Intelligent Healthcare Information Integration 5/4/09

Step 4: Equalizing the Playing Field
(“Open” is not a Four Letter Word; Systems That’d Suit)

If open-sourced crowdsourcing hasn’t shown you its formula is successful, you’re not paying attention. Look at Apache HTTP Server, look at Linux, look at Mozilla Firefox, Java, MySQL, Thunderbird, OpenOffice. Open source and crowdsourcing enhance innovation; support of open source allows profit. Healthcare needs such public/private cooperation to stimulate the innovation necessary for its salvation.

Of the open source EHRs currently available such as OpenEMR, OpenMRS, VistaA & Vista-Office EHR, FreeMed, tkFP, and Care2x, thus far, they are unusable for the masses. Still typically Windows 95-ish, very boxy with lots of columns and rows, their support sites are often heavily laden with tech-head jargon and formatted such that perusing them is laborious. Documentation is usually cumbersome or scanty, often difficult for the lay person to assimilate.

Wouldn’t it be great if a polished, open source EHR could incorporate a “best practices” approach for included elements/design? Everyone’s got their favorites, but from down here in my trench, standouts include:

• Eclipsys’ Peak Practice – best visual candy, great customizability
• Jay Parkinson and his creative Hello Health – Web 2.0 style, “intuitivity”
• Doctations – online implementation, share-the-sandbox inclusivity
• TeleAtrics – little known with one of the best physician or patient/parent visit summary note formats – not too big, not too small, juuuuust right
• Medicomp’s new CliniTalk – simpler, yet far more powerful coded data collection via voice, type, or pen click
• athenahealth’s athenaCollector – exudes billing and practice management power
• Medicity’s Care Collaboration Platform – share, share, share

Why hasn’t some clever bizhead figured out that the potential for a really slick open source EHR/PM, marketed and supported correctly, is astronomical? Vendors say up front fees are not the moneymakers, that ongoing support services are what generate profit. Still, the majority of my non-tech physician colleagues cringe far more at initial EHR cost figures than at the support fees. Lower the threshold for entry; make a visually pleasing tool designed for normal peeps, not gadget geeks; provide education and support par excellence – these would seem a recipe for sweeping adoption and profit.

Small community docs and hospitals could certainly use a truly functional, low entry threshold product to help them cross the digital divide for their two-thirds of U.S. healthcare provision. They need a playing field equalizer, because current vendor offerings are built mainly for the big boys. It’d be nice if some bIg BeheMoth-sort would see the value in thousands of small community sales globally, but if not (and not meaning to be insensitive) then come on, all you out-of-work developers and designers out there…wake up!

During the current economic slump: 1) band together; 2) steal a few from column A, a few from column B, etc.; 3) put together an EHR that really will help the befuddled medical masses with a healthcare tool we could all actually use; and 4) create yourselves some jobs while helping save the entire U.S. healthcare system – hell, the whole global economy – to boot!

Still to come:
Step 5: Verdant Health (Lush, Full, Eco-friendly, Yet More Jobs – “Green” in Every Sense)

Dr. Gregg Alexander is a grunt-in-the-trenches pediatrician and geek. His personal manifesto home page…er..blog…yeh, that’s it, his blog – and he – can be reached through http://madisonpediatric.com or doc@madisonpediatric.com.

Dr. Lyle on Information Overload 5/1/09

One thing you said the other day caught my attention – you said all that Twittering left you dazed and confused from information overload. I think we can all understand that feeling, and I would apply that analogy to the risks of interoperability. In other words, we better be careful what we wish for! Because if I get every piece of data for every patient, I will never get through my day.

As a primary care physician, I usually have about 10-15 minutes with each patient. Depending on their main complaint, I only need selected information. If I’m seeing someone for an acute sinus infection, I usually just need to know their active allergies and meds. If I’m seeing someone for a follow up to their three chronic diseases, I want the above, plus recent labs, tests, and recent specialty reports if relevant. If I’m seeing a brand new patient with a complex illness and I have an hour to work with them, then I would want all of the above, plus (maybe) notes from all past evaluations, drug history records, lab trends over many years, etc.

As you can likely see where I’m going, most outpatient care visits don’t need “everything”, and in fact, those visits would be ridiculously long and confusing if I had to wade through every piece of information ever accumulated on a patient. With that said, I can see a future what a computer might even intelligently summarize for you. And I have no problem with interoperability as a nice long-term goal.  

