NOSH ChartingSystem

A new open source health charting system for doctors.


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Forcing an Infant to Walk on Stilts – A Story about Meaningful Use

The comments from Jonn Lynn’s recent post about how crazy it would be for a person to create an EHR from scratch in the era of Meaningful Use were quite thought-provoking.  And from those comments, it got me thinking about the whole back story behind Meaningful Use.  I hate to beat upon a dead horse, but I find that the lessons learned from how Meaningful Use was created in the first place instruct us on how to navigate the future of health information technology, from the viewpoint of a primary care physician or an independent or small group practice.  But to understand and capture the essence of what I mean regarding the ills of the Meaningful Use program, I’d like to offer this analogy…forcing an infant to walk on stilts.

The Infant

Culturally, health care providers tend to be more cautious and conservative when it comes to new technologies, especially when it comes to impacts on workflow.  The concept of workflows is important later on as I talk about the “stilts” and something that Chuck Webster, MD has discussed quite extensively.  So when it comes down to it, most health care providers (from the newbies to the well-seasoned techie types, like me) are really embarking uncharted territory when it comes to health information technology.  As a group, we are literally infants trying to learn to walk when all we’ve done was crawl.

The Walk

I totally get why Meaningful Use was enacted.  At its core was to bring modern technology into the heart of healthcare, where the bastions of keeping the status quo had really done its job for many decades prior.  No other industry had stayed glued to paper more than health care; and for good reason.  It mostly worked before, but it was far from perfect. 

But I absolutely do not get how Meaningful Use was implemented.  This is where the crony capitalism part comes in because when it’s understood that those with the money, prestige, and power can signficantly influence how a government program is designed and crafted, then it sort of makes sense.  But even when it makes sense, it’s just wrong on so many levels.   Are these large vendor EHR’s experts when it comes to physician workflows?  Some pundits believe that is true.  I absolutely do not concur.  I don’t think most physicians believe it either. 

The Stilts

What is more important…just getting any old EHR or getting one that can speak to EHR A and B?  Because getting an EHR is like buying a smartphone or a car.  Physicians want to have good choices (not lousy, limited ones) that can still interact to each other when the day is done.  That is what a network infrastructure is all about.  A smartphone is worth zilch if it cannot make a call or e-mail to your friend (when it can’t connect to a network), even if it has the bells and whistles of storing contact information.  A car is worth zilch if it cannot drive 65 mph on a highway (when there are no highways), even if it has 450 hp sitting in the engine bay.  It appears none of these concepts and pitfalls were considered during the crafting of the Meaningful Use program.  It was as if these large vendor EHR’s had a permissible orgy fest (thanks to the government) pumping up their specs (and prices) with little regard for physician workflow and patient safety.

So instead of offering incentives to push EHR vendors to foster interoperability from the very beginning, we end up with a program that is very much applying a pair of stilts to an infant learning to walk.  Yeah, an infant walking on stilts is a cool trick…but is it really useful (I’m throwing the “meaningful” term right back at them!).  Does it help us as health care providers?  Does it help our patients?

Furthermore, what should have been an effort to ensure interoperability between EHR systems became a program strictly micromanaging every aspect of how an EHR functions and subsequently physician workflows.  Instead of a program that assumes positive intent, we get one that is punitive and condescending  towards health care providers, not to mention being a complete time waster.  (Clicking on check boxes to attest that you have indeed reviewed a smoking history on a patient seems so technologically advanced!  But, oh, I forgot to think about my care plan for my patient…where is that on this darn screen?!)  Does this forced and punitive method encourage infants to learn how to walk?  On stilts?

And speaking of adoption…yes, Meaningful Use did reach its goal for physician adoption of EHR’s.  But not without a cost.  The vast majority of EHR adoption was on the backs of hospital systems that did have the financial capital to invest in such a risky project.  And those physicians who work for these hospital systems still hate their EHR’s.  We now have a generation of potentially positive EHR adopters turn into EHR haters.  What could have been a fairly positive and physician centric process was wasted upon by greed and misguided legislation. 

And finally, I personally believe most of these established EHR vendors are working on outdated technology and there is no incentive for them to move away from that.  So instead of being a cool trick for an infant to do, it’s downright dangerous too.

My Infant Walks on Stilts…Now What?

Well, it’s been 4 years since the HITECH act was enacted and Meaningful Use has already gone through stage 2.  Pretty much, if you’re a physician who wants to get your full Meaningful Use money back to your practice, it is probably already too late now, and it’s only going to get worse.  A significant percentage that passed stage 1 didn’t pass stage 2.  Your government tax dollars pretty much funneled most of that money straight from the health care provider or hospital entity into the pockets of these large vendor EHRs.  And knowing that most health care providers hate to switch even though they hate their EHR, they’re stuck with a never ending, hefty bill.  Everyone’s happy as a clam, right?

The Fall

There will come a day when we look back at this time of “encouraging physician adoption of EHR’s” as a misguided attempt to do something that probably would have occurred naturally in its own time, in a much less traumatic way.  Had we kept the eye on the ball regarding supporting network infrastructures, we would be farther down the road.  Instead, we got sidetracked into a dead-end street and we have no choice but recognize where we went wrong and how to correct our course.

