Meaningful Use- Rise of the “Best of Breed”?????

Is the “Meaningful Use” financial incentive actually going to end? According to article CMS Promises Meaningful Use Replacement This Year significant changes in the program will be implemented in 2016 and possibly be in effect by 2019. The goal is a more “patient-centered” output and not endless data collection.

Meaning full use was defined by the government to be

1. The use of a certified EHR in a meaningful manner.
2. The electronic exchange of health information to improve quality of health care.
3. Stimulate the adoption of EHR through financial incentives for using (e.g. not let it sit in the corner) certified EHR technology for defined elements of clinical care.

After 32 Billion Dollars expenditure in incentive money, we have a dysfunctional, non-intraoperative, and user-unfriendly national conglomeration of systems that just can’t communicate with one another.  Sounds a bit like Congress, does it not? The outcome probably should not be called a system because every product is somewhat unique and the stated goal of being able to trade information between facilities (interoperability) is no closer than it was in 2004 when then-President GW Bush put the federal government into the electronic record business.

Now, CMS has reset its sights, deciding that the new goal is not to promote adoption of EHR technology, but to pay providers for (good) outcomes that result from using such systems.  This paradigm, in CMS mind, is to replace the fee-for service paradigm. Of course! Why not!  For example, someone arrives in ventricular fibrillation and you pull out all stops to try to get the heart beating synchronously again.  Shock after shock fails.  Drugs fail. Everything fails. The patient succumbs. The outcome:  well, it is no-so-good. But you do not get paid for the powerhouse effort that you are describing on the EH R record.  No.  You write that the patient was transferred to the morgue.  Hence, the outcome deserves zero reimbursement.  Certainly much less than I you had restored cardiac rhythm and transferred to the CCU, before the patient died, and then was transferred to the morgue. Make sense?  Maybe CMS will convince hospitals to keep investing in better equipment, at least so it is ready one of the CMS administrators show up in v-fib.  Or maybe they will not, and the outcome will be vfb à morgue. 

Now, how this will be done will be interesting to watch. It will be quite challenging because certain specialties provide isolated real-time care while the traditional life-long practice provides longitudinal care. For most of the latter, the patient is still present when outcome is determined. The reconciliation of these different, and somewhat competing, paradigms will be difficult to achieve.

The Electronic Health Record, so often written about in many of our prior blogs, will need to change its fundamental character.  An emphasis on creating legally defensible documents, and an emphasis on an EHR use as a billing tool, will both be expected to come in secondary to its use as a patient-centered tool.

It’ll be nice if it works.  No skeptics here, right?  Yet, the coming evolution of the EHR may present great opportunities for focused or “Best of Breed” electronic health records that handle specific medical areas of expertise. Yes, enterprise systems will continue, but they may be constructed as user specific modules (apps) to accomplish these new goals. Think of your cell phone. These systems will have to allow “plug and play” programs or specific “apps” to give the providers the necessary support to be efficient and financially successful.

Why Do Certain Electronic Health Record Installations Fail?

The article Denver Health CIO, COO quit, blame pricey Epic EHR installation, says Denver Health Medical Center (where Dr. Kamens and I trained during our early EM careers) our alma mater had considerable financial and personnel problems during their Electronic Health Record installation. As one might expect, the vendor and the hospital had different versions of what actually happened. Lots of finger-pointing ensued.

Implementation problems of this type may be caused by locally specific factors, but are not unusual throughout the EHR industry, and appear in diverse locations. Finding out (and revealing!) what those fundamental issues were would be a great help to other institutions and vendors.  Unfortunately scenarios of installation blunders are only rarely shared outside the vendor’s office, and we are left doomed to repeat history from which all could have learned.

In the old days (circa 1970’s-80’s) it was common to attend a hospital educational programs called M & M conferences. The New England Journal weekly case discussion at Mass General was a paradigm for many through which medical prowess could be advanced.  M & M stood for Morbidity and mortality. Wikipedia notes:

“M&M conferences “are traditional, recurring conferences held by medical services at academic medical centers, most large private medical and surgical practices, and other medical centers. They are usually peer reviews of mistakes occurring during the care of patients. The objectives of a well-run M&M conference are to learn from complications and errors, to modify behavior and judgment based on previous experiences, and to prevent repetition of errors leading to complications.^[1] Conferences are non-punitive and focus on the goal of improved patient care. The proceedings are generally kept confidential by law.^[2]M&M conferences occur with regular frequency, often weekly, biweekly or monthly, and highlight recent cases and identify areas of improvement for clinicians involved in the case. They are also important for identifying systems issues (e.g., outdated policies, changes in patient identification procedures, arithmetic errors, etc.) which affect patient care.^{[1][3]  “}

In the purely clinical realm, perhaps due to present liability issues, M & M’s may not be as forthright as in the past. For certain, every intern and resident dreaded to be on the podium at one of these events.  “And what were you thinking at that point, Dr. Ausgiblinken?  Today, it is likely that the extent of dread probably includes most staff, physicians, attending, and others. After all someone has to take the blame when things go south.

