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The Naiveté of mHealth

Last week I attended a seminar on mHealth sponsored by the Technology Association of Georgia (TAG).  The presenter was Arthur Lane, Director of Mobile Health Solutions at Verizon Wireless.  He gave a nice presentation and video of a system Verizon is designing to improve care of congestive heart failure (CHF) patients after hospital discharge.  CHF patients are treated effectively in the hospital setting with closely monitored vital signs and carefully administered medications / diet.  The problem is that once the patient goes home it is difficult to maintain the same level of monitoring and precision of the medication / diet regimen.  As a result re-admission rates for CHF are high, adding to the cost of care.

The Verizon system claims to correct this problem with smart phone technology.  The video showed a smart phone reminding a CHF patient to weigh himself before bed.  He has gained ½ pound since the morning.  When he wakes up the next morning the phone again reminds him to weigh himself.  He has gained another pound.  Weight gain day-to-day is an indication that CHF is getting worse.  The phone sends the weight data to a server, which in turn notifies a provider to call the patient and somehow prevent him from getting worse and showing up in the ER.   It was never clear to me how the provider was going to fix worsening CHF over the phone.

After Mr. Lane completed his presentation he joined 3 other panelists for a lively discussion moderated by a local physician whom I know.  Some of these panelists described their devotion to mHealth with near breathless excitement.  The physician moderator posed the ever-present question to the panel:  “How do we get doctors interested in this system (and mHealth overall)?”  The answers ranged from good – “Give doctors a product that is cost-effective” – to the ridiculous – “Align incentives by making physicians join ACOs.”  The silliest thought of the night was the suggestion from one panelist that health care is no different from banking.  I left the meeting with some concerns about who would pay for the Verizon system but decided to hold my reaction until I did a literature review.  After all, I am no cardiologist and have not treated a patient for CHF since med school.

 My review did not yield good news for Verizon or mHealth.

Turns out physicians have been working on home monitoring for CHF patients for years.  Unfortunately their studies do not support remote home monitoring for CHF to reduce hospital admissions.  A study from Yale Medical School published in the New England Journal of Medicine in 2011 randomized over 1600 CHF patients to either a control group or a remote monitoring group for outpatient care following admission for CHF.  There were no differences in readmission rates for CHF or for any other cause over the 6-month study.  Several other studies, including comprehensive reviews of existing literature, reach similar conclusions.

So what would a more realistic mHealth video look like?

Our CHF patient is discharged from the hospital all tuned up with appropriate medications, diet and smart phone remote monitoring using a CHF app.  The monitoring app works well at first, feeding him periodic words of encouragement and reminders to take his meds, record his vital signs, weigh himself, etc.  After several days of his phone going off constantly with all the reminders, alert fatigue sets in.   After ignoring the alarms for a few days he gets fed up and shuts the CHF application off.  The monitoring network detects the data interruption, and a provider calls the patient.  At first the contact with a real human helps, but after several calls alert fatigue strikes again.  Our patient recognizes the caller ID and stops answering.

In the meantime he tires of his medication regimen and diet restrictions and succumbs to the urge to scarf down some pizza and beer with some potato chips for dessert.  His smart phone isn’t smart enough to change his behavior.  The salt and fluid load makes his heart failure worse.  In the middle of the night he wakes up short of breath and calls 911.  Back to the hospital he goes.

