Free EMR Newsletter Want to receive the latest news on EMR, Meaningful Use, ARRA and Healthcare IT sent straight to your email? Join thousands of healthcare pros who subscribe to EMR and EHR for FREE!

Wow, That was Fast

Posted on February 19, 2016 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.

Well that sure didn’t take long…

In response to CMS Administrator Andy Slavitt’s comments last month regarding the future of the Meaningful Use Program and the need to recapture the hearts and minds of physicians I posted on open letter to Mr. Slavitt yesterday in an attempt to reach out to him regarding those issues.

I did not expect what happened next.

He answered within a couple of hours:

“Very thoughtful letter and I think likely reflects the views of many. I will share it internally because culturally people need to see the gulf between the policy ideas and the front line of medicine.

Believe all the fatigue and the laws we still need to implement and the current state of technology means it will take some time before differences are felt where they matter. Implementing laws like MACRA is a complex undertaking but the core of what you said I believe is the most important thing– It all begins with listening. The details matter here more than the principles but I’m a believer in that’s where it starts. And we have more focus groups and front line interactions than I have seen before. We are not just listening to “Washington” docs.

I try to always begin by calling it like we see it including hard truths. I believe we have work to do and want to orient people to the proper course. You always risk setting expectations when you lay out an agenda, particularly when there is no silver bullet. But it’s better than the alternative.”

Within moments I also received equally gracious responses from Patrick Conway and Kate Goodrich, also from CMS:

We both inherited the “meaningful use program” 6-12 months ago and do think the MACRA legislation providers an opportunity to transform the program, lessen burden, make much more simple, and flexible to meet docs needs. Happy to take ideas and input from you anytime and thanks for your work.”

Wow. You have to admit that this is not what one would expect from the “faceless, heartless bureaucrats” I have been criticizing in print and on Internet radio all this time. Is the paradigm changing? Maybe. Maybe not. But one thing is for sure – we physicians have to give them the chance to make good on their rhetoric. I certainly intend to to that.

Stay tuned….

An Open Letter to Andy Slavitt, Acting Administrator CMS

Posted on February 18, 2016 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.

Mr. Andrew Slavitt
Acting Administrator
Centers for Medicare and Medicaid Services
Washington, D.C..

Dear Mr. Slavitt:

No doubt you were surprised at the strong, widespread reaction to your comments regarding the Meaningful Use Program as part of your speech to the JP Morgan Healthcare Conference several weeks ago. Your quote regarding the hearts and minds of physicians was particularly noteworthy. After decades of Federal regulatory hostility towards physicians, some of us doctors were pleasantly surprised – even shocked – to hear you acknowledge:

– physicians exist beyond just being another cog in the healthcare machine.
– physicians actually have hearts and minds.
– physicians’ opinions might have value to you.
– programs that are poorly designed distract physicians from patient care.
– CMS aspires to a “cultural focus on listening and learning”

Many of us physicians reacted like starving prisoners when the Commandant announces that there will be extra cockroaches for dinner. Though the news was small, many of us were overjoyed.

But most of us (60% by a recent survey) reacted differently. The majority of us understand the political savvy of saying something controversial about your enemy. Such a move can create a useful distraction, driving the enemy to argue amongst themselves while you continue with work that you would rather we didn’t notice…and that is exactly what has happened. Like an octopus squirting ink into the water you have created an effective smokescreen to let you spend the next few months coding Meaningful Use into MACRA without any interference from us.

So the purpose of this letter is to ask the question: Which of the above interpretations of your comments is correct? What are your intentions?

If your comments are sincere then consider this letter a warm introduction to the group of rapidly growing, grass-roots full time practicing physicians whom this letter represents. Over the past few years we have acquired the policy expertise and political skills to be effective leaders and collaborators with you to bring truly meaningful improvements to America’s health care. Realize that the leaders of organized medicine with whom you currently work – including the AMA , whose membership represents less than 15% of practicing physicians – do NOT represent the “hearts and minds” of physicians that you profess to seek. If you mean what you say then we are reaching out to you.

