Monday, December 30, 2013

Meaningless Disuse!

Guest blogger Dr. Donald Kamens, MD FACEP gives his take on Meaningful Use and where we are today.

It seems that Uncle Sam, healthcare, and technology mix about as well as oil and water; maybe worse.  The problem is not only the ObamaCare tech debacle, actually. Ever since 2004, when the government thought it had to protect its interests (read Medicare) by assuring that data acquired in health care delivery was accessible, parse-able, and otherwise capable of supporting arguments to decrease reimbursement, it has tried to become a techie agency.  And O, how it has tried. 

At first there was a fledgling effort to create an office in DC to oversee healthcare IT, the ONC (Office of the National Coordinator).  In the near-decade since its instatement, there have been five (5) chiefs, only one of whom lasted for a full two years.  There is currently an acting chief, and likely, he can’t wait to get out of there either.

In its beginning the budget numbers were in the neighborhood of about $24M (thirteenth letter of the alphabet).  Since the advent of incentive programs based on the demonstration by vendors of EHR products of Meaningful Use, the bill is more like $70B+ (that’s the 2nd letter of the alphabet).  What gives?

It is the result of an extreme paranoia.  Clearly a total mental distortion that says:  “if we don’t know what is going on (in there), then we cannot come down on them enough to cut payments.” “So, we gotta know.” “And because we gotta know, we have to bribe the physician population to use devices to record what is going on.” $70B+ is a pretty big bribe.

What baloney.  Recording of medical record information has its historical basis on two needs:  to remind the physician what was done, last time; and to inform anyone covering in case the patient shows up unexpectedly.  Well….you give ‘em an inch…..and what happens… the legal world gets in on it and begins to use these notes to claim malpractice.  And then the insurance companies get in on the deal to determine what the will refuse to pay.

It’s just not needed.  Most all medical encounters can be summarized in just a few words.  If a study is being done on some clinical entity, then a bit more data would surely be of value.  But really, does anyone need 13 pages for an ED visit?  Or 8 for an urgent care stop? 

It’s time to get rid of this Meaningless Disuse program, and its huge expenditures that could otherwise fund significant helpful programs, and perhaps institute a Meaningful Pen/Tablet program. Or even a Meaningful Interface program that works like an ATM, or even as well as iTunes.  Give each doctor a new pen, or an iPad, and let him keep it if he can fill out an accurate chart, or template, in under 2 minutes.

Many physicians like EHRs; most don’t.  Those on the “no” side usually recognize MU is a severe piece of government overkill, that is doing few people any good, while creating long waits in many places as the staff struggles with machines.  

Tuesday, December 24, 2013

Malpractice Reform

Medical-legal issues always reside in the back of the mind of any provider whether the fear is realistic or not.

In the article, A Failed experiment: Health Care in Texas Has Worsened in Key Respects Since State Instituted Liability Caps in 2003,  it states that the evidence proves that medical testing does not decrease even in a provider friendly malpractice environment.

Attempts at reform include caps of pain and suffering, full-disclosure programs, provider education, provider education with the malpractice statistics have not fundamentally changed the "Adversarial Relationship" that providers have with attorneys.  Physicians are unable to internalize this as a "cost of doing business".  The long-term psychological effects on the defendants are real but hard to quantitate.

A plan of action is to adopt the New Zealand no-fault workers' compensation type system that eliminates the blame game and hopefully makes the patient whole.  The best solution to a malpractice suit is never to be named at all.

Monday, December 16, 2013

Zen and the Art of Human Medical Maintenance

The word Zen is derived from the Japanese pronunciation of the Middle Chinese word dzjen, which in turn is derived from the Sanskrit word dhyana, which can be loosely translated as "absorption" or "meditative state".
Zen emphasizes the attainment of enlightenment and the personal expression of direct insight in the Buddhist teachings.  As such, it de-emphasizes mere knowledge of sutras and doctrine and favors direct understanding through zazen and interaction with an accomplished teacher.
Wikipedia describes the following for evidence-based medicine- EBM:
Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.  Trisha Greenhalgh and Anna Donald define it more specifically as the use of mathematical estimates of the risk of benefit and harm, derived from high-quality research on population samples, to inform clinical decision-making in the diagnosis, investigation or management of individual patients.
in the novel Zen and the Art of Motorcycle Maintenance: An Inquiry into Values is a 1974 philosophical novel, the first of Robert M Pirsiq's texts in which he explores his Metaphysics of Quality, the author attempts to reconcile the natural, inexplicable forces of nature with an analytical approach to everything.
A comparable task is the fine tuning of EBM with the "Art of Medicine" to enhance the quality of medical care received and given.  This would lead EBM to become "Evidence Enhanced Medicine".

Wednesday, December 11, 2013

Could Your Electronic Health Record Function Without Workarounds?

The Electronic Health Record is a complex tool that hopefully improves communication, fix the legibility issue, and decrease medical errors.  However, the "Devil is always in the details".

