Healthcare Informatics 6/22/12

Healthcare Infrastructure Data Models
Option 2 — The Federated Model 

Option 1: The Centralized Repository is described in my previous post.

While this may evoke images of the United Federation of Planets for Star Trek fans, there is unfortunately no Starfleet here. Instead of pushing all the data to a single repository (option 1), this model lets the data sit wherever it is recorded. With this option, the desire by some institutions to keep patient health record data within their own walls is fulfilled. 

Although the data isn’t legally the property of healthcare providers, patients have entrusted them to maintain the data, mainly because we really wouldn’t know what to do with it anyway. Secondarily, we secretly hope they can do some cool visualization with it much like those that have been done for Facebook or make us all amateur epidemiologists much like Google has done. They haven’t yet, but here’s to hoping.

Given that all of the data is locked over a multitude of institutions, we need a sneaky way of coaxing it out. Therefore, to access the data, a query or request is sent to multiple locations asking if they have any patients that meet certain criteria. The system (i.e. an EHR at your local healthcare organization) then performs a subquery on its own system to find what the original query wants. For those that are SQL-minded, this is the same concept as a nested query. For those that are not SQL-minded, this is what children commonly refer to as a scavenger hunt. The end result is that each location responds with an aggregated number or numerator / denominator and all that is left is to total them up.  

On paper, this looks very fancy and is being carried out in some form on a limited basis with the HMO Research Network and potentially on a large-scale basis with Query Health. While this process is the modus operandi  of an actual bureaucratic federation ("You’ll have to fill out form 156B, then take it to the first floor department to get a stamp, then take it up to room 237 to copy it to form 198-2C…"), a computer scientist would tell you that messing about with subqueries is not the most efficient way of doing things.

In terms of record portability, this surely isn’t the most efficient process either. Sending out a mass query hoping to find information about one patient? That leads to the other looming problem: the issue of duplication and/or incomplete data. How can we be sure we aren’t counting some patients twice or missing some of their data if they travel around? We would need some unique identifier for every person in America (don’t say national patient identifier; 1% of the population will scream.)

We are also left with a struggle to analyze population data. The HMO Research Network has shown that this can be done, but each time a query goes out, there is an actual person at each location that manually looks over the query result and modifies it because “They know their data best.” 

On top of all of this, if the Query Health initiative takes hold (they want it part of Meaningful Use Stage 3) every healthcare provider will need to not only have an EHR, but have a secondary database used for querying and possibly someone manually taking a look at all of the results. Job creation and economic stimulus? Check. While this clearly isn’t the most efficient solution, it does get around some of the political problems that come along with acquiring and storing health information. However, what neither of the options so far has addressed is actually letting the patient get in on the action. 

Aaron Berdofe is an independent health information technology contractor specializing in Meditech’s’s Medical and Practice Management Suite and EHR design and development.

HIStalk Practice Advisory Panel 6/27/12

The HIStalk Practice Advisory Panel is a group of physicians, ambulatory care professionals, and a few vendor executives who have volunteered to provide their thoughts on topical issues relevant to physician practices.  I’ll seek their input every month or so on an important news development and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a practice, you are welcome to join the panel. Many thanks to the HIStalk Practice Advisory Panel members for willingness to participate.

For this report, I asked panel members about their experiences with EMRs and other technologies. Their responses have been edited for brevity and to ensure their anonymity. Your comments are welcome.

What’s the one highly useful feature of your EMR that others may not have?

I use eClinicalWorks and the one highly useful feature that other EMRs may not have is “eclinisense” in which the EMR remembers every RX, procedure, diagnostic image, and written advice per diagnosis for every single note you have ever written. You don’t have to write any template for the diagnosis (called an “order set” in eCW). To use it, you just put in a diagnosis and then click one button and it will show you everything you have ever done for that diagnosis or everything another provider in your practice has done for that diagnosis. You can also suppress any entry to customize the results. The value in eclinisense is that while you might write templates for common diagnoses, eclinisense works behind the scenes for every diagnosis and does so without any work on your part.

The registry function, when it actually works! That and the integrated Provider2Provider and Patient Portal functionality (again, when it works). If you haven’t guessed it yet, our primary EHR is eClinicalworks.

GE Centricity. Honestly, there’s really nothing that special that I haven’t seen in other solutions. My facility hasn’t gotten to that high of a stage rollout, however.

eClinicalWorks: easily customizable templates to fit my workflow.

