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Monday Morning Update 6/4/12

June 3, 2012 News 12 Comments

From Roger Collins: “Re: JAMIA article on dictating into the EMR. The authors measured ‘quality of care’ by looking at discrete quality measures in the EMR. By definition, clinicians who dictate their documentation aren’t using templates and would not have double-documented by checking off boxes. The study didn’t look at the transcribed dictation notes, so they had no way to know whether those clinicians even met the quality metrics, much less that they provided lower-quality care.” It appeared to me that the study looked only at whether the documentation was complete (tobacco use recorded, blood pressure taken, etc.) rather than patient outcomes, so I was suspicious about its conclusion that “physicians who dictated their notes appeared to have a worse quality of care than physicians who used structured EHR documentation.” But it does raise an interesting question: if we agree that transcribed dictation provides a richer narrative, then in our fanaticism to distill every encounter into a set of predefined checkboxes that will be used to measure quality, determine payment, and drive Meaningful Use payments, how are those checkboxes going to be populated without losing their original context? We’re reaching an electronic decision point: as a clinician, would you rather assess a patient based on the verbatim thoughts of your peers or a bunch of lists and graphs? And if the answer is that we need both, how do we make that happen? Your comments are welcome.

6-3-2012 4-22-51 PM

From CT Scan Moneyball: “Re: healthcare price disparities. One way to fix this is a fixed fee schedule like they have in Japan as described in this article, but it probably can’t happen here in our poisonous political climate. A bonus is controlling cost – Japan’s spending on health went from 7.7% to 8.5% of the gross domestic product over eight years, compared to an increase from 13.7% to 16.4% in the US.” 

6-3-2012 4-24-33 PM

From SmallTown CIO: “Re: MUSE 2012. The crew from MUSE have done a great job again with a well-organized conference. As a long-time attendee, it is a little strange seeing a younger crowd – some of the usual suspects I haven’t run into. However, at the same time it is great to see the up-and-comers that will keep MUSE and Meditech strong. The vendor exhibits have been good with some new faces. Forward Advantage, Iatric, and Dimensional Insight are among a few that have a bigger presence. Forward Advantage held a great party at House of Blues – definitely an extracurricular event highlight. The thing I appreciate more than anything at MUSE is the vendor exhibits aren’t ostentatious, which fits very well with the customer base of Meditech (we are all driven by cost effectiveness). It is great to see Meditech have a presence at the conference in terms of presentations. My hope is that next year they have a presence in the vendor exhibit area as well, where we can catch up on the latest software changes. All in all, it has been a good conference and I tip my hat to Alan Sherbinin and crew – nice job!" Thanks for the report.

6-3-2012 3-39-45 PM

From THB: “Re: Epic. Going down the path toward NHS implementation – they’ve posted a job to help prepare their product for the UK. Anyone know where I can find workflow documents for NHS hospitals?” I found the listing above. People thought Epic was kidding when they talked about world domination. They weren’t.

From Cyber Spy: “Re: hacking. Medical IT is highly vulnerable.” This article covers the development of Zero Day exploits. A former NSA hacker shows how randomly changing file data at the byte level will eventually cause a system to crash, and once that happens, he can often figure out why to discover a previously undocumented exploit. It mentions the secret Stuxnet cyberattack on an Iran (the White House financially admitted last week that it was a US-Israel creation and it got out of control) and that the Pentagon now considers cyberspace to be a theater of war. I seem to remember that at least one UK hospital was hit by a Stuxnet-caused outage, so if so, that means the US government may have caused patient harm in England.

From No Bull: “Re: sex in the road. Doctors could not get to their patients. Thank heavens for mobile medical devices.” A busy highway in Pennsylvania is closed for hours due to a bull-and-cow hookup, or as one state trooper described the scene, “They’re having relations in the road.”

6-3-2012 5-18-20 PM

From Wheeler and Dealer: “Re: deals between Congress and pharma. There other others between Congress, HIMSS, and IT vendors.” The House Energy and Commerce Oversight and Investigations Subcommittee (made up of 14 Republicans and nine Democrats by my count) reports on what it calls Closed-Door Obamacare Negotiations. It says the White House struck a PPACA deal with the Pharmaceutical Research and Manufacturers of America, committing to protect the drug companies from price controls, government-run prescription insurance, and new drug importation policies in return for $80 billion in payment cuts. The deal came together quickly when the Obama administration was getting beat up over PPACA the week of June 18, 2009, and was desperate to announce something positive before the Sunday political talk shows. I actually read this as pro-Obama: he told the drug companies that if they didn’t play, he was going to call them out as foot-dragging and hit their profits via mandatory rebates and the elimination of tax-deductible direct-to-consumer advertising. The gist of the findings is that Obama conducted closed-door meetings with drug companies after being critical of such practices as a candidate.

