Curbside Consult with Dr. Jayne 4/11/11

There’s been lots of buzz this week about the Care Connectivity Consortium. This initiative by Geisinger Health System, Kaiser Permanente, Mayo Clinic, Intermountain Healthcare, and Group Health Cooperative has been noted everywhere from The New York Times to Yahoo and MSN.

I can’t wait to see how this collaboration unfolds. Those of us who have spent the last several years knee-deep in Health Information Exchange know how difficult it can be to actually make this happen.

I’m interested in seeing details on the pre-work: consent, governance, and ownership. It’s challenging enough to get a productive HIE live that meets the legal hurdles of a single state, let alone meeting those of a disparate group covering Pennsylvania, California, Minnesota, Utah, and Washington (which just represent the headquarters states, not all the states where care is delivered, which will also have to be addressed).

The warm and fuzzy scenario presented in The New York Times piece: “A person walks into a clinic in Phoenix, say, and, with permission, her records from her hometown physician’s office in San Francisco are efficiently summoned with a mouse-click.” If only it were that easy!

Having been involved with attempts to jumpstart a regional HIE, I know that wading through the legalese for the patient consent and trying to fit it on a single page reminded me of the scene in the cult classic The Princess Bride, where the bad guy has a machine that sucks years of your life away.

The consent language for many data exchange projects can be nearly unintelligible for the lay person. I suspect the forms will become “just another form” that patients shuffle through and sign if they want to receive care, whether they understand it or not.

(Kind of like the paperwork in the Emergency Department – do they think patients actually read that? I don’t think so. They sign it because they are sick, hurting, and in need of care. When you just want to see your doctor, you don’t care about the HIPAA Notice of Privacy Practices, Patient Financial Responsibility statement, or anything else other than being treated.)

I’d like to see the details of how they’re going to do this. I’m sure it will be more than the proverbial single click – like documenting the patient’s consent or opt-in status, validating patient identifiers, etc. And once you have the patient identified, how useful will it be? I hope the Consortium goes “all in” with this and uses fully discrete data that can be exchanged and consumed by receiving physicians’ EHRs, not just another view vault application that’s the electronic equivalent of asking physicians to review paper documents from multiple institutions.

I applaud the groups’ ability to work out shared goals among the CEOs before it became too public. Kaiser’s CEO George Halvorson is quoted as saying, “The CEOs had to make sure the CIOs didn’t think this was crazy or impossible.” Probably a good idea, as this may have been a non-starter if too many people were at the table before the basics were agreed upon or if the CIOs opposed it.

But now that the basic agreement is done, what about the CMIOs and the actually physicians and caregivers who will have to use the system on a daily basis? I hope their input will be considered starting immediately, if this has not already happened.

How real-time will it really be? How are they going to handle corrections and errors? What about monitoring and maintenance of potential duplicate patients? Sensitive information, such as drug use, HIV status, sexual history, and the like? Patients who change their opt-in/opt-out status to avoid sharing certain information?

The devil will definitely be in the details. The answers to these questions, coupled with ease of use, will determine the success of this initiative (assuming the technical piece can be carried out in a timely and fiscally responsible way).

The New York Times pointed out that the groups also have insurance products. Collaboration could be seen as an attempt to compete with the lines of UnitedHealth, Aetna, and Wellpoint. Halvorson is quoted as saying, “This is totally focused on care.”

I really want this to work and be successful in a big way. This could pave the way for many other collaborative efforts that could be game-changers for the physicians in the trenches. The groups intend to exchange some data by the end of this year, so it should be fun to watch.

If any of the CMIOs from the Consortium organizations are HIStalk readers, I’d love to chat with you about the gory/geeky details of the project (preferably over a glass of wine and some chorizo fondue, but I’ll settle for Skype). Drop me a note if you’re interested in chatting.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 4/4/11

Surprise, surprise. At least someone in the federal government agrees with the rest of us that there is a conflict between the two CMS programs for e-prescribing. American Medical News reports that the Government Accountability Office has criticized CMS for “failing to align the two programs.”

