Dan Neuwirth is the CEO of MedCPU, provider of the innovative MedCPUAdvisor™ platform: with applications for decision support for clinical guidelines, Meaningful Use, and care pathways, that captures the complete clinical picture in real time, including narrative text and structured data to deliver the most accurate clinical and compliance guidance.

There’s no question that healthcare needs to adopt new technology that makes us more effective and efficient and curbs costs, like Electronic Medical Records (EMR) solutions and Clinical Decision Support (CDS) systems. In today’s world, providers of all sizes continue to find it challenging to integrate existing HIT systems with EMRs for a variety of reasons. As our industry evolves, technology solutions need to be smarter and empower seamless integration.

EMR and HIPAA guest author Susan White covers in depth how a lack of connectivity standards affects EMR integration. There are no mandated standards for EMR vendors to follow, making it hard to coordinate data sharing between medical devices and other systems (including from one EMR to another), even at the same facility. As those systems operate in disparate fashions, critical clinical information is often lost or stuck in silos. Most importantly, the information is not where clinicians need it most–at their fingertips, in an exam room, with a patient.

This lack of data sharing is a pervasive concern. One Markle report finds that roughly 80 percent of both consumers and physicians demand that hospitals and doctors be required to share information that improves coordination of care, cuts unnecessary costs, and reduces medical errors.

In 2010, more than $88 Billion were spent on developing and implementing EHRs, health information exchanges (HIEs) and other health IT initiatives. When you consider that the average 10-physician practice spends more than $137,000 per year on prior authorizations and pharmacy callbacks alone, you’ll have to agree that the lack of data integration and sharing get very costly. And although I agree with John Halamka, who recently wrote these challenges exist because healthcare is inherently more complicated than other industries, I am a strong believer that a lot of them can be overcome by the use of smart technology.

We need smart, flexible solutions, which capitalize on existing technologies and require minimal integration. Technologies that employ advanced screen extraction, for example, empower several important improvements in the clinical decision support space such as the capturing and analysis of both free and structured text. A lot of time such solutions are rendered ineffective as they either lack compatibility with leading EMR systems or are too hard to integrate.

As the industry evolves, developing robust protocols for capturing both structured and unstructured data along with standards for data integration and sharing will become increasingly important. With all the data points created on patients every day, we will need a consistent, secure, and reliable way to capture and share patient data among all systems and healthcare providers. What is your experience? What are top data capturing and integration challenges faced by your organization? Looking forward to continuing the dialog and hearing your feedback.

Lately I’ve been posting a number of tweets in a sort of Sunday Tweet roundup. I think it’s been fun to highlight some short Healthcare IT and EMR related tweets that people might find interesting. With a little bit of commentary of my own (let me know if you disagree).

Today, I decided I’d just go with a small quote from a comment that Chris Paton made over on Neil Versel’s Meaningful Healthcare IT News. Here it is:

We’re a long way from getting rid of doctors but they might find their role changes from being repository of all knowledge to being a trusted communicator and carer.

I’d been trying to summarize this position in a coherent way and I think Chris hit it on the head. Not only the part about being a long way from getting rid of doctors, but his description of doctors not being the repository of all knowledge, but instead a trusted communicator and caregiver is interesting to consider. Not to mention it’s a much better way to describe the transition than I did in my previous post about the subject.

I’m beginning to see a pattern here. Two weeks ago, I wrote about clinical decision support in context of Dr. Larry Weed’s new book. Two weeks before that, I commented about physicians worrying that patients would perceive them as being incompetent if they relied on CDS. Today, I’m back to the same topic.

Deny the obvious all you want, physicians, but clinical decision support is coming, and once it’s here, it’s not going away.

I just got back back from the new IBM Healthcare Innovation Lab in downtown Chicago, the company’s third such center in the U.S. and eighth worldwide. While kickoff included a “healthcare leadership exchange” with such thought leaders as HIMSS CEO Steve Lieber and Allscripts Healthcare Solutions Chief Innovation Officer Stanley Crane, the real star was not a person, but a computer. IBM’s Watson, to be specific.

People stayed after lunch mostly to see a demo of Watson processing healthcare data—and IBM Chief Medical Scientist Dr. Marty Kohn said this was the first audience to see this demo. Make no mistake, IBM is positioning Watson as a clinical decision support tool, particularly for the much-ignored area of diagnostic decision support.

