Readers Write 2/15/12

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!

iPad Fatigue: Choose Your Mobile Strategy Wisely
By Chris Joyce

I get the attraction of the iPad … your own personal device that’s sexy and lean, as opposed to the standard-issue, Windows XP desktop locked down by your hospital’s IT group or the clunky computer on wheels. The simple UI and the glossy new apps let you shed the pain of those legacy systems and, most important, you get mobility.

Given the glacial pace of innovation in healthcare, who can fault people for wanting to use these beautiful devices? We are all trying to create a sea change in healthcare IT, much like the iPhone did for telecommunications. But I’m going to say something that’s wildly unpopular: the iPad is not well suited for healthcare in its current state.

I’ve been working in tablet-based mobility for seven years (yes, there were tablets before the iPad). We’ve studied clinician data collection workflow in registration, the ED, home health, cardiology, radiology, orthopedics, and clinical trials. Trust that my opinions are carefully thought out from experience.

I will concede that the Windows-based tablet manufacturers deserved to be smacked around by Apple for their lack of vision and slow progress. Years ago, I, along with my customer (one of the largest health systems in California that had been using tablets in cardiology for years) sat down with the folks at Intel and Motion Computing to tell them that the C5 was too complicated and expensive. I shared what we needed in the ideal tablet: a bright, 12” screen with stylus support that’s ideal for documents, 8-10 hours of battery life, no external ports or other gadgets, and a sub-$1,000 price tag. Our request fell on deaf ears as they paraded out the next incremental chip set improvement in their roadmap.

When the iPad hit the market, we thought we’d finally gotten our ideal tablet. The price was right, the screen was bright, the battery life was unbelievable, it ran coolly and didn’t burn your arms, it booted in seconds, and the 1.5 pound. form factor (half the current tablets) was simple and elegant. Finally, we had the perfect complement to our mobile forms software. This wasn’t just a Windows laptop with the keyboard chopped off – it was an appliance, a tablet.

But it also has some major shortcomings that our customers are now discovering:

10” display
This is subtle because I like the more portable size, but those standard consents, ABNs and Medicare forms you’ve used for years don’t fit on a 10” display without disrupting the layout. Your app has to be “touch-aware” or you’ll interact with the screen when you rest your hand to sign or add a note. Our customers are counting clicks and don’t like the iPad because they have to scroll to use the forms that once fit on their 12” Windows tablets.

No stylus
This makes capturing signatures, annotations on diagrams, and unstructured notes impossible unless you buy a third-party stylus like Pogo. But that’s like writing with a crayon and there is no place to dock your pen. Are your patients going to be comfortable signing an informed consent with their fingers?

No handwriting recognition
The soft keyboard isn’t practical for a lot of data entry because you are still holding the tablet with one hand and pecking out everything with the other. And bouncing back and forth between numeric and alpha characters drives users absolutely mad. Handwriting recognition has its place in documentation, just like voice dictation, and it can be as fast as paper. There is nothing fast about the iPad’s soft keyboard when at the bedside.

Proprietary operating system and deployment isn’t enterprise-friendly
Obviously Apple wasn’t concerned with compatibility with “legacy” apps like Meditech or MS4, but in healthcare, that eliminates about 90% of current systems. Most hospitals have compromised for “runs on iPad” versus “optimized for iPad” using Citrix or a Web interface.

That leaves the end user with an underwhelming experience. Citrix apps don’t get the intimate integration with the display, touch, or the camera for image annotation. Not many vendors were prepared to rewrite their clinical systems in iOS or HTML5. The HTML5 standard hasn’t been published yet and isn’t consistently supported by all browsers (although it is the future). I know of several major healthcare systems that are still standardized on Internet Explorer 7, so I don’t anticipate adoption of HTML5 to be as high in healthcare as Apple would like you to believe. Again, we (healthcare) are not that nimble.

Lack of rugged form factor
Eventually your iPad will come into contact with fluids or the floor and you’ll realize it’s a consumer-grade device. These devices are often in a hostile environment, very unlike the environment in most iPad commercials.

The hype of hardware
One of our best mobile forms customers is a major health system in the Northeast. They gave each clinician an iPad, only to discover that they took them home to watch Netflix versus using them on their rounds. Hardware alone isn’t the answer. You also need software that’s mobile aware.

