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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.

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.