Practically speaking, this means that some physicians are buying standalone e-prescribing systems (or using free ones) to avoid a Medicare penalty in the future, even though they may be in the process of implementing a certified EHR to take advantage of the Meaningful Use program. The article covers how various groups are lobbying to have this situation remedied. But in response to a reader question, I also emailed the HIStalk Medicine Cabinet for their thoughts. Thank you to all the members of the Medicine Cabinet who responded with your thoughts on this issue.

Dr. Jayne,

You offered to answer questions about the incentive programs, so here is mine. It may sound complex and obscure, but it is actually relevant to a large number of physicians, so please bear with me.

1. The e-prescribing incentive turns into a penalty in 2012. The penalty is determined by whether or not you use e-prescribing this year. You must use it and report the appropriate code in the first half of 2011 to avoid penalties in 2012-15.
2. The largest portion of the Meaningful Use incentive is earned for 2011.
3. According to CMS, you cannot get both of these payments; if you get the eRx incentive, you cannot get MU, and vice versa.

If you use the G-codes in early 2011 to avoid the penalties in later years, do you eliminate your chance of getting the (much larger) Meaningful Use incentive? Or are you better off not using the eRX codes, taking those penalties over the years, but getting the MU money? It seems that we must make a choice.

Can you offer a solution to this dilemma?

Thanks very much,

Perplexed

Respondent 1

On the question at hand, it’s true that you can’t qualify for both incentives in 2011. However, you can delay the launch of your MU odyssey until 2012 and still qualify for the full MU incentive – it will just be shifted out one year. If you want to maximize the incentives across both programs, go for the eRX incentive in 2011 and start MU in 2012. Just make sure that you don’t let your first MU adoption year slip into 2013 — that’s when you’ll start to see decreases in the total MU payment stream.

Another note: due to a bureaucratic snag, if you choose to go for MU in 2011 and give up the eRX incentive, you still have to check the box on the eRX incentive program in order to avoid the penalties in the out years. Such are the wild and wacky ways of federal government programs!

Respondent 2

Since you can’t receive eRX and MU Medicare payments in the program year same year, I would report on eRx in 2011 to avoid later penalties and then start MU reporting in 2012. Ignoring the time value of money issue, one is still eligible for the maximum MU payment by starting in 2012. This approach assumes that all of the money will be available in the out years of the program (I think it will, but if you don’t think the money will be there, it would then make more sense to skip eRx and just pursue the MU dollars).

Just in case there is some confusion, you can get both eRx and Medicaid payments in the same year. It is only Medicare where you must pick.

Respondent 3

This is a perfect example of the left hand not knowing what the right hand will do.

The real crux of all of this is that you have to being willing to see CMS-sponsored patients (Medicare / Medicaid). The issue I have with both these regulations is that most practices cannot even survive financially if they see the required amount of patients that are needed to fulfill criteria to get the incentive payments.

As a pathologist, the e-prescribing and Meaningful Use do not apply. My wife is a psychiatrist and I spend a lot of time with her IT systems. As a solo practitioner, she has simply opted out. But I think if she were participating, the Meaningful Use payments are more money depending on the volume of patients you see.

My guess is that no one will have the volume required. Now don’t get me wrong, there are valuable other reasons to do e-prescribing or an EMR. My wife is using an EMR and will be switching to e-prescribing now that the Controlled Substances Act has allowed it for electronic submission. Before, it didn’t make sense to be doing manual prescribing for controlled psychiatric meds and electronic for others. She is not using either for incentive programs as she doesn’t qualify for either.

The bottom line: physicians should not chase the money, but do what is right for their patients.

Respondent 4

Meaningful Use incentive — total possible $63,750 for EPs (or thereabouts)

eRx incentive — 2% incentive program (2% of the group practice’s total estimated Medicare Part B Physician Fee Schedule). This falls to 99% of PFS in 2012, 98.5% of PFS in 2013, and 98% of PFS in 2014.

