DOCtalk by Dr. Gregg 10/4/13

Well, Tit My Tat

TIT: Meaningful Use implementation has become “detrimental to the very patient population it is designed to engage and empower.” (From EMR & HIPAA – Mandi Bishop)

TAT: Since its onset, MU has stirred a bazillion more providers and provider organizations out of their entrenched paper bunkers than all the glam and glitz and overpromises of the entire EHR industry. Patients can’t see the rewards of MU implementation until providers are truly using meaningfully. (They’re just starting to do so.)

TIT: EHRs, with all their required clicks and dropdowns and menus and pop-ups take sooooo long to navigate; they take up too much provider-patient time.

TAT: Try and document to the same degree with paper charts – making the output legible, mind you – and retrieve the same info you can via even a poorly designed EHR. How long did it take your staff to find the paper chart you needed? How long did it take to look up those drug-to-drug interactions in that ten-pound PDR? (Could you even read the tiny print?) How many times do you require patients to fill out those same, stupid paper forms and how long does that take?

TIT: Getting patients to understand the patient portal, plus getting them enrolled, takes an enormous amount of time away from patient care.

TAT: Getting anyone to do something new takes effort. If you’re providing them a quality patient portal that gives them self-care value, aren’t you actively engaged in patient care as you help them engage? It’s like teaching someone to ride a bike; it takes some time at first, but once they’re off on two wheels, they won’t need you anymore and will be wheeling happily away to a happier, enabled future.

TIT: Referring a patient – finding the provider’s HISP address and sending the Summary of Care document via Direct – takes so much time and even then the system doesn’t always work right.

TAT: Go ahead. Refer a patient the old-fashioned way. Send them without supporting documentation. Send them with minimally legible paper records via fax or snail mail. Send them with paper records tucked under the patient’s arm (still just as minimally legible.) It may save you time, but what about all the redundant discovery time it takes the specialist to discover what he/she doesn’t get from you or that he/she cannot decipher in your records? Duplication and redundancy and repetition and reiteration and replication and recurrence of effort is such a waste. Plus, the specialist probably charges a lot more for their time, thus the healthcare system as a whole just spent more money covering this superfluous labor. Talk about not working right.

TIT: MU has stalled the innovative spirit of the EHR industry.

TAT: Have you seen the number of new EHRs, new HIT tools, and the new developments in many legacy systems of late? Could innovation have been faster without MU? Maybe, but if the marketplace was still where it was back in 2009, would the industry be growing with just a 17-20% provider adoption rate?

TIT: Lots of providers are starting to balk at moving forward with MU – 17 percent by some accounts. MU has just become too cumbersome.

TAT: Turning that around a bit says that 83 percent of providers are still planning on MUving ahead. Let’s see then…17 percent using an EHR/EMR versus 83 percent trying to use one and do so with some connected purpose…? And some people say MU hasn’t made much difference?!?

TIT: MU isn’t right for everyone.

TAT: What is? How can you design anything, especially something on such a grand scale, which works well for everyone? Hector’s pup, even the iconic iPad isn’t right for everyone.

TIT: MU penalties will hurt those who don’t adopt.

TAT: Yep. Haven’t seen anything that’s worthwhile that doesn’t have some pain associated with its birth.

From the trenches…

“We’re still in the birth pangs of this giant HIT baby we’re all trying to deliver.” – Dr. Gregg

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 9/16/13

Cannoli and Crowdsourcing

In a recent post, I discussed the “take the cannoli” attitude that pervades certain segments of the HIT world. Several very kind comments via email about that post plus a recent “event” caused me a mental revisitation of the concept.

The event is the HealthTap “Summer 2013 Top Doctor Competition.” This has brought a slew of emails to my inbox. Several a day from the HealthTap promo peeps, in fact, which in their seemingly never-ending thrust to inspire my participation, have actually ended up causing me to react quite contrarily.

Lemme ‘splain, Lucy.

I was a very early HealthTap contributor, and because of those early efforts, I’ve continued to grow a certain “presence” in the HealthTap community via the social network, grown upon my early input. I say “early input” because it has been quite some time since I’ve engaged with the HealthTap platform to any real extent. I haven’t provided any new answers to medical questions or attempted to spread my online presence there in quite a while. I wasn’t 100 percent sure why I hadn’t continued participating with the HealthTap platform until I got hit with the cannoli, so to speak. Their recent email onslaught clarified my reticence.

