Comments on: Health Care IT — An Evolution or Revolution?

By: Grant Peterson, J.D.

Grant Peterson, J.D. — Mon, 03 Nov 2008 20:53:51 +0000

Your summary regarding regarding the Bill Gtaes Wall Street Journal article…”If Bill Gates is serious about this space, he’ll spend some time thinking about how we educate physicians, organize care delivery and study performance before he worries about IT” is compelling.

As a HIPAA consultant, I find clients confused, upset and frustrated by HIPAA regulations. In case after case, I have found the greatest part of my consulting is an educational effort…the results of which leave a healthcare client understanding HIPAA regulations, aware of how those regulations can benefit the organization and appreciative of a framework for conducting their security practices. In short, following precisely your prescription…thinking about how we educate physicians, organize care delivery and study performance.

Read more at HIPAA Vital Signs http://www.dgpeterson.com

Grant Peterson, J.D.
HIPAA Consultant

By: Howard C. Berkowitz

Howard C. Berkowitz — Mon, 18 Aug 2008 19:15:12 +0000

Wearing my system architect hat, my mantra has always been “what is the problem you are trying to solve?” Switching to the clinical analyst hat, I would argue that an EHR, by itself, solves nothing. What does solve problems is to think about the information a clinician needs to see, or record, during typical encounters.

From the software specification side, this is a use case. Use cases, however, go only so far; they don’t reflect the added value that could come from EHR information in a broader context.

Over the last year or two, I’ve been experimenting with how best to present information, and make it easy to focus the encounter, to be sure the appropriate actions are taken, and there’s a decent way to see patterns in data. Much of the recent work has been presenting physicians, in office practice, with a complex medical record in a structured way.

For example, the first page lists reasons for the encounter, with goals. While I haven’t seen it used to any great extent, and I fully understand that a reasonable number of people have impaired color vision, I find it well-received, for patients with multisystem disease, to color-code by system (e.g., red for cardiology, green for endocrinology). The color code is consistent through:
*Goals for encounter
*Current medications and therapies
*Laboratory or patient-measured values (I find having trending, or some statistical analysis, very useful here)
*A checklist of probable actions, such as prescription renewals, consulting referrals, etc. When these will go to different people, such as a nurse for pharmacy contact and a clerk for referrals, these usefully are on different pieces of paper, so they can be passed out.
*Significant previous medical history and labs, as a backup.

Now, all of those things involved data with the EHR, but I’m not showing clinicians the EHR, but what it can do for them.

In the managed care environment, anything that can cut administration is welcomed. There are some very simple additions to prescribing software that no one seems to use. Already in the EHR is the patient’s benefits manager. Most benefits managers have formularies, yet I have never seen a e-prescribing system that checks if the drug order is in the formulary. Being warned that a drug won’t be approved is most efficient at prescribing time, so a substitute can be suggested, or, if there’s a need for justification, the process can start immediately, rather than waiting for refusals and back-and-forth with the patient, pharmacy, PBM, and clinician.

How can we best present “this is what the EHR can do for you” rather than “we will create an EHR?”

By: William Hill

William Hill — Tue, 18 Dec 2007 07:16:48 +0000

Nice post! I’m a huge Bill Gates fan.

By: Liz

Liz — Wed, 21 Nov 2007 18:13:47 +0000

I enjoyed your post very much. EMR is an important topic right now and the more businesspeople like Bill Gates start to see the potential of EMRs, the faster the profession is going to have to work to keep up. In regards to your comment that physicians, being autonomous performers, are inherently resistant, I wonder if it would be best to begin the transition to EMR by reaching physicians before they realize their autonomy- during their training. We’ve already proven time and again that our country doesn’t do well with incremental change (see health care reform, decimal system…) and clearly the transition will be not only beneficial but necessary for congruence between physicians, health insurance companies, and other providers. Teaching hospitals are a great place to introduce the technology both to practicing physicans and to students who can then use their knowledge some day in their own practices.

