Free Wired EMR Practice Newsletter Want to receive the latest updates on EMR from a Doctor's perspective sent straight to your email? Get all the latest EMR and EHR updates from a practicing doctor for FREE!

Making Tablets More Effective for Data Capture

Six months ago I wrote about the virtues of using an iPad Mini tablet in the patient care setting.  At that time I was using my tablet almost all day, every day for multiple purposes including EMR data capture.  Things went well for a while, but as time passed I used the tablet less and less.  Eventually I stopped using it almost altogether except for displaying and annotating CT images during patient visits.  At first I did not understand why.  Was the non-Retina display finally getting to my 50+ year old eyes?  Was the external microphone I used to improve speech recognition losing performance?  Was the battery fading after 9 months of charge / discharge cycles?  Or was the “gadget lust” of a new tech-toy finally wearing off?

Each of the above may be just a little bit true.  But two other reasons are most relevant to me.  First, my efforts to add a medical vocabulary to the embedded speech recognition failed.  But most importantly, I became frustrated with how difficult the tablet was to hold for extended periods of time.  When I wrote that the tablet was “easily and comfortably held by its edge” I was wrong.  Tablets are beautiful to behold, but their clean lines and smooth surfaces make holding them for extended periods of time very cumbersome.

So I created something that would fix the problem by making a tablet more comfortable and safe to hold.  Now that the provisional patent application is registered I can share the design:

                 figure 11                     

The photos are of a nonfunctional mockup I made out of Styrofoam, balsa wood and spackling compound.  It is a grip that attaches primarily to one edge of a tablet computer and facilitates holding the tablet by its edge rather than the back.  It is shaped to fit the hand and allows both proper hand positioning and proper viewing angle.  It provides a mechanical interface between the tablet edge and a semi-pronated (handshake position) hand/forearm.  Its purpose is to facilitate extended use of the tablet by minimizing orthopedic strain to the hand, wrist, forearm, elbow, shoulders and neck.   The interface with the remaining 3 edges is minimal, preserving the ability to store the tablet-grip assembly in a coat pocket.

The external shell is a composite of plastic, rubber, metal, leather or similar materials.     There may also be a thin covering over the back and/or front faces of the tablet for protection and mechanical stability.  The top side is contoured to engage the thumb and guide the thumb to the home button.   The bottom is contoured to engage the fingers.  This shape gives the thumb and fingers stability and purchase to counter the tablet’s weight and torque in the yaw and roll axes.  The gripped portion has bilateral symmetry to allow left hand or right hand grip.  Openings and mechanical and/or electronic pass-throughs provide access to tablet buttons, ports, etc.  It could also include a stand for self-support on a tabletop and a place to store a stylus.  Some panels could be customized for color, shape (i.e., for different hand sizes) or material.

There is space available within the grip to add hardware and enhance functionality.  Examples include – but are not limited to – extended battery, external microphone / speaker, Bluetooth keyboard interface (to make the composite device appear as a keyboard to an external workstation), wireless USB, and apps that use cloud-based speech to text capability.  Any companion software component – an app – would be loaded into the tablet itself.

I need your help both to estimate the potential of this idea and get some advice on what to do with it next.  If you think this is an idea worth pursuing give me a like on Facebook at the bottom of the article.  If you feel strongly about it give it a Tweet as well.  And if you have some advice I would be grateful to hear it.

 

February 27, 2014 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 Doctor’s Best Use of the Tablet

I recently reviewed the Epocrates 2013 Mobile Trends report.  The study has a somewhat unusual participant profile, consisting only of primary care, 3 medical specialties and no surgical specialties; nonetheless the observations are probably close to the mark and are consistent with my experience with my first tablet a couple of years ago.

I purchased an iPad within a couple of months of the introduction of the first model thinking it was perfect for EMR use in my office.  I abandoned it after a couple of months when I discovered several shortcomings.  First, the first iPad was too heavy to hold by the edge and had to be held by a fully supinated hand (totally flat palm facing up).  Try that for 5 minutes and see how your forearm feels.  The first iPad was also too big to put in a physician’s white coat pocket.  And the screen resolution of the first iPad models was not good enough to display a busy EMR screen.   But the biggest drawback was that the early remote desktop apps did not work very well.

The iPad mini addresses all four of these issues.   The Mini is small enough to fit in a white coat pocket with the standard magnetic cover in place.  It is easily and comfortably held by its edge.  It needs a Retina screen badly but the display is better than the original iPad and is (barely) adequate for my 50-year-old eyes to see.   And remote desktop apps have come a long way.  It appears that similar advances have been made in tablets from other manufacturers as well.

