DOCtalk by Dr. Gregg 6/22/13

In the Kingdom of Happy Healthcare

Once upon a time, in a land far, far away, Eric Henry Roberts V went looking for a wife. Since he was the prince of the entire Kingdom of Happy Healthcare, he knew he would be able to find a wonderful wife. What woman wouldn’t want to marry the handsome prince and share this wonderful kingdom from atop EHR Mountain within the glorious walls of EHR Castle, the grandest castle in all the land?

EHR Castle had been built by Eric’s great, great grandfather who was known as Pen. He ruled at a time when the land was rife with outlaws and hooligans. At that time, the kingdom was a vast jungle. It was divided into many small lands ruled by warlords and chieftains. None of them spoke in person with the others and they rarely shared. They were the kings of their parts of the jungle and, by a long-held and poorly understood tradition, they all wrote decrees to each other on parchment. Thus, they were known as the “Paper Lions.”

The Paper Lions’ paper decrees had many problems. They were, by tradition, the only way the various tribal leaders spoke with the nearby leaders, discussing treaties and the like, but they were often more trouble than treaty. Their papers were often lost, hard to read, or so poorly written that many a war was started over the years simply due to poor communication.

Pen was one of the Paper Lions, but he developed a bigger vision than his fellow chieftains. He saw the value of working more cooperatively with others outside of his clan. He knew that resources abounded in other areas of the jungle that he could not access. He knew, too, that he held riches within his domain that others would want. He was the first to step away from the Paper Lions and develop a new way of connecting with his fellow warlords. He developed “The Talk.”

Pen figured out a clever way to make messages between tribes more reliable. He strung a network of wires running through the jungle from tribe to tribe. They put their decrees and other inter-tribe messages into little holders and sent them careening through the trees on these long wire pathways. Messages got to where they were intended. Plus, he developed a standard message format that all tribe leaders agreed to use to insure that everyone could read and understand the messages. The fellow chieftains dubbed this system “The Talk.”

The Talk worked. As tribes communicated more effectively, barriers between them fell. They worked together more. They eventually grew together, taming their vast jungle and joining forces under the wise leadership of Pen.

Pen was crowned king of the entire land of Happy Healthcare and adopted the kingly name, Eric Henry Roberts. All the generations since have proudly carried the E.H.R. (version II, II,IV, etc.) moniker.

Now Eric Henry Roberts V needed a wife. The word went out and many a comely woman aspired to his attentions. However, just as he was setting his sights upon the loveliest and gentlest among them, the Kingdom of Happy Healthcare was attacked by neighboring enemies. The attack was fierce and all of Prince Eric’s advisors beseeched him to use his Solomon-esque skills to assuage the enemy. Eric knew what he had to do.

The marauders were from the Land of Efficient Healthcare; they had long argued with their Happy Healthcare neighbors to the north. Eric knew that the ruler of their enemy was a good woman, though she had grown up indoctrinated with family values, values that included a longstanding feud mindset with the Kingdom of Happy Healthcare. No one even remembered what had started the feud, but it has burned ever more hotly through the years as Eric’s predecessors had driven the improvements and camaraderie within their kingdom. Now they had invaded. They were envious of what the E.H.R.s had built.

Eric also knew that the Queen of the Land of Efficient Healthcare had accomplished many of the same feats he and his forebears had; she had banded together disparate tribes within their land and brought peaceful coexistence and prosperity through cooperation and enhanced inter-tribal communication.

He also knew she had an exquisite daughter.

Prince Eric sent a special envoy to Queen Eleanor. The envoy rode non-stop to deliver the message. Eric had used the same message protocol that his great, great grandfather had established years ago with the warlords. His hope was that the message clarity would insure accurate communications between the leaders, just as it had done so many years ago.

This fact was not lost on Queen Eleanor. She understood and she accepted Prince Eric’s proposal; she dispatched her beautiful daughter the very next day.

Queen Eleanor’s daughter arrived in the Kingdom of Happy Healthcare within a fortnight. She dutifully married the handsome Prince Eric the very next day. The warring nations were now joined by royal matrimony and peace was declared.

