An HIT Moment with … John Shagoury

An HIT Moment with ... is a quick interview with someone we find interesting. John Shagoury is president of Nuance Healthcare.

Is the rich nature of the physician narrative getting too little attention in the rush to get codified data for interoperability?

Yes, as the healthcare industry and more recently policymakers work to make electronic health records commonplace, I believe that the concept of preserving the physician narrative has yet to receive adequate attention.

While the HIT Policy Committee has recognized “electronically capturing data” as part of the “meaningful use” criteria, the rich nature of the physician narrative needs to be specifically identified. In order to ensure that patients’ medical records do not suffer in quality, and that caregiver communication via shared notes does not lack necessary detail, electronic health records must not be reduced to point-and-click templates alone. The physician narrative should be accounted for and measured as part of quality care tracking under the American Recovery and Reinvestment Act.

This past June we surveyed more than1,000 of our physician customers on the topic of “meaningful EHR use” and learned that 94 percent of physicians surveyed either “agree” or “strongly agree” that capturing physician narrative as part of the documentation process is necessary for complete and quality patient notes. When you’re dealing with patient care and people’s lives, codified data only gets you so far. We must not forget that physicians treat people with problems, not just people’s problems; the details found in the physician narrative help to personalize the record, leading to high quality, patient-specific care.

Providers want a fast, sure payback on their capital investments. What’s your message to them?

If a healthcare organization is making any investment, including a capital investment in healthcare IT, it needs to align with a step-by-step workbook that outlines actual cost and benefits. All investments should be well supported with project goals at the technical, user, stakeholder and strategic levels. In addition to goals, the following should be crystal clear: what needs to be measured; how it will be measured; and how often it will be measured.

Another option to a capital purchase is an investment in a hosted (on-demand) solution. Regardless of what model an organization uses, I’d counsel providers to do both statistical and qualitative predictions and measurements. With the example of speech recognition technology (which is offered by Nuance as either a capital or on-demand purchase), an organization should estimate and measure the amount of traditional transcription cost that is expected to be saved, the projected physician satisfaction and efficiency levels gained, as well as quality improvement of patients’ health records.

While there’s no clear-cut playbook for which method of IT delivery fits which healthcare organization, working with an experienced vendor can help to ensure you invest in the right solution for your individual organization’s needs. Additionally, as the industry is increasingly identifying traditional transcription as an opportunistic area to boost efficiency, improve quality and reduce costs, we are seeing more organizations choose the on-demand model. It should be interesting to see if this trend continues.

While a capital purchase allows for full control of on-site software management, as well as data, security and process control, for many the on-demand model is more compelling. With on-demand, instead of installing software onsite, hosted software runs on the vendor’s servers. The vendor hosts the application and makes it available for users to access through Web browsers (via secure passwords). All of the customer’s data is stored at the vendor’s site; all maintenance of the software and server hardware, data backups, and tedious details of that nature are handled by the vendor. Healthcare organizations simply pay a monthly fee depending on their activity level; there are few extra costs or tasks associated with management and upkeep of the program for the customer. In addition to the benefit of less investment up front and fewer responsibilities on program updates and management, upgrades also happen automatically, and any glitches are the responsibility of the vendor.

The industry has taken some widespread negative PR and patient lawsuits over undelivered and uncommunicated critical patient results. Nuance acquired Vocada and its Veriphy solution in fall 2007. Was that a timely acquisition and will it be strategic going forward?

The decision to add critical test result management capabilities (CTRM – Veriphy) to Nuance’s healthcare portfolio was indeed strategic. The timely and accurate reporting of critical test results from the lab or diagnostic imaging group to the treating physician is an important aspect of patient safety. Unfortunately, and despite many regulatory and accrediting requirements, the typical “systems” for delivering and managing critical test results are mostly manual, disjointed, inefficient, prone to error, and frustratingly inconsistent.

In a recent study led by Dr. Lawrence P. Casalino, an associate professor at Weill Cornell Medical College, it was found that more than seven percent of clinically significant findings were never reported to the patient. As part of the study, the records of 5,434 patients at 19 independent primary care practices and four based in academic medical centers were reviewed. Casalino’s team extracted records that contained abnormal results for blood tests or X-rays and other imaging studies, and then searched for documentation that the patient had been properly informed of the finding in a timely way. After many interviews with physicians associated with the uniformed patients, the researchers found that of 1,889 abnormal results, there were 135 failures to inform.

Clinical laboratories are tasked with performing more than 10 billion tests per year and while critical results generally comprise less than two percent of all lab findings, the timely communication between the lab, physician, and patient is always crucial. Through use of critical test results management technology (Veriphy), leading medical centers like Virginia Commonwealth University Medical Center are automating the communication of patients’ critical findings so patients do not have to second guess if their results are normal and doctors do not have to worry about liability if a patient is not notified. VCU performs as many as 340,000 procedures annually, they went from being only 49 percent effective for critical message delivery and today critical results are communicated to the right caregiver within 13 minutes of being identified 99 percent of time. Phone tag is no longer relied on to ensure critical patient care.

Going forward, and increasingly as results like VCU’s become known, we expect Veriphy to be identified and deployed at more radiology, lab and even hospital-wide as healthcare organizations work to improve caregiver-to-caregiver communication and speed high-priority patient care.

