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Readers Write 10/29/12

October 29, 2012 Readers Write 2 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!

Note: the views and opinions expressed are those of the authors personally and are not necessarily representative of their current or former employers.


It’s Only One Extra Click
By Jonathan A. Handler, MD

10-29-2012 7-02-39 PM

Clinicians swear an oath to put patients first, so why is it so difficult to get them to adopt new processes and technologies designed to improve care? Perhaps my experience during the SARS outbreak can provide some insights.

In the middle of the SARS outbreak, I was the director of emergency medicine informatics at a large hospital in the heart of a major city. A tourist with SARS would likely come to our ED. SARS disproportionately affects caregivers, and our ED nurses serve as our first line of defense when working in triage. Since I had written our ED’s tracking system, they begged me to add a SARS screening tool. I refused, saying it would add work and they wouldn’t use it.

Persistent, they mounted a campaign to convince me. The screening required only a few questions. Only the first question needed to be answered if the patient had no fever. I could build it right into their existing workflow. It might save patient and caregiver lives. A compelling argument.

So I did it. We added just a single click to the workflow in the vast majority of cases.

Of the thousands of patients triaged the next week, on what percentage did the nurses do the single click needed to answer that first question on fever? One percent. What was the click rate for patients with a chief complaint of fever? Zero.

In a world of increasing patient volumes and decreasing staffing, time spent on health information technology (HIT) is largely an “unfunded mandate.” Many caregivers are overwhelmed, with literally not a second left to spare. Each second spent on an additional click must be stolen from something else. Faced with the choice of clicking a button to note that the current patient does not have a rare disease versus triaging the next acutely ill patient, the extra click loses almost every time. And rightly so.

Early HIT efforts (e.g. digital labs and EKGs, PACS) dramatically improved care and saved time for caregivers. More recent HIT (e.g. electronic documentation) has largely stolen time from caregivers without improving outcomes. Our hubris has been our belief that all HIT offers enough value to justify encroaching on direct care activities such as talking to patients, administering medications, and performing life-saving procedures.

Despite clearly proven benefit, for 150 years we’ve been unable to get clinicians to consistently wash their hands. Now we take away fast and easy paper and dictation, replace them with electronic health records (EHRs) driven by slow and clunky keyboard and mouse, ask clinicians to document more than ever, and we expect rapid adoption?

Not going to happen. When asked, clinicians will agree to anything that might improve care. When time is short, they will prioritize tasks in order of perceived importance. Care will supersede documentation and quality initiatives that are not relevant to the immediate need.

One therapeutic prescription: things that save time for clinicians – such as badge and biometric login, single sign-on, context management, transcription services, speech recognition with natural language understanding, analytics, mobile access, and seamless integration with the local health information exchange – must be considered “mandatory pre-requisites.”

Right now, most consider these “nice to have some day.” The issue is much more than clinician resistance: patients are suffering from delays in care due to EHRs, and too often the promise of HIT is not being realized. When we recognize that one extra click is nearly always one too many, we (and our patients!) will have taken the first step on the road to recovery.

Jonathan Handler, MD is chief medical information officer at MModal.

Prepare Now for More Patient Requests for Medicare’s Annual Wellness Visit
By Averel B. Snyder, MD

10-29-2012 6-52-27 PM

Medicare records show that less than seven percent of people aged 65 and older have taken advantage of the Medicare Annual Wellness Visit (AWV). While it’s surprising that so few patients are receiving this important benefit, what’s even more alarming is that many seniors don’t know the AWV is even available. In fact, another study conducted by the John A. Hartford Foundation found only 32 percent of seniors are even aware of the benefit.

As more seniors become aware of the AWV and its benefits, these statistics will undoubtedly rise—and quickly. There’s no better time to prepare than now, as Medicare’s Open Enrollment period is now underway, and more than 49 million Medicare beneficiaries are being inundated with literature about all Medicare benefits, including the AWV. Physicians must be prepared not only to answer patient questions about the AWV, but also to provide the service efficiently and effectively.

The AWV includes specific components that address all aspects of a senior’s health status—physical and mental. A comprehensive AWV involves not only a review of a patient’s medical history and medications, but also a conversation about his or her functional ability and lifestyle issues that impact health. A list of risk factors, conditions, and treatment options must be established. Cognitive function must be assessed, and a 5-10 year preventive screening schedule created.

Until now, many physicians have been hesitant to offer the time-intensive AWV. That’s certainly understandable, given the challenge the hour-long visit poses to physicians who have limited time to visit with patients, especially when ongoing acute care visits are a priority. Fortunately, there are steps that can be taken now to get ready to accommodate a growing number of patient requests for this benefit.

  • Step 1: Use a non-physician practitioner (NPP) to conduct the AWV. The Affordable Care Act allows NPPs to deliver the service—which in turn enables physicians to focus on problem-oriented visits.
  • Step 2: Automate the process as much as possible with an electronic solution that identifies age- and gender-appropriate health screenings based on the patient’s health risk assessment (HRA). This solution can also dynamically generate a personalized prevention plan, order screenings or tests indicated during the AWV and make necessary referrals. If you have an electronic medical record (EHR) system, the solution should be integrated. This reduces documentation time, ensures an accurate patient health record, and prompts physicians to ask questions at follow-up visits based on the wellness visit recommendations.