As the newlyweds retired to the royal bedchambers on their honeymoon night, they noticed that the maidservants had arranged the boudoir with all of the new couple’s personalized accoutrements. One among them stood out to both Eric and his lovely new bride: monogrammed pillow cases with the initials “E.H.R.” on them.

The new bride looked surprised and apologized to her new husband, “My lord, I most humbly beg your forgiveness. My servants have snubbed thee and for that I beg thy mercy.”

Eric was perplexed. “Why sayeth thou so, dear wife?” he asked.

“My ladies in waiting have placed only my pillows upon our bridal bed. They have neglected your royal highness’ seal,” she replied.

Said Eric, “But, dear bride, these are my marks. I fear they have neglected thine.”

Suddenly, as the awareness dawned upon him, Eric realized he knew not the full name of his betrothed. “Beloved,” he asked, “pray, tell me thy fullest name.”

“Why, Eleanor Hermione Rothwell, of course. The same as my mother, and her mother before her, and her mother before her,” she answered. “It is a proud maternal tradition of our land.”

“Aw,” said the goodly prince. “Now ‘tis clear. I see we are both well represented in our chambers as I am Eric Henry Roberts V. The royal ‘E.H.R.’ monograms connect us both.“

Eleanor smiled when Eric then strode toward her with a knowing (and not exactly royal) twinkle in his eye and said, “Let us now connect two lands, two peoples, and two E.H.R.s!”

The moral of the story? When EHRs connect, Happy and Efficient Healthcare finally get it on!

From the trenches…

“To the royal guards of this realm, we are all victims in-waiting.” – Cheshire Cat

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 6/2/13

_HIT Happens

Some days, dealing with HIT and EHRs leaves little to smile about. Those days are great for a little “_HIT Happens” observational humor.

Q: How many EHRs does it take to screw in a light bulb?
A: We may never find out because they won’t work together.

Q: What’s the best use for most EHRs?
A: Obtaining government incentive money.

Q: Why did the EHR cross the road?
A: Because MU said it had to.

Q: How are wisecracking yokels the same as EHR vendors discussing data migration?
A: Both commonly use the line, “You can’t get there from here.”

Q: What did the EHR say to the PM?
A: We’ll never know; the interface failed.

Q: How do you guarantee a loss of EHR data?
A: Migrate to a new EHR.

Q: When is an EHR like a “ball-busting” contagious disease?
A: When it has MUMPS.

Q: How do EHRs make doctors’ lives easier?
A: No…seriously…how?

Q: What do you get when you cross an HIT geek with a clinician?
A: An argument.

Q: Why are HIT experts and doctors so opinionated and egoistic?
A: No, seriously … why?

Q: What do you get when you have twelve HIT pros in a room?
A: Thirteen different opinions about the best way to manage an IT project.

Q: If Johnny has five EHRs and he gives Susie two EHRs, how many EHRs does Johnny have left?
A: Trick question: nobody’s stupid enough to have more than one EHR at a time.

Q: When are you likely to scream at your EHR?
A: Day 1, Day 2, Day 3, Day 4, Day 5, Day 6, (still counting …)

Q: How can you get an EHR vendor’s support team to answer your call for help?
A: You can’t, unless you have their address, some extra frequent flyer miles, and a baseball bat.

Q: What do you get when you take the “E” out of “EHR”?
A: Paper … tons and tons of paper.

Q: How do make an EHR crazy?
A: Ask it to manage immunization rules.

Q: Why did the EHR buy cool sunglasses and a Porsche?
A: Because it wanted to be HIPAA.

Q: Why was the EHR so popular?
A: Because it gave good UX.

Q: What do patient privacy and cloud-based EHRs have in common.
A: Nothing.

Q: Why is a locally hosted EHR better than cloud-based EHR?
A: Baseball bats are ineffective on clouds.

Q: Why couldn’t the EHR find true love?
A: Seriously? Have you ever used an EHR?

