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EMR Interfaces, MU vs Quality Care, and Data Outside EMR

Posted on April 20, 2014 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’m not sure I agree completely with this tweet. I don’t know enough about Covery My Meds to say either way. Although, I wondered if many EMRs will integrate with Covery My Meds. From my experience, EMR vendors don’t want to interface with many outside software companies. A few embrace outside companies interfacing with them. We’ll see if that changes over time.

I haven’t had a chance to look at this study yet, but did anyone think that quality of care would improve because of MU?

No doubt we’ll eventually have outside data from wellness tracking apps incorporated in EMR, but I don’t think it will ever be a free for all. There are tens of thousands of wellness apps and I don’t see doctors wanting data from just any app. They’ll want to only get data from apps they trust. That’s a high bar for most apps. Plus, once you win the trust of one doctor, you still have to win the trust of all the other doctors. There’s not a trusted third party that doctors look to for apps.

Will an EMR’s Quality Metrics Differentiate it from Other EMRs?

Posted on April 11, 2013 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In the emerging consumer-centered, value-driven U.S. healthcare marketplace, the EHR vendors that survive and thrive will need to differentiate their brand by successfully competing on the value (quality/price) their product actually delivers to its end users.

Bob Coi, MD

This is a fascinating look at EMRs and future differentiation in the EHR market. There’s little doubt we could use some EMR differentiation with so many EMR companies still out there. I’m just not sure that the quality of care that an EMR provides is going to be why a doctor selects one EMR over another EMR.

Every doctor I know wants to provide great care to their patients. Every patient I know wants to go to the doctor who provides them the best care. The problem is that most doctors don’t see a direct correlation between EMR use and the quality of care given. Patients don’t either, and the other challenge is that patients have no way to measure the quality of care they’re given anyway. The closest we come to knowing if the doctor provided quality care is that as a patient I know I’m sick and then I get better. I guess if I got better, then the doctor must have provided me quality care.

With this said, I think there’s the possibility that an EMR discovers a way to clearly show that something they do improves the care of the patient. The incremental document management and simple alert notifications that we see from EMR’s today won’t show that clear improvement in care.

No, we have to think much bigger to clearly show that the care provided was better because of the EMR and that the improved care wouldn’t have been possible without the EMR. An example of this would be integrating genomic data into the care provided. What if genomic data influenced which drugs you prescribed so that the drug was perfectly tailored to the patient? This is a great example where it would literally improve the care you provide a patient and it would be impossible without the technology to do the analysis. Assuming this technology was integrated with the EMR, it would be impossible for doctors not to use the EMR.

This is just one example. I’m sure creative entrepreneurs will come up with many more. Showing that EMR improves quality of care is a really high barrier. Plus, changing physicians perceptions on EMR is going to be really hard even if an EMR system does indeed improve the quality of care. Some company will do it and then Dr. Coi will be right that an EMR’s quality metrics will differentiate it from other EMR companies.

Study Shows Value of NLP in Pinpointing Quality Defects

Posted on August 25, 2011 I Written By

For years, we’ve heard about how much clinical information is locked away in payer databases. Payers have offered to provide clinical summaries, electronic and otherwise, The problem is, it’s potentially inaccurate clinical information because it’s all based on billing claims. (Don’t believe me? Just ask “E-Patient” Dave de Bronkart.) It is for this reason that I don’t much trust “quality” ratings based on claims data.

Just how much of a difference there was between claims data and true clinical data hasn’t been so clear, though. Until today.

A paper just published online in the Journal of the American Medical Association found that searching EMRs with natural-language processing identified up to 12 times the number of pneumonia cases and twice the rate of kidney failure and sepsis as did searches based on billing codes—ironically called “patient safety indicators” in the study—for patients admitted for surgery at six VA hospitals. That means that hundreds of the nearly 3,000 patients whose were reviewed had postoperative complications that didn’t show up in quality and performance reports.

Just think of the implications of that as we move toward Accountable Care Organizations and outcomes-based reimbursement. If healthcare continues to rely on claims data for “quality” measurement, facilities that don’t take steps to prevent complications and reduce hospital-acquired infections could score just as high—and earn just as much bonus money—as those hospitals truly committed to patient safety. If so, quality rankings will remain false, subjective measures of true performance.

So how do we remedy this? It may not be so easy. As Cerner’s Dr. David McCallie told Bloomberg News, it will take a lot of reprogramming to embed natural-language search into existing EMRs, and doing so could, according to the Bloomberg story, “destabilize software systems” and necessitate a lot more training for physicians.

I’m no technical expert, so I don’t know how NLP could destabilize software. From a layman’s perspective, it almost sounds as if vendors don’t want to put the time and effort into redesigning their products. Could it be?

I suppose there is still a chance that HHS could require NLP in Stage 3 of meaningful use—it’s not gonna happen for Stage 2—but I’m sure vendors and providers alike will say it’s too difficult. They may even say there just isn’t enough evidence; this JAMA study certainly would have to be replicated and corroborated. But are you willing to take the chance that the hospital you visit for surgery doesn’t have any real incentive to take steps to prevent complications?


