Road Trip to Meaningful Use Land

The voice on the phone seemed genuinely amused, “Let me see, the GPS can’t find our location, right?” Right. One U-turn by the burnt barn, a right after the Conoco station, another right at the end of the road, a left across the John Deere and two and a half hours from the city on highway W, brought me to a small and very white store front, housing a nail salon and a busy family physician practice. If I stretched out both arms, I could put one hand on the front desk, and place the other hand on the back of a waiting room chair. There were six chairs separated by small tables adorned with yellow silk flowers. A texting young man in jeans and baseball cap and a middle aged woman clad in floral attire and a big green purse, occupied two of those chairs. And then Bessie walked out the doctor’s office behind the usual and customary tennis ball footed aluminum walker which was almost as tall as her, and helped by the front desk lady made a slow trek to the one chair with arms on both sides. They were calling Joe to come pick her up. Joe was going to be there in ten, fifteen minutes, tops. It was 4 PM and they were running behind.

Looks can be deceiving though. This practice is an anomaly in the rural health continuum. There are computers in every room and not even a trace of paper charts. They’ve been on a top of the line Cadillac EMR since 2005, paying a small fortune every year for the privilege and for IT guys to support it. They kept up with all the upgrades and are on the latest and greatest certified version and would very much like to get the Meaningful Use incentive that will cover about three quarters of what they spent on EMR maintenance this year. The doctor would even like to try the patient portal. He thinks it could make him more efficient. They were all ready to go on October 1st, but then something happened. They started getting solicitation emails from their EHR vendor informing the doctor that there are several accessories that he must purchase in addition to his fully certified EHR, if he wants to qualify for Meaningful Use incentives, and of course, the Cadillac vendor has a special sale on accessories this month. Confusion and frustration were palpable around the huge, and completely out of place, formal pedestal dining table in the break room.

I’ve been to this movie before, and I never had any luck convincing this particular vendor that a certified complete EHR should allow the user to achieve Meaningful Use with no need for other bits and pieces that were not mentioned anywhere during the certification process. Unfortunately, those who certify EHRs and those who supervise the certifiers are turning a blind eye and a deaf ear to what is essentially a regulatory issue. In the break room the confusion and frustration were slowly changing to anger and the big plastic QT cups of pink lemonade that were brought in by someone didn’t help much. The conversation shifted to the various Meaningful Use measures and by now I wasn’t surprised to hear that they are doing rather well on most, from electronically prescribing everything to recording race and ethnicity and generating beautiful CCD clinical summaries. They weren’t sure how to give folks electronic copies of their medical records, but nobody ever asked for that and it’s highly unlikely that anyone will in the next three months. That should be good enough.

“Am I also good on immunizations? I don’t do many of those either… maybe a few HPV and some flu shots for elderly patients to save them a trip to the pharmacy. I shouldn’t have to report anything, right?” Eh… wrong, doc. Even if you only do one immunization in the next three months, you would have to test an immunization interface with the State registry, and your Cadillac EHR can’t generate the test file at this time although it is fully certified for Meaningful Use. I’ve been trying to get an answer from this vendor for months. I’ve asked CMS for a solution over a month and a half ago. I have written a blog post that got more page visits than anything I ever wrote before, and came up empty on all fronts. But the doctor seemed to be working his way to an innovative solution all by himself.

“So if I don’t give any shots after October 1st, I should be OK…. We have one bottle of HPV left anyway and Marcie needs her shot… I have a week to do that… They pay peanuts for shots, you know…. They’ll just have to go to the pharmacy…. It’s not that far…. I really don’t give many shots anyway… Yep. It should work… “. October is flu season, and I was wondering if Joe picked up Bessie by now and if the pharmacy is on their way home. I wanted to know if the pharmacy had a chair with arms for Bessie and if the pharmacy folks would also call Joe to pick her up after waiting in line for her flu shot. But instead, I just found myself mumbling that this wasn’t really the intent, but yeah, this should work.

