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Comprehensive Health Record Vs. Connected Health Record

Posted on March 26, 2018 I Written By

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

The “comprehensive health record” model is quite in vogue these days. Epic, in particular, is championing this model, which supplants existing EHR verbiage and integrates social determinants of health. “Most health systems know they have to go beyond their walls,” Epic CEO Judy Faulkner told Healthcare IT News. A number of other EMR vendors have followed Epic’s lead.

To date, however, most clinicians have yet to embrace this model, perhaps because they’re out of patience with the requirements imposed by EHRs. What’s more, the broader healthcare industry hasn’t reached a consensus on the subject. For example, a team of experts from UCSF argues that healthcare needs a “connected health record,” a much different animal than vendors like Epic are proposing.

The authors see today’s EHR as an “electronic file cabinet” which is poorly equipped to handle health activities and use cases such as shared care planning, genomics and personalized medicine, population health and public health, remote monitoring and sensors.

They contend that to create an interoperable healthcare ecosystem, we will need to move far beyond point-to-point, EHR-to-EHR connections. Instead, they suggest adding connections with patients and family caregivers, non-clinical providers such as school clinics for youth and community health centers. (They do agree with Faulkner that incorporating data on social determinants of health is important.)

Their connected health record ties more professionals together and adapts to new models of care. It would foster connections between primary care physicians, multiple specialists, hospitals, clinics, pharmacies, laboratories, public health registries and new models of care such as ACOs. It would be adaptive rather than reactive.

For example, if the patient at home with cancer gets a fever, her temperature data would be transmitted to her primary care physician, her oncologist, her home care nurse and family caregiver. The care plan would evolve based on the recommendations of team members, and the revised vision would be accessible automatically to the entire care team. “A static, allegedly comprehensive health record misses the dynamics of an interactive, learning health system,” the authors say.

All that being said, this model still appears to be at the vision stage. Perhaps given its backing, the comprehensive health record seems to be getting far more attention. And arguably, attempting to integrate a good deal more data on patients into an EHR could be beneficial.

However, both models are largely untested, and both beg the question of whether building more content on an EHR skeleton can lead to transformation. On the other hand, while the concept of a connected health record is attractive, my sense is that the components needed to this happen have not matured yet.

Ultimately, it will be clinicians who decide which model actually works for them, not vendors or abstract thinkers. Let’s see which model makes the most sense to them.

New Program Trains Physicians In Health Informatics Basics

Posted on January 18, 2018 I Written By

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

A new program has emerged to help physicians make better use of the massive flow of health information they encounter on a day-to-day basis. With any luck, it will not only improve the skills of individual doctors but also seed institutions with clinicians who understand health IT in the practice of medicine.

The Indiana Training Program in Public and Population Health Informatics, which is supported by a five-year, $2.5 million award from the National Library of Medicine, focuses on public and population health issues. Launched in July 2017, it will support up to eight fellows annually.

The program is sponsored by Indiana University School of Medicine Richard M. Fairbanks School of Public Health at Indiana University-Purdue University Indianapolis and the Regenstrief Institute. Regenstrief, which is dedicated to healthcare quality improvement, supports healthcare research and works to bring scientific discoveries to bear on real-world problems.

For example, Regenstrief participates in the Healthcare Services Platform Consortium, which is addressing interoperability issues. There’s also the Regenstrief EHR Clinical Learning Platform, an AMA-backed program training medical student to cope with misidentified patient data, learn how different EHRs work and determine how to use them to coordinate care.

The Public and Population Health training, for its part, focuses on improving population health using advanced analytics, addressing public health problems such as opioid addiction, obesity and diabetes epidemics using health IT and supporting the implementation of ACOs.

According to Regenstrief, fellows who are accepted into the program will learn how to manage and analyze large data sets in healthcare public health organizations; use analytical methods to address population health management; translate basic and clinical research findings for use in population-based settings; creating health IT programs and tools for managing PHI; and using social and behavioral science approaches to solve PHI management problems.

