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Why Accepting Patient Email is a Practical Requirement of the Affordable Care Act

Posted on July 31, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

The following is a guest post by Zachary Landman, M.D., Chief Medical Officer for DoctorBase.
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With the infusion of 30 million patients into the U.S. healthcare system in the coming years, the physician shortage is only going to worsen. In Massachusetts, which has had a similar healthcare legislation enacted since 2006, improvements in healthcare coverage and access are highly associated with physician shortages. Prior to the implementation of the health law in Massachusetts, internal medicine and family practice physicians were in deemed to be in “adequate” supply. Almost immediately following the legislation and in nearly every year since, however, the specialties have listed as “critical.”  While the percent of covered patients in the system has reached upwards of 95%, the result has been that physicians are increasingly difficult to visit. Appointment wait times have soared into weeks and months for some specialties and there has been frustration from both patients and providers regarding access.
MMA workforce 2006 and on
An even direr scenario is expected to play out on a national scale when 55 million people currently without insurance enter the healthcare market through subsidized exchanges. Economists predict that the current shortage of physicians will balloon to 63,000 by 2015 and escalate to 130,600 by 2025, due to both increasing demand and dwindling supply. To add salt the wound, a 2012 Physicians Foundation survey demonstrated that nearly half of the 830,000 doctors in the U.S. are over 50 meaning that as the number of patients swell, the supply of physicians will conversely retract.

Clearly, the way healthcare is provided will need to fundamentally change in order to accommodate the three main tenants of the Patient Protection and Affordable Care Act: Access, Quality, and Cost. One potential way is to simply force physicians and healthcare providers to see more patients in the current set of time or work longer or more frequently to maintain their level of reimbursement. Physician time, however, especially for chronically ill and complex patients has become a relatively “inelastic product.”

Physicians already experience significant rates of burnout, are feeling overworked, and have increased the frequency of patient visits to between and 6 and 9 minutes per encounter. Some studies suggest that trying to reduce this amount of time further may actually cause an increase in costs due to inadequate care, counseling, and increased frequency of complications. I would therefore argue that we have reached a point at which physicians cannot increase the volume and frequency of patient care without a fundamental alteration to the paradigm of healthcare.

Secure email may just be the answer. Securely messaging patients can provide a way to fundamentally alter the type and scope of care provided remotely leading to a maintenance or even reduction in the amount of patient care conducted in the office. The fundamental “if” in this scenario, however, is that it must save physician time. For example, physicians have known the value of hand hygiene in patient care for nearly two centuries, but only recently has widespread adoption been shown in an inpatient setting. What led to the main change? Time.  It takes considerable time to cleanse hands thoroughly between each visit. Only when the practice became a time-neutral or time saving event were physicians keen to alter practice behavior. With the inclusion of quick, visible, and easy to use dispensers outside each patient room, these two principles finally coincided.

It’s the same with email. Many physicians worry that by accepting patient messages, their already inelastic time will continually be stretched, forcing them to work longer and harder for a non-reimbursed activity.  After studying more than 11,000 physicians over three years, I have found that the effective use of secure messaging saves physicians on average 45 minutes per day.

Three hours and forty-five minutes per week. That’s a lot of time. And here’s where it comes from.

#1 – Triage. Physician messages should be directed to a practice manager or physician extender who triages the messages and forwards to the appropriate individual. In our case, we found that nearly two-thirds of “physician” messages could actually be handled by office staff. These messages were typically related to hours, availability, insurance coverage, consultant phone numbers, or other back office functions. Our surgeons found that by including a nurse practitioner or physician assistant could also further reduce the number of “MD-level” messages.

For example, minor concerns regarding wound or incision appearance, follow-up timing, suture removal, or questions from visiting nurses were all routinely and commonly handled by the midlevel provider. The exact nature of each question was handled in accordance with physician comfort and expectations. Ultimately, the number and quality of the messages that were directed to physicians were important, timely, and appropriate which led to fewer ED visits, sameday appointments, and phone calls.

#2 – Mobile. Physicians who are able to read, review, and send messages from their mobile device were able to find a considerable amount of “lost” time in their day. Physicians are constantly on-the-move: between patients, rounding, to the hospital and back, to lunch and back, on the elevator, etc. We found that these “micro-minutes” in each day added considerable effectiveness to mobile messaging. As discussed in #1, physician messages were already screened to be important and relevant and so a timely response is indicated. Physicians were able to answer these questions on-the-fly, leading to further confidence in the system on behalf of the patients and fewer voicemails or messages to return at the end of each day.

