|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.
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.
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.
A couple of weeks ago we rather unceremoniously added e-prescribing into our EMR system. Because of my mistaken interpretation of the CMS guidelines on Medicare e-Rx incentives and penalties we rushed e-Rx a bit. I thought each of our physicians had to do 10 Medicare e-Rx prescriptions before June 30. It turns out you are exempt from the 1% Medicare penalty if you have a certified EMR. The CMS guidelines are incredibly difficult to understand. No surprise there.
My thoughts after the first 2 weeks:
- The concept is sound and very useful. Although it only takes a second to grab a printed script off the printer and sign it, eliminating that step is refreshing and streamlines clinic operations much more than I would have thought. We have far fewer pieces of paper to push around. There might even be some cost savings on paper.
- Cultural acceptance has been effortless. I wondered if patients would be unhappy without that precious paper prescription. I should have known better. We have been calling in scripts forever.
- The darn thing works! I held my breath waiting for the wave of angry phone calls from patients and pharmacies. It never came. For the first few scripts we called the pharmacies to be sure they received the script. There was never a problem.
- The workflow changes will be interesting. Some changes are obvious. We had to get the front office staff to get pharmacy information from each patient and enter it in the system. Other implications are less clear. Do we really need printers in every exam room now? Do tablets become more useful over other PCs?
- Mistakes are rare and easy to fix. This evening on call I got a message from one of my partner’s patients alleging that her prescriptions were not “called in.” I got into the EMR from home and saw her e-scripts were created but were never signed. This was because we took the system off line at about the same time the chart note was created. We had to install a patch. I signed the prescriptions and fixed the problem in a second.
- The Surescripts HIE is WORTHLESS. This is the feature that allows the EMR to upload a patient’s medication list based on his/her recently filled prescriptions. But the feature forces a “workflow paradox:”
- Uploading prescription histories takes considerable time. The upload needs to be done in advance of the patient visit so it doesn’t impede workflow. I don’t understand why it is so slow.
- The upload cannot be performed until the patient gives consent. So you can’t do the upload until the patient arrives at the office and signs the form.
I suppose we could work around this via giving consent on the web portal; that would be very cumbersome. Even if it worked well the feature does not improve our workflow. The medication reconciliation step may make it worse. The bottom line is I don’t care what is in the Surescripts database. We ask patients what their medications are and they tell us. Done.
The interaction of humans and technology will always be unpredictable. A few months ago this thought was driven home to me in a rather malodorous manner…
I have obstructive sleep apnea (OSA) and use a CPAP machine every night to sleep comfortably. With OSA your airway collapses when you fall asleep. A CPAP machine is a small technological marvel, quietly delivering heated, humidified air under gentle pressure through a nasal mask to keep your airway open while you sleep.
One night while using the CPAP I was ripped out of a deep sleep by the worst odor I have ever encountered. How bad does a smell have to be to violently awaken you? Dazed and confused I sat up, clawed my CPAP mask off, gulped a few breaths and waited for the purple haze to clear. I looked down towards the floor next to the bed and realized with horror what had happened.
Our dog, Jade, is a Labrador who has blessed our household for nearly 14 years. Out of affection and respect for her sheer endurance no one begrudges old Jade her habit of passing gas almost continuously.
On the floor was Jade, sleeping comfortably with her posterior positioned next to my CPAP machine on the floor. Jade’s colonic gift had been sucked into my CPAP machine, heated, humidified and rammed up my nose into my gray matter. We are not sure yet if the brain damage is permanent or not. My wife and kids insist I’m no worse off than I was to start with.
History contains many other examples of technology’s unpredictable effects. Remember the “paperless office?” For several years in the early 1990’s, when PCs were new and word processors were first introduced, it was widely accepted that offices would soon have no need for paper. Just write your document on the computer, save it to your floppy disk (remember those? They were actually floppy back then) and deliver the floppy disk to the recipient, who would read your document on screen. Who needs to print documents anymore? Paper manufacturers were in a panic, sure that demand for their products was about to disappear.
As anyone over 40 years old remembers, the opposite happened. Office workers were happy to create documents on a computer screen but were unwilling to read them there; all documents still got printed eventually. Then we became obsessed with creating perfect documents. If a 20-page report had one comma out of place, fix the comma and reprint the entire document. Then find another mistake and reprint 20 pages again. Paper use skyrocketed. Today the paperless office remains an unreachable goal, an ethereal concept, a star by which you can navigate but that you will never reach.
Medicine is replete with examples of unintended effects of technology. A 5-minute web search produces a long list of unexpected medical outcomes such as heart problems from Fen-Phen and heavy metal poisoning from prosthetic hips. Even something as seemingly benign as an over the counter zinc-containing nasal spray has been found to cause permanent loss of smell.