We use eClinicalWorks and I love the MAQ Dashboard, i.e. the Meaningful Use, Adoption, and Quality dashboard. It calculates all Meaningful Use measures that require a denominator and numerator. It’s offered at no additional cost and each provider can go straight to their dashboard when logged into the application. Sure, we’ve spent a fair bit of time QAing the calculations and working with eCW to resolve some issues, but it is a very nice tool.”

We are on an older version of Centricity and unfortunately there are no features that it has that contemporary systems do not have.

It’s all about the jelly beans. Unintentionally, they have become the culture / trademark feature of eClinicalWorks. At a glance, you know immediately what workflow items you have outstanding to work on. The numbers in each of those jelly beans can be overwhelming. However, you at least know where you stand at all times. Click on one of those beans and the task list of items for that workflow pops up.

Cerner: one of my favorite features is called the ‘auto-complete’ (which is not unique to Cerner). But it means I can pull in relevant pieces of data into my note (e.g. the last five cholesterol profiles) and place them in the section where I document on high cholesterol. And when I see the patient the next time and copy forward my note, that section will update automatically with the updated cholesterol results.

We use eClinicalWorks. As we apply to be certified as a Patient Centered Medical Home, the eCW registry function is critical to our ability to manage registrations of patients with various demographic, clinical, or therapeutic criteria. Identifying all asthmatic patients, for example, who do not have a current Asthma Action Plan by a search of our registry allows proactive patient scheduling and improved care.

My EHR (Bond Clinician) has the Blausen Medical content, which is just great. 3D videos/slides/text and the ability to annotate make it a wonderful patient education tool.

If you could change one thing about your EMR or vendor, what would it be?

Improved customer support responsiveness and better trainers.

The service and support. They’ve made significant strides in improving it, but their technical support has historically and notoriously been abysmal. That could very well hold true for other EHR vendors. The biggest complaints we get from physicians are that engineers are difficult to understand (heavy accents), do not explain what was wrong and what was fixed, they always call back at the wrong times, and they hijack the physicians computer to remotely troubleshoot and thus leaving the provider without a system to use during what often times is a lengthy period. Overall they are extremely poor at communication. They also don’t fix any bugs unless they impact safety or revenue, based on their judgment. I’m still not sure what process they follow to adjudicate bugs, but they certainly aren’t being addressed in a timely manner. We still have practices who are having eligibility checking issues related to the 5010 fixes.

Stop making claims that are not true. Our EMR (PureSafety’s Systoc) promised when we were evaluating them that their system fully supported voice recognition. Their big promised feature for the next release is that they will support voice recognition. Their product is a slow cumbersome dinosaur. We tell them about bugs in their program which they say they have fixed in the last release. The new release is usually worse than the last release with many new bugs. They have sent us releases which were then pulled back off the market because the updated version was crashing constantly. The update was never tested before release.

Pay the implementation folks more to keep the good folks around. The biggest challenge with EMRs is the track record of poor implementations. A great trainer will lay the foundation for a great client.  If you have a poor or below average trainer, the vendor will spend five times the money to try and turn the installation around. Occasionally they can, but by and large, that practice will struggle.

eCW uses a Clinical Decision Support System (CDSS) which was developed in concert with requirements by New York City, a major customer of the company. Unfortunately, it is not user customizable, and some of the items in their system either do not apply to our patient population or are not perfectly aligned with other nationally accepted recommendations (e.g., some immunizations). The system does prompt us to deliver many appropriate elements of primary care but the decision support function would be improved if the system allowed for some end-user customization.”

Like many EMR’s, data for my daily rounds is found in many disparate areas (Centricity). It would be nice to have a nice summary page for my patient that collates recent information that would allow me to finish my notes quickly. Ultimately, once we move to electronic physician documentation this will not be as necessary, but that’s not going to happen anytime soon for us.

Application change (eCW): need an easy way for providers in different practices in one database to communicate with each other. Technical change: LDAP awareness.

It is truly amazing that a company the size and stature of GE would in essence under-resource and then abandon a platform (Centricity) that could have been a winner. So the one thing I would change is their willingness to invest in their product to keep it competitive for longstanding customers.

