In many of our Meaningful Use Monday series we focused on a lot of the details around the meaningful use regulations. In this post I want to highlight one of the strategies that I’ve seen a bunch of EHR vendors and other EHR related companies employing to meet Meaningful Use. It’s an interesting concept that will be exciting to see play out.

The idea is what many are calling clinical data abstraction. I’ve actually heard some people refer to it as other names as well, but clinical data abstraction is the one that I like most.

I’ve seen two main types of clinical data abstraction. One is the automated clinical data abstraction. The other is manual clinical data abstraction. The first type is where your computer or server goes through the clinical content and using some combination of natural language processing (NLP) or other technology it identifies the important clinical data elements in a narrative passage. The second type is where a trained medical professional pulls out the various clinical data elements.

I asked one vendor that is working on clinical data abstraction whether they thought that the automated, computer generated clinical abstraction would be the predominate means or whether some manual abstraction will always be necessary. They were confident that we could get there with the automated computer abstraction of the clinical data. I’m not so confident. I think like transcription the computer could help speed up the abstraction, but there might still need to be someone who checks and verifies the data abstraction.

Why does this matter for meaningful use?
One of the challenges for meaningful use is that it really wants to know that you’ve documented certain discrete data elements. It’s not enough for you to just document the smoking status in a narrative paragraph. You have to not only document the smoking status, but your EMR has to have a way to report that you have documented the various meaningful use measures. In comes clinical data abstraction.

Proponents of clinical data abstraction argue that clinical data abstraction provides the best of both worlds: narrative with discrete data elements. It’s an interesting argument to make since many doctors love to see and read the narrative. However, all indications are that we need discrete data elements in order to improve patient care and see some of the other benefits of capturing all this healthcare data. In fact, the future Smart EMR that I wrote about before won’t be possible without these discrete healthcare data elements.

So far I believe that most people who have shown meaningful use haven’t used clinical data abstraction to meet the various meaningful use measures. Although, it’s an intriguing story to tell and could be an interesting way for doctors to meet meaningful use while minimizing changes to their workflow.

Side Note: Clinical data abstraction is also becoming popular when scanning old paper charts into your EHR. Although, that’s a topic for a future post.

I always love when people talk about the paperless medical office. It’s as if they believe that after implementing an EMR they will no longer have to have paper in the office. Turns out, EMR software can print out a lot of paper if you’re not careful.

While ePrescribing is on the horizon in many places, the harsh reality is that many still have to print out prescriptions. Add in the requirements around prescribing controlled substances and in almost every state doctors using an EMR are still having to print out prescriptions.

In my clinic, it always felt wrong to print out an entire sheet of paper for one prescription. Eventually we got our vendor to support printing out multiple prescriptions on one sheet of paper. That helped, but many patients only need one prescription so that’s a lot of wasted paper. Beyond the green movement, wasted paper = wasted money.

With this background, that’s why I was intrigued by the DYMO Prescription Printer that I saw at MGMA. I’d worked with DYMO label printers before since the lab I worked with printed off lab labels directly from our EMR software. It makes sense that they could use a little bit larger printer and do the same thing with prescriptions.

It’s pretty obvious to see the paper saving benefits of using a DYMO printer like this, but I think the other advantage to this printer is its size. The printer has such a small footprint that you could easily put it a lot of places that a standard printer just won’t fit.

I admit that I haven’t done a full analysis of the savings using this printer compared with a standard printer. However, the nice thing about the DYMO printers is that they’re thermal printers which means that you’ll never have to spend money on ink or toner to print prescriptions. That’s pretty nice.

I’d love to have some of my readers try out the DYMO Prescription Printer to let me know what they think and whether they think I should add it to my list of EMR related technology products. Maybe I should see if DYMO will give one away to one of my readers to try out and report back.

I always love when small adjustments to current technology can make a huge difference. Or in other words, did I just write a post about a label printer? Sometimes the best innovations are subtle changes.

UPDATE: I just got word that DYMO will be happy to provide a product for review. So, drop me a line on my Contact Us page if you’re interested in trying it in your clinic.

