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Two boys, a dog, and our electronic health records
“Speak clearly, if you speak at all; carve every word before you let it fall.” – Oliver Wendell Holmes Sr.
One of our favorite stories is that of two boys talking to one another with a dog sitting nearby. One boy says to the other, “I taught my dog how to whistle.” Skeptically, the other boy responds, “Really? I don’t hear him whistling.” The first boys then replies, “I said I taught him. I didn’t say he learned!”
We spend a lot of time as physicians going over information with our patients, yet, according to the best data available, they retain only a small portion of what we tell them. Medication adherence rates for chronic disease range from 30% to 70%, showing that many doses of important medications are missed. Patients often don’t even remember the last instructions we give them as they are walking out of the office. This raises questions about both the way we explain information and how we can use the tools at our disposal to enhance the communication so vital to patient outcomes.
Obviously, we need to consider our words carefully and focus on teaching, not just speaking. What sets teaching apart from speaking is consideration of the learner. The better we understand our patients’ perspectives, the better the knowledge transfer will be. A simple way to address this may be better eye contact.
We have all heard the expression “the eyes are a window to the soul.” Yet, we now have computers that acts as a virtual shades, covering that window and drawing our gaze away from our patients. These shades can blind us to important clues, impeding communication and leading to misunderstanding, missed opportunity, and even patient harm. This is why some practices have chosen to use scribes to handle documentation, freeing up physicians’ eyes and addressing another obstacle to communication: time.
One of the most cited complaints from physicians is lack of time. There is an ever-growing demand on us to see more patients, manage more data, and “check off more boxes” to meet bureaucratic requirements. It should come as no surprise that these impede good patient care. We are thankful that attempts to modernize payment models are recognizing this problem. For example, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) helps to blaze the trail by focusing on care quality, practice improvement, and patient satisfaction for incentive payments. While these are early steps, they certainly point to a future more concerned with value than with volume.
As we move toward that future, we need to acknowledge that information technology can be both the problem and the answer. The current state of health IT is far from perfect. The tools we use have been designed, seemingly, around financial performance or developed to meet government requirements. It appears that neither physicians nor patients were consulted to ensure their usability or utility. Step No. 1 was getting EHRs out there. Steps 2-10 will be making them useful to clinicians, patients, and health care systems. Part of that utility will come in their ability to enhance communication.
Take patient portals, for example. The “meaningful use program” set as a requirement the ability for patients to “view, download, or transmit” their health information through electronic means. EHR vendors complied with this request but seem to have missed the intent of the measure. Patients accessing the information often are confronted with a morass of technical jargon and unfamiliar medical terms, which may even be offensive. For example, we recently spoke to a parent of a teenager with moderate intellectual disabilities. A hold-out ICD-9 code on the teen’s chart translated to her portal as “318.0 – Imbecile.” Her mother was appropriately upset, and she decided to leave the practice.
As we begin to understand technology’s advantages – and learn its pitfalls – we believe EHR vendors must enhance their offerings while engaging both providers and patients in the process of improvement. We also believe physicians need to leverage the entire care team to realize the software’s full potential. This approach may present new challenges in communication, but it also presents new opportunities. We hope that this collaborative approach will allow physicians to have more time to spend connecting with patients, leading to enhanced understanding and satisfaction.
Our knowledge of human health and disease is growing more sophisticated and so is the challenge of imparting that knowledge to patients. It is critical to find ways to do so that are relevant and understandable and give patients the tools they need to reinforce and remember what we say. This is one of the promises that we are just beginning to see fulfilled by modern EHR technology. Unlike the boy who was trying to teach his dog to whistle, our words have deep impact, and our roles as educators have never been more important.
This article was updated 3/24/17.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
“Speak clearly, if you speak at all; carve every word before you let it fall.” – Oliver Wendell Holmes Sr.
One of our favorite stories is that of two boys talking to one another with a dog sitting nearby. One boy says to the other, “I taught my dog how to whistle.” Skeptically, the other boy responds, “Really? I don’t hear him whistling.” The first boys then replies, “I said I taught him. I didn’t say he learned!”
We spend a lot of time as physicians going over information with our patients, yet, according to the best data available, they retain only a small portion of what we tell them. Medication adherence rates for chronic disease range from 30% to 70%, showing that many doses of important medications are missed. Patients often don’t even remember the last instructions we give them as they are walking out of the office. This raises questions about both the way we explain information and how we can use the tools at our disposal to enhance the communication so vital to patient outcomes.
Obviously, we need to consider our words carefully and focus on teaching, not just speaking. What sets teaching apart from speaking is consideration of the learner. The better we understand our patients’ perspectives, the better the knowledge transfer will be. A simple way to address this may be better eye contact.
We have all heard the expression “the eyes are a window to the soul.” Yet, we now have computers that acts as a virtual shades, covering that window and drawing our gaze away from our patients. These shades can blind us to important clues, impeding communication and leading to misunderstanding, missed opportunity, and even patient harm. This is why some practices have chosen to use scribes to handle documentation, freeing up physicians’ eyes and addressing another obstacle to communication: time.
One of the most cited complaints from physicians is lack of time. There is an ever-growing demand on us to see more patients, manage more data, and “check off more boxes” to meet bureaucratic requirements. It should come as no surprise that these impede good patient care. We are thankful that attempts to modernize payment models are recognizing this problem. For example, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) helps to blaze the trail by focusing on care quality, practice improvement, and patient satisfaction for incentive payments. While these are early steps, they certainly point to a future more concerned with value than with volume.
As we move toward that future, we need to acknowledge that information technology can be both the problem and the answer. The current state of health IT is far from perfect. The tools we use have been designed, seemingly, around financial performance or developed to meet government requirements. It appears that neither physicians nor patients were consulted to ensure their usability or utility. Step No. 1 was getting EHRs out there. Steps 2-10 will be making them useful to clinicians, patients, and health care systems. Part of that utility will come in their ability to enhance communication.
Take patient portals, for example. The “meaningful use program” set as a requirement the ability for patients to “view, download, or transmit” their health information through electronic means. EHR vendors complied with this request but seem to have missed the intent of the measure. Patients accessing the information often are confronted with a morass of technical jargon and unfamiliar medical terms, which may even be offensive. For example, we recently spoke to a parent of a teenager with moderate intellectual disabilities. A hold-out ICD-9 code on the teen’s chart translated to her portal as “318.0 – Imbecile.” Her mother was appropriately upset, and she decided to leave the practice.
As we begin to understand technology’s advantages – and learn its pitfalls – we believe EHR vendors must enhance their offerings while engaging both providers and patients in the process of improvement. We also believe physicians need to leverage the entire care team to realize the software’s full potential. This approach may present new challenges in communication, but it also presents new opportunities. We hope that this collaborative approach will allow physicians to have more time to spend connecting with patients, leading to enhanced understanding and satisfaction.
Our knowledge of human health and disease is growing more sophisticated and so is the challenge of imparting that knowledge to patients. It is critical to find ways to do so that are relevant and understandable and give patients the tools they need to reinforce and remember what we say. This is one of the promises that we are just beginning to see fulfilled by modern EHR technology. Unlike the boy who was trying to teach his dog to whistle, our words have deep impact, and our roles as educators have never been more important.
This article was updated 3/24/17.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
“Speak clearly, if you speak at all; carve every word before you let it fall.” – Oliver Wendell Holmes Sr.
One of our favorite stories is that of two boys talking to one another with a dog sitting nearby. One boy says to the other, “I taught my dog how to whistle.” Skeptically, the other boy responds, “Really? I don’t hear him whistling.” The first boys then replies, “I said I taught him. I didn’t say he learned!”
We spend a lot of time as physicians going over information with our patients, yet, according to the best data available, they retain only a small portion of what we tell them. Medication adherence rates for chronic disease range from 30% to 70%, showing that many doses of important medications are missed. Patients often don’t even remember the last instructions we give them as they are walking out of the office. This raises questions about both the way we explain information and how we can use the tools at our disposal to enhance the communication so vital to patient outcomes.
Obviously, we need to consider our words carefully and focus on teaching, not just speaking. What sets teaching apart from speaking is consideration of the learner. The better we understand our patients’ perspectives, the better the knowledge transfer will be. A simple way to address this may be better eye contact.
We have all heard the expression “the eyes are a window to the soul.” Yet, we now have computers that acts as a virtual shades, covering that window and drawing our gaze away from our patients. These shades can blind us to important clues, impeding communication and leading to misunderstanding, missed opportunity, and even patient harm. This is why some practices have chosen to use scribes to handle documentation, freeing up physicians’ eyes and addressing another obstacle to communication: time.
One of the most cited complaints from physicians is lack of time. There is an ever-growing demand on us to see more patients, manage more data, and “check off more boxes” to meet bureaucratic requirements. It should come as no surprise that these impede good patient care. We are thankful that attempts to modernize payment models are recognizing this problem. For example, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) helps to blaze the trail by focusing on care quality, practice improvement, and patient satisfaction for incentive payments. While these are early steps, they certainly point to a future more concerned with value than with volume.
As we move toward that future, we need to acknowledge that information technology can be both the problem and the answer. The current state of health IT is far from perfect. The tools we use have been designed, seemingly, around financial performance or developed to meet government requirements. It appears that neither physicians nor patients were consulted to ensure their usability or utility. Step No. 1 was getting EHRs out there. Steps 2-10 will be making them useful to clinicians, patients, and health care systems. Part of that utility will come in their ability to enhance communication.
Take patient portals, for example. The “meaningful use program” set as a requirement the ability for patients to “view, download, or transmit” their health information through electronic means. EHR vendors complied with this request but seem to have missed the intent of the measure. Patients accessing the information often are confronted with a morass of technical jargon and unfamiliar medical terms, which may even be offensive. For example, we recently spoke to a parent of a teenager with moderate intellectual disabilities. A hold-out ICD-9 code on the teen’s chart translated to her portal as “318.0 – Imbecile.” Her mother was appropriately upset, and she decided to leave the practice.
As we begin to understand technology’s advantages – and learn its pitfalls – we believe EHR vendors must enhance their offerings while engaging both providers and patients in the process of improvement. We also believe physicians need to leverage the entire care team to realize the software’s full potential. This approach may present new challenges in communication, but it also presents new opportunities. We hope that this collaborative approach will allow physicians to have more time to spend connecting with patients, leading to enhanced understanding and satisfaction.
Our knowledge of human health and disease is growing more sophisticated and so is the challenge of imparting that knowledge to patients. It is critical to find ways to do so that are relevant and understandable and give patients the tools they need to reinforce and remember what we say. This is one of the promises that we are just beginning to see fulfilled by modern EHR technology. Unlike the boy who was trying to teach his dog to whistle, our words have deep impact, and our roles as educators have never been more important.
This article was updated 3/24/17.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
The EHR Report: Seeing through a glass, darkly
Recently, we were invited to take part in an case presentation focused on a young female patient. The reason for our specific invitation was because a key component in the patient’s case was centered on her electronic health record. This kind of story was not new to us – in fact, stories like these are becoming almost common everywhere. But this particular conference promised to be very special, because the patient herself was asked to take an active role and present the story from a unique perspective – her own.
Seated on stage in a hospital gown and accompanied by her I.V. pole, the patient related a 4-month history of symptoms. She had obviously told the story dozens of times – through seemingly endless encounters – to her primary physician, hospital residents, medical students, emergency physicians, and just about anyone else who would lend an ear. Listening to her share her story with a large audience while still a patient in the hospital was incredibly powerful; it was difficult not to become emotional with her as she welled up with tears. She told a complex, though very coherent tale that included her past medical and family histories, her employment, her hobbies, and her unusual signs and symptoms as they developed over an extended period of time. When the patient was done, her case was presented from another perspective: the way it was recorded in her electronic record. For a brief moment, those seated in the audience were confused. Then the theme of the conference became evident – these were completely different stories.
This was no case of mistaken identity or registration error. The chart presented at the conference did belong to the patient, but the story told by the chart was wrong. Reading through the chart, it would be easy to come away with the same sense as her care team; this must simply be a common illness that wasn’t responding to conventional treatment. Encounter after encounter, a new plan was devised to address the presumed diagnosis. But the patient’s telling of the history barely mentioned any symptoms related to that diagnosis. Her version focused more on how her life was affected, how she could no longer take care of her daughter, how she could no longer exercise (which she did avidly), and how she was sinking deeper into despair and losing hope. Woven through all of this were the historical details and seemingly obvious physical manifestations that might easily disclose the real cause of her symptoms. A few basic questions about her family history would also reveal multiple immediate family members who suffered from the same disease! But even if these questions had been asked, and even if the story had been heard, the image in the mirror – her chart – did not reflect an accurate understanding of the patient.
We often solicit comments from readers, and the response is alway encouraging. It is clear that our colleagues in the medical community feel a strong sense of obligation to their patients and care deeply for maintaining the sanctity of the physician-patient relationship. However, many feel the electronic health record has become a barrier to developing and nurturing that relationship, standing in the way understanding their stories. One poignant letter from a cardiologist in Florida, Eugene H. Eisman, MD, does a beautiful job in crystallizing this sentiment. Dr. Eisman writes:
“Many of my patients end up hospitalized where I do not have privileges. Almost every attending is attentive enough to send me a discharge summary. These, however, are EHR-generated. The patient may have been hospitalized for 3 days, yet the summary is seven pages long. It is filled with total nonsense, such as whether the patient had traveled to North Africa (even though he was hospitalized with a fractured hip while skiing in Colorado). The attending has managed to cut and paste reports of every chest film and CBC, and I have pages of normal studies. The final diagnosis and discharge medications are difficult to find in this morass of words. I cannot force myself to read this document, and it is thrown into his chart after a cursory glance. Yet, I can’t sleep at night. Is there buried in this seven-page document a discovery of malignancy, etc.?”
Dr. Eisman’s words are powerful because they reveal an oft-overlooked truth about modern medical records. The patient’s chart, once considered a sacred text containing the key inflection points in a patient’s story, has become merely a filing cabinet in which to stuff every piece of data about the patient, no matter how mundane or trivial. No thought need be put into preserving the important details, because now absolutely every detail can be included. We have become so overloaded with the unimportant, that we may lose the truly critical in this sea of information. It has become, therefore, imperative that physicians rediscover the patient in their story, and not rely solely on the poor reflection we may find in their chart.
Thousands of years ago, the apostle Paul wrote that “we see now as through a glass, darkly.” Borrowing from his original meaning, these ancient words have been quoted throughout literature to describe an “incomplete understanding,” often mixed with a state of despair. Today, we might think of the electronic record as the glass – or mirror – reflecting the patient’s story. Ironically, in spite of having more information than ever, the image we see may be incomplete, and possibly even wrong altogether. While the amount of available data may at first glance appear enlightening, the reflection in the glass may be rather dark indeed.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care. Neil Skolnik, MD, is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
Recently, we were invited to take part in an case presentation focused on a young female patient. The reason for our specific invitation was because a key component in the patient’s case was centered on her electronic health record. This kind of story was not new to us – in fact, stories like these are becoming almost common everywhere. But this particular conference promised to be very special, because the patient herself was asked to take an active role and present the story from a unique perspective – her own.
Seated on stage in a hospital gown and accompanied by her I.V. pole, the patient related a 4-month history of symptoms. She had obviously told the story dozens of times – through seemingly endless encounters – to her primary physician, hospital residents, medical students, emergency physicians, and just about anyone else who would lend an ear. Listening to her share her story with a large audience while still a patient in the hospital was incredibly powerful; it was difficult not to become emotional with her as she welled up with tears. She told a complex, though very coherent tale that included her past medical and family histories, her employment, her hobbies, and her unusual signs and symptoms as they developed over an extended period of time. When the patient was done, her case was presented from another perspective: the way it was recorded in her electronic record. For a brief moment, those seated in the audience were confused. Then the theme of the conference became evident – these were completely different stories.
