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EHRs and Keyboarding: Is There an Answer?

Posted on November 28, 2017 I Written By

When Carl Bergman isn’t rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

One of the givens of EHR life is that users, especially physicians, spend excessive time keying into EHRs. The implication is that much keyboarding is due to excessive data demands, poor usability or general app cussedness. There’s no end of studies that support this. For example, a recent study at the University of Wisconsin-Madison’s Department of Family Medicine and Community Health in the Annals of Family Medicine found that:

Primary care physicians spend more than one-half of their workday, nearly 6 hours, interacting with the EHR during and after clinic hours. The study broke out times spent on various tasks and found, unsurprisingly, that documentation and chart review took up almost half the time.

Figure 1. Percent Physician’s Time on EHR

This study is unique among those looking at practitioners and EHRs. They note:

Although others have suggested work task categories for primary care,13 ours is the first taxonomy proposed to capture routine clinical work in EHR systems. 

They also make the point that they captured physician EHR use not total time spent with patients. Other studies have reached similar EHR use conclusions. The consensus is there too much time keyboarding and not enough time spent one to one with the patient. So, what can be done? Here, I think, are the choices:

  1. Do Nothing. Assume that this is a new world and tough it out.
  2. Use Scribes. Hire scribes to do the keyboarding for physicians.
  3. Make EHRs Easier. Improve EHRs’ usability.
  4. Make EHRs Smarter. Adapt EHRs to physician’s needs through artificial intelligence (AI) solutions.
  5. Offload to Patients. Use patient apps to input data, rather than physician keyboarding.

Examining the Alternatives

 1. Do Nothing. Making no change in either the systems or practioners’ approach means accepting the current state as the new normal. It doesn’t mean that no changes will occur. Rather, that they will continue at an incremental, perhaps glacial, pace. What this says more broadly is that the focus on the keyboard, per se, is wrong. The question is not what’s going in so much as what is coming out compared to old, manual systems. For example, when PCs first became office standards, the amount of keyboarding vs. pen and paper notations went viral. PCs produced great increases in both the volume and quality of office work. This quickly became the new norm. That hasn’t happened with EHRs. There’s an assumption that the old days were better. Doing nothing acknowledges that you can’t go back. Instead, it takes a stoic approach and assumes things will get better eventually, so just hang in there.

2. Scribes. The idea of using a scribe is simple. As a doctor examines a patient, the scribe enters the details. Scribes allow the physician to offload the keyboarding to someone with medical knowledge who understands their documentation style. There is no question that scribes can decrease physician keyboarding. This approach is gaining in popularity and is marketed by various medical societies and scribe services companies.

However, using scribes brings a host of questions. How are the implemented? I think the most important question is how a scribe fits into a system’s workflow. For example, how does an attending review a scribe’s notes to determine they convey the attending’s clinical findings, etc. The attending is the responsible party and anything that degrades or muddies that oversight is a danger to patient safety. Then, there are questions about patient privacy and just how passive an actor is a scribe?

If you’re looking for dispositive answers, you’ll have to wait. There are many studies showing scribes improve physician productivity, but few about the quality of the product.

3. Make EHRs Easier. Improving EHR usability is the holy grail of health IT and about as hard to find. ONC’s usability failings are well known and ongoing, but it isn’t alone. Vendors know that usability is something they can claim without having to prove. That doesn’t mean that usability and its good friend productivity aren’t important and are grossly overdue. As AHRQ recently found:

In a review of EHR safety and usability, investigators found that the switch from paper records to EHRs led to decreases in medication errors, improved guideline adherence, and (after initial implementation) enhanced safety attitudes and job satisfaction among physicians. However, the investigators found a number of problems as well.

These included usability issues, such as poor information display, complicated screen sequences and navigation, and the mismatch between user workflow in the EHR and clinical workflow. The latter problems resulted in interruptions and distraction, which can contribute to medical error.

