I try to avoid navel-gazing, which to me means commenting on someone else’s commentary – a practice all too commonly relied upon in the healthcare IT blogosphere. How many blogs, articles and rebuttals have been generated, after all, as a result of the Health Affairs/Mostashari back-and-forth in the past few days? Quite a few, and yours truly happily participated in the fringe commentary. So as you can see, sometimes a topic already covered by someone else just begs for a second opinion, which I’ll happily give if the context is right.

Yesterday I came across two pieces of online content that I couldn’t help but draw correlations between. The first, a blog written by Dr. Rick Weinhaus entitled “Humans Have Limited Working Memory,” tells the tale of our poor ability to retain information, made all too obvious by a common EHR design feature – the utilization of a row of clickable tabs at the top of a dashboard to designate the different categories of data that make up the patient visit.

Dr. Rick laments that since humans are capable of only retaining four to five unrelated elements in working memory, the row of one-click tabs, though logical, doesn’t work very well. In fact, it drives him “crazy.”

I certainly believe in our limited capacity for remembering unrelated things at any given time, and I’m sure other working parents will agree. Our capacity for keeping everything straight is finite – the more kids, colleagues, coworkers, patients, tabs, bells and whistles you add, the more likely you are to forget something, leave something behind, or, if you’re like me, leave your car door wide open in a parking lot while grocery shopping with two kids in tow. But I digress.

The second piece of content revolves around the results of a survey put out by CDW Healthcare on what clinicians find frustrating about implementing new health IT systems. Surprise, surprise, “too many passwords to memorize” came in at the top, emphasizing what Dr. Rick pointed out in his unrelated blog post.

So what’s a clinician to do? Especially those that work in multiple facilities on different EHRs? Are you like me, scribbling down usernames and passwords on a master paper document, which just screams “privacy breach waiting to happen?” How are vendors helping to address these issues – single sign-ons? Better, overall design? Whose doing it the right way when it comes to designing an EHR, or as Dr. Rick says, designing one “based on what humans are good at — using our visual system to make sense of the world?”

Please let me know in the comments below.

For quite some time, talking heads have noted that EMRs will be an essential part of ACOs, so much so that most doubt you can have a successful ACO organization without one.  What I don’t see asked as often, however, is whether EMRs are shaping the future of the ACO movement, both negatively and positively.

What would an ACO look like, if it could exist at all, without an electronic record or HIE in place?

* There would even more mistakes and delays in sharing patient records, as one can hardly expect a larger group of institutions to make *less* mistakes

*  ACOs could launch without having to spend millions of dollars on EMR software, hardware, training and support

*  Clinical workflow would remain the same, generally, even if doctors were forced to include larger numbers of co-workers in their network

And how are ACOs working with EMRs in place?

*  Aside from limited case studies in individual institutions , it’s not clear whether EMRs are turning large, newly assembled care organizations into safer places to get care.

*  ACOs are forming more slowly than they might be, arguably, because a comprehensive EMR is part of t he cost of doing business

* New clinical workflow patterns are being forced upon clinicians, cutting across multiple institutions. While this might ultimately increase efficiency, it’s hard to ignore how many human hours are being invested (or wasted, depending on your position) on new technology.

As you can see, I come down on the “EMRs may not be all they’re cracked up to be for ACOs” side of things. Now, I’d concede that I haven’t been completely fair — I know EMRs have yielded great benefits for some groups of institutions– but I’d say the jury’s still out overall.

If someone asked you how long it’s been since someone lit up an EMR, what would your guess be?  Five years?  Ten? Even 20? What if I suggested that the first EMR was installed 50 years ago in an Akron hospital?

According to IBM, the first EMR was rolled out at Akron’s Childrens Hospital in February 1962.  In Big Blue’s own words:

Though Dr. Lawrence L. Weed is credited for developing the first electronic medical record, the so-called Problem-Oriented Medical Information System (Promis), starting in 1969. But IBM, working with Akron’s Children’s Hospital, implemented a system years earlier that would be the grand-daddy of today’s EMR.

