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Wednesday, October 17, 2012

REC Blog Milepost 101


Rollin' along the REC highway, starting my second hundred posts. Don't think RECs are going to be around long enough for me to reach #200. Maybe if I wrote a post a day -- but, then I'd have to quit my job, which would render the effort moot.

For now, though, no shortage of topics to continue to discuss, Health 2.0 SF aftertones and more. The Health Care Blog is Tee'd up this morning with a good one (apropos of my prior post citing THCB's "Outlawing Templated Notes in the Electronic Health Record."
The EMR and the Case of the Disappearing Patient
By CHRISTOPHER JOHNSON, MD & MAGGIE MAHAR

The electronic medical record (EMR) is here to stay. Its adoption was initially slow, but over the past decade those hospitals that do not already have it are making plans for implementing it. On the whole this represents progress: the EMR has the ability to greatly improve patient care. Physicians, as well as all other caregivers, no longer have to puzzle over barely legible handwritten notes or flip through pages and pages of a patient’s paper chart to find important information.

With the EMR, it is easy to see what medications a patient is taking, when they were started, and when they were stopped. Physicians can easily find key vital signs – temperature, pulse, respirations, and blood pressure – plotted over any time frame they wish. All the past laboratory data are displayed succinctly. But it is not all gravy...
...Of course these days our wonderful scientific tools often give us the answer, and I certainly do not wish to toss all those things aside to go back to using only what Osler had. But medicine is not really a science. It is based on science, uses science, and is increasingly more scientific. But medicine also contains large measures of intuition, educated guessing, and blind luck. I do not think that aspect of medicine will ever completely disappear. When I read (or wade) through a patient’s record, I look for the story. When I cannot find a coherent story, I cannot give the best care.

For myself, even though I of course use the EMR, I refuse to use all those handy smart text templates. It takes me longer, but I type out my progress notes, organized as I did when I used a pen and chart paper. It takes me a little longer, but it makes me think things through. No billing coder has ever complained. More than a few colleagues have told me, that when we share patients, that they search through the EMR to find one of my notes to understand what is happening with the patient.


My advice to other doctors is this: don’t let the templates get in your way. Tell the story.
Interesting. But, on my iPhone 4s I use both the Dragon app (free) and the (likewise free) bundled Voice Memo utility. I can quickly email the dictated Dragon text to myself (it makes very few errors) and then cut and paste it wherever I need. I also have the iMac version here on my desktop (it wasn't free, but, then, it didn't cost much). Many EMRs support Dragon. The Voice Memo is essentially dictation.
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CRIME 2.0


Above, a GIS map of assaults reported to San Francisco PD just during the time I was there for Health 2.0. Why cite this? Well, Doc Gurley reminded me on this post of hers:
What the NFL and the Homeless Have in Common
Jan Gurley, MD, May 10, 2011
With a traumatic brain injury, you feel yourself slipping away. You can’t remember things that used to come easily, things like how to find the grocery store — acts and details that live, mocking, at the edges of your thoughts, just outside your grasp.

You know there’s something wrong, but you have a sense that it’s all your fault. Rage bubbles and pops to the surface, the only emotion that seems to escape the thick stew of depression that dulls your days.

You make lists and lists, trying to get your life under control. But two days later, you stare at pieces of paper, trying to remember what the scribble meant, which thing it is that you were supposed to do next.

Chronic pain is there all the time, and you try to plan and wait and be patient and stick with a process, but then you find yourself sitting, head in hands, unable to remember what’s next. All you know is that something’s wrong. And the rage squirms and writhes, trying to bubble up again.

The behavioral changes and impaired functioning caused by post-traumatic brain injury aren’t poignant science fiction. They’re real.

Traumatic brain injury, especially from repeated concussions, has become a pivotal topic in sport, particularly in the National Football League. Watching a game on TV, it used to be easy to scoff at the concept, as you watched players collide a million times and heard the dull thud of plastic against muscle, bone against bone. You’ve seen players get up and walk it off. How could it be life-damaging? And even if it is, didn’t they kind of ask for it?...


...Mild to moderate concussions can result in depression, loss of what are known as “executive functions” (such as long-term planning, delayed gratification, impulse control, and concentration), dementia, and behavioral problems. Concussions are also associated with higher rates of substance abuse and chronic pain.

A survey of retired NFL players found that more than 60 percent had suffered at least one concussion in their career, and 26 percent had had three or more. Among the homeless, a well-done study found that 58 percent of homeless men had had an episode of serious head injury, with one in five having experienced five or more episodes. These injuries led to neurologic changes that are not trivial: a significantly increased likelihood of seizures, mental health problems, drug problems and poor physical health.

Most alarmingly, 70 percent of the homeless reported their first episode of serious head injury before becoming homeless, suggesting, the authors noted, that “in some cases, traumatic brain injury may be a causal factor that contributes to the onset of homelessness, possibly though cognitive or behavioral sequelae of traumatic brain injury.” What’s more, a study like this may actually have under-represented the degree of injury and impairment associated with head trauma among the homeless, since only those people competent enough to seek services at a soup kitchen or shelter were surveyed.