Of course, training eight fellows per year is just a tiny drop in the bucket. Virtually all healthcare institutions need senior physician leaders to have some grasp of healthcare informatics or at least be capable of understanding data issues. Without having top clinical leaders who understand informatics principles, health data projects could end up at a standstill.

In addition, health systems need to train front-line IT staffers to better understand clinical issues — or hire them if necessary. That being said, finding healthcare data specialists is tricky at best, especially if you’re hoping to hire clinicians with this skill set.

Ultimately, it’s likely that health systems will need to train their own internal experts to lead health IT projects, ideally clinicians who have an aptitude for the subject. To do that, perhaps they can use the Regenstrief approach as a model.

Ophthalmologists Worry That EHRs Decrease Productivity, Boost Costs

Posted on January 16, 2018 I Written By

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

A new study has concluded that while EHR use among ophthalmologists has shot up over the last decade, most of these doctors see the systems as lowering their productivity and increasing their office costs, according to a survey published in JAMA Ophthalmology.

To conduct the study, the researchers emailed surveys to 2,000 ophthalmologists between 2015 and 2016. The 2,000 respondents, whose responses were anonymous, were chosen out of more than 18,000 active US members of the American Academy of Ophthalmology.

The researchers involved found that the EHR adoption rate for ophthalmologists, which is about 72.1%, was similar to rates among other specialties. Nonetheless, it’s a big jump from 2011, when only 47% of the 492 respondents reported using EHRs in their practice.

Most respondents were devoted solely to ophthalmology and had an average of 22 years of practice. They had an average of 5.3 years of EHR use, but nearly the entire group had previously used paper records. Eighty-eight percent of those currently using EHRs had been present for the transition from paper records to digital ones, researchers found.

Not surprisingly, given typical EHR acquisition and maintenance costs, the mean number of ophthalmologists in a given practice was higher among those with an EHR in place than practices without one. Researchers found that when practices were part of an integrated health system, a government health system, the higher the odds of their having adopted an EHR.

While the adoption rate has increased, ophthalmologists actually seem less happy with EHRs than they had been before. For example, many reported that they felt EHRs were undermining both their productivity and financial situation.

For example, more than half of respondents in 2016 reported that their patients seen per day had fallen since adopting EHRs. That’s an unfortunate change in perceptions since in 2006, more than 60% of ophthalmologists saw an increase in productivity after their EHR system was implemented.

Meanwhile, respondents were ambivalent about the impact of EHR use on revenue, with 35% reporting that revenue had remained the same after adoption, 41% a decrease and almost 9% an increase.

Despite concerns that EHRs were undercutting practice productivity, researchers reported that three previous studies of academic ophthalmology practices found no change in patient volume after EHR adoption.

There also seems to be a disconnect between what ophthalmologists think their patients want technically and what they want.  While 76% reported that their patients felt mostly positive or neutral toward EHR use, 36% of ophthalmologists would return to paper records if they had the chance.

That being said, ophthalmology practices do seem to see the benefits in keeping their EHR systems in place. For example, despite the fact that 68% saw paper documentation as faster, 53% of respondents felt their EHRs were generating net positive value.

All told, it seems that ophthalmologists’ concerns about EHR use are working themselves out. However, it also seems as though the doubts we see documented here are deeply rooted and may not go away quickly.

AI Project Could Prevent Needless Blindness

Posted on January 11, 2018 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.

At this point, you’re probably sick of hearing about artificial intelligence and the benefits it may offer as a diagnostic tool. Even so, there are still some AI stories worth telling, and the following is one of them.

Yes, IBM Watson Health recently had a well-publicized stumble when it attempted to use “cognitive computing” to detect cancer, but that may have more to do with the fact that Watson was under so much pressure to produce results quickly with something that could’ve taken a decade to complete. Other AI-based diagnostic projects seem to be making far more progress.

Consider the following, for example. According to a story in WIRED magazine, Google is embarking on a project which could help eye doctors detect diabetic retinopathy and prevent blindness, basing its efforts on technologies it already has in-house.