I was therefore surprised to learn from the Epocrates study that although a majority of providers (53%) use tablets for patient care related activities, only a small portion (2%) use tablets for actual patient care record keeping in an EMR.  So I thought it would be interesting to outline my current methods of using a tablet that put me in the 2% category as well as the 53%:

 

  • Entering data into my EMR via a Remote Desktop app.  There are important lessons here.  Don’t expect to stick a tablet in the physician’s hand and have it work like magic.  Our office workflow is designed to optimize the physician / tablet combination.  I use the tablet for only 2 data fields in EMR:  assessment and coding (CPT and ICD).  The office staff enters all the other parts of the note and initiates treatment workflow through the EMR at the physician’s direction.  After the patient is seen I review all parts of the note (on a laptop or desktop), make additions / corrections, and sign it.
  • Cloud based voice-to-text.  This takes the tablet from merely useful to spectacular. There are 3 characteristics of Apple’s built-in cloud-based speech recognition that make it comparable to the Dragon software I have used in various forms for over 10 years:  1.  It is embedded seamlessly into the soft keyboard, 2.  An inexpensive external microphone plugged into the headphone /microphone jack raises transcription accuracy tremendously, and 3.  It works well with Remote Desktop, eliminating the need for a “dictation box” or other similar workaround.  These attributes make up for its most serious drawback, the lack of a medical (or at least customizable) vocabulary.  At the moment I have the right people talking to each other to address that problem.
  • Hospital EMR.  Our hospital is still in the implementation phase of a new Cerner system.  I am still learning the system myself but my initial experience using the system on my tablet using Citrix Receiver has been very positive.
  • Patient education.  LUMA, a product of Eyemaginations, is a very nice product for showing surgical patients the complex head and neck anatomy of their diagnosis and/or proposed surgical procedure.  There are both online and iPad versions available.  I can switch back and forth between EMR and LUMA without losing the Remote Desktop connection.
  • Medical imaging.  I can’t load an image disk directly onto my tablet but I can load it onto my desktop and take a photo with my tablet to review relevant images with patients.  I have tinkered with some apps that allow me to draw on the image to help educate patients.  Still looking for a way to conveniently reduce the file size to facilitate copy-pasting into EMR notes.
  • Literature searches in the exam room.  Not glamorous but helpful, most commonly to review medication side effects.

 

I think that is a pretty complete use of the tablet for the physician.  No doubt new uses will appear before long.

 

August 27, 2013 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.

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.

e-Prescribing: First Impressions

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:

  1. 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.
  2. 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.
  3. 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.
  4. 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?
  5. 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.
  6. 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:”
    1. 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.
    2. 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.

 

July 8, 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.

Introducing the Patient Pad

 

One of the biggest theoretical advantages of bringing IT into the patient care environment is using technology to replace human labor.  This is more difficult than it sounds.  Some argue that EMRs are actually a step backwards in this regard, reducing health care professionals to data entry clerks.  One of our biggest labor costs is paying office staff to enter patient demographic and clinical information into the EMR.  IT options are available to automate that process.  We have had very good success with our web portal, which allows patients to enter their own data directly into the EMR from home.

But that same technology has failed miserably in our waiting room.  We have tried desktops in private areas and tethered laptops but patients will not use them.  Tablets would probably work better but we have not tried them because of the expense and the risk of theft.  Several commercial solutions are available that use tablets.

An Atlanta-based company, Digital Assent, has a solution and a business model that may help with both of these issues.  The Patient Pad is a tablet device that works well in the waiting room but its operating system renders the device useless outside the wireless connection.  The device itself must be seen to be fully appreciated.  It’s great for its intended purpose but you would never want to take it home.

The Patient Pad is dedicated to patient check-in and data entry in the waiting room.  Like the web portal patients enter their own demographic and clinical data into the Patient Pad, which is then pushed directly to the EMR.  The data input screens are customizable to match the practice’s existing data structure.  When data entry is complete the patient may keep the Pad and review relevant educational and marketing materials based on the information they entered.

Equally innovative is DA’s business model.  The physician gets the tablets for next to nothing.  The revenue comes from sponsors who place ads and educational material on the device.  We are currently working with several pharmaceutical and hearing aid companies to get material relevant to our practice on to the Patient Pad.

