Healthcare Talent Transformation

The Economic Lessons of mHealth

Dr. Michael Koriwchak, www.wiredemrdoctor.com

The recent HIMSS 2013 meeting witnessed the emergence of mHealth as a significant component of health information technology (HIT).  The meeting offered 35 educational sessions on mHealth. One of the meeting’s keynote speakers, Dr. Eric Topol, predicted a revolution in health care based on smartphones.  Connecting a smartphone to a currently available bio-sensor allows anyone to monitor and share with a physician his vital signs, heart rhythm, sleep patterns or blood sugar, and soon other physiologic data as well.  Eventually these systems will include software that will enable laypersons to interpret data and determine when physician involvement may be appropriate.  The way each of us will learn to interpret our own body’s data will become a natural extension of the way we now interpret our own “internal body cues” and symptoms.

Meanwhile, progress within the more established parts of HIT has ground to a standstill. At the HIMSS meeting results of a provider survey conducted by the American College of Physicians and AmericanEHR Partners were presented.  Among over 4000 surveys the percentage of clinicians that were “very dissatisfied” with their EMRs has increased by 10% from 2010 to 2012. 39% of EHR users would not recommend their EHR to a colleague (up from 24%).  Satisfaction with EMRs has clearly deteriorated since the 2008 pre-Meaningful-Use study published in NEJMthat showed 93% of physicians were satisfied with their EMR.  In the physician blogosphere the leading EMR story last week was about a physician class-action lawsuit against an EMR vendor who allegedly sold defective software and then abandoned the product.  Outside of mHealth there is not a lot to cheer about in HIT right now.

Why is mHealth growing so fast while the rest of HIT is stalling? There are many reasons but three important reasons bear discussion.

First, most mHealth projects don’t take on every patient at once.  An mHealth project designed, for example, to monitor congestive heart failure patients at home addresses only that population of patients and providers associated with a single diagnosis. A project with such a narrow, focused scope has a greater chance of success than a typical EMR project which must cover every patient and every physician regardless of diagnosis.

The other two reasons illustrate an important economic lesson. At the moment mHealth is a relatively unregulated industry. Any startup company can acquire a bio-sensor and/or write a mobile app for a smartphone and be off and running.  There are no Meaningful-Use-type regulations that require all mHealth apps to operate a certain way or meet a minimum set of requirements.  Barriers to entry are relatively low.

Third, many mHealth projects are marketed directly to consumers and are paid for directly by consumers.  The just-released Samsung Galaxy S4 smartphone has a suite of built-in mHealth apps and available biosensors to monitor sleep, calories burned, heart rate and (Samsung implies) blood glucose.  Consumers will purchase this phone like any other – with their own money.  There are no third party payers involved.  That means no insurance approval, no complex coding and billing, no politics ….so far less overhead and far more flexibility and speed.  All you have to do is build a quality, useful product.

mHealth currently operates in a free market where products can be designed any way their creators choose. Their target customers choose what products to buy – or not to buy at all – and how much to pay.  Many of these products will fail, but the ones that succeed may indeed revolutionize healthcare as Dr. Topol predicts.

EMR vendors, burdened by Meaningful Use requirements, have little bandwidth left to address customers’ real needs.  As Meaningful Use requirements and EMR certification raise the barrier to entry into the market, the market is increasingly dominated by the largest vendors at the expense of the smaller ones.  As competition is suppressed product quality and customer service both suffer. Given the AmericanEHR survey results it is no surprise that EMR vendors are now marketing to current EMR users who are unhappy with their present system. There are certainly plenty of those.

Unfortunately the freedom mHealth enjoys may soon come to an end.  The FDA’s upcoming release of its final regulations of mobile medical applications is expected soon.  These rules will likely impose an approval process similar to those already in place for drugs and conventional medical devices.  One source estimates the cost of this approval process for a single mHealth product will be as high as $24 million.  While that estimate seems high, there is no doubt that the cost of compliance will have a detrimental effect on the mHealth marketplace.  Costs will go up dramatically, smaller companies will be forced out, and true innovation will slow as mHealth companies expend most of their resources on compliance.  Those products that survive to reach FDA approval will no doubt seek third party payor reimbursement.  With that will come loss of price transparency, driving up costs even further.  The mHealth market will become as bloated and ineffective as the rest of the health care system.

Will the mHealth revolution survive?  Time will tell.

Dr. Mike Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship and Residency at Vanderbilt University Medical Center. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. Dr. Koriwchak has been working with information technology since 1977. In medical school, he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 30 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care. 