The tech giant reported last year that it had trained image recognition algorithms to detect tiny aneurysms suggesting that the patient is in the early stages of retinopathy. This system uses the same technology that allows Google’s image search photo and photo storage services to discriminate between various objects and people.

To take things to the next step, Google partnered with the Aravind Eye Care System, a network of eye hospitals based in India. Aravind apparently helped Google develop the retinal screening system by contributing some of the images it already had on hand to help Google develop its image parsing algorithms.

Aravind and Google have just finished a clinical study of the technology in India with Aravind. Now the two are working to bring the technology into routine use with patients, according to a Google executive who spoke at a recent conference.

The Google exec, Lily Peng, who serves as a product manager with the Google Brain AI research group, said that these tools could help doctors to do the more specialized work and leave the screening to tools like Google’s. “There is not enough expertise to go around,” she said. “We need to have a specialist working on treating people who are sick.”

Obviously, we’ll learn far more about the potential of Google’s retinal scanning tech once Aravind begins using it on patients every day. In the meantime, however, one can only hope that it emerges as a viable and safe tool for overstressed eye doctors worldwide. The AI revolution may be overhyped, but projects like this can have an enormous impact on a large group of patients, and that can’t be bad.

Doctor on Demand Stats Offer Insight Into Telmedicine Trends

Posted on January 5, 2018 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.

Recently, direct-to-consumer telemedicine provider Doctor on Demand released some statistics on its performance in 2017. While some of the report was self-congratulatory, I still think the data points are worth looking at, especially for clinicians.

For starters, it’s worth noting that the company now considers itself a fully integrated medical practice. For example, it’s begun offering lab testing services through Quest Diagnostics and Lab Corp. as part of a program to control chronic conditions such as diabetes, high blood pressure and high cholesterol levels.

Another factoid the stats offer is that its physicians are generally in their mid-career; apparently, Doctor on Demand’s average physician has 15 years of experience. The company doesn’t offer any perspective on why that might be, but it suggests to me that clinicians who participate are both confident that they can manage care remotely and comfortable with technology.

Why is that the case? My guess is that this work may not be attractive to younger doctors, who might feel uneasy managing patients online given their lack of experience. It also suggests older physicians, some of whom still consider telemedicine to be a poor substitute for face-to-face care, probably aren’t engaging with telemedicine either.

Other data provided by Doctor on Demand includes the top reasons for visits included treatment of cold and flu, prescription refills and infections, which isn’t surprising. It also notes that mental health visits climbed 240% over 2016, with anxiety, depression and stress being the most common symptoms treated. This is more interesting, as it suggests that among other problems, consumers feel they aren’t getting their mental health needs met in real life.

Meanwhile, when it comes to the company’s self-reported benefit statistics, I’m taking them with a large grain of salt, but I found them to be worth a look nonetheless. The company says it saved its patients nearly $1 billion in healthcare costs and saved over 1.6 million hours that would otherwise have been spent in doctor’s waiting rooms. These results were allegedly generated by a base of 1 million patients, according to the San Francisco Business Times.

I’m not writing this to suggest that Doctor on Demand is better or worse than other telemedicine companies and video services offered by privately-employed physicians or hospital telemedicine services. Still, I got a kick out of learning what trends a well-positioned telemedicine service was seeing in the marketplace. While Doctor on Demand’s results may not reflect the market as a whole, they certainly offer food for thought.

RCM Tips & Tricks: Shortening Length of Claims In Accounts Receivable

Posted on December 21, 2017 I Written By

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

There’s little question that health insurers do little to help your medical practice collect the reimbursement you’re due.  Not only that, ongoing changes in federal laws make improving your collections levels even more difficult.

As a result, physician practices need all the help they can get in shortening the days claims spend in Accounts Receivable, including the seemingly obvious challenge of collecting payment in full from payers, which don’t even honor rates set forth in reimbursement contracts in some cases.

