Some Notes and Then Myth #4, EMRs...

In this slow summer, we are working through the Seven Myths of Healthcare Technology. Myth #2 is "Technology Can Do Healthcare." [check it out below] Here's a comment I found out there--The writer certainly seems to have a reason for his anger. But is he completely correct? What do you think?
Community College - No Way

And is this an attempt at something "Swiftian?"

Responsibility-Based Rationing of Healthcare

"Eat the Elderly" kind of stuff? Or do you think he is serious? With all of the alternate-reality based rhetoric being put out there, I am honestly unsure...

And it looks like telehealth is happening without complex, expensive proprietary software systems...

The doctor is in and logged on

And we continue with…

The Seven Myths of Healthcare Technology; #4 EMRs are for the Doctors

As hospitals and medical facilities move to meet the technological mandates and requirements coming their way (from managers, regulatory agencies and insurance companies), they are confronting the issue of stakeholders--who are they and who is most important. Historically, the final word in healthcare has been that of The Doctor. What the MD says goes. As software is implemented in more and more systems, vendors and internal IT staff are having to customize and personalize software for each facility and clinic.

Healthcare software is not “off the shelf,” as some vendors might present it. It is more “out of the crates, custom-tailored, re-measured and stuck with unusual plug-ins and attachments to serve the vicissitudes of legacy systems.” In the process of making these applications work in the particular digital and business environment, sensitivity to end-user experience is considered essential. And doctors are the obvious end-user stakeholders.

Doctors are characterized as (just a little) demanding. Nurses everywhere tell tales (or at least roll eyes). This is no different, and perhaps worse, with software. Doctors are a technically saavy group and not shy about speaking up. But they are the wrong users on which to model EMR use.

Doctors use EMRs to mostly see data. They look at one or two views of data; to review intake information, view images; check results, or, watch for drug allergy alerts--then they look at the patient. They use systems to place orders or prescriptions--sometimes. Often, these orders are completed by PAs or nurses. Doctors do not move through an EMR very much--they tend not to do patient intake or to record new data very much. They are not the primary users of the digital tools---their skills lie elsewhere. There are certainly providers who are more “hands-on” with electronic systems. These are usually providers in record-intensive practices such as psychiatry or in the unique practice structures of the military.

Clerks, Nurses and PAs are the big users. They are the people using the record systems most--from patient intake through scheduling to checking for labs and rads. Very often it is they who bring up the patient record for a doctor and file orders. And it is the desk staff who are using the EMRs to communicate with insurance companies and other referral facilities. It is their workflow that should be modeled--and theirs are very different workflows.

People will say “Nurses really run the hospital.” I won’t get into that debate, but I will say “If they don’t control the hospital, they certainly control the information in it,” and that is the EMR…..

Telling Grandma "No."

“...creating a national health insurance to cover everyone will probably increase costs, not decrease them, just as feeding the world's hungry three full meals a day would not reduce our grocery bill. Personally, I think instituting universal health care is the humane thing to do, but let's be honest: Somebody will have to pay for it.”
Dr. Tom Shragg, The Sacramento Bee, Sunday, July 5, 2009