Knowing an implementation is coming up is a common cause for major anxiety too. Can we do anything about the fact that many doctors, nurses, other providers, and administrators shake in their boots when a new installation is on the calendar? Wouldn’t it be nice if they could be at least as relaxed and as confident as when about to have a colonoscopy? That should not be such a distant dream.  Really.  Nobody puts the clinical, IT, and administrative teams into Sims or Trendelenburg. But to look at their faces the week before the new system arrives, you wouldn’t know it. 

Could we have M & M conferences for EHR implementations, sharing analyses of the good as well as the bad?  Publically available, they could vastly improve implementations, avoid common failures, and create an important knowledge base. Such M and M reviews would be welcome tools from which to learn about what really happened and what problems could have been avoided.

One might discern whether problems encountered were:

1. Systemic
2. Caused by individuals, particular departments, or departmental relationship
3. Resulted from lack of buy-in by the providers
4. A result of insufficient training
5. Caused by Hardware and/or software issues
6. Plagued by Usability issues
7. Due to an absence of effective leadership
8. Arose from a combination of two or more of the above
9. Etc.

Data gleaned from such open discussion would certainly help all institutions and vendors. Become more effective at EH R implantation, for the overall benefit of patients, and healthcare delivery.

Opioid-Free Emergency Departments-Would You Go There?

In the article Opioid-Free ED: Coming Soon to a Hospital Near You, the author makes a case for an Opioid-Free Emergency Department. His concerns were for the potential drug abuse through narcotic prescription writing and eliminating a percentage of patients who are drug seeking.

 

He offers a table for alternative treatments.

Table. Non-opioid Alternatives for Pain Management

Condition	Analgesic
Renal colic	acetaminophen, indomethacin, ketorolac, lidocaine, rectal indomethacin
Back pain	acetaminophen, diazepam, ibuprofen, lidocaine patch, methocarbamol, trigger-point myofascial injections
Headache	diphenhydramine, ketorolac, metoclopramide, prochlorperazine, sumatriptan,
Musculoskeletal pain	acetaminophen, ibuprofen, lidocaine patch, naproxen, nitrous oxide, regional nerve blocks
Neuropathic pain	clonidine, gabapentin, ibuprofen, nortriptyline, pregabalin
Burns	acetaminophen, bupivacaine, ibuprofen, naproxen, nitrous oxide
Sickle cell crisis	hydroxyurea, ibuprofen, ketamine, nitrous oxide
Chronic pain	gabapentin, ibuprofen, lidocaine patch, prednisone, trigger-point injections
Pediatric pain	acetaminophen, ibuprofen, ketamine, nitrous oxide

Regarding this opioid-free approach, we have an alternative point of view; and it is backed by years of experience and success with narcotic-based analgesia when properly used.

There are certain conditions that narcotics definitively benefit, especially in their acute phases. Consider heart attacks, severe visceral (abdominal) pain, multiple injuries, fractures, ruptured disks, intubation & procedural sedation, sickle cell, cancer patients, etc., etc. Do you really want to practice without morphine or its derivatives as options?

Narcotics are easily titrated with proper protocols and PCA (patient-controlled analgesia) pumps. Most studies show that pain (as a presenting or prominent symptom) is the #1 or #2 reason for going to the Emergency Department.  Not uncommonly, once seen, it is undertreated.

What can be done? Balance is needed in clinical emergency medicine, and with care, a common sense practical approach can be reached. During any one patient encounter, the ED clinician should not impede his/her decision-making process by deliberating political correctness or evoking concern for the vast social ills that abound in the culture.  These are surely not the priority of the patient in front you, and so they should not be yours either, at least not during the encounter. Helpful failsafe protocols can capture some offenders, and some issues, but they are not perfect.  For example, refills can be limited or non-existent; a statewide or local e-prescribing history can limit repeat prescriptions to prior offenders without verification..

