EHR – Checklists & Bayesian Diagnosis

A very interesting recent article by Shiff and Bates published in NEJM proposes a rather ambitious benefit for EHRs.
The article aptly titled “Can Electronic Clinical Documentation Help Prevent Diagnostic Errors?” and aptly presented as a question rather than a statement, is exploring the possibility that EHRs can reduce diagnosis errors. The authors duly admit that there isn’t much evidence to support such forward thinking for the current crop of EHRs.

“Admittedly, evidence to support the existence of such a benefit is currently lacking, and our hypothesis runs counter to the sentiments and claims of many physicians, who argue that electronic documentation in its current incarnation is time-consuming and can degrade diagnostic thinking — by distracting physicians from the patient, discouraging independent data gathering and assessment, and perpetuating errors.”

However, they are envisioning a new breed of electronic documentation that will be capable of fulfilling such lofty goal. Most of the proposed characteristics of this new generation of software are incremental improvements to collection and presentation of information from various sources. This is in line with the national goals of fostering interoperability and the creation of an Electronic Medical Record for every American by 2014. Computerization is also viewed as a solution for the introduction of mechanical errors due mostly to poor handwriting and poor paper based book keeping, such as the benefit provided by electronic prescribing. All in all, the authors’ suggested “top 10” style list of desired improvements to EHR technologies are very sensible and have the potential to improve usability, collaboration and effectiveness.

An interesting aside is that the authors propose more textual data capture and more reliance on voice recognition as opposed to discrete data capture by “ticking boxes”. I hope the authors understand that dictation and free text do not lend themselves very well to “aggregation, trending, and selective emphasis or display of data so as to facilitate rapid judgments”, which are the cornerstone of the approach suggested in the article.

A more interesting suggestion is the use of Checklists for “Providing prompts”:
“Provide checklists to minimize reliance on memory and directed questioning to aid in diagnostic thoroughness and problem solving”

And to go with the checklists there is “Calculating Bayesian probabilities”:
“Embed calculator into notes to reduce errors and minimize biases in subjective estimation of diagnostic probabilities”.

This, of course is the opinion that decision support at the point of care has to become powerful enough to change the imperfect way medicine is practiced today.

“But we envision a redesigned documentation function that anticipates new approaches to improving diagnosis, not one that relies on the putative “master diagnosticians” of past eras. The diagnostic process must be made reliable, not heroic, and electronic documentation will be key to this effort.”

The question in my mind is at what point does decision support become too powerful and begins crippling both physicians and quality of care? And is there such a point?

For an opinion on this subject, I suggest Dr. Jerome Groopman’s excellent book “How Doctors Think”.

Health IT Strategic Framework – Field of Dreams

Health IT is on a binge. Every day we are served with a new acronym, a new committee, a new contract, a new grant and a new goal. Health IT is definitely creating jobs, which was indeed one of the goals. But there was one other stated goal.

It was supposed to help physicians and patients provide and obtain better health care by making pertinent information available at the point of care, by involving patients and their families in their own care and by using computers to improve accuracy of clinical information. It was supposed to benefit patients in a very immediate and tangible way. That was the original meaning of the over used term “patient centric”. It was supposed to be all about the individual patient.

There were secondary goals as well. A byproduct of computerization of Medical Records is, of course, the ability to conduct research to benefit populations and advance the science of medicine, but somehow, in the frenzy of spending federal funds, the byproduct became the main objective.

I am a big fan of Dr. Blumenthal and in perpetual awe of his work at ONC. Today I read the recently published Health IT Strategic Framework. The ONC’s articulated vision, which drives the entire framework, is the creation of a “learning health system”. An excellent vision to be sure; a vision which drives a framework of security, privacy, biosurveillance, data collection public health, medical research and reporting. I have no doubt that in due course, such learning health system will produce evidence based information to support cost effective care and benefit future generations of Americans and humanity in general.

How do you build such a learning health system? It seems that ONC is tackling the task head on, by actually building a system from the ground up, complete with a National network (NHIN), localized intermediaries (HIE), individual access points (EHR), education centers (HITREC), standardization (Meaningful Use), certification (NIST, NVLAP, ONC-ATCB, ONC-ACB, ONC-AA), all driven by rulemakings and generous financial awards.
This is the “Field of Dreams” theory (If you build it, they will come), and it does work sometimes, as Kevin Costner can attest.