A couple of months ago, I heard a story about a geriatrician who chose to stop giving courtesy flu shots to his patients because of Meaningful Use. I found it hard to believe then. Needless to say, I believe it now. I am certain this was not the intent at CMS and I am pretty sure this was not on the Meaningful Use roadmap at ONC. I am not in the habit of pleading and begging the powers to be to do the right thing, but I will make an exception this once. This unremarkable little practice in the middle of nowhere could have been the poster child for successful EHR adoption. Can somebody at HHS, CMS or ONC help these small practices stand up to the greedy whims of a powerful EHR vendor? And above all, can we do something to help Bessie keep her “I” in Health IT, please?

Disclaimer: In order to protect their privacy, the names of all people and locations mentioned in this post have been changed, as have certain physical characteristics, quotations and other descriptive details.

The Power of Empowerment

Grant Wood, American Gothic (1930)

Housing is expensive if you want to live in a Tudor style mansion on a half-acre wooded lot. Housing is a lot cheaper if you choose to rent a two-bedroom apartment on the fourth floor of a square building with no elevator, 45 minutes away from your workplace. And it won’t kill you to rent. Food is also very expensive if you want a varied, fresh and gourmet diet, but food can be cheap, and it won’t kill you to cook your own food and stick to a diet of mashed potatoes and boiled cabbage, with an occasional bit of tripe. Health insurance is very expensive if you insist on having all your medical needs covered by an insurance policy. Health insurance can be a lot cheaper if you pay for most of your medical care yourself and if you only buy limited coverage for the eventuality of falling off your dressage horse, and cheaper still if you promise to drop dead shortly thereafter.  Health care itself is very expensive if you insist on receiving medical care from highly trained professionals, using cutting edge technology in state of the art facilities. Health care can be a lot cheaper if you find a way to take care of your health without involving doctors and hospitals and their overpriced opinions, chemicals, machines and unnecessary procedures. It’s all about consumers empowered to freely make their own choices: mansion or rented apartment, steak or tripe, Cadillac or catastrophic health insurance, ICU or alcohol rub…..

The Consumer Empowerment terminology originated in the health insurance industry to mark the transition from having insurers pay for every cut, bruise and sniffle, to the more responsible way of paying for much of your health care directly out of your own pocket leaving the insurer responsible for rarely incurred catastrophic expenditures. The newly empowered consumers discovered that health insurance is now much more affordable, and perhaps even unnecessary, while health insurers discovered that magically, their profits are also improving, probably because empowered consumers seem to generate significantly less reimbursement claims, than the irresponsible and unempowered crowd served by public entitlements.

Although empowering consumers to pay for their own health care proved to be a stroke of genius, we have a long way to go before the overall cost of health care is contained. The problem here is that over the years Americans figured out that staying healthy doesn’t really pay off and quite the opposite is true, because once you get really sick there are all sorts of freebies made available to you, from amputations to chemotherapy to mastectomy to castration - a veritable smorgasbord to choose from, and the temptation is huge since the monetary value of these free goodies can add up to more than many people make in a lifetime of hard work. Not to mention the fatherly physician figures busy offering you helping after helping of a carefully selected array of the most expensive fare available. And then an innovative idea was put forward by selfless luminaries, and is catching on like brushfire after a long global warming induced drought. If health care insurers were able to cut costs and increase profit by empowering consumers to insure themselves, could health care providers achieve the same spectacular success by empowering consumers to care for themselves?

Empowering consumers to engage in their own health care may rank up there with cold fusion and perpetuum mobile in its transformational potential for humanity. Empowering millions of people to actively manage their medical care, by making their own medical decisions, breaking free of the old-fashioned paternalistic directives of financially conflicted physicians, and restoring the nineteenth century self-reliant approach to health care, will slash costs, improve quality and eliminate disparities in health and health care in one patient-centered fell swoop. And how do we accomplish such monumental task? We harness the unlimited power of the Internet. This is the Information age, and just like the Industrial age brought a car and a television set to every home, the Internet puts the entire world’s knowledge at the fingertips of all humanity with astounding effects already visible in the education attainment of our children. But the world’s knowledge is missing a vital piece of information pertinent to our goals in health care.

