Friday, September 21, 2012

Asking the Wrong Questions About the Electronic Health Record

By Ashish Jha, MD

The wrong question always produces an irrelevant answer, no matter how well-crafted that answer might be.  Unfortunately the debate on health information technology seems to be increasingly focused on the wrong question.  An Op-Ed in the Wall Street Journal argues that we have had a “Major Glitch” in the use of electronic health records (EHRs).  This follows on a series of recent studies that have asked the question “do EHRs save money?” Or “do EHRs improve quality?” with mixed results.  While the detractors point to the systematic review from McMaster, boosters point to the comprehensive review published in Health Affairs that found that 92% of Health IT studies showed some clinical or financial benefit. The debate, and the lack of a clear answer, have led some to argue that the federal investment of nearly $30 billion for health IT isn’t worth it.  The problem is that the WSJ piece, and the studies it points to, are asking the wrong question.  The right question is:  How do we ensure that EHRs help improve quality and reduce healthcare costs?

The fundamental issue is that our healthcare system is broken – our costs are too high and the quality is variable and often inadequate.  Paper-based records are part of the problem, creating a system where prescriptions are illegible, the system offers no guidance or feedback to clinicians, and there is little ability to avoid duplication of tests because the results from prior tests are never available.  Even more importantly, the paper-based world hampers improvement because it makes it hard to create a learning environment.  I have met lots of skeptics of today’s health information technology systems but I have not yet met many physicians who say they prefer practicing using paper-based records.

The problem is that some Health IT boosters over-hyped EHRs.  They argued that simply installing EHRs will transform healthcare, improve quality, save money, solve the national debt crisis, and bring about world peace.  We are shocked to discover it hasn’t happened – and it won’t in the current healthcare system.

Most EHR vendors today sell their products to doctors promising increased “revenue capture” (that is, improved billing resulting in greater payments to physicians and higher costs to the health care system).  In a fee-for-service world, the EHR, which is nothing but a tool, helps you get more “fee” for your “service”.  It’s not surprising that we aren’t seeing huge savings.

To understand how to best leverage the potential of EHRs to help the US improve care and save money, we will have to answer a series of other related questions:  how do we create incentives in the marketplace that reward physicians who are high quality?  How do we allow physicians to capture efficiency gains?  Today, if a physician becomes more efficient, he/she will likely lose revenue to insurance companies or to government payers.  When Kaiser Permanente installed an EHR and gave patients the ability to use the electronic system to message their physicians, they saw their ambulatory care visit rate fall by 20%.  This is a disaster in a fee-for-service world.  Sure, Kaiser was able to see real financial gains from their EHR – but how do we help the thousands of other physicians and hospitals that are not Kaiser gain efficiencies from their EHR?  That’s the question I’d like to see answered.

Now that we have made an important investment in EHRs, we need to figure out how to use this new technology to address the fact that the healthcare system is a mess.  We need to figure out how EHRs can promote coordination of care across sites, seamless flow of good clinical information, and smart analytics, to name a few things.  We simply can’t do that in a paper-based world.  I am sure that the healthcare industry single-handedly keeps the fax machine industry alive.  We need to stop. Period.  Every other part of our lives has become electronic and the benefits are clear.  Our lives are better because we bank online, communicate online, shop online.

The debate over whether we should have EHRs is over.  Can we fix our broken healthcare system without a robust electronic health information infrastructure?  We can’t.  Instead of re-litigating that, we need to spend the next five years figuring out how to use EHRs to help us solve the big problems in healthcare.

Ashish Jha, MD, MPH is the C. Boyden Gray Associate Professor of Health Policy and Management at the Harvard School of Public Health. He blogs at An Ounce of Evidence.This post first appeared at the Health Affairs Blog.

Filed Under: Tech, THCB

Tagged: , , , Sep 19, 2012

Interesting rebuttal to the WSJ article "Major Glitch" as Dr Jha says

The fundamental issue is that our healthcare system is broken – our costs are too high and the quality is variable and often inadequate

Installing an EMR won't change this since there is no silver bullet for our problems. EHRs like many of the technologies and initiatives are one part of the equation but they are definitely part o the soltuion
What they look like and how we interact with them will probably be very different to the current interactions and will involve current technologies and probably some that have not even been imagined yet or applied in that way to healthcare. Can you imagine wearing Google Glasses in your practice - probably not but I am willing to bet some variant of this will become mainstream at some point in our healthcare delivery system
Same is true of patient centered content and management. To that end I will be looking forward to talking to Clint McCellan (@clintmc1) this afternoon on this area and how we can push this aspect forward

Posted via email from drnic's posterous

Wednesday, September 5, 2012

VoiceoftheDoctor for the Month of September

This month we will be 
Sep 7

Brad Tritle (@BTritle)who is currenlty the chair of the HIMSS Social Media Task Force.  He is currently co-editing a forthcoming HIMSS book on consumer engagement and consulting under the Office of the National  Coordinator on consumer engagement for State HIEs and immunization registries. Amongst the areas of focus:
  • Health Information Exchange
  • Consumer e-health
  • Personal Health Records
  • privacy/security
You can read his interview ith HIMSS here
We will be discussing the dleivery of patinet care - where the patient and the change in system dleivery and technology innovation to achieve this including telehealth services for consumers, apps and how this relates to PHRs.  

