The Department of Veterans Affairs is trying to come to terms with a new challenge when it comes to medical records: should it allow young medical doctors some flexibility to use newly available Web tools to help them care for their patients?

Just about anyone who uses a computer and the Internet these days is familiar with online services that lets users store and share things like word processing documents and spreadsheets. And VA Assistant Secretary for Information and Technology and chief information officer Roger Baker is now trying to set official policy on whether such applications can be used in limited circumstances when accessing veterans’ personal information.

The tech world is abuzz with the term “cloud computing.”  For the uninitiated, “the cloud” refers to services that are provided by vendors whose servers may store data outside of the institution in which it is used.  This is a relatively new paradigm that security conscious institutions such as the Veteran’s administration are learning to cope with.  Historically many applications and all data were contained within a company’s own servers, on site.  This is changing.

 What if a “cloud” software solution beats the pants off of a home-grown application?  What if users –doctors in this case- begin adapting outside technology to their needs, in spite of regulations to the contrary?

 This seems to be happening more frequently.  Large, security minded institutions are going to have to deal with this reality in an ever more pressing manner.  You can’t at once have ultimate security and THE BEST, fastest and most user-friendly solutions without opening the doors to the outside a little. 

 As the costs of software development continue to plummet.  And better solutions make their way to market in an accelerated fashion, this trend will continue.  The latest and greatest will continue to rise up from the obscure.   And institutions that pass on software that provides real value will lag.  It will be interesting to watch the trend unfold.

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After my symposium session last Friday morning I was approached by a distinguished, professorial looking gentleman (the bow tie was the tip off).  Lo and behold he was a professor.  His name was William White and he happened to be the head of the Cornell Sloan Health Policy program.  He stated  that he enjoyed the story of our start up journey -flattery always works. And he picked up on a point that I had made in my talk as being a driving force in our venture.

That point was that health care information technology (IT) often hinders  communication instead of improving it.  And nobody is quite sure whether IT makes health care delivery more or less productive.  It seems so intuitive: computerizing records should make them safer, more efficient and more productive.   But that depends on how you define productive.  Productive for whom?

I would define productive as any activity that ultimately leads to improvements in  efficiency and delivery of patient care and satisfaction.  Anyone who’s been a patient knows that it’s possible to get lost in the system.  The system is just so complex.  Health care, however is still about human to human interaction. Patients want face time with their caregivers.  It is part of the healing process.

To the extent then, that EMR’s improve that human to human interaction, they are good.  But there’s the catch.  They do often interrupt the interaction.   For example, if a doctor used to be able to write his note in 2 minutes and it now takes 5 with the EMR, those 3 minutes are potentially shunted away from true human interaction.

I’d like to thank Professor White for alerting me to 2 interesting articles that hit on this point.  You can check them out for yourself if you want here and here.  I’ve summarized a few of the salient points below:

EMR’s are not all good or bad.  They do add unique changes to the  clinician patient interaction that at times improve care and at times hamper it.

How they work well:
-they allow clinicians to rapidly access reports and data in their office
-they can link to scheduling and billing systems and better coordinate the two processes
-they make medication look-up, easy
-they can code in automatic reminders for clinicians

Where they are lacking:
-data overload.  Cutting and pasting and template formation encourages overly verbose records.   Finding the needle in the proverbial information haystack may slow record review
-record keeping becomes a billing exercise.  Many EMRs are designed around maximizing billable charges by allowing clinicians/ hospitals to hit coding “bullet points.”  The system becomes divorced from the patient care and revolves more tightly around patient charges.  The two are not equal
-Interoperability between systems is poor.  Clinicians are forced to fax records anyway

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Bringing it back home… At TouchConsult we’re all for technology. But we’re advocating technology that works within the natural rhythm of the of the doctor patient relationship; technology that encourages more human interaction and better communication.   We’d like to see more companies tackle the health IT problem from this angle.  We believe that the market will eventually move this way.  And we’ll do our best to help push it in that direction.