This was no case of mistaken identity or registration error. The chart presented at the conference did belong to the patient, but the story told by the chart was wrong. Reading through the chart, it would be easy to come away with the same sense as her care team; this must simply be a common illness that wasn’t responding to conventional treatment. Encounter after encounter, a new plan was devised to address the presumed diagnosis. But the patient’s telling of the history barely mentioned any symptoms related to that diagnosis. Her version focused more on how her life was affected, how she could no longer take care of her daughter, how she could no longer exercise (which she did avidly), and how she was sinking deeper into despair and losing hope. Woven through all of this were the historical details and seemingly obvious physical manifestations that might easily disclose the real cause of her symptoms. A few basic questions about her family history would also reveal multiple immediate family members who suffered from the same disease! But even if these questions had been asked, and even if the story had been heard, the image in the mirror – her chart – did not reflect an accurate understanding of the patient.
We often solicit comments from readers, and the response is alway encouraging. It is clear that our colleagues in the medical community feel a strong sense of obligation to their patients and care deeply for maintaining the sanctity of the physician-patient relationship. However, many feel the electronic health record has become a barrier to developing and nurturing that relationship, standing in the way understanding their stories. One poignant letter from a cardiologist in Florida, Eugene H. Eisman, MD, does a beautiful job in crystallizing this sentiment. Dr. Eisman writes:
“Many of my patients end up hospitalized where I do not have privileges. Almost every attending is attentive enough to send me a discharge summary. These, however, are EHR-generated. The patient may have been hospitalized for 3 days, yet the summary is seven pages long. It is filled with total nonsense, such as whether the patient had traveled to North Africa (even though he was hospitalized with a fractured hip while skiing in Colorado). The attending has managed to cut and paste reports of every chest film and CBC, and I have pages of normal studies. The final diagnosis and discharge medications are difficult to find in this morass of words. I cannot force myself to read this document, and it is thrown into his chart after a cursory glance. Yet, I can’t sleep at night. Is there buried in this seven-page document a discovery of malignancy, etc.?”
Dr. Eisman’s words are powerful because they reveal an oft-overlooked truth about modern medical records. The patient’s chart, once considered a sacred text containing the key inflection points in a patient’s story, has become merely a filing cabinet in which to stuff every piece of data about the patient, no matter how mundane or trivial. No thought need be put into preserving the important details, because now absolutely every detail can be included. We have become so overloaded with the unimportant, that we may lose the truly critical in this sea of information. It has become, therefore, imperative that physicians rediscover the patient in their story, and not rely solely on the poor reflection we may find in their chart.
Thousands of years ago, the apostle Paul wrote that “we see now as through a glass, darkly.” Borrowing from his original meaning, these ancient words have been quoted throughout literature to describe an “incomplete understanding,” often mixed with a state of despair. Today, we might think of the electronic record as the glass – or mirror – reflecting the patient’s story. Ironically, in spite of having more information than ever, the image we see may be incomplete, and possibly even wrong altogether. While the amount of available data may at first glance appear enlightening, the reflection in the glass may be rather dark indeed.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care. Neil Skolnik, MD, is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
Recently, we were invited to take part in an case presentation focused on a young female patient. The reason for our specific invitation was because a key component in the patient’s case was centered on her electronic health record. This kind of story was not new to us – in fact, stories like these are becoming almost common everywhere. But this particular conference promised to be very special, because the patient herself was asked to take an active role and present the story from a unique perspective – her own.
Seated on stage in a hospital gown and accompanied by her I.V. pole, the patient related a 4-month history of symptoms. She had obviously told the story dozens of times – through seemingly endless encounters – to her primary physician, hospital residents, medical students, emergency physicians, and just about anyone else who would lend an ear. Listening to her share her story with a large audience while still a patient in the hospital was incredibly powerful; it was difficult not to become emotional with her as she welled up with tears. She told a complex, though very coherent tale that included her past medical and family histories, her employment, her hobbies, and her unusual signs and symptoms as they developed over an extended period of time. When the patient was done, her case was presented from another perspective: the way it was recorded in her electronic record. For a brief moment, those seated in the audience were confused. Then the theme of the conference became evident – these were completely different stories.
This was no case of mistaken identity or registration error. The chart presented at the conference did belong to the patient, but the story told by the chart was wrong. Reading through the chart, it would be easy to come away with the same sense as her care team; this must simply be a common illness that wasn’t responding to conventional treatment. Encounter after encounter, a new plan was devised to address the presumed diagnosis. But the patient’s telling of the history barely mentioned any symptoms related to that diagnosis. Her version focused more on how her life was affected, how she could no longer take care of her daughter, how she could no longer exercise (which she did avidly), and how she was sinking deeper into despair and losing hope. Woven through all of this were the historical details and seemingly obvious physical manifestations that might easily disclose the real cause of her symptoms. A few basic questions about her family history would also reveal multiple immediate family members who suffered from the same disease! But even if these questions had been asked, and even if the story had been heard, the image in the mirror – her chart – did not reflect an accurate understanding of the patient.
We often solicit comments from readers, and the response is alway encouraging. It is clear that our colleagues in the medical community feel a strong sense of obligation to their patients and care deeply for maintaining the sanctity of the physician-patient relationship. However, many feel the electronic health record has become a barrier to developing and nurturing that relationship, standing in the way understanding their stories. One poignant letter from a cardiologist in Florida, Eugene H. Eisman, MD, does a beautiful job in crystallizing this sentiment. Dr. Eisman writes:
“Many of my patients end up hospitalized where I do not have privileges. Almost every attending is attentive enough to send me a discharge summary. These, however, are EHR-generated. The patient may have been hospitalized for 3 days, yet the summary is seven pages long. It is filled with total nonsense, such as whether the patient had traveled to North Africa (even though he was hospitalized with a fractured hip while skiing in Colorado). The attending has managed to cut and paste reports of every chest film and CBC, and I have pages of normal studies. The final diagnosis and discharge medications are difficult to find in this morass of words. I cannot force myself to read this document, and it is thrown into his chart after a cursory glance. Yet, I can’t sleep at night. Is there buried in this seven-page document a discovery of malignancy, etc.?”
Dr. Eisman’s words are powerful because they reveal an oft-overlooked truth about modern medical records. The patient’s chart, once considered a sacred text containing the key inflection points in a patient’s story, has become merely a filing cabinet in which to stuff every piece of data about the patient, no matter how mundane or trivial. No thought need be put into preserving the important details, because now absolutely every detail can be included. We have become so overloaded with the unimportant, that we may lose the truly critical in this sea of information. It has become, therefore, imperative that physicians rediscover the patient in their story, and not rely solely on the poor reflection we may find in their chart.
Thousands of years ago, the apostle Paul wrote that “we see now as through a glass, darkly.” Borrowing from his original meaning, these ancient words have been quoted throughout literature to describe an “incomplete understanding,” often mixed with a state of despair. Today, we might think of the electronic record as the glass – or mirror – reflecting the patient’s story. Ironically, in spite of having more information than ever, the image we see may be incomplete, and possibly even wrong altogether. While the amount of available data may at first glance appear enlightening, the reflection in the glass may be rather dark indeed.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care. Neil Skolnik, MD, is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
The EHR Report: The vortex that sucks you in
Recently, a colleague of ours described the office electronic health record as “the vortex that sucks you in.” This statement occurred during a departmental meeting focused on physician burnout. When members of the department were asked about what things they felt contributed to a feeling of dissatisfaction with work, the electronic health record quickly emerged as a common denominator of dissatisfaction. There were certainly other contributors – the changing and challenging medical environment, fighting with insurance companies, decreased autonomy over practice decisions – but far and away the most cited contributor to dissatisfaction among members of the department was the EHR.
The reasons that EHRs have led to dissatisfaction seem to have changed over the last few years. Initially, physicians found it difficult to suddenly adapt practice styles developed over many years to the new world of electronic documentation. Suddenly they needed to type (or in the case of many, hunt and peck) notes into the history of present illness and fit patient histories into templates seemingly developed by engineers rather than physicians. Now, while most of us have adapted to the logistics of the EHR, there is no escaping the increasing demands for more and more information. There is also ongoing frustration with the lack of control in deciding whether information is relevant for the patient, as well as disparity between the promise and expectation of what electronic records should deliver and what we experience each day in front of us.
Given the degree to which EHRs are contributing to physician dissatisfaction and burnout, it is incumbent upon us to figure out ways to make the EHR work better for clinicians. The literature describes burnout as “a syndrome characterized by a loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment.” In a recent study, almost half of all physicians described at least one symptom of burnout. Interestingly, physician burnout is greatest in primary care specialties. Surprisingly, compared with other working adults in the United States, physicians are more likely to have symptoms of burnout (38% vs 28%) as well as express dissatisfaction with their work-life balance (40% vs. 23%).1 This issue is important because burnout – in addition to its negative effects on physicians’ experience and quality of life – can erode the quality of the care they give, increase the risk of medical errors, and lead to early ending of lifelong careers.2 The literature suggests that the high prevalence of burnout among U.S. physicians means that “the problem lies more with the system and environment in which physicians work rather than being due to innate vulnerabilities in a few susceptible individuals.” Not surprisingly, we have received letters from readers of our column over many years discussing how the entry of EHRs into their practice was a critical influence in their decisions to retire early.
In our discussion after the department meeting, several physicians described the need to do charting at night from home in order to have their work accomplished for the next day. This is not surprising to any of us who work in primary care and use EHRs. The ability to have access to the EHR anytime and from anywhere is a classic double-edged sword. It is certainly convenient to be able to complete our charting from home without having to stay late in the office on nights and weekends. Unfortunately, bringing work home also erodes into time that could otherwise be spent with family and pursuing other interests.
This is just one of many frustrations. Another common issue is superfluous documentation on the part of specialists. Often, the information is entered by physician extenders or using canned macros to “pad” the note. Sifting through paragraphs of this irrelevant – and sometimes inaccurate – information in consultant notes devalues the integrity of the interaction. It also minimizes the time that was actually spent in the office doing the real hard work of medicine instead of the rudimentary work of documenting things that were either never said or mentioned briefly in passing.
The week after our department meeting was the first week of work for our new interns. Rounding in one of our nursing homes, I handed the intern a patient’s chart and began to explain how the chart was organized – where the orders, progress notes, and labs were located in the chart. The intern had an odd smile on her face. I asked her what was wrong. She replied, “I didn’t know anyone still had paper charts; how do you enter a note there?”
So we come full circle. You can’t miss what you never had. Younger physicians do not resent the EHR, nor can they perceive the EHR to be contributing to discontent. That is not to say that it does not contribute; it is just difficult to identify problems when the way things are is what you have always known. The issue of EHRs contributing to physician burnout is real, and we need to learn more about its causes. Please email us with your thoughts about the aspects of EHRs that you find most frustrating or challenging. Our goal in hearing from you is that it is only by knowing the challenges that we face that we can begin to formulate solutions to overcome those challenges and together make tomorrow’s practice better than today’s.
References
1. Shanafelt TD et al. Burnout and satisfaction with work-life balance among U.S. physicians relative to the general U.S. population. Arch Intern Med. 2012;172(18):1377-85.
2. Shanafelt TD, Balch CM, Bechamps G et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
Recently, a colleague of ours described the office electronic health record as “the vortex that sucks you in.” This statement occurred during a departmental meeting focused on physician burnout. When members of the department were asked about what things they felt contributed to a feeling of dissatisfaction with work, the electronic health record quickly emerged as a common denominator of dissatisfaction. There were certainly other contributors – the changing and challenging medical environment, fighting with insurance companies, decreased autonomy over practice decisions – but far and away the most cited contributor to dissatisfaction among members of the department was the EHR.
The reasons that EHRs have led to dissatisfaction seem to have changed over the last few years. Initially, physicians found it difficult to suddenly adapt practice styles developed over many years to the new world of electronic documentation. Suddenly they needed to type (or in the case of many, hunt and peck) notes into the history of present illness and fit patient histories into templates seemingly developed by engineers rather than physicians. Now, while most of us have adapted to the logistics of the EHR, there is no escaping the increasing demands for more and more information. There is also ongoing frustration with the lack of control in deciding whether information is relevant for the patient, as well as disparity between the promise and expectation of what electronic records should deliver and what we experience each day in front of us.
Given the degree to which EHRs are contributing to physician dissatisfaction and burnout, it is incumbent upon us to figure out ways to make the EHR work better for clinicians. The literature describes burnout as “a syndrome characterized by a loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment.” In a recent study, almost half of all physicians described at least one symptom of burnout. Interestingly, physician burnout is greatest in primary care specialties. Surprisingly, compared with other working adults in the United States, physicians are more likely to have symptoms of burnout (38% vs 28%) as well as express dissatisfaction with their work-life balance (40% vs. 23%).1 This issue is important because burnout – in addition to its negative effects on physicians’ experience and quality of life – can erode the quality of the care they give, increase the risk of medical errors, and lead to early ending of lifelong careers.2 The literature suggests that the high prevalence of burnout among U.S. physicians means that “the problem lies more with the system and environment in which physicians work rather than being due to innate vulnerabilities in a few susceptible individuals.” Not surprisingly, we have received letters from readers of our column over many years discussing how the entry of EHRs into their practice was a critical influence in their decisions to retire early.
In our discussion after the department meeting, several physicians described the need to do charting at night from home in order to have their work accomplished for the next day. This is not surprising to any of us who work in primary care and use EHRs. The ability to have access to the EHR anytime and from anywhere is a classic double-edged sword. It is certainly convenient to be able to complete our charting from home without having to stay late in the office on nights and weekends. Unfortunately, bringing work home also erodes into time that could otherwise be spent with family and pursuing other interests.
This is just one of many frustrations. Another common issue is superfluous documentation on the part of specialists. Often, the information is entered by physician extenders or using canned macros to “pad” the note. Sifting through paragraphs of this irrelevant – and sometimes inaccurate – information in consultant notes devalues the integrity of the interaction. It also minimizes the time that was actually spent in the office doing the real hard work of medicine instead of the rudimentary work of documenting things that were either never said or mentioned briefly in passing.
The week after our department meeting was the first week of work for our new interns. Rounding in one of our nursing homes, I handed the intern a patient’s chart and began to explain how the chart was organized – where the orders, progress notes, and labs were located in the chart. The intern had an odd smile on her face. I asked her what was wrong. She replied, “I didn’t know anyone still had paper charts; how do you enter a note there?”
So we come full circle. You can’t miss what you never had. Younger physicians do not resent the EHR, nor can they perceive the EHR to be contributing to discontent. That is not to say that it does not contribute; it is just difficult to identify problems when the way things are is what you have always known. The issue of EHRs contributing to physician burnout is real, and we need to learn more about its causes. Please email us with your thoughts about the aspects of EHRs that you find most frustrating or challenging. Our goal in hearing from you is that it is only by knowing the challenges that we face that we can begin to formulate solutions to overcome those challenges and together make tomorrow’s practice better than today’s.
References
1. Shanafelt TD et al. Burnout and satisfaction with work-life balance among U.S. physicians relative to the general U.S. population. Arch Intern Med. 2012;172(18):1377-85.
2. Shanafelt TD, Balch CM, Bechamps G et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
Recently, a colleague of ours described the office electronic health record as “the vortex that sucks you in.” This statement occurred during a departmental meeting focused on physician burnout. When members of the department were asked about what things they felt contributed to a feeling of dissatisfaction with work, the electronic health record quickly emerged as a common denominator of dissatisfaction. There were certainly other contributors – the changing and challenging medical environment, fighting with insurance companies, decreased autonomy over practice decisions – but far and away the most cited contributor to dissatisfaction among members of the department was the EHR.
The reasons that EHRs have led to dissatisfaction seem to have changed over the last few years. Initially, physicians found it difficult to suddenly adapt practice styles developed over many years to the new world of electronic documentation. Suddenly they needed to type (or in the case of many, hunt and peck) notes into the history of present illness and fit patient histories into templates seemingly developed by engineers rather than physicians. Now, while most of us have adapted to the logistics of the EHR, there is no escaping the increasing demands for more and more information. There is also ongoing frustration with the lack of control in deciding whether information is relevant for the patient, as well as disparity between the promise and expectation of what electronic records should deliver and what we experience each day in front of us.