Enter Health Information Technology (HIT). HIT will pry loose the last piece of the puzzle – the secretive documentation amassed and jealously guarded by doctors in their offices. Information kept in detailed color coded charts and recorded in strange cult-like symbols that prevent anybody but doctors from understanding the contents. Once that information is made available to computers and the thousands of new high tech tools chomping at the bit to translate, analyze and recommend what you should buy to treat any ailment ever recorded, the Internet will bring this knowledge to every hamlet and fuel a renaissance of rugged Americanism where every man woman and child will be empowered to manage his or her own health care. The amount of money spent on health care will decrease sharply since the time people spend researching, diagnosing and treating themselves at home, and the cost of technology tools and over the counter remedies to facilitate these activities are not considered health care expenses. The quality of such care will be exponentially improved by harnessing the knowledge and insights of millions, instead of just one medical school graduate. And by definition, the Internet eliminates all disparities, as evidenced by the blossoming democracy in Egypt.

So much empowerment may seem a bit daunting to some who grew accustomed to getting advice from doctors. No need to worry though because this will be a gradual and gentle process. It’s not like you will have to perform an appendectomy on yourself come Monday morning, although it wouldn’t hurt to start practicing simple things like freezing warts at home and researching minor chest pain on Internet boards. When you finally keel over in pain, or are otherwise ready to confront a doctor, you must prepare yourself mentally to act as empowered as possible. While the civic minded insurers have been happy to empower people and let them spend their own money any way they saw fit, doctors find it much harder to relinquish control of their patients. You need to come in with all your symptoms researched, a tentative diagnosis formulated and most important, a preferred course of treatment that fits your cultural values and preferences. You need to resist your doctor’s efforts to tempt you into partaking in the smorgasbord of free tests and procedures, some of which will be harmful to you and others will be very unpleasant for your friendly insurer. If you concur with your doctor’s opinion and have some tests done, make sure you understand WBCs and RBCs, units and normal ranges for the lab you are going to use after shopping around for a good price, and be sure to validate whether you need a differential count or not. The Internet is your friend and all this information is available online. But whatever you do, don’t leave your doctor’s office without an electronic copy of your medical records in a computable format, because any day now, there will be a free app for all these decisions and iWatson will empower you to care for yourself and your loved ones in ways that the log-cabin pioneers couldn’t even dream about. Better, faster and infinitely cheaper.

CMS Owes an Apology to Meaningful Users

According to the July 2011 data from CMS there are over 75,000 clinicians currently registered for the various Medicare and Medicaid Meaningful Use incentive programs. A tiny fraction of these, 2246 to be exact, has successfully attested to meeting all Meaningful Use criteria (or claimed allowed exclusions), and about half have gotten the much coveted incentive checks. Considering that these figures include Nurse Practitioners, Dentists and Optometrists, it seems that the physicians that expressed interest in the incentives by registering with CMS are the same 6.9% that were identified by CDC in 2010 as using fully functional EHRs back in 2009. Even if we assume that the second half of 2011 will bring a surge in attestations to meaningful use of certified EHRs, it is still unlikely that a majority of those registered will go through attestation.

There are three broad reasons for these low numbers. First, there are those working their way through the 90 days attestation period as we speak, or are planning to start any day now. These folks have their ducks in a row and will attest in 2011. Second, there is a group that went ahead and registered with CMS “just in case”, but made no commitment to investing the energy and time needed to fulfill Meaningful Use requirements. These physicians are still debating whether they should upgrade their EHRs to a certified version, or if they already have a certified EHR, whether they are ready to begin documenting all the additional information in the specified formats as required for attestation. With less than 6 weeks left before the absolute last day for starting to measure, there is practically no chance that this group will be able to attest this year, and many registered with a clear intent to postpone Meaningful Use to 2012 anyway. Third, there is a significant number of doctors whose plans and efforts are being frustrated by shortcomings of EHRs and EHR vendors. This last group warrants a closer look.