With so much at stake – the loss of human potential, the damage to our society, the costs of care for these kinds of impairments – you might think that society would take very seriously the prevention of head trauma among the homeless. There is, however, a sense that people on the streets may have brought it on themselves.

Assaults resulting in head trauma are a daily occurrence in life on the streets. A head slammed into a dumpster, a dislocating punch to the jaw, a head laceration that’s been stapled closed: these are so common as to be considered “normal” for the homeless...

Dr. Gurley's writings on the issues of homelessness are tough (but necessary) reads.
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DUELING HIT STUDIES UPDATE

This stuff is starting to reek of Dueling Bible Verses or their secular counterparts Dueling Economic Theories.

Doctors Who Go Digital Provide Higher Quality Healthcare: Study Says Electronic Health Records Help Physicians Provide Better Care

ScienceDaily (Oct. 17, 2012) — The use of electronic health records is linked to significantly higher quality care, according to a new study by Lisa Kern and her team, from the Health Information Technology Evaluation Collaborative in the US. Their work appears online in the Journal of General Internal Medicine, published by Springer...
Firewalled ($39.95). Page One image here (png).
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JD KLEINKE ON ACOWATCH

JD is one of the clearest thinkers we have on health care business and policy. He's the Lewis Lapham of national economic health policy, to me.



Listen to internet radio with ACOwatch on Blog Talk Radio

JD joked during the interview that he managed to make everyone mad at him with his NY Times OpEd.

Not me, man. I found it spot-on.
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DURSA UPDATE

We had a great HealtHIE Nevada conference call today comprising some "lessons learned" advice regarding our incipient, front-burner project aimed at becoming a DURSA Signatory HIE (Data Use and Reciprocal Support Agreement).
Healtheway is a non-profit, public-private partnership that operationally supports the eHealth Exchange (formerly referred to as the Nationwide Health Information Network Exchange). The Nationwide Health Information Network Exchange (Exchange) has been operating as an ONC program since 2007. For the past three years, a rapidly growing community of public and private organizations (Exchange Participants) has been routinely sharing information in production. That community now represents thousands of providers and millions of patients...

Nice website, clean and functional.

The effort may well be less daunting than we'd feared. An adroit full court press might put us into compliance and participation by January 2013.
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UPDATE  
 
Science Based Medicine never disappoints. apropos of the workup/progress note "narrative" -
 
A PANDAS Story
Oct 17th, 2012, Steven Novella under Neuroscience/Mental Health
One of the skills I try to teach medical students on their journey to becoming experience clinicians is to consider and address the patient’s “narrative.” Patients have a certain understanding of their illness, its cause, and its role in their life.
They make sense of their situation as best as they can, resulting in a story they tell themselves. This is how humans generally deal with the complexities of life. There is a potential problem when the clinical narrative of the health care provider conflicts significantly with the illness narrative of the patient. Patients, for example, often feel that a highly specific diagnosis is necessary for optimal treatment of their condition. Until they are given such a diagnosis they feel they need to keep looking – for better diagnostic tests or different specialists (what I call the “Dr. House” narrative). The appropriate diagnostic and therapeutic algorithm for that patient, however, may not require a specific diagnosis, but rather eliminating certain diagnoses and then treating the probable category or clinical syndrome that remains. The clinical narrative, in other words, may be one of considering risks vs benefits with incomplete and imperfect knowledge.
Increasingly, it seems, the conflict of narratives is taking on a larger scale – not just between one doctor and one patient, but between the medical community and patient communities. Perhaps this is one manifestation of the new social media generation...
Interesting. Wonder what Messrs Weed and Weed would say?
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ARCH-IT UPDATE
 

