CMIO Rant with … Dr. Andy

The Problem List: Foe or Enemy?
By Andy Spooner, MD

I love the problem list. But I hate it, too.

I love that I can take a few seconds in the course of clinical care to deposit a problem into a list that ensures that I will not fail to address the matter as care progresses. A patient’s mother says that her child, who is being admitted for pneumonia, has seen a private allergist for an “immune system problem.” She describes no particular symptoms or treatment for this this problem, but she thought she should mention it to me, the admitting hospital physician.

Sounds like something to add to the “do” list. What I need to “do” is to clear up ambiguity and make sure I understand how this issue affects care. So I turn to the computer (yes, right in front of the patient!) and add:

… to the problem list.

(By the way, this is NOT how my EMR records problems. It’s intended to be a vendor-neutral depiction of how one might do it. I used a great program called Balsamiq Mockups—a handy tool when you want to convey a user-interface concept—to make these pictures.)

Later on, after I get a bit more information, I clarify this and add some further detail:

Total time investment: One minute.

Return on investment: This clinical issue is now part of the record and will be part of all future presentations of summary information on the patient. I can pass on this information in handoffs and in record sharing. I can be sure to address it with the patient and family. I can insert it—and all other problems—into my note automatically, if I want, and have instant documentation of the complexity of the patient. I can arrange the order by priority, by organ system, and by whether it is a hospital problem currently.

Larry Weed would be proud.

Another patient comes in with a stack of papers from a referring hospital. I paw through this mound and add a couple items to his problem list:

(I am a pediatrician, after all.)

You get the idea: Every time something new hits my radar, I tack it to the problem list.

Why?

• I can, in the start-and-stop world of hospital care, keep up with all of the issues that affect each patient.
• I can insert all of this information, along with necessary comments, into any note that I write. Instant assessment and plan. Instant support for my E & M code. And no necessity to copy my notes forward, in violation of the latest OIG and AHIMA dire warnings.
• I can go over each issue with the parents, and they can be fully informed of the things I am worried about. By looking at how I have ordered the list, they can tell what I am most worried about, and they might even have some advice for me about how I might realign that ordering based on their own concerns.
• I can sign out to my colleagues by running the problem list for each patient, and I know I have covered everything.
• All the diagnosis codes associated with the problems become available (in my EMR) to select in the billing process. And if the patient goes to an outpatient visit, those codes are also available there.

That’s why I love it. It saves time and ensures that nothing gets missed. It helps in communication. It rises above the tangled mass of notes and results and images to give me (and anyone else who cares) a concise picture of what the patient is dealing with, and how we are trying to help.

It’s a bit like the Getting Things Done approach that David Allen and others espouse, which I’ve been trying to master in my non-clinical work for the past decade. The GTD philosophy is that we are most productive when we move all of our “to do” lists and projects out of our minds and into a system so that we can use our brain for what it is good for (focusing on one thing at a time) rather than what it is not very good at (stressfully juggling long lists of things we need to do). It seems like the problem list might serve well as a way to reduce the stress of having to remember all the things we need to do for a patient, and improve our reliability in taking care of all of those things.

The problem list seems so useful when it’s used well.

But that’s the problem: when it’s not used well, it’s a mess.

Or, more specifically: When the responsibility for managing the problem list is not shared by a broad cross-section of people, it’s a mess. When it’s updated only by a couple of problem-list fanatics like me, it’s great… for a while. But then it falls into disrepair and disinformation in the hands of those who disregard its maintenance. “It’s tedious,” my colleagues say when I suggest that maybe we ought to use this part of our EMR for what it was intended. “Can’t take the tedium.” But copying stuff forward day after day is better somehow? What could be more tedious than that?

As an example of a problem list maintenance problem, consider the following. In March of 2014, I admit a patient to the hospital with this on her problem list:

(I sure hope that this patient has not had continual sepsis for over two years!) A quick click makes this acute problem “Resolved,” but then I notice that the patient has had a dozen ambulatory encounters with this “problem” continually listed as active on the chart over the past 27 months. Wow. And to think the patient could have logged in to our patient portal and seen that diagnosis at any time. Wonder if that would cause any patient/parent concern?

That’s an example of why I also hate the problem list.

Neil Mehta and others hit the nail on the head with a recent commentary in the Journal of General Internal Medicine, EHRs in a web 2.0 world: time to embrace a problem-list Wiki. Everybody contributes to the problem list. No one person is saddled with the tedium. Everyone capitalizes on the information—even the patient. The barrier to the use of the problem list, according to these authors, is that we spend all of our energy creating the note that conforms in the best way possible to the E & M coding guidelines (as we understand them). To a lot of folks, this means blowing in every conceivable fact. Result: Unreadable note. No way to grasp what’s going on with the patient.