We really need to prioritize our resources with respect to EMR adoption. If interoperability helps make local interfaces easier, then I am all for it! But it seems like those interfaces are reasonable enough already, and that the focus on interoperability is a much grander scale. I think the forces behind that movement (“grand interoperability goals”) need to better justify why that is more important than other things to help make a local EMR project work (e.g. more usable systems, more consistent clinical decision support knowledge, quality metrics defined and reimbursed, …) Are others talking about this, or am I going after a sacred cow?

Lyle Berkowitz, MD is an internist and healthcare informatics expert. He is Medical Director of Clinical Information Systems for a large primary care group in Chicago. He also blogs at Change Doctor.

News 4/30/09

From Evan Steele: "Re: SRS and CCHIT. Just a clarification regarding the post where you mention that ‘SRS is taking a strong anti-CCHIT stance…’ Although it sometimes appears as if that is our stance, there is a place for CCHIT software in lower patient volume settings (e.g. primary care and academic practices). That market represents a huge opportunity for the CCHIT vendors. SRS is designed for the high-volume, high-performance market segment and has built a large national network of such practices over the past 12 years. I like to view SRSsoft’s positioning as not ‘us versus CCHIT’ but ‘SRS for high-performance physicians’ and ‘CCHIT for lower-volume physicians.’" SRS, by the way, just announced it signed up Cascade Orthopaedics, a 15-doctor practice in Washington. Perhaps it is a coincidence, but the latest press release makes absolutely no mention of CCHIT.

From EMR Vendor: "Re: ACP conference. I think most vendors will echo the fact that the attendees were knowledgeable physicians, who came looking for solutions, and know they need to buy. Physicians attend this show for the education and the exhibit hours are really in 45-75 minute increments. ACP arranged for a vendor shootout/demo of four different products. Seems like everyone is in the queue for CCHIT 2008 certification, if they were not already certified. Some EMR vendors were overwhelmed with traffic and others looked pretty desolate. We were consumed by prospects as well as reps from other companies pitching their resumes." EMR Vendor exhibited at last weekend’s American College of Physicians Internal Medicine 2009 meeting in Philadelphia, which was attended by about 6,000 internists.

From Spicy Girl: "Re: Miami and Medicare fraud. OMG, this line made me laugh out loud: ‘These are probably not the kind of things the visitor’s bureau talks much about.’ Thanks for the smile! I needed it!"

EHR vendor MedLink International and Clinical Laboratory Management (CLM) enter into an affiliation agreement that includes CLM’s promotion of MedLink’s TotalOffice EHR and Medlink EHR Lite products. In addition, MedLink users will be able to interface with CLM for lab ordering and results reporting.

McKesson promotes Randy Spratt to the newly created position of Chief Technology Officer. Spratt will also maintain his current role as executive VP and CIO.

Within hours of winning confirmation as the country’s HHS secretary, Kathleen Sebelius was thrust into the middle of the public health emergency involving swine flu. Her confirmation had been swirling in some controversy, but those issues likely took a back seat to the more pressing need for a permanent leader to take charge. Baptism by fire hose, perhaps?

Sunset Medical Practice Group (OR) and Diagnostic Imaging Solutions (CO) select Digital Healthcare’s Retasure solution to assess the retinal health of their diabetes patients.

The JPS Health Network (TX) moves forward on plans to build a clinic dedicated to treaty the Fort Worth needy, including the homeless. The planned clinic would provide medical services plus offer "wrap-around" services targeted at reducing homelessness and moving people to permanent housing.

Executives from the EHR Association testify at this week’s National Committee on Vital and Health Statistics hearings to help define "meaningful use." During his testimony, Justin Barnes, the chairman of the HIMSS-sponsored EHR Association and VP for Greenway Medical Technologies expressed his support for building "on the successes of CCHIT, HITSP and NQF."

Most US physicians have a positive attitude toward the electronic promotion of pharmaceutical companies, with three-fourths believing the approach is equal or superior to face-to-face communication (which is likely good news if you want to get into the pharma business but don’t have the looks of a college cheerleader). It would be interesting to know if doctors (and their staff) feel the same way when selecting electronic medical records or practice management tools. Will the bag-carrying sales rep be replaced by a remote demo expert pushing product over a high-speed connection? Or will practices still desire the more personal, onsite approach that gives a sales rep a better understand all that is unique about their clinic?