#3 – Voicemail. Voice messages are the bane of nearly every provider’s life. They are difficult to understand, slow, and take considerable time to review, record, and answer. Through points #1 and #2, the volume and frequency of voicemails decline considerably. The top competitor to patient portals and secure messaging is the phone. It’s universally understood, easy to use, and an immediate response is obtained. Only when patients have an easy to use portal that they can easily access anywhere (and from any device), send a secure message with confidence that it will be reviewed by the provider in a timely manner, and rewarded with a response will patients choose a new system. That’s exactly what our experience has been and there’s absolutely no reason that this cannot be replicated on a national scale.

Whether secure patient email (and ultimately our healthcare legislation) is a failure or a success relates to the patient and provider experiences and our ability to create a harmonious interplay of accessibility, ease of use, and time.

Zachary Landman, M.D. is the Chief Medical Officer for DoctorBase, a San Francisco mobile health technology company considered to be the leader in mobile cloud-based health messaging services that serves more than ten thousand providers and nearly five million patients. Landman is a former resident surgeon at Harvard Orthopaedics and graduate of University California San Francisco School of Medicine. During his career at the intersection of healthcare, technology, and industry, he has developed interactive online musculoskeletal anatomy modules for medical students, created industry sponsored resident journal clubs, and published numerous peer reviewed articles on imaging and outcomes in spine and orthopaedic surgery. Currently, he is leading the development of DoctorBase’s pioneering patient engagement and automated messaging suite, BlueData.

Another Example Of EMR “Golden Age” Applications

Posted on July 30, 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.

Not long ago, John posted a piece about the “Golden Age of EMRs Being Over” and how that’s playing out from an EMR vendor perspective. Since writing that piece he’s found that while the Golden Age of EMR buyer frenzy has passed, we’re entering a new EMR Golden Age which will feature amazing applications for clinicians and public health administrators. John calls these applications Smart EMR.

Today, I came across some news which I think is a perfect example of the kind of innovative applications John is predicting will emerge as EMRs mature. At the University of Notre Dame, researchers have developed a system which uses collaborative filtering of EMR records to better guide treatment, manage disease and predict disease risks across a population.

Notre Dame computer science associate professor Nitesh Chawla and doctoral student Darcy Davis call the new system the Collaborative Assessment and Recommendation Engine (CARE). CARE uses collaborative filtering to detect similarities between patients and produce personalized disease risk profiles for individuals. It does so by looking at diseases in similar patients.

“In its most conservative use, the CARE rankings can provide reminders for conditions that busy doctors may have overlooked,” Chawla said in a prepared statement. “Utilized to its full potential, CARE can be used to explore broader disease histories, suggest previously unconsidered concerns and facilitate discussion about early testing and prevention, as well as wellness strategies that may ring a more familiar bell with an individual and are essentially doable.”

Ultimately, Chawla says, such a system can produce a host of benefits. For example, he suggests, it can reduce readmission rates, improve quality of care ratings, help demonstrate Meaningful Use and improve personal and population health. On a more micro level, it can allow patients to walk out of their doctor’s office with a list of recommendations based on predicted health risks, he notes.

This is just one example of the kind of new applications that are emerging as EMRs mature and the use of big data becomes a tool for wellness. I expect to see lots of announcements of this kind over the next year or two. It’s an exciting time.

NFL Uses eCW To Do Concussion Assessment

Posted on July 29, 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.

Late last year, the NFL announced that it was using eClinicalWorks’ EMR to standardize their healthcare documentation for players. (Around the same time, the NBA announced that it was implementing Cerner’s EMR.)

Now, we learn that the NFL is gearing up to launch eCW as part of a pilot study of data sharing. It’s also rolling out a program bringing concussion assessment to the field-side.

According to USA Today, the league is distributing iPads to every medical staff member — equipped with X-rays, imaging studies, notes and more — to boost its ongoing efforts to improve assessment of concussions.

All of the iPads rolled out to NFL clinicians will be loaded with X2 software which includes a standard concussion assessment instrument, the Sideline Concussion Assessment Tool (SCAT-3). SCAT-3 is the most advanced version available of neurocognitive test used to determine whether a player has a concussion, USA Today reports.