Given the degree to which EHRs are contributing to physician dissatisfaction and burnout, it is incumbent upon us to figure out ways to make the EHR work better for clinicians. The literature describes burnout as “a syndrome characterized by a loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment.” In a recent study, almost half of all physicians described at least one symptom of burnout. Interestingly, physician burnout is greatest in primary care specialties. Surprisingly, compared with other working adults in the United States, physicians are more likely to have symptoms of burnout (38% vs 28%) as well as express dissatisfaction with their work-life balance (40% vs. 23%).1 This issue is important because burnout – in addition to its negative effects on physicians’ experience and quality of life – can erode the quality of the care they give, increase the risk of medical errors, and lead to early ending of lifelong careers.2 The literature suggests that the high prevalence of burnout among U.S. physicians means that “the problem lies more with the system and environment in which physicians work rather than being due to innate vulnerabilities in a few susceptible individuals.” Not surprisingly, we have received letters from readers of our column over many years discussing how the entry of EHRs into their practice was a critical influence in their decisions to retire early.
In our discussion after the department meeting, several physicians described the need to do charting at night from home in order to have their work accomplished for the next day. This is not surprising to any of us who work in primary care and use EHRs. The ability to have access to the EHR anytime and from anywhere is a classic double-edged sword. It is certainly convenient to be able to complete our charting from home without having to stay late in the office on nights and weekends. Unfortunately, bringing work home also erodes into time that could otherwise be spent with family and pursuing other interests.
This is just one of many frustrations. Another common issue is superfluous documentation on the part of specialists. Often, the information is entered by physician extenders or using canned macros to “pad” the note. Sifting through paragraphs of this irrelevant – and sometimes inaccurate – information in consultant notes devalues the integrity of the interaction. It also minimizes the time that was actually spent in the office doing the real hard work of medicine instead of the rudimentary work of documenting things that were either never said or mentioned briefly in passing.
The week after our department meeting was the first week of work for our new interns. Rounding in one of our nursing homes, I handed the intern a patient’s chart and began to explain how the chart was organized – where the orders, progress notes, and labs were located in the chart. The intern had an odd smile on her face. I asked her what was wrong. She replied, “I didn’t know anyone still had paper charts; how do you enter a note there?”
So we come full circle. You can’t miss what you never had. Younger physicians do not resent the EHR, nor can they perceive the EHR to be contributing to discontent. That is not to say that it does not contribute; it is just difficult to identify problems when the way things are is what you have always known. The issue of EHRs contributing to physician burnout is real, and we need to learn more about its causes. Please email us with your thoughts about the aspects of EHRs that you find most frustrating or challenging. Our goal in hearing from you is that it is only by knowing the challenges that we face that we can begin to formulate solutions to overcome those challenges and together make tomorrow’s practice better than today’s.
References
1. Shanafelt TD et al. Burnout and satisfaction with work-life balance among U.S. physicians relative to the general U.S. population. Arch Intern Med. 2012;172(18):1377-85.
2. Shanafelt TD, Balch CM, Bechamps G et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
EHR Report: Smith vs. Smith: Errors in the era of EHRs
George Smith (DOB 2/12/51) is a 65-year-old male patient with a history of hypertension and hyperlipidemia who presents to his local emergency department complaining of worsening dyspnea. He has been suffering with a “chest cold” for the past week, and has also noticed a gradual increase in chest discomfort. The patient is unsure if this is related to exertion or due to his nonproductive cough, but describes the sensation as a “tightness that seems to be getting worse.” The emergency physician is appropriately concerned about a cardiac cause for his symptoms, but is reassured after a check of his electronic health record reveals a recent nuclear treadmill stress test showing normal myocardial perfusion and excellent exercise tolerance, with a low probability of coronary disease.
The only problem is that George Smith never had a stress test. In fact, it’s his twin brother James Smith – also with a birth date of 2/12/51 and a home in the same city – who just had the study done in preparation for surgery. The mix-up in the records began 3 weeks ago, when a tech in the cardiac testing department made an error registering James for his stress test, and now the results of his study have filed into the chart of his twin brother. Fortunately for George, the primary care physician who cares for both brothers happens to be in the emergency department seeing a different patient. He is “curbsided” by the ED doc and recognizes the identification error before the patient is to be discharged home.
This alarming situation – a fictionalized version of a story that happens regularly in hospitals all across the United States – highlights several serious problems with electronic health records. With all of their claimed advantages, EHRs have created a tremendous number of new complications. Some are obvious, such as increased documentation time, connectivity issues, hardware failures, and superfluous “overdocumentation.” But the more troubling issues with electronic records are the ones that are much subtler. Specifically, as the case above highlights, there is the tendency to “lose the forest in the trees” of the EHR, and actually make mistakes that can have devastating consequences. This month we want to cast a light on how electronic tools designed to improve quality and safety actually can compromise them, beginning with the unfortunate reality that …
Modern conveniences can make errors more convenient as well
One of the great advantages of a well-designed electronic record is the ease of locating information when you need it; by entering a few pieces of information such as a last name and date of birth, we can find the needed data in seconds. Unfortunately, this simple and elegant system has exposed a weakness in the people using it: confirmation bias – the idea that we all tend to see what we want to see. This is an adaptive behavior that we all develop to improve efficiency and successfully navigate all of the conscious and subconscious decisions we make throughout the day. Typically, confirmation bias serves to make our lives easier, but in the case above, it didn’t help Mr. Smith; on the contrary, it almost led to disastrous consequences. The error was fortunately recognized by his astute primary care physician, but this case could have ended much differently. The experience should serve as a reminder to us that …
We can easily lose the big picture
The days of hunting for missing patient charts are thankfully long gone, but there are a few critical aspects of paper records that have been lost in the translation to electronic form. One such missing piece was noted by a colleague when first transitioning to an EHR. After a day or two of struggling with the new software, he lamented “I’m missing the big picture!” He had lost the advantage of glancing at a paper chart and instantly recalling the details about his patients that he had compiled over many years of care. For many physicians like him, this may mean reviewing handwritten notes or jottings in the margin of the chart, but sometimes just the appearance of the chart itself is enough to trigger an intellectual or emotional response.
This notion simply doesn’t exist in the world of electronic “charts,” which are all uniform by design. In the quest to simplify workflow and encourage muscle memory, EHR designers have eschewed the intangible experience of holding a yellowing, dog-eared, overflowing patient folder. Instead, physicians now find themselves holding the same PC or tablet as they walk into every patient encounter, left with only a name and date of birth to distinguish one patient from the next. Even worse, the mere definition of a patient chart has moved from a physical construct to a metaphysical one. Charts can be anywhere and everywhere, and can be edited by any end user at virtually any point of care. This opens up almost limitless opportunities for error, and unfortunately …
Errors can last a lifetime
With each episode of care, the charts of the two Mr. Smiths could become more enmeshed, and the histories harder to untangle. (In this case, a passing reference to the stress test results in the ED intern’s history and physical of George Smith may perpetuate the mistake, even though the error has been caught this time.) When mistakes like this are identified, hundreds of collective staff hours can be required to unweave comingled medical records, even when they don’t result in patient harm. It is therefore critical to develop safeguards to prevent them from occurring in the first place, with efforts that include training programs, workflow process improvement, and technology enhancement.
Ultimately, it may be impossible to prevent all documentation errors. However, by focusing on the big picture and considering patient safety first, we can raise awareness of these and other critical issues and develop the tools and training necessary to make mistakes possible to avoid.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia.
George Smith (DOB 2/12/51) is a 65-year-old male patient with a history of hypertension and hyperlipidemia who presents to his local emergency department complaining of worsening dyspnea. He has been suffering with a “chest cold” for the past week, and has also noticed a gradual increase in chest discomfort. The patient is unsure if this is related to exertion or due to his nonproductive cough, but describes the sensation as a “tightness that seems to be getting worse.” The emergency physician is appropriately concerned about a cardiac cause for his symptoms, but is reassured after a check of his electronic health record reveals a recent nuclear treadmill stress test showing normal myocardial perfusion and excellent exercise tolerance, with a low probability of coronary disease.
The only problem is that George Smith never had a stress test. In fact, it’s his twin brother James Smith – also with a birth date of 2/12/51 and a home in the same city – who just had the study done in preparation for surgery. The mix-up in the records began 3 weeks ago, when a tech in the cardiac testing department made an error registering James for his stress test, and now the results of his study have filed into the chart of his twin brother. Fortunately for George, the primary care physician who cares for both brothers happens to be in the emergency department seeing a different patient. He is “curbsided” by the ED doc and recognizes the identification error before the patient is to be discharged home.
This alarming situation – a fictionalized version of a story that happens regularly in hospitals all across the United States – highlights several serious problems with electronic health records. With all of their claimed advantages, EHRs have created a tremendous number of new complications. Some are obvious, such as increased documentation time, connectivity issues, hardware failures, and superfluous “overdocumentation.” But the more troubling issues with electronic records are the ones that are much subtler. Specifically, as the case above highlights, there is the tendency to “lose the forest in the trees” of the EHR, and actually make mistakes that can have devastating consequences. This month we want to cast a light on how electronic tools designed to improve quality and safety actually can compromise them, beginning with the unfortunate reality that …
Modern conveniences can make errors more convenient as well
One of the great advantages of a well-designed electronic record is the ease of locating information when you need it; by entering a few pieces of information such as a last name and date of birth, we can find the needed data in seconds. Unfortunately, this simple and elegant system has exposed a weakness in the people using it: confirmation bias – the idea that we all tend to see what we want to see. This is an adaptive behavior that we all develop to improve efficiency and successfully navigate all of the conscious and subconscious decisions we make throughout the day. Typically, confirmation bias serves to make our lives easier, but in the case above, it didn’t help Mr. Smith; on the contrary, it almost led to disastrous consequences. The error was fortunately recognized by his astute primary care physician, but this case could have ended much differently. The experience should serve as a reminder to us that …
We can easily lose the big picture
The days of hunting for missing patient charts are thankfully long gone, but there are a few critical aspects of paper records that have been lost in the translation to electronic form. One such missing piece was noted by a colleague when first transitioning to an EHR. After a day or two of struggling with the new software, he lamented “I’m missing the big picture!” He had lost the advantage of glancing at a paper chart and instantly recalling the details about his patients that he had compiled over many years of care. For many physicians like him, this may mean reviewing handwritten notes or jottings in the margin of the chart, but sometimes just the appearance of the chart itself is enough to trigger an intellectual or emotional response.
This notion simply doesn’t exist in the world of electronic “charts,” which are all uniform by design. In the quest to simplify workflow and encourage muscle memory, EHR designers have eschewed the intangible experience of holding a yellowing, dog-eared, overflowing patient folder. Instead, physicians now find themselves holding the same PC or tablet as they walk into every patient encounter, left with only a name and date of birth to distinguish one patient from the next. Even worse, the mere definition of a patient chart has moved from a physical construct to a metaphysical one. Charts can be anywhere and everywhere, and can be edited by any end user at virtually any point of care. This opens up almost limitless opportunities for error, and unfortunately …
Errors can last a lifetime
With each episode of care, the charts of the two Mr. Smiths could become more enmeshed, and the histories harder to untangle. (In this case, a passing reference to the stress test results in the ED intern’s history and physical of George Smith may perpetuate the mistake, even though the error has been caught this time.) When mistakes like this are identified, hundreds of collective staff hours can be required to unweave comingled medical records, even when they don’t result in patient harm. It is therefore critical to develop safeguards to prevent them from occurring in the first place, with efforts that include training programs, workflow process improvement, and technology enhancement.
Ultimately, it may be impossible to prevent all documentation errors. However, by focusing on the big picture and considering patient safety first, we can raise awareness of these and other critical issues and develop the tools and training necessary to make mistakes possible to avoid.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia.
George Smith (DOB 2/12/51) is a 65-year-old male patient with a history of hypertension and hyperlipidemia who presents to his local emergency department complaining of worsening dyspnea. He has been suffering with a “chest cold” for the past week, and has also noticed a gradual increase in chest discomfort. The patient is unsure if this is related to exertion or due to his nonproductive cough, but describes the sensation as a “tightness that seems to be getting worse.” The emergency physician is appropriately concerned about a cardiac cause for his symptoms, but is reassured after a check of his electronic health record reveals a recent nuclear treadmill stress test showing normal myocardial perfusion and excellent exercise tolerance, with a low probability of coronary disease.
The only problem is that George Smith never had a stress test. In fact, it’s his twin brother James Smith – also with a birth date of 2/12/51 and a home in the same city – who just had the study done in preparation for surgery. The mix-up in the records began 3 weeks ago, when a tech in the cardiac testing department made an error registering James for his stress test, and now the results of his study have filed into the chart of his twin brother. Fortunately for George, the primary care physician who cares for both brothers happens to be in the emergency department seeing a different patient. He is “curbsided” by the ED doc and recognizes the identification error before the patient is to be discharged home.
This alarming situation – a fictionalized version of a story that happens regularly in hospitals all across the United States – highlights several serious problems with electronic health records. With all of their claimed advantages, EHRs have created a tremendous number of new complications. Some are obvious, such as increased documentation time, connectivity issues, hardware failures, and superfluous “overdocumentation.” But the more troubling issues with electronic records are the ones that are much subtler. Specifically, as the case above highlights, there is the tendency to “lose the forest in the trees” of the EHR, and actually make mistakes that can have devastating consequences. This month we want to cast a light on how electronic tools designed to improve quality and safety actually can compromise them, beginning with the unfortunate reality that …
Modern conveniences can make errors more convenient as well
One of the great advantages of a well-designed electronic record is the ease of locating information when you need it; by entering a few pieces of information such as a last name and date of birth, we can find the needed data in seconds. Unfortunately, this simple and elegant system has exposed a weakness in the people using it: confirmation bias – the idea that we all tend to see what we want to see. This is an adaptive behavior that we all develop to improve efficiency and successfully navigate all of the conscious and subconscious decisions we make throughout the day. Typically, confirmation bias serves to make our lives easier, but in the case above, it didn’t help Mr. Smith; on the contrary, it almost led to disastrous consequences. The error was fortunately recognized by his astute primary care physician, but this case could have ended much differently. The experience should serve as a reminder to us that …
We can easily lose the big picture
The days of hunting for missing patient charts are thankfully long gone, but there are a few critical aspects of paper records that have been lost in the translation to electronic form. One such missing piece was noted by a colleague when first transitioning to an EHR. After a day or two of struggling with the new software, he lamented “I’m missing the big picture!” He had lost the advantage of glancing at a paper chart and instantly recalling the details about his patients that he had compiled over many years of care. For many physicians like him, this may mean reviewing handwritten notes or jottings in the margin of the chart, but sometimes just the appearance of the chart itself is enough to trigger an intellectual or emotional response.
This notion simply doesn’t exist in the world of electronic “charts,” which are all uniform by design. In the quest to simplify workflow and encourage muscle memory, EHR designers have eschewed the intangible experience of holding a yellowing, dog-eared, overflowing patient folder. Instead, physicians now find themselves holding the same PC or tablet as they walk into every patient encounter, left with only a name and date of birth to distinguish one patient from the next. Even worse, the mere definition of a patient chart has moved from a physical construct to a metaphysical one. Charts can be anywhere and everywhere, and can be edited by any end user at virtually any point of care. This opens up almost limitless opportunities for error, and unfortunately …
Errors can last a lifetime
With each episode of care, the charts of the two Mr. Smiths could become more enmeshed, and the histories harder to untangle. (In this case, a passing reference to the stress test results in the ED intern’s history and physical of George Smith may perpetuate the mistake, even though the error has been caught this time.) When mistakes like this are identified, hundreds of collective staff hours can be required to unweave comingled medical records, even when they don’t result in patient harm. It is therefore critical to develop safeguards to prevent them from occurring in the first place, with efforts that include training programs, workflow process improvement, and technology enhancement.
