Category Archives: EHR

Day 48: Data Gathering transitions to Information Analysis

Transition (trăn-zĭsh’ən) n.

  1. Passage from one form, state, style, or place to another.
  2. A word, phrase, sentence, or series of sentences connecting one part of a discourse to another.

In the midst of running Medsphere I became aware that we were onto something very powerful. Somewhere along the line I finally “got it” that what we were actually doing was not implementing electronic health records but rather creating the data collection backbone that would enable future clinicians, researchers, and other interested parties to have access to large volumes of data that they could then turn into useful information and ultimately knowledge about health care delivery. This realization helped me move beyond the mere “features and functions” comparative sales pitch to a much more egalitarian view of how most any standardized information system could most likely serve as an effective tool to gather the data and transform it into clinical relevant and useful information. Since we could offer the tool at a fraction of the price of the other guys, it made perfect sense to me why the customer should select us!

The Veterans Health Administration clearly has led the way in this regard with their implementation (begun in 1996!) and utilization of an enterprise wide electronic health record to radically alter their outcomes. I was fortunate to help  transition this technology to the private sector with OpenVista implementation at Midland Memorial Hospital (and have followed with interest their successes with interest).  Kaiser Permanente also endeavored to initiate one of the largest ever civilian deployments of an EHR to the tune of ~$5Billion dollars across their 35  hospitals. This massive investment has paid off in spades, and we are now just far enough along that we are going to start seeing some of the incredible results enabled by a system wide electronic health record (regardless of variety).

Case in point: An embargoed article was just sent to me by my friends at Kaiser who are just publishing a new article in the Clinical Orthopedics and Related Research journal of the Association of Bone and Joint Surgeons. The paper demonstrates how an EHR-enabled, large-scale total joint replacement registry has enhanced patient safety, quality of care, cost-effectiveness and research, and how a national registry could improve clinical practice and reduce revision rates in the U.S.

Key points from the article include:

  • More than 600,000 total joint replacement procedures are performed each year in the U.S., and the volume and costs associated with these procedures are projected to increase dramatically over the next 20 years
  • Kaiser Permanente’s Total Joint Replacement Registry– the nation’s largest such registry with 100,000+ hip and knee replacement cases – allows caregivers to analyze specific data from standardized forms and Kaiser Permanente HealthConnect (Epic software), the world’s largest private sector electronic health record, to help identify best practices, evaluate risk factors for revision surgeries, assess the clinical effectiveness of implants, and study patient demographics, implant characteristics and surgical techniques related to post-operative infections, revisions and re-operations.
  • Data from the registry has been integrated into a risk calculator that surgeons and patients use to make decisions about treatment. Research from the registry on implants and surgical techniques has influenced changes in clinical practice and optimized both techniques and implants.

The article features some of the authors, surgeons, and even a patient case study of how the registry was used to make an informed clinical decision (my friends at Dartmouth would be proud!).  We are clearly just at the front of this curve wherein we actually start getting into outcomes, accountability, and real shared medical decision making with legit data on the various treatment options. It is going to be an exciting journey to be a part of this data to information transition.

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Filed under EHR, Innovation, Quality, Rational Choice, Transparency, VistA

“You Ugly”: Creating 8 cow software

Ugly (ŭg’lē) adj.

  1. Displeasing to the eye; unsightly.
  2. Repulsive or offensive; objectionable
  3. Likely to cause embarrassment or trouble

UPDATE: I was able to talk with several senior executives, including Jonathan Bush (CEO) and Rob Cosinuke (Chief Marketing Officer) about my concerns. The great news is that athena is finally getting serious about design and hired their first UX folks last fall. They have begun their work and I look forward to hearing about their progress. I also was given some insight into athena’s plan to leverage their new Communicator platform (functional PHR) as a first foray into creating virality (as in viral) to their software. The approach is still a “push” and I believe they will find that their design efforts will create more of a viral “pull” than anything else they can do on their side. As one of the best UX people I know recently said, ” UX design is business strategy, not just making something look pretty.”