Given these challenges, medical groups need all the help they can get in improving A/R. Here are some tips from medicalbillersandcoders.com:

  • Find claims which might be rejected ahead of time before submitting them to payers. Claims not paid when first submitted are far less likely to ever get paid.
  • Identify such claims using software that can track and respond to rules and regulation changes by payers. This software should also take into account the rate of denials by a given payer for all doctors.
  • Use software (such as practice management tools) to track all payments, and make sure that your practice is paid based on the terms the payer has agreed upon. Insurers pay less than promised for roughly 10% of claims.
  • Create a detailed system to address the aging of receivables, then track those claims by payer, as various payers might have different payment schedules and different procedures for addressing late reimbursement.
  • Make sure you follow up on unpaid claims as quickly as possible, as the sooner your practice follows up with health insurers the more likely you’ll get paid, and the less likely the claim will end up lost or ignored.
  • Using electronic tools, see to it that your A/R workflow is efficient, or your group may endure errors in documentation which slow down reimbursement. Practice management software can be helpful in addressing this problem.

Practices with a large budget may be able to invest in sophisticated, expensive tools which can perform in-depth claims analysis. This can help such practices improve time in A/R for claims.

However, if your practice is smaller and its budget can’t absorb high-end analytical tools, you can still improve your collections by being thorough and having a good workflow in place.

Also, it’s smart to make sure everyone on your staff is aware of your A/R goals. Even if they don’t have direct contact with collections or A/R, they can be the eyes and ears which help the process along.

Should Doctors Offer Concierge IT Security Services?

Posted on December 20, 2017 I Written By

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

Today, just for fun, I’m gonna start with a thesis and work my way back to see if you agree with its foundations. My conclusion: With the cost of IT security services climbing, the cost of care coordination rising and practice income in many cases remaining relatively level, group practices will have to change their business model substantially.

Specifically, though this may sound insane, I’m suggesting that they may have to begin charging patients for beyond-the-call-of-duty security efforts.

Of course, as we all know, practices are required to offer at least a minimal level of security protection as specified in rules like those in HIPAA. Necessary though it is, it’s a pricey exercise for many groups.

Even so, cold economics may push them to cut data protection further. Given that care coordination will be necessary to meet population health goals, and that quality monitoring and management are indispensable, they may see security as the most dispensable of these spending options.

As the need for care coordination staff, quality management and other necessities of value-based care rise, paying for IT security services will become almost impossible to pay for without borrowing from another source.

That source can come from an internal budgetary resource, such as money allocated for routine general expenses, or other overhead, such as salaries for existing staff members, neither of which is desirable. Of course, there’s also the possibility of obtaining a line of credit, but that’s arguably even worse for the future of the company.

But since no medical organization can go entirely without IT security protection, it will have to find the funds to pay for it somehow. Given that any of the possibilities discussed above will drain the practice and possibly cut its finances to the bone, but something will have to give.

At this point, many practices decide to sell their group to a hospital or health system. That’s certainly a legitimate way of taking on unmanageable levels of overhead and getting access to far more infrastructure options and financial resources.

But if that’s not the direction you want to take, here’s off-ball idea for recapturing some IT security revenue: concierge security services.

While every patient’s data needs to be protected, obviously, you could offer concierge security patients access to extra layers of security attentiveness, such as a private IT staff or to answer any data privacy and security questions they might have about the practice, hospital where they are seen or other entity.

Toss in a special “security report” (in all candor, probably info they could’ve read in any trade magazine), personalized to patient needs, and a free zip drive with secured copies of their data and you’ll have them hooked.

If this worked, and I’m not suggesting that it necessarily would, it could help carry the cost of mundane IT security services. What do you think? Would this model have a chance?

Six Years Later, What Has Meaningful Use Accomplished?

Posted on February 15, 2014 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

In Atlanta we are recovering from one of worst winter storms in many years. Weather events are financially devastating for a medical practice.  Revenue completely stops while expenses continue without interruption.   Today for the first time we saw patients in the office on a Saturday to recover a little.

During our 3 snow days this past week I decided to take on John Lynn’s challenge regarding what I would do if the Meaningful Use (MU) incentive money disappeared.  There has been a range of responses including one person who wouldn’t change a thing about MU.  However, recent data continue to support my long-held opinion that MU has been harmful to health IT and the EMR cause.

Think about where we were before MU was conceived.  Six years ago the NEJM study cited by the designers of MU showed a 4% EMR adoption rate.  Among EMR users the vast majority (72%-96%) reported a positive effect of EMR on patient care.  Among EMR users physician satisfaction was 93%.  Among EMR non-users, the major reasons for not getting an EMR included cost (66%), uncertainty regarding the return on investment (50%), and loss of productivity during implementation (41%).

Six years later, what has MU done for EMRs?  Medical Economics recently released an EHR survey of 967 physicians polled in late 2013 with very disturbing results:

  • 70% did not feel their EHR investment was worth the cost and the effort
  • 73% would not re-purchase their current system
  • 69% report coordination of care has not improved
  • 65% do not believe EHR has improved quality of care.  45% believe EHR has made patient care worse
  • 66% report financial losses resulting from EHR.  38% report significant losses.
  • Lack of system functionality was the most common complaint among EHR users (67%)
  • 45% of all physicians spent over $100,000 on EHR and 77% of the “largest” practices spent over $200,000.  It is unclear whether this is the total practice cost or cost per physician.  Increased staff costs and loss of productivity were also cited as major issues.

Also telling are data reported by CMS last May that a staggering 17% of all providers who attested for the 90 day period required for MU Stage 1 / Year 1 (2011) did not participate the following year.  A CMS survey of these “non-returning providers” (NRPs) showed many of them gave up for reasons related to the MU program as well as reasons related to dissatisfaction with their EMRs.

Analysis of these 3 studies suggests that the satisfaction rate among EMR users has fallen from over 90% to about 30% over the past 6 years.  The proportion of providers that believe EMR improves quality of care has fallen from 82% in 2008 to 35% in the 2013 ME survey.  The misgivings of non-EMR-users in the NEJM 2008 study were proven valid among the dissatisfied EMR-users in the ME 2013 survey: high cost, poor return on investment and loss of productivity.  Even 5 figure financial incentives can’t get MU / EMR participation beyond a very short time of 90 days.

How could EMR’s reputation among EMR users fall so far?  The Meaningful Use program is solely responsible.

Go back to 2008 for a moment.  Had the health IT market been left undisturbed, EMR vendors would have engaged their existing base of satisfied customers in order to improve their products and sell to new customers.  This base of early EMR adopters was unique and special.  Our practice was among those that had a fully functional EMR in 2007-2008.  We shared a vision and saw the potential for information technology to improve health care.   We had both the IT resources and the will to work hundreds of extra hours to build effective EMR systems from products that were almost useless as they came “out of the box.”  We willingly accepted that proposition.

In 2008 the early adopters would have gladly offered their own practices as examples to demonstrate the value of EMR and help their vendors sell to new customers.  This slow, evolutionary growth would have created a stable environment that allowed the health care system to safely assimilate the cultural and operational changes that EMR brings.  This environment would have also supported stable evolution and improvement of EMR products.  The result would have been modest but steady growth in the EMR market for decades to come.

But thanks to MU this never happened.  Replacement of stable, natural market forces with MU incentives drove immediate, explosive short-term growth in the EMR market.  But these MU-driven EMR purchasers are not like the practices before 2008 that freely chose to purchase a system. These practices had decided against EMR initially, at least partly because they lacked the IT resources to make EMR work for them.   MU coerced them to purchase EMR against their better judgment.

I have spoken with many of these physicians.  They do not share the inspiration and vision of the early adopters.  They are rightly unhappy and cynical, forced by MU to spend huge amounts of money on unproven, underdeveloped EMR products that they did not want and were not prepared to properly use. To these practices the question of EMR’s potential is irrelevant.  In their minds MU (and by association EMRs) lives next to HIPAA, SGR and RAC audits as another method for the government to intimidate doctors and intrude upon their practices.