Additional safety hazards included data entry errors created by the use of copy-forward, copy-and-paste, and electronic signatures, lack of clarity in sources and date of information presented, alert fatigue, and other usability problems that can contribute to error. Similar findings were reported in a review of nurses’ experiences with EHR use, which highlighted the altered workflow and communication patterns created by the implementation of EHRs.

Improving EHR usability is not a metaphysical undertaking. What’s wrong and what works have been known for years. What’s lacking is both the regulatory and corporate will to do so. If all EHRs had to show their practical usability users would rejoice. Your best bet here may be to become active in your EHR vendor’s user group. You may not get direct relief, but you’ll have a place, albeit small, at the table. Otherwise, given vendor and regulatory resistance to usability improvements, you’re better off pushing for a new EHR or writing your own EHR front end.

4. Make EHRs Smarter. If Watson can outsmart Kent Jennings, can’t artificial Intelligence make EHRs smarter? As one of my old friends used to tell our city council, “The answer is a qualified yes and a qualified no.”

AI takes on many, many forms and EHRs can and do use it. Primarily, these are dictation – transcription assistant systems. They’re known as Natural Language Processing (NLP). Sort of scribes without bodies. NLP takes a text stream, either live or from a recording, parses it and puts it in the EHR in its proper place. These systems combine the freedom of dictation with AI’s ability to create clinical notes. That allows the theory maintains, a user to maintain patient contact while creating the note, thus solving the keyboarding dilemma.

 The best-known NLP system Nuance’s Dragon Medical One, etc. Several EHR vendors have integrated Dragon or similar systems into their offerings. As with most complex, technical systems, though, NLP implementation requires a full-scale tech effort. Potential barriers are implementation or training shortcuts, workflow integration, and staff commitment. NLP’s ability to quickly gather information and place it is a given. What’s not so certain is its cost-effectiveness or its product quality. In those respects, its quality and efficacy is similar to scribes and subject to much the same scrutiny.

One interesting and wholly unexpected NLP system result occurred in a study by the University of Washington Researchers. The study group used an Android app NLP dictation system, VGEENS, that captured notes at the bedside. Here’s what startled the researchers:

….Intern and resident physicians were averse to creating notes using VGEENS. When asked why this is, their answers were that they have not had experience with dictation and are reluctant to learn a new skill during their busy clinical rotations. They also commented that they are very familiar with creating notes using typing, templates, and copy paste.

The researchers forgot that medical dictation skills are just that, a skill and don’t come without training and practice. It’s a skill of older generations and that keyboarding is today’s given. 

5. Offload to Patients. I hadn’t thought of this one until I saw an article in the Harvard Business Review. In a wide-ranging review, the authors saw physicians as victims of medical overconsumption and information overload:

In our recent studies of how patients responded to the introduction of a portal allowing them to e-mail health concerns to their care team, we found that the e-mail system that was expected to substitute for face-to-face visits actually increased them. Once patients began using the portal, many started sharing health updates and personal news with their care teams.

One of their solutions is to offload data collection and monitoring to patient apps:

Mightn’t we delegate some of the screening work to patients themselves? Empowering customers with easy-to-use tools transformed the tax reporting and travel industries. While we don’t expect patients to select what blood-pressure medications to be on, we probably can offload considerable amounts of the monitoring and perhaps even some of the treatment adjustment to them. Diabetes has long been managed this way, using forms of self-care that have advanced as self-monitoring technology has improved.

This may be where we are going; however, it ignores the already crowded app field. Moreover, every app seems to have its own data protocol. Health apps are a good way to capture and incorporate health data. They may be a good way to offload physicians’ keyboarding, but health apps are a tower of protocol Babel right now. This solution is as practical as saying that the way to curb double entering data in EHRs is to just make them interoperable.

What’s an EHR User to Do?

If each current approach to reducing keyboarding has problems, they are not fatal. I think that physician keyboarding is a problem and that it is subject to amelioration, if not solution.

For example, here’s Nordic’s Joel Martin on EHR usability:

… In reality, much of this extra work is a result of expanded documentation and quality measure requirements, security needs, and staffing changes. As the healthcare industry shifts its focus to value-based reimbursement and doing more with less, physician work is increasing. That work often takes place in the EHR, but it isn’t caused by the EHR’s existence.