One of my favorite stories from my childhood was the quaint but profound story of Johnny Lingo. As you recall, Johnny was a young man who was the original Bachelor on his sleepy south Pacific island. The village was abuzz as Johnny prepared to make an offer on his future wife. All the village girls primped and pranced in an effort to win his heart as they heard that Johnny was preparing to offer a significant sum for his wife. However, one young woman, did not participate in the festivities. Mohanna was different than the other girls and was treated very poorly by the other villagers as well as her own family for her plainness and painful shyness (the cutting words of her father, “Mohanna, you UGLY!” became a familiar epithet used around our home and on the playground).

But the noble Johnny Lingo saw something that no one else did. On the set aside day, Johnny gathered his friends and began the processional march into town. To everyone’s amazement, Johnny was followed by eight cows – more than had ever been offered in the entire history of the island. He passed house after house of eligible bachlorettes to both their deep disappointment and obvious dismay. Finally he came to the humble house of Mohanna’s father and offered his 8 cow dowry for his daughter. The shocked father questioned Johnny’s sanity, but ultimately agreed to the gifts in exchange for his daughter. Mohanna, affected deeply not only by the amount that was paid for her hand in marriage, but also by Johnny’s ongoing devotion and deep love for her, rapidly blossomed into an amazing beauty. For the first time ever, people were able to see the incredible beauty that had always been there.

Athena is the most powerful software “solution” I have seen in the market to date. I have highlighted the solution repeatedly because I believe so profoundly in the underlying principles (dang, there is some funny stuff in there):

The important concept to understand is that athena is promoting “service enabled software” meaning that an entire service organization is built up around the software platform. The software is a tool that is highly leveraged and works synergistically with the service organization to create an unprecedented practice performance level. Having implemented the software now for three months, I can see the real, tangible, and immediate benefits of athenNet services. It has lived up to its promise and we are pleased with our results to date.

HOWEVER, “athenaHealth you UGLY”!

It has a 1999 interface, with way too much content and information, too many clicks between screens, not enough help in creating templates, and not enough attention being paid to overall presentation and functional utility for the user. Athena simplifies my life in so many ways but it still reflects the complexity of the insurance world in which it lives and is optimized. This needs to be abstracted out for me just like they abstract out the other difficulties in my practice life.

Given the robustness of the platform, I remain shocked that athena only has about 1% of the overall market. I often heard Jonathan bemoan this fact as well. I would argue that if Jonathan Bush and his team would drop the 8 cows dowry to improve the UI, more people would be able to see and appreciate the inherent beauty of the platform. If you want viral growth, you have to have a viral interface that can be rapidly adopted. You can’t just push it out either, it has to get “pulled” out by the users because of its inherent “awesomeness” and the subsequent referral communities that build up around it.

I believe that athenaNet is 8 cow software, but its going to require to an 8 cow dowry to help others see it as well.

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Filed under 10422713, EHR, Innovation

Healthcare Pioneer: EHR Vendors start their outreach

Pioneer (ə-nîr’) adj.

  1. Of, relating to, or characteristic of early settlers
  2. Leading the way; trailblazing

When I worked shifts in the ER, I was trained and learned to be weary of people who were overly complimentary or attempted to become too familiar. It is a personality defect seen in those with borderline personality and often in drug seeking behavior. The appeal to the ego can provide a tug into the deep waters, but that natural hesitancy and wariness kept me in the safe shallows more than once. The often innovative ways these people appeal to the ego is almost as interesting as the sudden shift into the vicious when you don’t give them what they want.

So it is with that familiar wariness in which I review alot of incoming email I have been receiving as of late. The traditional EHR vendors are getting more and more innovative with their marketing approach. Take note of the interesting email from a company that I actually respect for a solid product – Greenway Technologies (see below). I evaluated them very thoroughly in late 2008 and noted that they have a very solid, traditional  system specifically tuned to the current quagmire in which physicians practice. They have a decent EMR, decent practice management, solid PHR, and an interesting twist on population management with their clinical research (glorified registry) functionality.