I’d make the assumption that both are not available, since that is the supposition, and calculate which provides the greatest return (this does not take account of cost of compliance both in pure monetary terms as well as disruption / effort / resources).

The numbers will depend on how long you think this lasts or applies, but I would assume at least six years (given the MU current timeline payout).

Respondent 5

The maximum incentives for the e-prescribing program were available in the earlier years of the program, 2009 and 2010 (2% of allowed charges). For 2011, the incentive is 1%.

True, you cannot receive e-rx payment concurrently with EHR incentives. But if you decided to participate in the e-prescribing program and collect incentives and not participate in the EHR program until 2012, that’s OK. You just can’t accept incentives from both in the same year (i.e. participate and collect incentives in e-rx program and EHR program in 2011).

Where it has gotten confusing is that while you cannot "double dip," so to speak, by collecting incentives for both at the same time, you are still required by CMS to report the G codes for the e-rx program during the first six months of 2011 just to avoid the penalty for 2012. It is completely permissible to collect EHR incentives in 2011, report the G code for e-rx for the first six months of 2011 to avoid the e-rx 2012 penalty, AND collect incentives for the EHR program for participation in 2011.

The other thing is there is no registration process for the e-prescribing program, but you must register for the EHR program. If you register for the EHR program and report the G code for the e-prescribing, CMS should know that you intend to collect the EHR incentives.

CMS has a FAQ on this. It doesn’t touch 100% on this, but does to some degree.

So there you have it. Providers should make their decisions based on the facts available at this point in time. It’s not clear whether there will be any regulatory, administrative, or legislative remedy to this any time soon. For those of you who are pediatricians seeing greater than 20% Medicaid patients, or other specialties seen greater than 30%, take your Medicaid incentive checks and run! Be glad you don’t have to deal with this silly business and be kind to the rest of us who do.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 3/28/11

Dr. Jayne interviews Doug Farrago, MD

Earlier this month on HIStalk Practice, I posted a piece called “Meaningful Use: 15 Things Your Practice Can (and Should) Do Now.” I jokingly included an Item 16, which was a suggestion to immediately identify a CMHO for the organization – a Chief Medical Humor Officer.

CMHOs are hard to come by, so I wanted to introduce you to the self-proclaimed King of Medicine, Doug Farrago. Doug is editor and publisher of the Placebo Journal, often cited as “the Mad Magazine of medical humor.” Since starting the Placebo Journal in 2001, he has also published a compilation of stories, The Placebo Chronicles, as well as penning the Placebo Gazette e-newsletter and the Placebo Journal Blog. A man of many faces, he also stars in Placebo Television.

According to his website, “Dr. Farrago has risen to national prominence in the publishing world by providing a humorous outlet for physicians while fighting back against the medical axis of evil (pharma, lawyers, insurance, and a whole lot more.)”

I’ve been reading Placebo Journal since issue #2 and have also been a contributor, so I’m a bit biased. But given the sheer bulk of guidelines, regulations, mandates, programs, requirements, and dictates that most of us in healthcare IT deal with on a daily basis, being able to draw humor from all of it is a rare talent.

USNews.com once called Placebo Journal “raunchy, adolescent, and very funny.” When creating it, what was your objective?

The goal was to make people laugh. Plain and simple. The magazine is intended to distract docs from the crap we have to deal with. The stories we tell, like in the old doctor’s lounge, are what keeps us going. It enables us to commiserate.

How did you become King of Medicine?

Initially, I had posted an editorial in the Boston Globe about something ridiculous about our healthcare system that they wrote about. I wanted to piss off the ivory tower docs down there that pontificate on everything as if they are experts, but yet haven’t seen a patient in years. I made the point that maybe I should decide everything and should be named King of Medicine. It just stuck as I continued with the Placebo Journal.

You’ve also been an inventor and entrepreneur. How have those experiences impacted your ability to continue delivering quality medical care in a changing healthcare environment?

