How to Quell Physician Discontent with EMRs

How do you quell physician discontent with Electronic Medical Records (EMRs)?

Easy.

Have the leadership of your physician organization interview the National Coordinator for Health Information Technology, then make sure your physicians read the spin.  This is one of my favorite excerpts:

Q: Many physicians are not seeing the expected financial return on investment after EHR implementation. Why is that?

A: How you implement the technology has a lot to do with the results you achieve. (ed: Now, note how he dodges the question) But the bigger issue is how the compensation system is designed. If physicians are operating in a fee-for-service environment, then many of the gains of EHRs -- for instance, in quality, safety and patient engagement -- aren't reflected in revenue. Physicians are doing more work and delivering better care and service, but the added value is not reflected in the reimbursement. (ed: Okay, that's what we said: we're seeing lower pay, not higher, despite doing more and more meaningless data entry work with EHRs.  We are often not finding return on our investment with the additional work.  Why are you now addressing nebulous issues with physician payment reform? Could you stick with the question, please?)

We've been an advocate for making sure that when value is added, it's reflected in increased physician reimbursement whether it's through the patient-centered medical home (PCMH) setting (ed: Alas: no. It is impossible for the Coordinator to stick to the question.  Now we're on to Value-Based Purchasing. WTF?  Doctors aren't PURCHASING value, dammit, we're providing CARE!), value-based purchasing or part of an accountable care structure. That's where the ability to manage information -- not just for individual patients but for populations (ed: Remember dear doctor, it's not about you and your patient, EHRs are about the population manipulation!  Huh?)-- becomes an absolute necessity, because in those models, it's not a question of whether there's a return on investment with electronic health records. (ed: Yes, dear Coordinator, in case you forgot, this WAS the original question)  A physician can't function in those models without an EHR. (ed: Really?  Since when?)

If you can stomach more, go on over and read the whole thing.  (And consider leaving them a comment about how you really feel about this spin).

There.  You're a believer in in all things EMR now, right?

Doctor?

Doctor?

-Wes

Ninety-six Buttons of Choice on the Wall

"Ninety-six buttons of choice on the wall,
Ninety-six buttons of choice...
Take one down, pass it around,
Ninety-five buttons of choice on the wall..."

Seriously, are all these action buttons on today's EMR's necessary on the main patient care screen? Increasingly, more and more action buttons are appearing - so much so that we even have to scroll down "below the fold."

EMR developers should take a page from Google: keep the main screen for the management of patient care full of plenty of white space.

Yours in IT consultancy -

-Wes

Query This

Why is it, with all the billions of dollars poured into health care information technology, that doctors can't query the information they hammer in to the computers themselves directly? Is it because our hospital administrators are scared of what we might find?

I am constantly amazed that I can't even query my work volume statistics. Despite the thousands of diagnosis and procedural codes that I have to enter on a computer to get paid, I'm not allowed to find out how many pacemakers I've performed for sick sinus syndrome versus complete heart block. I can't determine how many atrial fibrillation ablations I did last month without asking an administrator to "pull the data" for me.

Medicare gets the data.

The billers get the data.

Why can't I?

Should patient care information be valued less than billing data?

Don't get me wrong, there are plenty of good things that highly integrated electronic records can do for patient care, but seeing that doctors are the ones providing the care, shouldn't we be able to query, without restriction, any and all fields available pertaining to patient care? If I can program an Excel spreadsheet on my laptop to perform a nearly infinite number of queries, whay can't our billion-dollar electronic medical record companies make it just as easy for those providing the care to do the same?

Who knows, maybe we'll be able to find some improvements as a result.

Or might the potential that we find that all those information technology jobs are inefficient just too threatening to those in charge?

-Wes

Orson Welles: Meet the New York Times

The news grows more frequent and increasingly ominous as a cylindrical meteorite lands in Grover's Mill, New Jersey. A crowd gathers at the site and events are related by reporter Carl Phillips. The meteorite unscrews, revealing itself as a rocket machine, and onlookers catch a glimpse of a tentacled, pulsating, barely mobile Martian before it incinerates the crowd with Heat-Rays. Phillips' shouts about incoming flames are cut off in mid-sentence. (Later surveys indicate that many listeners heard only this portion of the show before contacting neighbors or family to enquire about the broadcast. Many contacted others in turn, leading to rumors and confusion.)