When you’re developing your mobile strategy, keep this in mind. The iPad is a beautiful device with multiple applications (just not healthcare data collection). It isn’t going to transform your hospital systems’ user experience. But don’t compromise – there are other options to consider. Look for vendors that can fill the gaps in your EMR with mobility solutions optimized for the right tablet for your environment (iPad, Android and/or Windows) and that upgrade your user experience/productivity.

Chris Joyce is director of healthcare solutions engineering for Bottomline Technologies of Portsmouth, NH.

If you have achieved Stage 1 Meaningful Use requirements or are planning to attest in the future, you are likely aware of the required core measure for implementing and tracking at least one clinical decision support (CDS) rule. The goal of this measure — along with maintaining active problem and medication lists and recording vitals and smoking status — is to improve the quality, safety, and efficiency of patient care.

So what exactly is CDS and why is it important? 

In simple terms, CDS gives physicians the clinical information they need for decision-making tasks. For example, during a patient exam, CDS tools can provide prompting to help a doctor determine a diagnosis or select an appropriate treatment plan. Alternatively, a provider may use CDS technology to improve documentation or identify billing codes or determine the most relevant data to forward to a specialist.

CDS technologies are particularly powerful when the engine is mapped to a wide variety of medical concepts and diverse reference and billing terminologies, such as LOINC, RxNorm, SNOMET CT, ICD, and CPT. CDS tools are more robust the wider the engine’s mapping. Strong CDS engines have the ability to identify and interpret patient information from multiple sources, whether the data comes in the form of lab and test results, previous therapies, or patient histories.

It’s important to keep in mind that CDS tools don’t make the actual clinical decisions for a physician, but support a physician’s own decision-making by sifting through existing data and presenting the most relevant information. As more clinical information becomes available online from EHRs and health information exchanges (HIEs), providers will rely more heavily on CDS technologies to identify the most pertinent information for a given situation.

Many commercial EHRs and HIEs have embedded CDS tools to help providers wade through vast amounts of clinical data. CDS technologies work behind the scenes to identify the most clinically relevant information within a practice’s EMR or from a connected reference lab or from HIE records. Search engines consider additional relevant details amongst on thousands of clinical scenarios and then interpret the cumulative data. Physicians are then presented with pertinent information at the point of care and offered details to aid with diagnosis and treatment plans, as well as critical data needed for compliance and reimbursement.

Though Stage 2 Meaningful Use is not finalized, look for the ONC to add additional CDS objectives in the core measures.

Dave Lareau is chief operating officer of Medicomp Systems of Chantilly, VA.

Super-Sized Productivity Gains from Computer-Assisted Coding?
By Akhila Skiftenes

The required migration from the ICD-9 to ICD-10 has significantly increased the demand for computer-assisted coding (CAC), moving beyond its early beginnings in outpatient specialty areas. The potential benefits from using this technology to make the transition to ICD-10 can be very compelling –improved coding productivity, accuracy, consistency, transparency, and compliance.

Yet CAC products require a substantial investment, and implementing one does not a guarantee that these benefits will be realized. Therefore, it is essential for an organization to complete a thorough analysis before investing in a CAC product.

Exceptional productivity gains have been reported by vendors. However, these are based on a number of assumptions and the specific circumstances for the organizations using the system. The following are key considerations when estimating CAC benefits for your organization.

First, estimates are often based on outpatient implementation data. As more and more hospitals move toward using a CAC in their inpatient areas as well, these productivity estimates need to be adjusted accordingly. Inpatient stays are longer and have more variability, making accurate CAC translations much more complex. Vendor products have made great strides toward accurate inpatient coding, but it takes more computing power and more time, so productivity gains will be lower.

Second, CAC works best when the documentation inputs are standardized. There are four standard formats for documentation: consultation note, history and physical, operative note, and diagnostic imaging report. The more variability in documentation formats for your organization, the longer the CAC process will take and the lower the translation accuracy.

Standard medical terminology used by the electronic medical record system also impacts the effectiveness of CAC. Many EMR systems use ICD-9 verbiage rather than SNOMED-CT for physician documentation. In these situations, the CAC application will translate to a lower level of accuracy since SNOMED-CT has a more modern standard for medical terminology and greater levels of specificity.

