DOCtalk by Dr. Gregg 3/30/12

Is the Clinical Narrative Really Dying?

While reading a recent piece by Scott Mace on HealthLeaders Media called Are EMRs Killing the Clinical Narrative, it made me wonder if the clinical narrative is really dying.

It’s easy to look at the typical point-and-click EMR note engine and think that it isn’t capable of catching the nuances of a good clinical story. Most EMRs are designed to capture codable data mainly for the purposes of billing and insurance claims. Many don’t seem to have had the clinical narrative as any part of a consideration during construction. Well, at least not as a big part of the build considerations.

Then again, think back, clinicians (those of you who aren’t recent grads). Remember those med school and residency notes you used to write? They were long, flowing notes that had to incorporate each part and piece of a medical story. They included every pertinent positive and negative that might in any way, shape, or form be part of the clinical picture.

For those of you are primary care providers, now think forward to the transition of your notes over the years. How much of that previous storytelling did you whittle away as your diagnostic skills improved, as your clinical duties increased, and as your confidence grew in your ability to glean the truly pertinent wheat from the superfluous chaff of your clinical notes?

I know my handwritten notes – a few years back before I went digital – sure weren’t anything like my residency notes of yore. I know that’s true for many of my primary care colleagues, too.

I remember chatting with a retired GP a few years ago who talked about seeing 50 to 60 patients per day. He said he could do that, in part, because his notes were as short as he needed in order to remind him of what he really needed to know. For instance, he said a kid with an ear infection got a note that went something like, “ROM – Amoxil” and that was it. Maybe that’s a bit short, but the idea was that he knew his patients and he knew what he needed to see next time he opened each patient’s chart.

These note-taking diminutions don’t apply to you specialists, of course. You guys and gals have truly perfected the art of the clinical narrative telling great, detailed stories, perhaps even better and fuller than those of your residency days. I love getting most specialists’ reports because they do the best job at telling the real “story” behind a medical encounter. They often include the clinician’s thoughts, diagnostic possibilities, and other vagaries. (I admit to feeling a little less than complete when I compare many specialists’ reports to my own typical patient note, whether digital or pre-digital.)

Comparing those dictated medical tales told by specialists to the reports I now receive from many EMR systems, including the biggest and “best” among them, is like comparing a Hemingway novel to a Bazooka Joe comic. Many, if not most, of the current system-generated notes I now see are atrociously limited in detail and almost completely bereft of nuance. They’re often little more than my friend’s old “ROM – Amoxil”. Sometimes they aren’t even that informative.

I don’t know about you, but my EMR notes are somewhere between Ernest and B. Joe. They do have more detail than I used to put into handwritten notes, but they aren’t really great stories. Overall, though, I think they’re better than their primary care pen-and-paper precursors.

Personally, I think we’re in a transition zone and I’m not too worried about the clinical narrative long term. As they advance, tools such as natural language processing, Quippe, and IBM’s Watson will likely reinstate some balance between pure data capture and the art of telling a medical story. I believe we’re trying to figure out the best balance that will enable data aggregation and manipulation while still providing the nuances yet inherent in the “art” part of medicine.

The clinical narrative — the story — with all its important nuances won’t go away. It needs to be told. But, it also needs to be balanced by the needs to find pertinent details quickly in the midst of busy days and heavy patient loads. Plus, information aggregation reveals insights we could never glean without digital data capture. We just need to find that balance point.

Maybe one day Watson and his ilk will enable a Hemingway-esque option while allowing us to breeze through to the gist of the tale with a little Bazooka Joe bubblegum wrapper version if we so desire, giving us what we all really seek: the best information when and how it’s needed.

From the trenches…

“Storytelling reveals meaning without committing the error of defining it.” – Hannah Erendt

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, directs the Pediatric Office of the Future exhibit for the American Academy of Pediatrics, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).

Practice Wise 3/30/12

EMR is the Great Magnifier

Paper processes do an amazing job of hiding practice dysfunction. Many doctors start their independent practices because they want to practice medicine their way. They hire staff to perform the front desk, bookkeeping, and nursing tasks. They provide good patient care. The insurance claims go out, payments come in, bills get paid, and they take home a decent salary, so things seem to work fine for them.

But it is common that there is nobody in the practice who has a strong grasp on process development. Each staff member or team builds their own processes and guards their own turf. The practice runs on the tribal knowledge of staff.