I do not blame anyone for wanting to get paid, which in medicine today means creating an E & M-complaint “receipt” for care. But the problem list can be harnessed to help you get paid (by clarifying a rich medical decision-making process), and do so a lot more efficiently, while it also makes our care provision more accurate.

We have to look to –and use — EMR software for the real purposes for which it was intended: a more organized approach to good medical care and medical records. But that’s a harder cultural shift than Larry Weed predicted.

Andy Spooner, MD, MS, FAAP is CMIO at Cincinnati Children’s Hospital Medical Center. A general pediatrician, he practices hospital medicine when he’s not enjoying the work involved in keeping the integrated electronic health record system useful for the pediatric specialists, primary care providers, and other child health professionals in Cincy.

News 4/29/14

Medfusion announces that its relationship with Allscripts has ended “due to unresolved payment disputes.” The termination is hardly a surprise given Allscripts acquisition of the competing JarDogs patient engagement platform last year. Medfusion says it will continue to provide uninterrupted services to the 30,000 Allscripts providers using its products through May 31, 2014; after that time customers wishing to remain on the Medfusion platform must contract directly with Medfusion.

Practice Fusion launches a population health management offering in collaboration with Merck, giving practices a real-time dashboard that compares a provider’s patient vaccination rate with other Practice Fusion providers.

The HIMSS Electronic Health Record Association (EHRA) tells the ONC it opposes the proposed 2015 voluntary certification EHR criteria, saying that by the time the final rules are published there won’t be enough time for vendors to properly code and test enhancements. EHRA also argues that “more frequent certification is not desirable and would be costly.”

AAFP board member Daniel Spogen, MD rants about the administrative hassles of EMR in an AAFP blog post. Among his complaints: EMRs lack interoperability, are not user-friendly, take time away from patient encounters, result in mixed patient outcomes, increase overall costs, and complicate office workflow. I guess his only goal was to fire up his peers since he fails to suggest any solutions and notes that EHR vendors have little incentive to change things.

The Federation of State Medical Boards approves telemedicine guidelines that include a policy to apply the same standards of care for remote medical encounters as for in-person encounters. The guidelines also call for physicians to be licensed where the patient is located; for providers to establish a credible patient-physician relationship; and for an adherence to safety and privacy principles.

Meanwhile, an Idaho medical licensing board has fined a physician $10,000 for prescribing a patient an antibiotic while working for Consult-a-Doctor, a telehealth provider that has since been purchased by Teladoc. The Idaho Board of Medicine sanctioned the physician, who was licensed in the state, for prescribing medicine without an in-person examination of the patient.  A group of  telehealth-friendly legislators are now pushing stakeholders to establish standards for the practice of telemedicine.

Pay-for-performance programs unfairly penalize providers treating large numbers of poor people, according to a panel commissioned by the Obama administration. The panel notes that it is often harder to achieve successful outcomes when treating people who don’t have much income or education because low-income people may be unable to afford medications or transportation to doctors’ offices and the less educated may struggle to understand written instructions for home care and medication use. As a result, the existing payment policies unintentionally worsen disparities between rich and poor by shifting money away from doctors and hospitals that care for disadvantaged patients.

Forty percent of physician practices are looking to replace their existing EHR, according to a Software Advice report. Among buyers replacing their EHR product, the most common replacement reasons: the current solution is too cumbersome and/or integration is needed between applications. Mobile support for tablets and smartphones, e-prescribing, and lab integration were the most desired features among potential buyers. Based on the above time frames, it looks like a pretty good time to be selling EHR if you’ve got a good product.

MGMA Health Care Consulting Group’s Rosemarie Nelson offers insights into the use of kiosks in practices to improve RCM and patient satisfaction and cites several examples of practices that have reduced their claim denial rates and A/R days while also streamlining the patient check-in and registration process.

Email Inga.

News 4/24/14

Greenway Health President Matt Hawkins is leaving the company to pursue “an exciting new leadership position outside of the company,” according to an email sent to Greenway customers Tuesday. The departure of Hawkins, who was CEO of Vitera Healthcare prior to the Greenway/Vitera merger, could be unsettling for any Intergy customers already concerned about Greenway’s long term product strategy. I emailed the company for a comment but have not yet received a response.

Athenahealth resigns from the HIMSS Electronic Health Records Association (EHRA) trade association saying it “never really belonged” since it is neither an EHR company nor a software vendor. In a company blog post, Dan Haley, athena’s VP of government affairs, says that because many EHRA members are unable to meet MU timelines and standards, the organization “consistently urges slower timelines, delayed deadlines, and lower bars” than athena. Given the collaborative ideals of EHRA, I think athenahealth might have been better served to simply say, “we aren’t a good fit” rather than throwing in the disparaging comments.