The bottom line: treat pain. Treat it strongly.  It is one of few things we can reliably do for people. (Yes, there are others, but the list of interventions that really make a perceptible difference is shorter than we would like it to be).  Remember the last patient you relieved of pain, and keep that image in mind. And if a member of my family is in desperate pain, please take care of them. Mo-phine would be just fine.

Being Honest about Electronic Health Record Costs

In the article Hospitals face budget woes with switch to electronic records, Brigham and Women’s, one of the most famous and profitable hospitals in the USA, lost money in their transition to an Electronic Health Record.

The article is interesting and hospital administrators should pay attention.

            The Electronic Health Record is potentially a great tool when built and used properly. These advantages have a steep price tab when all aspects are factored in.

1. Cost of system (including hardware and software)
2. Cost of ongoing Support
3. Data storage (consider HIPPA compliance)
4. Training
5. Repeat Training
6. Learning curves
7. Difficult user interfaces, frequent updates. These require re-learning and workflow readjustments that are seriously expensive. 
8. Costs of customization
9. Hiring more personnel
10. Getting providers to cooperate
11. Keeping EHR costs within rising clinic and physician budgets.
12. Matching the right diagnosis codes, right diagnosis, and accurate documentation.
13. Over-coding and under-coding
14. Charts that are written in “computer-eeze”.
15. The additional costs of needed modules.  For example: Voice Activated Technology and/or other programs make enterprise systems more user friendly (sometimes).
16. Malpractice worries with mega-data
17. HIPPA concerns
18. Computers and programs can be used to help solve problems but they do not accomplish this “magically”.
19. Volumes of incoherent data collected
20. Burn-out of the staff and providers
21. ETC.

A great many such costs are hidden. We see a good number of task forces created to improve efficiency.  Often they accomplish that goal by jury-rigging work-arounds that only last as long as the task force. A year goes by, and the facility is back to ground zero.

Bottom line, the EHR is a tool; it is not a global solution.  Hence EHRs should be customized to meet the clinical needs of the providers and staff, first. The wishes of the accounting department can be addressed after all the patients are cared for.  

Usability and the Future of the EHR

Many articles have been written correlating the weakness of  EHR usability and patient safety.  As a physician and EHR user, here are some key points that an EHR of the future, and the healthcare IT environment in which it lives, should address and push for.

1. A NATIONAL DATABASE: Creation of a national healthcare database with the intent of including every individual, with records presented via a standardized format.

a.Yes, this is a bit far off, and there are obstacles. However, we feel this goal is so key that planning and development now should take into account the needed sub-steps along the way, for its achievement. Otherwise, we will continue to be untangling spaghetti for eons.

b. Such a central database would streamline access to health information for every patient interacting with any Electronic Health Record in the country.  While the term "interoperability" is frequently tossed around, the fundamental point of interoperability is ability to easily share information. Central storage is not really necessary, but centralized access is.

b. Direct incentive-type funding.  Meaningful use was an understandable first effort. But putting huge incentives into time and work consuming data collection queries, has made providers suffer, with little benefit. When a national database is available, information can be more easily examined to determine how EHRs are being used in identifiably meaningful ways. 

c. Movement in this direction would be like putting the money in the bank.  As it became established, it would be a fundamental and available resource.

2. STANDARDIZATION OF CPOE: Creation of a standardized national Computerized Order Entry (CPOE) system with its user interface replicated at every care-site care would generate huge improvements in safety and efficiency. Modifiable order sets for key presentations could be built and maintained by specialty/sub- specialty authorities, and adjusted to meet local needs. 

a.  This would represent a significant advance, allowing providers of all stripes to interact with local systems when directing care, without endless learning curves.

b. Optimally, the entire staff should be able to use the system rather than the highest paid providers being the data input clerks. Various levels of authority would allow hierarchical verification and acknowledgement of orders, promote safety, discussion of clinical course, and appropriate supervision of ordering.

c. One would expect that developed orders would be care-setting specific (modular) and provide the most common orders in easy array of choices.

d. Order interaction with the pharmacy should also be care-setting specific i.e Emergency Department, operating room etc. Moreover, prescriptions/e-prescribing should be care-setting, care-track, and provider specific.

e. Simplification could be globally anticipated. For example calculators (such as pediatric dosing, and other weight/age based therapies) could be straight-forward and easy to use (see the local ATM)