The War of the Worlds Radio Drama by Orson Welles Plot Summary
This 1938 coupe was a classic example of how mainstream media can manipulate their audience. As we all know, these examples continue today and should serve as a powerful reminder to medical students, residents, doctors, nurses and ancillary health professionals how all sorts of instantaneously-available information, be it health care information or otherwise, can be shaped, manipulated, processed and pureed.

Want an example?

How about this: once again, the mainstream media's darling, The New York Times, gets punked.

-Wes

REPROGRAMU Results Released

PRESS RELEASE – FOR IMMEDIATE DISTRIBUTION

Chicago, IL – 29 Oct 2010 (AP): Results of the three-year REPROGRAMU trial (Realtime Evaluation of Physician Reactions to Organized Group Affiliations and Meaningful Use) were released by Dr. Benditt Throckmorton, MD, noted board-certified psychiatrist and principle investigator of the trial. The trial studied 3142 physicians’ attitudes regarding the implementation of “corporate group think” and a newly developed prerequisite called “meaningful use.”

“I was surprised to see how many doctors no longer feel meaningful,” said Dr. Throckmorton. “Depression, anxiety, and psychotic measures were at an all-time high as doctors searched for the cause of their ennui,” he said. When asked why this might be, he noted that while this was only preliminary research, the requirement to feel “meaningful” by e-prescribing, addressing quality measure checkboxes that pop up unrelated to the patient’s complaints, handing them a piece of paper they throw away, and reporting their patient’s race to the government might result and the “pile-on” of potential patient dissatisfaction scores that might result from NOT attending to their patient’s needs. “When the government comes first, it’s hard for doctors to feel meaningful for the care they provide,” he said.

Thankfully, it seems there might be help on the way. “We’ve found that forming Meaningless support groups really helps,” Throckmorton said. He also noted that recent preliminary studies have also found that “low-T” might be contributing to the condition. "It seems the symptoms of Meaningless Use Syndrome (lack of libido, lack of energy and enjoyment of life, and reduced, um, ‘height’) are similar in both conditions,” he said. “Our ongoing ‘T for TWO’ trial performed with Solvay Pharmaceuticals should help answer this question. If we find they correlate, then perhaps just a small injection will help male AND female physicians feel more meaningful soon.”

* * *

-Wes

Good Morning, Doctor

A conversation between man versus machine at 6:30AM:

What's the computer doing? It's just sitting there.


I don't know. Give it a minute.

(A minute passes.)

Screw this. I'm logging off and starting over again.


"Log Off!"


"OK."


What the...? *Sigh*

-Wes

The Electronic Medical Record and The Challenges Ahead

For those who have not seen it, one of the better discussions on the achievements, limitations, and future challenges of the adoption of the Electronic Medical Record can be found at the blog of Howard Luks, MD, The Orthopedic Posterous in a guest blog by R. Vaughn, MD. Be sure to read the comments from some very informed patients, IT experts, doctors and even, yes, yours truly.

Although long, you'll learn something.

Not bad for an ortho guy...

;)

-Wes

Gray Papers and Health Care IT Cost Savings

If we want to see where the money in health care is going, look to the stock market. Cerner, one of the big players in health information technology, has seen its stock soar 50% so far this year, much of it from the federal stimulus package. This is part of the grand plan to save costs in health care, after all: why ask questions? If we just pour a few more billion dollars to health care information technology, we're sure to see lower costs, right?

So this got me wondering, where did this "cost-saving" mantra come from?

Much of it comes from the backing of a single 2005 Rand Corporation research “study” that concluded "if most hospitals and doctors' offices adopted [health-care IT], the potential savings for both inpatient and outpatient care could average over $77 billion per year."

So I had to look this study up. Who is the RAND Corporation? How was the study done? What measures did they use? Is this conclusion of $77 billion on cost savings realistic?

The RAND Corporation mission is "to help improve policy and decisionmaking through research and analysis." In other words, it is a political organization. Importantly, it's so-called "research" is funded from federal, state, and local government agencies provide the largest share of the funding; however, RAND also conducts projects for foundations, foreign governments, and private-sector firms. Contributions from individuals, charitable foundations, and private firms, as well as earnings from RAND's endowment, offer a steadily growing pool of funds that allow RAND to address problems not yet on the policy agenda. As they say, they're a "think tank." They THINK they are doing research, I guess.