The mHealth community is so enamored with their toys they can’t see what is right in front of them:

  1. Peer-reviewed medical literature does not support the use of home monitoring for CHF patients.  Period.  LTE smart phones and glitzy medical apps do nothing to change that.
  2. Without supporting literature no one is going to pay for remote monitoring.
    Who is going to cough up the dough for all those smart phones, Bluetooth connected home monitoring devices, remote servers, and the army of providers that will be required to manage the terabytes of data that such a monitoring network would generate?  Neither ACOs nor any other ill-conceived “alignment of incentives” for physicians solve this issue.
  3. The mHealth folks fail to recognize that monitoring is not the endpoint.  The endpoint is changing patient behavior.  A smart phone constantly shrieking warnings and reminders is rendered useless by alert fatigue.  Patient behavior is a very tough nut to crack.  The Verizon video ends with a nurse talking to the monitored patient about his weight gain.  But that is NOT the end.  It is just the beginning.  No one knows what that nurse is supposed to say to change the patient’s behavior over the phone.
  4. Like many mHealth ideas this system creates unrecognized changes to the standard of care and thus changes medical liability.  What if our CHF patient who stops listening to alerts and stops answering the phone dies while he is in the monitoring program?  Who is liable?

 So it’s the same thing all over again with health IT.  No proof of effectiveness.  No way to pay for it.  No understanding of the medical challenges involved.  Unrecognized changes in standard of care and liability.  Health care is not the same as banking.  Duh.

 Verizon has no business getting into health care beyond the LTE connection itself.  They are going to lose their shirt investing in a treatment the literature says doesn’t work.  Perhaps unwittingly, the physician moderator said it best when he asked the panel, “Where is the app that slaps my hand when I reach for the bag of Oreo cookies?”

Don’t get me wrong, folks.  Our practice has enjoyed great success with EMR in over the past 7+ years.  Our experience just scratches the surface of the awesome potential of health IT.  I want you to succeed.  But the health IT industry is headed in a direction that will guarantee failure.  To succeed you must stop chasing pipe dreams and focus on the one goal that must be met before anything else – HIEs, mHealth or anything else – can succeed:

Find a reliable way for doctors to succeed with EMR in the office setting.  Upgrade EMRs to reflect some understanding of the practice of medicine.  Design patient portals that actually work.  Demonstrate that EMRs are effective at improving care.  Design a business model that shows the path to a return on investment.

Until that goal is met, nothing else matters.

October 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 Secure Texting Scam

I fondly remember going deer hunting with my father and grandfather in Pennsylvania where I grew up.  We hardly ever actually killed anything.  One deer hunting technique we never used was called “putting on a drive.”   You start with a group of hunters at each end of the woods.  The first group does the “driving” by walking through the woods making lots of noise.  The other group lies hidden at the other end.  The first group scares the deer towards the second group for an easy blindside kill.  Even if you like hunting it’s not very sportsmanlike.  The deer don’t stand a chance.

Recent developments in health information technology convince me that Washington politicians and health IT vendors are putting a drive on physicians. Together they coerce physicians into technology purchases that may be redundant and unnecessary.  One such example is all the noise health IT vendors make about secure texting.

In November 2011 JCAHO posted a notice deeming the use of texting to communicate physician orders as unacceptable.   This very short statement offered two supporting arguments:  1.  The sender’s identity could not be verified, and 2.  There is no way to preserve the text message for the medical record.  The statement did NOT mention any potential for hacking, eavesdropping or any other privacy / security issue.

The following April a small (5 physician) cardiology practice was fined $100,000 for a number of HIPAA violations.  The worst of these was putting appointment and surgical schedules on a publicly accessible online calendar.  Other violations included failure to appoint a privacy officer and failure to conduct a risk analysis.  The HHS press release for this settlement does not list texting protected health information (PHI) as one of the violations.  Nonetheless many secure texting vendors have cited this settlement as evidence that the Feds are prosecuting providers for texting PHI.  My inbox has been inundated with ads: “Don’t get caught texting PHI!  Buy our secure texting product today!”

Many providers have drunk the Kool-Aid, succumbing also to strong intuitive – but unverified – arguments regarding SMS texting.  It is widely accepted that every text has at least 3 copies:  the sender phone, the receiver phone, and one or more copies on the telecom servers involved in the transmission.  The first 2 clearly exist.  But has anyone verified current practices among telecom providers regarding server storage of text messages?  There is no credible source that clearly documents what those practices are.  Many providers and IT folks also intuitively believe that text messages can be easily monitored / intercepted remotely.