EMRs, ICD-10 Pave the Way to Business Intelligence

Posted on June 16, 2011 I Written By

Two articles I’ve written in the last 24 hours have gotten me thinking that we’ve already entered the post-implementation era of EMRs, even as implementation remains in progress at so many healthcare organizations. While the vast majority of hospitals and physician practices in the U.S. still don’t have full-featured EMRs in place, many are already looking well into the future.

As you may already know, HIMSS on Tuesday released its first-ever survey on “clinical transformation.” According to HIMSS and survey sponsor McKesson, “Clinical transformation involves assessing and continually improving the way patient care is delivered at all levels in a care delivery organization. It occurs when an organization rejects existing practice patterns that deliver inefficient or less effective results and embraces a common goal of patient safety, clinical outcomes and quality care through process redesign and IT implementation. By effectively blending people, processes and technology, clinical transformation occurs across facilities, departments and clinical fields of expertise”

As I reported for InformationWeek, 86 percent of organizations surveyed had a plan for clinical transformation in place or at least under development, and just 12 percent of respondents called organizational commitment a barrier to reporting on quality measures. And though nearly 8o percent indicated that they still gather quality data by hand and 60 said they don’t capture data in discrete format, more than half already had software specifically for business intelligence. This tells me that analytics is here to stay.

I kind of knew that anyway, since the bulk of the program at last week’s Wisconsin Technology Network Digital Healthcare Conference was devoted to BI, data governance and advanced analytics tools, even in the context of Accountable Care Organizations. (My story about this for WTN News appeared this morning.)

“I’m ready to declare the era of business intelligence,” said Galen Metz, CIO and IS director for Madison-based Group Health Cooperative of South Central Wisconsin. Though he criticized the proposed ACO rules for being too “daunting” for the average provider, Galen and other speakers said that it’s time to harness all the new, granular data being generated by EMRs and, soon, ICD-10 coding.

It may seem “daunting” now in the midst of all the preparations for ICD-10 and meaningful use, but it’s good to know that many healthcare organizations see a light at the end of the tunnel and know that the future bring better healthcare information in exchange for all the hard work and investment today.


More Unrealistic Expectations From the Public, This Time Involving CDS

Posted on April 21, 2011 I Written By

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.

Study Ignores Other Benefits of Electronic Health Records

Posted on January 25, 2011 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’ve now had two people send me links to a study coming out of Stanford University that says that EHR software doesn’t improve patient care in the US (Here’s one story about it from Reuters). So I figure that it must be a topic that my readers would enjoy me discussing. Here’s a portion of their summary:

A team from Stanford University in California analyzed nationwide survey data from more than 250,000 visits to physicians’ offices and other outpatient settings between 2005 and 2007.

They found electronic health records did little to improve quality, even when there was “decision support” software that gives doctors tips on how best to treat individual patients.

I’ve always found it a bit off to talk about EMR software as a means to improve the quality of care that a doctor provides. For the vast majority of healthcare, more information, clinical decision support, drug to drug interaction checking, drug to allergy checking, etc aren’t going to improve the care a doctor provides. First, because the doctors have been well trained to do many of these things already. Second, because if I come in as a generally healthy patient with a common cold, then of course the doctor doesn’t need any of these advanced EMR functionality.

Now in more advanced and complicated cases, there is potential that an EMR software could offer some benefit. I remember a doctor commenting back in 2009 on my blog about how the Body of Medical Knowledge could become to complex for the human mind to process it all. Whether we’re there or yet, is open for debate, but the concept is interesting. Although, this still only applies to the outlier cases.

I remember one time hearing a clinician tell me about how the Drug to Drug interaction alerts informed her of some medical knowledge that she hadn’t known previously. So, there are instances where various parts of an EMR software can provide better patient care, but is it dramatic enough difference to really improve the quality of care? I think that’s a hard argument to really make. At least with the current iteration of EMR software.

Other EMR Benefits
Quality of Care aside, I think the thing that studies like this (and their related headlines) miss is the other benefits of having an EMR system (see also my list of EMR benefits in my EMR Selection e-Book).

I can’t tell you how many times I’ve heard doctors talk about how they love the legibility and accessibility of patient charts in the EMR. No difficult to read handwriting (others or their own). No waiting for chart pulls. These are guaranteed benefits to having an EMR system. Sure, it’s hard to quantify them when it comes to dollar signs or improved quality of care. However, they’re a real tangible benefit to having an EMR. Not to mention that I still think there’s long term benefits to widespread adoption of EMR that we can’t even imagine yet.

I could go on about many of the other benefits. It’s just unfortunate that studies and those who report on these studies don’t take into account these other benefits of EMR software.

UPDATE: Over at HIStalk, Mr. H also points out that the study only focuses on a couple quality measures. So, it doesn’t actually say that EHR doesn’t improve quality of care, but instead it says that it doesn’t improve quality of care when it comes to the couple simple measures that the study used to measure it. There could be many other quality measures where EHR does improve the quality of care. We just don’t know.