician’s brain, even if it is just a sentence or two.

The tablet PC.  This is my favorite if you can’t afford to hire a scribe.  With a tablet you can work side by side with the patient and show what you are doing.  This demystifies the IT presence and gives you more time to navigate screens and get the work done.  It also showcases to the patient all that work you put in to get EMR.  They will notice.

The handwriting recognition in Windows 7 works well and is much better than Windows XP.  Handwriting in the chart in front of the patient is much more culturally acceptable than using a keyboard.

I tried an iPad for about a month.  The wow factor was great but the touch screen was a little too sluggish for a button-dense EMR screen.  Handwriting recognition that works with Remote Desktop is not available for the iPad.  The patients loved it though.

Laptops are most commonly used just outside the exam room, either at a workstation or on a rolling unit placed just outside the exam room door.  Carrying the laptop into the exam room works well as long as there is a convenient, safe place to put it.

Desktop PCs. Unless you have a scribe, using a desktop PC in the exam room will likely force you to turn your back to the patient to use the EMR.  I was hoping to avoid that problem by using the ill-fated spring-loaded arms to hold the monitor and keyboard.  Desktop PCs in exam rooms logged on to your EMR also raise privacy / security issues.

Hybrid techniques. Currently my assistant accompanies me in the exam room and uses a small netbook to take notes.  At the same time I use my tablet mainly for workflow (prescriptions, handouts, test ordering etc.) but I may jot down notes as well.  One of my partners uses a laptop for himself and one for his assistant, both on rolling workstations just outside the exam room.  They both work in the same chart at the same time – the MD on workflow, the assistant on documentation.

Speech recognition. I love it and use it every day.  But not in the exam room.  From a cultural standpoint it is too awkward.  Any extraneous noise wrecks the speech engine, and you will waste time deleting “word salad” from your chart note.  The patient must be totally silent during your dictation.  But it is not easy to be quiet when someone is talking about you as if you aren’t even there.

Remember the basics. Eye contact.   Listening.   Empathy.  Be sure you spend some time connected only to your patient.  Close the laptop, put the tablet down, and pretend you’re back in the good old paper chart days.

Think carefully about your exam room layout. The computer is yet another item that must be wedged into that tiny room.  Make some room by cleaning out anything that doesn’t really need to be there.  Think about wall-mounted document racks and folding work surfaces.

You won’t be able to guess what is going to work best for you ahead of time.  Pick an option, try it for a while, and then try something else.  If you have 2 exam rooms, set them up differently and see which is better.  As you gain experience your preferences may change.

Software and hardware aren’t there yet.  We still need products that operate based on how we practice medicine.

As technology changes so will our best practices.  We do our best to “roll with the punches,” keeping up as best we can.

October 25, 2010 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.