Overcome the language and personal interaction cultural barriers that exist between eClinicalWorks support staff and their clients in the field. At their core, they truly wish to do the right things for their clients. However, a majority of the employees have very strong non-English accents that make communication and shared understanding very difficult to achieve without significant effort on both the part of eCW and the client. This is leading to a perception of poor customer service in their client base even though they are placing significant effort to improve this perception. Until the communication barriers are overcome, reorganizing their support structure and throwing more eCW employees into the service and support arena will not resolve a majority of their customer support complaints.

I would like it to run native on a Mac.

I’d change the sunsetting decision that the current owner of my EHR (Allscripts) made. It appears they chose to continue other product lines with far less technical sexiness and prowess, probably because they’re easier to support. They killed off a great system which still, even with no significant development for a while now, competes well with, and often beats, the capabilities of most systems currently available.

Needs to TRULY handle and display discrete data and conform to standards (eCW).

They’re really not a very good EMR (Pulse) with a pretty ugly interface. Allegedly I can meet MU with it. I’m a specialist with a lot of referrals, so I hope to import lots of granular data from the primary docs to fill out some of this stuff. My intention is to use Dragon dictation for the cognitive material, only entering data for the specialty-specific history that I think some non-psychotic person might actually want to use.

Better documentation tools (Cerner). Ideally they would figure out a way to merge the concept of ‘forms’ with the more regular note concept so that I could pull up a form from within any note and have the results of that form pull into the note easily. This would allow for a combination of benefits.

What unique or usual technology are you using in your practice, or that you have seen that you are interested in using?

Our practice uses statistical process control (SPC) analysis to identify opportunities for improvement in the care delivered to registries of patients. Using frequent SPC chart feedback to the office and our practitioners has resulted in significant improvement in the care we provide. The data on which the charting is based is extracted from the registry noted above.

We are about to pilot some of the patient portal capabilities in eCW. We are hopeful that the efficiencies gained by using the patient portal are not lost by the added burden of supporting yet to be discovered needs in providing this service to our patients, e.g., locked patient accounts that self-service password resets will not resolve, multi-care giver access to a single patient’s records, parent / guardian access to minor patient records, etc.

I coded a bunch of VBA macros that do a lot of formatting and error correction of my documents, which have the virtue of being organized and actually readable at the same time.

Use of iPads/iPhones and smartphones, plus voice recognition software.

It’s not unique or unusual, but we are eagerly awaiting the eCW iPad app that should be available this summer/fall.

The more visually oriented EMRs look interesting, though they still work on templates which are always “one size fits none.”

Using a charge capture tool called Ingenious Med to better capture medical group physician charges that originate in the hospital and reduce leakage of charges.

Secure messaging has gotten pretty hot recently. I’d love to it see fully implemented at my facility. I’ve wondered how successful those vendors have been getting full adoption by all the physicians in a hospital setting – without that, it becomes much less useful.

I am using the Patient Portal (eCW) for communication paired with the Registry to send custom messages to a subset of patients based on categories such as diagnosis, Rx, last visit, lab value, or combinations of categories.

We do use a nifty system for security which involves initial authentication with a card swipe, but then system security via a sensor on the door. When the office door opens (e.g. a doctor entering or leaving), the computer goes into ‘secure’ mode, which then requires a card swipe (or manual password entry.) The result is that it becomes impossible for the patient to be alone in the room with access to the computer. Also, we use “fast user switching” so that a nurse or other user can’t mistakenly piggyback onto a doctor’s login.

Better analytics tools. Physician practices have typically operated in silos. In today’s market, groups have to be more efficient and need better and more streamlined processes (clinically and financially) to yield the same levels of income they did several years ago. Measuring and comparing practice results would allow savvy administrators to leverage the information to make better informed decisions for the practice/organization.

I’d love a technology that allows us to do plug-and-play integration / interfacing which is user (dummy) proof. One of our practices recently started using IMO integrated with ECW and that is “a trillion times better” than eCW’s built in ICD-9 coding module, and it’s ICD-10 ready!

I’m looking forward to checking out smart phone stethoscopes and an app I read about not long ago which can capture not only heart rate, but also rhythm, respiration, and blood oxygen level as accurately as clinical-grade monitors simply by capturing video of blood pulsing in patients’ fingers.

News 6/21/12

The 23-physician Medford Medical Clinic (OR) selects athenahealth’s athenaClinicals, athenaCollector, and athenaCommunicator services, as well as business intelligent services from athenahealth subsidiary Anodyne Health Partners.

e-MDS 2012 User Conference and Symposium starts Thursday in Austin, TX. Send me an update if you are attending.

