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Readers Write 1/17/11

January 17, 2011 Readers Write 10 Comments

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Remote Access Is Not Mobile Access
By Cameron Powell, MD

1-17-2011 6-27-11 PM

Healthcare organizations are quickly learning that both remote and mobile access strategies are required. See Table 1.

Remote access lets providers work in the hospital computing environment when they are not on location. This includes accessing the EMR and clinical applications via a PC or laptop from office or home. Secure the session with something like VPN, add the necessary authentication and encryption, and clinicians can use their Windows desktop and a browser to interact with hospital applications.

Offer mobile access when you need to empower providers to perform specific tasks anytime, anywhere. This would include visual assessment of images and waveforms, checking lab values, reconciling medication lists, checking allergy status – all while on the go. Providers want the data transformed into meaningful chunks; they don’t want to navigate the medical record from their Droid in order to make timely treatment decisions. Mobile data should be provided via native applications, built to run securely on a specific device and operating system.

Some organizations have considered using Citrix to provide interpreted or emulated application access to the EHR or CIS via a mobile device. Accessing patient monitoring data via a non-native solution is discouraged, because visual distortion is almost certain when things like medical aspect ratios cannot be controlled. [1] Further, the FDA is mandated to regulate mobile devices. [2], [3]

Mobile versus Remote Access

Consideration Mobile Access Remote Access


Single, personal mobile device

Anytime, anywhere cellular or Wi-Fi access

PC, laptop, or workstation-based, even if it’s a workstation on wheels


Native Application – Designed to run in the computer environment (machine language and OS) being referenced (i.e.: Android, iPhone, Blackberry, etc.)

Citrix or web access to desktop applications

Data Transformation

Improves clinical decision making at the point of care through data transformation – does something with the data.

Adds meaning with graphing, trending, colors, visuals cues, etc.

Looks and functions like the desktop electronic health record (EHR).

Presents data in the same fashion as the computer program being accessed.

Added Value

Works with clinician workflow by delivering in meaningful ways.

Incorporates evidence based medicine and knowledge-based prompting.

Supports office- or home-based access via computer.

Meaningful Use

Physician usage quickly ramps up, is sustained over time.

Initial usage spike, unsustained; often drops off after weeks/months.

Physicians will seldom help organizations achieve data access/sharing objectives when they have to go to the data.


[1] http://ahealthydoseofmobility.com

[2] http://www.ebglaw.com/showarticle.aspx?Show=12184

[3] http://www.law.uh.edu/healthlaw/perspectives/2010/kumar-fdamobile.pdf.

Cameron Powell, MD is president, chief medical officer, and co-founder of AirStrip Technologies of San Antonio, TX. 

Transcription Today
By Diligent Monk

Transcription is back.

As EMR adoption picks up in response to Meaningful Use, it is worth noting that lurking in the shadows is a familiar enemy to EMR companies: transcription. The age-old practice of dictating for capturing clinical observation is the most efficient, accurate, and preferred method for physicians to document a patient encounter.

Over the past few months, announcements from large organizations have signaled a return to relevancy for the transcription industry. IBM, Nuance, 3M, HealthStory Project, major universities from around the globe, and many other dominant players in the transcription service industry have made significant strides in utilizing technology to create more value from transcripts.

Enter the transcription technology revolution.

Partnering the skilled labor of transcriptionists with technology produces a rich and accurate dataset from a traditional transcript. Whether labeled natural language processing (NLP) or discrete reportable transcription (DRT), the concept is quick, simple to understand, and the value is just now being seen by the industry at large.

Using extensible mark-up language (XML), data is pulled from transcripts and provided in common transport standards (CCR, CCD, CDA) to be used in EMR systems and reports. A physician can dictate his/her notes and collect all of the data required for meeting the objectives and measures for incentive payment per the HITECH Act without purchasing an EMR.

Historically, the EMR sale was built on an ROI derived from transcription savings. Looking at a practice or hospital balance sheet, the transcription bill seemed to be the easiest to pick on, and with the point-and-click interface promoted by EMR vendors, it was a straight replacement for clinical documentation. EMR adoption would eliminate transcription costs. As an industry, the transcript was losing its relevancy in an age of electronic records, but physicians and practices weren’t thrilled with the results. And back to the revolution.

Permitting a physician to dictate in their preferred and normal manner, coupled with the ability to ‘tag’ the data elements of importance from the note, provides the best of both worlds.

Unfortunately, this does nothing to eliminate that pesky transcription charge, which is still the focal point of many EMR pitches. The transcription industry, however, counters that the prevention of productivity loss will more than cover the cost of their services and therefore be a win-win for all involved. As well, the risk of errors in reports is significantly decreased by the medical language specialists that review documents for clinical quality and integrity before submitting back for approval from the physicians.

As crazy as this sounds, and as hard to believe as it may be, transcribing may be the best way for practitioners to achieve Meaningful Use and the most cost-effective for their practice. The technology continues to improve and adoption continues to be strong, so yes, transcription doesn’t appear to be going away, and that may be a good thing.

