I was reading a blog recently when I saw a post regarding EMR (Electronic Medical Records) and usability. It looks like the Healthcare Information and Management Systems Society (HIMSS) has released a report about how they will integrate usability testing into their task of getting EMRs up and running. They admit that usability is one of the reasons EMR creation and integration has been so difficult. This is definitely one of the holy grails in the healthcare world. When you look at it initially, its easy to say the industry has been very slow to make this happen. However, once you dive into the topic, you realize how complicated it actually is.

I’ve been very lucky to have completed some research in this area. There are a huge number of issues that will slow down the acceptance of EMRs by hospital staff, especially nurses. Nurses are very important to look at when thinking about EMRs because they are the ones who will be in and out of the software constantly, as they interact with patients. Following are some of the concerns that really stood out to me:

Technical Abilities

I had the pleasure to meet a wide variety of nurses during my years at Elsevier. Nurses have a wide range of technical abilities. In general, older nurses are not very technically savvy, while younger nurses are. Addtionally, working in a hospital with software firmly in place (e.g. Veterans hospitals have EMRs fully integrated), increases this savviness. Nurses, who are not quick with computers, are nervous about how their lack of skill will slow down an already too busy work day. Having easy to use software, good training, and a slow paced integration will help alleviate these issues.

Time

Without changing anything in their current work load, nurses are already short on time. The argument can be made that EMRs will eventually ease their work load. However, there will be a learning curve (think about their technical abilities) and there has to be time to get used to the software. Integrating any changes into their current work will need to be done slowly and in such a way that they can still care for their patients. Additionally, the program will need to be easy, fast, and fit seamlessly into their workflow – all traditional goals in usability engineering.

Paper

Right now, nurses have a lot of paper they use to keep track of everything (care plans, notes on how the patient is doing, etc). The paper versions are fast to carry around. The papers can be found quickly in a folder. It’s tactile and easy to read off to people. Simple notebooks are sometimes used as a shift change tool.  The head nurse can quickly flip through pages and see exactly what is happening with each patient and update the next shift quickly. Perhaps customized, overview screens can be used to replace some of the notebooks, especially for shift changes.

Additionally, in some cases, hospitals do not have enough computers for each nurse. All notes are taken on paper. Then, nurses have to wait their turns to enter information into the system. Having more computers readily available will help this situation.

Personable

Nurses pride themselves on their patient interactions. This is why a lot of them choose their careers. They are there to make patients feel comfortable and help them get better quickly. Several admitted their concern about how those interactions could be affected if they have their noses in a computer. They’ve noticed how online forms tend to become very impersonal. When they ask patients information and enter it on a computer, it turns into a question/answer session with no real interaction. The nurse is staring into a computer screen trying to get everything typed in while the patient is feeling more like a number than a person. And, if the nurse chooses to talk to the patient without the computer, they then have to find the time to enter the data in afterwards, which is another task they do not have time for. Making screens exceptionally easy to fill out (easy to find fields, in an order that makes sense, with easy selection options) will help the nurses be comfortable. Also, Tablet PCs may help make this interaction seem less like data entry and more like it currently does with a paper and notebook.

Compatibility

Some hospitals have tried to get systems implemented. In some cases, they have different software for different departments (e.g. Emergency vs. NICU). Each specialty and each staff member seems to have different needs. Getting each person to the information they need quickest has to be a high priority. Once you can make everyone in one hospital happy, then you have to figure out how to tie this data into the entire medical community. It’s a big job!  Allowing customization for each hospital/department may relieve these issues. However, there should be a common, underlying data structure that will allow for easy integration with other record systems.

The above topics do not even include big issues such as security and patient safety and integration with private physicians, all huge issues that will also need to be dealt with. Even the Obama administration is aware of the integration issues. They have earmarked billions to help research and create an integrated EMR system. However, even with all the problems. This is a goal we need to strive for. If we do manage to design a system that will speed up the administration side of hospitals, enable easy access to a patient’s entire history, and save patients lives by catching potential mistakes, we’ll be able to help more people and give staff the time they want and need to spend more time with their patients.

