Giving a patient medications in the ER, having them pop positive on a test, and then withholding further medications because…
Monday Morning Update 3/9/09
From Bill Swerski: "Re: negativism. I can’t tell you how much I look forward to your news blogs. They just keep getting better and more informative. Your statement regarding not worrying about the economy and working harder is one of the most prolific statements I have heard in the past few months. The negativism to me is what is hurting the economy. This single quote needs to be plastered on billboards, bathroom stall walls, and anywhere else a Sharpie can be held! Our statement here for the bad times is ’Suck it up, cupcake!’"
With those kind words, let me say for the record that I’m just as hard-hit and discouraged as anyone else (my IRA and 401k are down 60%, so I’ll probably be working until I drop). I also don’t like the idea that I did the apparently unfashionable — paid my mortgage and taxes on time, lived within my means, and didn’t start crying for help because my house payment went up while its value went down, so there’s no bailout in my future (except paying for one to help the irresponsible people). Still, whatever degree of intelligence, ambition, and resourcefulness I had hasn’t seeped out of me just because others (some of them elected to high office) made truly boneheaded decisions. I’m knocked down, but not out. If your priorities were based entirely on accumulating wealth, it’s a great time to re-evaluate. One of my favorite sayings: I’ve never seen a hearse pulling a U-Haul.
It may already be too late, but if you want to attend the Monday, April 6 HIStalk reception at HIMSS, please RSVP immediately as we are just about to hit the cutoff of 300 (or it may have been 400 — hopefully the Ingenix folks sponsoring kept better notes than I did of what we decided). Please don’t RSVP if you aren’t sure you’re coming since someone else will lose their chance. Pretty nice digs: the 92-story Trump International Hotel is right on the river at the Loop and North Michigan. We will be in the largest room, the Grand Ballroom, which has views of Lake Michigan and lots of historic buildings through 24-foot windows. If you are the sort that likes to hobnob with movers and shakers, the RSVP list includes 27 CEOs and presidents and 56 VPs so far, plus an assortment of financial types, media people (what are they doing attending a blogger’s event?), and friends of HIStalk (that’s all of you, of course, but some of these are names you would know from reading). Thanks to Ingenix and Ingenix Consulting for sponsoring and for everybody attending. If it’s a great event, it will be because of the cool folks who chose to be there.
Speaking of the reception, a reader informs me that the NCAA basketball championship tips off the same night at 8:21 Chicago time. I wouldn’t have known since the only sport I care about is college football, but I know people obsess over their brackets and all that. Hopefully it won’t be too much of a conflict. That reader suggested a post-party viewing event and is looking into underwriting a modest one (heck, all you need is some Chicago dogs, a keg, and maybe … just thinking out loud … a couple of cheerleaders).
Gwen at Healthcare IT Jobs was curious about the University of Illinois at Chicago’s online MS in Health Informatics program whose ad is running to your right and on Healthcare IT Jobs, so she assembled some information (warning: PDF) about it, just in case you are curious. People often decide to further their education when the economy is unfavorable, so it’s a timely topic.
CalRHIO and OCPHRIO will launch a statewide system providing secure access to patient information in 23 Orange County, CA EDs in July. The Orange County group will use CalRHIO’s electronic platform, which I believe (but the press release doesn’t say) is Medicity.
Hopefully your Daylight Saving Time switchover went OK.
Young adults ages 19-29 make up the larges group of uninsured citizens, all 13.2 million of them. One reason: they’re too old to stay on the plan of their parents, but their employers don’t offer coverage or they can’t afford it. These are the folks, of course, who will have to bail out Medicare, fund the retirement of all of us baby boomer geezers, and pay massive interest on the federal debt racked up trying to keep an economic balloon with a hole in it inflated. Somehow I’m not feeling real good about their willingness to do that when the time comes.
A New York Times op-ed piece called The Computer Will See You Now seems to have gripes about EMRs that aren’t really described too well, but seem to be: (a) using the computer in front of patients is intrusive; (b) standard questions must be asked in order even when they clearly don’t apply; (c) the doctor might swear in front of patients when the computer does something wrong; and (d) computers lose context because doctors can’t underline, write bigger, or otherwise highlight something important. From those observations, the author suggests further studies are needed and perhaps EMRs should be maintained only on tablet PCs. That’s a pretty big and unconvincing leap from the anecdotal experience of one user, but lay readers will unfortunately assume it is authoritative since the Times ran it.
The Minneapolis-St. Paul paper highlights Amcom and VisionShare, healthcare software companies that "are proof, even amid all this economic turmoil, that we can build growth companies by making health care and other industries simpler and more efficient." Probably true.
Lobbying experts say Nancy-Ann DeParle’s industry ties shouldn’t disqualify her from being health czar, saying experience "on the other side" is not a negative because you need people who have worked in the field. I would ordinarily agree, but much of the Obama stimulus and reform plan is prescriptive in specifically advocating and advancing EMRs and she has profited greatly from being involved with companies that sell them. Still, I agree that shouldn’t rule her out. I think some in the industry would have preferred someone who has actually worked in healthcare, but I suppose at high-profile levels you’re always going to have someone who has risen to heights above the majority of us who actually do the work as non-profit employees.
