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Photo IDs as Part of the Patient Record – Flashy Trend or Future of Medicine?

Posted on June 5, 2012 I Written By

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

Some time ago I read about the sad case of a toddler who underwent surgery for lazy eye correction, only the ophthalmologist “corrected” the good eye instead of the lazy one. Apparently she realized her error mid way and fixed the lazy eye as well. The child’s mother learned of this later.

I find many categories of lawsuits to be frivolous (that infamous hot, scalding coffee case anyone?) but if the parents ever had a strong case against a doctor, Jesse Matlock’s parents certainly did. But reactionary impulses aside, I’ve been thinking about how such errors can be prevented.

ICD-10 coding for example offers laterality info, but its implementation is still a-ways from becoming reality. Also ICD codes simply help you or your organization bill appropriately. If you need laterality information in any stage prior, you’re probably dependent on your trusty clinical notes.

Today Reuters had an article about patient photos as part of hospital records. Apparently it’s being tried at Children’s Hospital in Colorado. When a child is brought in for treatment, his or her digital image is added as part of the medical record.

Reuter reports that compared to 12 occurrences of mistaken orders in 2010 (in which treatment intended for one patient was performed on another) the number had fallen to 3 in 2011. All three of the cases involved children whose photos were not added to their medical records on arrival. There are similar feel-good statistics on near miss cases in which another worker caught a medical error put in place by a colleague (33 near misses in 2010, 10 in 2011).

The Reuters article notes CH, Colorado sees something like 13500 patients a year. The improvement in numbers after photo ids might not seem like much but each error prevented helps us gainthat much more confidence in our care providers. The article states that some parents refuse photo ids for kids out of privacy concerns. Let’s face it, this is for a loftier purpose than a child modeling. One workaround could be to discard the patient’s ID soon after the encounter is complete.

While the article doesn’t explicitly discuss laterality, that too could be a possible use for photo ids, if maybe the photo can be marked to point out surgery sites for example.

In terms of cost, digital photography has never been more affordable than now. For a couple of hundred dollars you can buy a good quality digital camera and its needed accessories. Basic photo editing software can assist with keeping image sizes manageable. The big downside I see is that it increases the workload somewhere along the encounter – someone needs to take these pictures and upload them, and knowing how things roll downhill, it might well be the already harried nurses and aides.

But the payoffs to quality healthcare could be enormous. So what do you think – has the time come for this idea?

ONCHIT Health IT Software Contests – Some Thoughts

Posted on May 30, 2012 I Written By

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

Ken Terry at InformationWeek has an interesting editorial on Office of National Coordinator on Health IT’s (ONCHIT) latest contest for developers. This time the ONCHIT wants developers to come up with an IT product that can help ophthalmologists see better (yes, it’s a lame pun 🙂

Among the laundry list of requirements that this mythical software must possess: (I’m quoting from Terry’s article)

it must warehouse data from many different devices;
convert the data from proprietary formats to a single, vendor-neutral format;
enable clinicians to manipulate data and images;
and interface with existing EHR systems (presumably, just the top dozen or so)

Here’s the link to the slightly more detailed ONCHIT list. The first prize is $100,000 which is nothing to sneeze at.

Terry lists some problems uniquely faced by specialists such as oncologists and ophthalmologists: off the shelf EHRs don’t really grasp the nuances and details of information needed by specialists. Terry lists for example weight and height details that EHRs typically capture. Opthalmologists don’t really need this information. Typical EHRs on the other hand don’t allow for visual acuity information to be stored, at least not without (paid-for, and hence costly) customizations.

Looking at this issue as a some-time developer with some skin in the game, here’s how I see this process: ONCHIT wants to kick start IT development by getting developers interested via contests. This time it’s shining its light on opthalmologists. It has provided a list of not-so-impossible to design features, which might not capture all the nuances of features needed by ophthalmologists.

The major flaws I see in this process: the prize money is smallish, which means that the people that would be most interested in developing something would be the smaller IT shops. However, most IT developers don’t know enough about ophthalmology to truly understand what’s needed of their IT product. Till I saw Terry’s accompanying editorial, I was under the impression that this was a perfectly fine list of features to request. Also, I’m very underwhelmed by the “details” provided in the ONCHIT page. It is full of 20 dollar words, which will probably make little sense to the developers who are the intended targets of these words.