FDA Comes to HIT… But Through the Back Door
By Frank L. Poggio

For several decades, there has been a raging debate as to whether HIT systems should be regulated by the FDA. A search of HISTalk on ‘FDA’ brings up hundreds of mentions. Some clinicians believe FDA oversight is desperately needed; others feel it would be a major detriment to new development.

Now the debate is over. It came earlier this month through a back door called ONCHIT, probably while you were sleeping.

On January 7, ONCHIT issued the Permanent Certification Program Final Rules PCPFR. These are the rules that will transfer the testing activities from the ‘temporary’ agencies to ‘permanent’ ones as of January 2012. On the surface, you would think these rules would impact only the companies like CCHIT, Drummond, InfoGard, etc. But our creative friends at CMS–ONCHIT went many steps beyond that.

Here are some highlights from a vendor perspective.

A new entity was created called the ONC-AA called the Approved Accreditor agency. The current ATCB will be changed to ACB, or Authorized Certification Body.

In a nutshell, the ACB administers the test and the AA oversees the ACB. Today under the temporary rule, the ATCB does both. What is now a one-step process will become in 2012 a two-step process for software firms seeking certification. The AA will also be the agency that selects and contracts with the ACBs for testing services (such as CCHIT, Drummond, etc.) 

The new ONC-AA is required to insure that the ACBs conduct ‘surveillance’ of certified vendor products. Surveillance is CMS’s way of saying ‘audit’.

Here’s how the surveillance will work. The AA can walk unannounced into an ACB office and review all certification documentation, or can randomly sit in on tests. More importantly, the AA or ACB can audit at will, unannounced, the MU criteria out in the field at the providers shop to ensure the certified system really does what it was certified to do.

And it doesn’t stop there. Similar to the FDA processes, any user of a certified system (provider clients or their employees) can file a complaint directly with the ONC-AA or ACB stating that the vendor’s installed certified system DOES NOT MEET the certification criteria. At that point, the AA will conduct an investigation at the site and make a determination whether the vendor’s certification should be pulled.

If so, as with the FDA, press releases to that effect will be circulated. OUCH! Better start thinking about stronger client support in the future and set up internal channels to catch the gripes before they get so bad a user wants to scream ‘ONCHIT’.

On of my friends called this the ‘HIT Whistle Blower Act’, a good description. It’s just like the FDA: if a device or drug has an unexpected adverse impact, anyone can file a complaint. I hear a train a coming …

Frank L. Poggio is president of The Kelzon Group.

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Currently there are "10 comments" on this Article:

  1. Thanks to Frank Poggio for summarizing the huge document from ONCHIT on Permanent Certification Program Final Rules.
    I guess with the Feds carrot ….here comes their stick.
    Personally I think it will bring much needed discipline into the HIT vendors zoo.

  2. I don’t know who “Diligent Monk” is, but I bet he’s in the transcription business. His article is a nice try, but there is no way a physician can qualify for “Meaningful Use” incentives using only a transcription system. I don’t think the transcription system does e-prescribing, for example. And the use of NLP to retrieve “facts” from the transcript is, at best, over-sold. It’s pretty hard to do.

  3. Similar to the FDA processes, any user of a certified system (provider clients or their employees) can file a complaint directly with the ONC-AA or ACBstating that the vendor’s installed certified system DOES NOT MEET the certification criteria.

    While that means people can “blow the whistle” that the system deviates from the features and functionality specified under certification, this type of complaint process is very little like whistleblowers’ complaints to FDA, where the typical complaint is about lack of adherence to good manufacturing, appropriate data management and conduct of clinical trials, marketing exaggerations, or other factors that impact patient safety.

    Thus, I can see this happening:

    Complainant: this EHR is endangering patients.
    ONC: Well, patient endangerment’s not on the list of criteria for Certification or MU, so that’s not something we address.

    So, in effect, while this might prevent HIT companies from loosening their adherence to certification rules, it really does little to improve the safety or effectiveness of health IT.

    Sorry, I don’t really see it as a “backdoor FDA” measure.

  4. This is not the FDA. It is subterfuge.

    The HIT oversight in this Final Rule is weak. It is the same old story, the fox guarding the henhouse.

    The ONCHIT could not be counted on to maintain confidentiality. Thus, the messenger of deaths will be beheaded, considering the conflicted position of ONCHIT and Blumenthal, totally dependent on the HIT vendors and their champions to make the rules and policies.

    Sicko 2 is being produced.

  5. In response to NotQuite’s comments:

    The big medical transcription companies have offered eRx for quite some time. The smaller, technologically-deficient ones will probably never have the ability to do so, you are right. But like the EMR space, there is significant consolidation going on, with the small regional companies selling out to the big-boys. You’d be surprised how many transcription companies offer eRx, I sure was.

    Looking at Stage I and the pre-released Stage II incentives, there is no reason to believe that transcription-based physicians couldn’t meet the objectives. Whether or not Stage III can be obtained seems like an appropriate question as I have my doubts too, but to start, I trust the Monk.