6-3-2012 4-18-12 PM

From The PACS Designer: “Re: World IPv6 Day. This coming Wednesday, we’ll see the launch of the next Internet upgrade to IPv6, promoted as World IPv6 Day. The upgrade has become necessary since the supply of available IPv4 addresses has been exhausted. The challenge for IT departments will be testing IPv6 on all browsers and servers for compatibility with existing applications and security issues.” You can follow along on Twitter.

Listening: Fitz and the Tantrums, LA indie kids who sound eerily like a really good 1965 Detroit soul band, right down to the growling organ. They are amazing in this live video, especially the female lead singer, and were the subject of an episode of the excellent Live from Daryl’s House, where they did a better-than-the-original cover of “Sara Smiles.” On tour now, appearing in Houston, Birmingham, Greenville, Manchester, Charleston, and Raleigh this week.

6-2-2012 5-58-49 AM

Being blessed as I am with heightened perception of the obvious, I believe I see some agreement (95%) that hospitals should be able to provide a bill that the average patient can understand. New poll to your right: does the average hospital CIO encourage innovation or stifle it?

6-2-2012 6-13-26 AM

HMS customers meeting last week at its Nashville office: Millie Schinn (Hamilton General), Diane Sherrill (Medical Arts), Rob Malone (Houston Orthopedic), HMS Chief Medical Officer Frank Newlands, Cindy Jandreau (Northern Maine), and Angie Waller (McDonough).

The weekly employee e-mail from Kaiser Permanente CEO George Halvorson says KP has once again mined its HealthConnect database to discover a new treatment, as reported in the journal Neurology. In reviewing the records of nearly 13,000 ischemic stroke patients spanning seven years, it found that starting cholesterol-reducing statin drugs as soon as possible cuts the death rate by nearly half and raises the chances of the patient going home instead of to a nursing home by 20%. And if the patient was already taking statins at the time of their stroke, simply continuing the drug during their hospitalization dropped the death rate to 5% (if the drug was stopped, deaths jumped to 23%). As George concludes, “We are the only people in healthcare who have done that analysis. Our stroke researchers have done truly great work. This finding has the potential to save many lives. Every stroke treatment program on the planet Earth can and should either start to give or continue to give cholesterol-lowering statins to their stroke patients.” KP has already changed its stroke order sets to start statins on Day 1 as the default.

In less-cheery Kaiser news, its Oakland hospital gets hit with a $75K Department of Health fine for a 2010 incident in which nurses ignored a telemetry patient’s tachycardia alarms, including warnings that the alarm itself was about to shut down due to a low battery. The patient was found unresponsive and was resuscitated, but died afterward. The nurse says he didn’t call the doctor as instructed for the tachycardia because the patient seemed OK, and ignored the low battery warnings because he was too busy.

6-2-2012 7-37-32 AM

I curse the name McAfee regularly when Scan32 and MCShield suck the life out of my hospital laptop, especially during the once-weekly antivirus scan that assures a solid several hours of hourglass when I’m trying to work. Now I can humanize that annoyance with this story of founder John McAfee, who at 66 is living on the run in the jungle. Forty-plus police officers in Belize (specifically the Gang Suppression Unit) raid his guarded estate, kill his dog, and rouse him from the bed he is sharing with his 17-year-old girlfriend, charging him with running an illegal antibiotics factory and possessing unregistered weapons. He claims he declined to bribe a local official and the drug companies don’t want competition from the topical antiseptic and female Viagra that he’s developing, so they hired the police as muscle to claim he was operating a meth lab. A fascinating 2010 profile is here – the man’s clearly both a genius and a total wack job. I think we can agree that he looks great for 66, although perving around with a 17-year-old might be a bit much even in a country where it’s legal at 16. 

6-3-2012 5-21-32 PM

In the UK, Brighton and Sussex University Hospitals NHS Trust is fined $500,000 when hard drives containing the medical information of patients were sold on eBay. The hospital is upset about the size of the fine, says it can’t afford to pay it, and is appealing. It hired a subcontractor to erase 1,000 hard drives, but he listed 250 of them on eBay without the hospital’s knowledge.

This could be a hint of things to come (or a 1990s flashback). Three fired HCA doctors in Florida publicly criticize the chain for hiring huge waves of physicians to prepare for an ACO environment, then dumping those whose practices were not profitable. They also say the company doesn’t have the infrastructure to support the practices it’s buying. One doctor who left said that HCA was sloppy in controlling costs, paying multiples of what he paid in private practice for everything from business cards to transcription services. My experience is similar: hospitals in general are inefficient, bureaucratic, loaded with VPs of inconsistent talent and motivation, and the worst possible partner for a small business. I’ve sat in those meetings when docs complained and once they were gone, we mostly talked about how to marginalize them. Some physicians are fine with working for a huge corporation under their rules (like academic medical center docs), but the free spirit types hate every minute of it. Like any other business, entrepreneurs enjoy selling their businesses to big companies for a big one-time payday, but don’t usually last long with them as employees afterward.