Healthcare expert Dennis Quaid revisits Cedars Sinai with Oprah’s TV people and cameras, "to see what steps have been taken to ensure a similar mistake won’t happen again." Apparently the best case study on medical errors involves his twins, who unlike some victims had no lasting ill effects whatsoever, and the best investigator for the job is their actor dad. I thought his movie Everybody’s All-American was pure dreck, so I plan to call up Oprah to film me as I meet with studio executives to demand an explanation of how they will make sure something that horrifying never happens again. Dennis, of course, can do whatever he wants at Cedars because he’s hanging a potential lawsuit over its head, so they have to grit their teeth and pretend he’s got insightful thoughts as he lords around the place with the TV crew catching his good side. He’ll be great at HIMSS in any case since actors can make you love them by just being whatever you want them to be (I bet actors would make great salespeople).
A Massachusetts doctor who writes best-selling novels says the inspiration for his latest, The Second Opinion (# 1,563 on Amazon) came from a visit to his own doctor, who was too busy entering information into the computer to make eye contact. "I started thinking about electronic medical records and HIPAA (Health Insurance Portability and Accountability Act, which requires standards for electronic medical records and also helps to ensure patient privacy.) So that’s what I wrote about."
Nuance announces that its SpeechMagic has been rolled out in 12 London sites of HCA.
GE and Siemens are upset that Obama’s plan calls for cutting government spending on MRIs and X-rays, so they’re threatening to turn the lobbyists loose to argue that it would deny seniors "life-saving medical services" (taking a cue from HIMSS in using the term "advocacy" instead of the much less noble-sounding "special interest lobbying"). Like everybody else, they’re all for cutting massive healthcare expenses as long as it doesn’t cost them anything. Another entirely impartial group, the American College of Radiology and its radiologist members, also doesn’t like the plan. Both like to raise the specter of "actuaries" making medical decisions.
Healthcare IT mecca Beth Israel Deaconess Medical Center is on track to lose $20 million this year and layoffs are apparently coming. The Most Wired folks are always stretching to try to correlate IT investment to outcomes, so I expect they’ll modestly look away.
Some highly insightful equities research: an analyst notes that AMICAS offered $1.82 per share to buy out Emageon, so his target price is $1.82.
It was interesting to read the New York Times opinion piece from Dr. Coben (The Computer Will See You Now). You mention that the experience she has is anecdotal and that it is only the experience of one user. This one user has hit the nail on the head when she concludes that “that the computer depersonalizes medicine.”
The computer is a wonderful tool, but for most users it requires a conscious effort. Writing on a piece of paper or dictating after an exam is more intuitive and efficient for most doctors. With computers, it is a challenge to get physicians to tear themselves away from their patients, shift their focus to a computer screen and interface with a keyboard and mouse. Doing so requires deliberate effort to navigate oftentimes complex screens containing a myriad of dropdowns, check boxes and text boxes. The computer distracts the physician and dilutes the physician-patient encounter.
Making matters worse are certification bodies that certify software based solely on the number of features included and not based on the product providing a seamless user experience (read the 500+ CCHIT criteria to get a flavor of how ease of use and, hence, physician productivity are not on the EMR certification agenda: http://cchit.org/files/certification/08/Ambulatory/CCHITCriteriaAMBULATORY08FINAL.pdf)
With precision, Dr. Coben has identified the crux of the EMR adoption problem.
Mr Histalk: Your ususal cynicism is almost always delivered with laser like precision to exactly the right place ……. however you missed the boat in your review of Dr Coben’s piece. Dr Coben has detailed exactly why there is only 4% EMR (in the only reliable study available) in Office practice. The core transaction in healthcare is the doctor/ patient interaction that needs the full attention of the doctor. As is also detailed in the recent IOM study, EMRs are built for regulators, administrators, and doctors malpractice concern.. Far less than 10% of physicians can adequately type and interact with patients at the same time. Until EMRs are built to support this core transaction, we will not see significant uptake despite all the billions anyone want to spend or all the drum beating in the world. There is very little written about this, but try this one: “Paperless medical record not all it’s cracked up to be” by Edmond Blum MD in AMA News in 2-17-’03 issue
I think you could cut Dennis Quaid a little slack. Sure he doesn’t know anything about medical errors beyond his most recent experience (and is not a great actor). But he is keeping a small spotlight on medical errors in a way that a non-celebrity could not. And the more light that shines on the problem, the better. Also, as a celebrity, he’s reaching a group – the US weekly crowd, let’s call them – that wouldn’t otherwise have much exposure to the issue. Speaking at HIMSS, though? Now THAT makes no sense.
I read the Coben piece in the NY Times and found it more the grumblings of a recalcitrant doctor than thoughtful insight. Now don’t get me wrong as Steele rightly points out above, most EMR solutions stink when it comes to usability and integration to physician workflow and this is one area that CCHIT never even comes close to addressing – not really sure they should as this is something that the market must decide for itself.