Ultimately, it may be impossible to prevent all documentation errors. However, by focusing on the big picture and considering patient safety first, we can raise awareness of these and other critical issues and develop the tools and training necessary to make mistakes possible to avoid.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia.
How Zika Virus Reveals the Fault in Our EHRs
It is always noteworthy when the headlines in the medical and mainstream media appear to be the same.
Typically, this means one of two things: 1) Sensationalism has propelled a minor issue into the common lexicon; or 2) a truly serious issue has grown to the point where the whole world is finally taking notice.
With the recent resurgence of Zika virus, something that initially seemed to be the former has unmistakably developed into the latter, and health care providers are again facing an age-old question: How do we adequately fight an evolving and serious illness in the midst of an ever-changing battlefield?
As has been the case countless times before, the answer to this question really lies in early identification. One might think that the advent of modern technology would make this a much easier proposition, but that has not exactly been the case.
In fact, recent Ebola and Zika outbreaks have actually served to demonstrate a big problem in many modern electronic health records: poor clinical decision support.
In this column, we felt it would be helpful to highlight this shortcoming, and make the suggestion that in the world of EHRs …
Change needs to be faster than Zika
Zika virus is not new (it was first identified in the Zika Forest of Uganda in 1947), and neither is the concept of serious mosquito-born illness. While the current Zika hot zones are South America, Central America, Mexico, and the Caribbean, case reports indicate the virus is quickly migrating. At the time of this writing, more than 150 travel-associated cases of Zika have been identified in the continental United States, and it is clear that the consequences of undiagnosed Zika in pregnancy can be devastating.
Furthermore, Zika is just the latest of many viruses to threaten the health and welfare of modern civilization (for example, Ebola, swine flu, SARS, and so on), so screening and prevention is far from a novel idea.
Unfortunately, electronic record vendors don’t seem to have gotten the message that the ability to adapt quickly to public health threats should be a core element of any modern EHR.
On the contrary, EHRs seem to be designed for fixed “best practice” workflows, and updates are often slow in coming (typically requiring a major upgrade or “patch”). This renders them fairly unable to react nimbly to change.
This fact became evident to us as we attempted to implement a reminder for staff members to perform a Zika-focused travel history on all patients. We felt it was critical for this reminder to be prominent, be easy to interact with, and appear at the most appropriate time for screening.
Despite multiple attempts, we discovered that our top-ranked, industry-leading EHR was unable to do this seemingly straightforward task, and eventually we reverted to the age-old practice of hanging signs in all of the exam rooms. These encouraged patients to inform their doctor “of worrisome symptoms or recent travel history to affected areas.”
We refuse to accept the inability of any modern electronic health record to create simple and flexible clinical support rules and improve on the efficacy of the paper sign. This, especially in light of the fact that one of the core requirements of the Meaningful Use (MU) program – for which all EHRs are certified – is clinical decision support!
Unfortunately, the MU guidelines are not specific, so most vendors choose to include a standard set of rules and don’t allow the ability for customization. That just isn’t good enough. If Ebola and Zika have taught the health information technology community one thing, it’s that …
It is time for smarter EHRs!
For many people, the notion of artificial intelligence seems to be science fiction, but they don’t realize they are carrying incredible “AI” devices with them everywhere they go. We are, of course, referring to our cell phones, which seem to be getting more intelligent all the time.
If you own an iPhone, you may have noticed it often seems to know where you are about to drive and how long it will take you to get there. This can be a bit creepy at first, until you realize how helpful – and smart – it actually is.
Essentially, our devices are constantly collecting data, reading the patterns of our lives, and learning ways to enhance them. Smartphones have revolutionized how we communicate, work, and play. Why, then, can’t our electronic health record software do the same?
It will surprise exactly none of our readers that the Meaningful Use program has fallen short of its goal of promoting the true benefits of electronic records. Many critics have suggested that the incentive program has faltered because EHRs have made physicians work harder, without helping them work smarter.
Zika virus proves the critics correct. Beyond creating just simple reminders as mentioned above, EHRs should be able to make intelligent suggestions based on patient data and current practice guidelines.
Some EHRs get it half correct. For example, they are “smart” enough to remind clinicians that women of a certain age should have mammograms, but they fall short in the ability to efficiently update those reminders when the U.S. Preventive Services Task Force updates the screening recommendation (as they did recently).
Other EHRs do allow you to customize preventative health reminders, but do not place them in a position of prominence – so they are easily overlooked by providers as they care for patients.
Few products seem to get it just right, and it’s time for this to change.
Simply put, as questions in the media loom about how to stop this rising threat, we as frontline health care providers should have the tools – and the decision support – required to provide meaningful answers.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
It is always noteworthy when the headlines in the medical and mainstream media appear to be the same.
Typically, this means one of two things: 1) Sensationalism has propelled a minor issue into the common lexicon; or 2) a truly serious issue has grown to the point where the whole world is finally taking notice.
With the recent resurgence of Zika virus, something that initially seemed to be the former has unmistakably developed into the latter, and health care providers are again facing an age-old question: How do we adequately fight an evolving and serious illness in the midst of an ever-changing battlefield?
As has been the case countless times before, the answer to this question really lies in early identification. One might think that the advent of modern technology would make this a much easier proposition, but that has not exactly been the case.
In fact, recent Ebola and Zika outbreaks have actually served to demonstrate a big problem in many modern electronic health records: poor clinical decision support.
In this column, we felt it would be helpful to highlight this shortcoming, and make the suggestion that in the world of EHRs …
Change needs to be faster than Zika
Zika virus is not new (it was first identified in the Zika Forest of Uganda in 1947), and neither is the concept of serious mosquito-born illness. While the current Zika hot zones are South America, Central America, Mexico, and the Caribbean, case reports indicate the virus is quickly migrating. At the time of this writing, more than 150 travel-associated cases of Zika have been identified in the continental United States, and it is clear that the consequences of undiagnosed Zika in pregnancy can be devastating.
Furthermore, Zika is just the latest of many viruses to threaten the health and welfare of modern civilization (for example, Ebola, swine flu, SARS, and so on), so screening and prevention is far from a novel idea.
Unfortunately, electronic record vendors don’t seem to have gotten the message that the ability to adapt quickly to public health threats should be a core element of any modern EHR.
On the contrary, EHRs seem to be designed for fixed “best practice” workflows, and updates are often slow in coming (typically requiring a major upgrade or “patch”). This renders them fairly unable to react nimbly to change.
This fact became evident to us as we attempted to implement a reminder for staff members to perform a Zika-focused travel history on all patients. We felt it was critical for this reminder to be prominent, be easy to interact with, and appear at the most appropriate time for screening.
Despite multiple attempts, we discovered that our top-ranked, industry-leading EHR was unable to do this seemingly straightforward task, and eventually we reverted to the age-old practice of hanging signs in all of the exam rooms. These encouraged patients to inform their doctor “of worrisome symptoms or recent travel history to affected areas.”
We refuse to accept the inability of any modern electronic health record to create simple and flexible clinical support rules and improve on the efficacy of the paper sign. This, especially in light of the fact that one of the core requirements of the Meaningful Use (MU) program – for which all EHRs are certified – is clinical decision support!
Unfortunately, the MU guidelines are not specific, so most vendors choose to include a standard set of rules and don’t allow the ability for customization. That just isn’t good enough. If Ebola and Zika have taught the health information technology community one thing, it’s that …
It is time for smarter EHRs!
For many people, the notion of artificial intelligence seems to be science fiction, but they don’t realize they are carrying incredible “AI” devices with them everywhere they go. We are, of course, referring to our cell phones, which seem to be getting more intelligent all the time.
If you own an iPhone, you may have noticed it often seems to know where you are about to drive and how long it will take you to get there. This can be a bit creepy at first, until you realize how helpful – and smart – it actually is.
Essentially, our devices are constantly collecting data, reading the patterns of our lives, and learning ways to enhance them. Smartphones have revolutionized how we communicate, work, and play. Why, then, can’t our electronic health record software do the same?
It will surprise exactly none of our readers that the Meaningful Use program has fallen short of its goal of promoting the true benefits of electronic records. Many critics have suggested that the incentive program has faltered because EHRs have made physicians work harder, without helping them work smarter.
Zika virus proves the critics correct. Beyond creating just simple reminders as mentioned above, EHRs should be able to make intelligent suggestions based on patient data and current practice guidelines.
Some EHRs get it half correct. For example, they are “smart” enough to remind clinicians that women of a certain age should have mammograms, but they fall short in the ability to efficiently update those reminders when the U.S. Preventive Services Task Force updates the screening recommendation (as they did recently).
Other EHRs do allow you to customize preventative health reminders, but do not place them in a position of prominence – so they are easily overlooked by providers as they care for patients.
Few products seem to get it just right, and it’s time for this to change.
Simply put, as questions in the media loom about how to stop this rising threat, we as frontline health care providers should have the tools – and the decision support – required to provide meaningful answers.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
It is always noteworthy when the headlines in the medical and mainstream media appear to be the same.
Typically, this means one of two things: 1) Sensationalism has propelled a minor issue into the common lexicon; or 2) a truly serious issue has grown to the point where the whole world is finally taking notice.
With the recent resurgence of Zika virus, something that initially seemed to be the former has unmistakably developed into the latter, and health care providers are again facing an age-old question: How do we adequately fight an evolving and serious illness in the midst of an ever-changing battlefield?
As has been the case countless times before, the answer to this question really lies in early identification. One might think that the advent of modern technology would make this a much easier proposition, but that has not exactly been the case.
In fact, recent Ebola and Zika outbreaks have actually served to demonstrate a big problem in many modern electronic health records: poor clinical decision support.
In this column, we felt it would be helpful to highlight this shortcoming, and make the suggestion that in the world of EHRs …
Change needs to be faster than Zika
Zika virus is not new (it was first identified in the Zika Forest of Uganda in 1947), and neither is the concept of serious mosquito-born illness. While the current Zika hot zones are South America, Central America, Mexico, and the Caribbean, case reports indicate the virus is quickly migrating. At the time of this writing, more than 150 travel-associated cases of Zika have been identified in the continental United States, and it is clear that the consequences of undiagnosed Zika in pregnancy can be devastating.
Furthermore, Zika is just the latest of many viruses to threaten the health and welfare of modern civilization (for example, Ebola, swine flu, SARS, and so on), so screening and prevention is far from a novel idea.
Unfortunately, electronic record vendors don’t seem to have gotten the message that the ability to adapt quickly to public health threats should be a core element of any modern EHR.
On the contrary, EHRs seem to be designed for fixed “best practice” workflows, and updates are often slow in coming (typically requiring a major upgrade or “patch”). This renders them fairly unable to react nimbly to change.
This fact became evident to us as we attempted to implement a reminder for staff members to perform a Zika-focused travel history on all patients. We felt it was critical for this reminder to be prominent, be easy to interact with, and appear at the most appropriate time for screening.
Despite multiple attempts, we discovered that our top-ranked, industry-leading EHR was unable to do this seemingly straightforward task, and eventually we reverted to the age-old practice of hanging signs in all of the exam rooms. These encouraged patients to inform their doctor “of worrisome symptoms or recent travel history to affected areas.”
We refuse to accept the inability of any modern electronic health record to create simple and flexible clinical support rules and improve on the efficacy of the paper sign. This, especially in light of the fact that one of the core requirements of the Meaningful Use (MU) program – for which all EHRs are certified – is clinical decision support!
Unfortunately, the MU guidelines are not specific, so most vendors choose to include a standard set of rules and don’t allow the ability for customization. That just isn’t good enough. If Ebola and Zika have taught the health information technology community one thing, it’s that …
It is time for smarter EHRs!
For many people, the notion of artificial intelligence seems to be science fiction, but they don’t realize they are carrying incredible “AI” devices with them everywhere they go. We are, of course, referring to our cell phones, which seem to be getting more intelligent all the time.
If you own an iPhone, you may have noticed it often seems to know where you are about to drive and how long it will take you to get there. This can be a bit creepy at first, until you realize how helpful – and smart – it actually is.
Essentially, our devices are constantly collecting data, reading the patterns of our lives, and learning ways to enhance them. Smartphones have revolutionized how we communicate, work, and play. Why, then, can’t our electronic health record software do the same?
It will surprise exactly none of our readers that the Meaningful Use program has fallen short of its goal of promoting the true benefits of electronic records. Many critics have suggested that the incentive program has faltered because EHRs have made physicians work harder, without helping them work smarter.
Zika virus proves the critics correct. Beyond creating just simple reminders as mentioned above, EHRs should be able to make intelligent suggestions based on patient data and current practice guidelines.
Some EHRs get it half correct. For example, they are “smart” enough to remind clinicians that women of a certain age should have mammograms, but they fall short in the ability to efficiently update those reminders when the U.S. Preventive Services Task Force updates the screening recommendation (as they did recently).
Other EHRs do allow you to customize preventative health reminders, but do not place them in a position of prominence – so they are easily overlooked by providers as they care for patients.
Few products seem to get it just right, and it’s time for this to change.
Simply put, as questions in the media loom about how to stop this rising threat, we as frontline health care providers should have the tools – and the decision support – required to provide meaningful answers.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
EHR Report: How Zika virus reveals the fault in our EHRs
It is always noteworthy when the headlines in the medical and mainstream media appear to be the same.
Typically, this means one of two things: 1) Sensationalism has propelled a minor issue into the common lexicon; or 2) a truly serious issue has grown to the point where the whole world is finally taking notice.
With the recent resurgence of Zika virus, something that initially seemed to be the former has unmistakably developed into the latter, and health care providers are again facing an age-old question: How do we adequately fight an evolving and serious illness in the midst of an ever-changing battlefield?
As has been the case countless times before, the answer to this question really lies in early identification. One might think that the advent of modern technology would make this a much easier proposition, but that has not exactly been the case.
In fact, recent Ebola and Zika outbreaks have actually served to demonstrate a big problem in many modern electronic health records: poor clinical decision support.
In this column, we felt it would be helpful to highlight this shortcoming, and make the suggestion that in the world of EHRs …
Change needs to be faster than Zika
Zika virus is not new (it was first identified in the Zika Forest of Uganda in 1947), and neither is the concept of serious mosquito-born illness. While the current Zika hot zones are South America, Central America, Mexico, and the Caribbean, case reports indicate the virus is quickly migrating. At the time of this writing, more than 150 travel-associated cases of Zika have been identified in the continental United States, and it is clear that the consequences of undiagnosed Zika in pregnancy can be devastating.
Furthermore, Zika is just the latest of many viruses to threaten the health and welfare of modern civilization (for example, Ebola, swine flu, SARS, and so on), so screening and prevention is far from a novel idea.
Unfortunately, electronic record vendors don’t seem to have gotten the message that the ability to adapt quickly to public health threats should be a core element of any modern EHR.
On the contrary, EHRs seem to be designed for fixed “best practice” workflows, and updates are often slow in coming (typically requiring a major upgrade or “patch”). This renders them fairly unable to react nimbly to change.
This fact became evident to us as we attempted to implement a reminder for staff members to perform a Zika-focused travel history on all patients. We felt it was critical for this reminder to be prominent, be easy to interact with, and appear at the most appropriate time for screening.
Despite multiple attempts, we discovered that our top-ranked, industry-leading EHR was unable to do this seemingly straightforward task, and eventually we reverted to the age-old practice of hanging signs in all of the exam rooms. These encouraged patients to inform their doctor “of worrisome symptoms or recent travel history to affected areas.”
We refuse to accept the inability of any modern electronic health record to create simple and flexible clinical support rules and improve on the efficacy of the paper sign. This, especially in light of the fact that one of the core requirements of the Meaningful Use (MU) program – for which all EHRs are certified – is clinical decision support!