However, I couldn’t pull the trigger on them because they were tuned for the traditional. I didn’t see that they were leveraging the concept of the network, or their EHR as a platform, or that their UI technology was fluid or as modern as I wanted. I didn’t get a sense for the flexibility and freedom found in the notion of clinical groupware. And finally, I didn’t get the sense that they were going to take me to the next level. Please – don’t get me wrong,or  attempt to outKLAS me, or bang on their numbers which are impressive. They are a solid player who will do well – but it wasn’t for me or the network of primary care clinics that I am wanting to build.

Needless to say, I found their marketing approach to be quite pioneering:

Healthcare Pioneer,

You are probably wondering how you became designated as a Healthcare Pioneer by Greenway.  We define such an influencer as an organization or individual who is involved in leading the development of the Health IT community, implementing EHR’s at the point of care and optimizing the opportunity at hand presented to us by The American Recovery and Reinvestment Act of 2009/specifically the HITECH Act.  We polled our employee base and asked: “Who in your respective region/professional arena do you hold in high regards and value as it relates to our mutual $45+ Billion market place?” You were nominated for your leadership and dedication to creating the most efficient and effective healthcare transformation through Health IT.  As we grow our network of influential leaders, and jointly capitalize on the media driving our Health IT sector, we extend a gratuitous “Thank You” to you for being a part of our success.

In an effort to provide continued educational awareness, as well as provide mutually beneficial opportunities, we will begin disseminating periodic, customized Corporate Communications outlining current Industry news, industry achievements & milestones, Webinars, as well as pertinent Health IT Transformation and Healthcare Reform activity from Capitol Hill.

Did You Know?

  • 27,000 Healthcare Providers and Professionals call upon Greenway’s integrated EHR, Practice Management, Interoperability and Clinical Research solution everyday … denoted by the name PrimeSuite®.
  • 315 plus dedicated Greenway employees have driven over 30% annual revenue growth the past 3 years consecutively.
  • Over 19 Million Electronic Records are managed comprehensively and efficiently throughout 49 states (and the Nation’s Capitol) by highly satisfied Greenway customers.
  • Over 1,375 unique interfaces from 115 plus 3rd party vendor participants find themselves internally managed via Greenway’s PrimeExchange® interoperability engine producing hundreds of thousands of transactions monthly and creating a simplistic workflow for our thousands of customers.
  • Best in KLAS, our industry’s “Consumer Reports”, has ranked Greenway Best in KLAS three consecutive years in a row.  In 2008 Greenway was awarded Best in KLAS in 3 categories, including 2-5 Ambulatory EMR, 6-25 Ambulatory EMR and 2-5 Practice Management, making Greenway the only Ambulatory-focused organization to receive multiple Best in KLAS awards in 2008.
  • Greenway is a leading national speaker on how the current EHR “meaningful use” and Certification criteria are evolving. We have testified and/ or addressed Congress as well as both Presidential Administrations on twelve occasions regarding Health IT.

To Learn More:

Without question, there are some remarkable, opportunistic and exciting times before us and
Partnering with you will continue to be a Privilege. Thank you again for thinking Greenway!

Call today at 866.242.3805 or email us at info@greenwaymedical.com

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Filed under EHR, Entrepreneurship, Industry, Quality, Value

#FAIL! Proprietary EHR LockIn through CCHIT Certification

* I just found several blog posts that I had written but never posted. Sorry that these are late but there are still worthy of a link or two.

I just saw some serious lame legislation proposed out of New Jersey by some ill-informed congressional lackey legislating that all EHR’s be certified through CCHIT. This is absolutely ridiculous. Do you really want to outlaw Google Health and Microsoft HealthVault in the Garden State? I mean get real!

* CCHIT later published some comments about this

The unintended consequences of such legislation is highly problematic and well described by David Kibbe, Fred Trotter, Ignacious Valdez and others. I have seen CCHIT make great efforts to correct this and make the process more open but they have a fundamentally flawed and constrictive position – that they alone can bestow the quality seal of approval on software.

They don’t realize, of course, that any attempt to subvert innovation will be futile. “Life (or in this case innovation) always finds a way”. The notion of a new type of communication platform that will emerge as a result is already underway. Designated “Groupware” by David Kibbe or a new “Communication” platform by Myca or American Well, new tools will continue to emerge that defy current descriptions. Are you sure you want to lock down into today’s technologies through an already arcane certification process?