As per our previous post, residents at accredited American medical training programs will further curtail their work hours after new regulations take effect in July 2011.  Interns will work no more than 16 hour shifts.

Eighty-seven percent of 464 program directors surveyed in July 2010 said the rules will lessen residents’ ability to provide continuous care for hospitalized patients, and 65% said the rules won’t have any effect on resident fatigue.

“The core of the issue for patients is what is it that we need to do in terms of working within these recommendations to achieve the very best outcomes for patients,” said Darcy Reed, MD, MPH, senior study author and assistant professor at the Mayo Medical School in Rochester, Minn.

More than half of those surveyed said the rules will decrease residents’ ability to become competent in five core areas: medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice, said the study in the March Mayo Clinic Proceedings.

Regulations always produce unintended consequences.  The health care system as a whole is at a crossroads, as it struggles to do more with less and achieve the same results.  Residents are a valuable cog in the heath care machine.

We’ll see how the health care system adjusts to doing more, with less of the residents’ time….

The Vocera solution improves hand-off performance — at change of shift, during patient transfers, and at physician sign-out — minimizing the possibility of error and missed connections. Complementing existing communication and electronic medical record systems, the Vocera Hand-Off Solution helps hospitals and ambulatory care providers standardize, manage, and monitor the transition of medical information across care teams.

http://www.vocera.com/downloads/VHO_Technology_and_Benefits.pdf

We don’t know personally how well Vocera’s handoff system works.  We have seen some of their other products that seem to provide good value.  The product that we are familiar with is a wearable voice transmitter that allows health professionals to instantly voice “page” one another and talk like a walkie talkie.  This comes in handy because health professionals often have their hands full.  Example: sometimes a nurse needs to call an aid into a room to help move a patient.  With Vocera’s voice transmitter system he or she can do this while still adjusting the IV or checking vitals.

So congratulations to Vocera for this ringing endorsement.  While we’d be happy to share such a lofty recognition, we also recognize that the endorsement comes from the top down: the hospital system.   Our approach is different.  We are addressing communication issues from the other direction: the bottom up.  Our goal is to be the solution endorsed by health professionals.  Big difference.  The unfortunate trend in health care has recently been for the system to dictate the solution to the individual (whether it be patient or health professional).  We want to see that perspective change.  We don’t know if we’ll be the one who does it.  All we know is, until a product gains the full endorsement of individual users, there will still be work to be done.

We’ve learned that each specialty uses the program in a unique way.  This will help us to continue to refine the product and will give us valuable feedback on how to customize it in the future to meet the needs of different specialties.

Our ultimate goal is to provide signout solutions that fit doctors’ work habits.  And there’s no “one size fits all” when it comes to doing that.  One size fits all is for baseball hats.

While all residency programs force residents to log their work hours, it is unclear how many of them are honest in their reporting.  If 6/10 surgical residents are working more than the stipulated 80 hour work week, then more than half of the surgery programs would theoretically be at risk for probation.

Not long ago we were surgical residents and recognize the extreme time pressure that they face.  We also see the flipside: duty dictates that you prioritize the care of a sick patient over work hour stipulations.

Nobody knows exactly how this will play out.  Will hospitals provide more “mid level” providers (PAs, NPs) to pick up the slack so that these overworked residents can fall into compliance?  If so, with what money?  Will doctors merely cut back on services?  Or will residents in some specialties keep cranking out the hours in hopes of flying under the radar?

One thing is certain, mandated resident work hours are due to decrease yet again this July when the ACGME further limits resident intern shifts to 16 hours.   Articles such as the one above will draw more attention to the problem and closer monitoring by the ACGME may follow. If this is the case, systems may get further stressed and programs will have to find new ways to cope with and ever higher number of shift changes.