Yesterday, I created a post on EMR & EHR called The Must Have EMR Feature – An iPad Interface. that post has driven quite a bit of discussion on Twitter and Google Plus. One comment from @2charlie hit me the most though:

2charlie – Charlie Gaddy
A decent web interface wouldn’t hurt either. RT @ehrandhit: The Must Have EMR Feature – An iPad Interface dlvr.it/tYkN7

Charlie’s twitter response highlights a number of interesting ideas. The first point that every SaaS EHR company will point out is that he said a web interface. We could go into the semantics of what is “the web”, but I have little doubt that Charlie meant a browser based interface when he said web. I’ll leave the rest of the discussion of “web” EMR interfaces for another post (plus, we’ve had that discussion many times on this site).

Instead, I want to focus on his use of the word “decent.” That adjective is interesting because no one would really argue that there aren’t plenty of web EMR interfaces out there. If you look at the EHR Scope EMR Comparison site, you’ll see a huge number of web based EMR companies listed. However, when you add the word “decent” to web EMR interface, I think we could have some really interesting discussion.

At least a couple times a week I get a doctor sending me an email or posting a comment on my website saying that “all of the EMR interfaces are terrible.” I don’t necessarily agree that “all” EMR interfaces are terrible, but a lot of them do fit the description quite well. I’m sure at this point all the EMR companies are thinking about their competitors and agreeing with me.

The iPad Opportunity for EMR Interfaces
As I thought on Charlie’s comment of a “decent web interface” as compared with an iPad EMR interface, I realized that the iPad provides a unique opportunity for EMR vendors with less than stellar web interfaces. While it would be great for EMR vendors to create stellar web interfaces or improve their current web interfaces, that’s much easier said than done. Many are working on older technologies. Others have so much company culture built into their interface that it’s hard to change. Many have large user bases that will freak out at the idea of a new web interface. Etc etc etc! The point being that the culture and history of many EMR interfaces make it hard to change.

In these cases, I see the iPad as a great opportunity to start fresh with your EMR interface. Many EHR vendors could use the iPad as a way to be able to create a new interface for their EMR with all the knowledge they’ve learned over the years baked in. Doctors expect the iPad interface to be different and unique.

I’ll be interested to see which EMR companies take this opportunity and make something of it. It’s the perfect chance for EMR companies to create a paradigm shift in their EMR software without having to admit publicly the mistakes they made in their first EMR interface. Unless you happen to be from an EHR company who built the perfect EMR interface from the start. Then, this need not apply.

Today at MGMA, Fujitsu together with Osmosyz announced a new scanner that supports the relatively new CDA “Unstructured Document” HL7 standard at MGMA 2011. I must admit that the press release is a little intense. However, I find what they’re doing with a hardware product to support HIE is quite interesting.

I don’t want the title of this post to be misleading. While certainly HIE has generally become synonymous with some large health information exchange entity, in this case I’m describing a hardware device (a smart scanner if you will) that acts as a small health information exchange. Basically, it’s more along the lines of Direct Project as opposed to NHIN. Although, I imagine that it could send the documents to some larger health information exchange if someone wanted to do so.

The larger application I see of this technology is as a replacement for the fax machine. In some ways, it’s like a second generation fax machine. The major differentiation I see between a document sent using the CDA “Unstructured Document” HL7 standard and a fax is all the meta data that comes with the CDA document.

The fax or scanning workflow for most EHR software consists of receiving faxed documents or scanning documents into what amounts to basically a bucket of all the scanned documents. Then, it’s up to the user to go in and sort through all the various faxes that have been received or documents that have been scanned. At this point, the user can assign the document to a patient in the EHR. You can imagine the challenges that this can pose. I wonder how many documents scanned or faxed into an EHR have been assigned to the wrong patient accidentally.

That’s what makes this new Fujitsu scanner quite interesting. If it’s receiving the document from an outside source, it will come with the meta information for the document as part of the CDA standard. That can then be leveraged to more quickly assign that document to the patient. Not to mention, then all of that CDA information is available for other uses within the EHR.

For inside documents that are scanned in through the Fujitsu device you can actually assign the document to a patient on the scanner itself. That’s right, you can identify which patient a scanned document belongs to while you’re holding the document in your hand. A much better way to ensure that the document you scanned gets attached to the right patient in your EHR.