The Naivete of mHealth

Dr. Michael Koriwchak, www.wiredemrdoctor.com

I attended a seminar on mHealth sponsored by the Technology Association of Georgia (TAG). The presenter was Arthur Lane, Director of Mobile Health Solutions at Verizon Wireless. He gave a nice presentation and video of a system Verizon is designing to improve care of congestive heart failure (CHF) patients after hospital discharge. CHF patients are treated effectively in the hospital setting with closely monitored vital signs and carefully administered medications / diet. The problem is that once the patient goes home it is difficult to maintain the same level of monitoring and precision of the medication / diet regimen. As a result re-admission rates for CHF are high, adding to the cost of care.

The Verizon system claims to correct this problem with smart phone technology. The video showed a smart phone reminding a CHF patient to weigh himself before bed. He has gained ½ pound since the morning. When he wakes up the next morning the phone again reminds him to weigh himself. He has gained another pound. Weight gain day-to-day is an indication that CHF is getting worse. The phone sends the weight data to a server, which in turn notifies a provider to call the patient and somehow prevent him from getting worse and showing up in the ER. It was never clear to me how the provider was going to fix worsening CHF over the phone.

After Mr. Lane completed his presentation he joined 3 other panelists for a lively discussion moderated by a local physician whom I know. Some of these panelists described their devotion to mHealth with near breathless excitement. The physician moderator posed the ever-present question to the panel: “How do we get doctors interested in this system (and mHealth overall)?” The answers ranged from good – “Give doctors a product that is cost-effective” – to the ridiculous – “Align incentives by making physicians join ACOs.” The silliest thought of the night was the suggestion from one panelist that health care is no different from banking. I left the meeting with some concerns about who would pay for the Verizon system but decided to hold my reaction until I did a literature review. After all, I am no cardiologist and have not treated a patient for CHF since med school.

My review did not yield good news for Verizon or mHealth.

Turns out physicians have been working on home monitoring for CHF patients for years. Unfortunately their studies do not support remote home monitoring for CHF to reduce hospital admissions. A study from Yale Medical School published in the New England Journal of Medicine in 2011 randomized over 1600 CHF patients to either a control group or a remote monitoring group for outpatient care following admission for CHF. There were no differences in readmission rates for CHF or for any other cause over the 6-month study. Several other studies, including comprehensive reviews of existing literature, reach similar conclusions.

So what would a more realistic mHealth video look like?

Our CHF patient is discharged from the hospital all tuned up with appropriate medications, diet and smart phone remote monitoring using a CHF app. The monitoring app works well at first, feeding him periodic words of encouragement and reminders to take his meds, record his vital signs, weigh himself, etc. After several days of his phone going off constantly with all the reminders, alert fatigue sets in. After ignoring the alarms for a few days he gets fed up and shuts the CHF application off. The monitoring network detects the data interruption, and a provider calls the patient. At first the contact with a real human helps, but after several calls alert fatigue strikes again. Our patient recognizes the caller ID and stops answering.

In the meantime he tires of his medication regimen and diet restrictions and succumbs to the urge to scarf down some pizza and beer with some potato chips for dessert. His smart phone isn’t smart enough to change his behavior. The salt and fluid load makes his heart failure worse. In the middle of the night he wakes up short of breath and calls 911. Back to the hospital he goes.

The mHealth community is so enamored with their toys they can’t see what is right in front of them:

1. Peer-reviewed medical literature does not support the use of home monitoring for CHF patients. Period. LTE smart phones and glitzy medical apps do nothing to change that.
2. Without supporting literature no one is going to pay for remote monitoring. Who is going to cough up the dough for all those smart phones, Bluetooth connected home monitoring devices, remote servers, and the army of providers that will be required to manage the terabytes of data that such a monitoring network would generate? Neither ACOs nor any other ill-conceived “alignment of incentives” for physicians solve this issue.
3. The mHealth folks fail to recognize that monitoring is not the endpoint. The endpoint is changing patient behavior. A smart phone constantly shrieking warnings and reminders is rendered useless by alert fatigue. Patient behavior is a very tough nut to crack. The Verizon video ends with a nurse talking to the monitored patient about his weight gain. But that is NOT the end. It is just the beginning. No one knows what that nurse is supposed to say to change the patient’s behavior over the phone.
4. Like many mHealth ideas this system creates unrecognized changes to the standard of care and thus changes medical liability. What if our CHF patient who stops listening to alerts and stops answering the phone dies while he is in the monitoring program? Who is liable?

So it’s the same thing all over again with health IT. No proof of effectiveness. No way to pay for it. No understanding of the medical challenges involved. Unrecognized changes in standard of care and liability. Health care is not the same as banking. Duh.

Verizon has no business getting into health care beyond the LTE connection itself. They are going to lose their shirt investing in a treatment the literature says doesn’t work. Perhaps unwittingly, the physician moderator said it best when he asked the panel, “Where is the app that slaps my hand when I reach for the bag of Oreo cookies?”

Don’t get me wrong, folks. Our practice has enjoyed great success with EMR in over the past 7+ years. Our experience just scratches the surface of the awesome potential of health IT. I want you to succeed. But the health IT industry is headed in a direction that will guarantee failure. To succeed you must stop chasing pipe dreams and focus on the one goal that must be met before anything else – HIEs, mHealth or anything else – can succeed:

Find a reliable way for doctors to succeed with EMR in the office setting. Upgrade EMRs to reflect some understanding of the practice of medicine. Design patient portals that actually work. Demonstrate that EMRs are effective at improving care. Design a business model that shows the path to a return on investment.

Until that goal is met, nothing else matters.

Michael Koriwchak, MD - Techy Doc Who Puts Patients' Needs First

I don't normally attribute a whole blog to "reintroducing" contributors to our blog, but I'm making an exception for Dr. Michael Koriwchak.  All it takes is a short conversation with Mike and you know he has so much knowledge to share about EMR implementation he and his team have gained first hand.

In addition to blogging, Mike is an active member of our EMR/EHR Clinical Transformation group in LinkedIn and freely shares his knowledge. He's led his practice through their EMR implementation as well as MU. His insights as to what is important to docs and patients when it comes to healthcare and healthcare IT is beyond what most docs and IT professionals combined know. The advice he shares is timely and resonates with our readers.

Mike is an Otolarynagolost. His practice, Ear, Nose and Throat of Georgia, is a GE Centricity Showcase Site that welcomes other practices to visit and learn how they do EMR. Mike serves as the compliance officer for his practice, so he's definitely in the know about ARRA.

In addition to his contributions to our group, you might know him from his blogging at Wired EMR Practice or Healthcare Talent Transformation. Currently, Mike is also the Secretary of Docs 4 Patient Care.

As am EMR consultant, Mike knows there are MANY things that need to be changed with our emerging healthcare system and he wants to be part of the solution. I have every confidence that his technical and medical contributions for healthcare reform in his state of Georgia and Washington DC are what we need as a country.

In addition to participating on a HIMSS committee, Mike has applied for a vacancy on the HIT Committee in Washington DC.  Please reach out to Mike to get to know him. He has mounds of expertise to share in the EMR space. And if you know people he should meet or venues he needs to pursue, please don't be shy; give him a shout. Mike has our country and patients' best interests in mind and he's not afraid to pull up his sleeves and work.

You can find Mike on LinkedIn or drop him a note through his blogs on this site.

Thanks for all you do for us Mike!

Jonena

Musings from Mike:

Doctors Unenthusiastic About Obamacare Geeks

Deep Thoughts from the Meaningful Use Mountain Top

Meaningful Use Will be on Life Support by the End of 2012

Busting the Myths About EMR Implementation

The Unpredictable Effects of Technology

Our First EMR Workflow Engine

What if the Home Mortgage Deduction Looked like Meaningful Use?
Bedside Manner in the Information Age
The ROI of EMR Explained
The ROI of EMR Explained, Part 2: Show Me the Money

Health Wonk Review: Looking at the Future

Here on Health Wonk Review, our last issue included some recaps of the prior year, so in this issue (hosted by Workers' Comp Insider), we are looking to the future and what the coming year might hold for healthcare. Check it out: Health Wonk Review: Looking at the Future  

Our blogger, Dr. Michael Koriwchak is featured as he discusses why Doctors are Unenthusiastic about Obamacare Geeks.

Doctors Unenthusiastic About Obamacare Geeks

Dr. Michael Koriwchak, www.wiredemrdoctor.com

Despite the success of information technology (IT) in transforming many parts of the economy, the health care sector has proven itself immune to the seduction of smart phones and iPads.  This is puzzling at first glance.  It is certainly not due to any shortage of health IT products.  The problem appears to be on the demand side.

A recent article by Olga Khazan in The Washington Post provides some explanation. She reports on the third annual mHealth Summit, held earlier this month in Washington D.C.  The event has attracted such notables as Bill Gates and Ted Turner, according to the mHealth website.  The piece laments the “enthusiasm gap” between Health IT startup companies offering dozens of miracle products and those darn stick-in-the-mud physicians who just can’t get with the program.   But meetings like the mHealth Summit actually hurt the movement of Health IT that they profess to support.

The poster child for Ms. Khazan’s article is Dr. Eric Topol, one of the Summit’s keynote speakers.  HHS Secretary Kathleen Sebelius joined Dr. Topol behind the podium.  Together they offered Health IT Utopia – where “you can take a video of a rash on your foot and get a diagnosis…without making a doctor’s appointment.”  Then they criticized practicing physicians using the same old Obamacare propaganda.  Ms. Sebelius continued, “Americans still live sicker and die sooner than many of the people in other nations…Healthcare has stubbornly held on to its cabinet and hanging files.”  Dr. Topol called the medical community “ossified” regarding the adoption of health information technology.  The author starts the online post-article comment thread herself with the question, “How do we encourage doctors to be more open to these technologies?”

This kind of meeting is common in the Health IT (HIT) community.  A bunch of self-described HIT experts get together, pump each other up about the absolute perfection of their products, and then start bashing physicians because - literally and figuratively – we aren’t buying it.  At similar meetings I have heard HIT people brag about walking out on their doctor the minute he pulled out a paper prescription pad.  Doctors are called fearful, stupid, or rich fat-cats protecting their turf.  Now thanks to our “colleague” Dr. Topol we can add, “ossified” to the list of unflattering terms.  It comes as no surprise that the government is happy to join in the sing-along.  It is a free opportunity to serve Obamacare Kool-Aid.

I am a dedicated supporter of HIT.   Our practice’s EMR implementation reached a reasonable level of maturity long before Obamacare, HITECH incentives, and Ms. Sebelius came along.  We became Meaningful Use – compliant the first of October.  I believe in the potential of HIT to revolutionize the practice of medicine by reducing costs and improving efficiency and quality of care.  But I do not believe the HIT community is on a course that will take us to that vision. 

The IT community has indeed done great things for other parts of the economy – without government incentives.   They have yet to offer similar value to practicing physicians.  Health care is different from banks, grocery stores, and airlines.  It would take an entire book to fully explain the differences, but for now consider 2 indisputable facts that distinguish health care:  1)  In health care there is no tolerance for errors and unexpected outcomes, and 2)  In health care the beneficiary of a service is not the one who pays for it.

Consider Ms. Sebelius’ example of a rash on the foot.  In her utopian world you don’t need to see the doctor.  Instead you just take a picture of your rash, send it via the Internet (oops, I meant “The Cloud”) to a provider who looks at your photo, makes a diagnosis and sends you the treatment.  The job is done for less cost and with more efficiency…right?

Well, maybe…but what if the patient with an apparently simple rash is a brittle diabetic…and right next to the rash, beyond the photograph, is a near gangrenous toe?  Or perhaps this patient recently changed laundry detergents, or maybe went camping and had a tick bite.  Of course the clinician (who is probably not a doctor, in Sebelius-utopia) has no way of knowing; in this example the picture is the only information available.  Will we expect clinicians to make a diagnosis with so little data?  If not, then what additional information should be made available?  How will it be made available?  How should the standard of care for remote service be defined?  Doctors cannot be expected to spend precious dollars on IT products until we establish how they should be used.

Then comes the daunting task of paying the provider.  If patients paid for their own care they would be glad to pay a fair price for remote service in order to avoid losing time at work and save on gas, parking, etc.  This in turn would make it attractive for doctors to offer the service, and everyone would quickly buy in.  But third party payers have no incentive to give doctors more ways to provide service and get paid.  And in the health care regulatory environment doctors would take a huge legal risk if they attempted to bill insured patients directly for remote services.  Ms. Khazan mistakenly lays the blame at the doctor’s feet, accusing us of having no interest in saving money.  She also brings out the same old propaganda regarding the quantity-not-quality payment system.  Those arguments are complete nonsense.  Neither the HIT community nor the government knows the first thing about how to provide quality health care while at the same time making payroll for staff, getting the office rent paid, and still putting bread on your own table.

To address Ms. Khazan’s question, here are some ideas for the HIT community that will make doctors more receptive towards HIT:

First, stop insulting your target audience.  It’s hard for us doctors to do business with folks that call us fearful, stupid, greedy, “set in our ways,” “stubborn,” or “ossified.”  If you think so little of us physicians, why should we work with you?  Why should we trust our patients’ welfare to your products?  As the saying goes, you get more bees with honey.

Second, through your success digitizing other parts of the economy you have earned our respect.  But you need to admit that doctors know more about patient care than you do.  To us your health care products are the technological equivalent of black-and-white vacuum tube TV sets and brick-sized cell phones.  They reflect your lack of understanding of how to practice medicine.  Physicians will not get interested until you spend less time rubbing elbows with famous people and globetrotting academicians and spend more time working in the clinic with regular docs to learn how patient care works in the real world.

We docs are indeed set in our ways to some extent, and with good reason.  In our years of training we were repeatedly taught that even small changes in patient care could adversely affect treatment outcomes in unpredictable ways.  You don’t make changes in a cavalier fashion when patients’ lives are at stake.  There is more to lose than there is to gain.

Third, stop letting Kathleen Sebelius and her Obamacare cronies play you for fools.  They are giving you the time of day for only one reason – to make you dependent on government for survival.  Getting in bed with them may feel great now, but the morning after will be ugly.  Their goal is not to jump start your industry, but to control you forever.  Meaningful Use incentives were the first step.  Witness the fate of the American Medical Association.  For decades they have financially benefited from government support of the AMA-copyrighted CPT coding system.  But, faced with the prospect of Obamacare “reforming” CPT out of existence, the AMA chose to abandon its physician constituency, supporting Obamacare to preserve its CPT revenue stream.  The government owns the AMA.   Now they want to own you.

The government should not be your customer.  Doctors and patients should be.  It is not too late to change strategy.  Among regular docs there are plenty of early adopters willing to work with you.  Let’s talk.

Deep Thoughts from the Meaningful Use Mountain Top

Dr. Michael Koriwchak, www.wiredemrdoctor.com

In some ways I am grateful to see 2011 end.  Several extracurricular projects have drained the life out of me, including our Meaningful Use (MU) project.  As near as I can tell we survived.  Our 90 days of compliance for Phase 1 / Year 1 are completed.  Last night I completed my attestation online uneventfully.  We will get attestation completed for the rest of our physicians within a couple of weeks.  Then we will join the few (1%) of “eligible providers” that have complied with MU.  One would think that folks would be breaking down the doors of these “one-percenters” to learn the secrets of their success.  Yet a brief Internet search reveals no doctor testimonials on MU success beyond the second hand accounts offered by EMR vendors and consultants.  These are of little value.  So I am writing my testimony.

Over the past several months I have repeatedly criticized MU, with good reason.  But perhaps now that I have climbed the MU Mountain and my check will soon (hopefully) be on its way, I should soften my view a bit.  Sort of like final exam week…exams looked awful before you took them, but when you got done and you were somehow still alive, well, maybe it wasn’t so bad.

Well, sorry, it’s still that bad.  It took about 150 man-hours of work to complete this project.  And our EMR use, our quality of patient care and our practice efficiency is for the most part no better.  In some ways it is worse.  As a result of MU:

1. We now take blood pressures on children.  This is almost never medically relevant in an ENT practice.  We can’t exempt ourselves from this requirement because of our adult patients, in whom blood pressure is often relevant.
2. We waste volumes of paper printing clinical visit summaries that no one reads.  While the concept of a visit summary is OK, the document itself must include so much extra data, it is useless.  Our web portal, which we are in the process of replacing, does not support this requirement so we have to use paper visit summaries for now. 
3. Patient waiting time is increased while we process data on pneumovax status, smoking status and body mass index on every patient.  In our practice, these data are medically relevant for many patients, but not everyone.  Doing it for everybody is a waste.

To be fair, a couple of good things did happen:

1. Use of EMR-based prescriptions and true e-prescribing (e-Rx) improved with those physicians that were still hanging on to paper scripts and/or were not using e-Rx.
2. We were not maintaining true ICD-coded problem lists in the EMR before MU.  We had problem lists and diagnoses of course, and we were using ICD codes for billing.  But we had never combined the two processes before.

The entire process is complicated, confusing and intimidating.  Not only are the guidelines themselves a mess, but also there is a surprising amount of inaccurate and misleading information out there.  Even the CMS publication Attestation User Guide is missing a page compared to the actual attestation website.  After reading the User Guide I lost an entire night’s sleep thinking that the “children with pharyngitis” quality measure had been deleted because it is missing from that document.  I have 17 years of medical practice experience and 37 years of IT experience.  If I can’t figure this out, there is something wrong.

The view from the top of the MU Mountain looking down is no better than the view from the bottom looking up.  Meaningful Use remains an expensive distraction that forces the true benefits of EMR to be overlooked in favor of regulatory compliance.  MU also creates an unhealthy alliance between government and the health IT community.  The government wants to own health IT just like it wants to own the rest of health care.  Don’t fall for it.