Unfortunately, the MU guidelines are not specific, so most vendors choose to include a standard set of rules and don’t allow the ability for customization. That just isn’t good enough. If Ebola and Zika have taught the health information technology community one thing, it’s that …
It is time for smarter EHRs!
For many people, the notion of artificial intelligence seems to be science fiction, but they don’t realize they are carrying incredible “AI” devices with them everywhere they go. We are, of course, referring to our cell phones, which seem to be getting more intelligent all the time.
If you own an iPhone, you may have noticed it often seems to know where you are about to drive and how long it will take you to get there. This can be a bit creepy at first, until you realize how helpful – and smart – it actually is.
Essentially, our devices are constantly collecting data, reading the patterns of our lives, and learning ways to enhance them. Smartphones have revolutionized how we communicate, work, and play. Why, then, can’t our electronic health record software do the same?
It will surprise exactly none of our readers that the Meaningful Use program has fallen short of its goal of promoting the true benefits of electronic records. Many critics have suggested that the incentive program has faltered because EHRs have made physicians work harder, without helping them work smarter.
Zika virus proves the critics correct. Beyond creating just simple reminders as mentioned above, EHRs should be able to make intelligent suggestions based on patient data and current practice guidelines.
Some EHRs get it half correct. For example, they are “smart” enough to remind clinicians that women of a certain age should have mammograms, but they fall short in the ability to efficiently update those reminders when the U.S. Preventive Services Task Force updates the screening recommendation (as they did recently).
Other EHRs do allow you to customize preventative health reminders, but do not place them in a position of prominence – so they are easily overlooked by providers as they care for patients.
Few products seem to get it just right, and it’s time for this to change.
Simply put, as questions in the media loom about how to stop this rising threat, we as frontline health care providers should have the tools – and the decision support – required to provide meaningful answers.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
It is always noteworthy when the headlines in the medical and mainstream media appear to be the same.
Typically, this means one of two things: 1) Sensationalism has propelled a minor issue into the common lexicon; or 2) a truly serious issue has grown to the point where the whole world is finally taking notice.
With the recent resurgence of Zika virus, something that initially seemed to be the former has unmistakably developed into the latter, and health care providers are again facing an age-old question: How do we adequately fight an evolving and serious illness in the midst of an ever-changing battlefield?
As has been the case countless times before, the answer to this question really lies in early identification. One might think that the advent of modern technology would make this a much easier proposition, but that has not exactly been the case.
In fact, recent Ebola and Zika outbreaks have actually served to demonstrate a big problem in many modern electronic health records: poor clinical decision support.
In this column, we felt it would be helpful to highlight this shortcoming, and make the suggestion that in the world of EHRs …
Change needs to be faster than Zika
Zika virus is not new (it was first identified in the Zika Forest of Uganda in 1947), and neither is the concept of serious mosquito-born illness. While the current Zika hot zones are South America, Central America, Mexico, and the Caribbean, case reports indicate the virus is quickly migrating. At the time of this writing, more than 150 travel-associated cases of Zika have been identified in the continental United States, and it is clear that the consequences of undiagnosed Zika in pregnancy can be devastating.
Furthermore, Zika is just the latest of many viruses to threaten the health and welfare of modern civilization (for example, Ebola, swine flu, SARS, and so on), so screening and prevention is far from a novel idea.
Unfortunately, electronic record vendors don’t seem to have gotten the message that the ability to adapt quickly to public health threats should be a core element of any modern EHR.
On the contrary, EHRs seem to be designed for fixed “best practice” workflows, and updates are often slow in coming (typically requiring a major upgrade or “patch”). This renders them fairly unable to react nimbly to change.
This fact became evident to us as we attempted to implement a reminder for staff members to perform a Zika-focused travel history on all patients. We felt it was critical for this reminder to be prominent, be easy to interact with, and appear at the most appropriate time for screening.
Despite multiple attempts, we discovered that our top-ranked, industry-leading EHR was unable to do this seemingly straightforward task, and eventually we reverted to the age-old practice of hanging signs in all of the exam rooms. These encouraged patients to inform their doctor “of worrisome symptoms or recent travel history to affected areas.”
We refuse to accept the inability of any modern electronic health record to create simple and flexible clinical support rules and improve on the efficacy of the paper sign. This, especially in light of the fact that one of the core requirements of the Meaningful Use (MU) program – for which all EHRs are certified – is clinical decision support!
Unfortunately, the MU guidelines are not specific, so most vendors choose to include a standard set of rules and don’t allow the ability for customization. That just isn’t good enough. If Ebola and Zika have taught the health information technology community one thing, it’s that …
It is time for smarter EHRs!
For many people, the notion of artificial intelligence seems to be science fiction, but they don’t realize they are carrying incredible “AI” devices with them everywhere they go. We are, of course, referring to our cell phones, which seem to be getting more intelligent all the time.
If you own an iPhone, you may have noticed it often seems to know where you are about to drive and how long it will take you to get there. This can be a bit creepy at first, until you realize how helpful – and smart – it actually is.
Essentially, our devices are constantly collecting data, reading the patterns of our lives, and learning ways to enhance them. Smartphones have revolutionized how we communicate, work, and play. Why, then, can’t our electronic health record software do the same?
It will surprise exactly none of our readers that the Meaningful Use program has fallen short of its goal of promoting the true benefits of electronic records. Many critics have suggested that the incentive program has faltered because EHRs have made physicians work harder, without helping them work smarter.
Zika virus proves the critics correct. Beyond creating just simple reminders as mentioned above, EHRs should be able to make intelligent suggestions based on patient data and current practice guidelines.
Some EHRs get it half correct. For example, they are “smart” enough to remind clinicians that women of a certain age should have mammograms, but they fall short in the ability to efficiently update those reminders when the U.S. Preventive Services Task Force updates the screening recommendation (as they did recently).
Other EHRs do allow you to customize preventative health reminders, but do not place them in a position of prominence – so they are easily overlooked by providers as they care for patients.
Few products seem to get it just right, and it’s time for this to change.
Simply put, as questions in the media loom about how to stop this rising threat, we as frontline health care providers should have the tools – and the decision support – required to provide meaningful answers.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
It is always noteworthy when the headlines in the medical and mainstream media appear to be the same.
Typically, this means one of two things: 1) Sensationalism has propelled a minor issue into the common lexicon; or 2) a truly serious issue has grown to the point where the whole world is finally taking notice.
With the recent resurgence of Zika virus, something that initially seemed to be the former has unmistakably developed into the latter, and health care providers are again facing an age-old question: How do we adequately fight an evolving and serious illness in the midst of an ever-changing battlefield?
As has been the case countless times before, the answer to this question really lies in early identification. One might think that the advent of modern technology would make this a much easier proposition, but that has not exactly been the case.
In fact, recent Ebola and Zika outbreaks have actually served to demonstrate a big problem in many modern electronic health records: poor clinical decision support.
In this column, we felt it would be helpful to highlight this shortcoming, and make the suggestion that in the world of EHRs …
Change needs to be faster than Zika
Zika virus is not new (it was first identified in the Zika Forest of Uganda in 1947), and neither is the concept of serious mosquito-born illness. While the current Zika hot zones are South America, Central America, Mexico, and the Caribbean, case reports indicate the virus is quickly migrating. At the time of this writing, more than 150 travel-associated cases of Zika have been identified in the continental United States, and it is clear that the consequences of undiagnosed Zika in pregnancy can be devastating.
Furthermore, Zika is just the latest of many viruses to threaten the health and welfare of modern civilization (for example, Ebola, swine flu, SARS, and so on), so screening and prevention is far from a novel idea.
Unfortunately, electronic record vendors don’t seem to have gotten the message that the ability to adapt quickly to public health threats should be a core element of any modern EHR.
On the contrary, EHRs seem to be designed for fixed “best practice” workflows, and updates are often slow in coming (typically requiring a major upgrade or “patch”). This renders them fairly unable to react nimbly to change.
This fact became evident to us as we attempted to implement a reminder for staff members to perform a Zika-focused travel history on all patients. We felt it was critical for this reminder to be prominent, be easy to interact with, and appear at the most appropriate time for screening.
Despite multiple attempts, we discovered that our top-ranked, industry-leading EHR was unable to do this seemingly straightforward task, and eventually we reverted to the age-old practice of hanging signs in all of the exam rooms. These encouraged patients to inform their doctor “of worrisome symptoms or recent travel history to affected areas.”
We refuse to accept the inability of any modern electronic health record to create simple and flexible clinical support rules and improve on the efficacy of the paper sign. This, especially in light of the fact that one of the core requirements of the Meaningful Use (MU) program – for which all EHRs are certified – is clinical decision support!
Unfortunately, the MU guidelines are not specific, so most vendors choose to include a standard set of rules and don’t allow the ability for customization. That just isn’t good enough. If Ebola and Zika have taught the health information technology community one thing, it’s that …
It is time for smarter EHRs!
For many people, the notion of artificial intelligence seems to be science fiction, but they don’t realize they are carrying incredible “AI” devices with them everywhere they go. We are, of course, referring to our cell phones, which seem to be getting more intelligent all the time.
If you own an iPhone, you may have noticed it often seems to know where you are about to drive and how long it will take you to get there. This can be a bit creepy at first, until you realize how helpful – and smart – it actually is.
Essentially, our devices are constantly collecting data, reading the patterns of our lives, and learning ways to enhance them. Smartphones have revolutionized how we communicate, work, and play. Why, then, can’t our electronic health record software do the same?
It will surprise exactly none of our readers that the Meaningful Use program has fallen short of its goal of promoting the true benefits of electronic records. Many critics have suggested that the incentive program has faltered because EHRs have made physicians work harder, without helping them work smarter.
Zika virus proves the critics correct. Beyond creating just simple reminders as mentioned above, EHRs should be able to make intelligent suggestions based on patient data and current practice guidelines.
Some EHRs get it half correct. For example, they are “smart” enough to remind clinicians that women of a certain age should have mammograms, but they fall short in the ability to efficiently update those reminders when the U.S. Preventive Services Task Force updates the screening recommendation (as they did recently).
Other EHRs do allow you to customize preventative health reminders, but do not place them in a position of prominence – so they are easily overlooked by providers as they care for patients.
Few products seem to get it just right, and it’s time for this to change.
Simply put, as questions in the media loom about how to stop this rising threat, we as frontline health care providers should have the tools – and the decision support – required to provide meaningful answers.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
The scribe in the room and the scribe in the sky
A core feature of all electronic health records is the necessity of data input into discrete fields in the chart. This is most frequently accomplished by a combination of typing the information that is needed and selecting, by clicking, the discrete information that is required, such as specific diagnoses and lab and radiology studies. The need to efficiently and effectively input a large amount of information has presented perhaps the greatest challenge of going digital for many physicians, particularly those over 40 years of age who do not type very well.
A number of innovative solutions are now available to address this issue, none perfect, and all offering alternatives to traditional means of documentation. We will briefly review three of these alternative methods, along with some thoughts about the advantages and disadvantages of each method. Let us also say that a challenge for all the methods we will discuss is the cost of the methods, and an advantage that all these assistive technologies offer is the ability for physicians to save time and lessen aggravation. Proponents of all strategies that charge money to save physicians time state that the time saved is equal to revenue earned seeing more patients, which in turn more than pays for the cost of the solution.
Transcription software, the most popular of which is Dragon, has been available for quite some time. This software can accurately transcribe the physician’s dictated notes into the appropriate section of the EHR. Many of the most popular EHRs now have the ability to have speech recognition fully integrated into the workflow of documentation of the EHR. The benefit of transcription software is that the physician directly determines what is going to be documented in the chart and retains complete control of the note. The disadvantage is that the physician still takes time organizing the note and inputting data.
To address the issue of the physician’s needing to take time to input information into the EHR, some practices have begun to use medical “scribes” in the form of a person who is in the room during the visit and is trained to write a note as the doctor sees the patient. The scribe will also order labs and x-rays as requested by the physician. An advantage of the scribe is that the physician can focus on the patient and does not need to navigate the EHR or worry about inputting data at all. In addition, feedback is usually given to the scribe on an ongoing basis so the scribe learns the preferences of the physician. The disadvantage is that the scribe is in the room during the visit, which can be awkward for patients, particularly if sensitive information is being shared about psychological problems, family planning, STDs, or any of many other issues that are routinely discussed at primary care office visits.
Finally, a California company, Augmedix, is trying to blend a 20th-century concept with 21st-century technology, seeing and paying attention to patients while doing electronic documentation. We want to disclose that we have no personal or financial interests in the company. Augmedix is essentially a scribe service with a modern twist. The physician wears a small head-mounted computer that includes a microphone, camera, and transparent display. This allows visual and auditory data from the patient visit to be transmitted to a scribe (a real, live human) located remotely in one of Augmedix’s data centers. The scribe is “logged in” to a copy of the physician’s electronic record and documents the visit in the appropriate place in the chart. This occurs in real time, so when the physician is finished seeing the patient, the note is complete and ready to be signed off. The benefit here is that there is no additional person in the room during the visit, yet just as when a scribe is in the room, the physician does not have to deal with negotiating the complexities of input into the EHR. In addition, through a feature the company calls “concierge service,” Augmedix scribes have the ability to display data to the physician upon request. For example, if the provider says “show me the blood pressure from our last visit” or “bring up Mrs. Smith’s x-ray results,” the scribe can send the requested information right to the tiny display on the headset. This allows the clinician to be “untethered” from the computer.
The concept raises a number of technical and philosophical questions. Foremost among these questions is that of privacy. Pelu Tran, president, CCO, and cofounder, explained that the technology is completely secure and compliant with all privacy laws. The data feeds transmitted through the headset are encrypted and are not permanently stored on any of Augmedix’s servers. Once the documentation is complete, the information is destroyed. HIPAA laws allow for this arrangement in the same way other transcription services are allowed. One disadvantage is likely to be cost, but Mr. Tran states that internal data show that a typical primary care physician can have about one to three additional patient visits per day using this tool and that the added revenue from seeing more patients should cover the cost of the service. Another potential disadvantage is a question of whether the note will reflect the ideas of the physician versus becoming a transcript of the visit, including the important as well as extraneous information that might be difficult to wade through when looking back at a note.
As for us, we are still typing our notes into the EHR, for now. We remain intrigued by the range of approaches that are beginning to appear, offering options for solutions that improve the quality of physicians’ lives with attention to maintaining and improving the physician-patient relationship.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
A core feature of all electronic health records is the necessity of data input into discrete fields in the chart. This is most frequently accomplished by a combination of typing the information that is needed and selecting, by clicking, the discrete information that is required, such as specific diagnoses and lab and radiology studies. The need to efficiently and effectively input a large amount of information has presented perhaps the greatest challenge of going digital for many physicians, particularly those over 40 years of age who do not type very well.
A number of innovative solutions are now available to address this issue, none perfect, and all offering alternatives to traditional means of documentation. We will briefly review three of these alternative methods, along with some thoughts about the advantages and disadvantages of each method. Let us also say that a challenge for all the methods we will discuss is the cost of the methods, and an advantage that all these assistive technologies offer is the ability for physicians to save time and lessen aggravation. Proponents of all strategies that charge money to save physicians time state that the time saved is equal to revenue earned seeing more patients, which in turn more than pays for the cost of the solution.
Transcription software, the most popular of which is Dragon, has been available for quite some time. This software can accurately transcribe the physician’s dictated notes into the appropriate section of the EHR. Many of the most popular EHRs now have the ability to have speech recognition fully integrated into the workflow of documentation of the EHR. The benefit of transcription software is that the physician directly determines what is going to be documented in the chart and retains complete control of the note. The disadvantage is that the physician still takes time organizing the note and inputting data.
To address the issue of the physician’s needing to take time to input information into the EHR, some practices have begun to use medical “scribes” in the form of a person who is in the room during the visit and is trained to write a note as the doctor sees the patient. The scribe will also order labs and x-rays as requested by the physician. An advantage of the scribe is that the physician can focus on the patient and does not need to navigate the EHR or worry about inputting data at all. In addition, feedback is usually given to the scribe on an ongoing basis so the scribe learns the preferences of the physician. The disadvantage is that the scribe is in the room during the visit, which can be awkward for patients, particularly if sensitive information is being shared about psychological problems, family planning, STDs, or any of many other issues that are routinely discussed at primary care office visits.