To be sure, you will see some health IT developers develop something and send them out, just because. Hell, it’s a contest, and there’s decent prize money.

Here’s what I’d rather have seen: maybe a short video that shows an ophthalmologist at work, a couple of minutes where s/he describes the main challenges s/he faces and provides the top 5-6 things that is on hizzer wishlist in an EMR. Or ONCHIT could facilitate talks between developers and specialists so each side understands what is required of them. Till then we’re doomed to square pegs in round holes software products that frustrate everyone soundly.

Better EMR Design

Posted on May 23, 2012 I Written By

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

Now that we’ve heard the statistics about EMR use, we’re also hearing a lot of opinions on EMRs, and not all of them are laudatory. In fact I read some separate articles recently, and they pretty much said the same things in so many different words:

– EMRs are not intuitively designed. They do not reflect actual workflows that most doctors or hospitals follow. Rather the applications look like they’ve been designed by a bunch of programmers who then design the UI to look like how they’re underlying data are structured.
– Because they’re pretty much being foisted on hospitals and doctor’s offices through “incentive” programs, often the resources expended on them are sunk costs. To improve the workflow of a software to accurately reflect the needs of a particular hospital, you will need to pump extra money into it. That’s about as likely to happen as a software vendor providing you a customized solution without charging you anything extra.

Let me assure you – the medical establishment has it exactly right, at least in my experience. I work as a technical writer, so much of my working life consists of documenting the products that make it to your doorsteps, and I have experienced some of the same frustrations as you. I’ve complained about them, made myself unpopular with development teams and added my two cents to feature request lists, just like many of you.

But, I also see things from a programming perspective too, and I’m here as a sort of ambassador between both worlds. Many teams I worked with had an actual designer working as part of the team.
But the designer’s role was often making the colors look attractive enough, or the font large enough to appeal to a cross-section of users. One of my old bosses, different industry and everything, called this our Lipstick on a Pig game, and plenty of times that’s what the designer’s role was. Inventing plenty of shades of lipstick for the proverbial pig.

Ergonomic design was not what the designer was tasked with doing. One place I worked at even had a doctor on payroll. Except he had a doctor’s degree from Shanghai, had not cleared his exams in the States and had no idea how medicine is practiced in the States. It sure looked good on paper when their sales team went out to clients and talked about having a dedicated doctor on staff to help with software design.

And the effect of poor design on functionality is often perplexing, sometimes disastrous. Case in point – documenting all the drugs administered to a patient. It has been drilled into programmers that clicks are sacred things, you don’t want doctors wasting too many of them.

So because we don’t want too many clicks, we list each and every medication a patient has been administered, add some pagination logic around it and call it a day.

The doctor, who is the end user, for whom we designed this software system, now sees all the information in a “convenient” list and doesn’t need to open up a medication tree to view the medications under it. Except if she has a very sick patient with multiple encounters, the case history reveals a medication that is 31 pages deep. To get to Xanax, she might have to page through 30 previous pages.

While these “features” fall into the realm of merely annoying, they’re nowhere as disastrous as those modal alerts that Barbara J. Moore talks about in her KevinMD piece. A modal window is one of those annoying windows that you have to take an action on, otherwise you can’t proceed any further in your workflow. Moore points out the hazards of such alerts which force a doctor to take a choice, any choice, but aren’t available later if the doctor wishes to review the alerts at leisure.

So yes, software vendors need people who know the workflow to design the systems. But more importantly, you – the medical establishment – must keep requesting changes or suggesting features, or vendors will remain complacent about what they put out.

Affordable Care Act and Employee Health

Posted on May 14, 2012 I Written By

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

Over at, there was a super interesting brief on Affordable Care Act and its forthcoming changes regarding employee health. Starting in 2014, employers will be able to offer incentives to employees regarding their enrollment in employee wellness programs. Employers can offer incentives such as monetary rewards for positive employee behavior like enrolling in a smoking cessation program, or joining a gym at discounted rates. Or these can work like the proverbial stick, by imposing penalties on non-compliant employees, e.g. increasing the cost of participating in an employer health plan by $1000 for employees who say they have smoked in the last year.