For most teams, the data collected on the deployed iPads will end up being printed and placed in a paper chart.

However, eight teams — the Steelers, Baltimore Ravens, Denver Broncos, Houston Texans, New England Patriots, New York Giants, New York Jets and San Francisco 49ers — are part of a pilot program in which the results collected on the iPad will be sent via Internet into the patient’s EMR.  Eventually, if the pilot works as expected, the EMR data will be shifted as needed between all 32 NFL teams.

What makes the new pilot a bit unusual is that there’s apparently some politics involved in sharing medical data across the league.

The players, agents and the NFL Players Association are apparently concerned that when team members are being scouted by other teams in the league,  the medical data could potentially be used against them. They’re also concerned as to whether certain health information could work against players in free agency or grievance hearings.

The NFL told USA Today that it’s still working out how it will handle free agent medical records, calling the pilot program a “work in progress.”  The league does not intend to use the EMR to share records between teams until the pilot is over.

Halamka on Google Glass, Wrong EHR, and EHR Customer Support

Posted on I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.


Always great to read John Halamka’s view on the latest technology like Google Glass. I think there’s a place for wearable computing in healthcare. Plus, I’m excited that we’re just at the very early stages of its development.


Are the wrong EHR vendors going to die off?


I think it always has made or broken an EHR implementation. It’s not an easy task implementing an EMR. Many underestimate the effort required to do it right.

Healthcare Costs Hit Home

Posted on July 26, 2013 I Written By

As Social Marketing Director at Billian, Jennifer Dennard is responsible for the continuing development and implementation of the company’s social media strategies for Billian’s HealthDATA and Porter Research. She is a regular contributor to a number of healthcare blogs and currently manages social marketing channels for the Health IT Leadership Summit and Technology Association of Georgia’s Health Society. You can find her on Twitter @JennDennard.

I attended my first #HCLDR tweetchat recently, enticed by the topic of healthcare price transparency and a recent diagnosis that will soon send me in for outpatient surgery. Needless to say, my interest in the cost of healthcare services has intensified. While I do have insurance, that’s not to say that the expense will be tolerable. I have asked for every office involved to give me detailed explanations of what my estimated charges will be, how they arrived at those figures, how those figures might change, and what my percentage of those charges will be based on my insurance plan. And then I asked everyone to explain everything again. Luckily, I had the time and the resources to keep asking questions.

I even called another facility in the area to see if their estimates were competitive. That led me down another rabbit hole of inquiry. To truly know what you’ll pay for at a hospital, you not only have to take into account the hospital’s estimate, but also know that you’ll likely also receive a bill from the surgeon, lab, anesthesiologist, and pretty much any other –ologist you come into contact with – all of whom are likely contracted with the hospital, rather than its full-time employees. There was even a sign to this effect when I went in for my pre-op. No wonder patients feel so bewildered and slightly intimidated when faced with the cost of treatment.

Where does the money go? Who gets paid what for which service? If the hospital’s chargemaster says this, but writes down 50% of it due to contract with a payer, then what is the procedure’s true value? I was quoted $18,000 for one procedure, which was then whittled down to just over $3,000 after contract pricing and insurance plans were taken into account. That seems a little off to me. Was there ever a time when a hospital charged a patient what a procedure was worth? And what about patients that can’t afford care? I was candidly told by a hospital employee that sometimes those that don’t have coverage end up paying less than those that do. I’ve never been good at math, but to me, this just doesn’t add up.

I’m not the only one who has questions when it comes to healthcare price transparency. I’ve listed below some of my favorite tweets from the #HCLDR chat, and hope that you’ll find them pertinent to whatever healthcare situation you might find yourself in. (Special thanks to #HCLDR co-founder Colin Hung for Storifying the chat, thus providing me with screenshots of the tweets below. You can view the full Storify story here.)

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The Patient Portal Conundrum

Posted on July 25, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Healthcare has two major challenges hanging over its head.  The first is how to handle newly empowered and engaged patients.  The second is how to lower the skyrocketing costs of healthcare.  At the Healthcare Forum, Ashwin Ram, PhD, looked at how both of these issues are impacted by the patient portal.