6-3-2012 5-22-50 PM

New Hanover Regional Medical Center (NC) was set to go live Saturday with Epic. Their cost was given as $56 million.

6-3-2012 5-26-50 PM

The University of Missouri School of Medicine fires two radiologists and announces that its dean will retire following the announcement that the health system is the subject of a federal Medicare fraud investigation. The school says it believes that the radiologists, one of whom was the chair of the department of radiology at the time, billed for work performed by medical residents without reviewing their work. The MU radiology department says it will modify its software to prevent future occurrences and says it will pay for having the images of any concerned patients re-read, either by the health system or by an outside radiologist of the patient’s choosing.

I’d like to see Vince’s HIS-tory series continue. I know the best way to make that happen: send him fun anecdotes, old articles, or “where are they now” updates that will get him enthused to keep it going. He’s specifically looking for anyone who can facilitate connections to the folks who started companies back in the 1970s and 1980s so he can get their first-person stories, which would be very cool.

A Texas urologist and his practice manager wife are charged with healthcare fraud, with federal prosecutors saying the doctor submitted at least $1.5 million in fraudulent benefit claims since 2003. His claims indicated that he treated as many as 117 patients in a single day, sometimes billed for more hours than exist in a day, and billed for services provided by office personnel while he was traveling in Iran. The couple was indicted in 2010 for funneling $1.8 million to Iran for investments claimed to be charitable contributions, using a charity run by their daughter.

The Lexington, KY newspaper covers a non-profit mental health board whose for-profit subsidiary, run by the board’s retired CEO, sells scheduling, billing, and payroll software to other state-funded regional boards. It also notes that the retired CEO is married to the current CEO and continues to be paid as a consultant, while their son-in-law is the organization’s IT director.

Weird News Andy says the bomb squad and ED “cheated Darwin” again by removing unexploded fireworks from a man’s chest. He was apparently setting off illegal fireworks from a hand-held mortar to celebrate Memorial Day when “a firework intended for the sky penetrated his chest.” The hospital had to call the bomb squad to remove the pyrotechnic before they could operate. The last reports I saw said the patient is in critical condition with massive chest trauma.

E-mail Mr. H.

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Currently there are "12 comments" on this Article:

  1. Kaiser trumpets the benefits of its EHR on treatment of stroke that is a no brainer (all decent clinicians have treated strokes with statins at the day one get go) while a patient is dead in its ICU from neglect, despite the EHR. Such are exemplar reasons why the data shows that EHRs do not improve outcomes nor reduce the costs of care.

    Hey, by the way, were the ICU nurses so busy charting on its user unfrindly EHR that they had no time for the patients? Just wondering.

  2. Re. the JAMIA article. We need both narrative and structured but it’s going to take some time. We get there by innovation. It’s quite easy to design structured (preferrably customizable) templates, and NLP should – at some point – mature into the engine that can populate a structured template from dictation. Until we get there, providers should be using technology available today that gives them the flexibility to use VR and free text/clicking to complete their notes in real time. Wouldn’t it also be more valuable to those writing and consuming the note (clinicians, billers, coders) to have relevant structured (pharmacy orders, labs, vitals) and unstructured (radiology findings, etc.) pre-populated, to further reduce the time it takes to complete templates? Too little room to discuss it all here!

  3. Comment to your lead story: I manage patients and document findings and thoughts based on what is best for the patient. Meaningful use grids and grids for nurses are impediments to creatively effective clinical care that do not reflect the clinical status of the patients. A record laden with screens of grid generated gibberish is clinically useless as a clinical communication document.

  4. Ditto Carol (no relation!) about structured physician notes being impossible to interpret unless there is also a brief narrative summarizing the reasoning that the physician used. When peers are covering and the patient calls or a test result comes in, it must be clear how to advise the patient and move forward. We absolutely need structure where it creates value (smoking status, et al) but ONLY where it creates value. Brief narrative is essential, too. So I will always vote for a reasonable combination of the two.

  5. Greetings,

    I’m having a little trouble with your new survey. I’ve been in HIT since 1993 and still have no idea what the ‘average’ CIO does in terms of promoting or stifling innovation. My guess is that the smart ones promote ALL innovation, that many others promote innovation that isn’t disruptive, and that some, probably in a temporary position, discourage anything that even remotely rocks the boat.

    Real boats rock though and change is inevitable, and so we get to choose whether it happens to us or because of us.