We could of course try a bottom up approach.

Case 1. 60 year old John Doe presents at the ED with chest pain. What does the attending physician need as far as information is concerned? A good current medications and allergies list and a good current diagnoses list and a little time to listen to John and take a good history of present illness. What does the attending physician not need? John’s growth charts from when he was a baby, John’s immunizations records from high school, John’s record of taking antibiotics for an STD while serving in the Navy 40 years ago, John’s record of taking other antibiotics for a sinus infection 5 years ago, etc. It would be nice if the attending doc could “get online” and download a couple of paragraphs of information from John’s PCP.

Case 2. 55 year old Mary Doe has Diabetes and Hypertension and CAD. She is sitting across from a Cardiologist who is seeing her for the first time. What does the Cardiologist need in order to evaluate Mary? Pretty much the same information the ER attending needed, plus any pertinent test results that her PCP might have ordered. And just like the ER attending, the Cardiologist needs a little time to listen to Mary. Most likely Mary’s PCP already faxed the information over. It would have been nice if the PCP information would “magically” end up in the Cardiologist’s chart and the Cardiologist consult note would end up in the PCP chart. It would also be nice if Mary’s daughter could “get online” and look at everything the doctors are doing, or proposing to do, because Mary may want to discuss her options with her daughter who lives 1000 miles away.

Turns out that patients and doctors can pitch a good game in the backyard with just a bat and ball. So maybe all we need is a few more bats and balls – Internet access, simple file transfer, CCR and some very simple game rules, so no one gets accidentally hurt…..  Let’s get all of us in the game before pretending to be Shoeless Joe Jackson.

How to Health 2.0-ize Your Patient Portal

(Tips for Techie Docs and EHR Vendors)

First, we need to define the terminology. Patient Portals are software or web services accessible in real time by both physicians and patients. Patient Portals come in two flavors: tethered to an EHR and untethered.

Tethered Patient Portals are just a different view of the doctor’s EHR. This is a restricted view of a patient chart and it includes the ability to communicate with the clinic in a secure fashion.  Some EHR vendors provide their own Patient Portals, while others offer full integration with third party Portal vendors. In both cases, physicians use their EHR to communicate with patients.

Untethered Patient Portals are standalone Portals used for secure communications only. Patients can send and receive messages to/from their physician, but they do not have a complete view of their chart. Physicians cannot initiate communications directly from their EHR. Instead they need to log into a separate Portal application.

There is a third type of software/service usually mentioned in this context, and that is the Personal Health Record (PHR). The best known providers of this type of service are Microsoft Health Vault and Google Health. PHRs, however, are directed to aggregation of patient data from multiple sources and less concerned with real time communication between patient and doctor. PHRs are outside the scope of this discussion.

What is Health 2.0? The term derives from the better known Web 2.0 terminology. There are many definitions for Web 2.0, but generally speaking it is the new generation of web applications that are interactive (as opposed to static), collaborative, user centered and very social in nature. The most ubiquitous examples of Web 2.0 and its power are social networks liked Facebook, Twitter, You Tube and even Google Apps.  Health 2.0 means pretty much the same thing for health care oriented applications. The newer EHR technologies that are delivered over the web, the various online patient communities, telemedicine, and remote monitoring devices are all examples of Health 2.0 applications.

A Patient Portal has all the makings of Health 2.0, but it lacks a social aspect. If a Patient Portal could allow the creation of patient communities and facilitate social interaction of patients with similar conditions or interests, it would be the ultimate Health 2.0 application, and much more powerful than larger internet communities of patients. The reason for this is that a Patient Portal community is also a physical community – people who have the same doctor, usually reside within a commutable distance. A Patient Portal Community could create relationships and support systems not just in cyberspace, but in the real world as well. For example, a Diabetes community could bring together folks that may decide to go for walks together every Saturday; dialysis or cancer patients can arrange for carpools; young moms can get together for play-dates or outings at the mall….. The possibilities are endless.