Blaming the EHR without optimizing its use won’t solve the problem. Instead, we should take a holistic view of the issues causing provider burnout and use the system to create efficiencies, as it’s designed to do.  

The good news is that optimizing the EHR is very doable. There are many things that can be done to make it easier for providers to complete tasks in the EHR, and thereby lower the time spent in the system.

Broadly speaking, these opportunities fall into two categories.

First, many organizations have not implemented all the time-saving features that EHR vendors have created. There are features that dramatically lower the time required to complete EHR tasks for common, simple visits (for instance, upper respiratory infections). We rarely see organizations that have implemented these features at the time of our assessments, and we’re now working with many to implement them.

In addition, individual providers are often not taking advantage of features that could save them time. When we look at provider-level data, we typically see fewer than half of providers using speed and personalization features, such as features that let them rapidly reply to messages. These features could save 20 to 30 minutes a day on their own, but we see fewer than 50 percent of providers using them.

Optimization helps physicians use the EHR the way it was intended – in real-time, alongside patient care, to drive better care, fewer mistakes, and higher engagement. Ultimately, we envision a care environment where the EHR isn’t separate from patient care, but rather another tool to provide it. 

What does that mean for scribes or NLP? Recognize they are not panaceas, but tools. The field is constantly changing. Any effort to address keyboarding should look at a range of independent studies to identify their strengths and pitfalls. Note not only the major findings but also what skills, apps, etc., they required. Then, recognize the level of effort a good implementation always requires. Finally, as UW’s researchers found, surprises are always lurking in major shake-ups.

Join us for this week’s #HITsm chat on Using Technology to Fight EHR Burnout to discuss this topic more.

Patients Showing Positive Interest In NY-Based HIE

Posted on November 16, 2017 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

A few months ago, I shared the story of HEALTHeLINK, an HIE serving Western New York. At the time, HEALTHeLINK was announcing that it had managed to obtain 1 million patient consents to share PHI. The HIE network includes 4,600 physicians, in addition to hospitals, health plans and other providers.

This month, HEALTHeLINK has followed up with another announcement suggesting that it’s making significant progress in getting patients and physicians connected and perhaps more importantly, interested in what it can do for them. In particular, the study suggested that consumers were far more aware of the HIE’s existence, function and benefits than one might’ve assumed.

The study found that 90% of respondents said they knew their doctors use EHRs, a percentage which differed but remained high across all demographic groups study. Respondents also knew that their doctor could send and receive medical information back and forth with other healthcare providers involved in their care using EHRs.

Not only that, 51% of respondents felt that the use of EHRs by doctors and hospitals made healthcare “more safe,” though 24% said EHRs made no impact on their care and 18% said EHRs made care “less safe.” Fifty-eight percent of respondents said that electronic access is good for healthcare, and 24% answered “strongly yes” when asked whether electronic access was beneficial.

When asked whether electronic access is good for healthcare, 24% of respondents said “strongly yes” and 58% said “yes.” Things looked even more positive for the future of the HIE when patients were specifically aware of HEALTHeLINK, with 57% of this group of patients rating care as “more safe.”

Those who rated care as “more safe” using HEALTHeLINK also included respondents with a two-year degree, those who visited Dr. more than 15 times a year and those who fell into 35 to 44-year-old age bracket.(However, it is worth noting that 41% to respondents said they weren’t aware of the name HEALTHeLINK.)

The only significant downside mentioned by HEALTHeLINK users was a lack of face time, with 37% reporting that their doctor or healthcare professional was spending too much time on a laptop or computer, and another 11% saying that this was a significant problem. (Another 60% had no issue with this aspect of the electronic medical records use process.)

Despite those reservations, when asked if they were willing to cut their doctor to use the HIE to give the other providers instant access to medical records, 57 percent said “yes” and 24% said their answer was “strongly yes.”