The List is a program specifically designed to streamline better hand off of patient care plans. If hand offs continue to rise -and there’s no indication that they won’t- software like ours will be needed to better handle the myriad of data changing hands among residents in training.  For a free trial of the List go to www.thelist.md.

Hospitals race to implement new IT systems as stimulus deadline looms

The article follows:

Gaurov Dayal knows the computer system at Rockville-based Adventist HealthCare is a little moldy. It’s going on 20 years old, and paper charts still bridge the gap between nursing shifts. It’s no secret: All of health care is embarrassingly tardy to the digital age.

But that must end this year. It has to ― millions of dollars are at stake.  Dayal, Adventist’s chief medical officer, and his counterparts at hospitals all over the region are sprinting to install new health information technology systems by government-imposed deadlines, all to get a slice of $27 billion in incentives that became available in January.

The rush is creating a health IT economic development boom, but the rules for the money are confusing and deadlines are fast approaching, creating a situation rife with risk. Beneath the flurry of activity, doubts keep cropping up for executives: Did we select the right vendor? Will doctors go along with it? What bugs are waiting to be discovered? What unknown costs loom? Are we moving fast enough? …

“These are things that keep us up at night. Wow, what if this doesn’t work?” he said. “On the other hand, there’s no turning back.”

The race to modernize dates to 2009, when President Barack Obama signed the stimulus bill containing what is known as the Hitech Act. The law was meant to force the American health care system to shed its straitjacket of inefficiency ― the messy network of manila file folders, paper charts and illegible notes of olden days.

The law gives hospitals and doctors a carrot ― $27 billion in incentives for providers who prove “meaningful use” of electronic medical records. The money became available in January and will flow through 2014.  In 2015, though, the government will pull back the carrot and break out the stick, cutting Medicare payments to those who still haven’t met the standards.

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All this tells us a few things: 1) hospitals are under the gun to modernize their electronic medical records and 2) they are in a rush to implement ANYTHING that will get them a piece of the incentive pie.  Remember, many hospitals receive huge federal subsidies through Medicare and Medicaid.  Non compliance will not only put their incentive pay at risk but could potentially risk penalties in the future.

In the end rushing to implement such large systems as EMR’s may prove risky.  What are these risks?  Simply put, the systems are complex, expensive and need to satisfy many users.  Not an easy task.  Revenues of clinicians and hospitals depend on steady, efficient workflow.  And interrupting that workflow, no matter how well-intentioned, may have unpredictable and stifling side effects such as loss of production.  In addition, nobody really knows whether these systems will provide good return on investment; that may take years to figure out.

Let’s be clear, Touch Consult does not sell EMR’s.  And we cannot claim to be offering any solution  nearly as complex and all-encompassing.  However we’d like to think that IT solutions should be implemented with the following principles in mind.

1) systems should be designed around users, not the other way around.  A rush to chase government incentives calls into question whether this is truly most hospitals’ number one  priority.

2) bigger isn’t always better.  One size fits all solutions often fit none.  If hospitals can solve the interoperability problem-our partner Intehealth, in fact goes a long way toward doing so- then allowing smaller, best in breed solutions to compete for different parts of the IT ecosystem may be the way to go

In the end the only incentives that ought to matter are the ones that make users’ lives easier and patients’ lives better.  All the rest are superfluous.

These include

1. Simplified team subscriptions
Previously users had to add themselves as members or cross-cover for teams. Now all users are automatically added to all teams. “Teams” are now renamed “Lists”.

2. Simplified Settings page
The Settings page is now much easier to use and understand.

3. No more horizontal scroll bar
We have made the Patient Table & column widths adjust to fit the size of your browser window. We also made the left and right margins smaller so more information is visible. This means no more horizontal scroll bar in most instances.

4. Flagging (highlighting) patients is now visible when printing
A patient that is flagged remains visibly highlighted even when printing.

5. Much improved look
We have cleaned up the appearance of the Home Page, added a new menu at the top for easier navigation and a new logo for theList.md.