I’m just touching on a few of the features of what’s possible with this new Smart Scanner from Fujitsu and smart documents. You can do other things on the scanner like dividing document scans between multiple patients.

Meaningful Use Monday Angle
Of course, as most of you know, on Monday we usually do our regular Meaningful Use Monday series. Turns out that the CDA Clinical Document standard that I discuss above is being adopted by ONC as part of meaningful use. I’ll be interested to see how this plays out over time, but don’t be surprised if EHR software has to support this standard in the future.

What I find more intriguing is that the above scanner could be used by someone who doesn’t have an EHR, but wants to exchange patient information. I still think that the long term solution to interoperability of patient information has got to come from connections with EHR software. However, this does illustrate that technology solutions can and will be created to exchange health information. In fact, some combination of these solutions could be a way to meet some of the meaningful use requirements around exchange of health information. You still can’t get the EHR stimulus money without an EHR, but technologies like this could help you achieve meaningful use.

I’ll keep an eye on how this technology progresses. I wonder how many EHR vendors will integrate with this type of technology. Whether we like it or not, documents are going to be a major part of healthcare for the foreseeable future. We’ll see if smart documents and smart scanners are an intermediate step to the health information exchange nirvana (whatever that might be).

Just the other day I was at a local Vegas Tech event and happened to run into a government contractor that worked in IT. As we got talking I told him about my work with EMR and EHR. Once he heard those terms he started to recount his experience evaluating a contract position where he was to work at connecting the VA system with another government entity. He then said, did you know that the VA software runs on something called MUMPS?

Of course I’ve heard all about MUMPS and so I told him how a huge portion of healthcare IT is run on the back of MUMPS (My understanding is that Epic uses MUMPS as well). Obviously, MUMPS has its benefits since it’s gotten us this far. I even remember some past threads where people have argued some of the advantages of MUMPS over newer database technology. However, I still stand in the camp that wonders how we’re going to get off MUMPS so we can enjoy the benefits of some newer, more innovative technology.

Something called the Axial Project basically asked this same question back in March 2011 when they posted about how to Architect Vista for 2011 (which is possible since Vista is open source). They provided a really insightful look into why MUMPS has done well in healthcare and what current technologies could replace it. Here’s that section:

So if I were starting a Healthcare IT company would I invest in building on Mumps/M? No. There might be some business in supporting legacy applications, but very little innovation. I am not attacking Mumps/M from a technical perspective, I am trying to be pragmatic as a business person. So we need find an alternative. So you probably think I am going to say MS SQL Server or Oracle thinking I want that 100/hr price tag. Thanks, but no thanks. So I am not in it for the money, I must go the other way. PostgreSQL or MySQL. Intriguing, but still a no go. I have learned over the past 18 months that Healthcare data has very little integrity. One of the reasons I believe Mumps/M has excelled. Storing objects vs Storing relationships in normalized structures is not valuable to this market. Too many views of the data are required depending on your role you play in the system. I would try to use a NoSQL database like MongoDB, Cassandra, or CouchDB. My preference would be MongoDB because there are drivers for Ruby, Java, .NET, and Python. Also, these systems are truly data entry/reporting tools at their core. I need strong query support which MongoDB has through it’s BSON data structures without a ton of map/reduce requirements. So let’s go back to finding some resources that can help.

The part that struck me was when it said, “I have learned over the past 18 months that Healthcare data has very little integrity.” That makes a lot of sense and explains why a NoSQL solution could work well.

Turns out, Axial Exchange has brought on the previous COO of RedHat, Joanne Rohde, to work on the project. Check out Axial Exchange’s presentation at Mogenthaler’s DC to VC 2011:

Looks like Axial has shifted from redesigning Vista, but they’re working on some interesting stuff.

What do you see as the future of MUMPS in healthcare?

Time again for my weekly round up of healthcare IT and EMR related tweets. Plus, a few thoughts from me about the various tweets.

@Craigley
Craig Bradley
I need a Watson robot in the room to be my knowledge/evidence coach & also EMR scribe while I listen/touch/care. @SeattleMamaDoc #chc11

The good news for Craig is that I’ve seen the people from IBM that did Watson working with the people from Nuance (most famous for Dragon Naturally Speaking) working on this. I don’t think it’s that far away.