If, on the other hand, your comments are nothing more than political subterfuge, then this letter serves as a warning. We are not buying the political offal that you are selling. This physician group will use all of its intellectual, financial and political resources to make it far more difficult for you to destroy what is left of health care in America.

The choice is yours. We look forward to hearing from you.

Michael Koriwchak, M.D.
Vice President
Docs4PatientCare Foundation

Making Tablets More Effective for Data Capture

Posted on February 27, 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.

Six months ago I wrote about the virtues of using an iPad Mini tablet in the patient care setting.  At that time I was using my tablet almost all day, every day for multiple purposes including EMR data capture.  Things went well for a while, but as time passed I used the tablet less and less.  Eventually I stopped using it almost altogether except for displaying and annotating CT images during patient visits.  At first I did not understand why.  Was the non-Retina display finally getting to my 50+ year old eyes?  Was the external microphone I used to improve speech recognition losing performance?  Was the battery fading after 9 months of charge / discharge cycles?  Or was the “gadget lust” of a new tech-toy finally wearing off?

Each of the above may be just a little bit true.  But two other reasons are most relevant to me.  First, my efforts to add a medical vocabulary to the embedded speech recognition failed.  But most importantly, I became frustrated with how difficult the tablet was to hold for extended periods of time.  When I wrote that the tablet was “easily and comfortably held by its edge” I was wrong.  Tablets are beautiful to behold, but their clean lines and smooth surfaces make holding them for extended periods of time very cumbersome.

So I created something that would fix the problem by making a tablet more comfortable and safe to hold.  Now that the provisional patent application is registered I can share the design:

                 figure 11

The photos are of a nonfunctional mockup I made out of Styrofoam, balsa wood and spackling compound.  It is a grip that attaches primarily to one edge of a tablet computer and facilitates holding the tablet by its edge rather than the back.  It is shaped to fit the hand and allows both proper hand positioning and proper viewing angle.  It provides a mechanical interface between the tablet edge and a semi-pronated (handshake position) hand/forearm.  Its purpose is to facilitate extended use of the tablet by minimizing orthopedic strain to the hand, wrist, forearm, elbow, shoulders and neck.   The interface with the remaining 3 edges is minimal, preserving the ability to store the tablet-grip assembly in a coat pocket.

The external shell is a composite of plastic, rubber, metal, leather or similar materials.     There may also be a thin covering over the back and/or front faces of the tablet for protection and mechanical stability.  The top side is contoured to engage the thumb and guide the thumb to the home button.   The bottom is contoured to engage the fingers.  This shape gives the thumb and fingers stability and purchase to counter the tablet’s weight and torque in the yaw and roll axes.  The gripped portion has bilateral symmetry to allow left hand or right hand grip.  Openings and mechanical and/or electronic pass-throughs provide access to tablet buttons, ports, etc.  It could also include a stand for self-support on a tabletop and a place to store a stylus.  Some panels could be customized for color, shape (i.e., for different hand sizes) or material.

There is space available within the grip to add hardware and enhance functionality.  Examples include – but are not limited to – extended battery, external microphone / speaker, Bluetooth keyboard interface (to make the composite device appear as a keyboard to an external workstation), wireless USB, and apps that use cloud-based speech to text capability.  Any companion software component – an app – would be loaded into the tablet itself.

I need your help both to estimate the potential of this idea and get some advice on what to do with it next.  If you think this is an idea worth pursuing give me a like on Facebook at the bottom of the article.  If you feel strongly about it give it a Tweet as well.  And if you have some advice I would be grateful to hear it.

 

#HIMSS14 Highlights: the Snail’s Pace of Interoperability

Posted on February 26, 2014 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.

Ah, HIMSS. The frenetic pace. The ridiculously long exhibit hall. The aching feet. The Google Glass-ers. As I write this, day three for me is in full swing and I’ve finally managed to find some time to reflect on what I’ve seen, which includes a ridiculously long taxi queue at the airport, more pedicabs than I can count, beautiful weather and lots of familiar faces, which is what makes HIMSS so much fun. I’ve heard lots of buzzwords and sales talk, and seen only about an eighth of the exhibit hall, barely scratching the surface of what’s out there on the show floor.