American Health Network goes live on eClinicalWorks Care Coordination Medical Record for population health management to manage its three ACOs in Ohio and Indiana.

First Med Urgent Care (OK) will implement DocuTAP’s PM and EMR software.

The 37-provider Integrated Medical Alliance (NJ) selects Emmi Solutions to provide multimedia programs for patient engagement.

Forbes profiles Surescripts and its evolution from an “alliance of foes” to its current status as the dominant e-prescribing network. I vaguely knew that the company had been involved in a few mergers over the years but hadn’t realized the extent to which its success is based on the alignment of adversaries. Forbes notes that EHR vendors, who have traditionally been reluctant to facilitate the exchange of patient information, could possibly learn a lesson or two from Surescripts and its creators.

The AMA reminds providers to pre-order the 2015 edition of the ICD-9 codebooks, leading me to contemplate the wide-sweeping impact of the ICD-10 delay. Both providers and vendors are having to reassess everything from training and staffing to marketing and product development. I’m thinking if I were an ICD-10 coding expert I wouldn’t mind having another skill in my back pocket, at least for the short term.

McKesson Business Performance Services adds outpatient and inpatient facility coding services to its coding and compliance portfolio of services.

Navicure adds 300 new clients representing 1,225 providers in the first quarter and posts a 19 percent increase in revenues versus a year ago. Recently added customers include Nemours Children’s Health System (NJ), Western Psychological and Counseling Services (WA), and Arizona Digestive Health (AZ).

Athenahealth reports that 95.4 percent of its participating providers successfully attested for MU Stage 1 in 2013. CMS will release overall industry attestation rates in the next month.

ZirMed introduces Clinical Link, a HIPAA-compliant secure messaging tool that enables ZirMed users to exchange messages and clinical documents with other provider organizations, regardless of their EHR or PM system.

CVS MinuteClinic says it has surpassed 20 million patient visits since opening its first store-based clinic in 2000 and expects to add 150 new clinic locations in 2014.

HHS says two entities have collectively paid almost $2 million to resolve potential HIPAA violations following the theft of unencrypted laptop computers.

Email Inga.

DOCtalk by Dr. Gregg 4/22/14

Multiview: Prime Cut

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

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

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

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

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

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

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

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

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

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

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

But I do. Multiview is prime cut.

From the trenches…

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

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

News 4/22/14

The USA Today highlights the dilemma of rushed physician exams, which creates frustration and tension for both doctors and patients. As long as the pay for performance model dominates the market,  primary care physicians will continue to feel pressured to squeeze in as many patients as possible into their schedule. The implied “fix” is to change the reimbursement model, which will no doubt take time. No mention is made of the how EMRs, patient portals, and other technologies impact the situation, but obviously HIT alone isn’t the cure.

Orthopedists were the most highly compensated physicians last year, earning an average of $413,000. Cardiologists, urologists, and gastroenterologists took the next highest spots while family physicians were near the bottom at $176,000. The same Medscape survey found that 35 percent of employed physicians spend at least 10 hours a week on paperwork; only 26 percent of self-employed physicians spend more than 10 hours a week on admin tasks.

Maine’s HealthInfoNet HIE offers providers access to the state’s Prescription Monitoring Program through the HIE’s portal, giving clinicians a single sign-on to both systems.

Steward Health Care System (MA) selects athenaCoordinator Enterprise to enable care coordination for its employed providers and their patients.

Wikipedia tracks flu outbreaks up to two weeks faster than the CDC, according to Boston Children’s Hospital researchers. Using an algorithm that collected data on how many of 35 flu-related Wikipedia pages were viewed, researchers were also able to identify flu-related activity with 17 percent more accuracy than with Google Flu Trends, which was recently criticized for overestimating the incident of flu.

GetWellNetwork announces details of its GetConnected 2014 conference in Chicago June 3-5.

The CEO of scribe staffing company PhyAssist reports his business has grown from 45 scribes in 2008 to 1,400 today and expects demand to increase as more providers adopt EHRs.

Surescripts awards DrFirst and 31 of its EMR partners that have integrated Rcopia e-prescribing software within their EMR with its White Coat of Quality Award.

An AHRQ report on health information interoperability finds that MU criteria falls short of achieving MU in any practical sense and recommends that Stage 3 be used to advance interoperable health data infrastructure. The JASON report also recommends that Stage 3 require vendors to develop, publish, and verify APIs that allow third parties to build on them with new applications and that EHRs should have enhanced encryption and fraud detection capabilities.

The Society for Adolescent Health and Medicine recommends that EHR developers consider the special needs of adolescents when designing and implementing systems to ensure patients’ access and confidentiality requirements are met. In order for adolescents to realize the benefits of EHRs, providers should also advocate for adolescents’ specific privacy needs.

Email Inga.