    As for the NLP comment, the ability to locate data from free-text and marry it to a relevant dictionary (i.e. LOINC, ICD-10, SNOMED) is nothing new, just newly applied to medical transcription. I have seen this sort of technology used not just in healthcare, but other industries for over 20 years, assuming the transcription folks know what they are doing, it sounds reasonable to me.

  6. MIMD is right… just because a vendor does not deliver an MU criteria does not mean they danger patient safety. As an example a compliant to ONCHIT could simply be because the vendor system was certified to meet the demographic data criteria (of which there are seven IP elements today) and for some reason the system misses one, such as ‘preferred language’. The provider bought the system because it was ‘certified’ but the vendor failed to deliver the functionality. Hence, the provider fails on MU criteria and faces a penalty. Time to call ONCHIT.

    Also the FDA process is as MIMD stated, is far more detailed and specific, but then the FDA has been around for fifty+ years. Can’t wait to see what ONCHIT details will look like fifty years from now.

  7. In response to NotQuite’s comments:

    I completely disagree with your assessment. Given the current framework for Meaningful Use, anyone can get certified as a EMR module and augment that lack of functionality in existing solutions to comply with meaningful use. The bar to comply with MU is low and the industry has several year’s to prepare for level 3, which they are doing. As the Monk indicated the industry is undergoing a fundamental shift and redefining themselves as Clinical Documentation Organization’s capable of providing solutions to Automated Meaningful Use, Core Measures, Infection Control, Comparative Effectiveness and much more. And just in case NotQuite wasn’t paying attention, NLP is a proven, just ask the host of this board who bought A-Life several months ago. Other active vendors include NLP International and Coderyte.

    The ability for Transcription companies to add value to their existing service line is unmatched in the industry for the following reasons.

    Clinical databases are scarce in healthcare today and most analytical tools have trouble extracting meaningful information from free text, claims and pharmacy data. Most EHR’s have not been designed as clinical systems and have trouble sending or accepting 3rd party clinical data. Every day the US generates millions of dictated and typed medical reports each requiring a laborious and time-consuming process of data entry and manipulation, where highly trained and expensive experts manually cull the needed information from each report. Many HIT vendors can’t support the granular clinical data culled out of these reports to meet meaningful use and other regulatory requirements put in place by the Federal Government.

    With this guidance in mind clinicians now use a combination of Data Capturer methods and devices along with Natural Language Processing, Semantic Search and knowledge driven software to solve the myriad of logistical, technological, financial and administrative challenges inherent in the clinical documentation and care giving process. The Health Information Technology for Economic and Clinical Health (HITECH) Act brings together, for the first time, a focus on clinical documentation standards (CDA, C32), interoperability of healthcare coded data (SNOMED, ICD-9, ICD-10, ), EHR Adoption, Portability of Data (HIE, RHIO), and physicians’ incentives designed to speedily and accurately match disparate patients’ information when and where it’s needed, securely. Natural Language Processing (NLP) allows clinicians to document care any way they chose (pen, keyboard, and dictation) by providing a solution that can identify, encode and extract a meaningful set of appropriate healthcare data into a Certified EMR without changing their workflow.

  8. The monk is a shill
    Dictation is a tool used by physcians trained to use it. Newer providers have learned to use EHRs and are unfamiliar with paper charts. This notion of accurately extracting data from a transcribed report is simply not true. Transcriptionists change what was dictated and the provider almost never reads the report – they sign reports in bulk.
    I defy anyone who claims accurate results from NLP to risk their life on its results.

  9. ‘Been There’ makes a great point. Physicians regularly don’t read their reports and sign them in bulk, but this has gone on for an epoch and doesn’t change the fact that those transcripts were the norm for 60+ years before EHRs. That being said, for generations patients have ‘risked their life on its results’ and not all of them died.

    I would contend that the same possibility for error exists in both transcription and EHR, though only in transcription is there a human involved that could catch the error, an EHR doesn’t have that component included.

    That being said, I couldn’t agree more, errors in medical records are very scary (except to attorneys), but in the end, it isn’t the hammer or nail that poorly builds the house, it is the person wielding the tool.

    I wouldn’t ban the use of hammers because there are people that use them poorly or for the wrong purpose. As the crazy guy from “Happy Gilmore”‘s tee-shirt read, “Guns don’t kill people, people do.”

  10. Not sure why ‘Been There’ is so eager to dismiss NLP and transcription as a viable documentation method.

    If physicians have to take additional time away from a patient to document the encounter in the EHR, which reduces their efficiency and increases their aggravation, is that somehow improving the care giving process? Are they less or more likely to take additional and necessary time to care for their patients? Isn’t providing the best care possible the end goal?

    There are technologies available, although not well known in the market ‘yet’ that are providing the accurate data elements that ‘Defending’ refers to.
    And if so, shouldn’t all providers have the freedom to document however they prefer so long as the organization is not sacrificing the structured data that they need to meet organizational and national care goals?

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