Wikipedia states a workaround is a bypass of a recognized problem in a system.  A workaround is typically a temporary fix that implies a genuine solution to the problem is needed.  But workarounds are frequently as creative as true solutions, involving outside the box thinking in their creation.

Computer software that causes a computer to perform useful tasks beyond running the computer itself is called Application software, program, or app.

A GUI widget or control is an element of a Graphical user interface- GUI that displays information arrangement changeable by the user, such as a window or text box.  The defining characteristic of a widget is to provide a single interaction point for the direct manipulation of a given kind of data.

A true test of your EHR is:
  1. How many workarounds, apps and widgets are necessary additions to make the program usable?
  2. Are these add-ons value added or desperately needed to succeed?
These include some of the following resources: Scribes, Physician Assistants, Nurse Practitioners, Medical Assistants, Voice activated technology, Cut and paste, Macros, Typing courses, Artificial intelligence, Warnings, Error notifications, etc.

Some of these additions can add major value superimposed on an efficient, walk-up usable computer program.  The problem is they are necessary at great cost to survive the electronic world.

Monday, December 9, 2013

Number Needed to Treat

Wikipedia states the number needed to treat (NNT) is an epidemiological measure used in assessing the effectiveness of a health care intervention, typically a treatment with medication.  The NNT is the average number of patients who need to be treated to prevent one additional bad outcome (i.e. the number of patients that need to be treated for one to benefit compared with a control in a clinical trial).  It is defined as the inverse of the absolute risk reduction.  It was described in 1988.  The ideal NNT is 1, where everyone improves with treatment and no one improves with control.  The higher the NNT, the less effective is the treatment.

Recently, the American Heart Association and American College of Cardiology gave out new guidelines on the preventing atherosclerotic cardiovascular risk in adults.  These guidelines suggest the most "Americans" being on statin cholesterol lowering drugs.  This has created some controversy.

NOT being an expert, I cannot tell you whether these are ideal suggestions, but as a consumer there is a question to be asked.  How many people need to take these medications for life to make it a valuable endeavor?

All medications include cost, side effects, and compliance by the patient.

Conclusion- ask your provider and/or pharmacist for all chronic medications, what is the number needed to treat to obtain benefit from these ongoing therapies.  Once you know the number, work with your provider to assess your risk and need for any and all medications.

Monday, December 2, 2013

Value of Scribe Vs. Voice Activate Technology (VAT)

This is an interesting problem with strong advocates on both side of the equation.

After going to the recent ACEP conference, it was apparent that scribe companies are coming "Out of the Woodwork" to offset the labor intensive enterprise Electronic Health Records being imposed on most emergency departments.  Scribes cost approximately $12 - $18 per hour each.  To offset these costs, the provider must see 2 - 3 more patient per shift.  At this point with a general reduction of 20% of productivity per provider, this is not happening overall.  Providers are struggling to stay even.  In institutions where a scribe can function as a medical assistant, a "Go-For", data acquirer from the old medical records, interact with the patients, and print discharge instructions and prescriptions, the extra work is a plus.  This is how most urgent cares function with an all-encompassing medical assistant with multiple roles.  In institutions where the scribe just inputs what the provider states, they are expensive transcriptionists and typists.

Voice Activated technology is an extremely efficient alternative to transcription at much lower overall costs. The provider can dictate key components of the history of present illness and the assessment and plan- medical decision making sections of the records.  This creates a unique non-cookie-cutter chart which helps the private MD, consultants, and your own colleagues, if the patient returns for follow-up.  The problems come in where the EHR is not directly designed without a lot of work-arounds to allow easy dictation.  The initial cost is $1,500 per provider, but transcription costs $7 - $8 chart and the money is regained in time with increased productivity.

Which one is recommended?  It depends on the work flow of the ED, the EHR, and the personality of the provider.  My personal preference is a user-friendly EHR and VAT, so you can take the savings to buy more physician assistant and/or nurse practitioner FTE's.  This hopefully will lead to increased throughput, higher revenues, and increased patient and administration satisfaction.  If my scribe is an all-purpose medical assistant, this would make a reasonable alternative.

Tuesday, November 26, 2013

The Harsh Realities of Aging in the Workplace

One of the most difficult subjects for any medical practice is dealing with under-performance.  Viewed through its various lenses- including productivity, patient, staff and owner (hospital, etc.) satisfaction- under-performance is multifaceted and difficult to effectively engage from all perspectives.  An additional distortion is added when normal aging is thrown into the mix.

"You are as old as you feel" is a great saying.  However, if a healthcare provider does not have enough personal insight into his/her own actual competencies, normal workplace deterioration can, over time, lead to major interpersonal, financial, and professional problems.

Honesty with coworkers, employees, partners, and spouses is an idealized goal.  But such honesty- fraught with misinterpretation and potential conflicts- is rate, and seldom materializes.

Many solutions have been proposed, but a good resolution always requires creating a plan in advance to address performance and performance failures.  such a plan not only helps identify problems as they arise, but also gives concrete steps to support affected individuals, while anticipating potential snags that may appear over time.  Optimally, taking such steps as a group will get buy-in from co-workers and associates because everyone faces the possibility of such circumstances, at some point.