The MU program gave EMR vendors what they wanted – legislation requiring hundreds of thousands of providers to buy EMR products, with no need to prove that those products do anything useful.  But here’s the bad news: the Feds got what they wanted as well.  Through MU they created an EMR industry that is dependent on government incentives and penalties to maintain a stream of new customers.  This gives them complete control of the EMR market.  There is more bad news.  MU also destroyed the base of satisfied EMR customers from 2008, replacing it with a much larger base of unhappy, resentful customers.

So what happens as MU payments decrease with each passing year as MU requirements go up?  Who can argue that the market won’t collapse without another EMR stimulus package?  John Lynn’s question is appropriate and timely.  MU incentives will indeed disappear over the next couple of years.  How the EMR market will survive is not clear.

The Doctor’s Best Use of the Tablet

Posted on August 27, 2013 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

I recently reviewed the Epocrates 2013 Mobile Trends report.  The study has a somewhat unusual participant profile, consisting only of primary care, 3 medical specialties and no surgical specialties; nonetheless the observations are probably close to the mark and are consistent with my experience with my first tablet a couple of years ago.

I purchased an iPad within a couple of months of the introduction of the first model thinking it was perfect for EMR use in my office.  I abandoned it after a couple of months when I discovered several shortcomings.  First, the first iPad was too heavy to hold by the edge and had to be held by a fully supinated hand (totally flat palm facing up).  Try that for 5 minutes and see how your forearm feels.  The first iPad was also too big to put in a physician’s white coat pocket.  And the screen resolution of the first iPad models was not good enough to display a busy EMR screen.   But the biggest drawback was that the early remote desktop apps did not work very well.

The iPad mini addresses all four of these issues.   The Mini is small enough to fit in a white coat pocket with the standard magnetic cover in place.  It is easily and comfortably held by its edge.  It needs a Retina screen badly but the display is better than the original iPad and is (barely) adequate for my 50-year-old eyes to see.   And remote desktop apps have come a long way.  It appears that similar advances have been made in tablets from other manufacturers as well.

I was therefore surprised to learn from the Epocrates study that although a majority of providers (53%) use tablets for patient care related activities, only a small portion (2%) use tablets for actual patient care record keeping in an EMR.  So I thought it would be interesting to outline my current methods of using a tablet that put me in the 2% category as well as the 53%:

 

  • Entering data into my EMR via a Remote Desktop app.  There are important lessons here.  Don’t expect to stick a tablet in the physician’s hand and have it work like magic.  Our office workflow is designed to optimize the physician / tablet combination.  I use the tablet for only 2 data fields in EMR:  assessment and coding (CPT and ICD).  The office staff enters all the other parts of the note and initiates treatment workflow through the EMR at the physician’s direction.  After the patient is seen I review all parts of the note (on a laptop or desktop), make additions / corrections, and sign it.
  • Cloud based voice-to-text.  This takes the tablet from merely useful to spectacular. There are 3 characteristics of Apple’s built-in cloud-based speech recognition that make it comparable to the Dragon software I have used in various forms for over 10 years:  1.  It is embedded seamlessly into the soft keyboard, 2.  An inexpensive external microphone plugged into the headphone /microphone jack raises transcription accuracy tremendously, and 3.  It works well with Remote Desktop, eliminating the need for a “dictation box” or other similar workaround.  These attributes make up for its most serious drawback, the lack of a medical (or at least customizable) vocabulary.  At the moment I have the right people talking to each other to address that problem.
  • Hospital EMR.  Our hospital is still in the implementation phase of a new Cerner system.  I am still learning the system myself but my initial experience using the system on my tablet using Citrix Receiver has been very positive.
  • Patient education.  LUMA, a product of Eyemaginations, is a very nice product for showing surgical patients the complex head and neck anatomy of their diagnosis and/or proposed surgical procedure.  There are both online and iPad versions available.  I can switch back and forth between EMR and LUMA without losing the Remote Desktop connection.
  • Medical imaging.  I can’t load an image disk directly onto my tablet but I can load it onto my desktop and take a photo with my tablet to review relevant images with patients.  I have tinkered with some apps that allow me to draw on the image to help educate patients.  Still looking for a way to conveniently reduce the file size to facilitate copy-pasting into EMR notes.
  • Literature searches in the exam room.  Not glamorous but helpful, most commonly to review medication side effects.