Press release:
RECs Respond to House Letter to Sec. Sebelius
ARCH-IT says we cannot afford to suspend EHR Incentive Program
Washington, DC (PRWEB) October 16, 2012
On October 4, certain members of the House of Representatives Appropriations, and Energy and Commerce committees made public a letter to HHS Secretary Kathleen Sebelius in which they asked the Secretary to suspend the EHR incentive program. ARCH-IT, a national association of organizations committed to improving health care through information technology, believes that this would be an unfortunate development at a time when the healthcare sector is poised to make some significant gains.
“The House letter to Sec. Sebelius suggests that the ultimate desire is to further spur on the deployment of HIT around the country, and we wholly agree with this sentiment,” said Jonathan M. Fuchs, FACHE of the Arkansas Foundation for Medical Care, and the President of ARCH-IT. “However, retracting or suspending the program would run completely counter to this goal by undermining the federal commitment to HIT expansion. But even more concerning is that it would financially damage the small practices who have already invested in an EHR and are currently working to achieve Meaningful Use.”
“It is hard to fathom the fact that people in our government would oppose the important improvements in healthcare that information technology delivers, and the dramatic changes electronic medical records will have on the quality of care delivered to our patients and the health of the nation,” said Robert Schwartz, M.D., chair of the South Florida Regional Extension Center.
For the last 30 months, states, healthcare providers, health information exchanges, Regional Extension Centers (REC), EHR vendors, and others have been working hard to help bring the national healthcare infrastructure into the 21st century. The EHR Incentive Program has been a catalyst for much of this, providing a significant carrot in the form of incentive payments for achieving progressively more challenging levels of use of EHRs.
“This progress has not been easy. Adopting EHRs and using them effectively is a major operational challenge for providers and hospitals of all stripes. Unlike a new phone app that can be purchased cheaply and used separately from other phone functions, EHRs are expensive and fundamentally alter how a practice delivers healthcare services,” said Fuchs. “Unfortunately, all too often practices install EHRs without thinking through how it will be used, or how to implement those features their EHR vendor promised to deliver.”
According to data released by the Office of the National Coordinator for Health Information Technology, the 62 RECs around the country have enrolled more than 135,000 primary care providers in small practices—almost half of the 294,300 “eligible physicians” who have enrolled for the EHR incentive payments. Of these, more than 93,000 have already implemented EHRs—but 70,000 are still working on achieving the Stage 1 Meaningful Use requirements when they will get paid. In total, nearly 140,500 providers have been paid, according to CMS.
“These funds represent a significant stimulus and provide desperately needed cash flow for financially strapped medical practices. Any suspension of those funds will especially penalize small business owners who will be forced to lay off staff and curtail purchasing,” said Dr. Bernd Wollschlaeger, a physician in North Miami Beach, FL. “As a Steering Committee member of the South Florida Regional Extension Center (SFREC) I learned to appreciate the value of close collaboration of like-minded physicians using information technology solutions to maximize quality of care. The SFREC and many other RECs throughout the United States provide guidance and technical assistance on best practices to support and accelerate efforts to become meaningful users of certified EHR technology.”
ARCH-IT notes that Health Information Technology has a long history of bi-partisan support. When the Office of the National Coordinator for Health Information Technology was created in 2004, then-President George W. Bush set the goal of having the majority of the country using EHRs. ARCH-IT believes that America is well on its way to achieving that goal; the EHR Incentive Program is a major reason why; and that pulling back on the federal commitment to this program would set back the use of HIT for another generation. “This is a delay we can ill afford,” said Lisa K. Rawlins of the South Florida Regional Extension Center, and ARCH-IT’s Vice President. “With a growing shortage of primary care providers, we need to ensure that those we do have are operating at peak efficiency.  Furthermore, the many initiatives sponsored by the Department of Health and Human Services—including payment reform, PCMH (primary care medical home) and the recently enacted CMS innovation projects—require EHRs that are installed, and effectively used.”
The 62 Regional Extension Centers around the country currently help practices of all sizes effectively use their EHRs. A recent GAO report indicated that providers enrolled with their REC are more than twice as likely to have achieved Meaningful Use than their non-REC enrolled colleagues. The Association of Regional Centers for Health Information Technology (ARCH-IT) is the umbrella advocacy organization for the REC program. Formed in early 2012 by a group of forward thinking program directors, ARCH-IT works to support REC programs through education about the goals and successes of the REC program, works to establish partnerships that benefit local RECs and their members, and provides technical assistance to ensure that RECs continue to provide services of the highest quality.
www.archealthit.org

UPDATE:
STERNLY WORDED LETTER WATCH 

Now the Senate Republicans want in on the act.


Senate Republicans Send Letter to Sebelius with Concerns over Meaningful Use
October 18, 2012 by Gabriel Perna

In a letter to Kathleen Sebelius, Secretary of the U.S. Department of Health and Human Services, four Republican senators expressed concerns over several issues related to the adoption of EHRs through the Centers for Medicare and Medicaid Services (CMS) and the Office for the National Coordinator for Health IT (ONC)’s meaningful use program. This comes only a few weeks after House Republicans penned a letter to Sebelius asking for a suspension to the Meaningful Use program...
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UPDATE:

OK, THIS ANALOGY WAS INEVITABLE

As a long-time unalloyed "Mac Snob" (one who actually started his white collar career in 1986 in a radiation lab in Oak Ridge writing BASIC, FORTRAN, and xBase code on an IBM-XT running DOS 2.1 -- having great fun doing it; I didn't know any better at the time), I've long used the slightly less euro-clinical "semper fi" analogy: we come to love and swear fealty to that for which we have suffered mightily.

A notion reflected in the snarky old Apple ad wherein the tea-sipping admin lady declared to her perplexed boss "well, they can apparently just train themselves."

(How could it be any good were it that easy? "A Cute Graphics Toy.")

What is striking about this company [EPIC] is the degree to which the CEO has made it clear that she is not interested in providing the capability for her system to be integrated into other medical record systems.  The company also “owns” its clients in that it determines when system upgrades are necessary and when changes in functionality will be introduced.
I'm havin' a Bill Gates Microsoft Moment here. Coupled with a "Sharpen Your Forensic Audit Log Analysis Chops" itch.
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More to come...

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