Now all those good components of the ACA will still be applicable i.e insurance companies will not be able to refuse patients based on prior medical history. But I can’t help but notice the irony of the ACA being used to discriminate between a healthy employee and a sick one.

One of the examples cited in the brief is that it will be legal for an employer to offer a health plan to employees who fulfil certain wellness criteria such as enrolling in a gym in addition to the other health plan options available to its other employees. The cost of the other health plan options to a truly unwell employee could well be so exorbitant as to make it impossible for him/her to enroll in it. Options for such employees could be to enroll through a spouse’s plan or purchase private insurance through the health information exchanges. The brief says that there are plugs for these sorts of employer excesses, such as companies with over 50 employees will be penalized even if one employee enrolls in a subsidized state insurance program in lieu of the company sponsored one.

I’m also wondering if there will be any kind of guidelines for companies to design their incentive/penalty programs. Health and wellness are incredibly nuanced issues. For every person who can exercise a half hour a day and lose a pound a week, there are those who seemingly subsist on air and water and barely make a dent in their BMI. Genes determine plenty of factors in a person’s helath profile, including weight, propensity to develop certain conditions and so on. It makes me wonder if we’re oversimplifying things by gauging employee wellness based on criteria such as gym enrollment.

Plus what if you have lots of people like me who might enroll in a gym and never see the inside of it beyond the first few days? Simple enrollment might not be enough. But, to my mind at least, tying enrollment to outcomes has the unfortunate whiff of a mini nanny state in the making. Who wants to be the person at the company weigh-in whose BMI has come down by .1 while the muscled, rippled company health club employee looks at you quizzically? Not me.

I also worry about the unwell employee who feels pressured into signing up for risky activities (from his/her health perspective), simply in order to get the rewards offered or to avoid the penalties. S/he might have something truly tangible to lose both ways.

I would love to see how ACA transforms in the next couple of years but right now I think I have way too many unanswered questions.

A Rosa Parks for EMRs

Posted on May 7, 2012 I Written By

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

From the Healthcare blog, this week there’s a super interesting post on Regina Holliday, a widow turned patient rights advocate.

First some background about Holliday: She’s a widow with young kids, her husband Fred died after weeks of suffering from from cancer. She is now taking her patients’ rights advocacy before the American Heart Association by protesting the lag in how soon patients can see their medical records. Holliday’s personal experiences inform her protest.

From the post:

When [Hollidays] sought access to [Fred’s] electronic medical record, the hospital responded by saying “we must wait 21 days and pay 73 cents per page to see the story of his care. Then they told us we could go home to die.”

Per Meaningful Use Stage 1 guidelines, patient records must be made available within 4 days. Holliday is asking for access within 24 hours. American Hospital Association (AHA) in all its wisdom is asking for 30 day lag.

The one issue I don’t see addressed either by Holliday nor by Michael Millenson in his post is the question of cost. Who will bear the cost of making records available immediately? Will it roll downhill to the patient, or become a shared cost between patient and provider? Still I hope Holliday succeeds, it is a radical idea worth pondering over.

Pinteresting EMR Thoughts

Posted on April 30, 2012 I Written By

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

I heard about Pinterest maybe a couple of months ago and if my slow uptake of Facebook is any indication, I have a good two years to go before I add another website to the pantheon of websites I must check daily.

However some early adopters are already talking of how the healthcare world can make use of this site. I came across one such article today via the Healthworks Collective site where Mike Wilton shows us a bunch of different healthcare related Pinterest uses. Some doctors or hospitals are using Pinterest to market their services, one hospital is using Pinterest to request donations for children, yet others are targeting certain demographics (parents, cancer patients) by becoming their go-to resources on some topics.

Since I’ve sworn fealty to all things EMR, I went searching for EMR related boards on Pinterest, and I must say I was underwhelmed. I did come across one slightly interesting one called Healthcare Infofraphics that was the source of the widely pinned Top20 EMR Softwares pie-graph. You can also find other Healthcare IT Infographics.