Dr. Shragg describes himself as “a specialist in pulmonary and critical-care medicine with 30 years of experience.” In his opinion piece for the Sacramento Bee entitled “The Conversation: Is health care cost debate focused on wrong issues?” Dr. Shragg looks at some of the leading suggestions for healthcare reform in the US--EMRs, shifting of compensation from specialists to primary-care providers and a “single-payer” system---from his own view as an experienced special-care physician in private practice the US. His primary point is these solutions to rising healthcare costs are either inappropriate or plain wrong.
The doctor describes these foci of cost reduction as “the wrong birds.”
Dr. Shragg’s writing is reflective of his practical history. EMRs, he feels, are only a distraction from the healthcare process. Using and EMR, he writes, “slows me down and diverts my attention from the patient to the computer…These computer records may improve accounting, but not health care.” After 30 years in practice, Dr. Shragg (like most physicians) probably does little of his own charting, as nurses, PAs and other staff would be both taking and charting vitals, lab results, etc. He finds increased compensation for primary care over specialized care to be “naïve,” and “somewhat insulting.” As a specialist, he is understandably sensitive to the legitimate need for specialists. But as such, he has limited experience with the current US system’s “only pay for crises” incentive structure (it should be noted that the Doctor’s group practice does accept payment by most major insurance companies). And lastly, national health insurance might be “humane,” but it would not reduce the cost of health insurance (see above). All three are the “wrong birds.”
So, what does Dr. Shragg consider the “right bird?”
Dr. Shragg describes a 92-year old patient suffering a variety of late-stage ailments; renal failure, stroke and mild dementia among others. Her treatment included oxygen, consultation with a nephrology specialist, in-patient intensive care and dialysis. This is Dr. Shragg’s identified “bird.”
“If you wanted to eliminate the costs associated with that patient's treatment, you would have to empower somebody to deny the care she and her family desired. To borrow a popular expression, the elephant in the room that nobody addresses is the ‘R word:’ rationing.”
The US healthcare conversation is still ongoing, and no consensus has been reached, so it cannot be said if Dr. Shragg expresses the mainstream. But the Doctor’s does demonstrate something particular to US healthcare; commodification. Doctor Shragg’s access points to the issue are remuneration and funding--who is getting paid and who is paying them. In this dialectic, healthcare is a consumable--something to be bought and sold.
Every western nation currently has a national approach to healthcare, ranging from the single-payer/single provider (UK) to nationally regulated private-sector insurance with multiple providers (DE).
US focus on healthcare has only recently expanded beyond academia and industry, while many other nations are already at a “Phase 2” stage of revising a chosen healthcare architecture. In none of these nations is finance any longer a barrier to service. Citizens of the UK do not think about “health insurance.” They have “The National Health Service,” and like the Postal Service, it is expected and committed to deliver to everyone.
In none of these other nations is healthcare thought of as a commodity available only to those possessing adequate resources. They have already decided the question “who gets care?” with “Everyone.” Now they are working on the questions of access, of economies of scale and of quality of patient experience.
Canadian healthcare is one of the more mixed-bags of solutions. While healthcare is nationally defined as a basic right of all residents, its management is the responsibility of the Provinces; thus, there is Alberta Health Services, the Ontario Ministry of Health and the Ministry of Health of British Columbia, among others. Each Province has pursued its own solutions to healthcare. In Alberta, there is a single central authority (at present) that directly oversees each discrete facility. Ontario operates with a mix of state and private insurance, with regulated drug prices far below those in the states. The models in Canada, and the changes in these models are many and varied. As Canada successfully delivers on a national commitment to healthcare for all, the ways of managing delivery, access, quality of care, breadth of care and, yes, cost are always evolving.
This example of one nation successfully implementing a variety of solutions could serve as a valuable resource to the US in developing its own solutions. The US has a free-market hodgepodge of healthcare methods; state and local facilities and services; not-for-profit clinics; private practice and public-service doctors, and; insurances of all sorts. The successful mix of many Canadian models could quickly shorten the US learning curve. But to benefit from the Canadian example---or the French or the Swiss or the German--would still require a shift in US thinking. Other nations manage to deliver medicine and care to all of their people because they hold healthcare as a “must,” not a “maybe.”
Dr. Shragg writes of healthcare as something to be bought or “maybe” given as charity. His is not the only voice to lament the cost of late-stage care; but the US is the only nation to consider first and foremost the cost of care. If the US is to make a national effort (and to date the only national efforts have been the regulation of healthcare products--drug and device approval and patents and licensing), a true commitment by the nation must be made---to the nation.

The Seven Myths of Healthcare Technology 3. Technology Can Do It All

In a letter sent Tuesday to Sens. Edward M. Kennedy (D-Mass.) and Max Baucus (D-Mont.), President Barack Obama reiterated his commitment to promoting the use of information technology as a means of reducing healthcare costs.
healthcareITnews, June 4, 2009
A month later, HealthcareIT news reported
"President Obama called for fixing the broken healthcare system by building upon investments made in electronic medical records in a town hall meeting held Wednesday." [July 1, 2009]

