Intelligent Healthcare Information Integration 2/5/10

In Defense of Tablets

The good DrLyle recently sent a submission to these hallowed pages in which he stated, “…it is well known that the general idea of using a tablet in healthcare has tried and failed multiple times.” Hmmm…

Now, this isn’t the first I’ve heard of people poo-pooing the pen tablet as less than functionally desirable for doctoring duties. But, it inspired me to offer a defense of our little PT pals, a form factor which works in our office every single day.

Maybe having a desktop PC in every exam room works in an internist’s office, but when I see what the children do (and what the parents let them do) to our beautiful office space every, single day …Hoo Boy! I simply can’t imagine the condition of exam room PCs nor the cost of repair and replacement over time. We have video monitors in recessed wall boxes behind protective Plexiglas panels in each room for patient educational and PR purposes; even those have been pried into. The images of spilled goo and repeated poundings that a desktop would take in an exam room, if unattended by a staffer for even a few minutes, makes me shudder.

Currently, we use Lenovo X200 convertible pen tablets. They fly with Windows 7 and their battery life is much better than the Lenovo X41s we used previously. (Our EHR isn’t completely compatible with Windows 7/IE8, but the speed gain is worth the few glitches or inaccessible items. Besides, compatibility will be full-blown soon and we have a few XP machines around to access those items when infrequently necessary.) We often use them more as laptops than tablets; most of us prefer the regular keyboard and TrackPoint to the onscreen keyboard and pen. Still, the flexibility is there and we do employ all the different configurations at various times.

I haven’t yet seen a data input device — short of a scribe — that works as well as the old pen and paper in a busy, noisy pediatric office. Tablet pens, mice, TrackPoints, voice recognition, trackballs, regular or on-screen keyboards, handwriting recognition — all have their workflow problems. But the TrackPoint and keyboard combination, in our regular day-to-day chaos, works pretty well for us. Voice recognition is becoming a second choice away from the noisy hubbub, though I am admittedly slow getting going with it. (No excuse… just one of those cool things that keeps getting put off while life pressures edge it from the top of my To Do pile.)

It isn’t perfect, our little pen tablet arrangement. But, desktops wouldn’t be either, at least in our world. Plus, we never have an issue with turning our backs upon our patients to address the PC, something a desktop might require and which could sometimes be dangerous with our “rambunctious” clientele.

For now, I stand by — and with — our pen tablets.

From the trenches…

“I know that you believe you understand what you think I said, but I’m not sure you realize that what you heard is not what I meant.” – Robert McCloskey

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

News 2/4/10

Twenty New York medical practices leverage their city-funded EMRs to identify and contact patients needing follow-up care. The Panel Management Program is privately funded with $1.5 million from Pfizer.

McKesson offers special financing programs for physicians adding its PM or EHR solutions, including Practice Partner, Lytec MD and Medisoft. Options include 0% interest for 12 months with 25% down or a $1000 rebate for the first provider and $500 for each additional provider in the practice. McKesson also announces its new interoperability platform,  Practice Partner Connect, which is part of Version 9.3.3 of the Practice Partner EHR/PM solution.

Maine politicians debate passing a $10 million bond to help establish low-interest loans for physicians switching to EMRs. Republican opponents say they don’t want to pass any bond initiatives this year, preferring to defer the decision until 2011 when a new governor and Legislature come on board. One legislator says, “If it’s a good idea now, it can certainly be a good idea next January with the next governor and the next Legislature taking a look at what we should be responsibly borrowing for.” Besides, once the doctors get the money it will take them no time at all to purchase an EMR, implement it, and achieve meaningful use in time to qualify for stimulus funds.

Capario partners with AdminHealth and EHR Live to promote Capario’s revenue cycle management services. AminHealth is a provider of PM and EHR software, while EHR offers an open source EHR.

Diverse Technologies will provide sales representation for Pulse Systems in 10 Western states.

The 79-physician Twin Cities Orthopedics (MN) selects Identityware’s Indigo MD to provide secure identity management and SSO. The solution includes the use of a biometric device that works with the Identityware software.