Several common themes stand out based on the sessions and events I’ve been to, and the passions of those I’ve encountered. Whether it’s vendor breakfasts, social networking functions, exhibit elevator pitches or educational sessions, interoperability and engagement are still the buzzwords to beat. This particular HIMSS has given me a different perspective on each, and offered new insight into what’s happening with the Blue Button Connector. I’ll cover each of these in HIMSS Highlights posts over the next several weeks, starting with interoperability.

The industry seems far more realistic this year regarding interoperability – downright frustrated by the slow pace at which such a lofty goal is proceeding. Industry experts Brian Ahier and Shahid Shah perhaps expressed it best during a lively panel discussion at the Surescripts booth:

interoppanel

interoptweet3

interoptweet1

interoptweet2

Putting vendors’ feet to the fire will certainly initiate a quick and painful reaction, but probably not a sustainable one. True momentum will occur only when providers get singed a bit, too. Panelist comments at a Dell / Intel breakfast on analytics for accountable care brought this into sharper focus for me. The fact that too many disparate EMRs (and thus too many vendors poised to cause inertia) are making it hard for analytics to successfully be adopted and utilized at an enterprise level, highlights a bigger problem related to hindsight and strategy.

From my perspective – that of an industry observer and commentator – it seems many providers felt compelled to purchase EMRs because the federal government offered them money to do so, and hopefully just as many were optimistic about the role technology would play in positively affecting patient outcomes. Vendors saw a great business opportunity and moved quickly to develop systems that met Meaningful Use criteria (not necessarily going for best-fit as related to workflow needs and usability). Neither group truly knew what they were in store for, especially regarding longer term plans for health information exchange.

Providers now find themselves wanting to move forward with health information exchange and greater interoperability, but slowed down by the very IT systems they were so insistent on purchasing just a few years ago. Vendors (some more than others) are hesitant to crack open their products to allow data to truly flow from one system to another, and who can blame them? The EMR market, in particular, is poised to shrink, which begs the question, who will survive? What companies will be around at HIMSS 15 and 16? Those who keep their systems siloed, like Epic? Or those who are trying to break down the silos, such as Common Well Alliance members like athenahealth and Greenway?

It makes me wonder if providers wouldn’t have been better served with just had a handful of EMRs to choose from around the time of HITECH, all guaranteed to evolve as needed and play nicely with each other in the interest of health information exchange. Too many options have caused too many barriers. That’s not just my opinion, by the way. I’m willing to bet that a sizeable chunk of the 37,537 HIMSS 14 attendees would agree with me.

Do you disagree? Are providers (and patients) better served by more IT options than less? Let me know your thoughts, and impressions of interoperability advancement at HIMSS, in the comments below.

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.

Web Portal Use by the Numbers

Posted on October 7, 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.

With our first year of web portal use well behind us I started looking for practical ways to begin mining some data to get some basic statistical observations regarding patient use of web portal.  As with all new undertakings in health IT this was far more difficult and cumbersome than it should have been.  Nonetheless I got a few interesting observations documented over the past couple of days.  I did not do an exhausting review but I don’t think data like this exist anywhere else.

I was curious about what proportion of our network’s new patients have used the web portal over the past 6 months.  Overall 22% of our new patients used the web portal for clinical data entry.  This differs significantly from my subjective observation that about half of my new patients were using the portal; this data includes all 19 of our network physicians, not just my own.  I am in the process of looking at my patients only.

 

The breakdown by age is here – the first table  – web portal figure 1

 

Portal use is very steady at around 25% through age 65 years.  Use among pediatric patients shows parents are just as willing to use the portal for their children as they are for themselves.  It is reasonable to expect portal use to drop with increasing age but I didn’t expect 65 year olds to be using the portal as much as 25 year olds.  Portal use among patients in their 70’s and 80’s is quite respectable.  The bump in use in patients over 90 years of age is interesting but likely to be a statistical illusion due to the very small absolute numbers in those age brackets.

 

The second table shows the same data expressed as raw numbers rather than percentages.  All our new patients, regardless of portal use, tend to be from age 40 to 70 years.