Some physicians in the outpatient realm (ie direct care practices, ideal medical practices, concierge practices, solo practices, etc) have stayed on the sidelines waiting for the train to derail.  Perhaps, this is where our future lies.  Concepts of decentralized but meaningful data sharing and increasing use of natural language processing are fully compatible with these types of practices.  The concepts of patient centered and patient-stored data are just beginning to surface.  And to fill the void where these old, costly, legacy EHR products have failed to capitalize are where the new, bold upstarts are going to take a significant foothold and disrupt the status quo in time, once the specter of Meaningful Use expires.

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Electronic Medical Records, Workflows, and Meaningful Use

Below is a repeat post from my other blog (when I was a solo family physician).  I figured it was pertinent to discuss here and give you, the reader, some insight about what I think about health IT in general.  Enjoy!

As I’ve been trolling the blogs on KevinMD, and this one by Margalit Gur Arie, there are questions about whether electronic health records are the “panacea” to the problems with health care and whether they improve the quality of care of patients in the real world.

Although my own experince is just an n=1 of this question, here is my two-cents worth.

From the very beginning of my medical career, I had no illusions that electronic medical records could fix all the problems with our health care system.  But just like I envisioned the computer as the next tool that could spark further advancements in communication, the electronic medical record was an extension of that future.  Nothing more, nothing less.

I also was not going to wait for definitive studies to prove that electronic medical records could improve patient care or improve medical decision making.  For me, electronic medical records were a tool to simplify my tasks as a doctor, to automate certain tasks that humans are more prone to produce errors.  Also, all these studies are predicated on the assumption that all EMRs are equal…which are not.  It’s also assumed that these EMRs are easy to use…which universally, are not.  So these studies, in my mind, are moot.

I mean, look at all the world around you…Google, Yahoo, Facebook, Macbooks, laptops, iPhones.  We are now in an electronic world.  The electronic world took off nearly 50 years ago.  There were no studies convincing people that using the iPhone could be beneficial for you.  People can see the potential without these studies.  The reason why iPhones, iPads, and Android phones are so successful is because the user interface is intuitive and the device is able to combine several tasks and simplify what were separate tasks on separate devices into one.

It pains me to see the medical world falling so behind on this.  It pains me to see doctors office still using paper charts while in the very same room, medical staff were using computers to check their e-mail, buy something from Amazon, and update their Facebook accounts.

Financial entities, insurance companies, computer software companies, internet companies, high technology companies, shipping companies, even libraries and restaurants use computers to document and track their work efficiently and without significant redundancy.  Even WalMart has this supercomputer that minutely keeps track of all their purchases and goods and it even can predict buyer trends, to help their bottom line…because they all realize that there are certain things that computers can be really, really good at doing better than humans.  And there are certain things that humans are much, much better at doing than computers.

And if they did not use the computers to their advantage, they’ll be left in the dust.

It’s just that the physician’s office and hospitals are still at the starting gate and stalled in the first leg of the race, running around in circles about what these contraptions called electronic health records can do for them.  The insurance companies all know they have the upper hand in this because they use computers day in and day out in their industry and now they are trying to dictate to the doctors what kind of data they need, even if it doesn’t neccesarily improve patient care or respect patient autonomy.

This kind of dictation to the doctors is what all this meaningful use jargon is all about.  On paper, it seems like a good idea; to set a series of guidelines and features that an EMR must have so that it is certified as a good product.

I’m a car guy, so I’m going to use this analogy for people.

Let’s say you are a “certifier” and you are trying to make a list of cars that you want to “certify” that have a certain list of specifications.  The specifications include a car that makes at least 300 horsepower, has a navigation system, 2 cup holders, 4 wheels, a steering wheel, front disc brakes, and a fold down rear seat.  You compile a list of cars, but because you’re looking for a car that needs more than 300 hp, you’re really picking maybe 10 cars that can qualify.  And they all cost a lot!  But none of these 10 cars are easy to drive because with all that horsepower, the car has a tendency to swerve to the right or left when you press the accelerator pedal and you have to hold on to that steering wheel tight to keep from getting into an accident.  But you left out a pretty big list of cars that actually drives well and safely and still gets the job done…just not with 300 horsepower.

This is what has happend with meaningful use and EMR certification.  Some “certifier” has deemed a list of specifications that doesn’t necessarily define real “meaningful use”.  And this “certifier” has said that for EMR companies to be certified, they have to pony up $30,000 a year just to get a stamp of approval.  Back to the car analogy, Ford would have to go to their “certifier” to prove that their car makes at least 300 horsepower just to be on this list and Ford then passes on the cost to the buyer of the car.  Why would anyone in their right mind do that in the real world?  I certainly wouldn’t want to buy a car like that, and certainly not for that amount of money!

Even worse, this list of EMRs is the only one that the government will recognize so that the buyer of the EMR may get some reimbursement of their purchase.

What is the alternate view of EMR use?