Today, ONC’s HIT Policy Committee will reconvene to hear the latest iteration of draft recommendations on “meaningful use.” For those of you that are new to all of this, “meaningful use” is the legislative language used in ARRA, to insure that the ~$36 billion to be spent on clinician adoption of EHRs will result in EHRs being used in a meaningful fashion.

About one month ago, the meaningful use workgroup of the HIT Policy Committee released their first draft of recommendations which received significant comments during that initial presentation from others on the HIT Policy Committee along with some 790+ written comments in the comment period that followed (here’s Chilmark Research’s own comments).  The meaningful use workgroup chaired by Paul Tang and Farzad Mostashari (don’t be surprised to see Mostashari in senior position at ONC within next month or so) did an admirable job in this first draft but our final assessment of this draft, it was DOA.

Hopefully, the workgroup has taken a much closer look at what is actually doable within the time constraints of the HITECH Act, which are very tight and modifications have been made to insure that not only meaningful and substantial adoption occurs, but that adoption leads to better, high quality outcomes.  If we focus on just the technology, as it appears HIMSS special vendor committee EHRA would have us do, we are likely not to see meaningful adoption and use.  If, on the otherhand we set our sights on meaningful outcomes such as what the Markle Foundation suggests (disclosure, Chilmark Research did review and comment on earlier draft of Markle’s comments and is a signator to these comments) with clearly defined targets and let the innovators of healthcare create the means to get there without some prescriptive technology fix, we will see meaningful and sustainable adoption leading to measurable results that all citizens will benefit from.

PHILADELPHIA, PA � For years controversy has surrounded whether electronic medical records (EMR) would lead to increased patient safety, cut medical errors, and reduce healthcare costs. Now, researchers at the University of Pennsylvania School of Medicine have discovered a way to get another bonus from the implementation of electronic medical records: testing the efficacy of treatments for disease.

In the first study of its kind, Richard Tannen, M.D., Professor of Medicine at the University of Pennsylvania School of Medicine, led a team of researchers to find out if patient data, as captured by EMR databases, could be used to obtain vital information as effectively as randomized clinical trials, when evaluating drug therapies. The study appeared online last week in the British Medical Journal.

�Our findings show that if you do studies using EMR databases and you conduct analyses using new biostatistical methods we developed, we get results that are valid,� Tannen says. �That�s the real message of our paper � this can work.�

In January 2009, President Barack Obama unveiled plans to implement electronic medical records nationwide within five years, arguing that such a plan was crucial in the fight against rising health care costs. Of the nearly $900 billion in Obama�s planned stimulus package currently before the United States Senate, $20 billion is proposed for electronic health records.

Tannen says he and his group recognized that the large EMR databases containing compiled medical information could potentially give researchers the ability to study groups reflective of the total population, not just those who participate in clinical trials, and circumvent studies too costly or unethical for clinical trials. However, such databases contain observational information, which critics argue do not offer the same level of control as randomized trials.

�Our study cautiously, yet strongly, suggests that enormous amounts of information within electronic medical records can be used to expand evidence of how we should or shouldn�t manage

healthcare,� Tannen says.

To address criticisms of observational studies, Tannen�s group had to first determine a way to use EMR databases for insights on therapy efficacy and then prove the results they found were valid.

Beginning six years ago, Tannen�s team selected six previously performed randomized trials with 17 measured outcomes and compared them to study data from an electronic database � the UK general practice research database (GPRD), which included the medical records of roughly 8 million patients. Treatment efficacy was determined by the prevalence of cardiovascular outcomes, such as stroke, heart attack and death.

After using standard biostatistical methods to adjust for differences in the treated and untreated groups in the analysis of the database information, Tannen found that there were no differences in the database outcomes compared to randomized clinical trials in nine out of 17 outcomes.

In the other eight outcomes, Tannen�s group used an additional new biostatistical approach they discovered that controlled for differences between the treated and untreated groups prior to the time the study began. By using the new biostatistical method instead of the standard approach, the researchers showed there were no differences between the outcomes in the EMR database study compared to the randomized clinical trials.