Other early players in EMR evolution included doctors at the University of Vermont, whose PROMIS system and later the POMR (problem-oriented medical record) followed in the late 1960s, as well as the Mayo Clinic. Still, it seems we may have IBM and a pioneering children’s hospital to thank for much of what we discuss so passionately here today.

By the way, it’s interesting to note that while the technology has evolved in astounding ways, the EMR as a concept hasn’t changed nearly as much.  For example, even back then execs were noting that nurses were spending far more time handling paper than they needed to (and that one patient could generate 50 forms, a number which I’d bet still hasn’t changed). It’s amazing that a problem we defined 50 years ago still defies easy solutions, but there you have it.

Meanwhile, courtesy of Scribd, check out the actual IBM press release  on the subject (typed on an oldie-but-goodie typewriter):

Medicine is a risky business, and malpractice suits one of the nastier part of the trade. Whenever something major changes in the way medical care is delivered — including, say, the use of EMRs — it makes sense to expect the worst.

That’s exactly where Dr. Sam Bierstock stands. Bierstock, an interesting guy whose act includes a blues band performing songs on the perils of managed care and EMRs, is going national with his view that EMRs are opening up  bigger med mal liabilities than doctors realize.

“What few people realize is that using an EHR exposes physicians to an Orwellian level of analysis of every single act while doing their job,” writes Bierstock, who nonetheless sees himself as an EHR advocate.  As he rightfully notes, EHRs can be audited to see how long it took a physician to respond to an abnormal lab finding, to find out what doctors said in internal e-mails or even whether they scrolled down an entire screen before closing a document.

To my (admittedly limited) knowledge, there have not yet been any major lawsuits based actions doctors took which can be pinned specifically on the use of an EMR (other than, perhaps, HIPAA breaches). But it does seem credible that such suits are on the horizon. After all, not to be too cynical, but medical malpractice lawyers do work on commission, and if I were them I’d see this as an opportunity.

In his commentary, Bierstock argues that there must be “meaningful tort reform” before physicians can safely use EMRs. The question is what reforms are the right ones.  To date, I haven’t seen model legislation, much less a live bill, which directly addresses this issue.  Do any of you have more information to share, readers?

P.S.  OK, I was wrong about there being no case law on this subject. Here’s at least one example where a physician allegedly altered an EMR audit trail to make it appear that a problem had been flagged.

Doctors love them, but don’t think the iPad is ready to play a major role in clinical practice, as Apple hasn’t done enough to optimize it for healthcare, according to a new study by Spyglass Consulting Group.

According to a new report by Spyglass,  doctors don’t feel the iPad is ready to have an impact on care delivery. While 80 percent of physicians responding predicted that the iPad will have a positive impact on future care, it’s just not ready today, they said. (Most doctors I’ve talked with agree, noting that while it’s great for reading data, it’s extremely difficult to use for data entry.)

We’re not at all surprised to hear this given some of the iPad horror stories traveling around. For example, when Seattle Children’s Hospital pilot-tested iPads for its doctors, the result was a complete flop. Doctors there complained that that it was just too awkward to enter data into the otherwise sexy device. Shortly thereafter, IT switched its plans and rolled out a zero-client set-up.

So, what will it take to make the iPad clinically useful? To be successful in healthcare, Apple and its partners need to rewrite and optimize clinical apps to include gesture-based computing, natural language speech recognition, unified communications and even video conferencing, Spyglass research concludes.

I’d add that EMR/EHR vendors need to create native front ends for the iPad; given its penetration among doctors, I’m baffled by vendors who demand that doctors use their system via Citrix or the Web.

Unfortunately, with the exception of Epic’s Canto, few vendors offer a fully-fledged iPad app as a front end to their system. (One of few examples of a native iPad app from a smaller EMR vendor comes from Dr. Chrono, which, perhaps not so coincidentally, just got $2.8 million in venture funding.)

What’s more, Apple will have to do something about iOS security. It’s little wonder that 75  percent of doctors said that hospital IT departments weren’t eager to support mobile devices on corporate networks. While any device exposes networks to additional threats, Apple seems to have some particularly difficult problems, especially where its Safari browser is concerned.