When a plan is not in place, steps may need to be taken.  Fortunately, some people have the insight to recognize increasing limitations.  However, others have to be firmly counseled.  Because discrimination on the basis of numerical age must be avoided, competency, rather than age, should be the basis for any action.  Age discrimination is not an uncommon claim in workplace litigation, consequently, some jobs to have mandatory retirement ages built into employment agreements.  Yet, all of us know of very senior individuals who show no signs of slowing down; and - on the flip side - we know of those whose abilities seemed to have tapered off far earlier than otherwise expected.

The best overall solution is to establish a retirement pathway, one that allows for more senior members to shoulder increased administrative responsibilities, and avoids the type of battle faced by many practices in which less experienced "Baby-boomers" wind up unintentionally in charge.  Rarely do the more neophyte understand issues that face their maturing predecessors, and the situation can become tense and uncomfortable for all concerned.  Honesty and communication are extremely difficult in hindsight; unless pathways have been created to prophylactically deal with such issues, the character, mood, and even the stability of the group can all be placed in jeopardy.

Monday, November 25, 2013

The Fundamental Fracas in EHRs : Narrative vs. Structured Data

I wanted to share with you a white paper written by my colleague, partner and friend Dr. Donald Kamens.  He has extensive experience in emergency department administration, risk management and quality assurance.  He has been active in the development of software for the practice of emergency medicine, and the recipient of several awards from the American College of Emergency Physicians, including the 2005 Lifetime Achievement Award Informatics. Enjoy!

“We were probably mistaken to think of words on screens as substitutes for words on paper. They seem to be different things suited to different kinds of reading and providing different sorts of aesthetic and intellectual experiences. Some readers may continue to prefer print, others may develop a particular taste for the digital, and still others may happily switch back and forth between the two.”Nicholas Carr # OO4

We live in a time when electronic representation on-screen is the chief means of recording and communicating experience. Whether still, video, or text, our ever-increasing interaction with digital screens carries with it the uninvited companions of time constraint, peripheral bombardment, and reduced ability to linger and consider meaning.

For all of human history, the effort to record is intended to put forth story.  Long ago, narratives were written on memory itself, and before the creation of writing--perhaps 5-7 thousand years ago—they were transmitted from one individual to another orally.  However, with writing came a means through which records could be kept on objects such as stone, metal, wood, papyrus, and, of course, on paper.  The symbols and languages in which these records were kept evolved in various streams and patterns into the written languages of today. 

Now we have a new medium of storage, the database.  It functions, for all intensive purposes, not unlike memory in the ancient oral tradition, as it has the capacity to store information for recall.  There are key differences; however, between information stored in human memory, and information stored as electronic data.  Chief among these is highlighted by memory’s ability to parse, synthesize, and paint image out of data; it can embellish, alter, inflect, musicalize, and otherwise impart to the information characteristics that are absent in digital information.  There, data can be extracted, but it does not have the human quality of story.  Attempts are made via software to give it such a quality, but these always fall significantly short.  Of course, story can be stored as narrative itself, in the form of, say, voice bytes, readings, movies, text documents, and other forms in which a human has made the effort to create synthesized data forms that impart intended (and unintended) images to the viewer or reader.  Hence, a single datum may be a narrative. 

However, once a narrative has been broken down, and data has been extracted from it, that data cannot be brought back into an accurate narrative, except by human intervention.  This is not unlike Humpty Dumpty in the English nursery rhyme:

Humpty Dumpty sat on a wall,
Humpty Dumpty had a great fall.
All the king's horses and all the king's men
Couldn't put Humpty together again.

Indeed, the abstraction of any narrative into points of data is a great fall. And if Humpty represents the meaning inside any story, once extracted, it is not possible to put back together again...
Humpty appears in Lewis Carroll's Through the Looking-Glass (1872), where he discusses semantics and pragmatics with Alice.[20]
    "I don't know what you mean by 'glory,' " Alice said.
    Humpty Dumpty smiled contemptuously. "Of course you don't—till I tell you. I meant 'there's a nice knock-down argument for you!' "
    "But 'glory' doesn't mean 'a nice knock-down argument'," Alice objected.
    "When I use a word," Humpty Dumpty said, in rather a scornful tone, "it means just what I choose it to mean—neither more nor less."
    "The question is," said Alice, "whether you can make words mean so many different things."
    "The question is," said Humpty Dumpty, "which is to be master—that's all."
    Alice was too much puzzled to say anything, so after a minute Humpty Dumpty began again. "They've a temper, some of them—particularly verbs, they're the proudest—adjectives you can do anything with, but not verbs—however, I can manage the whole lot! Impenetrability! That's what say!"[21] datum plus another datum plus another, and so on, may not really be brought together into a true narrative, except by human intervention. 