Lest this begin to sound like a press release for HEALTHeLINK, let me stop you right there. I am in no way suggesting that these folks are doing a better overall job of running its business than those in other parts of the country. However, I do think it’s worth noting that HEALTHeLINK’s management is building awareness of its benefits more effectively than many others.

As obvious as the benefits of health information sharing may seem to folks like us, it never hurts to remind end users that they’re getting something good out of it — and if they’re not, to find out quickly and address the problem.

Usability, Interoperability are Political Questions: We Need an EHR Users Group

Posted on October 6, 2017 I Written By

When Carl Bergman isn’t rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

Over the years, writers on blogs such as this and EMRandHIPAA have vented their frustration with lousy EHR usability and interoperability problems. Usability has shown no real progress unless you count all the studies showing that its shortcomings cost both time and money, drives users nuts, and endangers patient lives.

The last administration’s usability approach confused motion with progress with a slew of roadmaps, meetings and committees. It’s policies kowtowed to vendors. The current regime has gone them one better with a sort of faith based approach. They believe they can improve usability as long it doesn’t involve screens or workflow. Interoperability has seen progress, mostly bottom up, but there is still no national solution. Patient matching requires equal parts data, technique and clairvoyance.

I think the solution to these chronic problems isn’t technical, but political. That is, vendors and ONC need to have their feet put to the fire. Otherwise, in another year or five or ten we’ll be going over the same ground again and again with the same results. That is, interop will move ever so slowly and usability will fade even more from sight – if that’s possible.

So, who could bring about this change? The one group that has no organized voice: users. Administrators, hospitals, practioners, nurses and vendors have their lobbyists and associations. Not to mention telemed, app and device makers. EHR users, however, cut across each of these groups without being particularly influential in any. Some groups raise these issues; however, it’s in their context, not for users in general. This means no one speaks for common, day in day out, EHR users. They’re never at the table. They have no voice. That’s not to say there aren’t any EHR user groups. There are scads, but vendors run almost all of them.

What’s needed is a national association that represents EHR users’ interests. Until they organize and earn a place along vendors, etc., these issues won’t move. Creating a group won’t be easy. Users are widely dispersed and play many different roles. Then there is money. Users can’t afford to pony up the way vendors can. An EHR user group or association could take many forms and I don’t pretend to know which will work best. All I can do is say this:

EHR Users Unite! You Have Nothing to Lose, But Your Frustrations!

A Look At Share Everywhere, Epic’s Patient Data Sharing Tool

Posted on September 28, 2017 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Lately, it looks like Epic has begun to try and demonstrate that it’s not selling a walled garden. Honestly, I doubt it will manage to convince me, but I’m trying to keep an open mind on the matter. I do have to admit that it’s made some steps forward.

One example of this trend is the launch of App Orchard, a program allowing medical practices and hospitals to build customized apps on its platform. App Orchard also supports independent mobile app developers that target providers and patients.

Marking a break from Epic’s past practices, the new program lets developers use a FHIR-based API to access and Epic development sandbox. (Previously, Epic wouldn’t give mobile app developers permission to connect to its EMR unless a customer requested permission on its behalf.) We’ll have to keep an eye on the contracts they require developers to sign to see if they’re really opening up Epic or not.

But enough about App Orchard. The latest news from Epic is its launch of Share Everywhere, a new tool which will give patients the ability to grant access to their health data to any provider with Internet access. The provider in question doesn’t even have to have an EHR in place. Share Everywhere will be distributed to Epic customers at no cost in the November update of its MyChart portal.

Share Everywhere builds on its Care Everywhere tool, which gives providers the ability to share data with other healthcare organizations. Epic, which launched Care Everywhere ten years ago, says 100% of its health system customers can exchange health data using the C-CDA format.

To use Share Everywhere, patients must log into MyChart and generate a one-time access code. Patients then give the code to any provider with whom they wish to share information, according to a report in Medscape. Once they receive the code, the clinician visits the Share Everywhere website, then uses the code once they verify it against the patient’s date of birth.