Dr. Ram pointed out that the internet is by far the leading source of health and wellness information.  However, patients aren’t looking to their doctors’ patient portal for this information.  Instead they’re looking to Facebook, Wikipedia, Twitter, and online patient communities.  Dr. Ram pointedly describes this shift:

The patient is the CEO of their health.  This stuff is happening.  It’s actually not a choice that we are going to make.  It’s already occurring and if we, the healthcare provider system and all the facets of it don’t drive this change, then some 20 year old kid in a Google garage will drive it for us and then we’ll wonder what happened.

Is healthcare going to drive this change?  Can patient portals be part of providers’ response to this change?

Dr. Ram suggested that “patient portals are great…if we can get people to use them.”  Therein lies the patient portal conundrum.  He offered a simple plan where EHR software gathers the information, patient portals garner patient engagement and then we see improved health as patients’ behaviors change.

Government regulations are pushing providers to engage with their patient through a patient portal.  Meaningful use requires organizations to not only make a patient’s health information available through a portal, but 5% of patients must view, download, or transmit their health information as well.   It is clear that providers need to not simply implement a patient portal, but also need to consider how they engage with healthcare consumers.  This will become even more important as we continue the shift away from fee–for-service to value based care.

Many people believe that most patients are passive consumers of healthcare, but a study by the CDC found that 68% of adults are actively trying to prevent at least one major chronic illness.   Dr. Ram described that we are “moving from this quick fix, reactive, I’ll see you when I’m sick mindset to a wellness oriented, proactive, let’s fix the problem before it occurs mindset. ”  Where are the patient portals that facilitate this kind of interaction?

People are not worried about sharing their health information online if they see value.  We know this because we see them using online patient communities every day.  However, we need to understand the user and their specific health needs so that we can provide information, coaching and resources highly tailored to that patient.  This highly tailored health experience is what could make regular patient portal use the norm and leads us down the road to behavior change.

To create engaged patient portals that drive behavior change, Dr. Ram asserted that, “It’s got to be mobile.  It’s got to be social.  You’re not going to change behavior without social pressure.”  Behavior change is social and that does not mean one person or a million people.  We need a small handful of people who care enough to be engaged in your life.  The technology that enables this is what will make the difference.

Furthermore, social pressures don’t all have to be human.  We can let the simple nudges happen automatically while we leave the higher value, more difficult things to humans.  This philosophy understands the value of automation while still embracing the value of human touch that doctors and friends provide.  Social rewards from both humans and computers matter more to the next generation of patients than money.

Healthcare is going through a fundamental software-based transformation.  Part of this has been driven through government regulation, but the more dramatic change will be driven by the empowered patient and the need to drive down healthcare costs.  The patient portal can play a key role in that transformation if healthcare providers use it to engage patients and leverage social pressures to effect behavior change.

Check out the full Healthcare Forum presentation by Ashwin Ram, PhD embedded below:

The Breakaway Group, A Xerox Company, sponsored this coverage of the Healthcare Forum in order to share the messages from the forum with a wider audience.  You can view all of the Healthcare Forum videos on The Healthcare Forum website.

EMRs Slow Rise In Outpatient Medical Costs

Posted on July 24, 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.

EMR use can slow the rise in outpatient medical costs by about 3 percent, according to a new study done by the University of Michigan.

The study examined more than four years of healthcare cost data in nine communities, including doctor’s visit fees and services typically ordered in labs, pharmacy and radiology.

The cost data, which encompassed 179,000  patients, was drawn from the years 2005 to 2009.    Researchers studied three Massachusetts communities that adopted an EMR during this period and six other communities to serve as a control group.

All of the communities, including the three communities that adopted EMRs  — Brockton, Newburyport and North Adams — were participating in the Massachusetts eHealth Collaborative pilot which funded entire cities’ worth of doctors’ offices. The eHealth Collaborative pilot was testing the premise that converting entire communities to EMRs generates the best results.

After analyzing 4.8 million data points, breaking costs down by hospital care and outpatient care, the researchers concluded that the communities which had an EMR in place saved $5.14 per patient per month on outpatient services.

Most of the savings came from radiology. Research leader Julia Adler-Milstein speculates that the presence of EMRs may have led to the ordering of fewer imaging studies because doctors had prior images and full medical histories available to them in the EMR.