When we assist clinics through their EMR implementation, we first do a process map with to approximate how their paper workflows will translate to the EMR. The staff tells us what their processes are when we are on site to observe their paper workflows. What we ultimately discover is that their actual processes are often so different that we question whether these workflow mapping activities are even fruitful.

When we are mapping workflows and doing on-site training, we tune into the staff dynamics. There is a common disconnect in many practices between the reception staff and the billing office. The receptionists think the billers are nags who don’t trust them to do their jobs and who hoard information from them. The billers think that the receptionists are not capable of getting the appropriate insurance information from the patients to generate clean claims, so they don’t let them complete patient registrations. They often hinder the claims process by hoarding rather than sharing information that could empower the receptionists to be the front line of the billing office.

Then there is the power tussle between the nurses and the schedulers. Schedulers don’t want the nurses messing up their schedules so they ask us not to give them certain appointment booking privileges. Nurses want to control the same-day appointments and don’t want the front desk to have that power over their schedules.

We see these dynamics over and over again and try to address them all the way through the implementation process. Although these dynamics existed when practices went live on various practice management software products in the past, the providers were usually unaware of the power struggles amongst their staff because the PM software rarely engaged them. Now that the providers are engaged in the EMR implementation, these same dysfunctional behaviors are affecting them.

Doctors have their own dysfunctional behaviors that become glaringly obvious when they go live on EMR. When using paper charts, it’s likely that nobody is verifying how they chart, when they chart, or even if they are fully charting a visit. They can complete a fee ticket/superbill and turn it in to billing — a claim gets processed and the paper chart gets filed.

A good EMR will require them to chart appropriate elements according to coding guidelines. I’m amazed when the doctors get mad at us or the EMR product for “making” them chart appropriately. They get mad about how many clicks it takes them to complete a note. Although they are charting more complete notes that protect them and their patients, they want to do it all in three clicks or less, yet make it comprehensive enough to generate a robust letter to the referring physicians and reap the maximum reimbursement.

They often remove items from their paper charts or don’t include information such as lab results if they don’t want to. I’m no longer shocked when practices ask me delete an item entered in error in their EMR. They do not want to see the item struck out, because back in the paper chart days, they just pulled it out and either discarded it or filed it elsewhere.

Striking out that information and noting the correction is the proper thing to do. Simply removing data from a chart has legal ramifications. It’s not the fault of the EMR software that these errors are now being pointed out to both clinic staff and their patients who request an e-copy of their chart or can see their chart on the clinic portal.

Many practices don’t address the underlying issues with their processes or their staff dynamics prior to implementation. It compromises the effectiveness and success of new EMR software processes. We are seeing widespread practice disintegration, and it is being blamed on the EMR software and the EMR vendors. However, the EMR is simply magnifying the existing dysfunction.

Before you throw out your EMR as the cause of all your new problems, consider that the problems already existed but were not visible in your hidden paper processes. Switching to another EMR is not going to solve your problems.

I recommend that all practices that are getting ready to implement EMR:

1. Spend the time and money to have an outside party assess practice leadership, processes, and staff dynamics. Small practices will forego this suggestion because of cost, but productivity losses, staff turnover, and patient dissatisfaction will be more expensive in the long run. The return on investment will be created through greater efficiencies, cohesive staff, and better patient care.
2. Document processes and enforce them from the top down. Everyone has to have skin in the game or it won’t work.
3. Engage in team-building exercises to develop cohesion between all departments, including the physicians. These activities can be facilitated by an outside consultant, or they can be simple activities like bowling together. Bridge the existing rifts.
4. Hold bottom-up staff meetings, allowing the staff to point out their issues and develop their own solutions. Empower them to build team alliances.
5. Pay for extended onsite implementation support. I’m always shocked when an EMR vendor tries to make a deal by cutting implementation days to lower price. Three days to implement a new EMR with all-new processes, even for a one-doctor clinic, is a risky proposition.
6. Define your leaders, empower them to make changes, and develop processes necessary for success. Allow them to lead you. The physicians should be falling in line along with their staff.

The key to a successful implementation and ongoing success of the practice is strong leadership. The person who was promoted from the front desk or billing office to the position of practice manager / administrator, likely does not have the leadership skills necessary to engineer this level of change management.

Invest in your leadership, send your managers for leadership training (or hire an experienced EMR project manager), and empower them to manage change in your practice. If the doctors aren’t willing to make changes, the staff won’t either be either, and your practice will suffer.