Sep 14
ID Experts - Is the EHR a target for Cybercrime.....

Sep 21

Clint McClellan (Twitter @clintmc1) who is Sr. Dir. of Strategic Marketing at Qualcomm Life and the President and Chairman of the Continua Health Alliance. HE and I will be talking about the Continua Health Alliance which is a non-profit, open industry organization of healthcare and technology companieswho are collaborating to improve personal healthcare.They are establishing a system of interoperable personal connected health solutions that will help empower everyone to enageg in their own personal health wellness amangement. Take a look at their vision video here

He and I will be discussing some of the examples and soltuions in the personal health space and how these have eveolved from personal smartphones to dedicated gateways and what opportunities will open up for application developers?

Sep 28

Healthstory - Liora Alschuler, CEO of the Lantana Group and co-founder of Healthstory initiative. She is Co-chair, HL7 Structured Documents Work Group responsible for HL7’s Clinical Document Architecture (CDA), the first standard for healthcare based on XML. 

We will be discussing the Healthstory Intitaive and the recently finalized Meaningful Use Part 2 guidelines

Join me this Friday at 2:30 ET on VoiceoftheDoctor
There are three ways to tune in:

• Stream the show live – click the Listen Live Now to launch our Internet radio player.
• You can also call in. A few minutes before our show starts, call in the following number:  Call: 1-559-546-1880; Enter participant code: 840521#
• is now on iTunes Radio!  Stream the show live – you’ll find this station listed under News/Talk.

Nuance Healthcare Asks Developers to Make #HealthIT Smarter


Nuance wants your help - we want to make #HealthIT smarter and have issued a challenge (similar to the successful challenge from HIMS2012)

Can you take the Clinical Language Understanding (CLU) software development toolkit and apply this in your application. The opportunity to convert free form narrative content into meaningful clinically actionable data without asking the user to fill in a form, check a box or select from a drop down list.

$5,000 prize plus additional prizes for the first 20 submissions.

Posted via email from drnic's posterous

Khosla says technology will replace 80 percent of doctors - I think not


Technology replacing doctors.....
Still missing The Human Element and besides in the

Mayo Clinic Proceedings March 2006 vol. 81 no. 3 338-344
they identified the most most important characteristics patients feel a good doctor must possess

  • confident,

  • empathetic,

  • humane,

  • personal,

  • forthright,

  • respectful, and

  • thorough

  • These facets are entirely human and will be hard for technology to replace

    Posted via email from drnic's posterous

    Tuesday, September 4, 2012

    The Trouble with EHRs - 26% report decrease in productivity #EHR #Speechrecognition #HealthIT

    Recent review by Medscape (Membership required)

    THe advice from EHR users included the suggestions:
    "Learn to Type VERY Well"
    Intelligent integration of speech recognition is a genuine solution to that challenge

    Rankings were interesting - Amazing Charts still hitting the top spot

    In Medscape's 2012 survey, the 5 top-ranked EHRs were Amazing Charts, Practice Fusion, VA-CPRS, and Medent. In Medscape's 2009 survey, the top-ranked EHRs were Amazing Charts, MediNotes, VA-CPRS, Misys (now Allscripts), and Practice Partner and eClinicalWorks tied for fifth place.

    Posted via email from drnic's posterous

    Five Technologies that will Change the Practice of Medicine

    Speech Technology

    Speech recognition offers efficiencies today but recent innovations and new technologies will expand the horizon of opportunity with speech technologies that will change the human computer interface, simplifying the interaction and offering new and innovative tools that increase efficiency and safety of healthcare delivery and reduce the administrative burden and decrease costs.

    Medical Intelligence in the Cloud

    We’re facing a tsunami of patient data. The ability to process and leverage this data at the point of care is gone. Cloud based intelligence, analyzing data content and delivering contextually relevant information in real-time will become essential.

    Continuous Mobile Monitoring

    Our current perspective of a patient’s healthcare record is comprised of snippets of our total healthcare record (imagine a piece of string as the record – all we get is a very short piece when we visit a doctor/facility). Continuous monitoring (wireless, cloud based and automatically monitored and tracked) changes this and offers more complete view of our health record and more important data that is not just single data points but trends and changes.

    Personal Health Management

    This is becoming essential as we move from a system that disconnects the purchaser from the payer. It’s as if we were buying a car but someone else was paying with no personal financial consequence – we would all buy Ferrari’s, Porsche etc. As we move away from this model, personal responsibility, personal health management tools and PHR's will become essential, not just for capturing and holding the data, but for helping people interpret and manage their own care. We will all become our own care coordinators for ourselves and our extended family, but will need the tools and solutions to help – these will come in form of PHP and health management tools.

    Social Media in Healthcare

    If World of Warcraft can engage a generation of young adults and teens to stay online, engaged and spending enormous sums of money, the gaming industry is doing something "right". Applying this to health and getting folks engaged is the next frontier. We have already seen that just giving a patient access to their medical record and putting a definitive Diagnosis of obesity has a positive impact on their behavior and general health. Imagine what else you could do with social media and gaming engagement.

    But as always - don't forget the patient. As I have noted before Doctor Please Look at Me not Your EMR

    This was amplified in a recent article in JAMA: A Piece Of My Mind (JAMA. 2012;307(23):2497-2498. doi:10.1001/jama.2012.4946) that included this drawing from a 7year old girl: