DOCtalk with Dr. Gregg 9/26/16

Vendor Apologies Work

This Saturday morning, as usual, I got up very early and started my typical routine, which includes checking my EMR to see what labs, prescription refill requests, consultant notes, and ER or urgent care notes may have come through since the night before. Only problem was, this morning, as compared to every other Saturday morning since we started on our current EMR, something was wrong – very, very wrong.

Not only couldn’t I access my EMR, I couldn’t even get to the sign-on page. (Yes, it’s a browser-based system.) All I could see when I tried to open the login screen was a blank, totally white page. Hmmm … that’s different …

I tried a couple of tricks in that browser with no luck. Well … maybe it’s a browser issue, I thought. Went to browser 2 … same problem. Hmmm …

All vendors have periods on downtime, you know, for system maintenance and upgrades and whatnot. However, before any scheduled downtime, most vendors notify their clients, as ours always does. Maybe I missed just such a notice thought I, so I double-checked my emails, including Junk and Spam folders. Nada. Hmmm, hmmm …

Well, glitches happen, my coffee hasn’t kicked in yet, and maybe I’m not really awake and am just dreaming. Maybe I’ll just go on about some business financial stuff (bills – ugh), run through emails, and then double back to this in a while.

However, an hour or two later, the same blank white browser page kept staring me down. “Maybe there is a system problem” now became my number-one thought.

Before I began to panic with dreadful doom-and-gloom thoughts, I decided to send the EMR support folks an email detailing what was happening on my end. Knowing I’m in the Eastern Time Zone and that they are West Coasters, I figured they may take a bit to respond – you know, wake up, grab coffee, etc. – so I sent the email and proceeded onto the aforementioned doom-and-gloom mental scenarios, such as:

• What if my EMR vendor has unexpectedly gone under, just shut the doors and shuttered the Web access? (Unlikely. They just raised a snootful of investor capital.)
• What if the system has had an irreparable glitch, maybe a total system failure? (Doubtful. They use some pretty great system architecture. Plus, at least some redundancies are in place to prevent total loss.)
• What if hackers have breached the system and are holding our data captive for some ungodly sum of ransom? (Prob’ly not. That investor money still wouldn’t make them as likely a target as many other, more prominent and likely more cash-rich, EMR vendors out there.)
• What if I somehow, for whatever the reason, we lost all access to all of our patient records? (Naw. But, still, a very scary mental picture came to mind, if only for a fleeting, though rather frightening, instant.)

OK, so I played the game of “Fear Factor” in my head and decided it might be best to walk away for a bit and give the support folks a chance to respond. Otherwise, I could envision doom-and-gloom overtaking my day, and it’s SATURDAY! No way I’m wasting a lovely, end-of-summer weekend on HIT anguish and angst.

After some workout time, some dog time, and some home puttering time, I returned to find that my EMR was fully back online, and that support had sent me a response email to say the system was back, and that it was “very unprecedented” and they had “put measures in place to ensure this will not happen again.” They also extended “sincerest apologies.”

OK, the world is once again spinning in greased grooves, and I go on about my patient-related morning duties with no signs of any lingering digital hiccup. My fears have abated, but my curiosity is still nagging away wondering what had actually occurred. Thus, later in the day, I responded to the support person’s email that I had received asking if she’d mind letting me know what exactly had “problem-ized” the system.

I didn’t hear back. Not Saturday. Not Sunday. No biggie, as I’m sure they have better things to do than explain their issues to some little trench grunt. Still, curiosity nagged a bit.

Come Monday, though, my curiosity quotient was fully addressed. In my email inbox, I received – and I’m sure all other clients of this EMR did as well – a wonderful email not only providing a full-blown apology for this “first time in [EMR’s] history that the service has been down for anywhere near this length of time,” but also a sufficiently detailed description of the problem. (Apparently there was a “system infrastructure upgrade” that was not expected to cause any downtime or service interruption whatsoever. Ah, the best laid plans …) It was the first time in their entire corporate history that such an unexpected and lengthy disruption had ever occurred.

But – and here’s the best part – the email didn’t end there, nor even with some politically-correct, corporate-speak apology. No, instead they proceeded to list important addresses to this issue should such an unintended disturbance reoccur:

• First, such a “system infrastructure upgrade” would be addressed in future so that such surprises were avoided. Additional redundancies were being deployed as well;
• Second, they started a public “status webpage” to communicate application status and any communications or solution estimates in real time;
• Third, they instituted a dedicated emergency phone number that will be monitored by in-house staff (read that as “not outsourced”), because they understood that the “inability to talk to someone when you aren’t able to access your records is very stressful and has a great impact on your practice;”
• Fourth, they offered a very sincere-sounding apology, directly from the co-founders;
• And, fifth, and what was especially high on my “Well, Ain’t That Cool” list, they sent us the personal cell phone numbers of both of the co-founders to use until the 24/7 emergency line was fully implemented!!