6. New login page
Graphics and text tell the story of how theList.md can help residents and training programs. There is a simple shortcut to the sample lists (orange button) as well as separate sign in page for existing users.

What do you think ?

As always, we value your comments and input. Click on “Contact” to send us a note.

theList.md team

ps, now we are working allowing you to choose what columns to print at the time of printing to make fitting onto a single page easier – one of our most requested features.

Now that we’re up and running at a few institutions, we’re finding that we are receiving some extraordinarily valuable feedback from our users.  (Second worn but valuable cliché: trust your users, they’re smarter than you).   Originally we designed the software so that it would mimic a residency program in structure. We allowed different user privileges for the different role players: site administrator, residents, attending and team captain.  We also created “Teams” and “Lists,” concepts that are common on a residency service.  Turns out we didn’t need to make it nearly as complex.

Users regarded Lists as useful but pretty much ignored the “Team” concept.  So we’re getting rid of the “Team” concept and just creating “Lists” that can be shared among all team members;  it will be up to the members themselves to designate how many different lists they want and who gets access to them.  And as far as privilege levels go, they just became cumbersome and superfluous.  About 2 levels of privileges were all that was necessary (enough to block out any list Nazis from always changing things up, but not so many that there wasn’t flexibility).  Most users, we have found agree on the settings and then go with the flow.

So we’re going to be making some new launches in the coming month or so.  They’ll greatly simplify the settings and hopefully the experience.  If only we would have known before.  Imagine the money we could have saved on coding all of those features…oh well.  Listen and learn.  Guess I better get back to work simplifying those help videos.  Take care and thanks for reading.

-inset picture: coffee table by George Nakashima, one of my favorite furniture designers.  Nakashima’s designs were elegant and highlighted the natural beauty and form of the material with which he worked.

Atul Gawande, famous surgeon, patient safety advocate, and best-selling author of The Checklist Manifesto agrees. Gawande of the Harvard School of Public Health has been pushing for the worldwide adoption of checklists throughout all walks of medical care as a simple, cost effective means of reducing medical errors and enhancing patient care.
Malcolm Gladwell had this to say about Gawande’s book:
     

 Gawande begins by making a distinction between errors of ignorance (mistakes we make because we don’t know       enough), and errors of ineptitude (mistakes we made because we don’t make proper use of what we know). Failure in the modern world, he writes, is really about the second of these errors, and he walks us through a series of examples from medicine showing how the routine tasks of surgeons have now become so incredibly complicated that mistakes of one kind or another are virtually inevitable: it’s just too easy for an otherwise competent doctor to miss a step, or forget to ask a key question or, in the stress and pressure of the moment, to fail to plan properly for every eventuality. Gawande then visits with pilots and the people who build skyscrapers and comes back with a solution. Experts need checklists–literally–written guides that walk them through the key steps in any complex procedure. In the last section of the book, Gawande shows how his research team has taken this idea, developed a safe surgery checklist, and applied it around the world, with staggering success…

Gawande thinks that the modern world requires us to revisit what we mean by expertise: that experts need help, and that progress depends on experts having the humility to concede that they need help.

We couldn’t have said it better.

But Gawande laments “If they [checklists] turn out to curb malpractice lawsuits too, he added, I don’t know what more we want in order for hospitals to adopt the concept.”

Well there is one more thing that clinicians want in order to adopt checklists into their practice: ease of use.

The List program is predicated on the checklist concept. Its signature feature is a task management “column” in which users can create and manage check boxes for all of their daily tasks. This may seem simple and not altogether revolutionary, but consider the fact that most residents currently carry around their own “list” in their pocket and write out their own tasks individually. Any busy resident will tell you if they lose their “list” they are screwed.
The List makes this easy and we’d even like to think, enjoyable. It syncs a medical team’s tasks together and provides for a level of information safety and consistency not seen in daily practice.

We’re confident that checklists are the way of the future. If it was up to us we’d make a checklist out of everything.