Though Tannen warns the ability to use EMR databases from the United States to measure the efficacy of therapies will take more than 10 years of national data, he says the results of his study should serve as a catalyst for more researchers to explore the accuracy of the information that can be obtained using EMR database studies.

�An appropriately configured EMR database could offer an invaluable tool, but we need to get to work now on how to configure it properly,� Tannen says. �If we don�t worry about this issue right now and promote a higher investment in the area of EMR research, we�ll lose an opportunity, an enormous health opportunity.�

Medical Billing | Medical Transcription | Medical Billing and Coding | Transcription Services

Not to many people have been focusing on the practical side of the ARRA EHR stimulus money that’s being given out to those who adopt an electronic health record. Take a look at this description of the EHR stimulus money available under Medicare. Also, please go and vote in this poll that tries to assess how many people will actually have enough Medicare reimbursement to qualify for the EHR stimulus money.

Are you planning on EHR stimulus money for your clinic?

Can electronic medical records really help us deliver better care at lower cost? Maybe, says Peter O’Toole, but it’ll require plenty of clueful cooperation between software and medical professionals. In this conversation with host Jon Udell, he discusses expert systems, knowledge representation, data interchange standards, and the subtle art of balancing constraints and freedom in the gathering of clinical information. Listen to the complete discussion on IT conversations – http://itc.conversationsnetwork.org/shows/detail4174.html

This is great news for the advance of electronic health records.  Kudos to Louisiana Governor Jindal for embracing this step forward and the state legislature for bringing this bill forward (The Electronic Health Records Loan Program Act – Senate Bill 246 by Senators Sherri Smith Cheek, Ben Nevers and Francis Thompson, and Representative Anthony Ligi).  The key element in all of this will be the federal interpretation of meaningful use. That is a very generic term and can cover a lot of ground.  If it is applied to streamlining record keeping, maintaining an orderly flow of information to prevent loss of info or duplication of testing etc, then that will be a good thing. If however, the federal overseers in DC decide that meaningful use must translate into cost savings, cuts in spending and the like, then we continue to worry about the temptation to penalize practitioners as well as limit choice and options for patients.  We have time and again urge the adoption of useful electronic tools in medical practice and health care, but we must temper that, always, with a prudent distrust and skepticism of the motives of the federal agencies behind these programs . . obi jo

DHH Secretary Alan Levine said, “We are looking forward to working with physicians and hospitals on Governor Jindal’s continuing efforts to better manage the health and well-being of our citizens. This program will help advance the use of technology in a meaningful way to provide better patient care.”

Jindal signs electronic medical records bill

Louisiana is creating a new electronic health records loan program designed to help hospitals and doctors go digital with medical records.  Gov. Bobby Jindal signed the bill creating the program, but the plan is tied to federal stimulus money the state has yet to receive.  The bill allows the state health department to apply for the stimulus money to dole out loans to health care providers for the purchase and implementation of electronic health record systems.  The state budget includes $5 million in matching money required for Louisiana to apply for the federal grant. State officials hope to draw down $25 million in federal money.  The law also allows the loan program to draw on other sources of funding if available.

Jindal signs electronic medical records bill – http://www.neworleanscitybusiness.com/uptotheminute.cfm?recid=25688&userID=0&referer=dailyUpdate

Jindal signs electronic medical records bill – http://www.nola.com/newsflash/index.ssf?/base/national-34/1247221707217270.xml&storylist=louisiana

Jindal signs electronic medical records bill – http://www.chicagotribune.com/news/local/wgno-news-medrecs0710-story,0,667165.story

Louisiana Gov. Jindal Signs Electronic Health Records Bill – http://hitconsultant.blogspot.com/

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Over the past few decades the medical zone have underwent drastic alterations. Unlike the other professional sectors the health care zone have publicized technology to a great extend. Medicine have greeted and welcomed technology to nearly all of its vital vicinities such as medical diagnosis, medical recording, surgical assistance etc.

