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Vivek Kundra: Training Physicians To Use EMRs Is The Key To Adoption

I attended the 29th annual Management of Change (MOC) Conference with Dr. Val.  The conference is sponsored by the American Council for Technology and the Industry Advisory Council.  MOC brings together government and industry leaders to share knowledge, collaborate, and develop actionable technology management strategies.  As a physician, attending this conference for the first time, I assumed a great deal of the conference topics would be over my head and in very “techie” terms. My hope was to get a glimpse of some of the technology solutions the government was considering as they relate to health care IT.

Vivek Kundra, first Chief Information Officer of the United States, addressed the audience early in the day in language that even a doc could understand. He spoke about the need to simplify government, and connect people to solutions, instead of “endless bureaucracies.” The same of course goes for medicine. How great would it be to connect our patients to systems that actually had interoperable medical data?

I was able to catch up with Mr. Kundra after his talk for a few minutes and ask him how technological simplification would apply to physicians such as myself, operating in a haphazard infrastructure with varying PAC systems, EMR’s and paper charts. He said the key would not only be investing in technology, but investing in training healthcare personnel to master new technologies. He acknowledged that different generations of physicians would embrace technology differently, but ultimately, if a physician says he “can do a better job on paper” then we have a problem.

I was very impressed by Mr. Kundra’s answer namely because it was so insightful for a man who’s expertise lies primarily in the technology field. He does not come from a healthcare background, and yet had hit the nail on the head. There has been so much talk about HIT being the “key” to cost savings and the next “breakthrough” in medicine. With very little discussion on how physicians feel about it. For some docs – particularly those that come from an older generation – the thought is quite terrifying. They are happy with their paper charts and manual dictations. Health technology is almost viewed as an impediment to those set in their ways, and accustomed to a system that has worked for them and their patients for years. This upheaval will not come without it’s challenges even after we find the best technologies for the tasks at hand. It will be imperative for government leaders to understand that the mission of HIT implementation may be just as difficult as finding the technology solutions they are currently seeking.

As Mr. Kundra and his team embark on this huge task, it will be important for physicians and health care personnel to engage with the government and serve as a guide for what docs need from technology, and what will and will not work for our patients. I hope next year’s conference is attended by more physicians such as myself and Dr. Val.

Tormented: EMRs’ Linguistic Handicaps

There are some things that Electronic Medical Records do well and there are some things that Electronic Medical Records do poorly. To say that I need Electronic Medical Records to help me type is nothing short of ridiculous. Unfortunately, when engineers meet computer programmers and try to help health care professionals type in the health care record in the name of “safety,” the results can torment those they’re trying to help.

Take auto-spelling, for instance. I have the nasty habit of typing “Lungs: Claer to A&P” and marvel at the auto-correction feature automatically correcting my typing to “Lungs: Clear to A&P.” This is an example of the wonders of electronics.

But when I type “DC Cardioversion” and the computer won’t left me type “DC” because it wants to know if I mean “discharge” or “discontinue,” the computer becomes intrusive, obstructive, and performs a service that should be right up there with water-boarding. I mean, is someone really going to mistaken that I mean “Discontinue cardioversion” or “Discharge cardioversion” when I’m typing my operative report? I could see this being a problem in the order-entry portion of the software, but when I’m typing by progress note or operative note?

Please.

Even better are the wonderfully useful letters “MS.” These might mean “magnesium sulfate,” “mental status,” mitral stenosis, “MS Contin,” “multiple sclerosis,” “musculoskeletal,” “Ms.,” or maybe even “Mississipi.” So, instead of being able to type a logical sentence without interruption, the doctor finds that that a drop-down pick list prevents those magic letters from being typed. It seems the chance that a nurse will wonder if you’re prescribing a drug in a southern state trumps the ability to enter a simple sentence on the computer. This is, after all, how we’re preventing medical errors.

But I wonder if these computer engineering road blocks are doing something much more insidious and detrimental to our health care delivery of tomorrow: like devaluing independent thought, reason, permitting the subtleties of context, and common sense.

No, better to torment instead.

The Achilles Heel Of Electronic Medical Records Systems

The following is a reader take by Paul Ravetz.

Does the “Art of Medicine” really exist, or perhaps more importantly, can it do so in the computer age?