Related Posts:

Meaningful Use Will be on Life Support by the End of 2012

Meaningful Use Will be on Life Support by the End of 2012

Dr. Michael Koriwchak, www.wiredemrdoctor.com

Recently, I attended the annual meeting of the primary professional organization for my specialty, the American Academy of Otolaryngology – Head and Neck Surgery. As you might expect the first thing I did was attend a mini-seminar on strategies to meet Meaningful Use (MU) requirements. These “mini-seminars” typically include 3-4 speakers presenting various viewpoints regarding the subject at hand. Presenting the supporting viewpoint on MU was Dr. K.J. Lee, who has been an icon in our specialty for decades. He had distilled MU requirements for Otolaryngology down to a few typed pages and reviewed each requirement, emphasizing how easy it should be.

The most interesting part of the presentation was the reaction of the audience. Presumably based on his professional reputation the audience initially bought into Dr. Lee’s enthusiasm for MU, hopeful that he was right. However, as he continued through the list of MU requirements his point of view became less credible, and the enthusiasm began to fade. When he suggested that it was no problem for ENT docs to ask and counsel patients about mammograms and colonoscopies, audience members began to stare at the floor and shake their heads. By the end of his presentation he had lost just about everyone. I have seen this happen before at MU meetings.

Later that morning in a different mini-seminar I gave my own brief presentation, a MU update. I was asked to give an update on how MU payments were going, presumably specific to our specialty. The August CMS report shows MU payments given to about 1100 providers so far (as of 7/31/11) totaling about $18 million. For the 6 weeks leading up to the meeting I tried, without success, to get MU payment data from CMS for ENT doctors. The best I could infer from the data available is that more than 1 but less than 28 individual ENT docs have been paid for year 1 MU. In any case the conclusion is clear: only about 0.1% of all eligible providers – and essentially no ENT docs – have met MU so far.

But isn’t it too early to draw conclusions? After all, the program just got started a few months ago. And the number of payments going out is increasing month to month. And providers still have a year to get the full payment.

My opinion is that the situation is worse than it looks, not better. I believe even this tiny number of payments represents an early peak of MU payments to providers who implemented EMR long before MU came along. Our practice is in this group, and we will begin our 90 day attestation period October 1. MU is achievable only for those providers that have already acquired several years worth of EMR skills. Once these early adopters are paid, no one else will be left. If I am right we should see MU payments plateau in Spring 2012 and start declining in the summer and fall.

MU remains a bad idea, especially for surgical specialties. It is not possible for a paper-based medical practice to complete the long process of selecting, installing and implementing EMR on the schedule imposed by MU. The provider skill set required to meet MU requirements takes at least 2-3 years to develop, and providers can’t even begin to acquire those skills until the EMR is chosen and installed. The MU schedule forces providers to rush the process, raising the risk of making catastrophic mistakes in the EMR selection and implementation process.

Busting the Myths About EMR Implementation

Guest Author: Michael Koriwchak, MD, EMR Consultant (www.wiredemrdoctor.com)

I am still crazy over the ridiculous EMR cost study recently published by CDW.  This regrettable study was obviously put together by a bunch of newbies that had no idea what they were doing.  A few weeks ago, during a rant on a previous post on this topic I promised I would review our practice’s implementation strategy.  It’s time to live up to that promise.

The CDW group assumed, as I imagine many still do, that EMR should be implemented as quickly as possible minimize the financial impact of decreased patient volume.  In our practice we took the opposite approach, realizing that if we brought in EMR slowly enough we wouldn’t have to decrease patient volume at all.  We overcame both the cultural and the financial barriers to EMR by creating an approach that was different from the prevailing wisdom at the time. Conventional project management principles don’t work in the physician practice setting.

1. We recognized that EMR was not a project with a defined end point – it would instead be an ongoing “work in progress.”
2. We avoided big “go-live” dates and hard deadlines for abandoning paper charts.  Paper charts were eliminated gradually, via attrition, over 2-3 years.   Docs are already uptight and uneasy about EMR; deadlines only make it worse.
3. We rejected the notion that we would have to decrease patient volume and lose revenue, even temporarily, to get EMR implemented.  Don’t even think about suggesting to a doc that (s)he will have to decrease patient volume.  We can’t tolerate it financially.
4. Every office and every physician was allowed to progress along its own timeline.  Every office has its own set of assets and liabilities – its own subculture.  It made no sense to force the same timeline on everyone.  We also offered (and continue to offer) each office / physician a fair amount of latitude on exactly how the EMR is used.  Some docs use speech recognition, some don’t.  Some offices didn’t scan outside records at first.  In the early days we didn’t care if docs wrote paper prescriptions.  The script pad is one of the hardest cultural icons for the physician to let go.