Here's the "highlights." Big "studies", you see, need highlights. (Other more politically-minded individuals would call them "talking points," but I digress.) If one reads these highlights, we note that there is no "Limitations" section, a standard section of any reasonable research study that mentions reasons why a study's conclusions might not be valid. Nope. These conclusions are absolutes.

And I'm still looking for the funding "disclosures." Can anybody tell me who funded this particular "study?"

But a little digging and we find these "methods:"

The RAND team drew upon data from a number of sources, including surveys, publications, interviews, and an expert-panel review. The team also analyzed the costs and benefits of information technology in other industries, paying special attention to the factors that enable such technology to succeed. The team then prepared mathematical models to estimate the costs and benefits of HIT implementation in healthcare.

Wow. Talk about a mish mash of data! I really have no worries now! Forget bias. Forget objectivity. Just throw everything in to a pot and, voilà, $77 billions of savings!

But it doesn't stop there. It seems much of the basis of this data came from "gray literature" (their words, not mine) defined as "the body of reports and studies produced by local government agencies, private organizations, and educational facilities that have not been reviewed and published in journals or other standard research publications." Most of us would call these "white papers" produced by industry, but when their blended with one's own politically- or industry-supported research and cost savings are extrapolated to make a political point, the papers become "gray."

Recently, there has been a flood of "investigations" in to conflicts of interest between researchers, their academic institutions, and the medical device and pharmaceutical industries by Congress. But I find these supposedly "independent non-profit organizations," funded by industry members of the insurance, information technology and pharmaceutical industry including Unitedhealth, Wellcare, Aetna, Blue Cross of California, Genentech, Amgen, and Intel (to name just a few) more insidious and covert. They promulgate messages that are not peer-reviewed, but peer-pressed into the media, government, and create policy decisions that we assume (naively) are unbiased and truthful.

Baloney.

-Wes

Why I'm Pessimistic About EMR Integration

Take a look at the major health care IT vendors. They're all working feverishly to collect, collate, process, and puree your health care information, billing codes, insurance carriers, hospitals, quality assurance mandates and red flags, etc.

The prize?

To become our national health care IT system. To own it ALL!

Now look at the pacemaker industry in the US.

Three big companies. All promoting their pacemakers.

Each manufacturer's pacemaker computer is unique to their pacemaker models, but does the same job: they each "talk" to their respective pacemakers and tells them how fast or slow to go and how much energy to use to do the job safely. To do this, they use "protocols." Protocols are closely-guarded trade secrets.

And so as a fellow, when we did not know which manufacturer's pacemaker was installed in a patient's chest, I could not bring a single computer to talk to the pacemaker inside a particular patient. Instead, I had to push a huge cart carrying multiple computer programmers to the patient's bedside, each with their own special printer paper and programming heads, to interrogate the patient's pacemaker at their bedside.

Recall that the first pacemaker was developed in 1949. Since that time, the basic design and construct of pacemakers has become fairly standardized. Sixty years have passed. Today, do any of these pacemaker companies' computer systems talk to their competitors' pacemakers?

Of course not.

Share protocols? Are you crazy? That would compromise their intellectual property!

You see, it's really not about what's good for the patient or doctor.

It's about the money.

'nuf said.

-Wes

Health Care Information Giants Like the Auto Industry?

Rick Peters, MD over at The Health Care Blog thinks so, describing them as "a few large players who build big, expensive systems on outdated technology platforms."

Ouch.

-Wes

h/t: Dr. Bobbs via Health Care BS.

On Cell Phones and Remote Diagnostics

Imagine the day where your Bluetooth headset, coupled with a cell phone on your waist, might transmit a text message to an emergency room that you're having a heart attack or cardiac arrest. The text message would contain your GPS coordinates and notify an ER and ambulance dispatcher automatically.

Far fetched? Well maybe not.

But the implications of such technology are not trivial. Would resources exist to respond to all the messages received? What would the battery drain be on such a cell phone device for such monitoring? How does one confirm that the device is not sending a false signal? What are the steps after a message is received - call the patient or do we just send the ambulance to reduce the "door-to-balloon" time? Who will man the telephone 24/7? How will they be paid? Are funds best allocated for damage control like this, or prevention of the heart attack in the first place?

While there might be a role for such services in patients identified at high risk for cardiac problems, deployment of such technology to the population at large might overwhelm our already understaffed ER's.