MacPractice is ready to move several applications to the iPad, including the MacPractice Interface for iPad. The interface sounds like a tweaked version of MacPractice’s existing iPhone application that takes advantage of the iPad’s larger screen. Also on tap: MacPractice Kiosk for iPad and MacPractice Web Interface for iPad. MacPractice is also working on an iPad EMR/EHR application to integrate with its MacPractice MD application.

The folks at EHR Scope blog did an awesome job of summarizing our recent EHR executives series on the proposed meaningful use criteria. If you missed the series, the EHR Scope article succinctly outlines the bottom line opinion of each executive to each question. It’s interesting to see what vendors share similar philosophies on certain topics and who provided the more unique perspectives.

If you are on the fence about employing voice recognition, you might want to check out CMIO magazine’s overview of different options and potential benefits. The common themes are faster turn-around and better workflow. If you follow HIStalk you might have seen that Mr. H is a new Dragon Naturally Speaking convert and is trying to convince me it’s worth the $70 to get on board. Heck, I need faster turn-around times and better workflows as much as anyone so maybe I should pony up.

If you are still not convinced about speak recognition, Dr. Steven Schiff provides a compelling argument for employing EHR, along with voice recognition software:

It’s only by joining electronic health record technology with voice recognition that we can ensure patients are able to fully understand and participate in the digital care process. Moreover, this coupling will allow physicians full access to a patient’s story and enable them to base their decisions on both their knowledge of medicine and on the history of that specific individual.

In Haiti, Dr. Elizabeth Cote of Harvard Humane Initiative, demonstrates how volunteer physicians and nurses are using mobile technology to help patients. In this clip Dr. Cote inputs patient data using an iPhone and an digital medical assistant application called iCharts by Caretools.

The ONC wants to learn more about how EHRs affect patient satisfaction with their medical care and will solicit opinions from 1,700 patients. The ONC will survey patients from 84 primary care practices using EMRs.

E-mail Inga.

News 02/02/10

From DrLyle: “Re: More thoughts on iPad. On one hand, it is well known that the general idea of using a tablet in healthcare has tried and failed multiple times. On the other hand, I do appreciate that the Apple iPad is lighter, easier, cheaper, and has better battery life… so it is closer to the ideal we need.  I think that the outpatient world (of 2-3 stable exam rooms and sitting with a patient, where a single doctor inputs most of the data) is usually better served by the traditional PC and keyboard and large screen… while the inpatient world (different room for every patient, multiple providers who may be putting in smaller parts of the record) may be a better initial entry for this portable of a device, with the caveat that the use of gloves may be a negative factor. But more importantly, we must remember that the iPad is not magic one way or the other, it is still simply a tool… it will be up to innovate vendors and providers to make it something special in healthcare… and at this time, most EMRs and implementers have not been particularly innovative in using this format – so we’ll see if this changes the game!” DrLyle shares some additional insights on the iPad here.

AAFP tells of four separate physicians who claim EHR has improved their practices’ efficiencies and improve quality of care. One doctor said his group charges patients $25 a year to access their records electronically. I don’t know what shocked me for: that a practice would charge for using what I suppose is a patient portal, or, that 80% of the patients are participating.

I suppose this practice could charge for the new iPhone app they’ve developed, but for now it’s free. Caduceus Medical Group (CA) creates its own app that allows patients to email physicians, schedule appointments, request prescription refills, and get directions. The app also includes links to the practice’s blog and health-related topics. The group plans to make the application available on other platforms, including Blackberry, Palm Web OS, and Android.

Wolters Kluwer Health introduces a new iPhone/iTouch application that facilitates CME credit for clinical research done online. The physician can use the XtraCredit application to document online medical research as a learning activity. Users also note in XtraCredit the search experience and the approved resources used. The physician pays five dollars and receives CME credit.

Quality Systems, parent company for NextGen, reports a 14% increase in quarterly revenue compared to last year and flat EPS. The market wasn’t impressed, and the stock price slipped from $60/share last week to $52.76 at Monday’s close.