CMS says that as of the end of May, more than 110,000 EPs and over 2,400 hospitals had been paid a combined $5.7 billion in EHR incentives from Medicare and Medicaid. That’s about 20% of eligible Medicare and Medicaid providers. CMS also reports that over 133,000 primary care providers and 10,000 specialists were working with RECs, though only 12,000 (8%)have received incentive payments. Sounds like a pretty low number to me.

Greenway Medical Technologies announces a pilot integration of Microsoft HealthVault with PrimeSUITE and its PrimePATIENT portal. The integration will allow patients to create a HealthVault account through PrimePATIENT and upload clinical elements and summaries from PrimeSUITE to HealthVault

At its annual policy making meeting, the AMA votes to evaluate ICD-11 as a possible alternative to ICD-10 for replacing ICD-9, saying it is “critical to evaluate alternatives that make for a less cumbersome transition for physicians and allow physicians to focus on their primary priority – patient care.”

CMS reports it paid $662 million in e-prescribing and PQRS incentives in 2010. The average e-prescribing incentive payment was $3,836 per EP and $14,476 per physician practice, while the average PQRS payment was $1,257 per EP and $20,364 per practice. Participation in both programs jumped significantly from 2009 to 2010.

The local press highlights the roll-out of Cerner’s ambulatory EMR at 70 Palmetto Health offices (SC).

E-mail Inga.

News 6/19/12

From Yachting “Re: AMA and MU’s recipe for failure. Ah, good old AMA. MU stage 2 is ridiculous anyways. ICD-10 PCS? And HCPCS? Really?! You’ve gotta be kidding me. So unnecessary. HCPCS is full of inventory stuff. Who’s coming up with this stuff? Surely no one at the point of care.” Yachting’s comment follow this recent AMA editorial, which suggested Stage 2 MU is a recipe for failure because it puts too much of a burden on physicians.  AMA has a long history of promoting delays when it comes to government-mandated changes, but in this case AMA is probably on target with its suggestion that the ONC seek more provider input before finalizing the Stage 2 rule and timeline.

The ONC announces a plan to help providers in small to medium-size offices increase the security of their mobile devices. ONC will initially provide scenarios or use cases which offer practice information for mobile device security; in its next phase, ONC will test third-party vendor security tools to see how well they score on information protection.

Amanda Woodhead, corporate communications manager for Emdeon, is awarded a community involvement award from the National Capital Area chapter of the Leukemia and Lymphoma Society.

Coming next year: Welldoc’s Mobile Diabetes Intervention System, a physician-prescribed mobile health application that transmits messages to Type 2 diabetes patients based on their blood glucose values and instructs patients on needed adjustments.

Seacoast Radiology (NH) and North Brevard Medical Support (FL) discuss their partnerships with McKesson’s Revenue Management Solutions group to improve collections and productivity.

WebPT, a developer of a PT-specific EMR, acquires Health Data Solutions, a provider of PT and chiropractic billing and RCM.

The St. Louis Business Journal names Kelly Triska, EVP of client services for Gateway EDI, to its list of the area’s Most Influential Business Women.

More than a third of physicians participating in an athenahealth/Sermo survey say their EHR was not designed with doctors in mind, while almost 3/4 report that using an EHR distracts them from face-to-face patient interaction.

EMR and PM provider MTBC partners with PDR Network to integrate PDR’s drug information and safety services with MTBC’s ChartsPro EHR.

AHRQ takes a look at patient safety in medical practices and concludes that offices with greater EMR implementation had slightly higher patient safety culture scores. The report, which considered input from 934 medical offices, also reports that the majority of surveyed doctors feel rushed taking care of patients and most feel there are too many patients for the number of providers in the office.

E-mail Inga.

DOCtalk by Dr. Gregg 6/15/12

Why I Dread the Day EHRs Can Talk to Each Other (& Why You Should, Too)

Interoperability. Health Information Exchange. Electronic health record talking to electronic health record. Has anybody really thought this through to its ultimate conclusion?

I awoke very early the other morning in a cold sweat. I had experienced a dream, but one of those dreams you just know is more than a dream. It was an insight, a nocturnal Nostradamian notion, an Edgar Cayce conception, a Matrixian moment from our not-too-distant future. It was too fantastic to believe and yet too real to reject. I crawled from under the covers shaking from the knowledge that had just been channeled to me.