Saying that perhaps 25 percent of all healthcare errors are errors of diagnosis, Kohn noted how getting the diagnosis right can prevent all kinds of unnecessary complications and spending. “Of course, if you’ve made the wrong diagnosis, picking the right course of treatment becomes a challenge,” Kohn said.

And after the diagnosis, Watson can prevent treatment errors by, say, scanning EMR data for patient allergies to recommend against a drug that might cause a harmful interaction, then suggest alternative therapies. Kohn presented the case of a 29-year-old pregnant woman who was diagnosed with Lyme disease. A common treatment is the antibiotic doxycyline, but Kohn noted that it’s contraindicated during pregnancy.

Watson, according to Kohn, draws preliminary conclusions according to presenting symptoms, then scans multiple sources of information to present recommendations. Watson does look at the notoriously incomplete and inaccurate Wikipedia, Kohn said, mostly because that user-edited site covers so many topics, but then verifies information from other sources.

Watson then displays reasons why it believes the diagnosis may be correct so the doctor can make an informed decision. “It won’t let you ignore all the possible diagnoses,” Kohn said. But it won’t actually make the final call. “Watson is going to be in a supportive role rather than actually making decisions.” Kohn added.

What the supercomputer does is process vast amounts of data in a short amount of time., something that even the sharpest human mind could never do. And that’s what clinical decision support is supposed to be all about.

I’m sure like many of you, I was completely intrigued by the demonstration of the Watson computer competing against the best Jeopardy! stars. It was amazing to watch not only how Watson was able to come up with the answer, but also how quickly it was able to reach the correct answer.

The hype at the IBM booth at HIMSS was really strong since it had been announced that healthcare was one of the first places that IBM wanted to work on implementing the “Watson” technology (read more about the Watson Technology in Healthcare in this AP article). Although, I found the most interesting conversation about Watson in the Nuance booth when I was talking to Dr. Nick Van Terheyden. The idea of combining the Watson technology with the voice recognition and natural language processing technologies that Nuance has available makes for a really compelling product offering.

One of the keys in the AP article above and was also mentioned by Dr. Nick from Nuance was that the Watson technology in healthcare would be applied differently than it was on Jeopardy!. In healthcare it wouldn’t try and make the decision and provide the correct answer for you. Instead, the Watson technology would be about providing you a number of possible answers and the likelihood of that answer possibly being the issue.

Some of this takes me back to Neil Versel’s posts about Clinical Decision Support and doctors resistance to CDS. There’s no doubt that the Watson technology is another form of Clinical Decision Support, but there’s little about the Watson technology which takes power away from the doctor’s decision making. It certainly could have an influence on a doctor’s ability to provide care, but that’s a great thing. Not that I want doctors constantly second guessing themselves. Not that I want doctors relying solely on the information that Watson or some other related technology provides. It’s like most clinical tools. When used properly, they can provide a great benefit to the doctor using them. When used improperly, it can lead to issues. However, it’s quite clear that Watson technology does little to take away from the decision making of doctors. In fact, I’d say it empowers doctors to do what they do better.

Personally I’m very excited to see technologies like Watson implemented in healthcare. Plus, I think we’re just at the beginning of what will be possible with this type of computing.

Sometimes it’s better to be lucky than good.

Last month, in my very first post for EMR and HIPAA, I mentioned Dr. Larry Weed in my commentary about the general public’s perception of clinical decision support. I referred to a 2007 study in the journal Medical Decision Making, which said, “Patients may surmise that a physician who uses a [decision support system] is not as capable as a physician who makes the diagnosis with no assistance from a DSS.” I then noted that Weed has been saying for more than 50 years that physicians shouldn’t have to rely on their memory to make clinical decisions when computers can help them process an increasingly voluminous knowledge base.

As it turns out, Weed read my commentary. (I’m guessing that a computer, i.e., Google Alerts, led him to the post. See, computers really can help find the information we’re looking for. Who knew?) And, as it also turns out, Weed and his son, Lincoln, a Washington, D.C.-area attorney who now consults on health privacy issues, just had their latest book, “Medicine in Denial,” published. They both contacted me last week to share this news.

“A culture of denial subverts the health care system from its foundation. The foundation—the basis for deciding what care each patient individually needs—is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new, secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical information,” reads the book’s opening paragraph.

Yep, that sounds like clinical decision support to me.