One secure text vendor I reviewed offers secure texting for the “bargain” price of $10 per user per month.  For our practice that totals $12,000 per year.   The app requires installation on both sending and receiving ends, so even after all that money is spent I can text “securely” only to employees inside my practice.  Too bad I don’t need secure communication inside my practice.  My EMR already does that.  So the product is both expensive and useless.  Most secure text products are structured similarly.

The argument for secure texting products fails in several ways:

  1. The November 2011 JCAHO directive regarding texting of physician orders does not mention privacy as an issue.  The two issues it does raise, identity verification and documentation in the medical record, are not solved by secure text products.  Furthermore, the JCAHO arguments should apply to voice conversations as well.  The voice of a caller cannot be objectively identified, and voice conversations are not preserved for the record either.   Telephone orders have been the standard of care for decades.  We have tolerated those “shortcomings” without difficulty.
  2. No federal agency has investigated anyone for texting PHI – although the secure texting vendors would like you to believe otherwise.
  3. There have been no documented PHI security breaches related to texting.
  4. The biggest security issue for texting is the smart phones themselves, where stored text messages are just waiting to be lost or stolen with the phone.  Secure text products don’t solve that problem either.  This is more appropriately handled by password protecting phones and remote-erasing technology for lost or stolen phones.  There are lots of other ways to address the problem, such as storing text messages in the cloud rather than on the phone.
  5. Physicians have been using text communications for almost 20 years, since the advent of text-enabled pagers.  This far predates SMS technology.  We contacted our answering service regarding the security of the text-pages that they send to our smart phones.  We were assured that their secure server adequately addresses the issue.  Really?  Don’t their messages pass through the same telecom servers as other texts to reach our smart phones?  Am I missing something?
  6. Smart phones can be eavesdropped for both voice conversations and text using the same methods.  If the eavesdropping argument is used to outlaw unsecured text, then voice communications should be treated similarly.
  7. How exactly do the wireless carriers handle text messages?   Why isn’t anyone grilling them about securing their servers?  Current practice across the IT community is that the owner of a database is responsible for its security.  Verizon Wireless, starting last April, has expressed great interest in health care and has declared its intention to establish a role in the management of chronic diseases.  How about something simpler and much more useful…like secure texting for health care providers?

The “logical” conclusion – ignoring common sense – is that PHI would be prohibited in all wireless communications.  Doctors would have to return to 1980’s era pagers that only emit a tone.  You call the answering service – on a landline – to get the message.  The privacy policies made necessary by the Information Age would force us back to the Stone Age.

Instead consider the following plan that would serve PHI privacy needs without all the hysteria and expense of add-on products:

–       Establish a set of practices for texting medical information that avoids or minimizes the creation of PHI.  This would include referring to patients by initials and avoiding the use of identity-establishing information.  I have done this for the past few months and it works well.  You can include all the medical information you want in a text, but if the patient is identified only by initials then it is not PHI.

–       Engage telecom providers to establish adequate security measures for its servers.  They should be doing this anyway.  There would be many users willing to pay a reasonable amount to cover the expense.  This would be much better than add-on products since it would be compatible across all users.

–       Aggressively implement protection for smart phones, starting with mandatory password protection and remote erasing, and implementing more sophisticated technologies as they become practical and widely available.

How do you get a marginal product to sell?  Either have the government make people buy it (Meaningful Use) or use marketing sleight of hand to create the illusion of a legal imperative.  Secure text marketing strategy works just like the deer drive.  The “drivers” are the secure texting vendors.  They leverage poorly written and randomly enforced government regulations to make lots of noise in an attempt to scare physicians.  At the other end of the forest lurks Secure Texting Snake Oil – products that only pretend to rescue doctors from prosecution and patients from identity theft.  Their only true effect is to raise health care costs without any improvement in quality of care or data security.