Judging by press releases and earning reports from publicly traded EHR vendor companies, business is booming and EHRs are selling like hot cakes. The flip side, of course, is that waiting times for software installation are steadily increasing for both new purchases and upgrades. Since ONC certification bodies have no requirements stating that the certified software should be in actual use by customers, many vendors were able to certify EHR versions that were not ready for general deployment. Some vendors deemed it necessary to charge significant fees for functionality required for Meaningful Use in addition to the ongoing maintenance fees which should have entitled their existing customers to a free upgrade to the certified version. Adding it all up results in many unhappy customers having to wait in long lines for something that should have been forthcoming, and having to spend large sums of money on something that should have been free. And when they finally reach the front of the line and pony up the various extortion fees, they may still end up right back where they started.

Over a year ago, on this blog, I posed a very simple question: “Can you buy an ONC Certified EHR, or a package of EHR modules, and discover to your chagrin that no matter how hard you try, Meaningful Use is not within reach?” After a close look at the certification criteria for EHR software, my conclusion was that “Physicians need to understand, and ONC needs to clarify, that although required by CMS, ONC EHR certification does not guarantee availability of all EHR features and functionalities required to achieve Meaningful Use.” Of course physicians did not understand and ONC did not clarify and here we are today fully engaged in damage control. The problems range from rampant software defects to impossible workflows to plain missing functionality. How is that possible?

If you ever dabbled in software development, you should know that successfully testing a few predetermined isolated function points in a large software package is never an indication that the software works as designed. To use our beloved car analogy, starting the car once, turning the lights on once and activating the wipers once provides no solid indication that the car is not going to explode after two minutes on the highway, let alone that both wipers and lights will keep on working as you proceed out of the dealer parking lot. Now imagine that the car seller is allowed to performs all these tests while you are standing aside, observing the final result only. So a hotwire instead of an ignition key, a string attached to the wrist to pull the wipers back and forth, and a bunch of little flashlights instead of brake lights are all possible. That’s the essence of Meaningful Use EHR certification testing. Sometimes you get lucky and sometimes the thing you just bought smokes, and barely limps along sputtering motor oil and antifreeze.

But nothing is more misguided and inappropriately tested as the various requirements for interoperability. There are several Meaningful Use measures requiring that the EHR has the capability of exchanging information with other facilities, and that the user performs just one test of that capability to qualify for incentives, and the test does not even have to be successful. Sounds easy when you sit in a conference room overlooking blossoming cherry trees on the Potomac. Returning to cars, imagine that the requirement is that the vehicle is able to tow another car, or a U-Haul little trailer, or a boat. During certification, the vehicle presents with a lovely towing package installed; the tester attaches a cardboard car model to it and the entire assembly is shown to be able to advance one inch from where it was originally located. Hence, the vehicle is now certified for towing cars. The first thing you discover after you purchase the certified vehicle is that the various towing packages don’t come standard with the car. You will have to pay for each one and pay to have it installed. To add insult to injury, the towing packages have only been tested with cardboard models and there is much work to be done before they can be tested with real boats, cars and trailers. And there are several hundred customers in line ahead of you. Perhaps you should call again in a few months, or better yet don’t call us; we’ll call you.

To qualify for Meaningful Use incentives a physician must perform at least one test of submitting either public health data or immunizations data to a public agency. Exclusions apply to those who do not administer immunizations and to those who practice in a State where there is no public agency capable of accepting such data. There are less than a dozen agencies where one could submit public health data, but many more immunizations registries up and running. A typical very large EHR vendor will have operational interfaces to less than a handful of immunization registries that are readily available for purchase, usually in States where health information exchange is very advanced. Everywhere else money can’t buy you an immunization interface. It can buy you a place in line, if the vendor is working on an interface with your State registry. Otherwise a rain check is the most you should expect.

