God Save The Quids

The fascinating thing about waste is that it's a true world citizen: no frontier will ever intimidate its all-pervasive logic. Not even an ocean.

The following story therefore comes as no surprise: in 2012, The Royal Berkshire Hospital (UK)went live with Cerner’s Millennium system as part of a £28m contract. But at a recent board meeting auditors estimated its current value at just £10.5m. The system has also been fraught with problems, including system crashes and the loss of patient appointments since it was deployed.

This very story made the headline news early June and I shall let you carry on to the article and indulge in the priceless quotes from Mrs. Chairman, Mr. Chief and Mr. Supplier.

 

HIT and Run

Your Hollywood Style EMR Press Review

 

It’s (almost) cherry picking season, but trust me, healthcare people’s mood is everything but jolly. This past quarter indeed, Health Information Technology (HIT) vendors are in for their money. If I were to squeeze it all into one scenario, I would say they’re all starring in a cheap movie production where they, vilains, all go for a ride in a Ferrari, but oooppsss, they suddenly run over a doctor, a patient and a taxpayer who were minding their own business in addition to crossing on green. Instead of calling 911, these loaded bastards go into reverse, drive over all three broken bodies one more time, empty their wallets and vanish into a Manhattan back street alley.

But not to worry. Right in line with the seasonal mood, I did the cherry picking for you…and found a few tasty quotes from articles and blogs, the various scenarios of which are all yours to enjoy.

 

A FISTFUL OF EMR DOLLARS

“(The EMR is) a scandal marred by industry influence, government complicity, and lack of evidence,” according to Tom Liu on his blog.

Source: InSight Blog

 

A FEW GOOD SENATORS

“Based on a range of objective data, it is clear that the current payment structure of the EHR incentive program does not provide enough oversight or safeguards to ensure the proper stewardship of taxpayer dollars.”

A smoother way to say “hey, you’ve been screwed”. This masterpiece of political bullshit comes right from 4 senators who called their latest EHR white paper…wait for it…“Reboot”.

Source: John ThuneSenator official web site

 

BILLION DOLLAR BABY

“RAND’s 2005 report was paid for by a group of companies, including General Electric and Cerner Corporation, that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, to a projected $3 billion in 2013, from $1 billion in 2005.”

It’s not me saying it, it’s Greg Scandlen in a January post titled “The HIT Scam”

Source: http://healthblog.ncpa.org/the-hit-scam/

 

THE HAPPY HOOKERS GO TO WASHINGTON

“After (President Bush called for digitizing national health records in in his 2004 State of the Union speech), every technology C.E.O. wanting a piece of health care would have visited me every day if I had let them. Over the next few years, Cerner and many of the other health care data companies increased their presence on Capitol Hill."

Please welcome this confession from David Brailer, whom President Bush had appointed as the nation’s first health information czar at the time.

Source:The New York Times

 

DUMBER AND DUMBER

“But does anyone really believe we should go back to paper?”

These were the only words that came out of recently-fired Allscripts CEO Glen Tullman in response to someone complaining about the EMR in a letter to President Obama. That’s like saying to a family of four living in 200 square feet that the prehistoric cave is overrated.

As for the rest of the article, I would say congrats to Tullman for downloading my Bullshit Bingo grids in due time.

Source: Forbes Magazine

 

THANK YOU FOR SMOKING US

Brian Klepper wasn’t too impressed with the above article either, so he responded:

“Physicians, purchasers and patients should take umbrage at Tullman’s article. Along with EPIC, Cerner, NextGen and other old guard EHR vendors, Tullman and Allscripts are directly responsible for most current EHRs’ outrageous costliness, lack of usability and interoperability, and their limited clinical decision support. Through their scale and influence over policy, they have effectively manipulated the EHR market, gouging purchasers and delivering marginally capable products. Health care costs more, and outcomes have suffered as a result.”

Source: The Doctor Weighs In

 

OTHER PEOPLE’S MONEY

“On a really good day, you might be able to call the system mediocre, but most of the time, it’s lousy.”

That was Michael Callaham, chairman of the department of emergency medicine at the University of California, San Francisco Medical Center, on the $160 million digital records system from Epic he turned on eight months ago.

Source: The New York Times

 

NO COUNTRY FOR OLD MEN?

“We called it the Sunny von Bülow bill. These companies that should have been dead were being put on machines and kept alive for another few years. The biggest players drew this incredible huddle around the rule-makers and the rules are ridiculously favorable to these companies and ridiculously unfavorable to society.”

That was Jonathan Bush - co-founder of the cloud-based firm Athenahealth and a first cousin to former President George W. Bush - on healthy dinosaurs.

Source: The New York Times

 

SOMETHING’S GOTTA GIVE

“Who's got time to listen to patients when the government demands 'meaningful' data entry?”

Good question, Anne Marie Valinoti. Thanks for asking.

Source: The Wall Street Journal

 

INDECENT PROPOSAL

“You can bet that no one is making Dr. Devlin use an electronic medical-record system.”