September 6, 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 Unhealthy Side Effects of Meaningful Use

Author’s note:  This article appears in Townhall.com Finance today, co-authored by Dr. Hal Scherz and myself.

Imagine a world where fossil fuel vehicles are gradually outlawed in favor of electric cars. The government would at first give incentives to those who purchase electric cars and then gradually replace those incentives with penalties for cars that use fossil fuel. As implausible as this appears, it is already happening with light bulbs, toilets and wind turbines. The government fancies itself as entitled to decide what works best for everyone.

A similar process is currently ongoing with health information technology (HIT).  The Feds have appointed themselves as the final judge of how HIT should be used. The American Recovery and Reinvestment Act includes a set of  “Meaningful Use” (MU) guidelines for the use of HIT by physicians and hospitals.  Beginning in 2010 the Act offered physicians financial incentives for MU compliance; by 2015 the incentives will be replaced by penalties for failure to comply with MU.

The benefits of HIT to patients and doctors appear to be obvious.  The potential for improved medical record legibility, ease of access and reduction of medical errors is easy to appreciate. We all enjoy the advances that information technology has brought to our phones, cars, banks and airports. So a program meant to accelerate the adoption of HIT would seem benign enough.

But physicians who care for patients every day understand what no one else does – that the benefits of HIT are not a forgone conclusion.  To us HIT has as much potential to harm patients as it has to help them.  We also understand that the fund of knowledge required to safely and effectively implement HIT has not yet been adequately developed.  It is therefore foolish, even dangerous, to force HIT into widespread use before it is well understood.

There is surprisingly little evidence that the electronic medical record (EMR) improves quality of care. There is in fact some evidence to suggest that EMRs currently in use may actually reduce quality of care and raise health care costs.  There are also no established EMR implementation strategies for medical practices.  Implementing a complex EMR system into a busy medical practice is like replacing an aircraft’s engines while it is still flying.  During implementation there can be no reduction in patient volume and no errors in patient care.  Information technology is the only medical technology that has been given a “free pass,” with apparently no need to prove itself the way we prove the worthiness of new drugs, medical devices and surgical procedures.

HIT is also the only business technology in the entire economy that has been exempted from the need to show a return on investment. There is no recognized business model that makes HIT profitable, or even revenue-neutral.  Like any business a medical practice must survive financially. A practice cannot purchase and maintain HIT without a strategy to recover the investment.

Health information technology will change the practice of medicine more than any drug, imaging modality, operation or minimally invasive endoscope.  It will profoundly affect the care of every patient.  No other past or current medical advancement can make that claim.

Any new technology, including health information technology, produces unexpected adverse consequences.  For adverse events in health care government mandates create a frightening multiplier.  What if the government had required all overweight patients to use Fen-Phen before its cardiac side effects were discovered?  What if all patients with arthritic hips had been required to receive cobalt-containing implants?  In an environment where every innovation is rightfully scrutinized before it is placed into widespread use, why do so many accept the unproven claims of HIT as unchallenged fact?

The alliance between government and the HIT industry has replaced critical analysis with blind enthusiasm and has replaced innovation with mindless regulatory compliance. What would today’s technology look like if the government had decreed back in 1984 that we had to purchase 4 MHz PCs or first generation brick-sized cell phones? They would still be “state of the art” today.  Had there been government-mandated demand for these early technologies there would have been no reason to build smarter phones or faster computers.

Within the HIT industry Meaningful Use now dominates the discussion at the expense of creativity.  MU incentives have sucked all the oxygen out of the room where original thought once took place.  In a healthy environment, demand drives technology, not vice versa. If there were an electronic medical record that allowed physicians to provide better patient care and run their practices more efficiently, we docs would line up around the block at 4 AM to get our hands on it, just we all did for iPhones and iPads?   No incentives would be necessary.  Someday that will happen…but only after the government incentives are gone.

July 13, 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.

My Presentation Submission to 2012 mHealth Summit.