How does a doctor or vendor facilitate such benefits? The answer is very simple: by adding Forum capabilities to your Patient Portal. Forums are websites where one can go and ask questions, receive answers, start a conversation and get to know other people with similar interests. There are multiple options for free Forum software you can download or have hosted for pennies a day (see below). For privacy and security reasons, Forums should not be integrated with your EHR, but should be accessible from your Patient Portal. Even if you don’t have a Patient Portal, you probably have a website for your practice. You can add a link to the Forums right there. The hard part for the doctor is to configure Forums for the conditions you see most often, to encourage your patients to sign up, and actively participate in the conversations, at least initially. Your patients will more than likely take it from there. If you feel up to it, you may even add a blog to your Forums where you can provide guidance and advice, promote health and wellness and empower patients and families to participate in their own care.

While global Internet communities have obvious advantages in their sheer size and diversity, small local communities have the ultimate power of transcending the Internet and affecting real change on the ground, and isn’t that what Family Practice is all about?

Sample Free Forum Software:
PHPBB - http://www.phpbb.com/
SMF - http://www.simplemachines.org/ 
Forum Software Reviews
http://www.forummatrix.org/
http://www.forum-software.org/forum-reviews

A Day at the Beach

(Casual Friday Fun Series)

Since they were toddlers Timmy and Tommy spent their summers together at Liberty Beach. The boys lived far apart on the Mainland, but each summer their parents brought them to Liberty Village for a well-deserved vacation. Since there were no other little boys in the time-sharing community, Timmy and Tommy brought their pails and shovels to the water edge and spent their days together building sandcastles on the beach. As the boys got older and the castles became more elaborate, their play became more contentious.

See, Timmy liked building tall narrow castles, and Tommy preferred the wider, lower and more fortified type. Arguing over the architecture was somehow part of the game and the castles ended up being not too narrow and not too wide, with the boys having great fun and working up a healthy appetite by the time they were summoned home for dinner.

These were the best of times until the summer before kindergarten. Tommy’s parents bought their little boy a brand new shinning metal shovel bigger than ever. Timmy showed up at the water edge with his old plastic shovel and pail. Tommy was hauling sand at an unprecedented rate with his new toy and Timmy wanted to play with the big shovel too. It wasn’t fair. The castle was getting wider and wider with every stroke of Tommy’s shining toy. Timmy, almost in tears, folded his arms across his chest and refused to play. Tommy kept hauling sand trying to get Timmy back into the game. He even added a few really tall turrets to the castle, but Timmy started yelling, screaming and kicking the castle with his bare feet. It wasn’t about the castle anymore; Timmy just wanted a turn at that big shinny shovel. Watching his hard work falling apart, Tommy got angry too.

It was getting late; almost dinner time, so Tommy patched the castle here and there and the boys ran home for dinner leaving behind a half-finished castle and with no appetite for mom’s casserole. Timmy and Tommy did not go back to the beach that summer. On the way home, in the back seat of the Land Rover, Timmy vowed to make his parents buy him the biggest shovel ever, so next summer he would build the tallest sandcastle Liberty Village ever saw. Tommy squished between his sisters in the old Chrysler minivan was clenching his big shovel, which didn’t look so shiny anymore, in his little hands, hoping against all hope that it will last until next summer....

The DEA IFR - Quick Review for ePrescribe

On March 24, the DEA has released its IFR on Electronic Prescriptions for Controlled Substances, which incorporates the public comments received on the NPRM from June 27, 2008. Looking at the current ePrescribe applications on the market today, the DEA IFR will require significant software development, particularly security related. It will also require changes in prescribers' workflows.
Here are the highlights (italicized text is quoted from IFR):

Obtaining Authentication Credentials - Allows remote identity proofing
"DEA is requiring registrants to apply to certain Federally approved credential service providers (CSPs) or certification authorities (CAs) to obtain their authentication credentials or digital certificates. These CSPs or CAs will be required to conduct identity proofing at National Institute of Standards and Technology (NIST) SP 800-63-1 Assurance Level 3, which allows either in-person or remote identity proofing. Once a Federally approved CSP or CA has verified the identity of the practitioner, it will issue the necessary authentication credential."

Two Factor Authentication - Biometrics may substitute for hard token 

"As proposed, DEA is requiring in this interim final rule that the authentication credential be two-factor. Two-factor authentication (two of the following – something you know, something you have, something you are). In the interim final rule DEA is allowing the use of a biometric as a substitute for a hard token or a password." 

Controlled Substances Pending Lists displaying all data elements

"DEA is requiring that the application display a list of controlled substance  prescriptions for the practitioner’s review before the practitioner may authorize the prescriptions. A separate list must be displayed for each patient. All information that the DEA regulations require to be included in a prescription for a controlled substance, except the patient’s address, must appear on the review screen along with a notice that completing the two-factor authentication protocol is legally signing the prescription."