The key concept behind HealthTap is crowdsourcing. They have created a platform for consumers to interact with healthcare providers that is free for all. (So far!) Consumers ask brief questions and doctors from all around provide short, non-patient-specific answers. Providers can also throw out little snippets of medical wisdom and knowledge that are available for all to search and see. There are followers and networks; there are contests and award badges – all the typical social network fun is there in a fairly nice-looking tool.

One conundrum re: HealthTap has been that of time. If I spend time providing expert knowledge or answers to questions there, it means I’m not spending time elsewhere – not with my family, not chillin’, not doing something that generates income, not in our local free clinic, not blathering on HIStalk Practice. While garnering a sense of “I done somebody good” is not an ignoble thing, in this situation it is a very impersonal sense of do-goodness. It isn’t like helping a friend, a family member, a patient, or a neighbor.

Now, I have no qualms about helping folks unknown – and I hope I have, at least a little – but what the recent overkill of HealthTap Summer 2013 Top Doctor Competition emails has done is to confirm my suspicions that my do-good sensibilities are being manipulated. (i.e., I think I see somebody taking my cannoli.)

HealthTap thrives via provider input. In fact, they’ve scored millions of dollars in investor capital based solely on the value of the provider expertise they’ve accumulated. But, unless you’ve nothing better to do, a provider gets zilch from the investment of time and intellectual property save a sense of trying to do something good. (Well, that and a digital wall full of contrived digital “awards.”)

With this new contest, I’ve recently been receiving several emails every day trying to inspire my further contributions so that I can “win” in their summer games. These emails are obviously auto-generated and daily conflict with themselves and the website’s own ranking telling me I’m in some #1 or #18 or #2 “Top” spot, all on the same day. Maybe I’m wrong, but I’ve started to feel a little put upon. I’ve started to feel more manipulated than inspired. I’ve started to wonder why I should spend my insufficient spare time helping the HealthTap hierarchy make millions when all I get is a badge. (“Badges? We don’t need no stinkin’ badges!” comes immediately to mind.)

If HealthTap is making money off my years of costly training and even more years of garnered health experience and all I get is a good feeling (OK, and a badge), isn’t that essentially a “take the cannoli” slap in the face?

There are probably lots of good folks at HealthTap, and I realize I’m not endearing myself to them here. I also know that lots of my colleagues likely disagree with my take on this. To be clear, I don’t have anything against the overall concept of making good, concise, and easily readable health answers freely available to consumers. But I’m sorry; I think too many companies are getting in on this whole “take the providers’ experience and knowledge and leave him or her naught but a thank you – or a badge” concept. (EHR vendors have been doing this for some time – taking their provider users’ experience and input to help create a more saleable product, often paying nada for the contributions.)

We’re in the healthcare realm here. It isn’t akin to asking a consumer what they like or don’t like about a refrigerator or toaster; consumers typically have no expertise nor vested interest in the value of their insights. OK, maybe they hope they get a better toaster someday, but, they generally haven’t trained for years as appliance design gurus. In the healthcare space, this is taking formally acquired know-how and profiting from it, with no remuneration to the expert.

In this particular instance, consumers get help while HealthTap gets money. The least HealthTap could do is share a little of that profit with the professionals they rely upon to generate both the resources and the profit.

If you’re going to make money off our (providers’) efforts or expertise, please have the courtesy to share. Healthcare doesn’t need any more vultures. Providers are getting squeezed enough as it is.

In other words, leave us some cannoli.

From the trenches…

“He looks like he’s just been told there’s no cannelloni in the world.” – Phil Stone

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 8/30/13

Take the Cannoli

“The Godfather.” What a classic film. Just chocked full of life lessons, some would say. Unfortunately, they’re not the life lessons most moms and dads would try to instill in their children.

You know, things like, “Violence is an acceptable solution to your problems,” or, “If you cross the family, you’ll get whacked,” or even, “It’s OK to spray grandpa in the face with pesticides.”