Key Hole Surgery is one of the relevant examples. Health care and technology successfully toiled hand in hand and that made the health care field one of the most authoritative, dominant and influential sector in today’s epoch.

iTMarkerZ Technologies also aims to impart technology into Health Care to make it more trustworthy, reliable and gracious. iTMarkerZ Technologies has put forward a brand new initiative in this regard as iTMarkerZ Technologies are on the verge of launching its new product – “Doctor Plus”.

On the whole Doctor Plus is EMR software. EMR stands for Electronic Medical Recording. The most significant procedure of hospitalization of a particular patient is the patient’s medical recording. Medical recording comprises of basic notifications such as age, patient’s present situation, diagnosis result etc. Medical recording assisted by technology is termed as electronic medical recording.

According to health informatics an electronic medical record (EMR) is a medical record in digital format. Electronic Medical Records Software provides a point and click interface that makes charting fast and easy. The comprehensive electronic medical records functionality includes appointments, patient tracking, E-mail and messaging, reports, coding tools, chart evaluation, template management, certified billing links and more in one integrated system. Data is located where a doctor or staff member would intuitively look for it and virtually all data needed to manage a patient visit from arrival to check out is accessible from just three screens. Typing is virtually eliminated as Tap-n-Go TM navigation and customizable Templates and Pop Up Text dramatically reduce the time needed to fully document a patient encounter to less than a minute. In healthcare, interoperability is the ability of different information technology systems and software applications to communicate, to exchange data accurately, effectively, and consistently, and to use the information that has been exchanged. Interoperability can also refer to legal interoperability, i.e. the regulatory issues of cross-border EMR implementations.

iTMarkerZ Technologies is on the brink of its bran new product launch “DOCTOR PLUS”.

Doctor plus is one of the initial launches of iTMarkerZ Technologies. Through this initiative of EMR iTMarkerZ Technologies targets to trim down the uncertainty and error vulnerability in medical recording of clinics or hospitals to great extend. Doctor Plus is typical EMR software that functions based on a single straight forward concept known as clinical Inter bonding. In Clinical inter bonding two or more clinics or hospitals are connected through internet and they will share a same database for electronic medical recording .As a result if a patient of one clinic is referred to any other clinic he doesn’t have to carry his medical details with him as it could be accessed from the database. Apart from that if a patient is admitted to a multi speciality hospital then the patient’s EMR will be send to the Para hospital sections such as X- Ray Unit, CT Scan Centre, Physician etc Doctor Plus makes the clinics functioning smooth assure proper treatment for the patient by offering apt and vivid medical details of the patient which result in faster recovery

How secure is your home, your car, your office? Do you use double bolt lock or have bars on your windows? How about internal alarms?

For the most part your answer to these questions depends on where you live and the value of your possessions. At the very least you have locks on your door, but you may leave the door unlocked from time to time. This is risky yet unlikely to result in major loss. If you do it too often and become lax in your home security then you give a thief opportunity that puts your possessions at risk.

Bank Vault

How do you secure data in your health information? Data that is stored must be encrypted with restricted access; when viewed it must only be displayed to a verifiable user with correct permission. Even with high-level security it is impossible to prevent a wandering eye on a screen. Early in our development of health information access the question of security and privacy always came up. Usually asked by doctors and nurses who raised this objection as a means to slow adoption. My quick response to questions on the security of electronic data was to point out that; currently fax machines in the hallway had patient data displayed, that behind the nurses station a white board with patient names and other identifying data was displayed for anyone visiting their unit; and that carts of patient charts are routinely rolled around the hospital and that these paper folders routinely would be left unattended. Electronic health information systems are much more secure than paper and non-electronic means. When records are electronic it means you can get access to your data much more easily than paper folders locked in a doctors cabinet or the basement of the hospital health records department.

Ideally we would want full control and access to all our own health information and be confident that it is not being misused or shared without consent. We currently don’t have that control. We rely on our doctors, our hospitals and other government agencies to maintain and control access to our health information. In the province of Ontario and many other jurisdictions individuals have the right to access and control permission to all their health information. Of course the practicality of receiving all this information from a hospital or doctors’ office makes it difficult. How would we get the paper forms and input them ourselves into our own health application? If records were electronic patient have better opportunity to access and control premission to their own information.