Wayne Health Physicians (NC) selects Docs Billing Solutions to provide Ingenix’s Caretracker EHR, PM, and RCM software.

Iatric Systems, a company specializing in providing interface services to MEDITECH hospitals, partners with Aprima to provide EHR/PM software. Iatric will focus on providing Aprima’s application to physicians affiliated with MEDITECH hospitals.

A Minnesota family practice physician, tired of insurance companies and red tape, starts his own cash-based practice that also offers house calls. He relies on a simple Web site and a barebones EMR to run his Timewise Medical practice. I like his approach to setting prices: $35 for one ailment, $54 for two, and a tongue-in-cheek recommendation to get a physical if you have three problems. Sounds a heck of lot simpler than insurance eligibility and authorizations, co-pays, and patient responsible balances.

Here is a new take on telemedicine. Medicine at Work provides employers with an on-site clinic for employees. A paramedic helps with vitals while a physician “examines” the patient using telemedicine technology. Employers pay for the service with a fixed per-employee, per-month fee and presumably reduce sick leave time. Patients win because they no longer need to leave work and drive to see a doctor about a rash, respiratory illness, or other minor ailment. I think I’d use it.

Medflow, a EMR vendor dedicated to eye care physicians, appoints Ippolit C.A. Matjucha, MD as medical director.

Forget meaningful use, certification, and privacy concerns. As much as anything else, physicians fear they’ll sink tens of thousands of dollars into EMRs that don’t work properly and the  vendor doesn’t (or can’t) make things right. The Huffington Post mentions a number of companies that filed bankruptcy, leaving their clients paying on loans for products not fully functional or never received. Am I the only who remembers these names: Acermed, MedComSoft, or Dr. Notes?  Lesson learned is that buyers need to conduct due diligence before taking the plunge.

E-mail Inga.

Intelligent Healthcare Information Integration 1/31/10

And In This Corner…

Boxing: the Sweet Science. Evidence of pugilistic contests can be found in ancient Sumerian, Mesopotamian, Minoan, and Egyptian art. The ancient Greeks record codified rules for fisticuffs and the onset of boxing as an honored profession.

Early pugilism in the more modern era had no written rules. It wasn’t until 1743 when Jack Broughton (Broughton’s Rules) and later John Chambers, in 1867, with the more widely known Marquess of Queensbury Rules, established some guidelines for what is to be considered “fair” when pounding upon another person that fist fighting began moving from bare-knuckled brawls to a sophisticated “science.”

These days, healthcare, and especially healthcare IT, could use some similar systematic set of statutes for what’s fair and what’s considered “below the belt.”

We are all only too aware of the titanic 15-rounder going on in Washington over healthcare reform. Some days it is difficult to tell who the inevitable winner will be … if any. But, in the subset of healthcare known as HIT, a couple of more sinister-appearing brouhahas are bubbling with just as much venom as that within the ring of the I-495.

As we move closer and closer to the onset of a digital national health Information network, the concern over who gets to play in whose sandbox broils more vigorously. This is a concern not only of those whose health information is being digitized for broadcast, but also for those who hold the dossiers.

As reported recently by Patty Enrado in Healthcare IT News, “Competition and lost revenue are keeping communities from participating in health information exchanges…” At the Regional Healthcare Stimulus Exchange Conference in San Francisco this month, one audience member argued that when it came to medical information sharing among healthcare providers and provider systems, “workflow issues [are] miniscule compared to the politics among providers.” Getting data-holders to share their data (play nice together in a shared sandbox) may not even be amenable to financial incentives. Tom Williams, executive director of California’s Integrated Healthcare Association suggested the state government may have to “’twist some arms’ and apply a stronger hand.” (Punch)

On the end user side of healthcare, consumers aren’t all that hep to trusting their personal patient portfolios to anyone, either. As Andy Greenberg noted in his recent article, The Next Health Care Debate, on Forbes.com this week, a study by the data privacy watchdog Ponemon Institute, shows that “Americans registered a deep distrust of anyone in either the federal government or private industry who might store digital health records…” Only 27% say they’d trust either the feds or a techno giant such as Microsoft or Google with their health records. Folks are much more inclined to let hospitals or their doctors store their info (71%) and are just fine with their personal doc having access to nationally stored data (99%). As Larry Ponemon commented, “There’s a lot of angst around centralizing this information, no matter whether it’s managed by private enterprise or government." (Punch, Punch)

This data will eventually be shared, I have no doubt. Systems and institutions will learn to “let my people” go and find ways to provide profitable healthcare services with mutually accessible data. Consumers will learn that the advantages to a reasonable sharing of their health data, in an as yet undefined and hopefully secure form, will lead to otherwise unobtainable individual as well as communal benefits.