I decided to turn my rant on the 2011 mHealth Summit into something productive and submit a talk to the 2012 Summit.  A description of the proposed talk follows, as it appears on the application.

We’ll see what happens…

 

Why are doctors so apparently reluctant to embrace mHealth?

It is easy to appreciate the mHealth community’s frustration regarding this question. Clearly the physician community and the mHealth community do not understand each other very well.  The purpose of this presentation is to establish a mutual understanding and better lines of communication between practicing physicians and the mHealth community.

The first part of the presentation addresses practicing physicians’ concerns about mHealth:

1.  What is mHealth?  Has it been clearly defined?

2.  The safety and efficacy of mHealth / HIT products are not proven.  Technology always has unintended consequences.  In medicine such unintended consequences can increase costs and can harm patients.

3.  There is no widely accepted business model that establishes the return on investment for mHealth / HIT products.

4.  Government regulations and incentives may also have unintended adverse side effects.

Many of these concerns originate from the cultural differences between the physician and HIT communities. Each of these cultures sees the health care system and the role of mHealth / HIT differently.  The second part of the presentation addresses the cultural differences between these two communities and how these differences impede the adoption of mHealth / HIT.  Examples of cultural differences will include e-prescribing, health information exchanges and telemedicine.

The final part will outline the concessions both physicians and the HIT community need to make in order to facilitate communication, promote adoption of mHealth and improve the quality of mHealth products.  This will be difficult but worthwhile for both sides.

June 26, 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.

EMR Note Cloning is Scarier than I Thought

The health IT community is well aware of the dangers of cloning notes in an electronic medical record.  I include myself in that group.  Until recently I prided myself for doing a good job, both in our EMR design and in my own personal practice, of using just the right amount of automation in our documentation workflow.  Two recent events showed me that I still have some work to do.

The first event occurred a few weeks ago when I was reviewing some records.  One patient note documented an enlarged salivary gland containing a stone.  That would be fine except for one small detail – I had removed that gland one week prior to the date of the note!  My nurse had created that note.  A conversation with her revealed she thought she was doing the right thing by always clicking the “previous finding” button, which I had programmed myself.  My nurse is extremely bright; this was my fault for not training her on this issue.  I had also signed that note.  So it was my fault twice.  After a 30 second conversation with my nurse it has not happened since.

The second event was when an attorney interviewed me regarding one of my patients.  I was a treating physician in a malpractice case (I am not the defendant thankfully).  The attorney wanted to know if, in my opinion, the physician defendant had met the standard of care in treating the patient despite the adverse outcome.

This was a high-risk case for note cloning; the patient had multiple abnormal neurologic findings that were stable over time.  In reviewing my records I was satisfied that my notes were accurate, complete and original for every visit.  I avoided cloning those abnormal but stable findings by describing the same exam but using slightly different wording at each visit.  How else do you avoid cloning?  But the attorney pounced on my small changes in description, trying to establish a trend in my notes that the patient was getting worse.  I explained the cloning issue to him, and he understood…. I think.  Nonetheless I felt somewhat uncomfortable defending my documentation, and I was not even the defendant.  In trying to avoid cloning notes I had stepped right into another problem.

This issue is huge in my practice.  I have a large volume of head and neck cancer patients.  The essence of caring for them properly is to monitor them for changes in their abnormal – but stable – physical findings.  A recurrence of cancer might manifest as a subtle change in one of these findings.

How do you document that an examination is stable and unchanging, but change your wording enough to document that you actually examined the patient at every visit?  We do not yet have the cloning issue figured out.

June 15, 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.

EMR Workflow Continues to Evolve

As we approach the midpoint of 2012 our practice will complete 7 years of electronic medical records.  Just like a musical instrument, we will never have EMR fully mastered, but our skills and wisdom continue to grow slowly with time.  Over the past several weeks one lesson is becoming clear.