That last one takes commitment to your clients, personal integrity, and a bit of moxie to float out the cell numbers of the top brass for any old trench grunt to use. (I promise, guys: I’ll try never to abuse it.)

I hope this very cool response, apology, and good-faith gesture sets a standard for any and all other HIT vendors to emulate. Stuff happens, to say it politely, but it’s the response to the “stuff” that lets clients know how much – or how little – you care.

From the trenches…

“If God doesn’t destroy Hollywood Boulevard, he owes Sodom and Gomorrah an apology.” – Jay Leno

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is chief medical officer for Health Nuts Media, an HIT and marketing consultant, sits on the board of directors of the Ohio Health Information Partnership, and is the semi-proud author of “Monsters Don’t Fart!”

Contacts

Jenn,  Mr. H, Lorre, Dr. Jayne, Dr. Gregg

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DOCtalk with Dr. Gregg 8/23/16

Dancing the MACRA-rena

It seems healthcare often lags behind in many things, like IT adoption and pricing transparency. Apparently, it also lags behind in fads. To wit, I just discovered that a certain 1990s dance craze has been reborn with a health IT twist …

————————————

[Chorus:]

Give happiness to your practice, MACRA-rena

‘Cause your patients are for generating money for you

Give happiness to your wallet, MACRA-rena

Heeey … MACRA-rena! Aaay!

(repeat once)

MACRA-rena has a father who’s called…

Who’s called the last name MU,

And while he was taking his oath as near failing,

She was figuring how to fail anew … Aaay!

(repeat once)

(Chorus)

MACRA-rena, MACRA-rena, MACRA-rena

You’re popular with the princes of Washington

MACRA-rena, MACRA-rena, MACRA-rena

Like insurers’ lobbyists and guns … Aaay!

(repeat once)

(Chorus)

MACRA-rena dreams of new payment models

And driving the latest reforms

She would like living with ev’ry doc

Draining their joie de vivre and more … Aaay!

(repeat once)

(Chorus)

From the cynical side of the trenches…

“You have to remember one thing about the will of the people: it wasn’t that long ago that we were swept away by the Macarena.” – Jon Stewart

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is chief medical officer for Health Nuts Media, an HIT and marketing consultant, sits on the board of directors of the Ohio Health Information Partnership, and is the semi-proud author of “Monsters Don’t Fart!”

Contacts

Jenn,  Mr. H, Lorre, Dr. Jayne, Dr. Gregg

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DOCtalk with Dr. Gregg 6/23/16

EHR Litter

Hot topics in HIT these days are all around interoperability, big data, data exchange, MACRA, etc., all of which pretty much revolve around the generation of data. But before we get too far down the data-generation path (if we’re not there already), maybe it’d be a good idea to consider a much less sexy concept – the notion of “EHR litter.”

In all likelihood, you’ve never heard of EHR litter before. I hadn’t. In fact, I think I may have coined the term. It came to me one day when out mowing my lawn …

Living on a fairly busy street in our town, one of the seemingly incessant scourges is that of litter. As I was picking up the fourth piece of somebody’s waste – a used Kleenex, I believe it was, yuck! – it struck me yet again how lovely it would be to just once mow the grass without having to handle the often gross refuse of my neighbors.

As I mowed on, it further struck me that so much of the detritus that I receive in digitally-created notes from hospitals and other providers is very similar to my yard experience: There’s good stuff in there, but doggone if there isn’t a whole heap of “litter” that just wastes my time!

Think about it. If “big data” is ever going to get us anywhere, it should be big, useful data, not copy-paste crap that often isn’t actually applicable to the current patient note, or system-generated phrases that add no value to the medical story other than making it easier/faster for some poor clinical schlub to get through his dullardly data-capture duties and get his bullet points all clicked to ensure reimbursement.

Whether obtained via fax, PDF on CD or flash drive, C-CDA, or secure messaging, so much of the “medical” content that we providers now have to wade through is like so much litter; it’s truly trash that takes time to scrounge through and wastes digital space. It serves no purpose for ongoing patient care.

To be honest, sometimes I’m not sure if it is any better than the old handwritten pen-and-paper notes that were often illegible. Both waste provider time, both provide limited (if any) value, and both are fairly infuriating. Both are, essentially, medical content litter.

All this waste-of-space content will divert us from our goals of making big data useful, data exchange worthwhile, and interoperability efficient.

I promise to do my best to eliminate “litter” from my notes. I hope you – be you provider or EHR vendor – will do your part to get rid of your EHR trash.

(And, if you happen to drive by my yard, please don’t throw your trash out there, either.)