Computers are both the boon and the bane of medicine. Electronic medical records (EMRs) are excellent for retrieval of information about labs, medications, and past medical history of our patients. These records are much easier to access than our old paper charts. However, I feel that the Achilles Heel of these advances lies in the fact that physicians are so busy inputting information into their computers that they do not spend enough time communicating with the patient.

Communication with your patient is the epitome of the Art of Medicine. It is vital that physician and patient understand each other. This includes not only what the patient says but what they mean. This takes time, a commodity which is in short supply in the age of EMR. One should always remember a basic caveat about computers, which is, “garbage in, garbage out.” If wrong information is fed into the computer, it doesn’t matter what algorithm that you use because you will be following a false trail.

Computerization of medicine will lead to great advances if it is implemented properly. However, the way things are presently being done cheats the patient out of the most important part of the doctor patient relationship – time to communicate. I always remember the precept advanced by Sir William Osler, the father of modern medicine, “Listen carefully doctor, the patient is giving you the diagnosis.”

The combination of the computer age along with the time to listen to the patient and to accurately define their problem will indeed lead to a new age in medical care, but to ignore one or the other is not to fulfill our obligation to our patients.

Paul Ravetz is a family physician.

*This blog post was originally published at KevinMD.com*

Electronic Medical Records: Advice For Physicians


Electronic Medical Records are coming.  The economic stimulus bill (furious spinning kittens notwithstanding) assured this.

Under the terms of the bill, CMS will offer incentives to medical practices that adopt and use electronic medical records technology. Beginning in 2011, physicians will get $44,000 to $64,000 over five years for implementing and using a certified EMR. The Congressional Budget Office projects that such incentives will push up to 90 percent of U.S. physicians to use EMRs over the next 10 years.

Practices that don’t adopt CCHIT-certified EMR systems by 2014 will have their Medicare reimbursement rates cut by up to 3 percent beginning in 2015.

(From Fierce Health IT)

There will be even more money for implementation.  We look forward to our checks (and are not counting on them yet).

Now it is time for the flies to start gathering.  Wherever there is lots of money, “experts” pop up and new products become available that hope to cash in.  Doctors, who are never lauded for their business acumen, will be especially susceptible to hucksters pushing their wares.  It seems from the outside to be an simple thing: put medical records on computers and watch the cash fly in.

Anyone who has implemented EMR, however, can attest that the use of the word “simple” is a dead giveaway that the person uttering the word in relation to EMR is either totally clueless or running a scam.  It’s like saying “easy solution to the Mideast unrest,”  “obvious way to bring world peace,” or “makes exercise easy and fun.”

Run away quickly when you hear this type of thing.

Just like becoming a doctor is a long-term arduous process, EMR implementation happens with time, planning, and effort.  It’s not impossible to become a doctor, but it isn’t easy.  With EMR adoption, the most important factor in success is the implementation process.  A poorly implemented EMR isn’t simply non-functional, it makes medical practice harder.  A well implemented EMR doesn’t just function, it improves quality and profitability.

How do I know?  Our practice ranks very high for quality (NCQA certified for diabetes, physicians are consistently ranked high for quality by insurers), and we out-earn 95% of other primary care physicians.  EMR allows us to practice good medicine in a manner that is much more efficient.

So how’s a doc to know who to trust?  What product should he/she buy and whose advice about implementation should they follow?  There are many resources out there.  Here are a few I think are especially worthwhile:

  1. Buy a product that is certified by Certification Commission for Health Information Technology. CCHIT is a government task force established to set standards for EMR products. Its goal is to allow systems to communicate with each other and enable more interfaces in the future.  The bonuses for docs on EMR are contingent on the system being CCHIT certified (think of it as something like the WiFi standard).
  2. The American Academy of Family Physicians’ Center for Health Information Technology and the American College of Physicians both have tools to help member physicians decide on an EMR. Your own specialty society may, too.
  3. Several professional IT organizations have programs to improve EMR adoption, including HIMSS and TEPR.
  4. Austin Merritt has written a good article of advice on his website Software Advice that underlines the importance of implementation.

The best advice I can give, however, is to visit a doctor’s office who is using an EMR successfully.  This office should be as close in make-up to your office as is possible.  You should be able to look at how they do it and see yourself in that situation.  Never buy a product before visiting at least one office like this (no matter how good the sales pitch).  When you visit, make sure you ask them about the implementation process.  How did they do it and how hard was it?