There is no way physicians could have anticipated this problem when they purchased a fully Certified EHR. There is nothing physicians can do now, or could have done earlier, to address this problem. And there is no way for EHR vendors to create over 50 working interfaces to State registries and deploy thousands of those interfaces to their customers before the clock runs out on 2011 reporting periods. By ignoring the reality on the ground, CMS erred in its requirement and ONC erred in its certification process. The only thing left to do now is for CMS to officially allow exclusion of public health measures across the board. An apology wouldn’t hurt either….

From EHR to HIE and Back

According to the latest count, there are 255 Health Information Exchange (HIE) organizations across the country, which amounts to an average of 5 in each State. If you are a practicing physician and have an EHR, chances are someone already knocked on your door offering to connect your practice to the local HIE for a small fee. If you don’t have an EHR, you may have had offers to access an HIE web portal, or maybe an HIE supplied EHR Lite, allowing you to at the very least view clinical data from other sources. Perhaps for free. If you are the proud owner of one of the full-featured EHRs, you may wonder what an HIE can do for you that your EHR is not already doing, and whether that service is worth your hard earned money.

In theory, a top-shelf EHR should be able to connect your practice to multiple facilities and allow you to exchange information to the best of all participants’ abilities. Granted most EHRs are still working on some of the connections, particularly to local facilities, but all in all, an EHR should be able to eventually provide for all your connectivity needs as shown in Figure 1. Note that for some types of connections, your EHR vendor can use a clearinghouse or portal approach to simplify and reduce costs of connectivity. For example, you don’t need a separate interface for each pharmacy – you use Surescripts as the clearinghouse and let them worry about it. You also don’t need an individual connection to each patient’s home – you communicate with all of them through one portal. With the exception of Surescripts pharmacy connectivity and a small number of reference labs, each connection, or interface, is costing you a pretty penny, and the more local the connection, the longer it takes to build.

Enter the local HIE. The value proposition of a regional exchange is in connecting you to local hospitals, imaging centers, State agencies and community resources. Figure 2 shows a typical HIE arrangement. If you compare this to Figure 1, it becomes apparent that your EHR vendor has a much easier job now. Instead of building an interface to each hospital, the vendor needs just one interface to the HIE and presto, you are connected to all hospitals. Yes, this is an outlandish oversimplification of affairs, since most players have no ability to connect to HIEs and since each message type requires its own separate interface (or special code to sort messages out). If your EHR vendor has a critical mass of customers in your area, all needing to connect to the same regional facilities, a connection to the HIE should create significant savings for the EHR vendor, and hopefully some of those savings will be passed down to you. The HIE will in turn try to get a portion of that money from you to cover their costs of building and maintaining interfaces. If there is more than one HIE in your referral region, your EHR vendor may need to repeat the effort for each HIE. This will increase the complexity and costs for all involved.

Some HIEs are trying to do more. Although EHR vendors are increasingly integrating abilities to exchange information between physicians through the Direct Project protocol, HIEs are attempting to do the same thing. Depending on your EHR vendor, the HIE may be a few steps ahead and will offer you that functionality. Of course, it will not be integrated in your EHR workflow, but it may still be worthwhile. Since most HIEs retain data exchanged through them (or have the ability to retrieve it from the source), they are also considering offering patients access to their data. If your EHR vendor does not offer a Patient Portal or charges a lot for one, this may be a very tempting proposition. Figure 3 illustrates this more comprehensive setup, which also includes connectivity to reference labs, as this is a simple thing to do and several HIEs are doing just that. The HIE menu of services in Figure 3 will cost you substantial subscription fees, and rarely some transactional fees, on top of what you are paying for your EHR.