As usual, the biggest flaw in all this is that Epic’s still at the center of everything. While patients whose providers use Epic gain options, patients whose health information resides in a non-Epic system gain nothing.

Also, while it’s good that Epic is empowering patients, Direct record sharing seems to offer more. After all, patients using Direct don’t have to use a portal, need not have any particular vendor in the mix, and can attach a wide range of file formats to Direct messages, including PDFs, Word documents and C-CDA files. (This may be why CHIME has partnered with DirectTrust to launch its broad-based HIE.)

Participating does require a modest amount of work — patients have to get a Direct Address from one of its partners — and their provider has to be connected to the DirectTrust network. But given the size of its network, Direct record sharing compares favorably with Share Everywhere, without involving a specific vendor.

Despite my skepticism, I did find Share Everywhere’s patient consent mechanism interesting. Without a doubt, seeing to it that patients have consented to a specific use or transmission of their health data is a valuable service. Someday, blockchain may make this approach obsolete, but for now, it’s something.

Nonetheless, overall I see Share Everywhere as evolutionary, not revolutionary. If this is the best Epic can do when it comes to patient data exchange, I’m not too impressed.

Connecticut Medical Society Launches HIE When State Can’t Pull It Off

Posted on September 7, 2017 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

The Connecticut State Medical Society had had enough. Its members had waited 10 years for the state of Connecticut to launch a functioning HIE, to no avail, so the Society decided to take matters into its own hands.

Now, the state’s physicians, healthcare facilities, and assorted other providers are sharing data via the medical society’s new HIE, CTHealthLink.  Participants who use the HIE not only share data but also have access to reports designed add value to physician consults and improve outcomes.

The CSMS project must have been daunting, but at least it had a model to use. Its approach is based on a provider-backed HIE in use in Kansas, the Kansas  Health Information Network (KHIN). KHIN brought the Kansas Hospital Association, the Wichita Health Information Exchange and greater Kansas City HIE eHealthAlign together.

If you read the HIE project overview, it becomes clear that CSMS wants to help members navigate MACRA requirements.  “The goal is to empower physicians as they transition to the new alternative payment models involving quality reporting, advancing care information, and improvement activities,” the CSMS notes on the CTHealthLink site.

Prior to the CTHealthLink rollout, CSMS leaders worried that clinicians would miss out on Medicare and Medicaid incentives provided for participating in an HIE, and be subject to penalties instead, according to Matthew Katz, Executive Vice President and chief executive officer of the physician group, who spoke to The CT Mirror.

Under MIPS, all physicians and many other clinicians can get incentives for participating in a HIE, an attractive prospect. However, the flipside of this is that eligible providers who don’t participate in MIPS by the end of 2017 would see a 4% cut in their Medicare reimbursement in 2019, obviously attractive prospect. Small wonder that the CSMS couldn’t wait longer.

The state’s clinicians have been quite patient to date. According to the Mirror, Connecticut’s first HIE effort was in 2007, when they attempted to create network specifically for Medicaid. Though the network was backed by a $5 million grant, it failed, as few physicians had adopted digital medical records at the time.

Between 2007 and 2016, the state followed up with two more efforts to connect state providers. Both efforts failed to create a functioning system, despite having $18 million in funding to back its efforts.

In contrast, CTHealthLink is steaming ahead. But there is a catch. At $50 to $120 per physician per month, joining the HIE can be pretty pricey, especially for large practices. For example. at $50 per physician per month, a medical practice of 1,200 physicians would pay approximately $720,000 per year, or as much as $1.7 million if the $120 monthly fee applied, noted Lisa Stump, chief information officer for Yale New Haven Health, who also spoke to the Mirror. This may very well inhibit the HIE’s growth.

Meanwhile, despite previous failures, the state of Connecticut hasn’t given up on creating its own HIE, this time with $14 million in federal and state funding. One of the key drivers is an effort to make Medicaid reporting simpler, which the state’s Department of Social Services is cheering on. The state’s HIE is scheduled to be functioning by the beginning of 2018. Maybe the fourth time will be the charm.