Julie McGovern is CEO of Practice Wise, LLC.

News 3/29/12

NextGen enters into a reseller agreement with Nuance, giving NextGen the opportunity to sell Dragon Medical speech recognition software directly to its Ambulatory EHR clients.

Speaking of NextGen, I see they are hosting their fifth annual NextGen Cares Golf Tournament April 23rd in Horsham, PA benefiting the Jayne Foundation.

Online physician networking site Sermo names former Revolution Health president Tim Davenport CEO. Davenport replaces Sermo founder Daniel Palestrant, who left the company in January to run Par80, a start-up focused on improving the patient referral process.

The Centricity Healthcare User Group hosts its annual meeting April 20-21st in Las Vegas. CHUG is not an official organization of GE Healthcare and the group limits its membership “to well-behaved licensed Centricity EMR users, GE Healthcare employees, and a few very polite consultants and vendors of products supporting Logician.”  I wonder if CHUG expects everyone to remain “well-behaved” and “very polite” while visiting Sin City.

Greenway Medical makes its PrimeMobile clinical and financial application available for Android smartphones and table devices.

Cool-sounding technology: Giffen Solutions launches MexCom, a smartphone app that will record, transcribe, and archive conversations. The app also allows physicians to access a patient’s health profile when a patient calls and to e-prescribe.  I didn’t see anything on their Website to suggest it interfaces with a practice’s EMR but otherwise the functionality looks handy.

The American College of Osteopathic Family Physicians names MDdatacor its vendor of choice  to offer the College’s Medical Home Quality Markers program. The program will use MDdatacor’s technology platform for patient data management and reporting  for members seeking PCMH recognition from NCQA.

A physician with Northwestern Memorial Physicians (IL) resigns earlier this month, blaming the practice for “technology troubles, billing errors, and lack of adequate office staffing.” Northwestern, which utilizes Cerner, rejected the resignation, claiming that Dr. David Vigder breached his employment contract and improperly engaged in talks with the practice’s chief competitor, NorthShore University HealthSystems’s Medical Group. Vigder responded through his attorney, providing details of the “severe computer problems” that made communication with specialists difficult. Northwestern has subsequently responded to Vigder with a lawsuit.  Stay tuned.

In an interview on Fox Business, athenahealth CEO Jonathan Bush discusses the need to get doctors to believe in the Cloud; he also shares impressions on the healthcare reform debate.

TransforMED, the AAFP subsidiary dedicated to helping organizations adopt the PCMH model of care, expands its leadership team and staff. In addition to the hiring of several project managements and practice enhancement facilitators, TransfoMED names Barbara Doty, MD and Laura Knobel, MD to its board of managers and  promotes Diane Cardwell to VP of healthcare solutions and Dan McKean to VP of business development.

Two practices within the University at Buffalo School of Medicine select PatientKeeper Charge Capture, which will be integrated with UBMD’s GE Centricity Group Management PM product.

CalOptima REC reaches it 1,000 member enrollment goal for primary care providers.

Email Inga.

News 3/27/12

The 38-provider St. Cloud Orthopedic (MN) selects SRS EHR.

A Maine public radio station profiles EMR adoption by solo physicians, including internal medicine physician Dr. James Raker. Raker adopted an EHR last year to “keep up with the industry” but feels they are more time-consuming than paper and do “nothing” to help patients. Raker also notes that an EHR conversion can be a daunting task for a solo physician and is one reason many are electing to join larger groups or seeking early retirement. Family physician Dr. Paul Wooden adds that EHRs make it challenging to give patients the attention they deserve and make visits less personal. Despite those negatives, Wooden finds EHRs helpful:

“They excel in terms of data capture, of making records available, keeping track of medication lists, allergy lists. They have the ability to check a patient’s allergy list based upon medicines that are prescribing, so that’s a real benefit.”

American Medical News provides some tips for physicians and small practices to ensure that a lost mobile device does not result in a data breach. The suggestions are targeted to providers who don’t have the benefit of a health system or large practice to manage their device security and include:

• Selecting a device that offers encryption tools or security apps
• Using a passcode lock
• Adding remote wipe capabilities
• Enacting required login to any applications that carry personal information.

Former Carefx Chairman and CEO Andrew Hurd is appointed president and CEO of Epocrates. Hurd takes over for Peter Brandt, who will step down as interim president and CEO and assume the role of vice chairman of the board of directors.

