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Time To Build EHRs That Address Human Complexity

Posted on September 1, 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.

As things stand in our world, caring for patients generally falls into two broad categories: treating the body and its innumerable mysteries, and caring for practicalities of the patient’s mental and social health. The two are interrelated, of course, but often they’re treated independently, as if each existed in a separate world.

But we know that this is a false dichotomy. People don’t go from being patients at one point and human beings later, and treating them that way can fail or even cause them harm. At every point, they’re people living in a complex world which may overwhelm their capacity for getting good healthcare. Their values, social networks, resources (or lack thereof), education and mental health status are just a few of the many dimensions that influence a patient’s overall functioning in the world.

This isn’t a new idea. As Frances Peabody noted in a 1927 lecture to Harvard Medical School students, “the secret of the care of the patient is in caring for the patient,” by understanding how a patient’s personal and emotional circumstances influence their health status. It’s a concept that needs revisiting, particularly given that the automation of care seems likely to further alienate doctors from patients.

Given how seldom physicians have a chance to address patients’ life circumstances, and how important it is that medicine returns to this approach, it was good to see the The Journal of the American Medical Association weigh in on the issue.

In the Viewpoint piece, entitled “Evolutionary Pressures on the Electronic Health Record: Caring for Complexity,” the authors contend that next-generation EHRs will need to do much more to help physicians address an increasingly complex patient mix.  They suggest that rising patient complexity – due to issues such as co-occurring chronic and rare diseases, organ transplantation and artificial devices – are changing the practice of medicine. Meanwhile, they point out, patients’ personal experience of illness and the social context in which they live are still important considerations.

But EHRs aren’t developing the capacity to meet these needs, they note:

The evolution of EHRs has not kept pace with technology widely used to track, synthesize, and visualize information in many other domains of modern life. While clinicians can calculate a patient’s likelihood of future myocardial infarction, risk of osteoporotic fracture, and odds of developing certain cancers, most systems do not integrate these tools in a way that supports tailored treatment decisions based on an individual’s unique characteristics.

Existing EHRs aren’t designed to help physicians use predictive analytics to deliver preventative care or services to targeted individuals either, they note. Nor are they helping clinicians to learn from past cases in a systematic manner, the piece says:

When a 55-year-old woman of Asian heritage presents to her physician with asthma and new-onset moderate hypertension, it would be helpful for an EHR system to find a personalized cohort of patients (based on key similarities or by using population data weighted by specific patient characteristics) to suggest a course of action based on how those patients responded to certain antihypertensive medication classes, thus providing practice-based evidence when randomized trial evidence is lacking.

The JAMA authors also take EHR vendors to task for doing nothing to capture social and behavioral data (otherwise known as “social determinants of health”)  which could have a big impact on health outcomes and treatment responses:

In this world of patient portals and electronic tablets, it should be possible to collect from individuals key information about their environment and unique stressors – at home or in the workplace – in the medical record. What is the story of the individual?  The most sophisticated computerized algorithms, if limited to medical data, may underestimate a patient’s risk (eg, through ignorance about neighborhood dangers contributing to sedentary behavior and poor nutrition) or recommend suboptimal treatment (eg, escalating asthma medications for symptoms triggered by second-hand smoke).

If EHRs evolve successfully to embrace such factors – and move away from their origins in billing support – physicians may spend much less time with them in the future. In fact, the authors speak lovingly of a future in which “deimplementing the EHR” becomes a trend, and care no longer revolves around a computer. This may not happen anytime soon.

Still, perhaps we can speak of “rehumanizing the EHR” with information that address the whole, complex person. A rehumanized EHR that Francis Perkins would use, were he alive today, is something physicians should demand.

EMR Analysis Detects Childrens’ Growth Disorders

Posted on September 16, 2013 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.

EMRs can be used to detect growth disorders in children, according to new research published in the Journal of the American Medical Association . The study, which was written up in FierceEMR, used a special automated growth monitoring algorithm integrated into an EMR system to track childrens’ growth.

To conduct the study, researchers compared three “control” years to an “intervention” year. An annual average of 33,029 children were screened, according to FierceEMR.

Researchers found that in a control year an average of four children were diagnosed with a growth disorder. During the intervention year, however, 28 new diagnoses of growth disorders were made among 32,404 children, FierceEMR reports.