  It is the telling of, and listening to, story that remains embedded in the human psyche as the common ground sought by both recorder and reader/viewer, and through which one human conveys (x) to another. The axiom “a picture is worth a thousand words” is quite familiar; adding “and a story includes ten thousand pictures” illustrates the huge chasm that electronic records face, between story and elemental structured data.

Physician par excellence and renowned philosopher of medical practice, William Osler, often reiterated to his students and colleagues “listen to the patient.”  In many ways Osler’s was a plea, an appeal with evident foresight lamenting a future time when information residing with the patient would become less important than that in the chart.  That time, the post-Oslerian era, has arrived.  Indeed, listening is so central to medical care that failure or inability to listen often lays at the feet of many medical liability cases. It also sits at the center of patients’ complaints about a healthcare system that seems to lack heart.  “My doctor just won’t listen to me.”  “I told him many times.”  How often have we all heard these petitions? Is there some underpinning, some systemic cause, some embedded characteristic of modern medicine that explains why this should be the case?  And can anything be done about it? Should anything be done about it?

Let’s examine the premise that structured data has become too preeminent in the medical realm, has established hegemony shoving story aside. The process of this revolution antedates electronic records, and began overtaking the conceptual, cognitive, framework of physician-patient relationships as quantitative laboratory and definitive imaging information rose to occupy the minds of providers. And yet, demise of story, demotion from its justified first tier in open communication, naturally cripples listening ability.

Think about it.

Are medical providers alone in being crippled this way?  It seems not. Indeed, deafness to the “real story” behind any human encounter is not isolated to medicine or medical records, but has become an embedded, pervasive, characteristic of our technological society. Even social media screens off one individual from another.

The impact of deafness pervading our lives is great: for when another does not hear, it feels to almost everyone within range that caring is thoroughly absent.  Hardly anyone is going to tell you that our society is a caring one.  Hardly. Not only medical providers, but also he service people with which we transact life, are seemingly deaf.  From cashiers to accountants, from clerks to lawyers, all are unable to hear about us, about why we have approached them—at this time, at this moment-- and about what really matters to us.  Their inability to hear does not mean they are unwilling to hear.  Just, perhaps, possessing insufficient tools with which to make the connection.

Instead of the connection of story, our lives are given representation in the new psyche of modern tech as merely data points; our narratives are lost, unspoken, or disparaged as lower class inhabitants of a data-rich informational world.  What, otherwise, is the source of our hesitation as we approach strangers with whom we need to interact?  With each desk, each clerk, each individual that we’d rather not encounter arises an unwanted dread.   Will we be “dissed” as if lower class due to whatever need we may have?  Will we bother the soul, the concentration (the texting?), of another when they are, due to our presence, required to extract from us data?

In fact one may often find that a reason medical providers are sought is because it is one place where hope exists to find a listening ear.

Whether that hope is realized or not is an unanswered question in every case.  And yet how many of you have witnessed the disappointment of those seeking care, only to be given the perspective that the provider did not really care?  So one wonders: was something more present in the disappointed physician-patient encounter than just bare-bones search for data on the provider’s part?  Or were the underlying forces perhaps hidden. Acquisition of structured data in the name of caring, while peering into-but not hearing--the story, has the potential to hide the truer hearts and minds caring under a cover of seeking to acquire data in its name.

Now, even a layperson knows that anyone presenting for medical care—whatever the setting--has a story.  Actually, they always have multiple stories.  And most often we medical types focus on two main themes:  the story of events leading up to the ED or clinic visit, and and the relevant back-story, or history of key past medical issues.

Lets take an example.  A patient presents to the emergency department icteric and febrile.  On the EHR or perhaps even on a paper template, and elevated temperature is recorded, moreover the triage nurse notes on the chart that the patient appears yellow.  The nurse completes a triage checklist, and notes therein that the patient has no prior history of liver disease, but drinks some. An hepatic etiology is first in the nurse’s mind. What then?

In this example, (somewhat exaggerated-but taken from an actual case), the patient is sent back to the main department (after several hours wait of course) and a physician assistant sees the patient, takes a history, and performs an exam.  The same data elements (icterus, fever) are discovered, and lab is ordered. 

Now the physician’s assistant did a quite good job of taking a history, and in fact the patient told the PA that he had just gotten off a flight from Nigeria, where he had been serving with the Peace Corps. 

There was no box on the template “just got off a plane from Nigeria” nor one for “recent travel”.   But a rather full template based on the chief complaint of “febrile illness” was nevertheless completed.  Moreover the PA included in a section of the chart a written note that included  the patient’s recent travel.

The very excellent clinical decision support system the ED had purchased, reported back that a workup for viral hepatitis, biliary tract disease, and other disorders that elevate the bilirubin, should be done.                                                                                                                                        
In the meantime, the patient’s lab work returned, his temperature normalized, and (having no insurance) was sent to a gastroenterologist’s office at the beginning of the following week...

About six days later the ED gets a call from the GI office complaining that they were not told about the patient’s international travel and exposure, and so were impaired in making a diagnosis, and initiating treatment for what was clearly a case of malaria. The patient’s  condition had become much worse, and he had been admitted to another hospital as an emergency.