Finally, there is a general belief built into benefits estimate that optimizing the CAC process is ongoing. Once CAC is implemented, it is vital for the Health Information Management (HIM) department to audit the output and identify any issues with the software’s documentation interpretation. A critical success factor is the working relationship between HIM and IT, with resources assigned on both sides for continued optimization.

When making a decision about CAC implementation and ongoing support, organizations need to incorporate all of these assumptions into the estimate of how much productivity can truly be realized.

Akhila Skiftenes is an associate consultant with Aspen Advisors of Denver, CO.

Virtual Patient Simulation: Strengthening Medical Decisions, Strengthening Outcomes
By James B. McGee, MD

Provide better patient care with fewer resources. Essentially, that is what healthcare reform is asking us all to do. Most providers agree that the only way to maintain the quality of patient care and decrease overall cost is to reduce errors, prevent duplicate or unnecessary tests, and discover more effective yet less expensive approaches to care.

As I see it, that is the simple reality we all have to work within. The real question is: what does it mean from a practical standpoint?

It means that the modern delivery of medical care is far more structured, more measured, and more reported on than I—or anyone—ever could have imagined. Even the most recently educated providers now have to learn new skills and processes in order to respond to federal and third-party payer demands. An entire generation of practicing physicians and physician extenders is being asked to change practice habits, yet still engage in complex decision making.

It is a tall order. However, virtual patients (VPs) offer a way to provide examples and feedback that can help train providers to work within the new constraints. Think about it: clinical decision making is a skill. Like any other skill, it needs to be practiced, refined, and updated regularly. Simulation in general offers a safe environment to assess specific skills and receive personalized, dynamic feedback. VPs can simulate a wide range of clinical decision-making scenarios without requiring dedicated space and time the way physical simulators do.

Simulators such as mannequins are a familiar way to practice clinical skills. VPs are a relatively new development best described as interactive web-based simulations used to develop, enhance and assess clinical decision-making for all types of learners (physicians, physician extenders, nurses, students, etc.). Branched narrative style VPs, in particular, do this by presenting a patient’s story and background information. They then challenge learners with multiple decision paths and show the impact of their decisions—without the risk of actually treating patients, of course.

Training with these realistic computer-based cases strikes a practical blend of simulation with the convenience of web-based delivery and centralized reporting. Think of them as “cognitive” task trainers.

Hospitals have long recognized that providers who pursue learning on a regular basis tend to have better patient outcomes at a lower cost of care. Educational programs like VPs provide a mechanism to make good clinicians better and—perhaps best of all—help novices improve the cognitive skills that lead to expertise.

One good example that I am aware of is Warwick Medical School in the UK, which created VPs to train new doctors to handle life-threatening acute medical emergencies. The doctors can practice over and over again. Through the VPs, they receive immediate, personalized feedback while responding to a rapidly evolving, life-threatening clinical challenge. This type of deliberate practice simply cannot be replicated in real life. In an actual emergency the doctors who practiced decision-making skills are more likely to perform successfully.

Given healthcare’s focus on accountability and other reform efforts, it is important to not lose sight of ways providers and nurses can improve the care and the safety of their patients. VPs provide a safe and objective way to identify variations in practice and decision-making; remediate using real-life examples; reassess until competency is demonstrated; and continually reinforce best practices.

In any given community hospital, providers with a wide range of prior knowledge, skills, and attitudes practice under one roof. Patients expect and deserve the highest level of expertise from all of their caregivers. Payers also expect a certain level of performance and have begun to reward superior performers.

Simulation provides an efficient way to assess clinician performance and provide feedback, whether in the form of clinical guidelines, performance metrics or formal educational programs. By strengthening medical decision making, virtual patients offer one way to reach everyone’s ultimate goal—better patient outcomes.

James B. McGee, MD is the scientific advisory board chairman and co-founder of Decision Simulation LLC, co-chair of the Virtual Patient Working Group at MedBiquitous, and assistant dean for medical education technology at the University of Pittsburgh School of Medicine. Additionally, he is an associate professor of medicine in the division of gastroenterology, hepatology, and nutrition and a practicing gastroenterologist.