Like the doctors surveyed by Spyglass, I have little doubt that iPads will end up assuming an important role in healthcare.  But given the snail’s pace at which native iPad apps are being launched, it may be a long time before that happens.

Valentine’s Day may be behind us, but I still wonder how many providers would be willing to write love notes to their EHR vendors, especially with rumors swirling that CMS will release Meaningful Use Stage 2 requirements in the next few weeks. (John Moore at Chilmark Research is apparently taking bets via Twitter, if anyone’s interested in doing a bit of gambling in preparation for the big HIMSS event in Vegas next week. He predicts it will be the Friday after HIMSS. I think it might just make good fodder for Farzad Mostashari’s keynote next Thursday morning, as he has been vocal about delaying the start of Stage 2 until 2014.)

Whether they’re released during or after the show, I decided it would be a good idea to bone up on Stage 1 versus Stage 2, and how what may or may not be included in Stage 2 will lead providers to love (or hate) their systems all the more.

I fortunately came across a very well written and comprehensive (though not too long) report from CSC entitled “Moving Ahead with Stage 2 of Meaningful Use,” which provides a very clear-cut picture of the challenges providers found with Stage 1, and what they are likely to encounter as challenges in Stage 2. It’s a brief, informative read that I highly recommend folks take a look at before they head to HIMSS in just a few days.

My biggest take away from the report was that the providers surveyed had done very little in Stage 1 to engage patients and coordinate care, which is not surprising given that most were concentrating on getting their EHRs up and running in time to fully attest for Stage 1. Combine this with the fact that formal ACO rules weren’t released until late last year, and I can understand why engaging patients and coordinating care just wasn’t on the radar of most healthcare facilities.

But oh what a difference a few months can make! The CSC report notes “Stage 2 is coming soon and a full year of operational use of capabilities will be required (rather than three months for Stage 1). Waiting until the final rule is issued to start moving is simply not an option.

“Now is the time for organizations to work in earnest to build capabilities to engage patients, coordinate care and electronically report on quality.”

And finally, the report notes that:

Three essential areas where organizations need to start now are:

1. Providing patients with access to their health information electronically through patient portals or directly from EHR systems.
2. Electronic capture of physician notes, including diagnosis and treatment, plus rationale for excluding patients from treatment recommendations.
3. Exchange of patient information at transitions in care.

I’d be interested to hear from our readers that have successfully attested for Stage 1 how they view these predictions for Stage 2. Are they manageable? Do they fit with your organization’s current strategy? Please share your thoughts in the comments below.

I’ve been inundated with two things as of late – HIMSS12 planning and all things business intelligence. I’ve spent the last few weeks helping prepare the Porter Research team for a webinar on providers’ perceptions of business intelligence, which I’m sure will be a big theme at HIMSS. As I’ve been looking over data from the latest Porter Research survey on BI, I’ve realized that providers know they need it but many aren’t quite sure how to define it, what they need out of it, how to implement it, or how to go about making it meaningful for their organization’s particular needs. And vendors in the healthcare space seem to be (or so I thought) just getting into the game of developing these sorts of tools – be they on a departmental or enterprise level.

Micky Tripathi, President and CEO of the Massachusetts eHealth Collaborative (MAeHC) – a nonprofit healthcare IT advisory and consultancy firm – alerted me to an interesting business intelligence tool called popHealth during my recent interview with him for a Porter Research feature on that state’s developing health information exchange. The MAeHC team, which includes among its services the MAeHC Quality Data Center, will be part of the Interoperability Showcase at HIMSS12, and will help to highlight the functionality and accuracy of the popHealth tool.

“popHealth was originally created as an open-source quality measurement tool by the Primary Care Information Project in New York City,” explained Tripathi, “which was headed at the time by Dr. Farzad Mostashari. Now that he’s the national coordinator for health IT, he’s been promoting it at a national level as a free, open-source tool that any organization in the country can use to send their clinical data to and get Meaningful Use clinical quality measures out of.”