Absolutely … not. This is a job that is continually being bastardized by the idiots who have are trying to game the system. More and more people are jumping in the mix getting between the patient and the doctor. The only way to fix that is to get creative and go cash pay. I haven’t made the jump yet as I am owned by a hospital. It is really tough to get off the stripper pole.

How has technology impacted your practice in the last 10 years?

There have been some great advances with the ability to get information in real time. It has, unfortunately, opened up some bad stuff as well. We are entering a world of “industrialized medicine.” Mooooooo……

Do you use an electronic health record (EHR)? How has it changed the way you practice medicine?

EMRs are great for many things. The positive part is that I have info at my fingertips that was tough to get to in the old days. It is the never ending f#cking clicks and boxes that I can do without.

What’s your funniest EHR story?

I don’t remember one in particular. In general, I have been using an EMR for four years. During that time, I have lost the ability to make eye contact with people. Is that a new disease?

You’ve been fighting the establishment for some time. I understand you were once asked to leave the American Academy of Family Physicians annual meeting after covertly handing out copies of the Placebo Journal. The next year, you appeared in the exhibit hall in lederhosen. What’s next?

Unfortunately, our organizations have sold us all out. I am older and maybe a little wiser now. At this point, I just want to get people to lighten up a little and make a point in the process. Or just screw with their heads a little.

You used to work with professional boxers. Based on that experience, do you have any advice for physicians and their staff members as they try to navigate the CMS program for Meaningful Use?

THROW IN THE TOWEL AND WALK AWAY!!

As an employed physician, are you required to participate in the Meaningful Use program or are you able to opt out?

Right now, I am playing the game. My goal is to opt out of this garbage as soon as I can. Then I am going to wear a t-shirt that says, “I got your Meaningful Use right here” to the next big conference.

Although the Placebo Journal has always been a print publication, you recently made the decision to go strictly digital. I understand the unreasonable costs of utilizing a government-run agency had something to do with that. Although it was just the US Postal Service in this case, can you draw any parallels to what’s going on with other government forays into healthcare?

There are 82 federal programs dealing with teacher quality in this country. How is that working out for us? The same will happen with medicine. It is all bloat.

The local people at the USPS are great, but the fact is, no one mails letters anymore. Why are stamps so expensive? Why were there tons of people not getting my journal via snail mail every month? Too much government does not equal better service. Sorry, folks. The less middlemen in the healthcare system, the better.

You also do public speaking. Have you ever spoken on healthcare information technology topics? Any key thoughts you’d like to share with HIStalk’s readers?

I have not spoken on HIT, but my talks would still work as I can easily poke fun at what technology is doing to us. Besides, it would make you folks stop and think for a while. Maybe, just maybe, too much technology is bad. There is a human component to patient care, you know. An EMR can’t do a rectal exam … yet.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 3/21/11

It’s officially spring and there was a full moon over the weekend to boot. I’m not sure what I was thinking when I decided to work this one.

One of the downsides of being a CMIO type is that I’ve had to give up any semblance of a “normal” practice. Most of what I do these days is emergency department coverage or urgent care. One of the things I enjoy doing, though, is Locum Tenens work. If you haven’t heard of that, basically it means that you’re for hire to anyone who’s willing to meet your terms. Sometimes Locum work is fun, because you can take an assignment at an exotic location or practice in a way you normally don’t, like with the Indian Health Service or the military.

In my case, though, I usually Locum in my own metropolitan area. Folks like to hire me because I’m proficient in several EHR systems and can hit the ground running. (Thank you, moonlighting shifts during residency! Thank you, best of breed strategy!) In addition to the variety, this lets me see under the hood of other systems and experience for myself how other practices are using technology to perform patient care.

You might think it would be a competitive intelligence issue — that practices would be reluctant to use someone like me because I might steal their secrets. Frankly, they’re just happy to get someone who can jump right in and they don’t have to pay extra hours for training time. Most of the time it’s fun, but sometimes it’s very humbling.