We had one physician who resisted EMR for almost a year.  I was approached several times to pressure this doc to “give in.”  I declined.  Then one day he discovered Dragon Speech and started EMR almost overnight.  We docs are self-selected fiercely independent souls; our training reinforces those characteristics.  I know this physician well; he had to do EMR on his timing and his terms.  If I had pressured him it would have backfired badly.  I probably would have behaved similarly.

To accommodate the physician’s need for independence the EMR adoption process was broken down into a large number of incremental steps.  After a short teaching session each physician had a training version of the EMR, complete with fictitious doctors and patients, installed on his/her laptop.  Over a few evenings the physician would work with the program to get used to the basic operations and functions.  Once the physician was comfortable we put the server communication software on the doc’s PC and showed him/her how to log in and use the same training EMR program on the server.  The training EMR on the server was configured with our custom templates.   The physician was then instructed how to create chart notes using our templates.  Then he/she could spend more time practicing at home, logging onto the server from there.

Then it was time to use the “real” EMR program on real patients.  But not all at once. Start with only one patient, the last patient of the day. Those first few notes took forever to complete.  But with our approach that was no problem.  For a while many of the docs printed out the completed EMR note and put it in the paper chart.  Why bother doing that?  It was a cultural trust issue.  With time, trust in the EMR increased and the practice disappeared naturally.

We advanced each doctor at his/her own pace.  Do EMR for the last 2 patients of the day, then the last 3, etc.  When ready, take on a half day of patients, then an entire day.  If there is a problem, back off.  Get the issues resolved and try again.   There were no deadlines and no pressure.  After getting settled with documentation move on to workflows such as prescriptions, ordering tests and imaging.  Then finally learn CPT/ ICD-9 charge code entry.

This process serves 2 goals.  First it allows the cultural change to an IT setting to progress at an acceptable, sustainable rate.  It also allows EMR to come in without decreasing patient volume.  It took almost a year to get 20 physicians in 15 offices implemented with basic EMR functions – but there was no panic, only modest chaos and no loss of patient volume.  We had our frustrating moments, but I am convinced that they would have been far worse with a conventional implementation plan.

Related posts:

The Unpredictable Effects of Technology
Our First EMR Workflow Engine
Why We Delayed e-Prescribing for One Year
What if the Home Mortgage Deduction Looked like Meaningful Use?
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The Unpredictable Effects of Technology

Guest Author: Michael Koriwchak, MD, EMR Consultant (www.wiredemrdoctor.com)

The interaction of humans and technology will always be unpredictable.  A few months ago this thought was driven home to me in a rather malodorous manner…

I have obstructive sleep apnea (OSA) and use a CPAP machine every night to sleep comfortably.  With OSA your airway collapses when you fall asleep.  A CPAP machine is a small technological marvel, quietly delivering heated, humidified air under gentle pressure through a nasal mask to keep your airway open while you sleep.

One night while using the CPAP I was ripped out of a deep sleep by the worst odor I have ever encountered.  How bad does a smell have to be to violently awaken you?  Dazed and confused I sat up, clawed my CPAP mask off, gulped a few breaths and waited for the purple haze to clear.  I looked down towards the floor next to the bed and realized with horror what had happened.

Our dog, Jade, is a Labrador who has blessed our household for nearly 14 years.  Out of affection and respect for her sheer endurance no one begrudges old Jade her habit of passing gas almost continuously.

On the floor was Jade, sleeping comfortably with her posterior positioned next to my CPAP machine on the floor.  Jade’s colonic gift had been sucked into my CPAP machine, heated, humidified and rammed up my nose into my gray matter.  We are not sure yet if the brain damage is permanent or not.  My wife and kids insist I’m no worse off than I was to start with.

History contains many other examples of technology’s unpredictable effects.  Remember the “paperless office?”  For several years in the early 1990’s, when PCs were new and word processors were first introduced, it was widely accepted that offices would soon have no need for paper.   Just write your document on the computer, save it to your floppy disk (remember those? They were actually floppy back then) and deliver the floppy disk to the recipient, who would read your document on screen.  Who needs to print documents anymore?  Paper manufacturers were in a panic, sure that demand for their products was about to disappear.