Since then, the ONC has contracted with the Mitre Corporation to further develop the platform for a national user base.

You can of course check out the popHealth website for more info, but in a nutshell, the tool is “an open source reference implementation software service that automates the reporting of Meaningful Use quality measures. popHealth integrates with a healthcare provider’s electronic health record (EHR) system using continuity of care records. popHealth streamlines the automated generation of summary quality measure reports on the provider’s patient population.

“popHealth supports healthcare providers and EHR vendors by reporting clinical quality measures from electronic health record continuity of care files. Providers are empowered to better understand, and analyze the health of their patient population, and meet Meaningful Use reporting objectives, through reports of clinical quality measures. EHR vendors and healthcare providers are free to download, use, and integrate the popHealth software in their systems.”

The popHealth team will at HIMSS also to announce the winner of their tool development challenge. Announced last fall, the competition challenges participants to “develop an application that leverages the popHealth open source framework, existing functionality, standards and sample datasets to improve patient care and provide greater insight into patient populations.”

As the need for business intelligence tools and demand for open source solutions grow, I’ll be interested to see if popHealth ushers in a new era of reporting – one that everyone can take advantage of thanks to its non-existent price tag.

Here’s an EMR adoption study which interested me largely because it runs counter to what I would have predicted.  The study, which surveyed physicians pre- and post- EMR implementation, found that doctors who owned a stake in their practice found their rollout to be tougher than physicians who didn’t have a stake.

I don’t know about you, but I would have assumed that the folks with more control — the owners — would have found it easier than those who have to adapt to the decisions others make.  But it seems that physician-owners simply feel the pain of change more acutely.

To conduct the study, which was published last week in the Journal of the American Medical Informatics Association,  researchers surveyed 156 physicians working with the Massachusetts eHealth Collaborative.  The surveys included a pre-implementation questionnaire  in 2005 and a post-implementation questionnaire in 2009.

Thirty-five percent of doctors who responded reported that implementation was very difficult, 54 percent said it was somewhat difficult and 12 percent not difficult. Those numbers square pretty well with what I’ve seen elsewhere. The twist here was that 38 percent of physicians with full or partial ownership stakes in their practices voted “very difficult,” versus 27 percent of non-owners. That surprised me. After all, aren’t most of the complaints coming from doctors who try to use the new systems?

According to Marshall Fleurant, MD, one of the study’s authors, the owners “probably experienced more underlying challenges associated with EHR implementation and workflow transformation” given their broader operational responsibilities.

While this study is interesting, it’s hardly the last word. Teasing out just which factors predict how doctors will react to EMR implementation, much less what it takes to support them, is still a new science.  But it never hurts to bear in mind that physicians making critical management decisions get support, too.

I’ve blogged before about the importance of decreasing the digital divide in this country in order to truly move healthcare interoperability forward. As I mentioned last month, “Only those patients who have access to these digital healthcare technologies will begin to clamor for them at their next doctors’ visits. Only patients’ whose doctors in turn have reached out to them via email, text or social media regarding the switch to electronic medical records, development of health information exchange and the benefits to care these will hopefully bring will be ready and willing to go with the digital flow.”

When news came across my somewhat cluttered desk of Emdeon’s initiative to provide electronic health record (EHR) technology to physicians in New Jersey’s underserved communities, I first thought, “Yes! That’s what I’m talkin’ about!” Then I put on my journalist/blogger hat and thought, “Will this truly change anything in these particular communities, or is this just good PR?”

A quick bit of background: Emdeon is partnering with the U.S. Department of Health and Human Services’ (HHS) Office of Minority Health, New Jersey Health Information Technology Extension Center (NJ-HITEC), the state’s REC, and the HIMSS Latino Community. Through the initiative, Emdeon will donate Emdeon Clinician licenses to 100 healthcare providers who practice within medically underserved areas and/or healthcare provider shortage areas, as designated by the Health Resources and Services Administration (HRSA), according to a recent Emdeon press release. The company will waive the license fee for these physicians for one year.