It comes as no surprise, then, that when we physicians contemplate EMR we see the introduction of an unpredictable technological force into the unpredictable environment of medicine. That raises more questions than answers. Will EMR free us to be real doctors again or make us slaves to data capture? Will health information exchanges give us the information we need at our fingertips, or will we be barraged with terabytes of useless data? Will e-prescribing be a blessing or a nuisance? Pardon us for not buying into the IT euphoria. Our patients and we will have to bear the consequences more than anyone else. As stewards of the health care system we recommend proceeding with some caution.
Perhaps nowhere in the blogosphere does one find more spirited healthcare IT debates than on the subject of e-prescribing. Go to KevinMD.com and see a recent post, Why are most physicians writing their prescriptions by hand? The debate in the comments section ran for almost a month after its posting.
To supporters of e-prescribing (mostly IT folks) it’s a no-brainer. No more non formulary scripts, no more messy doctors handwriting, far fewer errors, data capture for performance review, etc. You can check your prescription against the patient’s drug allergies and check for drug-drug interactions. When your patient arrives at the pharmacy the electronically transmitted prescription is waiting for him/her. What’s not to like?
Opponents of e-prescribing (mostly docs) will be glad to tell you. Why take something so simple and make it so complicated? The technique of paper script writing has withstood the test of time for over 50 years. A paper script takes only a few seconds to write. An e-script may take over a minute. For e-prescribing the doc has to do all the work (and foot the bill), yet the beneficiaries are everybody else except the physician.
The debate is a classic example of how IT folks and MDs see the world differently.
Our experience preparing to implement e-Rx has been very revealing. About 18 months ago we began to research the only integrated e-Rx product available for our EMR. I brought a very primitive preconception of e-Rx to the table: Complete the script on screen just like we are doing now, push SEND instead of PRINT, and that’s it. There should no significant changes to our existing workflow.
I was going through the online demo when I noticed something I thought was unusual. The e-Rx app was “updating” the patient’s chart long before the prescription was written. Exactly what was it updating?
The answer I got was very concerning. The e-Rx app accesses a pharmacy database called Surescripts, which contains data on recently filled prescriptions. When the e-Rx app is run it creates a behind-the-scenes “parallel list” of medications for each patient based on recently filled prescriptions. Well, not exactly…the database includes only those meds on which a pharmacy claim was filed. If the medication was purchased with cash it doesn’t show up in the Surescripts database, so it doesn’t get uploaded to your EMR either.
Why did this bother me so much? Every other method of chart updating currently used by our EMR – manual data entry, document scanning, patient portal, HL-7 update – has a historical precedent in the paper chart system. The e-Rx update does not. We have never had pharmacies push data to us before.
“Welcome to the world of health information exchange!” the IT folks say. In fact the tech support information I found promised even more functionality in the future. If a patient fails to pick up the prescription within 30 days, “the system” will notify the physician. From an IT standpoint it looks great, and soon it will get even better.
Not so fast. To the physician this looks very different than it does to the health IT professional.
E-Rx (at least the application we need to use for our EMR) introduces a potential new standard of care into the doctor-patient relationship. Current standard of care recognizes only one source of information regarding patient medications – the patient himself. If the patient forgets to tell me he/she is taking a critical heart medication that is the patient’s error, not mine. But what if the e-Rx app uploads data to my EMR showing that the patient has recently filled a prescription for heart medication? I obtained 2 medical-legal opinions and both concur that the physician is responsible for knowing what is uploaded to the EMR regardless of how the EMR handles that data once it arrives.
To make things worse, the list is not accurate – since the Surescripts database only includes medications paid for by insurance, our hypothetical heart medication might not be there either.
The soon-to-arrive 30-day notification feature has the same problem. What if the system notifies me that a patient fails to fill a prescription? Am I now liable for the patient’s non-compliance? Must I then assume the expense and liability for making “nanny phone calls” to these patients to remind them?
There are also workflow issues. Uploading prescription data forces us to create a medication reconciliation step to match the database med list with the list provided by the patient to resolve any discrepancies. Maintaining the medication list is already the single most burdensome part of our data entry. This would make it much worse.
What looks great through the eyes of IT doesn’t look so good to the physician. Don’t misunderstand me. Like all physicians I support steps that improve patient care and improve patient compliance. But unlike the IT folks we understand that more data is not necessary better. Too much data creates “white noise”, interfering with our ability to assimilate the useful data. Furthermore, more information creates more expense; it is inappropriate to expect physicians to assume such a large proportion of the burden. Some future model of health care delivery, such as an accountable care organization or medical home, may be able to handle this issue better.