Q: When will EHRs achieve true maturity?
A: Stardate 500606.67

Q: What’s the best way to wrap up a long day in front of an EHR?
A: Again, it has to do with the aforementioned baseball bat…

From the trenches …

“We all have [_]hit on our shoes. We’ve just got to realize it so we don’t track it into the house.” – Karl Marlantes

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 5/18/13

Dear Allscripts,

I fully realize that you have bigger fish frying on the Allscripts skillet. Further, you probably don’t really care about what one little solo trench grunt thinks, but I’d like to throw this out there anyway. If it gives you any cause to pause and reconsider any future decisions, maybe that’ll be worthwhile. (Lord knows some Allscripts decisions over the past few years could have benefitted from a pause or three.)

While I know you are aware of most of the backstory, please indulge me a moment for those who may not know it so well as I run through a brief history.

About two and half years ago, you acquired Eclipsys. When you did, you acquired my then-favorite EHR, Peak Practice. (I’ll try to call it Peak Practice, but I still think of it as Bond Technologies’ “Clinician,” which was the original incarnation’s name.) You then built a beautiful set of Web pages devoted to the new “Allscripts Peak Practice” and promised end users that it would continue to be supported.

Not being a corporate insider – and not having fly-on-the-wall transmogrification capability – I have no real clue as to why you decided shortly thereafter to pull Peak’s plug. I was told it was because you had too many products and Peak was more difficult to support, in part because it was so technically sexy. The founders understood how to support it, though Eclipsys certainly had its share of difficulties in learning how to implement it correctly. Maybe the latter colored your go-forward decision. Regardless of the reasons, Peak’s plug was pulled and the Web pages vanished.

At the time of the acquisition, I was working on the Eclipsys design team for Peak Practice’s “Notes 2.0.” (I had moved up the food chain with Clinician, starting with helping the Bond team bulk out the pediatric side of its offering, through MediNotes, and onto Eclipsys. It was a rocky ride, to be sure, but it had really started to get good.) We were fairly far along with the notes engine’s redesign and it was going to be gorgeous! If we’d have been allowed to finish its development, I have no doubt that it would stand up against ANY current EHR for both functionality and user experience.

I know this because two and a half years later, I am still using Clinician…er, Peak Practice. Why? Because frankly, after far too many demos, I haven’t seen much that is truly any better. Most often what I see doesn’t even come close. (OK, I have seen a couple of systems recently that do have some serious knock-my-socks-off wow factor, but, overall… diddly squat.) Most available EHRs/EMRs trail far behind Peak Practice in usability and functionality, if implemented correctly. And this remains true despite Peak having absolutely no development these past two and a half years! If Peak would have gotten development focus in that time … well, I can hardly imagine.

Moving forward, you offered to move existing Peak Practice clients onto your MyWay product for free. Many did. I did not. (Didn’t like it, not one little bit.) Now as you know, you’ve also sunsetted MyWay. If I was one of those poor wretches who had been forced to migrate once and then once again within about two years, I’d be livid – either that or I’d have transitioned into forestry or some other trade wholly non-EHR-related.

Migrating from one workflow to another sucks. Period. Doesn’t matter if it’s a better workflow in the end or not, the transition is still difficult. You know, it’s the whole “providers just want to provide, not become techies or practice redesign experts” thing. Paper to digital, digital to digital – transitioning your processes is an encumbrance, a nuisance, and, honestly, just a pain in the derrière.

Why did I lay out this whole trail of tears? Because I was recently informed that the EDI server which you maintain and which facilitates my e-prescribing and lab interface (for which I had to pay good money to obtain) is to be shut down August 31. I was told I can keep using Clinici…er, Peak Practice on my servers, but will lose those capabilities.

Once you’ve gotten a taste of the future, it’s virtually impossible to consider going back to the meager meals of the past. I want my delicious interfaces. Thus, without intervention or switching to a new system, I’ll be forced into Luddite mode.

Thus, my dear Allscripts, you’ve again left me feeling abandoned and abused. Is it your fault? Not really. You have a business to run and shareholders to satisfy. I get that. But, maybe, just maybe, the decision to tank Peak Practice in place of the now-tanked MyWay was a regrettable decision and one that deserves a revisit. Maybe the following option would be a cause to pause here for a moment to reconsider your choices.