The same press release also mentions “EHR adoption is lower among providers serving Hispanic patients who are uninsured or rely on Medicaid, and is lower among providers serving uninsured, non-Hispanic black patients than among providers serving privately insured, non-Hispanic white patients.”

The initiative sounds like a great idea, but the one-year stipulation got me thinking (a bad habit, I know). What will these physicians, who presumably can’t really afford this technology now, do after their year is up? I reached out to Miriam Paramore, Senior Vice President – clinical and government services at Emdeon, to learn more about the ins and outs of the program.

How did the initiative come about?
Miriam Paramore: During the fall of 2010, leaders from the Office of Minority Health (OMH) and Health Information Technology issued a public, written request to health IT vendors, asking them to pay special attention to healthcare providers within underserved communities. This initiative is known as The Alliance to Reduce Health IT Disparities. Emdeon is serving as a private partner with the OMH to offer access to health IT products and services to providers within undeserved communities in New Jersey. We were thrilled to volunteer and to work within these communities.

Has Emdeon ever done anything like this before?
We’re happy to do part of this effort with HHS and it is the first time we’ve partnered with them.  We have great empathy for the challenges of the physicians in underserved communities and we want to help.

What sort of challenges do small physician practices in underserved communities typically encounter?
In addition to challenges like poverty and health disparities amongst their patient population, providers in underserved communities and smaller practice offices face expensive costs associated with on-boarding EHRs. Emdeon created the Emdeon Clinician solution as an affordable EHR “lite” solution for these small practice physicians or those working in underserved communities. They now have an affordable, easy-to-use solution that will help them to qualify for federal HITECH stimulus dollars without unnecessary disruption and expense of a full-blown EHR system.

How will you work with these 100 physician practices to ensure they are able to continue using the donated EHR after the year-long license expires?
Once the 12-month period expires, providers will be able to continue using Emdeon Clinician for only $99 per provider, per month. Emdeon usually has a $500 implementation and training fee [that, for this program,] has been discounted to a one-time fee of $200 for the providers participating in this project. This is a considerable discount and the fee would only have to be paid once. We will begin outreach to these providers in advance of the expiration date so they are aware of the opportunity to remain with Emdeon Clinician for the low fee following the initial 12-month period.

How will Emdeon work with NJ-HITEC and the HIMSS Latino Community throughout this year to ensure that these practices receive continued training and support?
Emdeon has taken the lead with managing this initiative between all partners with monthly meetings to monitor progress. We have a dedicated project manager, who has mapped a process with the internal team to assist with implementing these physicians as soon as possible. Our custom phone number (1-855-840-7120) connects interested providers directly with a dedicated clinical sales executive who can assist them throughout the enrollment process.

The NJ-HITEC and HIMSS Latino partners are assisting in the recruitment of providers who practice within medically underserved areas for this program from their vast networks across New Jersey communities. These partners are working cooperatively with Emdeon to create a strategy that focuses upon identifying and recruiting providers within underserved communities who are willing to adopt EHRs, especially those interested in qualifying for federal incentive dollars.

How many practices do you anticipate being eligible, and how many do you expect will apply?
While we aren’t sure how many will apply, the HHS OMH recognized that the counties of Camden, Essex and Passaic have the largest percentage of underserved communities. Through our collaborative efforts with the OMH, HIMSS Latino and NJ HITEC, we hope to reach many of those physicians within those counties to take advantage of the 12-month program.

How will Emdeon and its partners determine if this program is a success?
Together with our partners, we believe success will be donating all 100 licenses to providers in underserved communities. The reporting element of this project will help OMH understand the progress of EHR adoption in the context of how long implementation takes in its entirety.

So it seems that Emdeon and its partners certainly have their ducks in a row when it comes to aiding and abetting these physicians before, during and even after the program is technically over. I’ll be interested to see if this model will, in fact, be successful, and if it can be supported in other underserved areas across the nation.