Researchers found no reductions in total cost or in hospital costs, a result Adler-Milstein attributes to the fact that community doctors, not hospitals, were taking part in the pilot study.

All told, this is interesting but perhaps not a huge deal. While a 3 percent savings is all well and good, I’d rather see results along the lines of what Canadians have seen. (A recent Pricewaterhouse Coopers study found that EMRs have saved the Canadian health system $1.3 billion since 2006.)

That being said, you can’t fix what you don’t understand. Let’s hope more serious academic attention is given to the problem of how and when EMRs can begin to bend the cost curve in a favorable direction.

CMS Shares Benefits Of Meaningful Use

Posted on July 23, 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.

CMS has released new data which lays out some of the benefits of Meaningful Use since the inception of the program in 2011.  The data outlines various ways in which Meaningful Use requirements have played out statistically.

According to the statement, the following landmarks have been reached over the last few years:

• More than 190 million electronic prescriptions have been sent by doctors, physician’s assistants and other health care providers using EMRs.

• Health care professionals sent 4.6 million patients an electronic copy of their health information from their EMRs.

• More than 13 million reminders about appointments, required tests, or check-ups were sent to patients using EMRs.

• Providers have checked drug and medication interactions to ensure patient safety more than 40 million times through the use of EMRs.

• Providers shared more than 4.3 million care summaries with other providers when patients moved between care settings.

It’s clear from these stats that e-prescribing is on a serious roll — though it’s interesting to me that over the last few years I’ve only had my scripts e-prescribed a couple of times.  Clearly there’s a lot more work to do there despite the large number.

On the other hand, these factoids aren’t staggering given that they’re cumulative over a few years. For example, while it’s encouraging that providers have shared more than 4 million care summaries (Continuity of Care Documents, I assume), that’s still a tiny fraction of the volume that we’ll need to see to say we have anything like real interoperability.

I was actually surprised to see that the reminders issued about appointments, tests and check-ups stood at a relatively modest 13 million. Primary care practices, in particular, are under such pressure to make sure patients hit their marks that you’d think setting up such reminders would be a no-brainer. But apparently it’s not.

All told, the numbers cited by CMS definitely suggest progress, but not as big of a win as the agency might have preferred. Let’s see the numbers for patient data sharing up in the hundreds of millions and then I’ll really be impressed.

MU Requirements Make a Decent EMR Suffer

Posted on July 22, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

If you’ve been missing the deep conversation we’re having in the “Develop Your Own EMR – You’re Still Crazy” thread, you’re missing some good conversation. Here’s one of the comments from Andrew Schechtman, M.D.

I’ve found the MU requirements can make an otherwise decent EMR suffer. For example, I previously used a web-based EMR that implemented an allergy documentation component that met MU requirements but was impossible to use in real-world clinical care. It didn’t allow one to enter a class of drugs (“I’m allergic to sulfas”) only specific agents. It didn’t allow an allergy entry without specifying the type of reaction. As any practicing doc knows, a good chunk of allergies come in as “I don’t know what reaction but my mom told me I’ve been allergic since I was a kid.” It met MU requirements but it was truly unusable. It continued in this unusable state for more than a year. I think it’s fixed now although I no longer use that product.

I’ve seen this from EHR vendors many times I’ve done demos. I’ll ask why something is there and then I’ll realize that it’s to satisfy meaningful use. I’ve often said something very similar about the healthcare billing requirements. EMR software could be so beautiful if it weren’t for insane healthcare billing and other government regulations like meaningful use.

I realize that it’s kind of water under a bridge at this point. Meaningful use is here to stay and the EHR incentive money is too tasty for most doctors and hospitals to ignore. However, I think the meaningful use requirements will eventually create an amazing opportunity for disruption. It will take a number of years for the billions of dollars of EHR incentive money to be spent. Plus, I think we’ll need some sort of healthcare collapse, possibly similar to the real estate collapse, to awaken people to the insane healthcare reimbursement. Both of those could create a tremendous opportunity for an entrepreneur to do something amazing for healthcare.

Big Data Impacting Healthcare

Posted on July 19, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

The following is a guest post by Sarah E. Fletcher, BS, BSN, RN-BC, MedSys Group Consultant.
Sarah Fletcher
It is generally agreed that bigger is better.  When it comes to data, big data can be a challenge as well as a boon for healthcare.  As Meaningful Use drives electronic documentation and technologies grow to support it, big data is a reality that has to be managed to be meaningful.