 

I think that is a pretty complete use of the tablet for the physician.  No doubt new uses will appear before long.

 

Our First Year with a Patient Portal

Posted on August 11, 2013 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

Last month marked the end of our first year with our web portal.  It has been a steep but worthwhile learning curve.  Similar to every other component of our IT system there were many bumps along the way.  Here are some observations worth sharing:

  1. If you build it – and promote it – they will come.  There is no question that patients in our North Atlanta market like the portal.  Over the first 12 months 12,518 patients have signed up and completed over 130,000 health, demographic and general consent forms.  Participation has increased steadily as we have refined web page usability and improved the reliability of the system.  Subjectively I think about 2/3 of my new patients are using the portal to enter their demographic and personal health information prior to their initial appointment.
  2. Overpromotion backfires.  Our telephone-greeting message says, “To schedule an appointment, dial 0 or go to www.entofga.com.”  Sounds reasonable enough, but patients have misinterpreted this message as meaning that we don’t want to talk to them.
  3. If it doesn’t work, patients get angry – with good reason.  Nothing is more frustrating than spending 45 minutes filling out all your information at home and then getting handed the same forms on paper at the office because your online data was lost.  The IT folks seem to think if the explanation for the failure is fancy enough that will make everything OK.  It doesn’t.
  4. Patients who choose not to use the portal at home don’t want to use it in the waiting room, either.  We have tried iPads, laptops and desktop kiosks.  We have trained our front office folks to promote it and even “walk patients through” the portal.  Nothing has worked.  We have considered recruiting those patients with a different technology such as scanned #2 lead pencil bubble forms, at least for the discrete data.
  5. Patients have little interest in using the portal as an ongoing tool.  After the initial creation of the account, data entry and first appointment, they rarely use the portal again.  Last month with over 12,000 patients enrolled we got only 6 prescription refill requests and 24 “ask the doctor” questions.   Appointment requests were slightly better at 134.  Our telephone appointment schedulers tell me they frequently get calls from folks who made an appointment request online but then immediately call for the same appointment because they were not comfortable with the online appointment concept.  One could argue that this is unique to our specialty practice or that the online forms and workflow need improving.  That may be true, but I am convinced that at least a part of this phenomenon represents cultural pushback from patients.
  6. The ROI on the web portal is in some ways an all-or-nothing situation.  For a while the portal was passing to EMR only about 15 of the 20 data fields required to complete our demographic database.  Intuitively one would think the portal was therefore “75% useful”.  The problem is if I have to pay staff to open the patient’s file to manually enter the 5 remaining fields, I may as well have them manually enter all 20 fields.  That makes the portal 0% useful.  I can’t reassign staff to better things until the portal passes 100% of the data to the EMR.  This also relates to the reliability issues described above.  Until we reach near 100% reliability the return on investment is limited.
  7. As with every health IT product we have ever tried, it doesn’t work completely as advertised.  Although the new patient workflow is going fairly well other features remain severely compromised.  In our vendor’s defense this is partly because our parent EMR has had some upgrades which in turn requires our vendor to update the portal to adapt to the EMR changes.  The point is that none of these products is “plug and play” and the industry has a long way to go before these products become easy to use and practical for everyone.
  8. There are unintended consequences of a web portal.  Unbeknownst to us our portal was directing patients to the vendor’s personal health record product.  The transition is apparently pretty seamless so patients often still thought they were still inside our portal when they encountered very personal questions (i.e., sexual history) that had no relevance to their ear / nose  / throat appointment.

As an “early adopter” practice we are pleased overall with the portal but I’m not sure how a more typical practice would feel.