Finally, a California company, Augmedix, is trying to blend a 20th-century concept with 21st-century technology, seeing and paying attention to patients while doing electronic documentation. We want to disclose that we have no personal or financial interests in the company. Augmedix is essentially a scribe service with a modern twist. The physician wears a small head-mounted computer that includes a microphone, camera, and transparent display. This allows visual and auditory data from the patient visit to be transmitted to a scribe (a real, live human) located remotely in one of Augmedix’s data centers. The scribe is “logged in” to a copy of the physician’s electronic record and documents the visit in the appropriate place in the chart. This occurs in real time, so when the physician is finished seeing the patient, the note is complete and ready to be signed off. The benefit here is that there is no additional person in the room during the visit, yet just as when a scribe is in the room, the physician does not have to deal with negotiating the complexities of input into the EHR. In addition, through a feature the company calls “concierge service,” Augmedix scribes have the ability to display data to the physician upon request. For example, if the provider says “show me the blood pressure from our last visit” or “bring up Mrs. Smith’s x-ray results,” the scribe can send the requested information right to the tiny display on the headset. This allows the clinician to be “untethered” from the computer.
The concept raises a number of technical and philosophical questions. Foremost among these questions is that of privacy. Pelu Tran, president, CCO, and cofounder, explained that the technology is completely secure and compliant with all privacy laws. The data feeds transmitted through the headset are encrypted and are not permanently stored on any of Augmedix’s servers. Once the documentation is complete, the information is destroyed. HIPAA laws allow for this arrangement in the same way other transcription services are allowed. One disadvantage is likely to be cost, but Mr. Tran states that internal data show that a typical primary care physician can have about one to three additional patient visits per day using this tool and that the added revenue from seeing more patients should cover the cost of the service. Another potential disadvantage is a question of whether the note will reflect the ideas of the physician versus becoming a transcript of the visit, including the important as well as extraneous information that might be difficult to wade through when looking back at a note.
As for us, we are still typing our notes into the EHR, for now. We remain intrigued by the range of approaches that are beginning to appear, offering options for solutions that improve the quality of physicians’ lives with attention to maintaining and improving the physician-patient relationship.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
A core feature of all electronic health records is the necessity of data input into discrete fields in the chart. This is most frequently accomplished by a combination of typing the information that is needed and selecting, by clicking, the discrete information that is required, such as specific diagnoses and lab and radiology studies. The need to efficiently and effectively input a large amount of information has presented perhaps the greatest challenge of going digital for many physicians, particularly those over 40 years of age who do not type very well.
A number of innovative solutions are now available to address this issue, none perfect, and all offering alternatives to traditional means of documentation. We will briefly review three of these alternative methods, along with some thoughts about the advantages and disadvantages of each method. Let us also say that a challenge for all the methods we will discuss is the cost of the methods, and an advantage that all these assistive technologies offer is the ability for physicians to save time and lessen aggravation. Proponents of all strategies that charge money to save physicians time state that the time saved is equal to revenue earned seeing more patients, which in turn more than pays for the cost of the solution.
Transcription software, the most popular of which is Dragon, has been available for quite some time. This software can accurately transcribe the physician’s dictated notes into the appropriate section of the EHR. Many of the most popular EHRs now have the ability to have speech recognition fully integrated into the workflow of documentation of the EHR. The benefit of transcription software is that the physician directly determines what is going to be documented in the chart and retains complete control of the note. The disadvantage is that the physician still takes time organizing the note and inputting data.
To address the issue of the physician’s needing to take time to input information into the EHR, some practices have begun to use medical “scribes” in the form of a person who is in the room during the visit and is trained to write a note as the doctor sees the patient. The scribe will also order labs and x-rays as requested by the physician. An advantage of the scribe is that the physician can focus on the patient and does not need to navigate the EHR or worry about inputting data at all. In addition, feedback is usually given to the scribe on an ongoing basis so the scribe learns the preferences of the physician. The disadvantage is that the scribe is in the room during the visit, which can be awkward for patients, particularly if sensitive information is being shared about psychological problems, family planning, STDs, or any of many other issues that are routinely discussed at primary care office visits.
Finally, a California company, Augmedix, is trying to blend a 20th-century concept with 21st-century technology, seeing and paying attention to patients while doing electronic documentation. We want to disclose that we have no personal or financial interests in the company. Augmedix is essentially a scribe service with a modern twist. The physician wears a small head-mounted computer that includes a microphone, camera, and transparent display. This allows visual and auditory data from the patient visit to be transmitted to a scribe (a real, live human) located remotely in one of Augmedix’s data centers. The scribe is “logged in” to a copy of the physician’s electronic record and documents the visit in the appropriate place in the chart. This occurs in real time, so when the physician is finished seeing the patient, the note is complete and ready to be signed off. The benefit here is that there is no additional person in the room during the visit, yet just as when a scribe is in the room, the physician does not have to deal with negotiating the complexities of input into the EHR. In addition, through a feature the company calls “concierge service,” Augmedix scribes have the ability to display data to the physician upon request. For example, if the provider says “show me the blood pressure from our last visit” or “bring up Mrs. Smith’s x-ray results,” the scribe can send the requested information right to the tiny display on the headset. This allows the clinician to be “untethered” from the computer.
The concept raises a number of technical and philosophical questions. Foremost among these questions is that of privacy. Pelu Tran, president, CCO, and cofounder, explained that the technology is completely secure and compliant with all privacy laws. The data feeds transmitted through the headset are encrypted and are not permanently stored on any of Augmedix’s servers. Once the documentation is complete, the information is destroyed. HIPAA laws allow for this arrangement in the same way other transcription services are allowed. One disadvantage is likely to be cost, but Mr. Tran states that internal data show that a typical primary care physician can have about one to three additional patient visits per day using this tool and that the added revenue from seeing more patients should cover the cost of the service. Another potential disadvantage is a question of whether the note will reflect the ideas of the physician versus becoming a transcript of the visit, including the important as well as extraneous information that might be difficult to wade through when looking back at a note.
As for us, we are still typing our notes into the EHR, for now. We remain intrigued by the range of approaches that are beginning to appear, offering options for solutions that improve the quality of physicians’ lives with attention to maintaining and improving the physician-patient relationship.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
Making the Final Rule Meaningful: What It Means for You
On Oct. 6, after many months of anticipation, the Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health IT published the 2015 Meaningful Use final rule. This long-awaited document, weighing in at almost 800 pages, contains some major changes to the Meaningful Use program beginning this year. By the time you read this, you’ll no doubt have heard about the major aspects of the changes. Regardless, we thought it would be useful to focus our lens on the new rules and consider how they will translate from the legislature into the real world.
What’s new?
Contrary to its name, the electronic health record incentive program has been considered hardly “meaningful” by physicians struggling to meet the objectives. Up to this point, it’s seemingly been more about busywork and aimless button-clicking than meaningful work. The 2015 final rule seeks to finally change that. In the press release accompanying the announcement, Dr. Patrick Conway, CMS Deputy Administrator, offered the following:
“We have a shared goal of electronic health records helping physicians, clinicians, and hospitals to deliver better care, smarter spending, and healthier people. We eliminated unnecessary requirements, simplified and increased flexibility for those that remain, and focused on interoperability, information exchange, and patient engagement.”
Expanding on his comments, we’ll first point out the change in length of the meaningful use reporting period. In 2015, it has been shortened to 90 days, regardless of stage. For most, this will elicit a huge sigh of relief, as providers now have the option to choose any continuous 90-day period within 2015 instead of being forced to report for the full year. This fundamental change adds tremendous flexibility to the program, as it eliminates the do-or-die scenario of full-year reporting and allows providers to retrospectively select an optimal attestation period.
Next is the streamlining of the required measures. From 20 measures, the list has been brought down to 10: 9 core objectives and 1 public health objective. In doing this, the CMS sought to remove the “checkbox processes” that have become a much-maligned hallmark of meaningful use. The agency also made an attempt to remove measures considered redundant, duplicative, or topped-out (such as demographic and vital sign documentation). Finally, the CMS essentially removed the core and menu structure and consolidated all measures, so that all providers are working off the same playbook, regardless of stage.
Third, and perhaps most interestingly, is the focus of the remaining objectives. As Dr. Conway related, the measures that the CMS has chosen to retain aim very clearly at a few key goals, with data-sharing principal among them. In fact, more than half the measures rely on information exchange. CMS has admitted that efforts thus far have not produced the kind of transformational interoperability intended, but that ultimately this is the direction EHRs need to take if they are to fulfill their true promise. Although we tend to agree (and we will be writing in greater detail about this in future columns), we feel it’s important to note that this will continue to be challenging for providers and vendors. Until data standards are universally adopted by EHR vendors, health care providers will be forced to bear the burden of imperfect interoperability.
Fortunately, one area in which the burden on physicians has been lightened is patient participation in meaningful use. The CMS has realized the impracticality of measures that rely completely on patients for success and removed the compliance thresholds for secure electronic messages and electronic portal usage. These tools need to be made available to patients, but providers are no longer held responsible for whether or not a certain percentage of patients choose to use them. In 2015, only one patient needs to “view, download, or transmit” information through a patient portal, and secure email capability only needs to be enabled, even if no one opts to use it.
Finally, the CMS is clear to point out that it sympathizes with those who have been unsuccessful in attaining meaningful use, encouraging them to submit requests for hardship exceptions “through the existing request process.” Unfortunately, this process is fairly narrow in scope and really only applies in cases of vendor delays or significant unforeseen consequences (such as bankruptcy, fire, or natural disasters). Still, there is no penalty in applying for an exception even if it is not granted, so, while CMS plans to grant only a limited number of exceptions, we would echo the encouragement to apply if needed.
What’s next?
The 2015 final rule is yet another step in laying groundwork for Meaningful Use stage III, which will be optional in 2017 and mandatory in 2018. The delay offers providers and vendors additional time to adapt and comply with the new regulations, while hopefully adding simplicity and flexibility to the process. Ultimately, this also better aligns reporting Meaningful Use with other incentive programs, all of which will be eventually consolidated under MIPS, the Merit-based Incentive Payment System (we’ll have more on this in a later column, but we want you to know that it is a new system of value-based reimbursement that will sunset the Meaningful Use payment adjustment at the end of calendar year 2018).
We applaud the efforts taken by CMS and the Office of the National Coordinator for Health IT to further streamline the Meaningful Use program and agree with their intent. According to the press release, they have attempted to “shift the paradigm so health IT becomes a tool for care improvement, not an end in itself.” We firmly believe in this idea, and are ultimately encouraged by the 2015 final rule.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
On Oct. 6, after many months of anticipation, the Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health IT published the 2015 Meaningful Use final rule. This long-awaited document, weighing in at almost 800 pages, contains some major changes to the Meaningful Use program beginning this year. By the time you read this, you’ll no doubt have heard about the major aspects of the changes. Regardless, we thought it would be useful to focus our lens on the new rules and consider how they will translate from the legislature into the real world.
What’s new?
Contrary to its name, the electronic health record incentive program has been considered hardly “meaningful” by physicians struggling to meet the objectives. Up to this point, it’s seemingly been more about busywork and aimless button-clicking than meaningful work. The 2015 final rule seeks to finally change that. In the press release accompanying the announcement, Dr. Patrick Conway, CMS Deputy Administrator, offered the following:
“We have a shared goal of electronic health records helping physicians, clinicians, and hospitals to deliver better care, smarter spending, and healthier people. We eliminated unnecessary requirements, simplified and increased flexibility for those that remain, and focused on interoperability, information exchange, and patient engagement.”
Expanding on his comments, we’ll first point out the change in length of the meaningful use reporting period. In 2015, it has been shortened to 90 days, regardless of stage. For most, this will elicit a huge sigh of relief, as providers now have the option to choose any continuous 90-day period within 2015 instead of being forced to report for the full year. This fundamental change adds tremendous flexibility to the program, as it eliminates the do-or-die scenario of full-year reporting and allows providers to retrospectively select an optimal attestation period.
Next is the streamlining of the required measures. From 20 measures, the list has been brought down to 10: 9 core objectives and 1 public health objective. In doing this, the CMS sought to remove the “checkbox processes” that have become a much-maligned hallmark of meaningful use. The agency also made an attempt to remove measures considered redundant, duplicative, or topped-out (such as demographic and vital sign documentation). Finally, the CMS essentially removed the core and menu structure and consolidated all measures, so that all providers are working off the same playbook, regardless of stage.
Third, and perhaps most interestingly, is the focus of the remaining objectives. As Dr. Conway related, the measures that the CMS has chosen to retain aim very clearly at a few key goals, with data-sharing principal among them. In fact, more than half the measures rely on information exchange. CMS has admitted that efforts thus far have not produced the kind of transformational interoperability intended, but that ultimately this is the direction EHRs need to take if they are to fulfill their true promise. Although we tend to agree (and we will be writing in greater detail about this in future columns), we feel it’s important to note that this will continue to be challenging for providers and vendors. Until data standards are universally adopted by EHR vendors, health care providers will be forced to bear the burden of imperfect interoperability.
Fortunately, one area in which the burden on physicians has been lightened is patient participation in meaningful use. The CMS has realized the impracticality of measures that rely completely on patients for success and removed the compliance thresholds for secure electronic messages and electronic portal usage. These tools need to be made available to patients, but providers are no longer held responsible for whether or not a certain percentage of patients choose to use them. In 2015, only one patient needs to “view, download, or transmit” information through a patient portal, and secure email capability only needs to be enabled, even if no one opts to use it.
Finally, the CMS is clear to point out that it sympathizes with those who have been unsuccessful in attaining meaningful use, encouraging them to submit requests for hardship exceptions “through the existing request process.” Unfortunately, this process is fairly narrow in scope and really only applies in cases of vendor delays or significant unforeseen consequences (such as bankruptcy, fire, or natural disasters). Still, there is no penalty in applying for an exception even if it is not granted, so, while CMS plans to grant only a limited number of exceptions, we would echo the encouragement to apply if needed.
What’s next?
The 2015 final rule is yet another step in laying groundwork for Meaningful Use stage III, which will be optional in 2017 and mandatory in 2018. The delay offers providers and vendors additional time to adapt and comply with the new regulations, while hopefully adding simplicity and flexibility to the process. Ultimately, this also better aligns reporting Meaningful Use with other incentive programs, all of which will be eventually consolidated under MIPS, the Merit-based Incentive Payment System (we’ll have more on this in a later column, but we want you to know that it is a new system of value-based reimbursement that will sunset the Meaningful Use payment adjustment at the end of calendar year 2018).
We applaud the efforts taken by CMS and the Office of the National Coordinator for Health IT to further streamline the Meaningful Use program and agree with their intent. According to the press release, they have attempted to “shift the paradigm so health IT becomes a tool for care improvement, not an end in itself.” We firmly believe in this idea, and are ultimately encouraged by the 2015 final rule.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
On Oct. 6, after many months of anticipation, the Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health IT published the 2015 Meaningful Use final rule. This long-awaited document, weighing in at almost 800 pages, contains some major changes to the Meaningful Use program beginning this year. By the time you read this, you’ll no doubt have heard about the major aspects of the changes. Regardless, we thought it would be useful to focus our lens on the new rules and consider how they will translate from the legislature into the real world.
What’s new?
Contrary to its name, the electronic health record incentive program has been considered hardly “meaningful” by physicians struggling to meet the objectives. Up to this point, it’s seemingly been more about busywork and aimless button-clicking than meaningful work. The 2015 final rule seeks to finally change that. In the press release accompanying the announcement, Dr. Patrick Conway, CMS Deputy Administrator, offered the following:
“We have a shared goal of electronic health records helping physicians, clinicians, and hospitals to deliver better care, smarter spending, and healthier people. We eliminated unnecessary requirements, simplified and increased flexibility for those that remain, and focused on interoperability, information exchange, and patient engagement.”