To this point DA has only worked with private pay cosmetic practices.  We are the first practice in regular medicine to try the Patient Pad.  As always we are implementing gradually, doing the patient interface first and then building the EMR interface.   So far it has been well received and is doing far better than the desktop workstations or laptops ever did.

I will post an update after we are fully implemented.

I have no financial interest in Digital Assent.

June 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 Future of Meaningful Use

I had the pleasure of attending two meetings last week related to health care IT.

The first meeting was a 5-hour event sponsored by the Physicians’ Institute for Excellence in Medicine, a subsidiary of the Medical Association of Georgia.  The meeting was dedicated to helping medical practices achieve compliance with Meaningful Use (MU) guidelines.  A $4000 incentive was offered to cover expenses related to MU compliance.

The first speaker was the Chief Medical Officer of the Atlanta Regional Office of CMS.  He gave a nice talk that covered both the minutia of MU and the broader scope.  The talk was well received by the group of about 50 participants.  When his talk was finished he left the meeting.

With The Government no longer present, the mood slowly changed over the remaining hours.  This occurred as the following issues were reviewed:

-       Over 18,000 Georgia physicians were invited to the meeting.  Despite the financial incentive only 50 (including administrators) attended.

-       The sum of the number of installed users claimed by each of the top EMR vendors exceeds the number of practicing physicians in the U.S.

-       Only 4% of practices have a truly functional EMR.

-       As we go from MU phase 1 to phases 2 and 3, the requirements go up but the financial incentive goes down.

 

When the meeting began I assumed I was the only MU “doubter” in the room.   But as the meeting continued the level of trust within the group increased, and the comments became more candid.  Each of us gradually realized that everyone in the room felt the same way – we were all doubters. This is a remarkable process occurring within a group of docs and administrators that is presumably at the top of the bell curve on MU interest!  The meeting ran out of gas and most of the participants dispersed about 30 minutes before the meeting was scheduled to finish.

The second meeting, completely unrelated to the first, took place over lunch the following day.  I invited the CEO of a local health care IT company to meet some programmers that I know.  This company sells a very nice tablet device / service for automated paperless patient check-in.  The purpose was to build an interface for this product to work with our EMR.

After the introductions the conversation took off immediately and continued without interruption for nearly 2 hours.  The longer we talked the faster the creative energy flowed.  Finally we had to force ourselves to stop because everyone had other commitments.  The only mention of MU came when I raised a question.  The CEO made it clear he had no interest in MU and that his product was designed to avoid dealing with MU.

The contrast between these two meetings was striking.  Similar individuals – those who are motivated to become thought leaders in HIT and are willing to donate uncompensated time – attended both meetings.  In the MU meeting the conversation was limited to a single closed-end question:  How do we jump through government hoops to get the money?  The true benefits of EMR were never discussed.  Quality of care and practice efficiency were rarely if ever mentioned.  Individual motivation and creativity were stifled and replaced with frustration and, I think, a bit of anger.

The lunch meeting the day after had a completely different feel.  As creative minds gathered around the lunch table the brainstorming began immediately.  New ideas came fast and furious, and each was measured appropriately – by how it would improve practice efficiency and quality of care. Despite the inexperience and clumsiness of the facilitator (me), the meeting was a success.

My experience with these 2 meetings makes me wonder if the future of Meaningful Use is already in doubt.  The Medical Association of Georgia offers a free MU seminar with expense reimbursement, and 50 physicians out of 18,000 invitees attend.  And even these select few highly motivated MU candidates are already frustrated.  During the meeting we saw numeric evidence that some statistics that describe EMR use are grossly overinflated.

Our (soon to step down) government HIT leader Dr. Blumenthal has claimed “The Age of Meaningful Use” has begun, citing survey statistics that 41% of office based physicians plan to achieve MU.  It is hard to reconcile that number with statistics from the MU meeting showing only 4% of practices have a fully functional EMR.  The difference can probably be found in how the survey questions were worded in each case.  Assuming that achieving MU requires a fully functional EMR, how are we going to get from 4% (or let’s say less than 10%) to 41% by the end of 2012?  I don’t see that happening.   And even those practices that achieve MU stage 1 and get their (Medicare) $18,000 may walk away from the MU stage 2/3 requirements that will be tougher and offer less incentive.

Current interest in MU is driven by 3 forces:  1.  Government incentive programs generate interest simply because they exist; 2.  The monetary value of the incentives, and; 3.  The support of EMR vendors.  Those of us who have chosen to pursue MU despite our misgivings are doing so more out of a sense of duty and a desire for credibility than out of any true enthusiasm for MU.  But it won’t last forever.