Provider-Backed Health Data Interoperability Organization Launches

Posted on April 12, 2017 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

In 1988, some members of the cable television industry got together to form CableLabs, a non-proft innovation center and R&D lab. Since then, the non-profit has been a driving force in bringing cable operators together, developing technologies and specifications for services as well as offering testing and certification facilities.

Among its accomplishments is the development of DOCSIS (Data-over-Cable Service Interface Specification), a standard used worldwide to provide Internet access via a cable modem. If your cable modem is DOCSIS compliant, it can be used on any modern cable network.

If you’re thinking this approach might work well in healthcare, you’re not the only one. In fact, a group of powerful healthcare providers as just launched a health data sharing-focused organization with a similar approach.

The Center for Medical Interoperability, which will be housed in a 16,000-square-foot location in Nashville, is a membership-based organization offering a testing and certification lab for devices and systems. The organization has been in the works since 2011, when the Gary and Mary West Health Institute began looking at standards-based approaches to medical device interoperability.

The Center brings together a group of top US healthcare systems – including HCA Healthcare, Vanderbilt University and Community Health Systems — to tackle interoperability issues collaboratively.  Taken together, the board of directors represent more than 50 percent of the healthcare industry’s purchasing power, said Kerry McDermott, vice president of public policy and communications for the Center.

According to Health Data Management, the group will initially focus on acute care setting within a hospital, such as the ICU. In the ICU, patients are “surrounded by dozens of medical devices – each of which knows something valuable about the patient  — but we don’t have a streamlined way to aggregate all that data and make it useful for clinicians,” said McDermott, who spoke with HDM.

Broadly speaking, the Center’s goal is to let providers share health information as seamlessly as ATMs pass banking data across their network. To achieve that goal, its leaders hope to serve as a force for collaboration and consensus between healthcare organizations.

The project’s initial $10M in funding, which came from the Gary and Mary West Foundation, will be used to develop, test and certify devices and software. The goal will be to develop vendor-neutral approaches that support health data sharing between and within health systems. Other goals include supporting real-time one-to-many communications, plug-and-play device and system integration and the use of standards, HDM reports.

It will also host a lab known as the Transformation Learning Center, which will help clinicians explore the impact of emerging technologies. Clinicians will develop use cases for new technologies there, as well as capturing clinical requirements for their projects. They’ll also participate in evaluating new technologies on their safety, usefulness, and ability to satisfy patients and care teams.

As part of its efforts, the Center is taking a close look at the FHIR API.  Still, while FHIR has great potential, it’s not mature yet, McDermott told the magazine.

Two Worth Reading

Posted on April 6, 2017 I Written By

When Carl Bergman isn’t rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

HIT is a relatively small world that generates no end of notices, promotions and commentaries. You can usually skim them, pick out what’s new or different and move on. Recently, I’ve run into two articles that deserve a slow, savored reading: Politico’s Arthur Allen’s History of VistA, the VA’s homegrown EHR and Julia Adler-Milstein’s take on interoperability’s hard times.

VistA: An Old Soldier That May Just Fade Away – Maybe

The VA’s EHR is not only older than just about any other EHR, it’s older than just about any app you’ve used in the last ten years. It started when Jimmy Carter was in his first presidential year. It was a world of mainframes running TSO and 3270 terminals. Punch cards still abounded and dialup modems were rare. Even then, there were doctors and programmers who wanted to move vet’s hard copy files into a more usable, shareable form.

Arthur Allen has recounted their efforts, often clandestine, in tracking VistA’s history. It’s not only a history of one EHR and how it has fallen in and out of favor, but it’s also a history of how personal computing has grown, evolved and changed. Still a user favorite, it looks like its accumulated problems, often political as much as technical, may mean it will finally meet its end – or maybe not. In any event, Allen has written an effective, well researched piece of technological history.

