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Big Brother Or Best Friend?

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The premise of clinical decision support (CDS) is simple and powerful: humans can’t remember everything, so enter data into a computer and let the computer render judgement. So long as the data is accurate and the rules in the computer are valid, the computer will be correct the vast majority of the time.

CDS is commonly implemented in computerized provider order entry (CPOE) systems across most order types – labs, drugs, radiology, and more. A simple example: most pediatric drugs require weight-based dosing. When physicians order drugs for pediatric patients using CPOE, the computer should validate the dose of the drug against the patient’s weight to ensure the dose is in the acceptable range. Given that the computer has all of the information necessary to calculate acceptable dose ranges, and the fact that it’s easy to accidently enter the wrong dose into the computer, CDS at the point of ordering delivers clear benefits.

The general notion of CDS – checking to make sure things are being done correctly – is the same fundamental principle behind checklists. In The Checklist Manifesto, Dr. Atul Gawande successfully argues that the challenge in medicine today is not in ignorance, but in execution. Checklists (whether paper or digital) and CDS are realizations of that reality.

CDS in CPOE works because physicians need to enter orders to do their job. But checklists aren’t as fundamentally necessary for any given procedure or action. The checklist can be skipped, and the provider can perform the procedure at hand. Thus, the fundamental problem with checklists are that they insert a layer of friction into workflows: running through the checklist. If checklists could be implemented seamlessly without introducing any additional workflow friction, they would be more widely adopted and adhered to. The basic problem is that people don’t want to go back to the same repetitive formula for tasks they feel comfortable performing. Given the tradeoff between patient safety and efficiency, checklists have only been seriously discussed in high acuity, high risk settings such as surgery and ICUs. It’s simply not practical to implement checklists for low risk procedures. But even in high acuity environments, many organizations continue to struggle implementing checklists.

So…. what if we could make checklists seamless? How could that even be done?

Looking at CPOE CDS as a foundation, there are two fundamental challenges: collecting data, and checking against rules.

Computers can already access EMRs to retrieve all sorts of information about the patient. But computers don’t yet have any ability to collect data about what providers are and aren’t physically doing at the point of are. Without knowing what’s physically happening, computers can’t present alerts based on skipped or incorrect steps of the checklist. The solution would likely be based on a Kinect-like system that can detect movements and actions. Once the computer knows what’s going on, it can cross reference what’s happening against what’s supposed to happen given the context of care delivery and issue alerts accordingly.

What’s described above is an extremely ambitious technical undertaking. It will take many years to get there. There are already a number of companies trying to addressing this in primitive forms: SwipeSense detects if providers clean their hands before seeing patients, and the CHARM system uses Kinect to detect hand movements and ensure surgeries are performed correctly.

These early examples are a harbinger of what’s to come. If preventable mistakes are the biggest killer within hospitals, hospitals need to implement systems to identify and prevent errors before they happen.

Let’s assume that the tech evolves for an omniscient benevolent computer that detects errors and issues warnings. Although this is clearly desirable for patients, what does this mean for providers? Will they become slaves to the computer? Providers already face challenges with CPOE alert fatigue. Just imagine do-anything alert fatigue.

There is an art to telling people that they’re wrong. In order to successfully prevent errors, computers will need to learn that art. Additionally, there must be a cultural shift to support the fact that when the computer speaks up, providers should listen. Many hospitals still struggle today with implementing checklists because of cultural issues. There will need to be a similar cultural shift to enable passive omniscient computers to identify errors and warn providers.

I’m not aware of any omniscient computers that watch people all day and warn them that they’re about to make a mistake. There could be such software for workers in nuclear power plants or other critical jobs in which the cost of being wrong is devastating. If you know of any such software, please leave a comment.

April 9, 2014 I Written By

Kyle is Founder and CEO of Pristine, a company in Austin, TX that develops telehealth communication tools optimized for Google Glass in healthcare environments. Prior to founding Pristine, Kyle spent years developing, selling, and implementing electronic medical records (EMRs) into hospitals. He also writes for EMR and HIPAA, TechZulu, and Svbtle about the intersections of healthcare, technology, and business. All of his writing is reproduced at kylesamani.com

Health IT Tweet Roundup – Neil Versel Edition

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As you know, each weekend I like to do a roundup of interesting tweets and add a bit of commentary. This time I thought it would be fun to grab some tweets from just one person, Neil Versel. Neil has been doing a number of really great posts on his blog Meaningful Health IT News lately (Full Disclosure: Neil’s blog is part of the Healthcare Scene blog network). The following tweets highlight some of Neil’s recent blog posts.


I agree that Blue Button Plus is a great step forward for Blue Button. This post is particularly interesting because Neil didn’t see the promise of Blue Button before the changes were made and it was called plus.


This is a great discussion on the meaningful use requirements and Blue Button’s role in them. Join in if you have some knowledge on the area about what your EHR is doing.


Neil’s right about people who don’t cover healthcare regularly not understanding many of the true dynamics at play. I do find it interesting that Neil is such a fan of clinical decision support. I still think it’s in such an infant state. I can’t wait for much more advanced clinical decision support.