Where are Nuance’s healthcare R&D dollars being focused?

With expertise in speech recognition, clinical communication and documentation, as well as diagnostic imaging, our R&D dollars are directed at expanding upon the capabilities and technological advancements we are already recognized for across the healthcare industry.

As mentioned earlier, preserving the physician narrative as part of patients’ electronic health records is extremely important. We will continue to improve the recognition capabilities of our speech solutions, expand our already formed relationships with EHR vendors and work to perfect natural language processing capabilities. We believe that data extraction and analysis of the unstructured clinical narrative, as well as the conversion of the unstructured narrative to structured, discrete documentation is critical for improved ongoing patient care.

Moving forward, we will continue to focus on ways for our customers to find value from the physician narrative for caregiver utilization in real-time, as well as to drive extensive analysis for enhanced care and operations moving forward. We will also remain focused on supporting current and emerging standards associated with HL7 CDA implementation guides to ensure the data the our customers capture is accessible and shareable for use within their enterprise, regionally and nationally as deemed appropriate.

With unnecessary imaging procedures costing between $3 billion and $10 billion annually, we will also work to expand upon and promote our RadPort solution as a viable, and cost-effective, solution for managing high-tech diagnostic imaging utilization. Earlier this year, Nuance co-founded the Imaging e-Ordering Coalition, which is an alliance of leading healthcare providers, technology companies and diagnostic imaging organizations working to promote electronic decision-support (e-Ordering) as a solution to assure that all patients receive the most medically appropriate diagnostic imaging test for their specific condition.

RadPort is an electronic decision-support tool that provides ordering physicians with clinical information at the time they are ordering a patient’s exam. By producing a "utility score" for the requested exam, physicians can assess the medical appropriateness of the exam to ensure it will be reimbursed by the patient’s health plan and most importantly to verify that it aligns with the patient’s conditions and care needs.

In addition to decision support, we are working with many customer sites to collate and analyze their ordering, documentation and patient outcome data via a Rubik’s cube like data warehouse, called RadCube. Over time medical groups can determine how often their providers’ selections of higher utility scans improve patient outcomes. RadCube collects a tremendous amount of data, automatically structures and classifies it and then provides a visualization of current activity to drive improved care, business and management decisions.

What does the short- and long-term picture of healthcare IT look like from the company’s point of view?

For the first time, healthcare IT is in the spotlight. In the short-term, we’ll see a combination of big promises from vendors that are simply unable to deliver matching technological advancements alongside market leaders that have been focused on addressing specific healthcare pain points for some time.

It is an exciting time to be in healthcare. As healthcare reform has captivated the nation, HIT has also risen in recognition and priority. As part of the American Reinvestment and Recovery Act, $19 billion is allotted for incentive payments starting in 2011 under Medicare and Medicaid for providers determined to be “meaningful EHR users.” As we anxiously await the definitive meaningful use definition, which is expected in the spring of 2010, Nuance is working to educate policymakers on how speech recognition can help national EHR adoption and utilization.

It is proven that a major EHR usability hurdle for physicians is the task of typing. Speech recognition does two things to improve EHR utilization.

• It makes physicians more productive. Because the majority of people speak faster than they can type, clinical documentation can be done more efficiently when speech recognition is applied; this allows doctors to spend more time practicing medicine.
• By allowing physicians to speak vs. type, they are empowered to create a highly detailed narrative of the patient encounter that can not be fully represented in structured templates alone, or perhaps would not be as complete if a physician was tasked with typing the note. EHRs will only be valuable if the information captured within them supports improved, ongoing patient care. We believe speech recognition can help to improve the quality and detail of information captured in patients EHRs and will be more broadly used in the short-and-long term.

In addition to speech recognition as core to EHR workflow, we are also working to educate policymakers on Capital Hill about the value of electronic, evidence-based clinical decision support to help eliminate medically unnecessary diagnostic exams. The technology, RadPort, rates medical imaging exams (at the time a doctor is ordering them) on a scale of appropriateness of 1-9. The rating is based 100 percent on the likelihood in which this particular exam will or will not contribute to positive outcome for the patient (will it help them?). Nuance is also a co-founding member of a national Coalition (The Imaging e-Ordering Coalition), which supports providing physicians with guidance regarding the ordering of patient-appropriate imaging services. Obama has talked exhaustively about the importance of reducing unnecessary exams and we are confident this technology can help.

Over the next 3-5 years, the healthcare space will move from IT laggard to more of a leadership position. The meaningful application of IT to healthcare is incredible and necessary. It can drive advancements in efficiency, cost savings, and patient care. Whether it’s clinical decision-support or applications to document the patient encounter without the keyboard or pen, we’ll see doctors’ tech toolkits evolve with new solutions to improve care.

Moreover, we’ll see the impact that strategic enterprise-wide HIT can have on a healthcare organization as a whole. The ultimate long-term goal will be interoperability and the availability of a patient’s medical history across any care-providing site, affiliated or not. With the right application and management of HIT, we can expect to see improved patient care and physician efficiency, while the cost burden associated with the current health care system is dramatically reduced.