Until that future day, I’m keeping my left up and my mouthpiece in. (Bob and weave)

From the trenches…

“To me, boxing is like a ballet – except there’s no music, no choreography, and the dancers hit each other.” – Jack Handy

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

HIStalk Practice Interviews Neil Zimmerman

Neil B. Zimmerman, MD is a physician with National Hand Specialists of Baltimore, MD.

Give me a bit of background on your practice.

We, my partners and myself, have a very, very large hand practice. I think we might be the biggest in the country. In fact, I know it’s the biggest in the country at the present time. We’re affiliated with the National Hand Center in Baltimore. My office, which is nine physicians — we’re all hand surgeons.

“Hands” is a bit of a misnomer, but hand is the entire upper extremity, fingertips all the way up to the shoulder. We are a combination of orthopedic and plastic surgery specialists who just do upper extremity stuff, but that can involve arthritis, nerve compression like carpal tunnel, a lot of microsurgery or tissue transfers.

The way that the practice works is that it’s a very, very high volume practice; on a typical day starting at 8:30 a.m. until about 5:00 p.m., I see somewhere between 40 and 50 patients and I do that three days a week. My partners’ practices are similar.

Needless to say, we were anxious — beyond anxious — to even make a transition into electronic medical records of any type, simply because of the volume. It is a complex practice; it’s not cookie cutter as far as these patients. A lot of them are second, third, fourth opinions. A lot of them are legal matters that require all these long reports that we have to write.

We were highly trepidatious about a lot of the programs that were out there. The physicians were totally maxed out as far as what we could do seeing patients. We did not have, physically, any face-time available for the patients.

My office manager, another person, and then myself looked at a lot of these different electronic medical records systems. Every one of them came in there and they said, “Well, here’s what we can do for you. We can do this template, and that template.” I said, “Time out, hold it. My job and what I’ve been trained to do, and what I enjoy doing and how I really make a living is not the clerical or support end of this. It’s my face-to-face time with these people and being able to listen to them and care for them and interact with them.”

I said, “If I’m just going to be doing a template here, there’s no way I can do what I want to do.” I said, “We need somebody who’s going to respect that.”

These folks from SRS came in there and said, “OK, our job is to let you guys do what you do. We’ll figure out the rest that goes with it.” It probably took nine months, six to nine months. We talked to the transition team. They called and we had conference calls. We dissected the way that everything in our office moved. From patients getting in the door until me seeing them and taking care of the notes. We were, at that point, doing regular transcription; and we discussed how the transcription came back and how it was routed it and everything.

I’m sure as every other medical group, we had one or two guys that were interested in making a change and seven guys who weren’t. Some of which were vehemently opposed to the electronic medical records of any type. We had long, extensive planning on how to move forward through this. Instead of trying to intimidate people into using it, we used the carrot approach. I started with the guy who sits next to me who was also upbeat and really up on the thing.

We went from having a group of nine people who didn’t even want to be in the same room with any electronic medical records to try and decide who would be next to get on the band wagon with doing this thing. It has worked out extraordinarily well for us.

We were real careful, as far as our integration, inasmuch that I didn’t want to do everything. I figured we could just get up and running with our EMR system and hold off on the e-prescribing. I’m an orthopedist mainly, so with additional radiography we’ve got coming this upcoming year, we just didn’t want to do too much for fear of breaking it down.

