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Ideas From John Halamka’s Basement

I attended a teleconference meeting* with John Halamka yesterday at the Cisco booth at HIMSS. It was an exciting experience – and quite intimate since I was there with only 1 other reporter and two Cisco staff. The room was closed off from the exhibit hall but we could be viewed through glass and John’s face was about 4 feet tall in front of us. It actually felt a bit like a TV news room – with glowing lights, cameras, and mics everywhere.

I arrived a few minutes late because I was having trouble finding the booth with the McCormick numbering system – but Frances Dare graciously welcomed me, and John immediately responded (from the screen in front of us): “Oh, hello there new person!” It was most amusing.

I’m sure that John had said some brilliant things prior to my arrival – but I had the chance to ask him my very own questions for about 30 minutes. Here are some highlights:

Dr. Val: How are we going to get doctors in solo practice to get on board with a national EMR effort?

Dr. Halamka: What we’ve found in the Boston area is that even if you give solo-practitioners an entire online EMR system for free, they still don’t want to use it because it takes effort to learn how to do so. They’re just not willing to put in the time. However, now that there are financial incentives in place (the stimulus bill includes $44,000/doctor to adopt an EMR system), suddenly their willingness to comply has increased dramatically.

Dr. Val: How do they get the right EMR?

Dr. Halamka: Hospitals pay 85% of the development costs for a good EMR, and professional organizations pick up the other 15%. Then the EMR is licensed for free to the solo practitioners – they’re incentivized to adopt it, and all they see is an online browser. They don’t have to deal with the back end at all.

Dr. Val: Have you used voice recognition systems at your hospital?

Dr. Halamka: Yes. We’ve found that voice recognition systems don’t work well in the ER because it’s too noisy in there. Also, the nurses don’t like having to tote around another piece of electronic equipment to do their jobs. However, we love our voice recognition dictation system – I can call in my note and have it return to me to insert into the electronic chart in near-real time. That’s great. Of course, voice recognition works best for the narrative portion of a note in the medical record, it’s not so good for structured data.

Dr. Val: How are we going to get doctors on the same “practice page” so that patients receive consistent care for similar problems, no matter where they are in the country?

Dr. Halamka: We need to implement more physician decision support tools and create rule sets based on best practices/evidence. Some are already doing this successfully: Health Dialog uses nurses (via phone) to walk patients through treatment decision trees. UpToDate is a good resource for doctors. At our hospital we’ve even negotiated in advance with the local insurance plans to have them automatically approve radiology tests based on pre-determined rule sets. That saves the docs a lot of time because they don’t have to call for approval for every single radiology test that they order. If the test is indicated by the rules, then it’s automatically approved.

Dr. Val: Some doctors have had bad experiences with rule-based quality measures. One ER doc I know was reprimanded for doing the right thing (clinically) because it didn’t comply with a rule set. How do you address the inflexibility of rule sets in the face of complex human lives and situations?

Dr. Halamka: Quality measures must be based upon clinical data, NOT administrative or claims data. Administrative codes are too far removed from what’s actually happening clinically – so if we are going to automate quality scores, they have to be analyzing the right data sets. However, quality scoring is not perfect. My hospital actually got “dinged” for reporting too much. We’re very transparent at BIDMC and tried to supply all our quality measures to a local oversight body. Of course, the other hospitals weren’t reporting anything like the level of detail that we were, so we looked like an outlier – and a really bad hospital. Of course it was just an artifact. But it took some time to clear up.

Dr. Val: I once heard someone say that judging a hospital’s quality based on administrative data is like judging a restaurant’s quality by its grocery list.

Dr. Halamka: That’s a good one. I’ll have to use it. Well thanks for the call – I’m speaking to you here [points to the white curtains behind him on the screen] from my basement!

Dr. Val: Thanks for your time! I look forward to your HIMSS lecture tomorrow on what the stimulus bill means for IT.


*TelePresence Fireside Chat – Sunday, April 5 (3-4pm CT) – Dr. John Halamka, CIO of CareGroup Health System will conduct a live interview via TelePresence, an immersive in-person meeting experience, from his home in Boston along with Frances Dare of Cisco, who will be onsite at HIMSS. The discussion will focus on a number of issues pertaining to the stimulus funding package. Additionally, Mrs. Dare and Dr. Halamka will discuss how technology such as healthcare telemedicine and remote video will play a role in not only time and cost savings but also helping serve rural populations.

Recent AP article about Cisco.

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2 Responses to “Ideas From John Halamka’s Basement”

  1. DrV says:

    I don't know how you get these, Val

  2. DrV says:

    I don't know how you get these, Val

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