From the trenches …

“If what I write is literature, I guess you’d better emphasize the ‘litter.’” – Lydia Lunch

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is chief medical officer for Health Nuts Media, an HIT and marketing consultant, sits on the board of directors of the Ohio Health Information Partnership, and is the semi-proud author of “Monsters Don’t Fart!”

Contacts

Jennifer,  Mr. H, Lorre, Dr. Jayne, Dr. Gregg

More news: HIStalk, HIStalk Connect.

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DOCtalk by Dr. Gregg 4/22/14

Multiview: Prime Cut

Looking around at EMR/EHR options again – or, as always – one thing has begun to really stand out: the value of “multiview.” (In case you don’t know what “multiview” means, it refers to the ability of an EHR to allow the viewing of more than one function, and especially more than one function of more than one patient, at a time.)

OK , maybe the term “multiview” isn’t an industry standard, but I’d argue that it should be. After becoming comfortable with a system that easily allows viewing multiple components of a patient’s record at the same time, and one that also easily allows multiple views of multiple patient records at the same time, it has become virtually impossible for me to even consider any system that only allows a “one patient – one component” (OPOC) view.

OPOC seems comparable to the Buddha’s blind men describing an elephant by only experiencing one “view” of it.

Once you’ve become comfortable with multiple perspectives, with being able to see multiple “stories” at one time, with seeing interrelated parts and pieces, it becomes insufferable when you are only allowed to view the “one story, one element” window format of OPOC that seems to be the general industry standard in HIT.

The good part is that seeing what is available in EMR/EHR systems is becoming easier. More current EHR vendors are now offering “free” or “trial” versions that allow you to “try before you buy.” I love that. There’s no EHR demo, and certainly no EHR sales pitch, that can ever allow a provider to get as full a sense of what it’s like to work with a new EHR as a trial version can. Getting your hands on a system, even with a single “John Doe” test patient, provides so much more useful data on what it will be like to operate within the workflow of a new EHR. Kudos to those vendors who have figured out the value of the EHR test drive.

The hard part for me is looking at otherwise very intriguing systems who offer otherwise great functionality (and even otherwise wonderful pricing), but who are limited by the OPOC view.

Honestly, I don’t think it possible to go backwards. To even consider losing the ability to see multiple views within a patient’s chart at the same time, and especially to consider losing the ability to see multiple views within multiple patients’ charts at the same time, seems to have become a nonstarter. OPOC is a rate-limiting step, to be sure. I can’t seem to move past the consideration.

Even with a system that doesn’t offer all the specialty-specific features I’d prefer, even with a system that doesn’t provide 2014 MU certification (yet), even with a system that doesn’t have all the connectedness I’d prefer – all of this pales when compared to working with a system that allows me to see what I want, when I want, and as much as I want in the resizable, moveable window way with which I’ve so quickly become accustomed. Multiple views of multiple stories are multiply wonderful.

Multiview is one of the most dramatic ways that computerized documentation trumps paper records on a day-to-day-what-really helps-with-patient-care functionality basis. A paper chart requires flipping back and forth; OPOC systems do, too. Multiview allows a provider’s brain to do what it does best: easily view, consider, and synthesize multiple, disparate factors. Gray matter, at least the vast majority of non-eidetic-memory gray matter, isn’t very good at remembering all the little details; computers excel at this. But, gray matter beats the digital pants off of silicon for processing the bejesus out of data when given a multifactorial view. Gray matter can consider connections and nuances related to the human condition that escape even the most sophisticated electronic brains. (Watson, Tianhe-2, Mira, and their ilk may soon overtake us on this, but not just yet. Plus, gray matter is far more portable.)

Multiview has become my documentation standard of care. If you haven’t been fortunate enough to experience multiview in your EHR/EMR system, you’re probably better off. It’s hard to miss what you’ve never known.

For me, I’m now fully spoiled. Anything less than complete multi-manipulable, multi-scalableable, and multi-viewable has become multi-unacceptable. It’s like trying to pretend that chuck roast is fine, that I don’t know the exquisite texture and flavor of filet mignon.

But I do. Multiview is prime cut.

From the trenches…

“I’m very interested in structure, how multiple stories are assembled in different ways; that is what memory does as well.” – Nicole Krauss

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, an HIT and marketing consultant, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).

DOCtalk by Dr. Gregg 3/31/14

HIT’s Next Big Role

MU has done its duty. Providers are adopting EHRs.

Patient charts are no longer merely a massive collection of indecipherable scribbles within mountains of paper. Great. Providers are digitizing. Great. Healthcare data is becoming mineable. Great. But what movement in the outcomes needle has been driven?

Notes in legible digital format are of little more value than paper records if EHR X can’t share digitally equivalent data with EMR Y. Digital data is worthless without aggregation, analytics, and evaluative proceedings.