Medical databases are becoming petabytes of data from any number of sources covering every aspect of a patient’s stay.  Hospitals can capture every medication, band-aid, or vital sign.  Image studies and reports are stored in imaging systems next to scanned documents and EKGs.

Each medication transaction includes drug, dose, and route details, which are sent to the dispensing cabinet.  The patient and medication can be scanned at the bedside and documentation added in real time.  Each step of the way is logged with a time stamp including provider entry, pharmacist verification, and nurse administration.  One dose of medication has dozens of individual datum.

All of this data is captured for each medication dose administered in a hospital, which can be tens of thousands of doses per month. Translate the extent of data captured to every patient transfer, surgery, or bandage, and the scope of the big data becomes clearer.

With the future of Health Information Exchanges (HIEs), hospitals will have access not just to their own patient data, but everyone else’s data as well.  Personal health records (PHRs), maintained by the patients themselves, may also lend themselves to big data and provide every mile run, blood pressure or weight measured at home, and each medication taken.

One of the primary challenges with big data is that the clinicians who use the data do not speak the same language as the programmers who design the system and analyze the data.  Determining how much data should be displayed in what format should be a partnership between the clinical and the technical teams to ensure the clinical relevance of the data is maximized to improve patient outcomes.  Big data is a relatively new event and data analysts able to manage these vast amounts of data are in short supply, especially those who can understand clinical data needs.

Especially challenging is the mapping of data across disparate systems.  Much of the data are pooled into backend tables with little to no structure.  There are many different nomenclatures and databases used for diagnoses, terminology, and medications.  Ensuring that discrete data points pulled from multiple sources match in a meaningful way when the patient data are linked together is a programmatic challenge.

Now that clinicians have the last thousand pulse measurements for a group of patients, what does one do with that?  Dashboards are useful for recent patient data, but how quickly it populates is critical for patient care. The rendering of this data requires stable wireless with significant bandwidth, processing power, and storage, all of which come with a cost, especially when privacy regulations must be met.

Likely the biggest challenge of all, and one often overlooked, is the human factor.  The average clinician does not know about technology; they know about patients.  The computer or barcode scanner is a tool to them just like an IV pump, glucometer, or chemistry analyzer.  If it does not work well for them consistently, in a timely and intuitive fashion, they will find ways around the system in order to care for their patients, not caring that it may compromise the data captured in the system.

Most people would point out that the last thousand measurements of anything is overkill for patient care, even if it were graphed to show a visual trend. There are some direct benefits of big data for the average clinician, such as being able to compare every recent vital sign, medication administration, and lab result on the fly.  That said, most of the benefit is indirect via health systems and health outcomes improvements.

The traditional paper method of auditing was to pull a certain number of random charts, often a small fraction of one percent of patient visits.  This gives an idea of whether certain data elements are being collected consistently, documentation completed, and quality goals met.  With big data and proper analytics, the ability exists to audit every single patient chart at any time.

The quality department may have reports and trending graphics to ensure their measures were met, not just for a percentage of a population, but each and every patient visit for as long as the data is stored.  This can be done by age, gender, level of care, and even by eye color, if that data is captured and the reports exist to pull it.

Researchers can use this data mining technique to develop new evidence to guide future care.  By reviewing the patients with the best outcomes in a particular group, correlations can be drawn, evaluated, and tested based on the data of a million patients.  Positive interventions discovered this way today can be turned into evidence-based practice tomorrow.

The sheer scope of big data is its own challenge, but the benefits have the potential to change healthcare in ways that have yet to be considered.  Big data comes from technology, but Meaningful Use is not about implementing technology.  It is about leveraging technology in a meaningful way to improve the care and outcomes of our patients.  This is why managing big data is so critical to the future of healthcare.

MedSys Group Consultant, Sarah E. Fletcher, BS, BSN, RN-BC has worked in technology for over fifteen years.  The last seven years have been within the nursing profession, beginning in critical care and transitioning quickly to Nursing Informatics.  She is a certified Nurse Informaticist and manages a regular Informatics Certification series for students seeking ANCC certification in Nursing Informatics.  Sarah currently works with MedSys Group Consulting supporting a multi-hospital system.