Same Ms. Valinoti on Fox’ new show “The Mob Doctor”

Source: The Wall Street Journal

 

That’s it for the book and movie title games, I promise.

Cheers from the pit,

Nado

Fifty Shades of Waste

And still counting. Welcome to the EMR Library!

As hospitals worldwide are ramping up on the Lean track, Toyota style, I thought I’d gather a reader’s digest of Waste at its very best. Who knows, that might work towards triggering more product recalls (and refunds) from EMR vendors.

The good news with waste is that it’s creative, extremely creative. And just like a villain in a good thriller, it always shows up where you least expect it. So if I was to reorganize the shelves of the hospital library downstairs, I would supply the following classics as each of them, I'm afraid, has a story to tell about the EMR, waste, and all of the above.

TITLE	ABSTRACT
Three men on a sinking boat	It’s more than that, actually.
Nineteen eighty-four bugs	And still counting.
There might be blood	If you don’t fix half of those bugs by Xmas.
Journey to the End of the Blight	If you want your hospital to decay, let the EMR be your guide.
Wuthering Eights	As in the millions you just sent down the drain.
It’s a wonderful lie	I know, it’s not a book, it’s a movie. But the EMR stars in it.
Indecent proposal	Would you spend millions to sleep with an EMR vendor the Government has chosen for you beforehand?
Jacques the Fatalist	He’s not the only one.
King Clear	Forgot to rule the EMR interface.
The Death of Ivan Ilyich	Could have been avoided if the EMR had not lost his lab results.
The Bored Ultimatum	That’s the EMR training time threshold after which physicians and nurses may explode.
Desperately seeking value	And still looking.
Brave new ward	This is the story of a doctor who’d rather be exiled on an island and treated like a savage than using crap technology.
One hundred years of solitude	Is what happens when you call the vendor’s helpdesk for a bug fix.
Much ado about nothing	Is what you’re told when you dare complaining about the on-hold music.
Pride and Prejudice	Just remove the pride part.
The quiet American doctor	Is losing his legendary cool.
In search of lost time	Yep. That’s all we ask for.
The wind of the pillows	Haven’t felt that one for a while.
The trial	Sounds like a realistic ending.

Note: this list has been compiled by a bunch of pissed off physicians over a couple of lunch breaks. They welcome more book suggestions to further enrich their little library!

 

 

It's itchy. It's scratchy. It's reality.

ITCHY QUESTION:
When will we see more billion-dollar health tech companies?

SCRATCHY COMMENT:
That's probably not the first question that would come to my mind, but hey. Maybe we'll see an article titled "When will we see more ERM companies deserving their billions?" one day.

 

Pimp my EMR

 

(EMR Wannabe – Part 4 : Customization)

Robert Rubin once summed it all up in the following sentence: “All of us as consumers have gotten spoiled, ... We expect customized goods and services at commodity prices…The only way we can do that is to cut the fat out of our price structure.”

Damn right. This is the world we’re living in, people. And we, not-so-healthy healthcare buyers of inglorious EMRs, are no different. We consume and we expect, yet the thing is neither customizable nor affordable. And vendors don’t seem to be ready to put their price lists on a diet.

Think about it: if there are so many EMRs out there and if the latter are so equally daunting for users, blame it on their “customizability” index being close to mean sea level. But…wait. That’s not fair. Yes, an EMR is customizable, sometimes, a few things here and there, maybe. Depends…if you’ve got a) plenty of time and b) tons of cash.

 

 

It’s like bumping into your EMR vendor on the hospital parking lot after a sales meeting: you’re driving a brownish 1985 Buick Sedan while he just got his initials embroidered on the leather seats of his brand new Porsche. Because I guarantee you that the extras you’ll pay to get the system to fit 10 miserable percent of your basic needs will secure at least 5 generations of Porsche driving in his family.

OK, Nado, don’t let the dollar figures blur your mind. Focus on today’s point. And today’s point is: how exactly do you expect vendors to pimp your ride?

I’m not asking for a Gadgetmobile. I want an EMR that is FULLY AND EASILY CUSTOMIZABLE ON-SITE – not at the vendor’s HQ where geeks will always have something more important to do. Pretty much everything in the system should be Lego-like from the start (as opposed to: the day after hell broke loose), from displays and dashboards all the way to workflows, templates and data tables. Here's what I mean... 

Customizable Patient List

Upon login, Cardios and Pediatrons for instance don’t want to have the entire patient list popping up on their welcome screen. They want to see their patients and their patients only, on a grid that can be configured as they wish since they don’t want to be presented with the same information first. Some might even want to access patient data directly from their calendar, which has all appointments covered for the day.

 

Data Input: See separate thread.

Distribution

Can we fax the report here, email the order there, send a copy by mail to the referring physician, cc: Doc Buster on lab results? That’s basic flexibility when it comes to distribution. But more questions shall be asked…and properly answered: How do you make sure this note was read by Fred the Bonehead? How are critical findings brought to our attention? And how do you know that proper action has been taken accordingly by the right recipient? How do you track and audit all that, in all departments – each having its very own ways?