By: Pal

Pal — Tue, 20 Nov 2007 01:56:24 +0000

Agree with you. And don’t forget the nurses, nurse practitioners, physician assistants, medical records staff and others. I know of one very large practice where the physicians (and no one else) were “consulted” on EHR implementation. The roll out was a total and complete (and expensive) failure because the organization did not consult with the heaviest users of the EHR (and the paper records).
Also, in the health care space, we are all “learners” and should be. As you know, health plans don’t approach their daily mission and business challenges standing in the shoes of a nurse or a hospital CEO or a consumer. We should all trade places occasionally and the industry would be better off. We need constant education to understand and respect the perspectives of all stakeholders in the health care arena.
I think there is plenty of room in this space for you — and Bill Gates. : ) I just hope he truly steps into the arena, as you have. Your thoughtfulness and insight constantly raise the bar.

By: Maggie Mahar

Maggie Mahar — Fri, 09 Nov 2007 17:22:29 +0000

I agree completely; until doctors recognize that 21st century medicine must be a team sport, shared medical records won’t create the collaboration we need.
On other hand, EMR can reveal who isn’t playing with the team. When I wrote my book, one solo practioner who I interviewed said “I don’t want someone looking over my shoulder.”
With electronic medical records, someone is looking over your shoulder, seeing what you’re doing and what you’re not doing. (Even if the EMR is shared by doctors in separate practices who are only linked electronically).
And if you’re ignoring what other doctors are doing (in terms of prescribing, etc.) someone is likely to call you on it–in a collegial way. (Or at least that’s what one would hope.)
That does happen at places like the VA and Kaiser.
By contrast, no one knows what the many solo or small group specialists in Manhattan are doing. Are they practicing good medicine? Some are; some aren’t.
Finally, I think the large multi-speciality group practice will ultimately become the norm in many places simply because, given the cost of real estate, not to mention IT, it’s getting harder and harder for a small group practice to stay afloat.

By: Susan L

Susan L — Fri, 09 Nov 2007 13:41:46 +0000

To the extent to which Bill Gates wants to help “put people at the center of the health-care system, and put them in control of all their health care information,” bravo Bill Gates.

Also, if I may be forgiven for mentioning it, about this 1300 member doctors group in Dallas–aren’t such groups as these, with their increase in market power, responsible for an important share of the rise in health costs recently? So I don’t really see their advocates as disinterested.

By: Hiram

Hiram — Thu, 08 Nov 2007 13:56:13 +0000

Charlie,

Let me first say that IT is not the ’solution’ for anything, regardless of what the salesman says to you. Information Technology is simply a tool that enables a solution. Hint: That solution must be designed BEFORE you slap an IT tool on top of a problem. Otherwise - bigger problem! But you need to know what the problem is before you can solve it. You say it’s organizational. I say you are on the right track, but it’s bigger than that. Waaay bigger. Organizational implies roles & responsibilities. But, we need to define - at the very least - the organization’s purpose before we can assign any roles. Let me illustrate. Dr. Landes said: “the EMR is not the point of the patient encounter.” I agree. However, here is logical question #1 (BTW, I love questions): “So, what exactly is the point of the patient encounter?” And (once we have answer #1), here is logical question #2: “OK, what do we need to do to ensure that the encounter fulfills it’s intended purpose (the point)?” And (once we have answer #2), here is logical question #3: “How do we measure the success of that encounter?” The reason we are having such difficulties is because there is NO consensus among the protagonists of Health Care on the answers to those 3 fundamental questions. Go ahead, ask around. Ask the primary care Drs, ask the health insurance folks (you know them), ask the patients, ask the hospital administrators, ask the lab technician, ask the nurses, ask the politicians, ask the software manufacturers, ask the investors, ask the drug companies, etc. Not until those questions are answered FIRST and we have consensus at the our health care leadership level can we begin to develop the processes that will form a viable health care infrastructure (read: The solution) and then develop an organization to support that model and (lastly) slap an IT tool to enable the whole thing to work (faster).

Pretty monumental you say? Yes. That is exactly why it is such a monumental problem, or should I say… “wicked”?

By: TD

TD — Thu, 08 Nov 2007 12:09:02 +0000

Excellent post.

By: Dr. Val

Dr. Val — Tue, 06 Nov 2007 19:46:34 +0000

Very well said.