If you don’t have an EHR, some HIEs will offer you a one stop shop, which can include a lighter version of an EHR (geared to Meaningful Use), which includes electronic prescribing. This may be a cumbersome solution if you still need to maintain a paper chart, and perhaps this is why the top HIE vendors offer EHRs that are fully functional and which only need to be connected to your Practice Management System (PMS), as shown in Figure 4. In this scenario, you would have to pay the HIE a hefty price, but you won’t have to pay extra for another EHR. Finally, there is at least one HIE out there, and I am certain more will follow, which can accommodate your billing needs as well.

Having come full circle, Figure 5 illustrates the complete transformation of the HIE into a complete EHR and PMS. The difference between Figure 1 and Figure 5 is not just terminology. The system in Figure 1 stores data either in individual physician databases or in a national database of all EHR customers for an Internet based EHR. In Figure 5, you are accessing an EHR that contains the data of other physicians, hospitals and care agencies in your area. This is a much more powerful configuration and better suited to care coordination and care management. This is pretty much how large health care systems are set up and in most cases the HIE is run by their enterprise EHR vendor. In fact, just like HIE vendors are building EHRs, most large EHR vendors either have, or are quickly assembling, formal HIE capabilities (master patient index, good interface engine, robust database structures).

So here is a wild prediction: it may take a while, but eventually small EHR vendors will be replaced by strong HIEs, and weak, failing or nonexistent HIEs will be displaced by large EHR vendors who had the ability and wisdom to become HIEs, and there will be no distinction between the two types of software vendors. Right now the 255 HIE organizations across the country are struggling to find a way to become sustainable businesses, and most EHR vendors, while posting record profits, are struggling to provide much needed interoperability. A marriage of necessity is inevitable. What should we name the baby?

Bending the Curve with EHRs

The post you are about to read may not be suitable for wonks. Its claims are not fact checked. Its author is not a researcher. And its opinions are not fully thought through. Reader discretion is advised.*

EHR adoption rates are picking up significantly, exceeding the most optimistic expectations. Instead of an EHR for every American by 2014, as the President commanded, we will have dozens of EHRs for each American long before that. And in health care, more is always better, not to mention the freedom of choice that comes with having a different EHR in each care setting. Not surprisingly, we are seeing a decrease in health care expenditures taking place in parallel with the uptick in EHR adoption. Following best practices in health care economics research, when two phenomena develop in parallel, the learned assumption is that there is a causality connection between the two. Deciding which phenomenon is the cause and which is the effect is discretionary and commonly based on undisclosed agendas.

It is therefore postulated here that health care expenditures are inversely proportional to EHR usage rates. The following is a rigorous analysis of the mechanisms by which EHRs are reducing health care costs, intended to inform policy makers as customary in most health care related studies, which cannot be completed, or published, without a salient recommendation of interest to policy makers.

Productivity Optimization – Numerous carefully estimated anecdotal studies consistently show that introduction of an EHR in ambulatory practice can reduce provider productivity by 50% or more. This directly translates into 50% (or more) savings in health care expenditures for office visits. Unfortunately, the same studies also show that in most cases this reduction in office visits is transient, with most providers regaining ability to charge for as much as 80% of their pre-EHR visit volume within six months to a year. Still, 20% long term savings is significant and could probably be optimized further by introducing more speed tempering features into certified EHRs. Equally rigorous studies show preliminary evidence that the savings realized from introducing fully functioning EHRs in Emergency Departments far exceed those in the ambulatory sector. Unlike other Socialist countries that were compelled to nationalize the entire health care system just so they can reduce productivity and discourage utilization by creating long waiting lines, Yankee ingenuity is producing better results at lower costs.

Banishment of THE Pen – The Physician Pen has been long known for being the most financially devastating instrument ever invented. In spite of pharmaceutical reps efforts to the contrary, EHRs are successfully removing all pens from medical practice, including but not limited to, the Physician Pen. Where physicians used to carry several handsome pens in that little pocket right under their embroidered name and title, they now carry an EHR contained in a device that may or may not fit in a less accessible pocket and either way requires both hands, ample light and an adequate supply of battery power to order the simplest thing. The better EHRs also provide various speed bumps on the road to ordering by popping up multiple warnings and good financial advice equidistantly placed at 10 to 15 milliseconds intervals. Data from the very similar retail industry shows that impulse buying is greatly increased by simplifying the process, such as the one-click checkout at Amazon. The reverse logic must also be true, so increasing complexity should reduce impulse ordering in medicine. Judging by Amazon’s successful strategy, the savings in health care are expected to be spectacular.