I know if you’re related to EMRs, a) your world isn’t as interesting or visual as say cupcakes, or quilts b) Pinterest is relatively new (hell, you can’t just sign up, you need an invite to register). But, seriously, do you think people are going to find screenshots of your software interesting enough to pin to their boards and share with others? And yeah, don’t bother scanning the tri-fold handout that you shoved into people’s hands at the last tradeshow. It might have worked great on paper but it looks cluttered and unimaginative on Pinterest.

I’m going to offer some tips here for anyone with any Pinterest interest, but more so for EMR vendors:
– it’s still early days. If you’re not on Pinterest and none of your nearest competitors are there too, maybe you can increase your cool cache instantly by signing up and creating a much viewed board.
– Make us see things. Instead of reams of text, maybe we need one pic of a happy client, a speech bubble and a super short compliment.
– Play to Pinterest. It’s a highly visual site. So what works for you on FB or Twitter might not work for you here.
– Approach it sideways. Yes, you want to sell your product and make money. But if you answer questions that your target demographic typically asks, your content will probably get pinned a lot more.

– don’t be square
. Dare to do something out of the box. I would prefer my cartoon strip slightly funnier but I give Dell props for this attempt at making an unboring visual about EMRs.

Or maybe you should wait out. Pinterest has a lot of buzz. But so did Myspace and Foursquare. I even wrote a cringe-inducing article on Foursquare back in the day.

Moral Obligation and Tweets

Posted on April 24, 2012 I Written By

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

I must say this headline from Fierce Health IT gave me a great many giggles today: Healthcare social media a ‘moral obligation’. No shred of irony in the article either, which quotes Farris Timimi, M.D., medical director for the Mayo Clinic Center for Social Media, thusly:

“Our patients are there. Our moral obligation is to meet them where they’re at and give them the information they need so they can seek recovery,” Timimi said. “You’ve got to be ready for it. You build it for the patients; not for yourself.

“This is not marketing,” he added. “This is the right thing to do.”

Are you sure it’s not just a way to log in to Facebook while you’re on the clock, Dr. T?

Not to come down too hard on Dr. Timimi, but I can think of plenty of other medical things which are “moral obligations”: saving patient lives, or low cost accessible healthcare for all. Being able to find a condesed tweet about bunions – um, not so much. I mean, healthcare is already quite a messpool to be in without doctors and hospitals flogging themselves over not being social media savvy enough. And not everyone can be a social media rockstar John D Halamka.

I know I’m being wilfully dense tonight. And the esteemed Dr. Timimi probably had stuff like Facebook pages and cancer blogs in mind when he talked about healthcare info via social media. But I scoured Twitter for “medical advice” and “cancer” and found that there’s some accidental giggles to be had:

Tim Brookman ‏ @T_Brookman
Next person that texts me for medical advice is getting told to apply icyhot directly to their genitals

nicole west ‏ @NicNac19
I love when friends come to me & ask medical advice & I actually know the solution… just don’t quote me, lol.

saintseester ‏ @saintseester
will not be giving free medical advice on anonymous social media. You’d be an idiot to take advice like that anyway.

Official Cancer Page ‏ @Cancer69_
#Cancer is big on trust and if you lie to them they will make sure you regret it
(yeah, yeah, I getit.. they’re talking about the sun sign)

So, EMRs Do Reduce Tests Ordered? Partners Says Yes

Posted on April 16, 2012 I Written By

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

About the same time last month, I brought your guys some unwelcome news – that physician access to electronic records perhaps doesn’t reduce the number of tests subsequently ordered, and hence doesn’t reduce healthcare costs as much as previously thought.

Except that maybe it does. At least that’s according to an article in Chicago Tribune that summarizes the findings of a study by Partners Healthcare, and a research letter published in the Archives of Internal Medicine (full text, PDF).

According to the study:
– It looked at health information exchange and test data between Mass. General Hospital and Brigham and Women’s over a 5 year period from Jan. 1, 1999 to Dec. 31, 2004.
– The study looked at 117,606 patients during this period. Of these, 346 patients had recent off-site tests, of which 44 were done prior to the HIE rollout.
– The study found that for patients with recent off-site tests, there was a 49% reduction in number of tests ordered.
In number terms, the number of tests ordered per person reduced from 7 in 1999 to 4 in 2004.
– There was however a slight increase in number of tests ordered for the population that didn’t have any prior testing done during the same time period – increasing from 5 per person to 6 per person.