As anyone over 40 years old remembers, the opposite happened.  Office workers were happy to create documents on a computer screen but were unwilling to read them there; all documents still got printed eventually.   Then we became obsessed with creating perfect documents.  If a 20-page report had one comma out of place, fix the comma and reprint the entire document.  Then find another mistake and reprint 20 pages again.  Paper use skyrocketed.  Today the paperless office remains an unreachable goal, an ethereal concept, a star by which you can navigate but that you will never reach.

Medicine is replete with examples of unintended effects of technology.   A 5-minute web search produces a long list of unexpected medical outcomes such as heart problems from Fen-Phen and heavy metal poisoning from prosthetic hips.  Even something as seemingly benign as an over the counter zinc-containing nasal spray has been found to cause permanent loss of smell.

It comes as no surprise, then, that when we physicians contemplate EMR, we see the introduction of an unpredictable technological force into the unpredictable environment of medicine.   That raises more questions than answers.  Will EMR free us to be real doctors again or make us slaves to data capture?  Will health information exchanges give us the information we need at our fingertips, or will we be barraged with terabytes of useless data?  Will e-prescribing be a blessing or a nuisance?   Pardon us for not buying into the IT euphoria.   Our patients and we will have to bear the consequences more than anyone else.  As stewards of the healthcare system we recommend proceeding with some caution.

Related posts:

Our First EMR Workflow Engine
Why We Delayed e-Prescribing for One Year
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Our First EMR Workflow Engine

Guest Author: Michael Koriwchak, MD, EMR Consultant (www.wiredemrdoctor.com)

About a year ago, when our experience with our EMR approached the 5-year mark, I thought it was time we approached more advanced projects to automate our workflows.  In a practice like ours, which includes surgery, some of the most repetitive, time-consuming, labor-intensive workflows are those that prepare patients for the operating room.  Analysis of this workflow reveals there are 2 types of components:  very simple and very complex.  There is not much in the middle.

Complex steps, performed by an MD or nurse, include:

1. Design of surgical procedure
2. Location of procedure
3. Choosing preoperative labs, imaging, consultations (i.e., cardiology)
4. Interpreting results of the above testing
5. Communication with the referring physician and preop consultants

Simple steps consist of generating the paperwork to reflect the medical decisions made in the complex steps:

1. Chart notes documenting need for surgery and surgery design
2. Initiate preop workflow with appropriate staff (i.e., surgery scheduling)
3. Preoperative History and Physical
4. Informed consent forms
5. Preop and postop orders – implementation of above complex decisions
6. Preop and postop patient instructions and other supporting information

With these thoughts in mind I began creating a set of body-site specific templates with the sole purpose of initiating and directing the above workflow steps from a single computer screen.  We have been using 2 of these templates for about 6 months; I would describe the results as a good first attempt.  This project is one of the few done by a physician that directly addresses workflow as well as documentation.

Three challenges make this process slow and laborious.

The first challenge is to automate the simple steps as fully as possible while leaving the complex steps in full control of the physician.  This is much more difficult than it sounds.  Too much automation will usurp control of clinical decision making from the physician; too little results in failure to fully leverage the EMR technology and may make the workflow more cumbersome than it was to start with.

The second challenge is making the templates user-friendly, which in this case means doctor-friendly.  That means getting rid of all the screen clutter and “white noise”, keeping only what is useful and necessary.  Many of the EMR’s built-in, “hard-wired” screens fail to do this well.

The third challenge is getting the code written correctly so the template interfaces properly with the EMR itself.  This includes trivial but maddening issues such as preventing duplicate actions from duplicate button clicks.  This also becomes frustrating when the template you are creating attempts to overcome shortcomings of the EMR itself.

Currently my conclusions are:

1. The effort is worthwhile.  Although the workflow engine is far from perfect and far from finished, it is quite useful “in the trenches” taking care of patients in a busy clinic.  Every time I use the workflow engine I save $6.50, my estimate of what I would pay our staff to do the paperwork by hand.
2. Some of the grunt work required to design and write a workflow engine is unavoidable.  An EMR that is flexible enough to write useful custom workflow engines must by definition require a high level of effort to customize.
3. Software improvements are required in order to make workflow engine creation practical for most practices.  My IT experience is about as good as you will find among non-IT-professionals (35 years) but my skills are pushed to the limit making these templates.  That is unacceptable.  Notwithstanding conclusion #2, the situation can and must be improved.

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Why We Delayed e-Prescribing for One Year
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The ROI of EMR Explained
The ROI of EMR Explained, Part 2: Show Me the Money
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