Watching it with my Sicilian wife the other day – yeah, that’s right; she’s “connected,” so watch your step, pally – a line popped out at me that rang a sad HIT bell. Rocco Lampone and Pete Clemenza are driving along with traitor-to-the-don, Paulie Gatto, toward Paulie’s unbeknownst whacking. Pete says he needs to “take a leak” and has Paulie pull to the side of a country road. As Pete whizzes, Rocco whacks. Paulie slumps over the wheel, minus some of his brain. Pete zips up and walks back to the car telling Rocco to “Leave the gun. Take the cannoli.”

They leave Paulie and the instrument of his demise for all to see. The message is clear: the Corleone family will not tolerate traitors.

But there’s more than this. Leaving the gun shows their confidence, their arrogance that they can’t be touched. Taking the cannoli adds the “this is all just a part of the job” flavor to the message.

“We whack who we want and we keep the sweets.” This appears to be the take home message that far too many of the HIT “family” have garnered from “The Godfather.” It is becoming ingrained into some vendors’ unwritten corporate philosophies and become part of their modus operandi.

Take, for instance, Practice Fusion’s recent opt-out approach to sending emails to patients, addressed as if having been sent from the patients’ own doctor or other healthcare provider and asking patients to review and rate their provider. Regardless of whether Practice Fusion notified their EHR users via email (I’ve signed up for their EMR – though I don’t use it – and never saw such an email) or whether they wrote about it in their blogs or forums, it seems many providers were unaware that these emails were being sent on their behalf. Thus, the real benefit of these emails is obviously not for the loyal PF-using providers; the real benefit of these ratings is for PF, i.e., the cannoli is theirs.

If this wasn’t a bullet to the head for the providers, why wouldn’t they use an opt-in system instead? Do they think they are wiser or more caring about the patients that these providers serve than the providers themselves? Do they really believe, as they said in response to one blogger’s (John Lynn) recent post about this, that they are the correct arbiters to administer a patient feedback program “designed to provide your practice with a controlled, quality channel for accurate patient reviews”? Who provides this control? Who insures the quality? Who judges which reviews are “accurate”?

Seems to me that PF is a Rocco and their providers are Paulies (though Paulies who hadn’t turned out their boss to any enemy). These PF loyalists took a shot from behind and PF walked away with a cannoli in the form of nearly two million reviews that likely helped bolster investor interest.

I’m oversimplifying, I’m sure, and I’m not intending to pick on PF. There are loads of examples of non-healthcare folks (and some from within our midst) stepping into the healthcare IT space, taking what they could get from it, and walking away with some seriously sweet green cannoli, i.e., cash, that is ultimately generated by the labors of healthcare providers.

To us providers, if you take our money, we are making an investment in you. If we commit to the use of your tools, we are establishing a trust with you. If you take our dollars, or our good faith, and walk away – whether by acquisition, merger, or business failure – you are leaving us in a lurch, often a very expensive lurch from which to “unlurch.” If you take our efforts and then profit from them while leaving us with naught but the “you did a good deed” pat on the back, you have essentially stolen from us.

There are numerous HIT vendors, healthcare websites, and other such Roccos that come to mind, but my mission is not to point fingers or even ask for any cannoli back. My motivation for writing today comes from the mere hope that my colleagues – doctors, nurses, PAs, NPs, etc. – will begin to see that all of our so-called “helpmates” in the HIT space are not always goodly intentioned. They may mouth off about serving the greater good, helping providers or patients, and facilitating improved care, but all too often it appears that C-suites are C-suites; they care more about the cannoli than the caregiver – or the cared-for.

We need to watch our backs…and our cannoli.

From the trenches…

“Leave the gun. Take the cannoli.” – Pete Clemenza, in The Godfather

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 7/26/13

The Kicker

Blogging sometimes seems like an extended version of tweeting. You blast out your thought(s) du jour to a largely unknown crowd and respond to those folks who happened to read and whose buttons you happened to have pushed. Blogging just involves longer thought trains than tweeting. It’s sort of the interim step between being a full blown (i.e., real) writer and a tweeter.

But sometimes it gets bigger than that. Sometimes, through the interplay of commentary, you learn something cool or you connect with someone you might otherwise never have met. That’s the really fun part — the kicker — to being a part of the blogosphere.