In the US, many of the players--drug makers, provider organizations and insurance companies--have been calling for increased IT investment as the key solution to the problems of healthcare in the US. The advantages of increased IT efficiency are clear. Yet the healthcare business process lags far behind other businesses in the use of electronic automation. Most providers and facilities are just beginning to look at electronic record management, and many are still using only paper records. The most advanced use of IT for healthcare is by the Federal government. The Department of Defense is well along in development of a "lifetime electronic record" and the VA continues to set a high standard for management efficiency. And Medicare/Medicaid manages one of the largest patient bases and payment processes electronically.
But does electronic automation provide ALL the answers?
In Canada, aggressive support of HIT has been a policy of both the Federal and Provincial governments since 2000. A number of hospitals in the greater Toronto area became very active in digitizing patient records and integrating digital patient records into the care process. Record access has been greatly increased. There are years of data recording increased record accuracy and improved efficiency in data entry. Many of the hoped for results have been realized.
Yet, this past year, the Province of Ontario presented a grant pool of millions of dollars to support possible solutions to wait-time reduction. It seems that even after all of the HIT implementations of the last eight years, patients are sometimes experiencing emergency-room waits in excess of five or even 10 hours (these grew even longer in the 2007 flu season). The back-ups waiting for hospital admissions are staggering and seemingly without a solution--even from "fully integrated" HIT systems. According to a 2006 survey by Ipsos Reid, 42% of Canadians surveyed felt that '"a patient wait time guarantee that would reduce wait times for key health services' was the most important to them personally."
So, why has IT not been the solution to the Number One issue for Canadians (lower taxes got only 19%)? Because the solution is not about the technology. According to providers at a number of well-digitized hospitals in Ontario, patient records and patient interaction are great in the ED--patients' records can be created, their histories can be accessed, and intake moves pretty quickly. In-patient care has also been greatly improved; medication conflicts are avoided, patients are correctly identified and prescribed, etc. These providers are quite clear that the breakdown is the connection between in-patient and out.
Because of the differences in workflow and practice, HIT systems are different in the ED than in the rest of a facility. And connecting the data from the one to the information from the other to create usable knowledge that would enable efficiencies is not as easy as just installing a data-mapping agent. It takes people and, more importantly, it takes changes in the ways those people work.
Emergency Department staff do not access bed-management resources. Why would they? Emergency care is just that. And as we have discussed earlier (Myth #1), healthcare providers focus on the immediate task at hand--the here and now. They only look for a clinic/bed assignment when they are done with a patient--and then it can become a rushed, time consuming task for staff both in the ED and on the wards. Perhaps, Upon initial diagnosis of a patient, the search for a clinic/bed assignment were begun (to run in concert with the continued efforts in the ED) in anticipation of an eventual need for admission. Then patients might move more easily and quickly into the inpatient population, and that would reduce the long queues of people waiting in the ED.

A non-technical solution to a problem of technology--Sometimes, Healthcare IT cannot do it all--and should not......

Separate is Not Equal: Two Tiers in Healthcare

People get healthcare in Canada--Canada is committed to it, and is pretty successful at it. The vast majority of medical treatment--diagnostic, prescriptive, inoculations, etc.--are delivered regularly and well to just about everyone who needs them. As for the resource-intensive 5% (which account for nearly 95% of costs)--transplants, reconstructive surgeries, machine-therapies--Canadian healthcare by and large delivers that too. But the system feels the stretch of resource limitations. Canada considers healthcare everyone’s equal right, to the full measure that resources allow. One tier for everyone.
Some people want more than this equal level of care. They would like more additional personal service (private rooms), additional services (collagen treatments) or more speed (appointment now, not Thursday). And so people speak of a “Second Tier.”
Most often, this is seen as “cut to the front of the line,” which is a commodification of healthcare that runs counter to the idea of healthcare as an equal right. Some have proffered the idea of an alternative, more expensive system. On both sides of the border, separate is not considered equal. What to do then?
But Canada has an answer. What services National resources cannot support for everyone are available to those who want it through secondary insurance. Many employers provide their people such supplementary coverage as an option. Better rooms? Supplement to cover the difference between the core services and the “preferred.” Extra dental? Supplement. Employee premiums are well under $100/month with varying options of deductibles and partial payments (80/20, for example). This would seem to be a de facto two-tier system.
Canada has moved past the issue of healthcare access and is now confronting the difficulties of delivering with limited resources, and increasing expectations from users. There are still only so many operating rooms, so many organs available and so many MRIs. But what of those things of which there are extras? In the efforts to deliver a baseline of healthcare to all members of society, over-stocking and over-provision create excess capacity. Could such excess capacities be used as a different kind of “second tier?” Could a clinic charge a premium for a 6pm appointment with a doctor working hours above his “core” commitment that week? And could this premium revenue be used to expand general resources?
Excesses cannot be planned, and an immediate concern would be the redirection of funds to create excesses instead of enabling services to all. But it is a thought. And if these excesses (an ENT’s hours, a bed in a 30-day rehab facility, late-night imaging) were paid for as “premium,” could they then be offered to US citizens? And billed to US healthcare payers? And as the overheads of billing and collections of these services would be aggregated (and as these services are already lower in cost than in the US), could they be competitively priced? Perhaps passing the savings to the patient as $0 co-pays instead of the usual $25?