Customer Intimidation – As EHRs become better at measuring the abysmal state of our health care non-system, and expose the horrors and frequency of medical errors by either careless omission or profit-driven commission, it is estimated that health conscious consumers will increasingly avoid dangerous encounters with the medical complex, thus further reducing utilization and cutting costs. Strategic publicity campaigns advertising security and privacy breaches in other computerized industries, and in health care if any are found, should eliminate another segment of customers. However, the largest cost savings are projected to come from customers refraining from seeking care for, or even mentioning, potentially embarrassing health problems for fear of public exposure through interconnected EHRs.

Accelerated Attrition – EHRs are very powerful tools. So powerful that the prospect of having to purchase and use an EHR is more than enough to prompt older physicians, particularly those in private practice, to consider retirement or transition to other occupations. The evidence shows that there is direct anecdotal correlation between negative reaction to introduction of EHRs and acceptance of cost-saving team approaches to provision of medical care. The semi-natural attrition of experienced and highly compensated physicians who insist on treating, and charging for, every sore throat and every knee scrape, in spite of mounting evidence that lower paid resources can refer those to appropriate specialists with equal outcomes, should in the course of time increase the amount of savings directly attributable to the prevalence of EHRs.

Free Labor Procurement – EHRs are particularly adept at encouraging and showcasing the historical selflessness and ethical conduct of medical doctors, by providing multiple means for doctors to contribute to the wellbeing of their patients practically free of charge, at all hours of day and night. From the ubiquitous email to the occasional webcam session to the continuous evaluation of uploaded self-quantification vital data from patients empowered to have their health expertly monitored, physicians using EHRs can provide this simple courtesy service to their customers from the office, the home, the yacht or the golf course. These proactive preventative measures should result in extensive reductions in disease burden. Constantly connected physicians, armed with the latest monitoring tools, could detect strokes, heart attacks and maybe even cancer years before actual manifestation of symptoms. And at no cost to society.

The implications for policy makers are pretty straightforward. EHR adoption should continue to be encouraged at all costs. EHRs must evolve to seamlessly and continuously connect to all consumer monitoring devices, which implies a preference for cloud based technologies, and a security breach here and there is not necessarily an impediment to success. EHRs should continue to increase the levels of automated decision support, improve analytics and increase frequency and scope of various alerts. Basically, keep up the good work. We’re right on target.

*Disclaimer partialy plagiarized from the UK version of The Daily Show

Voices of Primary Care: What is a Medical Home?

Guest post by ANONYMOUS, MD

I have heard of the "Nursing Home" and I am not sure most of us aspire to getting there…

We all carry an image of our own HOMES: it is often idealized in phrases such as “Home-sweet-home” or “There is no place like home” or "Home is where the hearth is”. We even talk about being “HomeSick”.

Do any of these even remotely resonate with “THE Medical Home”?

Now granted, a “homey” doctor’s office may be a worthy goal. Making our patients feel “at home” with proper hospitality and kindness, a relaxing environment, maybe even the smell of baking are all likely to be improvements over our current obsession with best business practices, efficiency and evidence. To the extent that these characteristics become the defining feature of “The Medical Home” we might be on to something.

But "The Medical Home" instead seems to suggest that the doctor’s office is the place where health resides.

Isn’t the intention of the medical home movement really an effort to reassert the importance of solid, comprehensive primary care built on the ongoing relationship between the patient and his or her primary care physician? If so, why not say so?  What would we call that? How about good Primary Care?