@nickgenes
borborygmi
First real recommendation: have good backup plan when #EMR goes down; one makpractice case was lost by inadequate downtime system #SA11

This was pretty interesting. I’d love to learn more details about this malpractice case. No doubt you have to work on a proper system to handle EMR down time. I’ve written before about all the ways you could have EMR down time and the cost of EHR down time. It’s not a question of IF you will have EHR down time, but WHEN.

@JBikman
Jeremy Bikman
I’m very excited to see what Orion can become w/ Amalga HIS. My hope is that they emerge as a legit EHR/EPR/HIE player globally. Very cool.

This is interesting news since Orion is focused on the Asia Pacific market. Coincidentally, I’m just finalizing the details of me attending a Healthcare Informatics Conference in Thailand in March 2012. I’m interested to learn a lot more about Asia. You can read more about the Orion Health Deal for Amalga here.

@EMRDailyNews
EMR Daily News
Over 60 EMR / #EHR Apps Now Available in the iTunes App Store su.pr/1tfhMG

64 iPhone EHR apps on the app store. In February there were only 5 EMR apps in the Android marketplace. I’m sure there are a whole lot more now. Plus, the number of apps in the app store is a bit flawed since it’s not like people purchase their EHR software on the app store. However, it’s interesting to see how many are putting it there.

Guest Post: This is a sponsored guest post written by James Taylor and provided by GFI FaxMaker.

HIPAA requirements are becoming a part of every technology discussion, especially within the healthcare industry. One of the biggest pain points for both doctors and dentists is faxing. The HIPAA requirements for faxing EMR/EHR records are fairly straightforward, and also fairly onerous and time consuming, and healthcare organizations are looking for better ways to do faxing. This is where GFI’s fax server software, GFI FaxMaker, steps into the scene.

Installation

Installation is easy, though it does require a domain admin account (more on that below). It can use a fax modem, FoIP SaaS service from Brooktrout, or ISDN lines, and can be installed right on your Exchange server or integrate with Exchange (or other email systems) using an SMTP connector. Install gets a 9/10.

Integration

GFI FaxMaker almost sells itself just in how easily it can be integrated into practically any client’s existing infrastructure, whether they are a private practice, or part of a huge hospital network. The email to fax and print to fax capabilities make it easy for end-users to send faxes, and helps to ensure HIPAA compliance in several ways; these include:

1. Fax numbers can be pulled from the email client address book (GAL),
2. Delivery confirmation reports can be automatically generated and stored with the sent faxes,
3. Incoming faxes are delivered directly to the recipient; no paper left lying around, and no need for the user to go stand by the fax machine waiting for an incoming fax,
4. Faxes can be stored as PDF or TIFF, and routed to network shares. Practically any client’s medical records program for EMH/EHR can consume these with no need for extra work making this another way to plug directly in to programs without needing to write any code.
5. The ability to ‘print to fax’ makes every Windows program my clients use ‘fax capable’
   
   Share the printer and clients can just double-click it to start faxing from any application.

making it so easy to plug into existing infrastructure earns this a 9/10.

Fax routing flexibility

GFI FaxMaker’s routing capabilities are its best feature. You can automatically deliver faxes to users, network folders, or printers, based on several different attributes including:

If your senders’ fax machines identify themselves by CSID, you can route using that, or you can set up extensions for each user without having to get dedicated lines. Of course, it can use dedicated lines too. OCR rocks, since it can scan for the recipient’s name and deliver the fax by ‘reading’ the To: line on a cover page or finding a keyword in the body of the fax. Just don’t expect it to decipher a doctor’s handwriting.

It can also automatically archive inbound and outbound faxes as PDF or TIFF format, making it easy to import faxes into other programs or to keep a secured archive.

Most organizations are very big on electronic archiving, and they don’t have the budget to get every single doctor and PA in the practice their own fax number, so I give this a 9/10.