I got just such a kicker recently. Actually, I got a double kicker, though not through my own blog ramblings this time, but rather via the “Comments” section on another.

Those comments were left by Dr. Andrew Schechtman. He shared a bit of his group’s experience as they searched for an EHR. I found his comments on this — and on the current state of affairs of EMRs/EHRs — to be well written and insightful. He seemed a bright light, so I looked for and found him on LinkedIn. I sent a message asking him to chat. We connected via Skype shortly after.

I’m in Ohio; Andrew is in the San Francisco Bay area. I was in a tee shirt and at home as it was later evening for me and I had just hung up from a two-hour conference call. I was tired and hadn’t even had a chance at dinner yet.

Andrew came onto the video call with his stethoscope still draped across his neck. In dress shirt and tie, he closed his office door and said he was just wrapping up patients. I wasn’t sure how this would go since I was beat and his brain was probably still processing the day’s patients and workload.

We started off with the obligatory ”how do you dos” and the “here’s where I come from” stuff. But it didn’t take long to forget my fatigue (and my stomach growls) as the conversation turned to deeper stuff. (Well, “deeper,” if you call HIT “deep.”)

What I found most enjoyable was the demeanor that Andrew exuded. He was an obvious geek, yes, but not in an outwardly obvious way. He was calm, easygoing, considered, and pleasant. He had a good sense of humor and laughed gently. I would wager that his patients would say, “He has a good bedside manner” – confident, but not cocky; caring without being overbearing; lightly delightful.

(Sorta sounds like a man-crush, doesn’t it? Ack. It’s not intended that way; he was just an impressive fellow.)

The first kicker for me (from participating in the blogosphere commentary) was meeting this enjoyable fellow a half a continent away. The second kicker was something he told me while we Skyped.

Andrew was describing his experience with looking at EHRs from various vendors. All the same stuff you hear: too cumbersome, too little “stuffings”, too expensive, too much resistance from his partners, etc. At one point, he had actually adopted one of the better known “free” EHRs and started documenting his encounters even though the rest of the group was still on paper. (He documented digitally and then printed his notes out to stick in the group’s paper chart folders!) But then he started talking about the EHR that he eventually adopted for his group.

He said they had looked at ElationEMR back in 2010 and decided to walk away from it (seeing it as one of the “too little stuffing” EMRs at the time.) About a year later, just as they were just about to go with one of the more widely adopted EHRs – one of the biggies – they decided to give ElationEMR one more look. So much had changed in this startup system, in lots of good ways, that they opted to put their faith in the newbie.

They adopted and implemented. Andrew got the front office up and running with minimal training. In fact, pretty much the entirety of the staff’s training consisted of a little seven-minute Camtasia video he created. (He granted me permission to share it with you, FYI.)

The staff was up and running. Period.

On live day one, after similar minimalistic training, he challenged his partners to “just do one or two patients with it today.”

That day – go-live Day One – with no schedule adaptations, the partners were also up and running, most having documented all of their first day’s encounters on the system. Not just one or two patients, but all of them.

Let me repeat that: not just one or two patients, but all of them.

No downtime. No reduced numbers to accommodate training and workflow adaptation. No major fuss or muss.

That was a real kicker for me. How many EHRs can really and truly be incorporated into a busy practice’s workflow with such little disruption? It’s nice to know it is possible.

Nice to meet you, Andrew, and thanks for the inspiration.

From the trenches…

“The sad thing is he’s a good kicker. He’s a good kicker. But he’s an idiot.” – Peyton Manning (on Mike Vanderjagt)

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 7/12/13

The Nightmare Just Off Elm Street

SETTING: Nowhere, Ohio. Park Avenue Medical Building and parking lot, just down from Elm Street.

SCENE: A dark and stormy night.

CAM pans from Elm Street and Park Avenue corner street sign to an empty parking lot as rain beats down relentlessly. CAM moves toward the Park Avenue Medical Building. Building windows are dark save for one lit window on second floor. CAM slowly moves toward it. CAM zooms in through rain-drenched window to posterior of a lone man, PROVIDER, hunched sadly over a laptop PC. Lightning strikes and thunder rolls. CAM moves over his shoulder to focus on laptop screen. View of an electronic health record entitled “Extormity” comes into view over PROVIDER’s shoulder.