Among orthopedic practices, we had heard so many nightmares. It’s like, “Oh my God, I can’t see patients,” the doctors are saying. “We’re not doing this, forget it, I’m outta here. Just let me take care of patients and take the thing out of my office,” and that kind of stuff. So we were really worried about this thing, but it has worked out just great for us.

What is it that SRS did differently than the other programs that you looked at?

What they did is they looked better from my point of view as a physician. This sounds arrogant, but reality is that it has to be doctor-centric. It has to be based upon me being able to see my patients and take care of them without really changing a lot of what I do in order for me to continue to provide the care I wanted.

For me to sit down, sit in that room, and pull down a bunch of pull-down menus and click-in boxes and do all this typing — that’s not what I do for a living, nor do any other doctors that I know. A lot of people in the hospitals have EMR systems like that and the physicians all dread doing it. But I still carry my digital Dictaphone in my pocket. I see my patients, I crack out my dictation very expediently, and I’m in with the next one. Then my stuff comes back to me, all my paperwork and my labs and everything.

But I’m very, very mobile now. I never know when I’m done with surgery. Some days it’s 1:00 p.m., some days it’s 4:00 p.m., but I just said, “Okay, I’m out of here,” because I can take my laptop, or I can even use my home computer and just VPN into our system and I’ve got every piece of paper that I can if I’m sitting in the office. For me, it got me out of the office today — I was done at 1:00 p.m. — it got me out about three hours earlier because I wasn’t sitting doing all my stuff there, which I normally would be, or taking home all those charts.

How do you interact with the EHR? What type of information are you looking up? And what information are you actually keying in?

I’m keying in very little, looking up a ton. I have it with me at all times. I have a tablet when I’m seeing patients or when I’m in the operating room. I go and I look at it before I even talk to anybody, to review their medical history. I mean, I know what procedure I’m doing, but I don’t remember all the little details like who’s allergic to what or exactly what the numbers of their nerve studies were.

I go to the computer, I look at their name, and I remember what their nickname is. If they’re allergic to something. And then I go out there and I look like I’m a genius. They’re like, “Oh, you remembered I go by Cookie” or something like that. So I make all these little notes to me.

Then when I’m done with my surgery, I dictate my notes. That will come back within a day. Then all I have to do is just quick-sign it because I dictate it to myself. I don’t have to proof it. Some of the more complicated reports that I do, like medical/legal stuff, have three or four pages. I have these IMEs that come with a list of questions from attorneys or insurance companies. I do a bunch of those. I see them in the office and I dictate my report.

A couple days later, it comes back into the SRS system and what I do then is I open up the document, and it opens up into Word, and I edit it. I mean, the regular routine carpal tunnel or kid with a wrist fracture stuff, I don’t need to edit. But these legal ones that someone’s going to be looking at with a yellow highlighter, I go through it word by word and I edit it and do all my other stuff. Then I take the edited document, I send it to my secretary or whoever, who sends it to whoever wanted it. But I can do all that stuff at home now, which is so much better than sitting there doing it on paper.

What practice management system do you use?

We’re using Misys now. We have all kinds of different Misys systems. Do you want to hear how we got to the SRS thing? Because we originally were going to do the Misys EMR. Misys scared us because we were a real early adopter or accepter of their practice management system. They said, “Oh, a couple years we got coming down the line with EHR, you’re going to like it.” They brought it in. I probably looked at it three times. Every time they brought that thing in there it wouldn’t work.

Then they kept saying, “You can do this, you can do this, you can do this.” I said, “I don’t want to do this.” I said, “I want to do what I do.” He was like, “Well, if you use this you have to make a template and do all this stuff.”

Then we went and looked at a couple other practices that were using that system successfully, but it just wasn’t fitting for us. I’m sure it’s fine for some people or for some kind of practices. But surgeons in particular, I think — again this sounds bad; forgive me — there’s a little bit of the personality … it’s a little more of an aggressive personality. It’s like OK, I’ve got to operate on these people, this is the way I want to do it rather than kind of ‘I’ll go with the flow’ thing. I mean, you wouldn’t want a surgeon that came in and said, “Well, I think I could fix this.” You go, “I can fix it.” It’s the same kind of thing. They want the system to work the way they did it.