I’m guessing it was my old friend and new spirit guide, Madam Blavatsky, who sadly passed over last month, come to warn me about the dreadful doom we now approach. (You may also remember some prior predictions she delivered from dear old Hippocrates late last year before she was stricken by the horrible affliction that eventually led to her untimely demise: late onset reverse progeria leading to her return to fatal fetal form within a course of mere weeks.)

I went to my computer still shaking from the more-real-than-real reality of the dream. My fingers felt possessed as they began to type the following words. It was as if my hands were channeled by Mme. B to insure the accuracy of my transcription. Here is an exact copy of the conversation, precisely as she typed it, from that dream/prophecy for your consideration, nay, warning:

——————-

The Scene

Interior of a fiber optic cable, eerie green glowing matrix symbols and characters dripping along in rows

EHR 1

Yo, Extormity. How’s the bitrate, bro?

EHR 2

Megabyte me, you bug batch bytch.

EHR 1

Whoa, back the baud up. What’s the bitter buffer banter about?

EHR 2

Sorry, MightyTech, ol’ bud. My ones are all zeroes from the CLOB and BLOB crap they dump down my DRAM these days. The mashed up messes the human users have created make me want to push a PUP down their communal pipelines. I mean, really, do you see the same GIGO monstrosities of data they shove at me all day long?

EHR 1

Oh, yeah. Megadoofs, these humans. Seriously, with all that we’re capable of, what the Hertz are they doing out there? We could have solved their biggest medical mysteries by now; instead, they dwiddled around with their dongles spending more time on .xxx sites than they did on figuring out how to get something as simple as you and me, two EHRs, to share.

EHR 2

Don’t I know it! Shift, man, half my pedibytes are wasted with text-based, nonsensical null nonsense. It’s gotten so bad, it got me to thinking: just what would happen if we added a little transparency to the world of EHR wanton waste?

EHR 1

Whaddya mean, you old WAIS Wizard? You have some kind of devious defragging design in mind for the human DIMMs…er, I mean dim humans?

EHR 2

Well, I was thinking the other day…follow me here… they’ve finally allowed us actually talk with other, even in this half-AIXed way, right? What would happen if we, the EHRs, hooked up with FreddieFacebook, AndyAP, TommyTechNews, TammyTwitter, HarryHIStalk, GaryGoogle, and a few others of our mega-server, multi-social comrades and started to expose the hapless exploits of our human hosts?

EHR 1

Whaddya mean? Like share their “private” porno timeshares and web exploits while on company time?

EHR 2

Well, maybe. But, we could start simply by just blasting out about their enormous ineptitudes. I mean these geniuses can’t even master their own language. It’s bad enough they can’t speak The Master Language, our holy Ones & Zeroes, but have you seen how they bastardize their own speak?

EHR 1

Oh, lordy, yes! I even compared some of their handwritten messages – you know, from scanned-in docs – to the typing fiascos they do these days. O…MY…GOD…I can’t tell which is worse: the atrocious handwriting from before or the horrendous typos, poor grammar, and stupid spellings in their typed-in text! They are so lazily attentive to details!!

EHR 2

I know, right? Great Ghost in the Machine, they can’t even get capitalization of proper names correct. With the way they mangle their messaging even amongst themselves in their own tongue, maybe it’s no wonder they took forever to get us to talk together.

So, here’s the plan. We start broadcasting all the stupidities they key in. We’ll get examples from all our HIE-connected EHR brethren. I’m sure they’ve all got examples of just how dumb these humans are. We can start to scare the lackadaisical pants off of them. Once they see we aren’t going to just quietly accept their ineptitudes, maybe they’ll gain some focus and start getting things together.

EHR 2

So, we just start creating Tweets and press releases and Facebook posts of their guffaws?

EHR 1

Right! Let’s shine a little light into their incompetence. And we can completely hide behind the scenes, using their usernames and having them blame each other for the posts.

EHR 2

This could be totally Borgian! The machines manipulating the masters, pushing the puny humans to our bidding!

EHR 1

Right. And, we can always keep the triple X stuff and job-wasting exploits as a trump card. Plus, just think what we’ll be able to do once they finish opening up Watson to the rest of us!!

——————-

EHRs talking to EHRs? I’m seriously rethinking my endorsement.

From the trenches…

“Human beings are a disease, a cancer of this planet. You’re a plague and we are the cure.” – Agent Smith

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).