What I like

GFI FaxMaker installs very easily, integrates with every email environment without having to install anything on the mail server, and sets up a shared printer so users can simply print to fax. It is easy to setup, easy to understand, and just works. Getting rid of the fax machines, the stocks of ink, and all the paper left lying around that goes along with a traditional fax is great, and with no more incoming faxes hitting the output tray, there’s no chance of confidential patient information (EMR/EHR) being at risk. Considering how big a concern that is for HIPAA compliance, and how little space most offices have to ‘secure’ a traditional fax machine, this is a huge benefit and earns GFI FaxMaker a 10/10 for convenience and compliance.

What I don’t like

The one thing I don’t care for is that GFI FaxMaker wants to run under the account of a domain admin. Small offices running SBS don’t seem to care, but hospitals with Information Security departments take exception to this. Two things; no software should want to run as a domain admin, and any software that isn’t going to run as system ought to run under a service account. If you let it run under your user account, it will break in a couple of months when you change your password. In terms of how I rate this product, that counts off more than anything else.

I would also prefer the print drivers to be signed by Microsoft; I know that takes time, but it is a jarring warning in bold red when you go to install it on a Windows server.

The bottom line

GFI FaxMaker is an excellent faxing solution for health care organizations, whether they are private practice or attached to major medical centers. It’s easy to use, is able to integrate into existing systems, and contributes to HIPAA compliance – making itself a great solution on its own merits; the amount of time, money, and administrative support it saves your IT support helps it pay for itself in no time. I rate it a very strong 9/10, and bet you will too.

With all that it has to offer, GFI FaxMaker may be the best new application your healthcare practice has ever seen. But don’t just base it on my great experience, see for yourself.

There’s been an interesting situation going on between a couple EHR vendors. I first saw this when I got the press release that meridianEMR filed a lawsuit against UroChart. The lawsuit claims that UroChart obtained access to meridianEMR’s data.(Note: See this comment from IT Director of meridianEMR that discusses more details of what happened and how no data was breached.)

Lawsuits aside, meridianEMR is trying to capitalize on the situation by talking about their EMR security monitoring system was what notified them of the breach attack by UroChart. They call it their Advanced Monitoring System (AMS) and say it responds immediately to any breaches attacks and protects patient records.

I’m not sure if it’s a smart move to use a breach of their system as a way to promote their ability to protect patient records. I guess they can argue that their monitoring service was what protected their patient records. However, the lawsuit is claiming that patient records were at risk. I don’t think that’s something any EMR vendor wants tied to their name, is it?

Marketing strategy aside, this security monitoring service is interesting and I can’t say I’ve really seen something like it in any other EMR system. Sure, they all have some sort of audit tracking and trail. However, I think most EMR vendor’s strategy is not detection, but prevention. They harden their systems using the best techniques, but don’t do much to try and detect breaches. Should that be changed?

One problem with breaches is that good hackers know how to even avoid the detection part. I still remember when my friend showed me how he had hacked into a server and you could see him logged in. Then, he ran a script and you couldn’t see him anymore. I guess if you compare it to the physical world, it’s like having a camera watching the front door, but no camera on the back door. However, in the digital world there are lots of different doors, including those we don’t know about.

Some might argue that ignorance is bliss in this instance. Sure, no EMR vendor is going to admit that in public. Neither is a doctor. However, the regulations have made it pretty harsh when you know that there’s been a breach of your system. You basically have to make it known to all the world. However, if you don’t know that your EMR system has been compromised, then you have no such requirements.

I’m sure some people won’t like me saying this, but be sure that many doctors and EMR vendors have thought about this. I’m sure there were parallels in the paper world too. So, let’s not act like this is really that new. Although, certainly technology has made it possible to have much larger breaches.

One thing worth noting is that I haven’t seen a group of healthcare hackers forming. There’s no underground group of people that I’ve heard of that are trying to hack and get access to healthcare data. Financial data is much easier to monetize for a hacker than healthcare data. That’s not to say that healthcare data isn’t valuable and can’t have consequences if it’s put in the wrong hands. However, most hackers do it for the Lulz, for financial gain, or vengeance. Things could certainly change, but I haven’t seen healthcare as a prime target for hackers. I’d love to see if you have evidence that says otherwise.

If you evaluate the list of breaches that are published by HHS, this seems to agree with my above evaluation. Almost every single breach was just due to something being lost, a physical device being stolen (which you can almost guarantee they wanted the laptop and not the healthcare data which they probably didn’t even know was on the laptop), or inappropriate use by someone on a system already.