What happened?  Clearly this is a case where the medical record and the related medical decision, judgment, and approach were adversely colored by the gulf between narrative and structured data.  Data was recorded and attended to, but the fundamentals of the patient’s story, even though recorded in narrative form, was missed.   

Attempts have been made—and they abound--to extract data from narrative.  And similarly, considerable effort has been directed toward trying to construct a narrative out of the data.  Both exist, both have failed.

When one reads a narrative built from data, it is, of course, not unlike trying to understand the phraseology of a robot.  It is rather unclear, rather disjointed, and is absent in many key details.   On the other hand, attempts to accurately extract data from a narrative are recipes for disaster.  A case encountered recently is one in which the physician dictated via voice recognition software that the patient was complaining of “low chest pain.”  The EHR in question extracted a data point like this:

                               Y        N
CHEST PAIN?  [    ]   [  X   ]

No chest pain indeed. The lawyers loved this one, especially after the patient died of an MI after an inferior wall MI.

How can this issue be addressed?

The only hope to bridge this “great divide” between narrative and data is to face it head-on, embrace it in a sophisticated manner, do so with tools that are appropriate for the task, and then analyze and evaluate the state of our capacity in a realistic fashion.  Do any such tools exist?  Perhaps. But where?

The simplest tool, and one that has been successfully employed by some paper templates, and EHR spin-offs, is to create and retain BOTH narrative AND data.  This functionality has been called a “harmonized” EHR.  Terminologically, this is to be distinguished from the use of “hybrid” EHRs which (like hybrid cars) indicate systems in which a provider can have one foot in the electronic world, and the other in the paper world.  Granted, when a provider is not experienced in this methodology of using a harmonized system, it may feel a bit cumbersome.  However, when narrative thought of as a non-structured data (like a picture or other image), and retained, without trying to extract contained embedded elements, an effective “work-around” results.  Such an approach is not without its own problems, however.  What do you do when the narrative and data are both present, but simply do not harmonize?  What if the narrative from the above example says “the patient was complaining of yellow skin.” And the data says: 

ROS- Dermatologic system:
                              Y           N
Skin Yellow?   [     ]    [  X  ]

Such problems are common in systems that try to carelessly harmonize data and narrative, and they are fertile ground for plaintiff’s attorneys.  And yet harmonization permits the creation of a solid chart if the provider takes the time to be sure the narrative and data correspond, and if the EHR allows this to happen easily.

So where can we extend our technology to do better in this arena?

A good start may be to think of the issue as one not unlike language translation.  Say, Swahili to English.  Or Greek to Afrikaans. Language translation is certainly a tricky business, whether between spoken and written languages from disparate lands, or between the mental structures by which we communicate (image, narrative, data).  

Can formalized principles of translation, give us usable criteria to bring these two different medical languages, narrative and data, into closer harmony? Here is what would, at minimum, be necessary:

Accuracy.  If structured data is extracted from a narrative text, the meaning should be accurately and without error reflected in the data that is extracted.  On the other hand, if a narrative is constructed in the other direction, from data, it should be represented in a fashion that does not unnecessarily embellish the story with items or words that could result in misinterpretation.  That means that, for example, all or many key articles of the English language would need to be left out:  no, yes, and an, the, etc,…..And yet, in that case, would you not wind up with robotic sentences that could not actually be read as narrative.

Second: literal meaning should be retained whenever possible.  That is not easy either, but any attempt at extracting data from narrative needs to be faithful to the meaning of the “story.” Literalness is not an easy criterion, since an isolated element from a story has far less likelihood of communicating original meaning than does the narrative sentence or phrase, from which it was drawn.

Third: distortion should be guarded against. That is, translation from narrative into data should not distort the meaning of the original communication, nor obscure its intent.  Again, this is not easy to do.  In the icteric patient noted above, the data should be able to be placed in a pre-designated pre-structured location on or in the chart.  If no such data lacunae are present, say for “international travel,” an EHR should be able to create them, on the fly.  And of course, guarding in reverse, suppose the patient’s hematocrit was 17 gm/L,  extrapolation to the narrative should clearly say not simply “anemia,” but rather should indicate hemolysis on the basis of malaria.

In closing, consider again William Osler’s words.  He said “Listen to the Patient.”  He did not say “listen to the data.” 

In medicine, we are admittedly in deep trouble.  In the modern EHR realm we are in  a related sort of trouble, since this tool of great promise subtly erects communicative walls between patient and provider, and we need to find ways of listening through. Listening means paying attention to the patient’s story, but neither exclusively to the narrative, nor solely to the elemental structured data that appear, but instead, to both at once. 

Unless we recognize this need for harmonization, and unless we achieve the ability to create simple medical records with our ears, eyes, and minds attentive to the patient, our situation as providers will not improve.  The individual who seeks our help must remain first in our minds, and thus, first in our electronic tools.   How we, as providers, recognize and deal with the “great divide” between story and data, how we select electronic tools that support our efforts to do so, is long going to be a key part of listening to the patient.           