Musings of a Mercenary Doctor

Training and staff proficiency makes a huge difference. There’s one group where I cover acute/sick visits. The physician shift splits two nursing shifts, so each physician works with two different nurses. I only work there once a quarter and it’s a large group with multiple locations, so I haven’t met everyone.

Recently I had the Jekyll and Hyde day. My morning nurse was spectacular – every patient history was nearly 100% complete, all medications were reconciled, and needed labs and diagnostic studies were pre-ordered based on standing orders. We rocked through 38 patients, too good to be true.

Remember that scene in Titanic where the crew in the crow’s nest shouts, “Iceberg! Dead ahead!”? Well, someone should have shouted that during shift change.

I spent the next couple of hours absolutely treading water and gasping for air. The semi-retired nurse who was staffing me apparently thought free-texting everything was a good idea, effectively sabotaging any smartness of the EHR workflow to select the right documentation forms or to share information between today’s symptoms and the patient’s previous notes.

Instead of reconciling medications she just entered new medications, creating duplicates. No tests were pre-ordered, making for a backup in radiology after I sent three patients simultaneously just to get the exam rooms clear for new patients. Although the volume had slowed significantly, it felt like we couldn’t get ahead. I kept focusing on the fact that at least I got to get in my lifeboat and go home at the end of the day.

Shirley is super-nice and does phone triage better than anyone I’ve worked with in a long time. She knows exactly how to counsel patients and is excellent with procedures. By late afternoon, the other physicians were gone except the two of us doing evening coverage.

According to my colleague, because she’s well-liked and is close to retirement, no one has the heart to either tell her that her misuse of the EHR is sabotaging the docs or that she needs retraining. Although they grouse about her at every provider meeting, they’ve decided they’re OK with it because they don’t want to hurt her feelings or rock the boat. The younger nurses don’t want to work nights and weekends and they can’t afford to lose her.

One of the great things about being a mercenary is not having to deal with office politics and being able to push the limits a bit. I decided to ask her how she thought the shift was going. She admitted being aggravated because she’s “not good with computers” and said she’d been frustrated since their go-live last year. I decided to dig a little deeper and see what I could do to help.

Turns out she’s semi-retired and works evenings and weekends because she helps care for her grandchild during the week. It also turns out that the practice did all the staff training last year during the morning, while many physicians were on hospital rounds, so they wouldn’t have to cancel patients. She never had formal training on the system. They asked one of the 21 year-old medical assistants to let her “shadow” and “learn the system” one afternoon.

Are you kidding me? I can only imagine what that was like for Shirley, trying to catch up after the fact and trying to learn from someone a third her age who was also learning the system.

I asked her if I could show her a couple of small things that might make her life (and selfishly, mine) easier. In just a couple of minutes between patients, I taught her how to reconcile medications and worked with her 1:1 on the next few patients. By the end of the shift, I had fantastic med lists and she felt like she had accomplished something. We spent a few minutes talking about how the logic of the system works and what happens downstream when you free-text. She honestly had no idea the havoc she was causing.

I cornered the other physician when we hit a lull. He was surprised. He had no idea Shirley hadn’t been trained. The docs had abdicated any responsibility during the EHR implementation, leaving it up to the office manager. He didn’t know about her work situation or what was behind it. I could tell he felt bad for complaining about Shirley rather than figuring out a solution. I told him what I showed her and what Shirley was now able to do.

In short, I spent about thirty minutes training/mentoring her rather than doing her job for the rest of the shift. I was happy, she was happy, and you can bet the next physician she staffs will be happy. As I finished my notes and the last few patients were trickling out, the other doc was showing her how to access his medication favorites list so she could use it to enter medications on new patients.

I hope he’s able to help his partners understand the situation and get her the training she needs (and deserves). I ended up seeing over 60 patients that shift, but the most important “care” I delivered didn’t have an ICD-9 code attached to it. Even on hectic days with systems that don’t always work the way we want, remember to look out for each other.

E-mail Dr. Jayne.