  6. Another heart break of monitors story. What is going on? Just recently at Mass General, then, a dead man at UPMC Shadyside, now, a dead patient at the famous high quality Kaiser Medical Center run by George H. OMG! Did George have a press release about the monitor story with the fanfare of his EHR rediscover the wheel story?

    Or is it that these catastrophes were always occurring but now, due to the EHR, they are being more accurately documented?

  7. Re: the cow-and-bull story, maybe it’s time to serve up some content-driven tunes to enhance the Listening section?

    The Beatles “Why Don’t We Do It In the Road?” (too obvious but still classic) or the not-so-old-school Bloodhound Gang “The Bad Touch” (shameless Discovery Channel plug) would fit nicely….

    [From Mr. H] Funny, I immediately thought of the first one myself (along with Blue Oyster Cult’s “Career of Evil” and its line, “I’d like to do it to your daughter in a dirt road’ line since I just saw the movie Roadie that it was in). I was just all proud of myself given my near-zero farming knowledge for not calling them “two cows” like the newspaper did since that would have implied two female bovines (not that there’s anything wrong with that.)

  8. JAMIA article. The use of structured documentation tools augmented by front-end speech recognition should accomplish those dual goals.
    So for those at Partners migrating to Epic, the mantra should be: Notewriter with SmartLinks and Dragon.

  9. A non-IT/EHR story that not-tired-of-suzyrn make about the monitors, rather than the poor judgment of the nurse. If you read the story, it’s clear that the nurse made a *conscious* decision to not notify the doctor.

    “A nurse told state investigators he did not notify the doctor when the patient’s heart rate rose because the patient frequently had a high heart rate, seemed to be all right and “always checked out fine.”

    This was in direct contradiction to the doctor’s orders:
    “A physician asked to be contacted if the patient’s heart rate exceeded 120 beats per minute.”

    The article states that “patient’s heart rate soared to 141 to 153”.

    Net, technology can be an enabler, but healthcare still comes down to the judgment of healthcare professionals. And when that judgment is wrong, bad things happen like the death of the patient in this case.

  10. Two comments. First with respect to the Japan comparative. Price control does not equate to cost control. Price control typically leads to short cuts and/or shortages. And consumers typically lose in that scenario.

    Second, regarding the “Wheeling and Dealing” – doesn’t this bother anyone else? That the government is so entrenched in business that it can strike a deal! “protecting the drug companies from price controls” as if that is a bad thing. We should all be protected from government meddling price controls. Let the market set prices. And government-run enterprises (how well does that work!?)The fact that the government is so involved spawns corrupt politics, unfair competition and everything that makes this health care system so inefficient and expensive. Again, consumers lose in this scenario as well.

  11. Re: We’re reaching an electronic decision point: as a clinician, would you rather assess a patient based on the verbatim thoughts of your peers or a bunch of lists and graphs? And if the answer is that we need both, how do we make that happen? Your comments are welcome.

    Both are needed, I believe. It was the solution I saw work well in this project: link which used both highly structured templates modeling the domain of invasive cardiology, and easily added dictation in this fashion:

    The “templates” were 1) well organized into sections (about 15 in this scenario) for the mission at hand; 2) customized to two different users, the doctors and the case technicians; 3) they were supplemented with the opportunity for dictated addenda to each section with the observations, findings etc. that did not precisely fit the template, through a tie-in to the organizational transcription services; and 4) the resultant reports were also divided into the same sections, providing reviewers a well organized, thorough document from the medical and information science perspective.

    I add that the templates were kept on paper, and separate data validation and entry personnel interacted with the computers. It was felt that the time of invasive cardiologists in a very busy invasive cardiology unit was simply too valuable for them to be fiddling with a computer. I still believe that is a preferred arrangement for critical care/subspecialty areas.

  12. Re: JAMIA article by Linder — Properly validated NLP can extract many structured data elements from free text and populate the EMR data fields while retaining the richness of the narrative. NLP of narrative text (typed, dictated, or using front-end speech recognition) can be used together with structured data entry in an EMR to get the best of both worlds. Although the article’s authors (and Chupacabra above) suggest NLP is not yet able to do this, a significant body of literature suggests this capability is commercially available today. As just one example, the Linder JAMIA article looked for documentation of smoking history. In an earlier JAMIA article by Uzuner (http://jamia.bmj.com/content/15/1/14.long) NLP showed good performance in extracting smoking history from discharge summaries. Although NLP was not perfect, neither is structured data entry — especially if it’s not used. In the Linder article, structured data entry captured tobacco history in only 38% of cases.

  13. Vince Ciotti (Roots)

    In response to the request regarding early vendors and HIS Systems, I was a systems developer for Spectra Medical Systems in the early 70’s. Back then our only competitor was Technicon (now Eclipsys) and IBM. I would be happy to chat with Vince.

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