Friday, November 15, 2013

Comparison of ACA Website Problems & EHR Issues

Having been involved in the content side of software development, it is not surprising the ACA website is fraught with problems.  Problems with various EHR solutions are well-documented.

The bottom-line: They are not written from the point of view of the end-user and try to solve many problems with a click of a mouse!

A successful website or software product should be designed with the end-product concept developed first- What is the end goal?  Then, develop the code to create the product.

A final common pathway has to be created with a creative design team that has to interface with the programmers.  What works for programmers does not necessarily or automatically work for normal end-users.

The ACA website has taken on the overwhelming task of integrating the needs of the IRS, insurance companies, state to state variation, and finally the consumer.  Creating a rules engine to encompass the endless number of scenarios would probably be a nightmare.

The ability of the various consumers with different levels of computer expertise has to be factored into the development process- obvious prompts, reminders, and potential suggestions.  The fact is even a "young computer geek" may not know the difference between a co-pay, deductible, coinsurance, or total maximal annual out-of-pocket expenses.  The site has to show the products in such a manner that is intuitive, so a selection is made according to your lifestyle, income, and pre-existent conditions.  There has to be instant access to ACA calculators to get a ball park figure based on your personal data prior to choosing a policy.

The insurance sites have to be transparent in regards to participating providers, clinics and hospitals.  This "shoe" is 1-2 years from becoming a huge problem with access issues.

How does this site with multiple moving parts keep all the data confidential and does not release the information about what providers the consumer was looking at?  This might lead to HIPPA Part 2, with all the burdens associated with HIPPA.  The IRS involvement becomes a HUGE issue we will leave for another day.

Conclusion, the website needed a proactive, experienced leadership team that could grasp all these moving parts and create an interface that with time would work.  This is very reminiscent of EHR usability and efficiency problems...

Monday, November 11, 2013

Dealing with ED Consultants

Consultants are vital to the success of any Emergency department.  The ED group's personal and collective relationship dramatically impacts care, throughput, and the "bottom line" for the ED group and the hospital.

Treating consultants with respect and honesty will ingratiate you into their network, which encompasses 95% of the institution.  Lunchroom gossip will not just entail ED horror stories, but comments about the skill and efficiency of the ED.

Consultants can make or break the quality of care and the headache level of the ED.  The goal is to develop relationships:
  1. Do not be so "ED-centric".
  2. Be sensitive to their schedules and time.  Do not wait to notify them right after they've left the building or at dinnertime- a head-up call is always appreciated!
  3. Take their advice, if reasonable, though you may have a different opinion.  Medicine is still an art and there are many pathways to success.  Use mutually agreeable department protocols.  Changing policies and philosophies at 0300 hour will not win or make you any friends!
  4. Thank them for their input and help.
  5. Help the with ED logistics.
  6. No shouting matches in public.  Go outside and have a discussion!
  7. Learn about their interests and families.
  8. Go to the lunchroom and interact like a regular staff member even if you hate going.
  9. Visit their department meetings.
  10. Do not wake them up, unless it is necessary.  Night shifts, diurnal rhythms, surgical schedules take their toll over time.
  11. If there is a significant problem, respectively agree to disagree.  Have a pre-planned conflict resolution pathway.  Notify the proper people in a timely manner depending on the seriousness of the patients' condition.  Continue to observe and treat the patient appropriately.
The bottom-line is to do what is right for the patient and be their advocate- everything else can be resolved!

Monday, November 4, 2013

EMR Advocate | Meaningful Use Audits by Expert Jim Tate

Stage 2 Meaningful Use Audits: Hospitals and Patient Engagement Requirement
By Jim Tate, EMR Advocate and Meaningful Use Audit Expert
Twitter: @JimTate

Some times it is almost too easy to see what lies ahead. They say hindsight is 20/20 but from time to time peering into the future can also be a breeze. A specific challenge coming for Stage 2 Eligible Hospitals (EHs) and Critical Assess Hospitals (CAHs) hides in plain sight in the Core meaningful use (MU) measures. Difficult to achieve, as it is dependent on new technology and workflows, it might be even more difficult to document during an audit.
This Stage 2 requirement seems so simple, and is shorter than a Tweet: “Provide patients the ability to view online, download, and transmit information about a hospital admission.” However, don’t forget this MU measure is Core and very difficult to exclude unless the hospital is way out in the boonies far from the reach of widespread broadband internet access. Fail to meet this MU requirement for Stage 2 and that EHR incentive goes totally away for the year. I would not want to be the bearer of that news to the hospital board or administration. Even if there is a successful attestation on this measure it could be problematic during an audit. Hospitals tend to use technology from various vendors. If you choose a “best of breed” patient portal how hard will it be to track those patient trips to the portal to view their discharge information?
Enough talk. Let’s see what this “patient engagement” portends. There are two parts for our consideration. One is what the hospital must do, the other task is for the patient. 
Hospital action required: “More than 50 percent of all unique patients discharged from the inpatient or emergency departments of the eligible hospital or CAH (POS 21 or 23) during the EHR reporting period have their information available online within 36 hours of discharge.” There is no way around this and no short cuts. You have to have a portal and you have to make discharge information available within a limited amount of time.
Patient action required: “More than 5 percent of all unique patients (or their authorized representatives) who are discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH view, download or transmit to a third party their information during the EHR reporting period.
So we don’t need to dust off our crystal ball to see a curve ball is coming our way. I can already hear the hue and cry that will emerge in 2014 over this issue. As the wizard said in Lochiel's Warning: “coming events cast their shadows”.