To this point I have equally supported 2 types of workflow for the exam room.  The first involves the physician working solo in the exam room with a laptop or tablet computer.  The medical assistant remains at the nurses’ station to support workflow.  In our financially strained environment we can’t afford to add another medical assistant to put in the exam room with the physician.   In this model the EMR enhances the physican’s documentation and workflow control capabilities and eliminates the need for an assistant in the exam room.

In the second workflow the doc never touches the computer.  Instead a medical assistant or nurse accompanies the doc to the exam room and documents on a laptop.  After capturing the results of the physician interview and the exam findings, the assistant documents workflow in the EMR.   The doc uses the workflow engine to initiate and control workflow.  It works well but carries the expense of an additional assistant, some $40k per year including benefits.

Over the past year I have been blessed with 2 exceptionally talented RNs who are both outstanding clinicians and savvy computer users.  The first of them will be going out on maternity leave soon, so the second was hired.  For several weeks they have both been working and training together so I have had the (expensive) luxury of having an extra assistant to bring to the exam room.  Thanks to them I have come to realize there is no reason for me to operate the workflow engine.  For most patients the RN can listen to my conversation with the patient and initiate the treatment workflow via the workflow engine.

By allowing the RN / assistant to operate the workflow engine we eliminate the need to keep an assistant at the nurses station and this eliminate the additional expense.

We have also replaced our web portal vendor after several frustrating, unsuccessful years.  I am very excited about the Intuit product.  Although I have been wrong many times about similar technologies in the past I remain hopeful that that the new portal will be attractive to patients.  If that happens we will finally be able to automate several workflows and get a measurable return on investment on the portal itself.

Combining a successful web portal with a sophisticated workflow engine operated by staff holds the promise of taking our practice to the “next level” with our EMR.  This will allow us to automate data input, workflow management and patient communication.  This is very important to physicians.  As a group we docs see EMR as something we constantly put resources into but rarely get anything back out.   This would be a big step past that barrier.

May 8, 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 “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.

Deep Thoughts from the Meaningful Use Mountain Top

In some ways I am grateful to see 2011 end.  Several extracurricular projects have drained the life out of me, including our Meaningful Use (MU) project.  As near as I can tell we survived.  Our 90 days of compliance for phase 1 / year 1 are completed.  Last night I completed my attestation on line uneventfully.  We will get attestation completed for the rest of our physicians within a couple of weeks.  Then we will join the few (1%) of “eligible providers” that have complied with MU.  One would think that folks would be breaking down the doors of these “one-percenters” to learn the secrets of their success.  Yet a brief Internet search reveals no doctor testimonials on MU success beyond the second hand accounts offered by EMR vendors and consultants.  These are of little value.  So I am writing my testimony.

Over the past several months I have repeatedly criticized MU, with good reason.  But perhaps now that I have climbed the MU Mountain and my check will soon (hopefully) be on its way, I should soften my view a bit.  Sort of like final exam week…exams looked awful before you took them, but when you got done and you were somehow still alive, well, maybe it wasn’t so bad.

Well, sorry, it’s still that bad.  It took about 150 man-hours of work to complete this project.  And our EMR use, our quality of patient care and our practice efficiency is for the most part no better.  In some ways it is worse.  As a result of MU:

  1. We now take blood pressures on children.  This is almost never medically relevant in an ENT practice.  We can’t exempt ourselves from this requirement because of our adult patients, in whom blood pressure is often relevant.
  2. We waste volumes of paper printing clinical visit summaries that no one reads.  While the concept of a visit summary is OK, the document itself must include so much extra data it is useless.  Our web portal, which we are in the process of replacing, does not support this requirement so we have to use paper visit summaries for now.
  3. Patient waiting time is increased while we process data on pneumovax status, smoking status and body mass index on every patient.  In our practice these data are medically relevant for many patients, but not everyone.  Doing it for everybody is a waste.