Thank goodness HIEs are starting to connect, even though mostly with hospitals thus far. But, we are finally starting to see signs of data sharing, and buzz terms like “data analytics” and “big data” are replacing “meaningful use” and “interoperability.”

As a whole, EHRs may not be beautiful, nor fully functionally friendly, but that’s mainly an issue of refinement. As a whole, our collected data isn’t very well connected, but that’s a “yet” thing; it’s happening. Data input and capture, data sharing, and data analytics are important – nay, vital – to changing healthcare, to be sure. Most of these are on a roll, and there are some up-and-comers in process to take this data and its analyses to exciting new heights. The challenges of grabbing and scrutinizing data are becoming overcome.

Well then, now that we’re seeing reports of some 60% or so of providers gathering data digitally, and now that HIEs are starting to show signs of respectable life beyond the mostly (or wholly) defunct RHIOs and CHINs, the question becomes: what’s the next big step for HIT? If changing healthcare is all about improving outcomes – and who can argue that good outcomes should always be the goal for healthcare? – will digitized data and its analyses be enough to drive us to, and through, that hoop? (Can you tell I’ve been catching some March Madness?!) Will better measurements yield better results?

Maybe. Some, anyway. I’m a huge fan of smart data used smartly. However, we’re talking about human beings here, not just manipulable metamessages and figurable facts.

People are full of subtext, subplots, and subtly subversive subterfuge, especially when it comes to lifestyle choices, and healthy – or non-healthy – behaviors. We all have our daily rationalizations and self-interest self-deceptions. We say we want one thing, but proceed to act in complete contraindication to that end.

HIT’s next big challenge will be more about the marketing to, and motivation of, the men and women of healthcare, both in front of and behind its delivery. How do we persuade human beings to change their health habits, and healthcare delivery habits, given the inherent difficulties of being human?

How will the 40% of providers not yet on EHRs become driven to adopt? Obviously, the MU carrot-stick thing hasn’t been enough.

How will we motivate independent or non-institutional providers to connect to HIEs? There won’t be any more MU-esque goodwill monies flowing from the feds.

How will providers be motivated to continue to collect data? It seems inefficient to think that “prizes” and “beatings” (i.e., carrots and sticks) will suffice to keep the data collectors feeding the data miners.

How will providers be inspired to change communication habits (with other providers and with patients) and alter longstanding workflow patterns to capitalize on the new values that connected HIT can bring? Change is hard, even if it’s good change; changing habits is even harder.

Lastly, how will Jane and Joe Sixpack become aware of the advantages of connected data and motivated to both gather and share it? Beyond the tech-heads, fitness-buffs, early adopters, and fad-focused, there’s a whole wall of folks that will need inspiration before the full-bore, major-shift, healthcare-change tipping point is reached.

This challenge – the inspiration of consumers – may just be the key to all the rest. If HIT can motivate and massage consumers to become fully actualized healthcare participants on a grand scale, their participation will spur the remaining provider change.

Providers are inspired by need; they respond to it. That’s what got most healthcare folks into the field in the first place. If consumers of health services display or voice a specific need to their healthcare providers, their providers respond. That’s what they (we) do.

Here’s where HIT has its next big role. We must develop more user-friendly patient portals, portals that are less one-way, more interactive, and which become integral to the consumers’ thought processes for healthcare information and communications. We must tie these portals to the nascent but burgeoning world of wearable tech and smart phone tools that measure body metrics and provide insights into behavior patterns. Then, we must bring HIT analytics into the mix to enable a massive shift in personal health data that can be aggregated and utilized for both provider scrutiny and patient empowerment. And, it’s imperative that dashboards presenting this info be made human eyes-friendly.

Consumers need a new, friendly, non-intimidating healthcare face. They have had enough of the world of medicine’s non-transparency and egoism. They want to understand health issues without obtaining a degree in medical terminology. The whole patient empowerment movement arose from such needs.

If HIT steps up to help fill that order, consumers will find unprecedented empowerment. When they do, they will begin to spur their providers with new needs to which the providers must, by training and by inclination, respond. If healthcare consumers start expecting easier, more understandable access to healthcare data, if they begin to demand simpler communications via IT, if we all share with our healthcare providers the need to empower us as partners, not paternalized patients, then providers will respond. As I said: that’s what providers do.

The unadopted providers will adopt or die. The unconnected will connect or fail. The old style communicators will learn new methods or face extinction.

HIT can motivate change in consumers that will drive transformation in providers. That’s its next big role. When the men and women both behind and in front of healthcare delivery are playing together in a friendlier and more equitable sandbox, well, that’s when the outcomes needle starts its shift.

From the trenches…

“Step with care and great tact, and remember that Life’s a Great Balancing Act.” – Dr. Seuss

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, an HIT and marketing consultant, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).