Have a question or concern about the meaningful use audit and appeal process? Contact him at:

Monday, October 28, 2013

Using an EHR to Expand Your Urgent Care Practice

In a world where you have to document in a specific way, one should take advantage of the data accumulated in the EHR to accentuate your practice.
  1. Auto fax all appropriate documentation to the primary care provider or appropriate specialist the patient has been referred to: a) PCP will consider you an adjunct to their practice rather than competition; b) encourage the PCP to send patients to the UC rather than the ED, if they are confident of your capacity and capabilities; c) create a specialist list that wants and appreciates your business; d) patients will appreciate the cohesiveness of care without having to repeat more tests and spending excess time explaining what might have happened.
  2. Select an EHR that gives condensed summary of events rather than 10-15 pages that nobody will read.
  3. Use your practice management reports to keep track of where your patients are coming from: walk-in, after hour referral, overflow referral, Google search.
  4. At the end of every quarter send every referral provider a report of how much business you are sending and/or returning to them.  Most surgical specialists do not realize the direct impact you may have on their bottom line.  This can dramatically help when favors are needed that do not necessarily have to be solved in the ED.
  5. Your practice management system's ability to keep up with real-time authorization, coverage, co-pays, and payments dramatically speed up the front-desk leading to more satisfied customers.  If one can eliminate 15-20 minutes of the office visit, which is a great bonus and encourages repeat business.
Conclusion- make sure to purchase a software suite (Practice management and documentation) that improves your bottom line!

    Wednesday, October 23, 2013

    EMR Advocate- Jim Tate shares his thoughts regarding MU Audits

    Worst Practices for Meaningful Use Audits

    October 16, 2013 | By

    6 "Worst Practices" that put Meaningful Use Incentives at Risk6 “Worst Practices” that put Meaningful Use Incentives at Risk

    We’ve all seen articles, interviews, and blog posts telling hospitals how to be prepared for potential audits of their meaningful use (MU) incentives. “Lessons Learned” and “Best Practices” abound in an attempt to give advice about protecting those EHR incentives from recoupment. There is a lot of money on the table, not to mention careers, and the audit process should not be taken lightly. There is simply too much at stake and a wrong move during the audit or appeal process would take a hospital’s staff to a place where it should never have to go.
    Sometimes it is best to look at what not to do, the so-called “Worst Practices”. In the past year I have worked with numerous hospitals that have been down the dark and scary road of meaningful use audits. In the long ago days of 2011 there was a lack of clarification and guidance on the CMS EHR Incentive programs, but we wanted those seven figure incentives. Hospitals were moving quickly to adopt certified technology and achieve meaningful use even though the “knowledge gap” was very, very wide.
    Allow me to present a few “Worst Practices” that I have come across in the past year. Employing these will put your ability to obtain and hold on to those lovely incentives at risk.
    1. No one in charge: Assign a committee to be responsible for the audit process and requests for documentation. When things go wrong there will be plenty of people to blame.
    2. Insufficient documentation: Just assume you can always go back and recreate reports that you can’t find. All that data is in there somewhere, I’m sure we can find it if we need to.
    3. Ignore requirements: We are not really sure what is this “syndromic surveillance submission” business. We only have to do one test? Let’s just say “yes” and move on.
    4. Undocumented MU strategy: What was the reasoning behind those core measures that were excluded and menu measures that were not chosen? Who was that staff member that made the decisions?
    5. Blame the EHR vendor: This entire mess was created by our vendor. It is their job to make sure there are no problems. They should be responsible and make this go away.
    6. Don’t perform a Security Risk Assessment: I’m pretty sure we did one of these a few years back and it was OK. Probably still good now.
    I could go on and on but you get my point. Don’t shoot yourself in the foot. Hold your head up high. Don’t cut corners. Do things in such way so that if you are asked to explain your actions two years down the road, you will be able to maintain eye contact and not “hem and haw”. How is that for a “Best Practice”?

    Wednesday, September 25, 2013

    EMR Advocate Newsletter: Here Come the Sticks!