Adler-Milstein: Interoperability’s Not for the Faint of Heart

Adler-Milstein, a University of Michigan Associate Professor of Health Management and Policy has two things going for her. She knows her stuff and she writes in a clear, direct prose. It’s a powerful and sadly rare combination.

In this case, she probes the seemingly simple issue of HIE interoperability or the lack thereof. She first looks at the history of EHR adoption, noting that MU1 took a pass on I/O. This was a critical error, because it:

[A]llowed EHR systems to be designed and adopted in ways that did not take HIE into account, and there were no market forces to fill the void.

When stage two with HIE came along, it meant retrofitting thousands of systems. We’ve been playing catch up, if at all, ever since.

Her major point is simple. It’s in everyone’s interest to find ways of making I/O work and that means abandoning fault finding and figuring out what can work.

Health IT End of Year Loose Ends

Posted on December 13, 2016 I Written By

When Carl Bergman isn’t rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

In that random scrap heap I refer to as my memory, I’ve compiled several items not worthy of a full post, but that keep nagging me for a mention. Here are the ones that’ve surfaced:

Patient Matching. Ideally, your doc should be able to pull your records from another system like pulling cash from an ATM. The hang up is doing patient matching, which is record sharing’s last mile problem. Patients don’t have a unique identifier, which means to make sure your records are really yours your doctor’s practice has to use several cumbersome workarounds.

The 21st Century Cures Act calls for GAO to study ONC’s approach to patient matching and determine if there’s a need for a standard set of data elements, etc. With luck, GAO will cut to the chase and address the need for a national patient ID.

fEMR. In 2014, I noted Team fEMR, which developed an open source EHR for medical teams working on short term – often crises — projects. I’m pleased to report the project and its leaders Sarah Diane Draugelis and Kevin Zurek are going strong and recently got a grant from the Pollination Project. Bravo.

What’s What. I live in DC, read the Washington Post daily etc., but if I want to know what’s up with HIT in Congress, etc., my first source is Politico’s Morning EHealth. Recommended.

Practice Fusion. Five years ago, I wrote a post that was my note to PF about why I couldn’t be one of their consultants anymore. Since then the post has garnered almost 30,000 hits and just keeps going. As pleased as I am at its longevity, I think it’s only fair to say that it’s pretty long in the tooth, so read it with that in mind.

Ancestry Health. A year ago September, I wrote about Ancestry.com’s beta site Ancestry Health. It lets families document your parents, grandparents, etc., and your medical histories, which can be quite helpful. It also promised to use your family’s depersonalized data for medical research. As an example, I set up King Agamemnon family’s tree. The site is still in beta, which I assume means it’s not going anywhere. Too bad. It’s a thoughtful and useful idea. I also do enjoy getting their occasional “Dear Agamemnon” emails.

Jibo. I’d love to see an AI personal assistant for PCPs, etc., to bring up related information during exams, capture new data, make appointments and prepare scripts. One AI solution that looked promising was Jibo. The bad news is that it keeps missing its beta ship date. However, investors are closing in on $100 million. Stay tuned.

 

Health Data Sharing Varies Widely From State To State

Posted on November 4, 2016 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

A new report from the CDC concludes that many physicians have interacted with shared health data, though only a small percentage of them had checked off all of the boxes by sending, receiving, integrating and searching for patient health data from other providers. The study also found that data sharing practices varied widely from state to state.

According to the CDC data, 38.2% of office-based physicians had sent data electronically to their peers in 2015. A nearly identical amount (39.3%) had received data, 31.1% integrated such data and 34% has searched such data from other providers.

On the other hand, physicians’ data interactions seem to have been somewhat limited. The CDC indicated that just 8.7% of office-based doctors had performed all four of these data sharing activities, a level which suggests that few are completely comfortable with such exercises.

Another striking aspect to the data was that it laid out the extent to which physicians in different states had different levels of data sharing activity.

For example, it found that in 2015, physicians fell below the national average for sending patient data in Idaho (19.4%), Connecticut (22.7%) and New Jersey (24.3%). In another anomaly, 56.3% of physicians in Arizona had sent information electronically other providers, a figure well above the 38.2% national average, with Idaho at the bottom of the range.