So anyway, that’s our long story. We’ve been up and running now for 15 months, I think.

Do the SRS and Misys systems integrate?

It’s been great. It was far less of an issue than I thought. It downloaded the demographics from the practice management system. We’re buying a digital radiography system. I looked at a lot of them, but I wanted one that SRS would stand behind. They are marketing one now called Fusion. Reason being that as much as it just totally integrates and slips into that thing and the startup was so good with the EHR thing, I said, “If we’re doing it, these people did such a good job before. This is the one I want to go with.” Next couple weeks we’re changing — some of us are changing — to Dragon as far as with digital dictation. That’s going to be a change for me though.

Did it concern you at all that the SRS is not CCHIT certified?

CCHIT, what’s that?

CCHIT? I guess it didn’t concern you if you’re not familiar with it! It’s a certification that will likely be required in order to get economic stimulus money.

No, and I’ll tell you why. I thought about that, at length, and the information that you’ve got to provide to get that stimulus. First of all, I don’t see how I could ever do that in my private practice because one of the requirements is that I have to be able to distribute to my patients information about preventative care.

It’s like, that’s just one of them, but the information that would be required for me to provide would require probably, a substantial part of another employee, which would override the $40-some-odd-thousand that we would make, if we even get it back, from that stimulus money. So I said, “Forget it.” I said, “It’s a good idea, but it’s cheaper for me to not worry about that and move forward than to try and comply with what they wanted out of that.” So, no, that does not bother me one bit.

I was concerned at first. I go, “What the hell is this all about?” Then I realized and I did some more checking and I go, “No, I don’t want to do that anyway.”

What kind of return on investment have you seen so far?

Probably minimal to none, and I think that I’m about as busy a private practice as you can get, I think. I think the reward is going to come later, but if you’re really honest with the money that you’ve got to put into an EHR, it’s going to be a negative investment for quite a while.

We have not eliminated any employees. We’ve transitioned filers to scanners. We’re going to redo our office, at some point, to have more patient care space, which I actually think is going to translate into money. I’ll tell you what will eventually translate into money, but it’s somewhat non-tangible, and that is that our billing efficiency has gone up, I think in part due to this because we no longer have to play where’s-the-chart to do the billing.

I was worried when I started this that I wouldn’t be able to see as many patients, but my productivity actually went up. But it’s really hard to quantitate that, and that wouldn’t apply to all practices. But we’re lucky enough to have to turn people away. So if we could see more, it’s great. But if we weren’t running ‘at mass’ appointments already, it wouldn’t ever come to be.

Last question here – why do you feel that EMR adoption continues to be so low among physicians?

Honestly, physicians are scared to death; and we’re scared to death about the healthcare thing coming down. We don’t know whether we’re going to get cut big time, or we’re not going to get cut — temporarily. A lot of physicians feel very much under fire. This is the first time in my 23 years of practice that I’m looking at a pretty dismal outlook for the upcoming year as far as income. Even if I see as many patients, I think I’m going to make less money with the same productivity level. That’s the number one reason.

But if you want to turn the clock back to before that whole stuff started, the main reason is it’s expensive. We’re nine people. It’s a nine people, high-volume practice and it costs us a lot of money. I think that’s something awfully large to bite off for a private practice. Especially if you’re really honest and say, “What’s the short-term return? What’s the long-term return?” It’s huge, just because of your productivity and not filing your stuff. Right off the bat, nobody’s writing you a check; you’re not going to see anything back on it. It’s a long-term bond.

I could tell you what some of my partners said. It was, “I’ve been doing this for 30 years. I’m not changing for anybody what the hell I do.” I mean that was a real common one. It’s like, “Screw this. What do I have to spend money for?” Those of us that prevailed said, “OK, long-term, in order to store our files, we’re going to make more money. It’s going to be more lucrative if we do this thing electronically.” But they’re looking for a check that’s not coming.

I hope I don’t hurt anybody by saying that about the return on investment, but that’s the truth. The return on investment is short. I’m not going to tell you you’re going to make a lot of money on it right away, but eventually — maybe.