I would strongly argue that standardizing features and functionality is not the problem. These should be allowed to freely evolve and grow per the needs of users and the skills of developers. What should be standardized is the interoperability requirements of data, the database requirements, and related infrastructure elements that will enable the data to be truly liberated. These standards will do more for the industry than any other single legislative or policy initiative. This is where we need government help to force agreement on specific principles where the choice is not as consequential as just making a decision (driving on left or right side of the road is irrelevant; but it is clear that we need to make the determination!).

Legislative mandates for features and functions = #FAIL!

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Filed under EHR, Innovation

Whats the new spelling for the AMA? S-E-R-M-O

Spelling (spĕl’ĭng) n.

  1. The forming of words with letters in an accepted order; orthography.
  2. The art or study of orthography or the way in which a word is spelled.

Whoa . . . just ahead of a 21% cut in physician salaries we have an epic battle shaping up within the physician community. The AMA, long the Godfather and voice of physicians around the country, apparently is feeling the heat from a younger, more svelt upstart from across (cyber)town. I have just received back to back emails from Sermo CEO Daniel Palestrant essentially declaring his succession from the physician union. This comes at a critical time when further fracturing of physician leadership and political strength put in jeopardy the opportunity for the physicians to have a unified voice (or is it because the stakes are so high that this group is compelled to speak up?):

The leading missive from 7/1/09 (might require log in):

Dear Dr. Shreeve,

As physicians, our first step in the healthcare debate needs to be clearing the air about who speaks for us on what topics. Today, I am joining the increasing waves of physicians who believe that the AMA no longer speaks for us. As the founder and CEO of Sermo, this is a considerable change of heart, given the high hopes that I had when we first partnered with the AMA over two years ago. The sad fact is that the AMA membership has now shrunk to the point where the organization should no longer claim that it represents physicians in this country.

The AMA has drawn its power from the support of the physician community. The waning membership reflects our objection as the AMA has failed us consistently for over 50 years. Make no mistake, the debate within the AMA about how to stop their membership decline is not new.  What is new is the lengths to which the AMA appears willing to go to deceive the public on this topic.  The AMA routinely claims that their membership is 250,000 practicing physicians.  At best, this is 25-40% of practicing US physicians and even that claim is based on some stretching of the truth.  The 250,000 total includes a number of non-practicing constituencies, including medical students, residents, and subscribers of the AMA’s journals.  Paying membership is generally accepted to be far lower.  How much lower?  Actual numbers are remarkably difficult to come by.

At this critical moment in history, we cannot watch the AMA fail physicians so completely yet again.  Nor can we stand by and let false perceptions about who speaks for physicians persist. At the very least, all parties should understand the intrinsic conflicts of interest that are in play, and the AMA should be held accountable to these truths.  Better yet, physicians should call for sweeping changes within the AMA.   In the best-case scenario, the AMA will shed its relationships with insurers and abandon tactics that take advantage of physicans to generate millions of dollars in revenue.  It is an inherent conflict of interest to claim advocacy for physicians while profiting from a reimbursement system that makes it increasingly difficult for physicians to practice medicine.

The flight from the AMA signals that physicians don’t believe the AMA is willing to make these changes. The longer that the public and our lawmakers cling to the perception that the AMA represents the voice of US physicians (and the AMA succeeds in perpetuating this), the more imperiled the medical profession will be and with it the broader US healthcare system.  It’s time to turn to entities like Sermo where physicians are establishing a new voice to collectively discuss the future of our profession.

There can be no healthcare reforms that have any chance of succeeding without buy-in from physicians.  As a country, we cannot risk another failed reform effort.  As physicians, we cannot risk letting the AMA represent our interests.  This is our time to educate the public about which voices truly represent us and our commitment to our patients.

Daniel Palestrant, MD
Founder & CEO
Sermo, Inc.