Meanwhile, the percentage of physicians who had received information electronically from other providers fell below the national average of 38.3% in Louisiana (23.6%), Mississippi (23.6%), Missouri (24.2%) and Alabama (24.3%). States where physicians exceeded the average for receiving information included Massachusetts (52.9%), Minnesota (55%), Oregon (59.2%) in Wisconsin (66.5%).

Where things get particularly interesting is when we look at the states were physicians had integrated electronic patient information they had received into their health data systems, a significantly more advanced step than sending or receiving data.

States that fell below the 31.1% average of physicians during such integration include Alaska (18.4%), the District of Columbia (18.6%), Montana (18.6%), Alabama (18.8%) and Idaho (20.6%). States that performed above the national average included Indiana (44.2%) and Delaware (49.3%).

Also worth noting was the diverse levels to which physicians had searched for patient health information from other providers, a data point which might suggest how much confidence they had in finding data. (Physicians who felt interoperability wasn’t serving them might not bother to search after all.)

The study found that while the average level of physicians who searched was 34%, several states fell below that average, including the District of Columbia (15.1%), Mississippi (19.7%), Pennsylvania (20.8%), Texas (21%), Missouri (21.6%) and Oklahoma (22.8%).

On the other hand, 10 states boasted a higher level physicians who searched than the national average. These included Ohio (47.2%), Alaska (47.3%, Colorado (47.5%), Maryland (47.9%), Virginia (48.3%), North Carolina (48.8%), Delaware (53.9%), Wisconsin (54.1%), Washington (58%) and Oregon (61.2%).

If it’s true that integrating and searching for data indicate higher levels of faith in the ability to use shared data, this actually looks like an encouraging report. Clearly, we have a long way to go, but substantial numbers of physicians are engaging in shared data use. To me this looks like progress.

A Circular Chat On Healthcare Interoperability

Posted on September 6, 2016 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

About a week ago, a press release on health data interoperability came into my inbox. I read it over and shook my head. Then I pinged a health tech buddy for some help. This guy has seen it all, and I felt pretty confident that he would know whether there was any real news there.

And this is how our chat went.

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“So you got another interoperability pitch from one of those groups. Is this the one that Cerner kicked off to spite Epic?” he asked me.

“No, this is the one that Epic and its buddies kicked off to spite Cerner,” I told him. “You know, health data exchange that can work for anyone that gets involved.”

“Do you mean a set of technical specs? Maybe that one that everyone seems to think is the next big hope for application-based data sharing? The one ONC seems to like.” he observed. “Or at least it did during the DeSalvo administration.”

“No, I mean the group working on a common technical approach to sharing health data securely,” I said. “You know, the one that lets doctors send data straight to another provider without digging into an EMR.”

“You mean that technology that supports underground currency trading? That one seems a little bit too raw to support health data trading,” he said.

“Maybe so. But I was talking about data-sharing standards adopted by an industry group trying to get everyone together under one roof,” I said. “It’s led by vendors but it claims to be serving the entire health IT world. Like a charity, though not very much.”

“Oh, I get it. You must be talking about the industry group that throws that humungous trade show each year.” he told me. “A friend wore through two pairs of wingtips on the trade show floor last year. And he hardly left his booth!”

“Actually, I was talking about a different industry group. You know, one that a few top vendors have created to promote their approach to interoperability.” I said. “Big footprint. Big hopes. Big claims about the future.”

“Oh yeah. You’re talking about that group Epic created to steal a move from Cerner.” he said.

“Um, sure. That must have been it,” I told him. “I’m sure that’s what I meant.”

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OK, I made most of this up. You’ve got me. But it is a pretty accurate representation of how most conversations go when I try to figure out who has a chance of actually making interoperability happen. (Of course, I added some snark for laughs, but not much, believe it or not.)

Does this exchange sound familiar to anyone else?

And if it does, is it any wonder we don’t have interoperability in healthcare?