PROVIDER sighs heavily and sinks even lower into his chair.

PROVIDER
Cripes, even the big ones with all the bells and whistles suck. (PROVIDER sighs again.)

CAM pulls back to reveal a translucent, ghostly figure fading into view several feet beyond laptop, facing PROVIDER.

GHOST
Woooooooooo…wooooooooo. (Chains rattle somewhere OFF CAM.)

PROVIDER barely budges as he wearily looks up to GHOST. GHOST looks a bit dismayed.

PROVIDER
Dude, I’ve been looking at EHR demos for hours every day and night the past six weeks trying to find a new one. You gotta do way better than that if you want any kind of scare factor. I’m pretty much scare-sapped at this point.

GHOST
Aw, man! This is my first gig as a ghost. I thought I had the training down. Shoot, you’re really messing with my new ghost confidence.

PROVIDER
Sorry. I didn’t mean to poo-poo your poltergeisting. It’s just that weeks of going cross-eyed looking at all these EMRs and EHRs and PHRs and PMs and patient portals and all has me fully strained and drained. If you think some booing and chain-clanking are scary, you should see some of these monstrosities.

GHOST
Really? You mean computer stuff? I’m sort of a computer guy…well… I was when I was alive. That’s rather disturbing to hear. Computers should be cool and helpful, not draining. Lemme see. What’s the problem?

GHOST floats through laptop and PROVIDER to stand behind PROVIDER.

PROVIDER
(Shuddering.) Whoa…that was a little freaky.

GHOST
Oh, yeah, that’s a pretty cool part of being dead!

GHOST peers at laptop. He lets out a low, rumbling noise, like a belly growl.

GHOST
Ugh. Really? That’s the state of EHRs these days? I can see why you’re stressed, my man.

PROVIDER
Yeah. Tell me. And this is actually one of the better ones, at least for functionality.

GHOST groans again, a deep, unnerving snarl.

GHOST
You got any others I can see? This is pathetic.

PROVIDER
Sure. (Pulling up another tab on his laptop screen.) Take a look at this one. It’s one of the more popular ones. Well, “popular” at least in terms of sales. Most of the users I’ve spoken with, though, don’t seem to be so impressed.

GHOST
What a mess! Look at all those lines and columns and rows. Looks like the old Windows 95. Look at all that clutter. There’s nothing intuitive about it. This makes it look like EHR folks have learned nothing about user experience measures.

PROVIDER
Yeah. Most keep promising that their “next UI” will be “really awesome,” but few have figured that out beyond a sales pitch. Here’s one that does a little better.

PROVIDER pulls up another tab on the laptop. A more eye-catching EHR pops open.

GHOST
Well, that’s pretty. Sophisticated, clean, looks smart. What’s wrong with that one?

PROVIDER
Not enough “oomph” in the tank. Has a pretty nice UX – nice until you actually have to dig into the meat of care provision matters. Lots of missing functionality. Would takes a ton of time to customize to our needs. And their billing system is pretty woeful. It seems like you can get some of what you want in all of them, but none of them have all of what you want, or even all that you need.

GHOST
Too bad. And too bad I’m dead. If I was still alive I would jump feet first into this. I had no idea the development was so horrendous of such important systems. Electronic health records should be leading the way for IT creativity and functionality. I mean, really, they are at the crux of some of the most important needs for humanity. I can’t believe their design and dev work are so behind the times.

PROVIDER
So, who are you anyway…or who WERE you before you started your new chain-shaking role? How do you know anything about computer UX and UI work?

GHOST
Oh, I forgot. You probably don’t recognize me in un-earthly form. (Extends a ghostly hand.) Hi, I’m… er… I WAS… Steve Jobs.

PROVIDER attempts to shake hands, but hand passes right through.

PROVIDER
Figures. I finally get with somebody who could actually do something about the state of EHRs and he’s a ghost. And not even a very good one. I need a drink.

GHOST
Wish I could join you. By the way, how come you’re not using a MacBook?

From the trenches…

“Maybe I should just pick up that bottle and veg out with you; ignore everything going on around me by getting good and loaded.” – Nancy Thompson in A Nightmare on Elm Street

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).