Expanding on his comments, we’ll first point out the change in length of the meaningful use reporting period. In 2015, it has been shortened to 90 days, regardless of stage. For most, this will elicit a huge sigh of relief, as providers now have the option to choose any continuous 90-day period within 2015 instead of being forced to report for the full year. This fundamental change adds tremendous flexibility to the program, as it eliminates the do-or-die scenario of full-year reporting and allows providers to retrospectively select an optimal attestation period.
Next is the streamlining of the required measures. From 20 measures, the list has been brought down to 10: 9 core objectives and 1 public health objective. In doing this, the CMS sought to remove the “checkbox processes” that have become a much-maligned hallmark of meaningful use. The agency also made an attempt to remove measures considered redundant, duplicative, or topped-out (such as demographic and vital sign documentation). Finally, the CMS essentially removed the core and menu structure and consolidated all measures, so that all providers are working off the same playbook, regardless of stage.
Third, and perhaps most interestingly, is the focus of the remaining objectives. As Dr. Conway related, the measures that the CMS has chosen to retain aim very clearly at a few key goals, with data-sharing principal among them. In fact, more than half the measures rely on information exchange. CMS has admitted that efforts thus far have not produced the kind of transformational interoperability intended, but that ultimately this is the direction EHRs need to take if they are to fulfill their true promise. Although we tend to agree (and we will be writing in greater detail about this in future columns), we feel it’s important to note that this will continue to be challenging for providers and vendors. Until data standards are universally adopted by EHR vendors, health care providers will be forced to bear the burden of imperfect interoperability.
Fortunately, one area in which the burden on physicians has been lightened is patient participation in meaningful use. The CMS has realized the impracticality of measures that rely completely on patients for success and removed the compliance thresholds for secure electronic messages and electronic portal usage. These tools need to be made available to patients, but providers are no longer held responsible for whether or not a certain percentage of patients choose to use them. In 2015, only one patient needs to “view, download, or transmit” information through a patient portal, and secure email capability only needs to be enabled, even if no one opts to use it.
Finally, the CMS is clear to point out that it sympathizes with those who have been unsuccessful in attaining meaningful use, encouraging them to submit requests for hardship exceptions “through the existing request process.” Unfortunately, this process is fairly narrow in scope and really only applies in cases of vendor delays or significant unforeseen consequences (such as bankruptcy, fire, or natural disasters). Still, there is no penalty in applying for an exception even if it is not granted, so, while CMS plans to grant only a limited number of exceptions, we would echo the encouragement to apply if needed.
What’s next?
The 2015 final rule is yet another step in laying groundwork for Meaningful Use stage III, which will be optional in 2017 and mandatory in 2018. The delay offers providers and vendors additional time to adapt and comply with the new regulations, while hopefully adding simplicity and flexibility to the process. Ultimately, this also better aligns reporting Meaningful Use with other incentive programs, all of which will be eventually consolidated under MIPS, the Merit-based Incentive Payment System (we’ll have more on this in a later column, but we want you to know that it is a new system of value-based reimbursement that will sunset the Meaningful Use payment adjustment at the end of calendar year 2018).
We applaud the efforts taken by CMS and the Office of the National Coordinator for Health IT to further streamline the Meaningful Use program and agree with their intent. According to the press release, they have attempted to “shift the paradigm so health IT becomes a tool for care improvement, not an end in itself.” We firmly believe in this idea, and are ultimately encouraged by the 2015 final rule.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
Making the final rule meaningful: What it means for you
On Oct. 6, after many months of anticipation, the Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health IT published the 2015 Meaningful Use final rule. This long-awaited document, weighing in at almost 800 pages, contains some major changes to the Meaningful Use program beginning this year. By the time you read this, you’ll no doubt have heard about the major aspects of the changes. Regardless, we thought it would be useful to focus our lens on the new rules and consider how they will translate from the legislature into the real world.
What’s new?
Contrary to its name, the electronic health record incentive program has been considered hardly “meaningful” by physicians struggling to meet the objectives. Up to this point, it’s seemingly been more about busywork and aimless button-clicking than meaningful work. The 2015 final rule seeks to finally change that. In the press release accompanying the announcement, Dr. Patrick Conway, CMS Deputy Administrator, offered the following:
“We have a shared goal of electronic health records helping physicians, clinicians, and hospitals to deliver better care, smarter spending, and healthier people. We eliminated unnecessary requirements, simplified and increased flexibility for those that remain, and focused on interoperability, information exchange, and patient engagement.”
Expanding on his comments, we’ll first point out the change in length of the meaningful use reporting period. In 2015, it has been shortened to 90 days, regardless of stage. For most, this will elicit a huge sigh of relief, as providers now have the option to choose any continuous 90-day period within 2015 instead of being forced to report for the full year. This fundamental change adds tremendous flexibility to the program, as it eliminates the do-or-die scenario of full-year reporting and allows providers to retrospectively select an optimal attestation period.
Next is the streamlining of the required measures. From 20 measures, the list has been brought down to 10: 9 core objectives and 1 public health objective. In doing this, the CMS sought to remove the “checkbox processes” that have become a much-maligned hallmark of meaningful use. The agency also made an attempt to remove measures considered redundant, duplicative, or topped-out (such as demographic and vital sign documentation). Finally, the CMS essentially removed the core and menu structure and consolidated all measures, so that all providers are working off the same playbook, regardless of stage.
Third, and perhaps most interestingly, is the focus of the remaining objectives. As Dr. Conway related, the measures that the CMS has chosen to retain aim very clearly at a few key goals, with data-sharing principal among them. In fact, more than half the measures rely on information exchange. CMS has admitted that efforts thus far have not produced the kind of transformational interoperability intended, but that ultimately this is the direction EHRs need to take if they are to fulfill their true promise. Although we tend to agree (and we will be writing in greater detail about this in future columns), we feel it’s important to note that this will continue to be challenging for providers and vendors. Until data standards are universally adopted by EHR vendors, health care providers will be forced to bear the burden of imperfect interoperability.
Fortunately, one area in which the burden on physicians has been lightened is patient participation in meaningful use. The CMS has realized the impracticality of measures that rely completely on patients for success and removed the compliance thresholds for secure electronic messages and electronic portal usage. These tools need to be made available to patients, but providers are no longer held responsible for whether or not a certain percentage of patients choose to use them. In 2015, only one patient needs to “view, download, or transmit” information through a patient portal, and secure email capability only needs to be enabled, even if no one opts to use it.
Finally, the CMS is clear to point out that it sympathizes with those who have been unsuccessful in attaining meaningful use, encouraging them to submit requests for hardship exceptions “through the existing request process.” Unfortunately, this process is fairly narrow in scope and really only applies in cases of vendor delays or significant unforeseen consequences (such as bankruptcy, fire, or natural disasters). Still, there is no penalty in applying for an exception even if it is not granted, so, while CMS plans to grant only a limited number of exceptions, we would echo the encouragement to apply if needed.
What’s next?
The 2015 final rule is yet another step in laying groundwork for Meaningful Use stage III, which will be optional in 2017 and mandatory in 2018. The delay offers providers and vendors additional time to adapt and comply with the new regulations, while hopefully adding simplicity and flexibility to the process. Ultimately, this also better aligns reporting Meaningful Use with other incentive programs, all of which will be eventually consolidated under MIPS, the Merit-based Incentive Payment System (we’ll have more on this in a later column, but we want you to know that it is a new system of value-based reimbursement that will sunset the Meaningful Use payment adjustment at the end of calendar year 2018).
We applaud the efforts taken by CMS and the Office of the National Coordinator for Health IT to further streamline the Meaningful Use program and agree with their intent. According to the press release, they have attempted to “shift the paradigm so health IT becomes a tool for care improvement, not an end in itself.” We firmly believe in this idea, and are ultimately encouraged by the 2015 final rule.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
On Oct. 6, after many months of anticipation, the Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health IT published the 2015 Meaningful Use final rule. This long-awaited document, weighing in at almost 800 pages, contains some major changes to the Meaningful Use program beginning this year. By the time you read this, you’ll no doubt have heard about the major aspects of the changes. Regardless, we thought it would be useful to focus our lens on the new rules and consider how they will translate from the legislature into the real world.
What’s new?
Contrary to its name, the electronic health record incentive program has been considered hardly “meaningful” by physicians struggling to meet the objectives. Up to this point, it’s seemingly been more about busywork and aimless button-clicking than meaningful work. The 2015 final rule seeks to finally change that. In the press release accompanying the announcement, Dr. Patrick Conway, CMS Deputy Administrator, offered the following:
“We have a shared goal of electronic health records helping physicians, clinicians, and hospitals to deliver better care, smarter spending, and healthier people. We eliminated unnecessary requirements, simplified and increased flexibility for those that remain, and focused on interoperability, information exchange, and patient engagement.”
Expanding on his comments, we’ll first point out the change in length of the meaningful use reporting period. In 2015, it has been shortened to 90 days, regardless of stage. For most, this will elicit a huge sigh of relief, as providers now have the option to choose any continuous 90-day period within 2015 instead of being forced to report for the full year. This fundamental change adds tremendous flexibility to the program, as it eliminates the do-or-die scenario of full-year reporting and allows providers to retrospectively select an optimal attestation period.
Next is the streamlining of the required measures. From 20 measures, the list has been brought down to 10: 9 core objectives and 1 public health objective. In doing this, the CMS sought to remove the “checkbox processes” that have become a much-maligned hallmark of meaningful use. The agency also made an attempt to remove measures considered redundant, duplicative, or topped-out (such as demographic and vital sign documentation). Finally, the CMS essentially removed the core and menu structure and consolidated all measures, so that all providers are working off the same playbook, regardless of stage.
Third, and perhaps most interestingly, is the focus of the remaining objectives. As Dr. Conway related, the measures that the CMS has chosen to retain aim very clearly at a few key goals, with data-sharing principal among them. In fact, more than half the measures rely on information exchange. CMS has admitted that efforts thus far have not produced the kind of transformational interoperability intended, but that ultimately this is the direction EHRs need to take if they are to fulfill their true promise. Although we tend to agree (and we will be writing in greater detail about this in future columns), we feel it’s important to note that this will continue to be challenging for providers and vendors. Until data standards are universally adopted by EHR vendors, health care providers will be forced to bear the burden of imperfect interoperability.
Fortunately, one area in which the burden on physicians has been lightened is patient participation in meaningful use. The CMS has realized the impracticality of measures that rely completely on patients for success and removed the compliance thresholds for secure electronic messages and electronic portal usage. These tools need to be made available to patients, but providers are no longer held responsible for whether or not a certain percentage of patients choose to use them. In 2015, only one patient needs to “view, download, or transmit” information through a patient portal, and secure email capability only needs to be enabled, even if no one opts to use it.
Finally, the CMS is clear to point out that it sympathizes with those who have been unsuccessful in attaining meaningful use, encouraging them to submit requests for hardship exceptions “through the existing request process.” Unfortunately, this process is fairly narrow in scope and really only applies in cases of vendor delays or significant unforeseen consequences (such as bankruptcy, fire, or natural disasters). Still, there is no penalty in applying for an exception even if it is not granted, so, while CMS plans to grant only a limited number of exceptions, we would echo the encouragement to apply if needed.
What’s next?
The 2015 final rule is yet another step in laying groundwork for Meaningful Use stage III, which will be optional in 2017 and mandatory in 2018. The delay offers providers and vendors additional time to adapt and comply with the new regulations, while hopefully adding simplicity and flexibility to the process. Ultimately, this also better aligns reporting Meaningful Use with other incentive programs, all of which will be eventually consolidated under MIPS, the Merit-based Incentive Payment System (we’ll have more on this in a later column, but we want you to know that it is a new system of value-based reimbursement that will sunset the Meaningful Use payment adjustment at the end of calendar year 2018).
We applaud the efforts taken by CMS and the Office of the National Coordinator for Health IT to further streamline the Meaningful Use program and agree with their intent. According to the press release, they have attempted to “shift the paradigm so health IT becomes a tool for care improvement, not an end in itself.” We firmly believe in this idea, and are ultimately encouraged by the 2015 final rule.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
On Oct. 6, after many months of anticipation, the Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health IT published the 2015 Meaningful Use final rule. This long-awaited document, weighing in at almost 800 pages, contains some major changes to the Meaningful Use program beginning this year. By the time you read this, you’ll no doubt have heard about the major aspects of the changes. Regardless, we thought it would be useful to focus our lens on the new rules and consider how they will translate from the legislature into the real world.
What’s new?
Contrary to its name, the electronic health record incentive program has been considered hardly “meaningful” by physicians struggling to meet the objectives. Up to this point, it’s seemingly been more about busywork and aimless button-clicking than meaningful work. The 2015 final rule seeks to finally change that. In the press release accompanying the announcement, Dr. Patrick Conway, CMS Deputy Administrator, offered the following:
“We have a shared goal of electronic health records helping physicians, clinicians, and hospitals to deliver better care, smarter spending, and healthier people. We eliminated unnecessary requirements, simplified and increased flexibility for those that remain, and focused on interoperability, information exchange, and patient engagement.”
Expanding on his comments, we’ll first point out the change in length of the meaningful use reporting period. In 2015, it has been shortened to 90 days, regardless of stage. For most, this will elicit a huge sigh of relief, as providers now have the option to choose any continuous 90-day period within 2015 instead of being forced to report for the full year. This fundamental change adds tremendous flexibility to the program, as it eliminates the do-or-die scenario of full-year reporting and allows providers to retrospectively select an optimal attestation period.
Next is the streamlining of the required measures. From 20 measures, the list has been brought down to 10: 9 core objectives and 1 public health objective. In doing this, the CMS sought to remove the “checkbox processes” that have become a much-maligned hallmark of meaningful use. The agency also made an attempt to remove measures considered redundant, duplicative, or topped-out (such as demographic and vital sign documentation). Finally, the CMS essentially removed the core and menu structure and consolidated all measures, so that all providers are working off the same playbook, regardless of stage.
Third, and perhaps most interestingly, is the focus of the remaining objectives. As Dr. Conway related, the measures that the CMS has chosen to retain aim very clearly at a few key goals, with data-sharing principal among them. In fact, more than half the measures rely on information exchange. CMS has admitted that efforts thus far have not produced the kind of transformational interoperability intended, but that ultimately this is the direction EHRs need to take if they are to fulfill their true promise. Although we tend to agree (and we will be writing in greater detail about this in future columns), we feel it’s important to note that this will continue to be challenging for providers and vendors. Until data standards are universally adopted by EHR vendors, health care providers will be forced to bear the burden of imperfect interoperability.
Fortunately, one area in which the burden on physicians has been lightened is patient participation in meaningful use. The CMS has realized the impracticality of measures that rely completely on patients for success and removed the compliance thresholds for secure electronic messages and electronic portal usage. These tools need to be made available to patients, but providers are no longer held responsible for whether or not a certain percentage of patients choose to use them. In 2015, only one patient needs to “view, download, or transmit” information through a patient portal, and secure email capability only needs to be enabled, even if no one opts to use it.
Finally, the CMS is clear to point out that it sympathizes with those who have been unsuccessful in attaining meaningful use, encouraging them to submit requests for hardship exceptions “through the existing request process.” Unfortunately, this process is fairly narrow in scope and really only applies in cases of vendor delays or significant unforeseen consequences (such as bankruptcy, fire, or natural disasters). Still, there is no penalty in applying for an exception even if it is not granted, so, while CMS plans to grant only a limited number of exceptions, we would echo the encouragement to apply if needed.
What’s next?