To be fair, a couple of good things did happen:

  1. Use of EMR-based prescriptions and true e-prescribing (e-Rx) improved with those physicians that were still hanging on to paper scripts and/or were not using e-Rx.
  2. We were not maintaining true ICD-coded problem lists in the EMR before MU.  We had problem lists and diagnoses of course, and we were using ICD codes for billing.  But we had never combined the two processes before.

The entire process is complicated, confusing, and intimidating.  Not only are the guidelines themselves a mess, but also there is a surprising amount of inaccurate and misleading information out there.  Even the CMS publication Attestation User Guide is missing a page compared to the actual attestation web site.  After reading the User Guide I lost an entire night’s sleep thinking that the “children with pharyngitis” quality measure had been deleted because it is missing from that document.  I have 17 years of medical practice experience and 37 years of IT experience.  If I can’t figure this out there is something wrong.

The view from the top of the MU Mountain looking down is no better than the view from the bottom looking up.  Meaningful Use remains an expensive distraction that forces the true benefits of EMR to be overlooked in favor of regulatory compliance.  MU also creates an unhealthy alliance between government and the health IT community.  The government wants to own health IT just like it wants to own the rest of health care.  Don’t fall for it.

December 30, 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 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.

Meaningful Use Will be on Life Support by the End of 2012.

Earlier this week I attended the annual meeting of the primary professional organization for my specialty, the American Academy of Otolaryngology – Head and Neck Surgery.  As you might expect the first thing I did was attend a mini-seminar on strategies to meet Meaningful Use (MU) requirements.  These “mini-seminars” typically include 3-4 speakers presenting various viewpoints regarding the subject at hand.  Presenting the supporting viewpoint on MU was Dr. K.J. Lee, who has been an icon in our specialty for decades.  He had distilled MU requirements for Otolaryngology down to a few typed pages and reviewed each requirement, emphasizing how easy it should be.

The most interesting part of the presentation was the reaction of the audience.  Presumably based on his professional reputation the audience initially bought into Dr. Lee’s enthusiasm for MU, hopeful that he was right.  However, as he continued through the list of MU requirements his point of view became less credible, and the enthusiasm began to fade.  When he suggested that it was no problem for ENT docs to ask and counsel patients about mammograms and colonoscopies, audience members began to stare at the floor and shake their heads.  By the end of his presentation he had lost just about everyone.  I have seen this happen before at MU meetings.

Later that morning in a different mini-seminar I gave my own brief presentation, a MU update.  I was asked to give an update on how MU payments were going, presumably specific to our specialty.  The August CMS report shows MU payments given to about 1100 providers so far (as of 7/31/11) totaling about $18 million.  For the 6 weeks leading up to the meeting I tried, without success, to get MU payment data from CMS for ENT doctors.  The best I could infer from the data available is that more than 1 but less than 28 individual ENT docs have been paid for year 1 MU.  In any case the conclusion is clear:  only about 0.1% of all eligible providers – and essentially no ENT docs – have met MU so far.

But isn’t it too early to draw conclusions?  After all, the program just got started a few months ago.  And the number of payments going out is increasing month to month.  And providers still have a year to get the full payment.

My opinion is that the situation is worse than it looks, not better.  I believe even this tiny number of payments represents an early peak of MU payments to providers who implemented EMR long before MU came along.  Our practice is in this group, and we will begin our 90 day attestation period October 1.  MU is achievable only for those providers that have already acquired several years worth of EMR skills.  Once these early adopters are paid, no one else will be left.  If I am right we should see MU payments plateau in Spring 2012 and start declining in the summer and fall.

MU remains a bad idea, especially for surgical specialties.  It is not possible for a paper-based medical practice to complete the long process of selecting, installing and implementing EMR on the schedule imposed by MU.  The provider skill set required to meet MU requirements takes at least 2-3 years to develop, and providers can’t even begin to acquire those skills until the EMR is chosen and installed.  The MU schedule forces providers to rush the process, raising the risk of making catastrophic mistakes in the EMR selection and implementation process.

September 15, 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.