The New York Times Foray into EHR Usability

So the New York Times is throwing its hat into the Electronic Health Records (EHR) usability debate, mixing up terminology to reach a predetermined conclusion, as is customary in modern media coverage. The story starts with a blazing inferno in 1904 Baltimore and ends with a categorical statement from a highly credentialed source naming usability the “single greatest impediment to physician acceptance”. In between this skillful framing of the subject, there are the obligatory dissenting arguments from two EHR vendors and a bewildering array of expert arguments confusing usability with safety and interoperability standards, complete with the usual comparison of health care to aviation. 

The 1904 Baltimore fire, for example, where fire trucks from other cities were prevented from assisting the locals because their hoses could not connect to Baltimore’s water hydrants, makes an excellent argument for the need of interoperability standards in electronic medical records. It contributes nothing to support usability standards, since the problem was not traced to the color and softness, or ease of operation, of the non-Baltimore fire hoses. Nevertheless, most readers have no desire to perish in a blazing inferno induced by EHRs, so a receptive mindset is established upfront, whether it has anything to do with what follows, or not. The little jab at the vendors of fire hoses opposing standardization because they “did not want competition”, and so they “undermined the usefulness of, and investment in, the technology of the day”, is also helpful in framing the desired perception of what’s to follow.

The next nugget designed to create fear, uncertainty and doubt (FUD) is a statement from a computer scientist which obviously deserved its own two line paragraph: “This is an issue that potentially affects the health and safety of every American”. Yes, “changing the size, color and placement of graphic icons on a screen”, cited as an example of the deterministic and measurable science of usability, will definitely do wonders for the health and safety of every American. It will also contribute to gainful employment of many newly minted usability professionals, which is a good thing in these difficult economic times, and it shouldn’t raise the cost of producing EHRs by more than rich doctors can bear. And if government hires its own experts and then dictates where all the little icons should be placed, and what color they should be, maybe EHR vendors can actually cut costs by firing their own experts. After all, there is usually only one way to do things right, and when Bill Joy said that “innovation happens elsewhere”, he probably meant that it happens in federal government agencies and their contractors.

Let’s not forget that according to quoted “specialists”, usability standards worked well for “jet plane cockpits, air traffic control towers and nuclear power plant controls”, ergo “[s]ome of that expertise, …. , can surely be applied to doctors’ offices and hospitals”. Surely. Most Americans have little understanding of those complex industries and are both in awe of their potential disasters, and grateful for not being burned to a crisp by nuclear explosions and great balls of jet fuel fires on a daily basis. If all it takes is placing colorful little icons in certain spots on a computer screen, then by all means, let’s do it. Never mind the advances in avionics, composite materials, computer aided design and testing, and nuclear technology, the improved safety records must be all due to the novel placement of little icons. This is supported by a similar development in health care where marble floors and the presence of at least one atrium has significantly improved the quality of medical care as evidenced by a recent study that shows that critical access hospitals, that lack marble and atriums, provide inferior care. Probably because stepping on smooth Italian marble shaded by exotic banana trees, is much more satisfying for users, than walking on discolored linoleum with peeling edges flanked by cheap plastic ferns.

As to the categorical closing statement naming usability of EHRs as the “single greatest impediment to physician acceptance”, whatever acceptance means, I would suggest a quick literature review of physician surveys that constantly place the price of EHRs and the lack of calculable return on investment as the #1 impediment to technology adoption. Perhaps the experts interviewed or quoted in the New York Times are confusing usability with usefulness.

The government has a clear role in defining interoperability standards for EHRs and the FDA has a duty to ensure reasonable safety of software and devices used in medical care, but the placement and color of little icons has nothing to do with either and with all due respect to user experience experts, clinical safety should be left to those expert in that field. Forcing all EHR vendors to hire interior designers and to order Italian marble and live banana trees, because they seem reassuring, satisfying or just plain cool, will not increase the usefulness of EHRs. It will however drastically increase EHR prices, which are already on the rise as an unintended consequence of Meaningful Use. Once EHRs become truly useful to physicians, there will be no need to be concerned with the dubious “acceptance” factor.