Which EMR do I recommend?  Remember, I have been on EMR for over 12 years, so haven’t had much of a chance to shop around.  You hear raves and horror stories with every product.  Here is some basic advice:

  • Get a solid CCHIT-approved brand that has been around for a while
  • Don’t pay as much attention to price as you do function.  Since the EMR will be absolutely central to the function of your office, it is a dumb mistake to overly-emphasize cost.
  • Realize you are paying for a company, not just a product.  It is not like buying a car, it is more like having a child or getting married.  REALLY research that side of things.  A good EMR with a bad company behind it should be avoided like the plague.
  • See how connected the user-base is as well.  A solid user group will do much to make up any deficiencies in the product and/or company.

So much time is spent shopping over EMR products, but buying an EMR is like being accepted into Medical School; your work is just beginning.  That’s OK, because like medical school, the effort put in gives a very worthwhile product.

**This post was originally published at Dr. Rob’s blog, Musings of a Distractible Mind.”

What Can We Learn From The Military Health System?

jeffgruenheadshot2Together the Department of Defense and the Department of Veterans Affairs have the largest and most advanced IT infrastructures in US healthcare. As the Obama administration ramps up funding for electronic medical records and other IT initiatives, one might ask what the public and private sectors can learn from the military IT systems (aka AHLTA and VISTA).

I interviewed Dr. Jeff Gruen about the upcoming Military Health Summit at the World Health Care Congress, April 14-16 in Washington, DC.  Jeff is Head of the Global Healthcare Practice at PRTM, a management consulting firm and a Chairman of the Military Health Summit.

You may listen to our conversation by clicking the arrow button, or read a summary of our conversation below.

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Dr. Val: To set the stage, tell me a little bit about the World Health Care Congress, and what the Military Health Summit hopes to achieve.

Dr. Gruen: This is the 6th annual World Healthcare Congress (WHC), and the first year for the Military Health Summit. We expect 1500 to 2000 participants – the WHC is the premiere event for healthcare services and the healthcare system at large. It brings together people from across all sectors of healthcare and in addition to the general summit events we have this exciting Military Health Summit track.

Dr. Val: What does the healthcare system at large have to learn from the military health system?

Dr. Gruen: Three things: first, we can use the military health system as a case study for IT initiatives, since they’ve already achieved broad adoption of an EMR. It’s not perfect, but it’s used widely and is getting better. The DOD and the VA are working hard to make their systems interoperable.  Second, because the military health system is both a payer and a provider, it serves as a wonderful laboratory for inventing new ways of delivering care. Realigning incentives between inpatient and outpatient care or primary and specialty care can be achieved nicely in the military system, which is like a giant, international Kaiser Permanente. Third, the military has developed very advanced battlefield techniques and devices for saving lives – including telemedicine. So it’s fun to hear about these advances.

Dr. Val: How will healthcare reform impact the Military Health System – do you have any predictions based on what you’ve heard on Capitol Hill?

Dr. Gruen: It’s impossible to know exactly, but let me offer a couple of observations. First, there’s a sense of national patriotic commitment to make sure that our service men and women (and their dependents) get the very best care possible. There’s a real desire to apply the best practices from the commercial sector to the military. PRTM feels very passionate about this, especially since one of our own is currently serving in Iraq right now.

There are a few core problems in healthcare, and they all fall under the rubric of “the right care delivered in the right environment by the right provider at the right time.” These problems may be addressed with interventions including providing point of care decision support, tools that would decrease provider practice variation, and connected convergent care – the idea that we have to move from a system that is designed for acute care to one that is very good at managing chronic care. We also need to move to a system where all the data is present in a very transparent way across environments to allow us to apply the same protocols regardless of whether someone’s in the hospital, or at home, or in a nursing home.  The military health system could get these systems in place in a faster and broader way than the general healthcare system.

Dr. Val: Who should attend the Military Health Summit? How do they register?

Dr. Gruen: Those who should attend include: 1) People actively involved in the Military Health system because it offers an opportunity to interact with their luminaries. 2) Anyone on the commercial side of healthcare who’d like to do work with the military 3) Anyone who is interested in health reform 4) People with a particular interest in health IT (disease management and telemedicine in particular) 5) Anyone who wants to hear about the coolest new things coming out of battlefield medicine.

To register, one need only go to the World Health Care Congress website and follow the prompts for the Military Health Summit.

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