For more information on participating in the program, check out: http://www.emdeon.com/newjersey/

I’ve had the good fortune in the past year or two to watch one of my daughters’ favorite babysitters blossom into a full-time nursing student at the University of West Georgia. Not only do my girls benefit from her great bedside manner, including an infinite amount of patience, but I get an occasional inside glimpse into the world of digital medical record keeping in the greater Atlanta area.

Her training at West Georgia has taken her to Children’s Healthcare of Atlanta – Egleston, Wellstar Cobb and Austell, Fayette Piedmont, Tanner Medical Center and Gentiva Healthfield Hospice. She graciously offered to share her rookie’s perspective on the electronic medical records – including SCM/Quest (Allscripts Sunrise Clinical EHR system) and Meditech – she has used at several of the facilities she has trained in.

How long have your healthcare training facilities had EMRs in place?
All except Gentiva Healthfield Hospice – in-home hospice care, for the most part, sticks with paper charting. If they were to make the switch to an EMR, they would have to have access to a central database from their personal computers/iPads/Blackberries, etc. All others have had some sort of electronic database for at least five years.

How intuitive did you find them to be in your first training sessions/rounds?
Once I had been trained in the first system I encountered, the rest seemed very user-friendly. They have been in use long enough now that they are efficient and fairly self-explanatory.

They all allow an employee to cluster patient care and spend enough time with the patient because the time stamp on documentation can be changed to the time that the intervention was completed. For example, I could complete a full assessment on a patient, bathe them and administer their medications without having to document in the computer every few minutes. I could just open their EMR after completing their care and add the correct time stamp on my documentation.

What were the easiest to use, and what were the most difficult?
Meditech was the most difficult to use, perhaps because I had limited access as a student. It was difficult to find complete admission notes and patient histories.

Speaking from a “rookie’s” perspective, what would you tell vendors of these systems to better their products?
Add a patient verification requirement before each documentation session, i.e. each set of vital signs, medications given, etc. (Something simple, like a box with the patient’s name and DOB and an “Ok” button)

Did your supervisors express any enthusiasm or dissatisfaction with any particular systems?
All expressed enthusiasm, but they also were concerned any time a system was to be updated with even minor changes. Fayette Piedmont uses one EMR system for Labor and Delivery, and a completely different system for the rest of the hospital. This means, for the staff, that a new baby’s records have to be re-entered into a new system once they are discharged from labor and delivery and admitted to the NICU or postpartum unit. It also means the pharmacy has difficulty accessing vital information when, for instance, they need to know a baby’s weight to send the appropriate dose of medication to the NICU.

How aware are you of post-implementation training that goes on with EMRs, based on the facilities you’ve trained at? Do your supervisors ever mention it?
Once an employee is hired, they usually must display proficiency with the charting system within a specified training period. When Fayette Piedmont updated SCM/Quest, they did not retrain each employee, but they did send out a packet with a detailed description of the changes. From what I have seen, the older nurses who may have preferred paper charting at one point do not seem to have any problems with the electronic charting.

Have you been made aware of any increase/decrease in positive clinical outcomes as a result of physicians/nurses using these systems? Any examples you feel comfortable sharing?
The major changes to these systems each time they are updated usually involve the addition of safeguards. For example, the newest version of SCM/Quest has the patient’s name, weight, room number and allergies on every page of the charting system, and in multiple locations on the page.

For the employees who pay attention, this has reduced many documentation errors. There is also an embedded link to drug guides in every electronic medication order with explicit instructions and safe dose ranges. For the employee who knows these features are there, they are a tremendous help, and they do serve to protect the patient. It is still possible to document in the wrong patient’s chart, without realizing it, in any system.

Needless to say, it will be interesting to see how her experience with EMRs changes as she continues her studies and then moves into the professional world of nursing, which will likely coincide with healthcare facilities continuing to move through the various stages of Meaningful Use.

Stay tuned for next week’s post, in which I’ll profile an EMR educator, and find out what other students are facing when it comes to EMR training. In the meantime, what sort of healthcare IT-related challenges will our new workforce face in the coming year? Please share your thoughts in the comments below.