What is interesting in this story, however, is the potential for delivering therapy (not just making a diagnosis) in patients with previously-implanted cardiac pacemakers and defibrillators using wireless technology. Medtronic, St. Jude, Boston Scientific and others already have wireless platforms available for their defibrillators that feed information from their devices to a central server for doctors to review on-line to assess device function and the treatments delivered. What if the doctor could review an event real-time and program a device remotely to respond in kind?

This ability may not be far off and offers a dazzling array of potential for remote therapies as well as diagnostics: imagine remote-controlled drug therapy or the ability to reprogram the device to prolong battery longevity without the patient having to make a trip to the doctor's office. Likewise, if a previously undiagnosed arrhythmia arises that can be managed easily by repramming the device remotely, maybe we could save a few more trips to the emergency rooms.

But similar issues remain as with the cell phone mentioned earlier - reliability of internet connections and wireless transmissions, the problems with battery drain on the device for such computer-monitoring overhead, reimbursement for such "therapy-delivery" expertise by the "treating" physician? Is it safe to do in the first place? These are just a few.

The potential for significant medical cost savings and patient convenience might just drive this bus. And if these engineering and logistical issues for such technological therapies can be resolved, it will be a whole new era in medical device therapy.

-Wes

Photo credit.

Dragging My Heels in Healthcare

Intel’s Chairman Craig Barrett thinks I’ve been dragging my heels about using information technology in healthcare.

Hmmmm. Dragging my feet over something that represents hours of unpaid labor and exposure to litigation… What could I be thinking?

Yesterday in an interview by CNBC’s Maria Bartiromo at the World Economic Forum in Davos, Switzerland, Mr. Barrrett blamed the medical profession for lapses in implementing information technology in the healthcare arena in the area of chronic health management.

Bartiromo: Where else could technology enable better health care?

Barrett: Well if you look at it from a standard engineering analysis, about 80% of the cost in health care is in people who are chronically ill or old, and the real issue there is in fact, to keep them out of the hospital. That’s remote diagnostics and remote monitoring. Taking care of people who are chronically ill in their home. How do you do that? Information technology. Remote monitoring devices fire that information back to the doctors’ office let them keep track of the individual without having the individual have to go to the doctor’s office. Diabetes, congestive heart failure, all these things are amenable to information technology (and) diagnostics in the home.

Bartiromo: You could have all your information on a chip, I guess.

Barrett: Of course you could. I mean, we could have done this a long time ago if the medical profession would kind of get with it in this space. They’ve been kind of dragging their heels.

Whoa there Mr. Barrett! Are you suggesting that manufacturing of home monitoring devices containing Intel chips is the responsibility of the health profession? Have WE been dragging our feet or have YOU?

And Mr. Barrett, could there be an itsy bitsy reason that we have been dragging our feet? Could it be because no one is willing to compensate doctors for monitoring people using gizmos at home? Is this a trivial piece of information? I would suspect that you, “Mr. Swiss Alps,” don’t do much that isn’t going to compensate you, now do you? Or are you, “Mr. Six-Inches of Powder,” going to lead the charge at bridging this gap given your prescience on this issue?

It’s not about just getting the data to the doctor. That, sir, is NOT healthcare. Instead, it’s about differentiating signal from noise. With a data dump to doctor’s offices, who will sift through the mountains of data (pun intended) to determine which data represent a problem in a particular patient versus a significant change? Data can change in expected ways when certain drugs are administered: like the elevation of a white blood count after steroids are administered. Will your little data processor be capable of making higher-order decisions? Unlikely.

More importantly, if a data point exceeds a pre-defined parameter and a doctor like me is notified by an e-mail using your handy-dandy device, who will follow-up to make sure I received and acted upon the notification? E-mailing data this way, without personal contact, is like planting a sinister bomb on my desk that is waiting to explode in my face. If I don't happen to check my e-mail that week because I am inundated by the scores of aged entering their twilight years, will you take the liability heat, or will I?

Pompous, arrogant sound bites do little to address these critical issues regarding information technology’s application in health care.

I'm sure there's plenty of doctors who'd like to have a weekend in Switzerland to discuss our "economic" thoughts, too, Mr. Barrett. Just ask.

-Wes

Addendum: Dr. Helen has more discussion and interesting commentary on this post.