 

 

Digital Health Could Seal Fate of Small Hospitals

Posted on August 30, 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 am not a healthcare investment expert by any means, but two recent pieces of news make me wonder if the digital health movement will inadvertently result in the hurried demise of already struggling small and rural hospitals.

According to a recent CB Insights report covered by MedCity News, 362 digital health deals last year accounted for an all-time high of $1.5 billion. Of those deals, 55 were exits – smaller digital health companies bought up by larger players. CB Insights notes the majority of these acquired companies were those that provided products that make administrative health processes more efficient, such as EMRs and revenue cycle management systems. This is an assumption, but I’m inclined to think these EMR companies priced their products below their more corporate competitors. These companies may well have supplied their systems to the budget-conscious small and rural hospital market.

As most everyone knows, small and rural hospitals are facing an uphill battle these days when it comes to keeping their doors open. A recent Georgia Health News item noted that three rural hospitals in the state have closed in 2013, with some predicting an additional 20 facilities will close within the next two years. The article cites constant cash shortages, claims disputes with payers, lower projected payments to hospitals from Georgia’s new state employee benefit contract, and reduced indigent care funding as contributing factors to the poor financial health many small Georgia hospitals find themselves in.

While these may be specific to Georgia, they are almost surely indicative of similar problems seen by similar institutions in the U.S. At least 849 facilities across the country will soon face the common problem of increased scrutiny by Medicare as a result of the current “bloated and unwieldy” state of the critical access hospital program, which was designed to financially stabilize small hospitals by providing them with higher Medicare reimbursement rates.

It looks to me as if the digital health exits noted above are perhaps indicative of a broader industry trend. Small and rural hospitals are already under enormous pressure to care for underserved populations in a fiscally responsible way. As the healthcare vendor market consolidates and looks to digital health as the next best venture, will we see more affordable EMRs folded into those that are less so? Where will small healthcare facilities turn for their healthcare IT?

Where do you think these two trends will converge in the next year or two? Please share your comments below.

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.

The Week of the EMR Celebrity

Posted on July 18, 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.

What a strange week in healthcare IT it’s been, particularly where EMRs are concerned. First came breaking news that Kim Kardashian’s privacy potentially had been breached (insert ironic arch of eyebrow) by Cedars-Sinai employees who had inappropriately accessed patients’ private medical records last month. Then came much more noble press via NPR, which has devoted a series on All Things Considered this week to profiling the world of EMRs:

I had to shush my husband – clap a hand over his mouth, actually – when the NPR interview with Farzad Mostashari came on. “I’ve met that guy!” I told my husband. “He’s a celebrity in our industry, but for all the right reasons!” It was almost invigorating, especially after reading Kardashian headlines, to hear him discuss the many points we’ve all been debating and/or covering for the last few years. He was just as much a compelling cheerleader for the adoption of EMRs and the impact they are likely to have on patient safety as he had been when he bounded across the stage at HIMSS a few years ago.

Which brings us to the middle of the week, when CMS released its latest set of data touting the latest round of EMR success:

  • More than 50% of eligible health care professionals and 80% of eligible hospitals have begun using electronic health record systems since the meaningful use program launched in 2011
  • Shared more than 4.6 million EHR copies with patients;
  • Sent more than 13 million appointment, test and check-up reminders;
  • Checked medication interactions more than 40 million times; and
  • Sent more than 190 million electronic prescriptions

I’m beginning to think that CMS and federal agencies like the ONC are really getting the hang of this media game. I’m sure it’s no coincidence that NPR ran its stories the same week CMS released its latest success story. I just wonder how the general public is digesting this information. With 80% of hospitals now on EMRs, it’s a safe bet that the majority of patients in this country (even Kim Kardashian) have information stored away in one. Are they beginning to realize the benefits this technology brings to their care? Or are most patients still uneasy with the lack of eye contact from their doctors, who are now glued to a computer screen?

Do the CMS numbers tell the whole truth? Has patient safety increased to the detriment of patient satisfaction with bedside manner? Let me know your thoughts in the comments below.