The 150-provider Polyclinic (WA) signs a contract with Swedish Medical Center to implement Epic EHR. Swedish Medical Center already uses Epic across its four campuses.

The AAFP, AAP, ACP, and AOA release a Guideline for Patient Centered Medical Home Demonstration Projects, which includes a set of endorsed guidelines for any project testing a medical home model. Included are recommendations on who should collaborate on projects, how participating practices should be chosen, what type of support should be provided, how practices should be reimbursed, and how results should be analyzed.

The AMA and the Michigan State Medical society partner with Compuware’s Covinst to provide Michigan physicians increased access to HIT tools and information. Some of the initial programs include e-prescribing and EHR/PM options.The AMA will use feedback from Michigan physicians to build on its upcoming nationwide portal project.

E-mail Inga.

Intelligent Healthcare Information Integration 4/29/09

The Creatively Maladjusted

One of the most famous doctors of all time – a true visionary and a tremendous healer – once offered what I believe to be one of his finest insights:

“Human salvation lies in the hands of the creatively maladjusted.”

Personally, I know very few creatively maladjusted folks. I know a slew of the maladjusted, and a peck or two of the creative, but rare is the convergence of the two. If information technology is to “save” healthcare, there is no doubt that it will be HIT’s creatively maladjusted who bring about its salvation.

Let me flesh that notion up a mite:

• “Healthcare” is a mess – way too many middle men who have way too little “care” for health between me and my patients
• Healthcare information technology has become pretty much a similar mess – way too many “solutions” which only seem to broaden the chasms between me, my patients, and good healthcare provision
• For one mess to rescue another mess, it’s going to take people from beyond the pale who are free of institutionalized bias and restraints to deliver us to the HPL (Healthcare Promised Land)

Sadly, the business of HIT has now been around long enough to have become institutionalized. Sad, this is, because instead of becoming a functional, helpful, advancement that delivers powerful new tools for improving people’s lives, it has become more like a writhing swarm of locusts all looking to feed upon the crops of our lives and our economies. And, the Stimulus monies are essentially a non-pesticided entire Corn Belt of fresh feed for these ravenous grasshopper hordes.

Historically, the use of electronic technology to advance healthcare was envisioned by some pretty smart people for some pretty durn good reasons. I’ve been fortunate enough to have met a few of these pioneers, like Drs. Larry Weed and Ron Pion. Larry early on saw the value of the “peripheral brain” for doctors and Ron enabled patient education via television. They “got” the value of technology in improving the provision of healthcare. Unfortunately, many since have seen fit to merely “get” the “value ($)” portion of HIT. Thus, the institutionalization (and degradation) of originally noble ideas began.

A similar institutionalized situation used to exist until the above-quoted famous doctor (and a few others of his ilk) brought forth some seriously creative maladjustment to dislodge acceptance of the then accepted norms. Those normative notions, most of now see, were pretty seriously twisted despite their widespread promotion. However, “normal” has never been synonymous with “correct.”

Racism was once a major institution, in both thought and deed. But, in living up to his famous quote, Dr. Martin Luther King, Jr. helped us see through his creative maladjustment that a better way was possible. Healthcare now needs some maladjusted creators to step up and call out the institution of healthcare IT.

There are a few of these miscreants, these heretics, around. Again, I’ve been lucky enough to have met a few. But, in the deafening drone of the institutionalized swarm, their visionary voices are hard to hear. Occasionally, I read some other blog brat promote attacking the walls of the HIT establishment as they discuss some of these innovative disrupters, but they, too, are small voices amidst a roar.

I suppose the important thing for the small voices is to keep talking, keep envisioning. To again quote the good Dr. King:

“Our lives begin to end the day we become silent about things that matter.”

Dr. Gregg Alexander is a grunt-in-the-trenches pediatrician and geek. His personal manifesto home page…er..blog…yeh, that’s it, his blog – and he – can be reached through http://madisonpediatric.com or doc@madisonpediatric.com.

News 4/28/09

From Practice management guy: "Re: pitching products in the age of ARRA. While it’s true that providers are heavily focused on EMR right now, they are also more worried than ever with declining reimbursements and the growing trend for higher deductibles and bigger co-pays. As a practice management vendor, we are seeing practices ask for for more tools to manage the patient A/R, especially on the front end. To be competitive, vendors need to have an option to verify insurance up front and on the fly. The tools must also calculate the expected patient responsible portion. Welcome to the world of consumer-driven healthcare!"