These findings directly contradict the Health Affairs study that I mentioned earlier. The Chicago Tribune article has a little researchers-play-nice subsection at the end where the Health Affairs and Partners researchers try to interpret each other’s contradictory results.

If I may add my 0.02:
– Even though the Partners study follows a larger population of patients, the data that is used to calculate the reduction (346 and 44) is way too small
– The Health Affairs studied some 28,000 patients spread across 1,187 doctor’s offices, while the Partners study followed a larger population of patients at two huge Mass. hospitals that entered into a partnership with each other.

While this not directly discounting anything each group has found, I would think the HA study is more representative of what’s going on in different parts of the country, where doctors are using different (in capability/costs) EMRs and labs to get their results. In Partners case there may well be a tacit agreement on EMR brand, or even tacit trust between the labs/facilities that each hospital uses.

Very interesting though, and I’d really love to see what else comes out on EMR and healthcare costs.

What the EMR Industry Can Learn From Facebook

Posted on April 9, 2012 I Written By

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

A couple of interesting posts on caught my eye (one of them by way of KevinMD, but I’ve learned to go to the horse’s mouth, so to speak, for everything I read on KevinMD). In his first post on a Facebook model for EMR, Chris Rangel takes us through a generic history of the Internet – right from the days when you had to manually connect to a server through the green-on-black Bulletin Board Services and modem in order to access any information. Apparently servers were not connected to one another and you had to hangup the connection in order to server hop.

(If I sound clueless about this, well, I grew up in India where circa 1995, some kind of UNIX based primitive mail system was all the rage, and since my friends and I didn’t really know anyone outside our immediate circles who had access to “electronic mail”, our forays consisted of sitting in adjacent terminals and mailing each other funny jokes.)

And then came the evolution of HTML and dynamic server content, and so on, till we finally reached the clouds, literally. Ours is an age where most of the information we use resides on a server somewhere and the mode of accessing them is through apps or browsers.

Using Facebook as an example, Rangel explains why we would want our EMR systems to work the same way – our health records should be automatically pushed down to a server every time we have a healthcare encounter. For physicians or pharmacists, all they would need to do is to access our information through a browser or an app on a tablet. In theory, this should make for more efficient healthcare encounters, higher sharing of information, and easy switches from one doctor’s office or facility to another.

Healthcare utopia, no? No. At least not yet.

We have so much more work to do before communication between health silos in various doc offices, hospitals, pharmacies, labs etc is truly functional. If 90s style browser wars (where did Netscape go?) and the social networking wars (FB, MySpace, Diapsora, Hot or Not) are anything to go by, the winner of the healthcare battles may not be the one or two well-known entities that dominate the market today, but disruptive companies that are currently developing something we deem frivolous now, but which may hold the key to our digihealth future.

Obamacare Before SCOTUS

Posted on April 2, 2012 I Written By

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

So the Affordable Care Act got hauled up before the SCOTUS last week. From the way the questions were framed it looks like the individual mandate portion might be struck down, though it is too soon to tell.

I have mixed feelings about the Affordable Care Act. On the one hand I can see why affordable health for all must be a priority. I know people who use the ER room as their sole point if contact with the healthcare system, and sadly some of them have paid the price with their lives. There’s also a selfish reason behind my reasoning. Each time someone uninsured turns up at the ER, and gets top notch care, it is MY tax dollars that fund the treatment. Surely there are better ways to use tax dollars.

And yet a mandate makes me queasy. If the government mandates health insurance today, will it start mandating annual exams and flu shots a few years down the road. I think the most succint response on this topic was summarized thus by a Twitterer: “The problem with the mandate is the insurance is private. Make the insurance public and call it a tax. Problem solved.”

I can hear Americans collectively go This isn’t Canada at this point. But think about it: directly or indirectly, we are paying for the uninsured with our tax dollars. Public health insurance might take away some of the worries we have around bouts of non-insurance resulting from unemployment or old age.