Because a key component of the AWV is a personalized preventive health plan that’s updated each year, it’s also important to use a solution that provides recommendations for areas such as nutrition and exercise that are based on accepted guidelines and protocols. That way, you don’t have to have a number of staff members on hand who are trained to address those specialty areas.

Every year, the government spends $500 billion to treat Medicare patients impacted by chronic conditions. Many of the most costly chronic conditions — including heart failure, coronary heart disease, and diabetes — can be easily prevented with routine screening, which is what the AWV is designed to ensure. NPPs and technology can help physician practices offer this valuable benefit to patients in an efficient and cost-effective manner, and as a result, improve the quality of patient care and the level of patient satisfaction.

Averel B. Snyder, MD is co-founder and chief medical officer of Senior Wellness Solutions

Throw MU Out the Window!
By Darius LaGrippe

I don’t watch the presidential debates because they are irrelevant. I already know who I am voting for, and I’m certain the adorable concerns of swing voters are of no interest to me.

On the other hand, I sure do like to start a debate from time to time. Like right now.

It could be argued that the introduction of MU has destroyed more jobs than it has created. MU might be the cause of incredible amounts of lost patient information. MU might even be taking technology backwards.

Let’s face it. Smaller vendors with tighter budgets don’t have the free cash flow like that of larger corporations for development and marketing expenses, which denies startups and small vendors competitive resources for meeting the newest regulatory mandates, not to mention the Meaningless Use requirements that reimburse physicians for adopting electronic health records.

Unfortunately, those small, down-to-earth, client-focused private vendors ultimately dissolve or are absorbed. In my opinion, the products being acquired often are better than the larger companies’ product offerings, but when you answer to the stockholders, the
clients are there for your benefit. So who cares about the product?

Adopting electronic health records is very costly. Especially when the chief benefactors are ultimately the larger EHR vendors sucking up the stimulus milk shake through the government straw. With all these EHR products on the outs, who is responsible for maintaining that software and database you paid eleventy-thousand dollars for three years ago?

Not the vendor, because they are off the hook when your maintenance agreement expires, and they are not offering a renewal for your product. What kind of crappy loophole is this? During this realization, you might scream out loud like me, exclaiming, “This should be unlawful!”

The vendors are bound by the same HIPAA requirements as doctors and can be held accountable for HIPAA breaches. Last I knew, HIPAA had a six-year retention requirement, which follows federal statute for limitations for civil penalties(42 CFR Part 1003). If the physicians are required to maintain those records, shouldn’t the vendors be held to the same standard? Of course they should. Vendors should be required to either support and maintain those records for six years from when the product is shelved during “end of life cycle” or provide a comprehensive migration path for those clients at very little cost.

However, being a victim of an acquisition shouldn’t automatically force the physicians into a product they don’t want. The physicians shouldn’t be pigeonholed into a downgrade, upgrade, or migration. They should have the option to refuse the new product and seek a new one. Physicians should be able to demand their patients’ data from the vendor in a reasonable amount of time. Vendors should relinquish ownership of the patient data to the clients so they can at least explore their own migration path.

We’re talking about people’s health. Their lives. The records shouldn’t suffer the same attrition as the employees of the acquisitions, and the demise of the EHR shouldn’t be an albatross around physicians’ necks.

If the intentions of the HIT stimulus were to engage patients in their healthcare, provide physicians means to better electronic systems, and possibly even boost the economy, they are doing it wrong. That $19 billion should have been invested into the smaller companies to help produce better, cheaper technology at a faster pace and to keep the industry competitive. Instead we see attrition, poorly integrated products with no better standards than we had four years ago, and innumerable amounts of lost patient records.

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Currently there are "2 comments" on this Article:

  1. I agree with much of what Darius says (“Throw MU Out The Window!”). But I have to disagree on his view of which vendors have benefited from the stimulus program.

    I believe the large vendors haven’t really benefited, and in fact have been the ones dragging their feet the most in meeting the MU requirements. Large practices and health systems, who are their main clients, had already purchased EHR technology.

    When ONC is cranking out new MU requirements every couple of years, and a vendor can only manage a major software update every 12 months and then takes several years longer to get their client base upgraded, you can see why they would be nervous.

    On the other hand, MU has been a boon to HIT startups. The MU checklist looked to many of them like a recipe for success: if we just build something that has this list of features, and price it low enough, we are in the game. Of course, not all those EHRs are very good. And many of them will stumble in trying to get to MU2. But there are hundreds of them.

    The ones that are left standing are likely to represent a long-term challenge to the existing vendors, because many are cloud-based, low cost, and able to incorporate new capabilities much more rapidly than the large established vendors.

  2. Amen to Brother Handler!!! There is no quality without use… and there is no use without usability! So let’s shift from using HIT to propagate more work to using HIT to automate and delegate work!

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