The founder of Bond Clinician once offered to buy Peak Practice back from you. I was told you wouldn’t give it up because you didn’t want the competition. But considering the recent success rate in the outpatient EHR world that you’ve “enjoyed,” perhaps a little creative thinking might be in order. Why not offer Mr. Bond (or anyone else smart enough) the opportunity to buy back the rights to Clinicia…er, Peak Practice, perhaps structuring a royalties deal where you and your shareholders could reap the benefits without worrying about supporting the product?

Sounds like you have your hands full unscrambling some recent events and turning a rather large ship into calmer waters. Perhaps doing the right thing by Peak and letting it go would create some good karma. Besides, do you seriously think competition from a revived Clinician would be something you really need to worry about for the foreseeable future when there’s so much else more pressing on your To Do list? Do you really think letting a great system go to pasture is doing you, your shareholders, or the world of healthcare in general any great service?

Sincerely,

From the trenches…

PS: I know, this is more fantasy than anything, but it was fun to dream just a little.

“You can’t put abandonment and alienation under arrest.” – Carrie P. Meek

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 5/5/13

Dumbing Down and Smartening Up

Both sides of the healthcare provider/consumer “aisle” are talking about patient engagement and patient empowerment these days. The most interesting part of the recent momentum around these agenda items is that there doesn’t seem to be a whole lot of consensus on exactly what those two terms mean nor how they should be addressed.

On the patient empowerment side, people are talking about putting more emphasis on patient-centered care, making the patient the center of healthcare rather than having the provider or the institution or the insurance company or the technology vendor at the focal point. This seems like a no-brainer considering that the definition of “health” according to Merriam-Webster is “the condition of being sound in body, mind, or spirit.”

I’m not sure how anyone could see health and its care as anything other than a very personal, “patient-centered” issue. After all, body, mind, and spirit are unique to the individual. But, debates continue around who controls a person’s health data and how much access or input a person is allowed into their own care.

On the patient engagement issue, most people are focused on tech tools allowing providers to connect with patients and patients to connect with their health care data. This is important, but it seems to me that it’s not unlike the idea of giving everyone an iPad, but one with a DOS-like user interface. How “engaging” would that be? In other words, what good are patient engagement tools if the information and user experience (UX) aren’t “engaging?”

One thing seems clear: people on both sides are talking about making complex health information easier for non-medically trained people to understand. The impact of helping people to understand their health issues has been validated in numerous studies; when people understand their health issues (i.e., when their health literacy is higher), their health outcomes are better.

I’ve long been an advocate of simplifying medical information into “human-ese” to give patients the best chance of understanding complex medical information. I learned this years ago when making my own patient newsletters, back in the days when “desktop publishing” and “WYSIWYG” word processing were big buzzwords. (Yikes! Self-dating!!) Taking complicated health issues and trying to make them easy to understand and hopefully engaging for non-medically trained folks – and to do so for several such topics all on one side of a single piece of paper – was quite the challenge.

But, there are two sides to every aisle. The needs for understandable medical information in lay terms for lay people are quite different from the needs of providers for using medically complex jargon to communicate profession to professional.

The contentions of those who oppose “dumbing down” medical information have some valid arguments. If all of our medical documentation is to be available via patient portals and their ilk, providers fear that taking time to write all their notes in terms simple enough for patients to understand will take an ungodly amount of time. (And, providers’ time is precious enough as it is, what with all the coding and bullet points and mouse clicks and all!) Plus, some providers fear that the communication of professional concepts will be hampered, impeded even, if all of the complex medical terms used in patient records must be broken down into lay terms. (Imagine trying to sum up the tauopathy known as progressive supranuclear palsy – PSP, the cause of actor Dudley Moore’s death – into layman’s language when including it in a differential diagnosis!)

Me? I truly see both sides. I want my patients empowered; making things understandable for them helps that process. But, I also don’t want to see the simplicity of complicated conceptual discourse via sophisticated technical jargon fall prey to vocabulary Luddism.