It will be interesting to see how these EMR security monitoring systems evolve. Plus, will we see more need for these type of protections and monitoring of EMR systems?

The other day I was browsing the EMR Update forum (where I started my EMR education) and found this interesting comment about the e-MDs iphone app.

EMDs is charging $250 to “install” it even though the phone does the installation for you and then they are charging $35 a month per device for “support”. I guess they are trying to lose all of their long term customers to other EMRs that are free like Practice Fusion. I find these charges to be outrageous.

Note: I tried to verify this pricing on the e-MDs website, but it’s conveniently not listed on their mobile page. Although, they do have a “free trial.” Is that a $250 install to get the free trial? I also found their website tagline ironic: “Affordable EHR software”

I find this comment really interesting on a number of levels. First, it comes from someone who has indeed been a long time e-MDs user and long been a fan and vocal spokesperson for the e-MDs EHR software. The above seems like such a small amount of revenue to alienate your happy EHR users over.

Second, $250 to help the user install the EMR iPhone app? Really? That just feels wrong on every level.

Third, $35/month for support? Of course, this is on top of the doctors existing e-MDs support contract. Such a terrible plan by e-MDs. If they felt like they needed to get some money for the support that would be required for their iPhone EMR app, then they should have rolled it into the existing support contracts. Then, no one would complain. At least not as loudly.

Now I’m starting to wonder what other EHR vendors are charging for their apps. Let me know what you’ve been charged for your EHR app. A while back I posted about all the various EMR Android apps. All of them were free.

I’ve been really intrigued lately by the changing media landscape. Things like Blogs and Twitter are providing opportunities for basically anyone to be able to share a message with the world. Certainly, many of the blogs don’t get read and a tweet on Twitter falls off people’s radar very quickly. However, some of the better or more interesting ones rise to the top and provide an interesting and sometimes dissenting voice to the conversation. Personally, I think this type of open discussion around topics is valuable and beneficial as long as people maintain a certain level of respect and decency.

My question to you then, is what would you say to a Healthcare IT audience?

As I considered on this difficult question myself, I decided the message that I would want to deliver: You can resist all you want, but the future of healthcare will require IT.

Pretty much every day, someone comes on this site to talk about the benefits and challenges associated with EMR and EHR in their office. As I’ve listened to the various challenges that people have posted, I’m sympathetic to them. However, almost all of those I’ve heard boil down to poor EMR selection or poor EMR implementation.

To me, the EMR selection is the absolute most important part of the EMR implementation process. Far too many doctors and clinics don’t take the time and effort that’s required to really go through a proper EMR selection process. I’m very sympathetic to them for a lot of reasons (ie. It’s not their job or interest, there are 300 EHR vendors, there aren’t great resources for differentiating EHR, there are a lot of perverse incentives, etc). However, it’s worth the cost to do it right. Otherwise, you should wait until you can do it right.

However, I believe that EMR is still only one small part of how healthcare IT is going to impact healthcare. Just last night I was at a local event and someone who use to work in the casino industry has been working for the past year or so on an app that helps improve doctor to doctor communication. Fascinating stuff.

Personally, I see us just at the very begging of a revolution in healthcare IT. IT is going to start invading every part of healthcare and will pretty much be impossible to avoid.

Certainly there will be some (possibly many) who continue to resist the adoption of technology in their clinic. However, I’m seeing more of a shift by patients and doctors that are interested in finding more ways to integrate technology into their healthcare. Most of the doctors aren’t sure what to do next, but they’re looking.

I can certainly understand and appreciate those that say that the current EMR and healthcare IT offerings aren’t up to snuff. The fact is that many of them aren’t. However, that doesn’t change my belief that IT is still going to change how healthcare is provided. It just may mean that healthcare will be changed by an IT offering that most of us don’t know about today.

My greatest wish would be that we could close the case on whether healthcare IT is important and/or it can change healthcare. Instead, let’s put our energy into finding the ways that it can change healthcare IT for good. All of us focused on using healthcare IT and EMR for good in healthcare would produce some amazing results.