Looked at another way, the rate of growth disorder diagnoses was 0.1 per 1000 screened children in the control years versus 0.9 per 1000 screened children in the intervention year, FierceEMR noted.

These study results are part of an emerging body of literature suggesting that EMRs to help clinicians detect and manage disease states.

For example, another study appearing in the Journal of the American Medical Association found that EMRs can be associated with a drop in emergency department visits and hospitalizations among diabetics.  That study, which analyzed all of the 169,711 records for patients enrolled in the Kaiser Permanente Northern California diabetes registry during a four-year period, found a 10.5% decline in hospitalizations for preventable ambulatory care sensitive conditions where EMRs were in use.

Another study, which recently appeared in BMJ Quality & Safety, recently concluded that EMRs can help reduce hospital readmissions of high-risk heart failure patients by sorting out high from low risk patients in the ED.

Are Cloud-Based Health Record Banks Better Than HIEs?

Posted on March 22, 2013 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.

This week a group of researchers published an opinion in the Journal of the American Medical Association suggesting that cloud-based record banks are a better way to share patient health data than HIEs. I think their view is interesting and sensible, and so here’s a short recap.

The authors argue that cloud-based health record banks are a more logical way to share such data than HIEs, reports MedCityNews. After all, as they note, interoperability challenges make it “inefficient” to share patient data, as every organization has to be able to communicate with every other organization where a patient has been treated.

But cloud-based health record banks wouldn’t pose the same challenges, they note.  These record banks would be more scalable and easier for end institutions to use, according to the authors.  Though local providers could keep copies of a patient’s health record, the electronic health record would be stored in a cloud-based bank in the patient’s community, they say.  When patients moved, their records would travel to a different community health data bank.

This approach isn’t just a theoretical discussion. It’s backed by a group called the Health Record Banking Alliance, which was founded by one of the article’s authors, Dr. William Yasnoff, MD, PhD, FACMI, former senior advisor for the National Health Information Infrastructure. The group has developed white papers outlining a proposed architecture and a business model for community health record banking.

My take on all of this is that the cloud-based community health record bank is a very worthwhile idea. After all, in theory it can greatly reduce the amount of infrastructure build out and interoperability issues providers face in connecting to HIEs.

That being said, the HIE concept is firmly planted in the industry’s mind, and despite all of the issues involved in building out HIE networks, I don’t see providers changing gears to embrace a completely new model. What about you?

New Patient Safety Standards Proposed For EHR Certification

Posted on July 11, 2011 I Written By

Katherine Rourke is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

Here’s a proposal that could make Meaningful Use standards and vendor certification programs more valuable. Authors writing for the Journal of the American Medical Association have suggested that the Joint Commission’s National Patient Safety Goals for 2011 be included in EHR certification and MU criteria.

Here’s how the JAMA authors suggest linking EHR standards with the NPSG list:

* Patient identification:  EHRs can and should make patient identification more reliable, in part by including patient photos. EHRs should also require caregivers to re-enter patient initials if patients seem to have similar names, the comment suggests.

* Physician notification:  EHRs should not only ping physicians when a patient has abnormal test results, but also require doctors to respond by a given deadline, according to the article.

* Improving medication safety:  As long as they don’t warp clinical workflow and create additional risk of error, EHRs should support bar code med administration and clinical decision support, the JAMA authors say.

* Infection control:  EHRs should track patients with dangerous infections, and also offer checklists which can improve clinicians’ compliance with IC protocols, according to the proposal.

* Medication reconciliation:  One of the most obvious ways the NPSGs, Meaningful Use and EHRs can work together is to support appropriate med reconciliation, particularly by improving interoperability between med lists across organizations and varied EHRs, the writers suggest.

* Suicide risk:  Here’s an intriguing idea. The authors argue that EHRs should include a checklist to assess risk for patient self-harm, as well as notifying clinicians for patients who should be screened for depression.

As an analyst, rather than clinician, I don’t have any direct comments on the list of safety proposals. But I must say that from my perspective, this approach seems smart, practical and even better, focused.  Adding specific patient safety goals to EHR standards — rather than debating over broad safety issues — looks like a great idea.  Am I missing something here, or do you share my enthusiasm?