Now there’s a thought…

RECs--What, Who and How?

The American Recovery and Reinvestment Act of 2009 (ARRA) has more than just EHR money in it. The act also seeks to encourage the establishment of "regional extension centers" (RECs) to provide support and assistance. Funding is being made available to organizations who meet certain requirements, and this funding is to range from $1-10 Million per year in two-year awards. So far, the government has published some criteria and guidelines for preference. Among other things, they are proposing to give preference to:
• Organizational plans and implementation strategies that include multi-stakeholder collaborations that make use of local resources, such as universities with health-related programs; medical or professional societies; state primary care associations; state or regional hospital organizations; large health centers and networks of rural and/or community health centers; state Area Health Education Centers; HIEs; and government entities such as public health agencies, libraries and information centers with health professional and community outreach programs, and consumer/ patient organizations.
• Applicants identifying viable sources of matching funds, including but not limited to grants from states and not-for-profit foundations, and payment for services from providers.

(as reported by Helen Pfister of Manatt Health Solutions. For her full write up, see ihealthbeat)

Historically, Federal programs have accede to state and local organizations--particularly in matters of geography. And in this instance, as is often seen as sensible, preferred organizations would be those connecting to and working with "local resources, such as universities...and consumer/patient organizations." And while extant organizations may understand their populations, local universities are often restricted in whom they can serve and where they can operate--to the state or locality in question. "State/local organizations" are often funded to serve--and only serve--residents of their state or locality.
In regional community healthcare services, all of this is counterintuitive to success. Providers serving similar populations in similar environmental and economic environments face the same problems and work towards similar solutions. Environments and economies do not stop at the legal boundaries of local or state government. The circumstances and life issues of The Blue Ridge Mountains extend across township, county and even state lines. Providers know this fact that bureaucrats miss. According to a survey of providers and provider organizations released by eHealthinitiative last month (available here), "Nearly half of respondents said that regional extension centers should not be constrained to a specific metropolitan or state boundary." In the eHealth survey, "local government-sponsored entities," are found very poorly suited to manage RECs by 42% of respondents.

The RECs are to provide support, guidance and knowledge-management resources to regional organizations receiving funding. Traditionally, providers have largely depended on publications, conferences and vendors for guidance on industry trends and software support. And vendors certainly meet the
other requirements to;
• Describe proposed levels and approaches of support for providers to be served;
• Address how the applicant would structure its organization and staffing to ensure providers served have ready access to reasonably local health IT "extension agents" and provide training and ongoing support for these critical workers;
• Demonstrate the capacity to facilitate and support cooperation among local providers, health systems, communities and health information exchanges ("HIEs");
• Demonstrate that the applicant is able to meet the needs of providers prioritized for direct assistance; and 
• Propose an efficient and feasible strategy to furnish deep specialized expertise (in such areas as organizational development, legal issues, privacy and security, economic and financing issues, and evaluation) to all providers served, as well as intensive, individualized, "local" presence from an interdisciplinary extension agent to smaller groups of providers assigned to individual agents.

And while vendors are experienced at offering service and support, providers are not that trusting. The absolute last choice by providers and provider groups to manage RECs was vendors--71% of those surveyed find them to be the MOST poorly suited. (Strangely, as to those who DO trust them, only 9% of those surveyed thought they were best suited. Note: Technology vendors made up 11% of the survey).

So who then is to create and manage the RECs?
Associations? HIEs? Not for Profits? Or will new things be formed among vendors, state agencies and inter-jurisdictional NGOs? The comment period for the regulations close at 5pm ET today. It will be interesting to see what people (and vendors, associations and providers) have to day...What do you all think?