|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.
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.
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.
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
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:
- 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.
- 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.
- 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:
- 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.
- 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.
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.
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.
I am presently devoting all of my extracurricular time to preparing 2 talks for the upcoming Annual Meeting of the American Academy of Otolaryngology – Head and Neck Surgery. The big talk is a 1-hour instructional course entitled, “Navigating the Unknown Waters of EMR.” My blogging over the past year has already organized most of the relevant material. Nonetheless as I try to bring it all together some new thoughts emerge.
One such notion is that EMR stabilizes office workflow by giving the medical office an IT infrastructure similar to other industries. For example, FedEx has a very elaborate computer system that supports their workflow. Employees may come and go, but the IT infrastructure forces the work to be performed in a certain manner.
The medical practice has never had anything like that. Consider the example I used in an earlier blog on workflow design using an EMR. In that post I reviewed how a “simple” workflow – handling patient phone calls – was improved through the use of an EMR and a contemporary phone system.
Let’s take a look at patient phone call workflow in paper chart office. Often there is no formal workflow. Whoever is near the phone answers it, takes the message, and hangs up. That person may or may not attach the message to the paper chart. They may then choose any method of communication (voice mail, e-mail, text, phone log slip, sticky note, etc) to notify whomever they choose (doctor, nurse, assistant, etc.) regarding the message.
This continues until something bad happens. A patient may complain that his phone call was never returned, or a referring physician with an urgent problem is left on hold too long. Then the doctor sits down with the office manager and says, “Things are out of control around here. We need to organize better how we do things. Let’s come up with a plan for patient phone calls and then stick to it.” The manager dutifully comes up with a plan, meets with the staff, and cleans things up. Phone calls are handled well for a while, but over the next 12-18 months workflow slowly deteriorates until the next adverse event occurs, and the cycle repeats.
Performance on handling phone calls deteriorates when there is no infrastructure supporting the patient phone call policy. In a paper chart office the plan for handling phone calls lives only in the brains of the office manager and staff. As memories fade and staff inevitably turns over, the information is lost and the plan falls apart.
In a practice with EMR and a good phone system, the phone call policy is preserved indefinitely in the programming of these two systems. Our phone system’s caller menu routes all non-appointment phone calls to the same extension. The EMR system makes patient charts from all offices available in real time to the single person in our practice assigned to patient phone calls. The cycle of workflow deterioration, adverse event, and workflow restoration is broken.
Once our patient phone call workflow was programmed into our phone and EMR systems 4 years ago we have had very few problems.
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.