Ultimately, there is a fine line between usability, functionality and simply a change in this mind-numbing tradition bound industry that seems wedded to practices based down by Hippocrates. Change is a coming, the big question is, who will be the dinosaurs hopelessly stuck in the Brae Tar-Pits, and who will evolve.
For an example of evolution and counter to the NY Times article, the WSJ recently had a brief clip of a physician using his EMR in daily practice: http://blogs.wsj.com/health/2009/02/27/how-does-a-doc-really-use-an-electronic-medical-record/
I must also disagree with Dr. Coben’s assessment of the “negative” impact EMR’s have on doctor-patient relationships. My daughter’s pediatrician has a PC in every exam room loaded with one of Mr. HISTalk’s sponsor EMR’s, and we’ve never had a bad experience. Not only does the physician sit at the keyboard and enter assessment/progress notes, she does so while interacting with my entire family. She’s also able to review past visits, as well as show growth charts based on my daughter’s height, weight, etc.
It seems to me that as with most things repetition improves efficiency, and over time even the most computer illiterate docs can become adept (if not lightning fast) at using a PC.
I’ve also found that the most successful EMR users are those that are open to change…
Re: Hearse/U-Haul: My pastor used to say that from the pulpit all the time too. Then, as he was travelling to Arizona for the holidays, he came upon a couple college guys that were driving a hearse (probably one they found for cheap). Guess what??? They were pulling a U-Haul trailer. Now he can’t say he’s never seen it, because he has.
I couldn’t agree more with your thoughts on Dennis Quaid. While the medical community could certainly see some improvements made…Doctors, Nurses, Healthcare IT professions and the like have one giant thing in common…we’re all HUMAN and unfortunately….humans make mistakes.
Re: Dennis Quaid comments… most entertaining piece I’ve read in some time. John Glaser look out! It’s probably because I agree with your assessment and it was nice to see someone come out and say what many were thinking. I’m not judging his motives or the frightening reality of what took place, but at the same time, I don’t think he’s ready to head up the HHS or FDA. I’m just not sure he would agree. As Inner Space said, the posiitive side of all this is the spotlight on patient safety.
Seems to me that there a balanced view on the use of data input devices to support EMR’s by Physicians should consider both the needs of the Physician entering the data and the needs of the Physician involved later in the continuum of care’s need for that data. Physicians need to agree to these standards first and foremost. The rest of us just deliver to these standards with as reasonable and cost effective soltuion that ensure patient safety and care effectiveness as practical.
I agree with the well thought out comment by the SRSSoft CEO and the more matter of fact comments from Disbelieveing MD more that the bulk of design to date has been patient payor compliance driven and not necessarily patient care driven. I would encourage us “solution delivery” folks to not take lightly just how low the MD EMR adoption numbers are. This is not just the “rantings” of technophobic MD’s. They are quickly adopting the use of other data devices (iPhones for example) in very large numbers. They just have chosen not to adopt the solutions we have delivered to date in the same numbers; that points the issue is “our” solutions and not the end user. Let’s roll up our sleeves and fix the problems with the electronic care process holistically.
I for one am very optimistic we can do this (with or without the gov’t stimulus and preferably without)…
“…actors can make you love them by just being whatever you want them to be…”?
True also with presidential candidates.
We have all seen doctors struggle with using electronic health records and we have also seen docs use them without any interruption in their eye contact and interaction with the patient. I think this is a combination of a number of things. The hardware and exam room set up: you have to be able to make eye contact no matter where the patient is and while tablets allow one to have something the same size as a paper chart that you can write on, you can also succeed with thoughtful placement of a fixed computer. Training: If you don’t spend the time learning the software and practicing before seeing patients with it, you will have to be looking down a lot so follow the recommended training and do at least 20 practice chart notes before you go live. Then you will find that muscle memory will lead you where you want to go and you can often find things much more easily than in a paper chart. You can also show the patient graphs of their labs, BMI etc that facilitate training and immediately print out appropriate patient education without rooting around in drawers and cabinets. Bring the patient into the computer along with you. Organizational issues: make sure that everything is not left to the physician to enter. Data should be entered by the lowest paid person capable of doing the job. So that might be the patient completing an online health history, medical assistants to gather the vitals and preliminary HPI information, front desk staff to order routine mammograms, etc. Software: You do need the software to allow you to take the history in any order that the patient presents it and you need it to be stable and not crash or blow up. Certification can never really test for what is functional as what is functional for me might be intolerable for you so we do have variety in the marketplace. Make sure when you look at demos that you have vendors run through the exact same script of something you commonly see without interruption before you take a deeper dive into features. That gives you a chance to look at the flow and how many clicks it takes, whether it drives you to take a history in one fashion or allows you to skip around. A lot of times at demos, we as physicians have some many questions that we never see that scenario end to end as it would likely play out in our offices.