Through the end of February, the EHR Incentive program paid EPs and hospitals almost $3.9 billion. Here’s how that breaks down for EPs:

• Medicare payments of over $636 million to 35,341 EPs, including 31,650 MDs or osteopaths.
• $511 million from state Medicaid programs to 24,443 EPs.
• Total payments to EPs: almost $1.2 billion.

February, by the way, was the biggest month ever for EP incentive payments: $326 million to 17,285 EPs.

TRA Medical Imaging (WA) contracts with Zotec Partners to manage the billing operations for its 52 physicians.

CMS informs physicians who were not deemed “successful electronic prescribers” in 2011 that they may contact the agency’s QualityNet Help Desk, should they have questions about this year’s 1% Medicare payment adjustments that will be imposed for failing to meet 2011 e-prescribing requirements. Though the e-prescribing incentive program does not have a formal appeals or review process, CMS has agreed to review concerns to identify any unusual or extenuating circumstances that may warrant further consideration.

US Representative Nancy Pelosi participates in a ribbon-cutting ceremony for Practice Fusion, which recently moved into a new building after completing a $1 million renovation. Pelosi  said that the rapidly growing Practice Fusion exemplifies the kind of innovation that lawmakers had in mind when they passed the Affordable Care Act. Am I the only one who doesn’t quite get the connection between the Accountable Care Act (not ARRA) and Practice Fusion’s growth?

E-mail Inga.

More news: HIStalk, HIStalk Mobile.

From the Consultant’s Corner 3/23/12

Now Is Not the Time to Delay Your ICD-10 Preparation

That sound you hear is an entire industry collectively groaning and sighing. Why? Because the Department of Health and Human Services (HHS) is taking steps to postpone the date when “certain health care entities” must start using the ICD-10 diagnosis and procedure code sets.

Many of those who’ve already started down the path to ICD-10 conversion are groaning in frustration over the proposed compliance delay. You may want to listen to them. The sighs of relief coming from procrastinators should be your wake-up call to keep pushing full steam ahead toward ICD-10 compliance.

It’s like when the college professor gives you an extra two weeks to finish an important term paper. The procrastinators take their feet off the gas, while the A students keep preparing diligently. The latter is exactly what your organization should be doing with regard to ICD-10.

I often compare the ICD-10 transition to pulling off a Band-Aid. It’s going to hurt no matter when you pull it off, so you might as well face the pain sooner rather than later.

Let’s face it. Balancing many priorities — including governmentally-led programs such as achieving Meaningful Use (MU) and 5010 — have been a tall order and an all-consuming task for most healthcare providers, vendors, and consultants. Simply keeping up with the various phases of MU has robbed most providers of the time and resources needed to do ICD-10 impact assessments and project plans. Many of the payers, IT vendors, and clearinghouses are likewise playing catch-up. So while a few major stakeholders have made steady progress toward ICD-10 implementation, most have not.

Lately there’s been talk of a dual track, where some organizations need to meet the original Oct. 1, 2013, deadline for ICD-10 compliance while others get an extension. In a word, that would be disastrous because it would add an extra layer of confusion. Determining which healthcare entities are using ICD-9 and which are using ICD-10 after October 2013 would be difficult at best. But that may be the situation in which we’re placed, so we need to be prepared.

If HHS does decide to grant you a few more months to get ready for ICD-10, don’t squander that time. Put it to good use by continuing to consult with your physicians, payers, and vendors. If they’re behind schedule, hold them accountable. Don’t forget that hospitals and practices have the most to lose from being behind the curve on ICD-10. There can be major disruptions to cash flow, so now’s the time to refocus and get cracking.

You can start by asking yourself these questions:

• Have we done an ICD-10 impact assessment?
• Do we have a project plan and a conversion team in place – one where the roles are clearly defined?
• What are the budgetary requirements which need to be planned for?
• Do our IT partners currently have the development bandwidth for ICD-10 conversion?
• Are our payers and clearinghouses making good progress or dragging their feet?

If the ICD-10 deadline does get pushed back, that doesn’t mean you can start lounging in a hammock. Getting ready for this new coding system is a huge undertaking. Hospitals and practices that use this extra time wisely will have far fewer headaches when the real deadline arrives.

Brad Boyd is vice president of sales and marketing for Culbert Healthcare Solutions, a professional services firm serving healthcare organizations in the areas of operations management, revenue cycle, clinical transformation, and information technology.