The 2015 final rule is yet another step in laying groundwork for Meaningful Use stage III, which will be optional in 2017 and mandatory in 2018. The delay offers providers and vendors additional time to adapt and comply with the new regulations, while hopefully adding simplicity and flexibility to the process. Ultimately, this also better aligns reporting Meaningful Use with other incentive programs, all of which will be eventually consolidated under MIPS, the Merit-based Incentive Payment System (we’ll have more on this in a later column, but we want you to know that it is a new system of value-based reimbursement that will sunset the Meaningful Use payment adjustment at the end of calendar year 2018).
We applaud the efforts taken by CMS and the Office of the National Coordinator for Health IT to further streamline the Meaningful Use program and agree with their intent. According to the press release, they have attempted to “shift the paradigm so health IT becomes a tool for care improvement, not an end in itself.” We firmly believe in this idea, and are ultimately encouraged by the 2015 final rule.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
F43.22 Adjustment disorder with anxiety (about ICD-10!)
On Oct. 1, 2015, take a few moments to reflect on 17th century British haberdasher John Graunt. Why? Because Graunt was not merely a purveyor of men’s clothing, but also a demographer and developer of one of the earliest known statistical studies of disease.
Historians consider his 1662 book, “Natural and Political Observations Made Upon the Bills of Mortality,” to be a seminal moment in the genesis of disease classification. Though it was merely a rudimentary beginning, it led others to build upon its framework in categorizing causes of death. But it wasn’t until almost 200 years later that British statistician William Farr proposed a new system to bring medical statistics beyond just mortality. This newer schema, promoted even by Florence Nightingale, would go on to become the impetus for the International Classification of Diseases, Injuries, and Causes of Death, eventually known as the International Classification of Diseases (ICD).
In just a few short weeks, the U.S. health care system will finally embrace the 10th revision of that system, but even this version is far from new. The World Health Organization completed work on ICD-10 in 1992, and it was first adopted by other countries starting with Australia in 1998. In fact, we are among the last developed nations to move into the modern era of disease classification with ICD-10, and this month we felt it would be worthwhile to mark that milestone with a bit of history and a commonsense explanation of what to expect.
Modern terminology
A modern health care system can’t function optimally with a disease classification scheme that is 40 years old; ICD-9 codes, initially conceived in 1975, lack specificity and are replete with antiquated descriptors.
One need not look very far to find examples. The code 200.1, for example, was originally termed “lymphosarcoma,” a deprecated term now replaced with “non-Hodgkin’s lymphoma.” More strikingly, the code 318.0 was initially termed “imbecile.” Today we know this term more appropriately as “moderate intellectual disabilities.” Even if we put political correctness aside, the modern term is clearly a much more accurate and useful descriptor for the diagnosis. But the enhancements in ICD-10 don’t end there.
Increased specificity
Perhaps more important than the descriptors themselves is the logic behind the coding system.
All ICD-10 codes begin with a letter, followed by a series of numbers. These numbers reveal a much greater level of detail than was ever part of ICD-9, such as causal relationship, severity, temporal factors, location, quality, and status. For example, as revised in the ICD-10 system, the ICD-9 code 725.9 (pain in limb) “explodes” into dozens of codes specifying location, all beginning with the prefix M79. These include M79.622 (pain in left upper arm), M79.674 (pain in right toes), M79.652 (pain in left thigh), and so on. Or, in the case of 465.9 (upper respiratory infection), the codes expand to specify the area of infection and causal agent, such as J02.0 (acute streptococcal pharyngitis) or J20.4 (acute bronchitis due to parainfluenza virus).
While this all might seem overwhelming at first, it’s important to note there will be some initial flexibility. The Centers for Medicare & Medicaid Services has stated that for the first year of implementation, it will accept any ICD-10 code from the correct “family,” regardless of specificity (i.e., as long as the letter and first two numbers are correct). In the case of “pain in limb” as above, any 3 digits following M79 with be acceptable. But there is a legitimately good reason to be as specific as possible with the new codes starting now: medical cost management.
Medical cost management is the idea that reimbursement should be related to patient complexity. In other words, caring for sicker patients is more costly and time consuming, so providers should be compensated appropriately. Private insurers have been focusing a lot of attention on this, as their reimbursement rates through Medicare Advantage plans are based on the complexity of the patients they cover. Gradually, this has trickled down to physician payments, as value-based care is growing in importance. Accordingly, we would encourage all physicians to code in a way that accurately reflects the level of morbidity in their patients. After all, if you’re taking care of really complicated patients, you should be getting paid appropriately for it. That’s where ICD-10 can be advantageous, as it allows providers to plainly document the severity of disease in their population through a system that’s easy to capture and collate.
Avoiding insanity
There is a point where the need to be so specific translates into some fairly funny ICD-10 codes. We simply can’t avoid citing a few examples: Z63.1 (problems in relationship with in-laws), W61.52XA (struck by goose, initial encounter), and our personal favorite, V91.07XD (burn due to water skis on fire). While quite funny, this level of specificity also brings up a critical question: With so many codes, how does one find the correct one for the diagnosis when seeing a patient?
Thankfully, 21st century tools make the task of locating the appropriate code much simpler than it would have been when ICD-10 was first conceived. Using plain-text search engines such as those from Intelligent Medical Objects, clinicians can be as specific as possible when searching for diagnoses. There are also apps for mobile devices and Web-based tools like ICD10Data.com that are user friendly and completely free. Most importantly, EHR vendors have been anticipating the transition to ICD-10 and have built many of these tools into their products already.
Closing thoughts
We fully acknowledge that this transition to increased specificity may be anxiety provoking, but we are also forced to accept that it is necessary. While it is debatable whether figures like Graunt and Farr are worthy of accolade or ire (though on Oct. 1 most will probably choose the latter), it’s undeniable that there is a need to gather and tabulate statistics on medical diagnoses. That need was first formally addressed well over 300 years before the dawn of electronic health records and will continue to be addressed for hundreds more. In the meantime, we have a code we’d like to propose for ICD-11: E011.13 – anxiety due to heath information technology. Like ICD-10, this is a concept that’s far from new and certainly here to stay.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
On Oct. 1, 2015, take a few moments to reflect on 17th century British haberdasher John Graunt. Why? Because Graunt was not merely a purveyor of men’s clothing, but also a demographer and developer of one of the earliest known statistical studies of disease.
Historians consider his 1662 book, “Natural and Political Observations Made Upon the Bills of Mortality,” to be a seminal moment in the genesis of disease classification. Though it was merely a rudimentary beginning, it led others to build upon its framework in categorizing causes of death. But it wasn’t until almost 200 years later that British statistician William Farr proposed a new system to bring medical statistics beyond just mortality. This newer schema, promoted even by Florence Nightingale, would go on to become the impetus for the International Classification of Diseases, Injuries, and Causes of Death, eventually known as the International Classification of Diseases (ICD).
In just a few short weeks, the U.S. health care system will finally embrace the 10th revision of that system, but even this version is far from new. The World Health Organization completed work on ICD-10 in 1992, and it was first adopted by other countries starting with Australia in 1998. In fact, we are among the last developed nations to move into the modern era of disease classification with ICD-10, and this month we felt it would be worthwhile to mark that milestone with a bit of history and a commonsense explanation of what to expect.
Modern terminology
A modern health care system can’t function optimally with a disease classification scheme that is 40 years old; ICD-9 codes, initially conceived in 1975, lack specificity and are replete with antiquated descriptors.
One need not look very far to find examples. The code 200.1, for example, was originally termed “lymphosarcoma,” a deprecated term now replaced with “non-Hodgkin’s lymphoma.” More strikingly, the code 318.0 was initially termed “imbecile.” Today we know this term more appropriately as “moderate intellectual disabilities.” Even if we put political correctness aside, the modern term is clearly a much more accurate and useful descriptor for the diagnosis. But the enhancements in ICD-10 don’t end there.
Increased specificity
Perhaps more important than the descriptors themselves is the logic behind the coding system.
All ICD-10 codes begin with a letter, followed by a series of numbers. These numbers reveal a much greater level of detail than was ever part of ICD-9, such as causal relationship, severity, temporal factors, location, quality, and status. For example, as revised in the ICD-10 system, the ICD-9 code 725.9 (pain in limb) “explodes” into dozens of codes specifying location, all beginning with the prefix M79. These include M79.622 (pain in left upper arm), M79.674 (pain in right toes), M79.652 (pain in left thigh), and so on. Or, in the case of 465.9 (upper respiratory infection), the codes expand to specify the area of infection and causal agent, such as J02.0 (acute streptococcal pharyngitis) or J20.4 (acute bronchitis due to parainfluenza virus).
While this all might seem overwhelming at first, it’s important to note there will be some initial flexibility. The Centers for Medicare & Medicaid Services has stated that for the first year of implementation, it will accept any ICD-10 code from the correct “family,” regardless of specificity (i.e., as long as the letter and first two numbers are correct). In the case of “pain in limb” as above, any 3 digits following M79 with be acceptable. But there is a legitimately good reason to be as specific as possible with the new codes starting now: medical cost management.
Medical cost management is the idea that reimbursement should be related to patient complexity. In other words, caring for sicker patients is more costly and time consuming, so providers should be compensated appropriately. Private insurers have been focusing a lot of attention on this, as their reimbursement rates through Medicare Advantage plans are based on the complexity of the patients they cover. Gradually, this has trickled down to physician payments, as value-based care is growing in importance. Accordingly, we would encourage all physicians to code in a way that accurately reflects the level of morbidity in their patients. After all, if you’re taking care of really complicated patients, you should be getting paid appropriately for it. That’s where ICD-10 can be advantageous, as it allows providers to plainly document the severity of disease in their population through a system that’s easy to capture and collate.
Avoiding insanity
There is a point where the need to be so specific translates into some fairly funny ICD-10 codes. We simply can’t avoid citing a few examples: Z63.1 (problems in relationship with in-laws), W61.52XA (struck by goose, initial encounter), and our personal favorite, V91.07XD (burn due to water skis on fire). While quite funny, this level of specificity also brings up a critical question: With so many codes, how does one find the correct one for the diagnosis when seeing a patient?
Thankfully, 21st century tools make the task of locating the appropriate code much simpler than it would have been when ICD-10 was first conceived. Using plain-text search engines such as those from Intelligent Medical Objects, clinicians can be as specific as possible when searching for diagnoses. There are also apps for mobile devices and Web-based tools like ICD10Data.com that are user friendly and completely free. Most importantly, EHR vendors have been anticipating the transition to ICD-10 and have built many of these tools into their products already.
Closing thoughts
We fully acknowledge that this transition to increased specificity may be anxiety provoking, but we are also forced to accept that it is necessary. While it is debatable whether figures like Graunt and Farr are worthy of accolade or ire (though on Oct. 1 most will probably choose the latter), it’s undeniable that there is a need to gather and tabulate statistics on medical diagnoses. That need was first formally addressed well over 300 years before the dawn of electronic health records and will continue to be addressed for hundreds more. In the meantime, we have a code we’d like to propose for ICD-11: E011.13 – anxiety due to heath information technology. Like ICD-10, this is a concept that’s far from new and certainly here to stay.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
On Oct. 1, 2015, take a few moments to reflect on 17th century British haberdasher John Graunt. Why? Because Graunt was not merely a purveyor of men’s clothing, but also a demographer and developer of one of the earliest known statistical studies of disease.
Historians consider his 1662 book, “Natural and Political Observations Made Upon the Bills of Mortality,” to be a seminal moment in the genesis of disease classification. Though it was merely a rudimentary beginning, it led others to build upon its framework in categorizing causes of death. But it wasn’t until almost 200 years later that British statistician William Farr proposed a new system to bring medical statistics beyond just mortality. This newer schema, promoted even by Florence Nightingale, would go on to become the impetus for the International Classification of Diseases, Injuries, and Causes of Death, eventually known as the International Classification of Diseases (ICD).
In just a few short weeks, the U.S. health care system will finally embrace the 10th revision of that system, but even this version is far from new. The World Health Organization completed work on ICD-10 in 1992, and it was first adopted by other countries starting with Australia in 1998. In fact, we are among the last developed nations to move into the modern era of disease classification with ICD-10, and this month we felt it would be worthwhile to mark that milestone with a bit of history and a commonsense explanation of what to expect.
Modern terminology
A modern health care system can’t function optimally with a disease classification scheme that is 40 years old; ICD-9 codes, initially conceived in 1975, lack specificity and are replete with antiquated descriptors.
One need not look very far to find examples. The code 200.1, for example, was originally termed “lymphosarcoma,” a deprecated term now replaced with “non-Hodgkin’s lymphoma.” More strikingly, the code 318.0 was initially termed “imbecile.” Today we know this term more appropriately as “moderate intellectual disabilities.” Even if we put political correctness aside, the modern term is clearly a much more accurate and useful descriptor for the diagnosis. But the enhancements in ICD-10 don’t end there.
Increased specificity
Perhaps more important than the descriptors themselves is the logic behind the coding system.
All ICD-10 codes begin with a letter, followed by a series of numbers. These numbers reveal a much greater level of detail than was ever part of ICD-9, such as causal relationship, severity, temporal factors, location, quality, and status. For example, as revised in the ICD-10 system, the ICD-9 code 725.9 (pain in limb) “explodes” into dozens of codes specifying location, all beginning with the prefix M79. These include M79.622 (pain in left upper arm), M79.674 (pain in right toes), M79.652 (pain in left thigh), and so on. Or, in the case of 465.9 (upper respiratory infection), the codes expand to specify the area of infection and causal agent, such as J02.0 (acute streptococcal pharyngitis) or J20.4 (acute bronchitis due to parainfluenza virus).
While this all might seem overwhelming at first, it’s important to note there will be some initial flexibility. The Centers for Medicare & Medicaid Services has stated that for the first year of implementation, it will accept any ICD-10 code from the correct “family,” regardless of specificity (i.e., as long as the letter and first two numbers are correct). In the case of “pain in limb” as above, any 3 digits following M79 with be acceptable. But there is a legitimately good reason to be as specific as possible with the new codes starting now: medical cost management.
Medical cost management is the idea that reimbursement should be related to patient complexity. In other words, caring for sicker patients is more costly and time consuming, so providers should be compensated appropriately. Private insurers have been focusing a lot of attention on this, as their reimbursement rates through Medicare Advantage plans are based on the complexity of the patients they cover. Gradually, this has trickled down to physician payments, as value-based care is growing in importance. Accordingly, we would encourage all physicians to code in a way that accurately reflects the level of morbidity in their patients. After all, if you’re taking care of really complicated patients, you should be getting paid appropriately for it. That’s where ICD-10 can be advantageous, as it allows providers to plainly document the severity of disease in their population through a system that’s easy to capture and collate.
Avoiding insanity
There is a point where the need to be so specific translates into some fairly funny ICD-10 codes. We simply can’t avoid citing a few examples: Z63.1 (problems in relationship with in-laws), W61.52XA (struck by goose, initial encounter), and our personal favorite, V91.07XD (burn due to water skis on fire). While quite funny, this level of specificity also brings up a critical question: With so many codes, how does one find the correct one for the diagnosis when seeing a patient?
Thankfully, 21st century tools make the task of locating the appropriate code much simpler than it would have been when ICD-10 was first conceived. Using plain-text search engines such as those from Intelligent Medical Objects, clinicians can be as specific as possible when searching for diagnoses. There are also apps for mobile devices and Web-based tools like ICD10Data.com that are user friendly and completely free. Most importantly, EHR vendors have been anticipating the transition to ICD-10 and have built many of these tools into their products already.
Closing thoughts
We fully acknowledge that this transition to increased specificity may be anxiety provoking, but we are also forced to accept that it is necessary. While it is debatable whether figures like Graunt and Farr are worthy of accolade or ire (though on Oct. 1 most will probably choose the latter), it’s undeniable that there is a need to gather and tabulate statistics on medical diagnoses. That need was first formally addressed well over 300 years before the dawn of electronic health records and will continue to be addressed for hundreds more. In the meantime, we have a code we’d like to propose for ICD-11: E011.13 – anxiety due to heath information technology. Like ICD-10, this is a concept that’s far from new and certainly here to stay.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