The follow on upper cut (From 7/2/9):

Dear Dr. Shreeve,

Yesterday I posted on Sermo about the need for a new voice to represent physicians. The Sermo community’s response was clear. 2,400+ physicians voting in less than 24 hours. 90% say that the AMA does not represent them. That is a bold statement and the general public will take note.

The need for physicians in this country to have a strong voice has never been greater. And Sermo, a community of well over 100,000 US Physicians, needs to make its voice heard. Yesterday’s posting was the beginning of a regular series that will make your voice heard on issues critical to our profession. Results from these postings will be publicized to the media.

Believe it or not, we are already making dramatic progress. I have been contacted by major media outlets who are interested in what physicians on Sermo have to say. Beginning next week our voice will be heard.

Add your voice to the first topic:

The Biggest Risk to US Physicians Today: The AMA

Sincerely,

Daniel Palestrant, MD
CEO & Founder
Sermo Inc.

I have commented about Sermo before (here and here). I think it can be a useful tool – the virtual lounge if you will – which I totally get. Some of the hallway conversations were useful, but I had other settings in which to engage to my clinical and personal satisfaction. And just like the real thing, I never felt comfortable hanging out in the posh lounge with slightly better food when all my patients, colleagues, and fellow health care workers were sent somewhere else. It is the same discomfort I feel on the rare occasions I have flown first class and sat uncomfortably watching all the “regular” people pass pass on the way to the back of the plane.

Obviously a Sermo style virtual lounge has alot of potential and possibilities. While some of my previous comments can be taken as somewhat down on the platform, I am generally very much in favor and supportive of what Sermo is doing. In fact, I believe the collective intelligence within the network is a wonderful place to harness the cognitive surplus of physicians. Moreover, online communities of experts who can share real medical knowledge in real time, discuss and comment in warp speed peer review, and allow a business commodity to be created from voyeurism certainly has earned my respect.

The breakthrough is not in the message nor even the messenger, it is the manner in which I am getting this message that is most impressive. 100,000 physicians strong (and growing), online and interactive, and now muscling up for the biggest fight of their life. Perhaps most useful of all, is the ability to aggregate the physician voice into a common unified message. My articles above highlight the role of aggregators, and this specific type of network effect grows in influence and power to the point of being a  political force to reckon with. Perhaps the 100,000 member barrier represents the political tipping point to take on the slothful big brother?

Should be interesting to follow – looking forward to seeing if the new kingpin has the staying power to dislodge the king. Looks like he has certainly swiped the scepter.

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Filed under Change Agents, Consumerism, EHR

The Myth of Prevention and EHR’s?

Prevention (prĭ-vĕn ‘shən) n.

  1. Preventing or slowing the course of an illness or disease
  2. Intended or used to prevent or hinder; acting as an obstacle
  3. Carried out to deter expected aggression by hostile forces.

I was just referred this article which I found to be thoughtfully crafted. Abraham Verghese is a Professor and Senior Associate Chair for the Theory and Practice of Medicine at Stanford University. I found the article interesting, by somewhat anachronistic in terms of his perception of prevention and electronic medical records.

First, he raises an important point about the many overstatements as they relate to prevention. When we talk about how effective screening programs could be in identifying people for early interventions we have to realize what we are saying and what tools we are using for identification. Some tools can be too blunt, and not find the people we are looking for (false negatives), while other tools can be too sensitive and capture too many who actually may not have the disease (false positives). This is brought home in the example Dr. Verghese uses around the pitfalls of new diagnostic imaging equipment (and the situation is much worse with genetic testing at this point in time!). With these newer, more sensitive imaging studies you can pick up calcium deposits in a health individual can lead you down a pretty wild (and expensive) goose chase for someone who is completely asymptomatic. He also demonstrates that the “value” of some prevention recommendations as somewhat questionable  – meaning – that while taking cholesterol lowering drugs has clearly shown to be efficacy reducing cholesterol levels and cardiac risk, is it really worth $150K/additional life year extended?

Well, that depends on if it is your life I assume. My point being, that you need additional information to be able to make these difficult, complex decisions. You need to not only know the relative efficacy of the regimen, but also the cost of the regimen to truly get at the “value” of the intervention. In addition, patients have modifiers to which they will place on the intervention in terms of cost in time, pain, and other inconveniences that are unique to their own values. This is where shared medical decision making can have such an impact – lay out the good, the bad, and the ugly and allow the patient to make a decision based on all the available evidence according to their own value system.