Curbside Consult with Dr. Jayne 3/7/11

Welcome to HIStalk’s new Monday feature, Curbside Consult. For those of you not familiar with the term, a curbside consult happens when another physician wants to ask your opinion about something, but doesn’t want to write a formal consultation request in the chart or actually send the patient to see you.

Curbsides have a certain appeal for both sides. When busy subspecialists like infectious disease (ID) docs are in short supply, they don’t want their time wasted by what they consider simple questions, like validating an antibiotic selection for a hospitalized patient. If the request is made formally, they have to see the patient and write a note, when often it’s an answer they can just give off the top of their heads (and are happy to do so).

My favorite ID consultant requires that you call his cell phone to curbside him prior to writing a formal consultation request. Eighty percent of his business is in curbsides, because he likes to save the “real” consultations for patients who are truly complex. I think it’s also his way of having some semblance of a home life. If he formally consulted on everyone he was called about, he’d never see the outside of the hospital. (It probably would be a different story if there were ID specialists around every corner, but there aren’t, at least in my market.)

For those of us that ask for the occasional curbside, often the question is one that we know the answer to, but want a colleague to validate. Maybe it’s not something we see every day, or we want to confirm that we’re operating with the latest and greatest information.

The worst kind of curbside is when a non-physician tries to ask for one — also known as the Supermarket Consult. Definitely to be avoided, as no physician ever wants to try to diagnose a rash in the frozen foods aisle.

The worst one of these I ever experienced was when I worked for a small-town hospital that had a float in the town’s Founders’ Day parade. Waving and throwing candy from my Astroturf-covered perch (wearing a white coat and scrubs, no less) a patient stepped out of the crowd in the middle of the parade route and asked me if I had an update on new medications for constipation. (With patients like that, who needs HIPAA, anyway?)

On HIStalk, Curbside Consult is about sharing physician opinions on the hot topics, not only from me (Dr. Jayne), but from the HIStalk Medicine Cabinet. Response from potential Cabinet members has been good. I haven’t gotten back to everyone yet since I worked entirely too much this weekend, so stay tuned.

When Mr. H offered to run my posts on their own night, it was exciting, yet a little bit nerve-wracking. I appreciate the opportunity and think it will be a chance to have more focus on CMIO/CIO/CMO/physician topics independent of the news, rumors, and updates. And so, here we go!

A Study of an Enterprise Health Information System

Mr. HIStalk opened the door on this one in his Monday Morning Update, so I’m going to walk right through.

For those of you who haven’t seen it: Jon Patrick, Professor at the University of Sydney’s Health Information Technologies Research Laboratory, wrote about implementing Cerner FirstNet in emergency departments in New South Wales. 

(As an aside, you can take the CMIO out of clinic, but you can’t take the clinic out of Dr. Jayne. The author also had an article about extracting data from narrative pathology reports on melanoma patients, which I downloaded to read on my way to the beach later this month. Using optical character recognition and concept tags to gather data and improve care? Fabulous!)

I agree with Mr. H though. Forget Cerner, as this applies to vendors and applications that are too numerous to count. Being the person who often has to have the less-than-pleasant conversations with vendor CMOs and physicians when there are issues at my hospital, I’d like to share my observations.

Although there are some significant defects out there, many vendors are working hard to remedy these and to implement aggressive protocols to bake quality into their products and design defects out. The best of these organizations are adopting techniques long used by manufacturing to ensure quality. This is still a relatively emerging industry, though — some folks are building Model T Fords, while others are building models that will go for 200,000 miles.

Vendors are under the gun from clients and prospects to make their products pretty, which translates too frequently into something that might look nice but isn’t clinician-friendly, usable, or safe. Vendors are also pressured to make their systems “fully customizable,” which often means allowing users to do things which are, for lack of a better word, stupid. I’d love to see a rebuttal of the article addressing what parts of the system were implemented against Cerner advice or best practices.