“Deep disorder pervades medical practice. Disguised in euphemisms like ‘clinical judgment’ and ‘evidence-based medicine,’ disorder exists because medical practice lacks a true system of care. The missing system has two core elements: standards of care for managing clinical information, and electronic information tools designed to implement those standards. Electronic information tools are now widely discussed, but the necessary standards of care are still widely ignored,” reads the book’s description.

The Weeds believe current EHR systems don’t measure up, and they said so in comments submitted in response to the December 2010 President’s Council of Advisors on Science and Technology (PCAST) report on health IT, which recommended against standardizing EHR formats. “Sound standards for the structure of medical records provide essential standards of care for managing clinical information.  Medical practice needs these standards no less than the domain of commerce needs accounting standards for managing financial information.  Failure of recognize this principle is a root cause of health care’s failures of quality and economy,”  the Weeds said in their comments.

It’s a principle that Larry Weed, 88, has been advocating since he developed the problem-oriented medical record in the 1950s. In 1991, the Institute of Medicine report, “The Computer-Based Patient Record:  An Essential Technology for Health Care,” (revised 1997) said that the problem-oriented medical record “reflects an orderly process of problem solving, a heuristic that aids in identifying, managing and resolving patients’ problems.”

And 20 years later, medicine hasn’t changed much. Perhaps, though, it takes longer than that. Lincoln Weed also referenced a story I wrote for InformationWeek on May 10. I noted that the Consumer Partnership for eHealth’s Consumer Platform for Health IT referred to consumers as “”the most significant untapped resource” in healthcare.

Well, wouldn’t you know, Larry Weed has written the following: “patients are the largest untapped resource in medical care today.” That was from his book, “Medical Records, Medical Education, and Patient Care”. That book was published in 1969.

Instead of ending this post on a down note, let me just add that I would have had an interview with Dr. Weed this week, but he just left the country for a speaking engagement. He’s 88 and still traversing the globe, fighting for what he believes in. Don’t we all wish we had that kind of passion?

One of my favorite conference speakers, Lexington, S.C., family physician Allen Wenner, M.D., who created Primetime Software’s Instant Medical History software, often jokes that many of his contemporaries “need to die” before we see much change in the way physicians practice medicine. I’m increasingly convinced that he’s right.

It’s, of course, older doctors, that seem to be the most resistant to change. They also happen to be the ones most likely to hold leadership positions, if for no other reason than their seniority.

That’s why I’m so troubled by the attitude of physicians such as Arvind Goyal, M.D., a family physician in Rolling Meadows, Ill., who’s on the faculty of Chicago Medical School/Rosalind Franklin University in North Chicago, Ill., and is a past president of the Illinois State Medical Society. Last week, the Chicago Tribune published a lengthy, scathing letter from Goyal, in which he thoroughly trashed electronic medical records based on a negative experience he had with “a popular brand of EMR” at a Federally Qualified Community Health Center.

Goyal brought up some salient points about what can go wrong with a poorly implemented EMR. “The system was slow generally, froze up a few times a day and crashed every few months, requiring us to reschedule patients. Pricey service calls, multiple system updates, periodic shutdowns, user training and hiring of a full-time IT expert at a significant cost helped some, but the dissatisfaction persisted,” he wrote.

He ticked off the standard laundry list of why physicians struggle with EMRs, including the argument that “documentation and accessibility of information in EMR is more time-consuming than paper records.” Forgive me if I’m wrong, but that sounds like a workflow problem more than a technology problem.

“Federal incentives for adoption of EMRs come with complicated bureaucratic requirements,” he added. Perhaps, but will you still be making that argument when Medicare and then private payers start requiring EMR usage as a condition of reimbursement?

“Data backup is a prudent need and often requires an additional investment.” Well, duh, but isn’t that true of your home computer as well? Your practice management systems?

But Goyal really stepped over the line when he repeated one of the greatest fallacies in medicine, that doctors know all.

“In my successful suburban solo family practice of several years, I did not use electronic medical records. Knowledge of each patient I served was on the tip of my tongue when an emergency-room doctor seeing one of my patients called in the middle of a night. I was available 24/7 with few exceptions. The paper records were organized such that I was able to access clinical details quickly when needed,” Goyal wrote.

How can knowledge of each patient be on the tip of his tongue if he’s woken up in the middle of the night and his precious paper files aren’t right there next to his bed? Is his memory that good that he knows every pertinent detail of every patient, even when still in a haze from an unexpected wake-up call? Yeah, nice try.