 

 

 

March 29, 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.

How to Overcome the Cultural Barriers to EMR Adoption

My latest writing went to a publication for my specialty, ENT Today. I can’t reproduce it here but please follow the link to read it: ENT Today article.

February 17, 2011 I Written By

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

My Practice is in a Microsoft Commercial. No, really…

We did a commercial for Windows 7 in health care several months ago.  They just released the final version last week.  It was a lot of fun and gave me an opportunity to get the EMR message out.  The message of the commercial is similar to an earlier blog post.

Check out the video and have a good laugh or see it embedded at the bottom of this post.

After seeing the final version of the video 3 thoughts come to mind:

  1. I really do believe all that stuff I said about W7.  It works well.
  2. The camera does not put on 10 pounds.  I put them on (and lots more) myself.
  3. Thank God my kids look like my wife.


Get Microsoft Silverlight

January 9, 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.

How the Best of Intentions can Backfire

My meanderings through LinkedIn last evening uncovered a recently released study entitled, “Physician Practice EHR Price Tag” published by CDW Healthcare.   The authors are not named but there does not appear to have been any physician input.  The study, presumably written by IT folks at CDW, appears to be aimed at an audience that includes physicians. It is an admirable attempt to measure both the obvious and subtle costs associated with setting up and maintaining an electronic medical record system. The study also attempts to assess the return on investment by estimating the increase in revenue from having a more efficient EMR–driven practice.   Any study like this will by nature be heavily dependent on assumptions; this report outlines them well.

Without regurgitating the entire study here, there are two numbers worthy of discussion. The first is their estimate that the first year of EMR implementation will cost approximately $120,000 per physician. Most of this ($100,000) represents decreased revenue due to decreased patient volume during the first year.   This figure was derived by asking 200 paper-based group practices to estimate how far patient volume would drop during EMR implementation.  The average (? mean) of the estimates, 10%, was then run through some normative data to calculate the $100k figure.  The second number is their estimate that after EMR is “fully implemented and adopted,” the practice will benefit as much as $150,000 per physician from improved practice efficiency and increased patient volume.

While I respect CDW’s efforts to provide guidance to physicians, I have two major problems with this study. First, why would you ask group practices with no EMR experience to guess how far their patient volume would drop while they were learning EMR?  Why not ask practices who have already implemented EMR and get real data? And while we’re thinking about it, why did they assume that patient volume has to drop in the first place? When we implemented our EMR system almost 6 years ago, our transient drop in patient volume was near zero.   We recognized upfront, as the CDW study does, that any drop in patient volume represents a greater cost to the practice than the EMR system itself.   To us any drop in patient volume was unacceptable.  Our implementation strategy was the opposite of what CDW suggests; instead of moving as quickly as possible we moved slowly enough to avoid any drop in patient volume. Without that economic pressure we were able to take as much time to implement as we needed.  I will cover the details of our implementation strategy in the future.

My second objection is that this study will hurt the EMR movement because it will discourage physicians from getting EMR.   This is yet another example of how IT people and physicians see the world differently.  IT people see the $120,000 upfront cost compared to the $150,000 per year benefit and conclude that the benefits of EMR are, once again, obvious.  Who wouldn’t invest $120,000 to get a $150,000 annual dividend?

The physician sees the data from a more personal perspective.  We see the $120,000 upfront loss as a valid and terrifying figure.  We dismiss the $150,000 per year benefit as a pipe dream and conclude that EMR is economically unfeasible. The physician cannot regard these figures as just cold numbers on a spreadsheet.  That $120k is a direct, devastating loss of personal income.  Doesn’t matter what could happen in future years…we wouldn’t survive the first year.   And an annual $150k / physician benefit after EMR is “fully implemented and adopted?”  Who are they kidding?  Even as one of EMR’s biggest physician supporters I can’t accept that figure as credible.  I also don’t know how you define “fully implemented and adopted.”  Our experience demonstrates that EMR is never “fully implemented.”  It is always a work in progress with bugs to fix, new features to add and improvements to make based on experience.

This study’s sophomoric approach is typical of a “me too” latecomer to healthcare.   Doctors regard this kind of thing just like we do a brand-new pharmaceutical rep that shows up at our office, bright-eyed and ready to sell us all over again on an old drug that’s been around for years.  Listen politely, check your watch, hope the lunch they brought is pretty good and pray your pager goes off to get you out of there.

December 17, 2010 I Written By

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