July 21, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

300 Automatic E&M Coders in EMRs

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Automated coding has been a popular topic ever since I first started blogging about EMR software 7.5 years ago. In fact, back then the discussion was usually around how great automated E&M coding was going to be for a doctor. Everything from increased coding levels to firing your billing person were talked about. However, I think the reality is that we’ve seen something much different happen.

Many people hate the automatic E&M coding in EMR because it is wrong so often. If they can’t trust it to do the right coding, then what savings are they really getting from the automation? To put it in the words above, they still need their billing person. Plus, the idea of coding higher is great because it can mean more revenue. However, it also can be seen as upcoding and give you plenty of grief as well. “My EMR told me to do it” isn’t a great defense for over coding a visit.

As I think about these automatic E&M coding engines, it makes me wonder why we don’t have someone who’s created a really great coding engine like we have with drug databases. Since there isn’t that means that every one of the 300+ EMR vendors has their own coding engine. That means we have 300 different E&M coding engines all with different ways to approach coding.

I imagine many would argue the reason the E&M coding engine needs to be part of the EMR is because it needs deep integration with the EMR data. This is true, but the same is going to be true as we enter the world of smart EMR software with deep CDS applications. EMRs aren’t going to build all of these pieces. They’re going to have to enable entrepreneurs to build some really cool stuff on top of their EMR. Why not do the same with E&M coding?

Although, it’s also worth consider, is medical billing one area where human touch is better than automated coding?

May 30, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Smart EMR & CDS

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For those who don’t know, I’ve started a series of EMR, EHR and Healthcare IT video interviews with some of the leaders of our industry. You can attend the video interviews live and can ask questions on Twitter. If you want to receive email notifications of upcoming interviews, just subscribe on this page. Tomorrow I’ll be doing another video hangout on Hospital EHR and Healthcare Analytics with Dana Sellers and James Kouba.

The following video embed is from an interview I did with Sean Benson and Andre L’Heureux from Wolters Kluwer Health. We had a great discussion about the gap or white space between EMR software and what clinicians want them to do. We also talked about the challenge of integrating EMR with CDS systems. Plus, I asked them what EMR vendors could do to make the Smart EMR of the future possible. Their answer was quite interesting. We also discussed the challenge hospitals face of clinical knowledge management in their organization. Then, we wrapped up the conversation with a look at the WKH Innovation Lab’s sepsis project.

I think there’s a lot to be excited for when it comes to creating smart EHR and getting the most from clinical decision support systems. Enjoy the Smart EMR and CDS video interview embedded below.

May 21, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Guest Post: Overcoming EMR Integration Challenges

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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.

September 15, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Jeopardy!’s Watson Computer and Healthcare

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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.

May 25, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Skills in Search As Valuable as Memorization

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Neils’ article about Unrealistic Expectations about Clinical Decision Support made me think of how important the ability to know where to find the information can be in so many different situations. In fact, memorization of where to search might be more valuable and useful than strict memorization of everything.

The core point is that with very rare exception, the human mind can only store and recall so much information. However, if you only have to remember where to find a certain piece of information, it’s much easier to remember. For example, many of my readers probably don’t realize that I have a network of TV blogs. I get a lot of credit on those websites for listing out the music for those shows. Funny thing is that I’m not all that good at identifying songs. However, I am great at searching and finding the information.

Why can’t we accept this from doctors? Why do we expect that doctors should know everything as opposed to accepting that they don’t know everything, but they know where to find out more? Many actually can accept this.

Of course, many people might appropriately ask the question, “If my doctor’s just going to look up the information, why don’t I just look it up myself?”

There are quite a few reasons why it’s not the same. Let me just give one of them. While Doctors don’t know everything, they have been trained to identify the relevant information. Understanding what’s relevant turns out to be incredibly valuable when trying to solve a problem.

How about an example for comparison sake. Many Windows users are quite familiar with what’s affectionately called the Windows “Blue Screen of Death.” To the untrained eye, the blue screen of death is a daunting screen that provides an information overload of error messages of what went wrong your computer. To an IT person like myself, I can quickly identify the 1 or 2 lines that are actually relevant to the problem and find a possible solution.

While certainly not a perfect comparison, I think the skills that a trained doctor uses to identify a medical issue are similar to the above scenario. Funny thing is that no one would have any issue with me doing a search for how to solve the problem the blue screen of death identifies. However, many are uncomfortable with the idea of their doctor doing a similar search.

This isn’t to say that patients shouldn’t participate in their own care. That’s a related, but different topic. However, I echo Neil’s call for patients to be more accepting of doctors who use clinical decision support and other tools that help provide better care. Not to mention his call for doctors to not be afraid to admit when they don’t know everything, but that they have the tools, resources and skills to provide great patient care.

May 6, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Medical Establishment Continues to Cling to Status Quo

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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.

May 5, 2011 I Written By

Medispan Clinical Expands CDS Offerings by Wolters Kluwer Health

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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.

March 1, 2010 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.