Furthermore, it’s great that Goyal is available to other doctors around the clock in case of an emergency, but is he available to patients? Medicine is changing. It’s supposed to be about patients, not physicians. But some physicians still wrongly believe they know everything and will do just about anything to cling to the status quo.

In case you haven’t noticed, the status quo isn’t so good.

Yet again, someone needs to educate the general public about healthcare in general and health IT in particular.

HealthLeaders last week asked the question, “Does Decision Support Make Docs Look Dumb?” The story, apparently based on a 2007 study (not 2008, as HealthLeaders reported) in the journal Medical Decision Making, says: “Most clinicians would agree that evidence-based decision support tools have the potential to improve clinical quality. But patients’ perception of the tools—and the physicians who use them—might be yet another barrier to their adoption. The problem is twofold: Some patients are skeptical of docs who need a computer to help them make a diagnosis. And some physicians don’t want to be seen as being too reliant on technology.”

We’ve long known that physicians have resisted clinical decision support, for a variety of reasons. They trust their professional judgment. When they only have a few minutes with each patient, they believe it simply takes too long to look up information that might help reach a more accurate diagnosis or devise a better care plan. The technology simply isn’t up to snuff. Or there isn’t enough electronic data available on each patient for CDS to have a positive effect.

But to read the conclusion of that Medical Decision Making study is to see an entirely different excuse for shunning clinical decision support: “Patients may surmise that a physician who uses a [decision support system] is not as capable as a physician who makes the diagnosis with no assistance from a DSS.”

HealthLeaders interviews other clinicians and researchers who have found similar sentiments. “Patients object when they ask their doctor a question and then she or he immediately types in the question into their laptop and then reads back the answer. It gives patients the feeling that they just paid a $25 copay to have someone Google something for them,” Illinois State University information systems professor James Wolf tells the publication.

“Physicians are reluctant to adopt computer-based diagnostic decision aids, in part due to the fear of losing the respect of patients and colleagues,” Wolf adds.

If this is true, it represents failures on many levels. IT systems designers haven’t made their technology easy to use. Physicians and healthcare entities haven’t done a good job educating patients and journalists like myself have truly failed the public by continuing to feed them false expectations about healthcare.

First off, Wolf’s statement that patients feel like they wasted only a $25 copay perpetuates the myth that a physician office visit only costs $25. If patients think they may have wasted $25, how do you think insurance companies and employers must feel that another $150 of their money went out the window?

The part about losing respect is perhaps more troubling. Physicians need to put their fragile egos away and do whatever they need to do to provide better care. The status quo just isn’t cutting it.

I’ve had the distinct honor of interviewing Dr. Larry Weed on several occasions. Weed, the octogenarian inventor of the problem-oriented medical record and the SOAP note, has been calling for CDS and other IT for more than half a century. Yes, more than half a century. He’s been actively working on such technology since the early 1970s. In a 2009 interview with the Permanente Journal, Weed said:

Computer technology maximized access to voluminous data and knowledge, thereby exposing the limited information processing capacity of the human mind. Scientists cope with this limitation by controlling the research environment, defining the variables involved, and limiting the scope of their investigations. Practicing physicians do not have that luxury. The time constraints of practice and the enormous scope of information implicated by multiple problems in unique patients make it impossible for the human mind to function with scientific rigor. Physicians inevitably resort to dangerous cognitive shortcuts.

I realized that medicine must transition from an era where knowledge and information processing capacity resides inside a physician’s head to a new day where information technology would provide knowledge and the processing capacity to apply it to detailed patient data. The physicians’ unaided minds are incapable of recalling all the necessary knowledge from the literature and processing it with data from the unique patient. An epidemic of errors and waste is occurring as we persist in trying to do the impossible. Changing this requires that we recognize the crucial distinction between electronic access to information and electronic processing of information. This requires a rational standard of data organization in medical records. Yet, these points are still not recognized in most current discussions of health information technology.

As a result, I have been involved for the last 60 years in trying to design and develop a medical care system in which patients are no longer dependent on the limited, personal knowledge their caregivers happen to possess. The medical care system must resemble the transportation system, where consumers use knowledge captured in maps, road signs, computerized navigation devices, and the like at the time of need. Patients, like travelers, will be expected from childhood on to develop the necessary skills to navigate the system.

At all times, patients should be supported by caregivers who are highly trained in the necessary hands-on skills, like removing the appendix or listening to heart sounds, just as in the travel system there are pilots, mechanics, air-traffic controllers, and others who perform functions that travelers cannot perform.

