Thursday, March 25, 2010

EHR Data Exchange - Where is the Bang for the Buck?

In the past months I have been religiously dialing in and listening to the ONC  Policy and Standards committees meetings. The amount of work done by the members is nothing short of monumental and the combined knowledge and experience is astounding.

Like most of us in the HIT industry, I have spend many hours poring over the IFRs, NPRMs, Power Point schematics and every work product available, and like most everybody else I am a bit lost in the sea of acronyms, harmonizations and network diagrams.

The bottom line, though is that we are hopeful that physicians will adopt and use EHR technology which is built to the standards defined by ONC. The promise for physicians is that the eventual interoperability will facilitate meaningful exchange of clinical information, which will in turn provide the ultimate ROI in the form of better, less wasteful care.

In order to validate this assertion, let's examine the most common occurrence of the need to exchange clinical information in private practice: Referrals. Below are three diagrams of a typical referral process from PCP to Specialist and back, one for paper offices, one for offices on current EHR software and one for the futuristic EHR capable of exchanging standard driven discrete data.



Let's note first that the efficiency offered by Patient Portals or PHRs (shaded in pink) is mediocre today, but should become significant as online patient access to records and bi-directional physician-patient communications become common practice. Meaningful Use is correctly encouraging that.

The gray shaded areas show steps that are made more efficient by the introduction of EHR technology. A conventional EHR for example, eliminates the need for printing, scanning and filing exchanged documents in the physical chart. The futuristic EHR will further eliminate the electronic faxing (directly into the EHR) and replace it with discrete data transfer.

These particular tasks are only a small part of the referral workflow and not even the most time consuming.
None of these tasks are performed by Physicians. 

Of course, there is more to Interoperability than just referrals. There are prescriptions, laboratory tests, radiology and administrative transactions, for which we have pretty good standards. Then there are surgeries, admissions, discharges, transitions of care and more, which need some more work, but just like referrals, basic document transfer is very acceptable from a physician point of view and already electronically occurring in practice.

While the change from paper to the currently available, non standardized,  EHR technology can be shown to provide significant time saving for office staff, the transition to standards based EDI for referrals offers only incremental benefits to the practice, while requiring major and complex technology retooling. Not to mention the elaborate infrastructure of intermediaries  of every form, shape and governance, which deserves its own separate analysis.

Granted, the capture of, and ability to report on, discrete clinical data, promises great advances in research and quality measurement. It may also be offering tangible benefits to a variety of other stakeholders. However, we are asking physicians in private practice, most practicing solo or in very small groups, to make a significant effort, in both time and money, to purchase and use certified EHR technology with all the complexity and expense of harmonized acronyms.

Shouldn't we be able to at least show them where THEIR bang for THEIR buck is?

8 comments:

  1. Hmmmmmm.

    Their bang for their buck will be mere survival.

    The environment is changing and along with it minimum efficient scale for physician practices. Solo and "very small" groups will not survive. There will be much wailing and gnashing of teeth.

    This happens in many industries -- medicine is not special.

    t

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  2. That is true.
    However, if we REALLY want to meaningfully exchange clinical information, and assuming that such exchange leads to cost effectiveness or at least better quality (which I think it should), then why not set up something quick and simple while fiddling around with perfection?
    What would have happened to cell phone adoption if we waited around until they finished designing the iPhone?
    Isn't starting simple the most efficient road to mastery, particularly for the less motivated?

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  3. > Isn't starting simple the most efficient
    > road to mastery, particularly for the less
    > motivated?

    Sure.

    The trouble is the definition of "simple". For too many small practices, if it isn't as simple as a fax machine it won't be adopted. There is little administrative talent in the place -- they're doing well to produce an electronic bill. Word processors are used like fancy typewriters and 90% of the capability is ignored. In many ways they're still doing late 19th century processes using 1970's technology -- they haven't really made it to 1990's equipment and processes yet. You know this at least as well as I do. I don't see how this can possibly be accomodated and and I don't think it is worthwhile to try. (cf. Thomas Kuhn's famous book on scientific revolution)

    So, what's "simple" in this context?

    t

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  4. Simple is exactly what the Internet, email, word processing and more recently Web 2.0, have brought to communications.
    Simple is what we are both doing on this web page right now. If instead of typing down, or dictating, what I want to say, I had to be mindful of checking a bunch or required blog boxes and if I had to spend a fortune on some special software, we wouldn't be having a nicely recorded conversation right now. We would not be exchanging ideas.

    So if the goal is to exchange information, why not do just that? We obviously have the tools already and all of us, including doctors, know how to use them.
    If, on the other hand, the goal is to exchange structured information, then I would have to question the immediate benefit of this added constraint. I would actually have to question the long term benefit as well, considering that technology will most certainly be able extract structured information from narratives in the not so distant future.

    To make the argument simple :-), why not let docs just exchange documents using well established and commonly available means? Why insist on a completely arbitrary documentation format? Whose databases are we in need of populating with all this clinically meaningless data?
    I just don't see the benefits to either doctors or patients. The first priority should be information availability, not data mining capabilities.

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  5. > Simple is what we are both doing on
    > this web page right now.

    I say this isn't simple enough for them. They won't do it except under existential threat.

    t

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  6. As you pointed out at the very beginning, the existential threat is already there :-)

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  7. Not that it is simple, but we are beginning to see AI coding systems that work right off of a doc's dictaton. One way to start is to have docs dictate notes and send off to a transcriptionist. I understand the difficulty of being entirely candid in notes dictated in the presense of patients -- some will probably have to be dictated after the visit ends. Notwithstanding, I like this better than template oriented documentation for any number of reasons, expressed far better by one of my informatics heroes Virgil Slee than I ever could.

    Docs dictate & file transcriptions, their auto-coding service makes clinical and financial abstracts from the transcript to go off to payers and others. Call it "simple for the doc". Maybe this is the road to mastery.

    > Whose databases are we in need of populating
    > with all this clinically meaningless data?

    This is another good question to explore -- if data is clinically meaningless, why have it at all, in any form? And I do not want to hear that CPT codes (properly) are clinically meaningless.

    t

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  8. I too Agree with your points specifically that EHR technology can be shown to provide significant time saving for office staff, the transition to standards based EDI for referrals offers only incremental benefits to the practice, while requiring major and complex technology retooling.But not used effectively

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