3. INTELLIGENT CLINICAL DECISION SUPPORT: It is time for research to progress in the realm of clinical decision support. Artificial Intelligence is making its way into the world (think Siri), and medicine should not be behind in this exploration. 

a.  A real potential benefit of an EHR in clinical care is in the promise of AI. Right now, most of the research needed on any one case is still on our shoulders. Who of us does not do a google search or explore a reliable source (like "Up-to-Date") on a frequent basis to support of clinical decisions.  The butler (Siri's colleague) can help do that for us. 

b. A good system ought to be aware of your needs, even before you are conscious of them.  Should not a differential diagnosis be automatically generated from the information within your CC, HPI?  If the computer recognizes certain symptom complexes, the provider is supplied can be given easy access to information, treatment protocols, policy recommendations, and appropriate reminders to consider key diagnostic options.

c. Also included should be medication alerts that indicate potential severity of pharmaceutical choice and dose.

4.   SIMPLIFICATION: in the design, construction, and implementation of the actual EHR. For example:

a. Make nursing notes, provider notes, labs, x-ray reports, etc. accessible without having to go to multiple screens to find them.  This is technology available now.  Tabs, mouse-overs, and other tools should be fully implemented in the EHR space. (Google News is a good example of a summary presentation that includes all potentially important items)

b. Artificial intelligence/decision support suggestions should appear in a way that supports the provider’s ability to look over and collate all the data.

c. Another example exists in the sometimes disparate modules that comprise an enterprise EHR.  Direct interaction between the EHR and the tracking board is essential to assist providers and caregivers in controlling a flood of information and prioritizing decision making. Why put information in twice, three times, or more?

These are just a few suggestions. Please add your own below. Let's help make the record a real-time clinical assistant instead of just a medical-legal document and a billing tool for reimbursement.

Real-Time Artificial Intelligence Utility

Artificial intelligence (AI) is defined by Wikipedia as intelligence exhibited by machines or software. In the article 10 Ways Artificial Intelligence Could Make Me a Better Doctor, the author lists 10 ways to take advantage of AI support. Number 6 on the list is:  “Help me make hard decisions rational.”

The others are worth reading but are more related to time management aspects of practice. Being guided toward trustworthy, intelligent, rational decisions based on up-to-data, practice guidelines, and cost consciousness would help most any clinician. After all, there is already doing this processing in their gray matter.

Here are some practical areas in which a well-functioning EHR-AI (Electronic Health Record Artificial Intelligence) system could effectively support providers in making timely good clinical decisions

1.     Creating an easily understood differential diagnosis hierarchy
a.   It would be quite helpful if the AI used incoming clinical data to create a hierarchical differential diagnosis tree (perhaps graphic) based on likelihood and potential risk. The AI could supplement the clinician’s differential diagnosis, and create a high-risk profile, with alerts, individualized for each patient.

2.     Fully probe the Differential Diagnosis
a.   For example, if a pulmonary embolism is considered, the AI could risk stratify the patient using clinical scoring schemes. It may ask the provider for more data, and could give the provider instant access to relevant clinical articles and best practice guidelines.
b.   It could then make recommendations regarding the work-up needed.
c.   It could provide real-time cost data for any testing.

3.     Developing a treatment plan
a.   The AI system would most commonly offer established treatment protocols
b.   It would show time frames, when treatment is time critical
c.   It might offer alternatives if patient refuses
d.   And it might also give guidance on shared-decision making data

4.     Selecting appropriate medications
a.   AI could use tailored real-time displays to signal:
     i.     Significant clinical side effects
     ii.    Allergies
     iii.    Drug-drug interactions
     iv.    Cost analysis
     v.    Data supporting alternative (non-pharmaceutical) treatment

5.     Disposition Analysis:
a.   At time of disposition, the high-level AI system could address key areas to remind about needed attention:
b.   Scan the final-stage record to be sure no key oversights exist
c.   Flag and display any unaddressed high-risk warnings
d.   Verify prescribed follow-up times
e.   Recommend consultants, primary physicians and/or others

Most clinicians already do all these things with each patient. The AI, if functioning expediently, would function as another “eye” on the case. Quality of care should improve, and perhaps come closer to its higher potential.

No, an AI system will never replace flesh-and-bones clinicians, but it has the possibility of greatly augmenting their performance capacity.  If these clinical decision support systems appear on the market, and are well build, acquiring
one for a busy practice would be a no-brainer.