Yet, few outside of academic medicine have ever heard of Weed and his pioneering work. Instead, we rely on shoddy reporting and sound bites designed to score political points to shape our opinions. Why do you think the debate around “healthcare reform” focused so much on insurance coverage rather than actual care? And why do you think patients still believe office visits and prescriptions really cost just $10 or $20 or $30? And why do so many people still expect their physicians to know everything?

We must do better.

Since I know I have a number of EMR vendors that read this blog, I know they’ll be interested to learn the news coming out of Wolters Kluwer Health about a new clinical decision support (CDS) offering called Medi-Span Clinical. Here’s a part of the press release announcement:

Wolters Kluwer Health, a leading global provider of information for healthcare professionals and students, today unveiled Medi-Span® Clinical, a robust clinical decision support (CDS) platform that delivers the functionality, interoperability and medication-related CDS necessary to advance the practice of evidence-based medicine and to achieve meaningful use of health IT.

From the looks of their website page about Medi-Span Clinical, this looks like it’s the announcement of the features that they have listed nicely as “launching in 2010.”

APIs OFFERING CLINICAL DECISION SUPPORT
SCREENING INFORMATION LAUNCHING IN 2010
Drug Interactions™ API
Route Contraindications™ API
Drug Allergy™ API
Duplicate Therapy™ API
Dose Screening and Drug Orders™ API
Drug Disease Contraindications™ API
Pregnancy, Lactation, Age and Gender™ API

APIs OFFERING CLINICAL DECISION SUPPORT
REFERENCE INFORMATION
Trissel’s IV-CHEK™ API
Integrated MedFacts Module™ API
Integrated Drug Facts and Comparisons™ API
Drug Image and Imprint™ API

That’s quite a robust offering of services that can really benefit an EMR. I tried really hard to get our EMR to implement Medispan since that’s what our pharmacy uses. Unfortunately, they chose to integrate a different drug database mostly because of cost of Medi-Span I believe. We’ll see if they are regretting that after announcements like this.

I know there are a number of interesting API services like this out there. I’d be interested to hear more about EMR vendor and users experiences with the other people in the industry.

One other interesting piece from the press release:

“In addition to unprecedented interoperability, Medi-Span Clinical delivers advanced end-user controls over alerts and warnings that reduce the risk of ‘alert fatigue’ and drive adoption at the point-of-care,” said Subramanian. “By deploying Medi-Span Clinical within their EMRs, providers and vendors alike are able to advance the meaningful use of health IT and provide clinicians with the advanced point-of-care CDS they will actively embrace.”

I think that a third party service offering like this can really help an EMR vendor. It kind of makes sense to have it separated, but tightly integrated through an API. I’m sure it’s all a bit technical for many readers of my blog, but let’s just say it’s a good thing for the EMR industry for these capabilities to continue to improve.

Also, it should help an EMR vendor meet some of the meaningful use guidelines. Although, it does seem a bit gratuitous to use the buzzword meaningful use like this. I wonder if I’ll get any press releases that won’t include that term somewhere.

“Physician order entry and decision support I believe offer the most chance of improving healthcare delivery. There are a lot of information systems with bells and whistles that don’t focus on physicians’ real needs.” – Neil R. Powe, MD, MPH, MBA, Chief of Medical Services, San Francisco General Hospital source

I previously posted about the benefits of EMR interoperability. The above quote touts Physician order entry and clinical decision support as the most likely to improve healthcare. Are these the three most promising features of an EMR or is there something they’re missing? What’s the killer feature of an EMR that will make every doctor implement an EMR whether they like it or not?

Clinical Decision Support has been called out as an important part of an EMR system. You’ll get no argument from me on this. What I have been thinking a lot about is what people call “Alert Fatigue.” For those unfamiliar with the term, it basically means that a doctor gets so many alerts that they grow numb to the alerts and stop looking at them. For those that are married, it’s like your wife’s nagging. It happens so much that you stop listening (ok, that was a joke. I hope none of us do that or have reached that point. I’m just lucky to have a wife who doesn’t nag).

I think this concept of “alert fatigue” is really important and I think it will be impossible to create an EMR that strikes the perfect balance. Some EMR offer too many alerts and some probably offer too few. So, my question for you is which side should we adopt? Is it better to have too many alerts which doctors then might ignore or is it better to have too few alerts and not be alerted to something important?

There’s some real challenging issues associated with both. Liability unfortunately being a major part of each. Where do you stand on this issue?