For me, I needed to have an EMR that would fit my work flow, how a doctor thinks and how we document encounters intuitively so that we don’t need to spend a lot of time figuring out how to use it.  I only managed to pick a few EMRs, and most I nixed because I could not afford it as a small, solo doctor.  The one I picked initially worked “OK” but the there were things I needed to automate but could not use without adding a whole bunch of “macros” that I programmed for myself to interface with the EMR so I can order labs, send bills, send faxes, and scan documents.  It worked for a while but with any macro, any change to the system “broke” the macro and I had to start over from scratch.  Every EMR I continued to look for, was constructed in a way that looked like the billing was the central part of the system and documenting encounters took a back seat.  I understand we have to make money through billing, but it should not be how a doctor sees a patient during an appointment.  It made no sense to me and I did not see how it would help my workflow to be efficient with that kind of framework for an EMR, which was the norm; not the exception.  In an act of desparation, I gave up looking for one and I decided to make my own since I spent a lot of time making macros anyways.  Crazy, I know.  I was that desparate!

And how I made it was all based on what made sense for a doctor’s work flow when I see a patient.  I was a doctor, I know my own workflows and it was based on how I was taught in medical school.  I want ready access to all patient parameters, not through multiple clicks, screens, or special terminologies that only exist in IT world.  I want automated tasks and scheduling features, reminders of important alerts, and not have these clinical decision making tools that impede my ability to document my encounter.  I created this system all on my own and I used it for myself and with my patients for the past 1 1/2 years.  And it worked really well for me and I was much more efficient that I could ever be with my practice.  Ironically, the landscape of medicine had changed so much by the time I was using it (see my previous posts) that it didn’t matter how efficient I was.  The odds were against me.  That is where the limitations of EMRs can go, at least in primary care.  But I still believe that a good, user-friendly EMR is what doctors need, not to fix health care or even prevent a patient from dying, but that good communication and efficiency from using an EMR allows a doctor to focus and do what computers can never replicate…practice the art of medicine.

And that was what I did with my practice; spending quality time with my patients and the computers were way, way in the background (even though the computers were doing lots of things for me…but out of the way of the patient).  That is what improves patient care; that is what reduces health care costs.

Here’s the link to my new project…NOSH EMR, coming soon for public consumption!


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To certify or not to certify, that is the question…

As I’m planning the rollout stage of my project to interested developers and physicians, I am pondering the implications of certification for the NOSH ChartingSystem.   As a background, an electronic health record system has to be certified by one of 5 Authorized Testing and Certification Bodies approved by the Office of the National Coordinator for Health Information Technology (ONC-ATCB) so that a user (physician, practice, or hospital) of the system can claim for monetary incentives from Medicare or Medicaid when the system has demonstrated “meaningful use”.

These ONC-ATCB’s (the largest being CCHIT) ask for pretty hefty fees to test your system to get the certification, ranging between $20,000-$40,000.  Furthermore, as I understand it, the certification applies to the specific version of the software only, so if you have continued updates and modifications, you’ll have to re-certify your product.  No wonder most EMRs cost so much to the doctor – the costs likely get passed down to the doctor for the certification.

Furthermore, based on the HITECH Act that was passed in 2009, physicians who see Medicare patients and who do not use a certified EMR by 2015 will see a gradual reduction in payments (1% per year) as a penalty for not using a certified EMR.

In my own personal experience as a solo family doc, I used an EMR ever since I began my practice in 2004.  Unfortunately, I had a version of an EMR that was not certified and I wasn’t able to upgrade due to the significant increased cost for a certified product (being a primary care physician).   Looking at all the core standards that attest to meaningful use, my practice and system met all the standards, but I would not be able to claim incentives due to my EMR being uncertified.  Knowing that I was going to see reduced payments (with already reduced payments across the board from Medicare and insurance companies by not keeping up with inflation), I felt that the system was somehow rigged against me even though I “did the best thing” with electronic health records.

CCHIT then came out with a separate program (called the EACH program) for people with “legacy” systems that did not qualify for certification but if all the technology that was used in the entity met “meaningful use”, then they could alternatively certify the system.  Unfortunately, I got a heart attack with the price tag of “gasp!” $40,000 (that was more than 50% of my income!!!).

And so, regrettably to my patients, I opted-out of Medicare as I saw no light at the end of the tunnel.  (More about that at my other blog).  So now that I have my electronic health record system waiting in the wings, an open-sourced product with the aim of being low-cost to the physician, does it even make any sense to be certified?  Is the risk of Medicare payment reductions worth it for physicians wanting to use a low-cost system?  I also think (but I can’t confirm) that most physicians would rather buy a certified product just because it is.   But if an uncertified product was incredibly intuitive to use and that it would actually help their productivity so that they can spend more quality time with their patients and improve outcomes, would it offset the risk?

At this stage in the game, I obviously cannot afford to certify my product.   Even if I could afford to certify it one time (I was thinking of Kickstarting my project for the aim of certification), the whole concept of this type of certification is antithesis to the open-source way (updates, modifications, improvements, low cost).  But I think if there was a growing community of doctors along with like-minded computer programmers and developers who stand in solidarity against this rigged game and somehow these rules were reversed through political means or by sheer mass protest, I’m all for it!

What are your thoughts?