    EMR Advocate Newsletter
    Certified Technology & Meaningful Use 

    September 2013
    Here Come the Sticks 
    For years we have talked about the carrot and stick approach to the CMS EHR incentive program. First came those lovely front loaded incentives that drove EHR adoption. Then, almost as an afterthought, we vaguely mentioned the penalties ("fee adjustments"). Well the carrots are getting smaller and the sticks are coming. For many Medicare providers who have delayed jumping in with both feet, it may already be too late to avoid the penalties. Let's look at the facts. 
    CMS states clearly: "If Medicare eligible professionals, or EPs, do not adopt and successfully demonstrate meaningful use of a certified electronic health record (EHR) technology by 2015, the EP's Medicare physician fee schedule amount for covered professional services will be adjusted down by 1% each year. The adjustment schedule is as follows:
    • 2015-99% of Medicare physician fee schedule covered amount
    • 2016-98 % of Medicare physician fee schedule covered amount
    • 2017 and each subsequent year-97% of Medicare physician fee schedule covered amount
    If less than 75% of EPs have become meaningful users of EHRs by 2018, the adjustment will change by 1% point each year to a maximum of 5% (95% of Medicare covered amount)."
    That doesn't sound too bad, right? Just get you act together by 2015 and all will be well. However, that is not the case. The penalties are based on activity two years prior. That's right you pretty much have to have your act together in 2013 to duck those 2015 "fee adjustments". Permit me to quote directly from CMS scripture: "EPs who first demonstrated meaningful use in 2011 or 2012 must demonstrate meaningful use for a full year in 2013 to avoid payment adjustments in 2015. They must continue to demonstrate meaningful use every year to avoid payment adjustments in subsequent years........EPs who first demonstrate meaningful use in 2013 must demonstrate meaningful use for a 90-day reporting period in 2013 to avoid payment adjustments in 2015. They must continue to demonstrate meaningful use every year to avoid payment adjustments in subsequent years."
    Now for you Medicaid EPs there is a bit of a twist. In the Medicaid EHR Incentive program there are no penalties against Medicaid reimbursements but you will be penalized for those Medicare charges if you don't reach meaningful use. Kind of a "damn if you do, damn if you don't" situation.
    I can hear the wheels turning out there. What if I practice where there is no broadband Internet access? What if my town is hit by an tornado/hurricane/firestorm/tsunami? What if I never actually see a patient in person? What if there in no way on Gods's green earth I will ever achieve meaningful use? Funny you should ask. CMS has outline a process for hardship exceptions that should put your mind at ease for some of you. For the rest the stage is now being set for those who will begin receiving reduced payments in 15 months. A stitch in time save nine.  
    Jim Tate 
    JimpixJim Tate, President of EMRAdvocate, is a veteran of numerous EHR implementations in the United States and Asia. He consults with EHR vendors on interface and functional specifications, business strategy, documentation, and certification. The EMRAdvocate team has worked with over 200 EHR vendors  in the development of certified EHR technology. Jim speaks frequently at national conferences on HIT adoption, EHR certification, Meaningful Use, EHR Incentive Audits and is a partner at HITECHAnswers, the foremost Meaningful Use education portal.  Jim is committed to the proper use of technology to improve health care and may be reached at
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    Tuesday, September 24, 2013

    How to Help the ICD 9/ICD 10 Blues

    Doctors and providers are taught to come up with a medical diagnosis compatible with the patient's condition.  However, this diagnosis must be translated into an ICD9 or ICD 10 code to create a CPT code (billing codes), which may be a foreign language to the provider.
    Most EHRs compel one to pick a diagnosis that has a specific code..  The search engines take you to a particular area, but not necessarily to the proper code without an extensive, time-consuming search.
    A quick solution to become "trilingual" (speak English/ICD 9/ ICD 10) will be of great aid to providers, office staff, billers, etc.
    When the clinician comes up with the diagnosis they can "Google" this with their diagnosis and ICD 9 or 10.  This will take you to the location that has proper way of writing the diagnosis in this alternative universe with a code.
    The clinician can then properly search their diagnosis list saving time.  The office state gets the number they want to finish the billing summary.
    The one feature can save frustration and time.  This may be the ICD9 / ICD 10 "Google Stone".

    Monday, September 16, 2013

    Motivation for Visit and Patient Satisfaction

    A classic history and physical exam is a key component of the medical interaction and record of the patient and provider.  The goal is a coherent, focused account of the visit in the chief complaint and history of present illness area of the chart.  Electronic and paper charting templates prompt one to include the components for completeness and billing codes.
    They are many techniques to obtain this information, but most leave out a crucial bit of information that may lead to higher patient satisfaction scores while dramatically speeding up the process.
    This crucial component is patient motivation for taking the time out of their complex lives to obtain medical care that may take up to 6 hours and still not answer their questions. 
    Patients are motivated by multiple reasons:
    • Fear of Illness - I was worried that I was having a stroke or heart attack!
    • Family related - My spouse made me come.
    • Accident or insurance related
    • Problem that has persisted with no "magic cure" in sight
    The list goes on...

    Asking the patient the circumstances and their concerns of the visit initially will narrow the scope of the visit dramatically.  This allows the provider to focus on the acute problem at hand.

    Eliminate the classic response of "You're the Doctor" - you should know and figure out what's wrong - and address their psychological needs.

    Your patient will think you are an astute clinician who cares.  Your satisfaction scores might go up and the #1 complaint of the provider didn't listen to me will go down!