Multiple Signature Support: See separate thread

 

 

Customizable Prescription Lists

Hospital prescription lists have 600 000 entries, out of which Cardios typically use 30. Their prescription list should therefore be limited to those 30. Remember Heart Doctors probably love a good time saving feature more than any other doctor out there.

 

Access Rights and “Need to Know” Factor

When a hospital employee “inadvertently” peeks into Britney Spears’ medical records, it’s a nationwide scandal and we start discussing new measures towards protecting patient confidentiality. But hey, why is it just for VIPs? If I don’t want my hospital-security-guard of a neighbour to peek into my lab results, it’s nothing more than my legal prerogative. But in reality, EMR or no EMR, hospitals are a bit like Spanish Inns right now. Pretty much any employee within the hospital can grab a chart in an EMR as if it was paper – when one should only be granted access to a specific chart if they have a need as a regulatory user to access it. And that requires serious customization leeway backstage. And the “need to know” variable must be factored into the EMR equation.

Order Sets

If I’m a 30-year-old male, the system shouldn’t display pregnancy or geriatrics related options. We want evidence-based ordering features, reflecting the standard procedures for given demographics, departments and healthcare facilities. In other words, the system should never provide me with click-and-make-a-mistake opportunities.

 

Team Healthcare

Let’s not forget this is where most of the workflow complexity lies. Hence the need for super flexible, super customizable technology. A technology that's able, among other cool stunts, to ensure ALL provider findings are reflected into a single, concise and complete discharge note. Go ahead, impress me.

You probably see where I’m going from here: towards the “one-system-does-it-all” model. Because I am convinced that one system can do it all, provided it is designed with the objective to embrace any scenario and any workflow – as opposed to: just making quick bucks. Sometimes it’s all about the intent.

On the hospital front, that means one vendor, one rep, one support & maintenance contract, one hotline. Plus it reduces the number of interfaces required, which is yet another hidden pain in the mass.

 

 

 

It's itchy. It's scratchy. It's reality.

ITCHY URL:

Adopting an EHR is not simply a matter of choosing one,it involves making a sandwich: an EHR (with condiments) between two slices of exit strategy.

SCRATCHY COMMENT:

Depressing but bang on. If that's the only way not to get fried, then I'll have a large (rum and) Coke to wash it down. Cheers.

 

EMR Wannabe - Part 3

ELECTRONIC SIGNATURE

MAKE CHART WARS HISTORY!

Here is an extract from a rather spirit-lifting brainstorm on the future of clinical documentation, recently published in Healthcare IT News. It envisions the following ceasefire to “chart wars”:

“Imagine the following -- the entire care team jointly authors a daily note for each patient using a novel application inspired by Wikipedia editing and Facebook communication. Data is captured using disease specific templates to ensure appropriate quality indicators are recorded. At the end of each day, the primary physician responsible for the patient's care signs the note on behalf of the care team and the note is locked. Gone are the "chart wars", redundant statements, and miscommunication among team members. As the note is signed, key concepts described in the note are codified in SNOMED-CT. The SNOMED-CT concepts are reduced to a selection of suggested ICD-10 billing codes. A rules engine reports back to the clinician where additional detail is needed to justify each ICD-10 code i.e. a fracture must have the specifics of right/left, distal/proximal, open/closed, simple/comminuted. 

First things first, I am glad to hear that SNOWMED and ICD-10 are now able to interact freely  like good old buddies. That just made my day.

More good news: here comes the multi-authoring concept, which I tend to cherish dearly. But shouldn’t the same happy rule apply to signature? Isn’t signature multiple in essence, especially in teaching hospitals?

Shouldn’t Frank the Resident be able to choose his staff physician as the next signer of a report so the system routes the request for their review upon completion?

And what about the other nagging scenario a.k.a “rollover”? Frank the Resident starts a note and moves on to something more urgent, but the note gets stuck in the queue. No one can access it. Wouldn’t it be good if the system was able to “move” the note to the attending after a predefined time frame? And if the assigned attending hasn't signed it within yet another predefined time frame, wouldn’t it be neat if the system opened it for other staff members to take over?

OK, this is nice, but the above scenarios entail clear protocols and workflows to be established per department beforehand. Yes they do. Because that’s a must, a milestone, a step that can’t be overlooked.

But would this be enough to make “Chart Wars” history? Good question. Maybe a couple of additional light sabers are required to properly support resident and attending Jedis, such as:

·        Over the Shoulder Signature - Frank The Resident presents his note to the attending and they can both sign it off together at the same time - no need for the attending to login in with their own credentials.

·        Oooops Feature – provides a predefined timeframe within which the signer should be able to modify his/her note before it is locked. That would eliminate the whole addendum crap.

·        Multi-level Signature - allows for more than two signatures when required – and often required it is.

·        Add-My-Two-Cents Feature - staff members are trainers, so allowing for comments and track changes might prove helpful to simplify the training workflow.

Here were my two cents on signature. If you can think of more features, please feel free to comment!