It would seem that both sides of the aisle are correct. How we address this with a workable meet-in-the-middle approach is the real question. Bringing everyone onto a level health education and medical vocabulary playing field seems silly. Both of these so-called “smartening up” and “dumbing down” approaches have significant hurdles and/or negative impacts.

Thus, I propose a solution for which I’m far too uneducated (and, given my previous self-dating, likely far too old!):

• How about we set Watson, or a whole herd of smart humans and lesser computers, to the task of smartening up natural language processing to the point where I, as a doctor, can type any confoundedly complex medical lingo I want into a patient’s medical record and their patient portal spits out an NLP-derivation in regular old human-ese?
• Oh … and could we also task some UX experts to present that information in patient portals that are actually visually pleasing and truly engaging?

Just a dumb thought, from the trenches…

“I may be dumb, but I’m not stupid.” – Terry Bradshaw

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 4/19/13

The Phrase That Pays

We’ve all heard some radio station running a contest with a “phrase that pays.” You call in or they call you and if you mention the “phrase that pays,” you win a prize. It’s a pretty common promo thing.

Reading a forum thread the other day, I noticed a phrase which really caught my eye. It wasn’t an unusual phrase (nor one “that pays,”) but rather it was a very common phrase that I see used over and over by providers these days. It’s a phrase I’ve found myself using at times and it’s a phrase that I think we all really need to stop using.

The phrase? Well, it’s some form of the following: “…that we are required to do.”

This particular time it was a clinician bellyaching about reducing the number of clicks “that we are required to do” in order to see a patient. I’ll reference neither the particular provider nor the forum; I’m not interested in any bashing. What I would like to do is point out the particularly inappropriate way that we providers have started to bemoan our fate – a fate that we ourselves have chosen.

The perspective which has induced this phraseology is essentially a mental trap, one that is perhaps easy into which to fall. Not all providers have fallen into this trap, but it is a snare into which the vast majority of today’s doctors seem to have been lured.

The trap? Simply this: all of the reimbursement hoops and digital documentation hurdles are obstacles with which we must – I repeat, must – contend.

There is simply no truth whatsoever within this contention.

We as providers are not required to perform clicks. We don’t have to hit bullet points. We’re not forced to follow proper documentation procedures. We actually don’t even need to concern ourselves with structured documentation of patient care at all.

We do all of these things because we choose to do so. We choose to play in the Medicare, Medicaid, third-party-payer reimbursement playground. We choose to accept Meaningful Use monies. We choose to follow SOAP format documentation guidelines. We choose the EHRs we use or at least we choose the institutions for whom to work and, thereby, choose to accept the EHR that they have chosen. We choose to accept these models of reimbursement and these methods of documentation.

We could just as easily choose to employ a concierge practice model that forgoes all third-party payments and, therefore, third-party payment requirements. We could offer our services for barter, for pigs or eggs or maybe handyman or childcare services in trade. We could offer to provide healthcare services for free and use other skill sets to generate maintenance income. We could document in any way felt. We absolutely could make other choices for how we opt to play in the healthcare arena.

Just because the vast majority of us choose to play in the standard healthcare sandbox in no way eliminates the function of choice which we have undertaken. We want the monies, we want to work within the healthcare “box,” and we choose to do so. But, we are not “required” to do so – not in the least.

The alternative? Remember that it’s a choice we’ve made.

Remember that we have all chosen to play within this space. Remember that we have chosen to play by these rules. Remember that we have the option to play differently (though that option may be a tough change to make). Remember that we are all a part of this, that we set the rules together. And, remember that we can change them, too.

We providers are not blameless for the choices we make. We don’t serve at the pleasure of the feds; neither do we function at the whim of EHR vendors. We don’t even serve any institutional or ACO master without consent. As long as we choose to play in the sandbox, we need to remember that the system within which the majority of us have chosen to participate is, in part, of our own making. Bellyaching about it doesn’t do much and whining about things “…that we are required to do” isn’t helping anybody’s cause. It’s simply not a phrase that pays.

A phrase that does pay? Here’s an option that I’m going to try to keep in mind: “I have an idea that might make things better…”

From the trenches…

“There is no phrase without a double meaning.” – African proverb

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).