From Eve: "Re: Medzio. It’s actually A.D.A.M., Inc. (www.adam.com) who launched the Medzio Health Network and Medzio iPhone application. A.D.A.M.’s development team developed the application, built the partner network, and submitted the app for approval in App Store. The participating partners – LIVESTRONG.com, Health 2.0, HelloHealth, etc. were recruited by A.D.A.M. to build out the Medzio Health Network." Got it.

Hopefully Fujitsu’s new EMR is more user-friendly than its name. Fujitsu’s new HOPE/EGMAIN-GX V2 is the company’s latest EMR software release, presumably designed to run on Fujitsu’s mobile devices. Good luck trying to find out more information on the software because we couldn’t find any details on Fujitsu’s website, nor anywhere else (at least any places that were written in English).

In an article highlighting the use of EMR in Tennessee’s Tri-city region, the president and founder of Holston Medical Group claims EMR saves his practice saves over $800,000 a year in transcription costs. Dr. Jerry Miller led the transition to EMR 13 years ago and claims the conversion took a lot of work and expense, but was worth it.

The burnout rate among surgeons ranges from 30 to 38% and stems from such factors as enormous workloads, family life stress, and grief over unsatisfactory outcomes. Younger surgeons and female surgeons are especially at risk.

Thanks to the Internet, information on swine flu is spreading faster than the actual disease.The CDC is tweeting updates (twitter.com/cdcemergency) and posting podcasts. The WHO and HHS are also providing regular updates that include the number of confirmed cases by state. If you are a visual  person, try the Google Maps site that displays confirmed outbreaks by location. Or, if you prefer your data aggregated from multiple sources, Healthmap is your best bet.

Clearinghouse vendor Navicure releases a new software version that includes such features as denials management, aging analysis, and interactive graphs.

Forbes profiles Steve Schelhammer, a former teacher and yearbook salesman who formed disease management company Accordant Health Services, sold it for $100 million, and is now CEO of Phytel, which analyzes EMR data to find non-compliant patients and sends them messages asking them to schedule a visit. Practices pay for the service, but benefit from increased visits.

The AHRQ contracts with Rand Corporation to develop a toolset for implementing e-prescribing. The goal is to boost e-prescribing adoption rates by providing physicians a how-to guide, including advice on the most appropriate workflows.The estimated cost of the project is $120,000.

Scriptnetics, the makers of Medscribbler Open Source EMR software, has met the Microsoft Platform Test requirements for SQL Server 2005. Scriptnetics claims that Medscribbler Open Source was the first EMR to be designed for the handwriting capabilities of the Tablet PC. The software looks to be a "lite" EMR; that is, it doesn’t have all the features of a full EMR and is limited to two clinicians and two administrative people in a single practice. However, Scriptnetics also offers a "Pro" and "Enterprise" version of the software, which presumably you can upgrade to if you outgrow the free version. It’s probably not a bad model for Scriptnetics, assuming the free version is decent enough to earn a doctor’s loyalty. And, it’s likely an attractive alternative for clinicians on a shoe-string budget, especially if the top concern is automation and not necessarily qualifying for ARRA funds.

Thinking of Miami brings up images of beautiful beaches, cool architecture, exotic foods, and Medicare fraud. Case in point: a recent HHS study finds that south Florida is home to only 2% of the the nation’s Medicare beneficiaries, yet accounts for 17% of the Medicare’s total spending on inhalation drugs. The government blames fraud. Also noted in this article from the local paper is the story of a dermatologist who wrote $620,000 in false prescriptions for expensive inhalation drugs. A local pharmacy paid the doctor a $100 kickback per prescription. These are probably not the kind of things the visitor’s bureau talks much about.

SRSsoft announces that the 23-provider group OrthoNeuro (OH) is installing the SRS hybrid EMR solution. OrthoNeuro’s CEO is quoted as saying that a "CCHIT-certified EMR would drastically interfere" with their high-volume practice. SRS is taking a strong anti-CCHIT stance and it will be interesting to see how their strategy plays out. Also interesting: Evan Steele, the company’s CEO (and occasional poster to HIStalk and HIStalkPractice) recently mentioned on his blog that he has been nominated to the HIT Standards Committee, the group charged with defining the EHR certification criteria. Hope he makes it because it would be fun to see if he is able to mix things up a bit.

E-mail Inga.