I don’t think these types of decisions can be made with the type of information we have today within the current clinical infrastructure. First, the physician gets paid to order the test and not talk to you about whether or not pros and cons of whether you should get it. Furthermore, the doctor has very little to no data upon which to inform that conversations anyway. In the relatively rare areas in which we have evidence, we might not have other components required for decision making in terms of cost and experience of patients undergoing regimen. In the case of prevention items mentioned above, we might choose not to go on statins at $150K per year but instead invest $10,000 in a personal trainer who is going to get rid of the root problem anyway. Without the underlying information, this would never even surface as part of the decision making process. We absolutely must be gathering, comparing, and sharing result outcomes in order to increase our capacity as healers who use the right treatments for the right patients at the right time and in the right way.

Which leads me to my final point – you absolutely need EMR’s to function as an 21st century physician knowledge worker. We are purveyros, translators, and mediators of medical information for our patients. They can get most of it on their own now, but we can still add significant value through our interpretation, personal experience, and ability to process the myriad data points with our clinical acumen (the sum total of our diagnostic prowess which comes from experience, practice, expertise, and intuition). The EMR can be a very effective tool to help us gather, process, and present this information in a way that is meaningful and useful to our patients (actually most EHR’s don’t do this natively today, but with little effort a physician can lift the required information and present it in a format that is highly useful [alling all designers – get into health care!]). Furthermore, I truly dislike the characterization that the EHR makes the relationship cold and sterile.  I believe the current  generation of physicians, who have all grown up with the internet, see the EHR as an indispensible tool that helps them be more effective, efficient, and caring for their patients.

My sense is that I am more optimistic that we will get there with prevention, and that EHR’s will play a vital role to give us the clinical feedback to know whether our treatments (or prevention) efforts are having the impact that we hoped. Furthermore, I am hopeful, that efforts like the X PRIZE and others will help drive us to associate those outcomes with the total costs required to help us acheive the results so we can begin to understand the true value of the intervention. It is in this setting of data liquidity and information transparency, that they myth dissipates into a new reality of next generation medicine.

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Filed under EHR, Healthcare, Prevention, Quality, Transparency

#FAIL! Proprietary EHR Lock In through CCHIT

Lame (lām) adj.

  1. Disabled so that movement, especially walking, is difficult or impossible:
  2. Weak and ineffectual; unsatisfactory:

I just saw some seriously lame legislation proposed out of New Jersey by some ill-informed congressional lackey MANDATING that all EHR’s be certified through CCHIT. This is absolutely ridiculous. Do you really want to outlaw Google Health and Microsoft HealthVault in the Garden State? I mean get real!

The unintended consequences of such legislation is highly problematic and well described by David Kibbe, Fred Trotter, Ignacious Valdez, Neil Versel, and others. I have seen CCHIT make great efforts to correct this and make the process more open but they have a fundamentally flawed and constrictive position – that they alone can bestow the quality seal of approval on software.

They don’t realize, of course, that any attempt to subvert innovation will be futile. “Life always finds a way” (or in this case innovation). The notion of a new type of communication platform that will emerge as a result is already underway. Designated “Clinical Groupware” by David Kibbe and others or a new “Communication” platform by Myca or American Well, new tools will continue to emerge that defy current descriptions. Are you sure you want to lock down into today’s technologies through an already arcane certification process?

I would strongly argue that standardizing features and functionality is not the problem. These should be allowed to freely evolve and grow per the needs of users and the skills of developers. What should be standardized is the interoperability requirements of data, the database requirements, and related infrastructure elements that will enable the data to be truly liberated. These standards will do more for the industry than any other single legislative or policy initiative. This is where we need government help to force agreement on specific principles where the choice is not as consequential as just making a decision (driving on left or right side of the road is irrelevant; but it is clear that we need to make the determination!).

Legislative mandates for features and functions = #FAIL!

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Filed under EHR, Industry, Leadership