Some additional thoughts:

• Too many systems allow clients to “customize” patient safety out of the implementation. When I learned that there was a preference in my system to disable allergy and drug interaction checking, I cringed. (This was years ago when I was but a mere Physician Champion, before some of my colleagues decided I was an “IT sellout” and had crossed from “us” to “them.”) Within a few months, some of my colleagues demanded that we allow users to turn it off. Their reasons (no kidding) included “I know what medications interact with each other” and “I know what the patient is taking, I don’t need the computer” and “I hate it, turn it the [bleep] off.” There’s no class in medical school that teaches you how to deal with peers who act like this. The only thing you can do is make sure your patients and loved ones don’t go see them.
• User errors can be reduced, but they can’t be eliminated. At our hospital, we aggressively track errors in documentation and look at trends between physician offices and across the system. Good staff training, low turnover, and accountability all lead to fewer errors. Surprise!
• Patients give bad information, which no amount of decision support or application design can fix. Until we have fully integrated interoperable platforms that remove human memory or manual data entry from the equation, this is going to be an issue. On the other hand, when everything is fully automated, errors can become magnified and nearly impossible to fix. Talk to anyone who’s been the victim of medical identity theft and you’ll know immediately how horrible this can be.
• The ability to review longitudinal patient data is sorely lacking in many systems. In this world of accountable care and shared risk, the concept of episodic care needs to die a quick death.
• Data integrity has to be paramount. It doesn’t matter how slick your user interface might be or how few clicks it takes to document — if the data gets vaporized, it’s game over. My first EHR had this handy little feature: the templates accommodated unlimited input, but the documents only accommodated X number of characters. Not knowing any better, I trusted my vendor (ha!) and didn’t discover this undocumented functionality until patients came in for follow up visits and many Assessment/Plan sections (traditionally done at the end of the note) were missing. My risk management consultant loved that one, let me tell you. On the other hand, that EHR was extremely easy to use, was highly standards-based, and had a workhorse scanning solution that I still miss. But it ate my notes, so it had to go.
• Several vendors still use design philosophies that revolve around the individual visions of key leaders regardless of user needs. Granted, they’re baking in the Meaningful Use requirements because they have to, but the world has changed and what was cool 20 years ago is no longer what healthcare needs. There are peer-reviewed studies on usability and user interface design, and some of these folks must never have seen the articles. HIMSS did a piece on EMR Usability a couple of years ago and I know the systems that have design elements that hopscotch all over the place or color schemes that induce vertigo are designed by people who haven’t seen it.
• Vendors should spend the money to hire medical proofreaders to look at their products. Nothing screams “we rushed this to market” like misspelling medical words. I saw this more than once at HIMSS in the nether reaches of the exhibit hall. Once you lose providers’ trust with something like that, it’s extremely difficult to get it back.
• Allowing existing users to beta-test your product, if they’re willing to donate the time (or if you’re willing to pay for it) can make a huge difference in the quality of releases. This allows for detection of those issues that are particular to the way individual clients use a system. Otherwise, there’s no place like production.
• Vendors need to disclose their defects. More and more are doing this in a meaningful way. On one hand, I understand the call to have the FDA regulate systems. On the other hand, as a physician, I know that the FDA is, in many ways, a joke. Deserving products can’t get to market because of the complexity of the process, manufacturers with deep pockets continue to slipstream their products, and the vitamin/supplement industry got themselves classified in a way so they can say what they want, produce what they want, and generally get away with it.
• Hospitals and practices need to thoroughly test their systems prior to go-live, regardless of what the vendor says or how many clients they have live. Your staff will find shortcuts and features that no one has seen and will rapidly become dependent on these, much to the consternation of your call center, trainers, analysts, and the vendor. The only way to trust the system is to test the living daylights out of it before taking it live.

Unless physicians and their IT teams understand these points, they aren’t ready to leave paper. Those who do understand need to play an active role pushing vendors to improve and vendors need to address core functionality.

If progress isn’t made, the likelihood of a federal mandate increases. We’ve already seen what Meaningful Use has done to the industry. As Scotty once said, “She can’t take much more of this, Captain.”

E-mail Dr. Jayne.