Two step prescribing - Readiness to sign -> Prompt for two factor  authentication -> Sign
Registrants must indicate that each controlled substance prescription shown is ready to be signed. When the registrant indicates that one or more prescriptions are to be signed, the application must prompt him to begin the two-factor authentication protocol. Completion of the two-factor authentication protocol legally signs the prescriptions. When the two-factor authentication protocol is successfully completed, the application must digitally sign and archive at least the DEA-required information."

No paper duplicates allowed, unless transmission fails
"DEA has clarified that the application may print copies of an electronically transmitted prescription if they are clearly labeled as copies, not valid for dispensing. If a practitioner is notified by an intermediary or pharmacy that a transmission failed, he may print a copy of the transmitted prescription and manually sign it. The prescription must indicate that it was originally transmitted to a specific pharmacy and that the transmission failed."

Digital Signatures - Either by the application or Prescriber Private Key 
"When the practitioner uses his two-factor authentication credential as specified in § 1311.140(a)(4), the electronic prescription application must digitally sign at least the information required by part 1306 of this chapter and electronically archive the digitally signed record. If the practitioner signs the prescription with his own private key, as provided in § 1311.145, the electronic prescription application must electronically archive a copy of the digitally signed record, but need not apply the application’s digital signature to the record".

Audit logs need to be augmented
"The application provider and the registrants must develop a list of auditable events; auditable events should be occurrences that indicate a potential security problem. For example, an unauthorized person attempting to sign or alter a prescription would be an auditable event; "

Daily Audit Checks - 24 hours reporting
"The applications must run the internal audit function daily to identify any auditable events. When one occurs, the application must generate a readable report for the practitioner or pharmacist. If a practitioner or pharmacy determines that there is a potential security problem, they must
report it to DEA within one business day."

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.

View larger image [Scribd]

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?

We are, or could be, Better than Banks!

I try to stay away from Banks as hard as I try to stay away from the doctor's office. Unfortunately I had to visit both recently. A week ago I had to take my son to an orthopedic surgeon (nothing serious), and today I had to go to the bank.

The Bank

Granted, I needed a rather tricky service involving a public notary, but it was not a very complex transaction. I brought with me 3 sets of 5 forms (in duplicate) that I received through regular mail after several phone conversations with another bank. No, there was nothing online for me to fill out and be done. No, they couldn't fax anything over and no, I couldn’t fax it back. eMail? No, we don’t do eMail.

The bright young clerk at my local branch took the forms and after failing to understand the purpose and after asking around for a while, finally called the main office and literally read the forms out loud for the person on the phone.

Since I had plenty of idle time I started looking around. There was a computer on every desk, but there were also wire trays full of forms and yellow folders. This is a fairly new branch of a fairly large bank with lots of marble and glass everywhere.

On the other side of the room, there was another clerk attending to a young couple. I have no idea what they were doing, except that they were told to "sign here... and here.... name and address …..social goes here…yes, you need both…" several times and each time some new form was being presented by the very nice clerk and pulled away upon completion.

I walked out 45 minutes later with my stack of partially notarized forms that I would have to send back to the original bank by regular mail. The remainder required more forms to execute…..

The Doctor

Last week, I called the orthopedic surgeon for a consultation. The front office lady gave me a URL to go to and input my son's information, which I did. I noticed that if we would need more visits, I could book them online.

On the day of the appointment, we walked in and they snapped his picture straight into the EMR. They took my insurance card, slid it through a card reader and my son was told that he could update any changes to his info on one of the two computers in the waiting room (he found a way to get on Facebook instead).

It was a quick visit. The doctor came in chatted for a bit, checked out my kid’s elbow, said to just leave it alone (I love this type of doctor), shook hands and walked out. He never wrote anything. He is probably one of those docs that prefer to document in between patients. I know he read the histories before he came in though, so I assumed (and also verified with the nurse) that his computer is in his office.

We walked out 45 minutes later and as we were walking to the parking lot, I realized that I did not have to touch either a pen or piece of paper. And neither did the receptionist (insurance cards are plastic). And neither did the doctor.

When it comes to paperless office, Healthcare is eons ahead of Banks…..