We need to ensure that proper percautions are being taken to store our information. To secure our health information the personal identifying data must be encrypted and only viewable by verified access. While user name and password is relatively simple, there are better ways to ensure privacy and security. A smartcard with proper token identification would be a strong method to secure access.

The NEXUS system is used by the US, Mexico and Canada for “trusted travelers”. The system issues a card for this program that uses several layers of security. First a person registers online and their user name and password is issued; then a face-to-face interview is conducted and documents verified (passport, driver’s license etc.); photo id is made and a retina scan is taken along with other details; then a card is issued with an RFID. When entering the country, rather then wait in a lineup, the “trusted traveler” uses the NEXUS card; unsheathed from the RFID blocking cover to access a self-help KIOSK. The traveler positions themselves in front of a device that takes a retina scan, which is compared to that on file, the proximity of the card is all that is required to match the individual to the online file. No swiping or entering of card number or pin is needed. The system verifies who you are by something you are carrying (the card) and your physical attribute; your retina scan. The process is quick and easy. The difficult part was in the verification and issuing of the card.

In Ontario the government issues an OHIP (Ontario Health Insurance Plan) card that is used for payment of services. Many individuals still have the old “red and white” card that is simply an embossed plastic card with only a 10-digit number on it.

OHIP Card

To create a secure and private electronic health application one could use the credit card and banking industry model. A credit card is issued from a specific institution, with the first grouping of numbers uniquely identifying the bank and card issuer, then there is a unique number associated with the individual. The card also has security features like check-digit algorithm, and security code. Other features like holograms, photos and smartcard and magnetic swipe all can be implemented on cards. The ability to add RFID would further enhance such an access verification tool.

Each card would be associated with an individual. Also with this model a card can have sub-accounts so that a parent can access records for child of other family member that has granted them access. This would be useful for better service traking. Take for example a child whose parent are divorced, each parent can have their child added to their card so that access to care is unencumbered when the child is with the other parent. This is also useful for family members such as elderly parents. The card has the ability to be a security key into an electronic health application. It isn’t the only consideration, it is a good start.

“Once upon a time, going to your doctor was simple. You knew his first name, or perhaps just called him “Doc.” He lived just down the street and made house calls. And if you were sick, you would see him that day, because, well, you were sick” … that’s how the story starts for Hello Health! (founded by an American and Canadian in NY)

Hello Health attempts to make healthcare simple and accessible to patients and promises  to taking medicine to its basics.  With Hello Health, you can interact with your doc in your favourite means of technology.  If you have query and you would like to just e-mail, you just e-mail and its Free!  You make your appointments online and access your records as well.

At the primary care level, as the first point of contact for the patients, accessibility and responsive care is crucial for patients and especially for patients with chronic diseases like diabetes, cancer, heart disease and COPD.

So is Hello Health disruptive ? Absolutely in private healthcare market like US, its bringing the medicine back to basics and attacks the complex payer/physician centric model.  In market economics, as the value propositions of the consumers change, new players emerge to provide the missing value and this is often called as invisible hand and works in most cases. It remains to be seen whether it will work in healthcare.

Can a service like Hello Health, work in a single payer system like Canada ? Of course, it can, provided it meets the regulatory requirements of the government and the docs adopt the government certified EMR

Hello Health!

(Electronic Medical Record), of course with lots of incentives.

Accessing a primary case physician is  relatively easy (caveat: if you have a family physician) in the Canadian Healthcare system and every one is aware of the improvement needed in terms of technology adoption.

In US, the question remains whether the proposed mandatory legislation by Obama administration can hinder a service like this. Boston Globe has a good coverage on this. http://bit.ly/WE67p

Also this type of pay for use service only serves the basic healthcare needs and Can it fix the completely ailing US healthcare system, where complex care consumes most of the resources in the system ?

It remains to be seen and the quest for solving the healthcare puzzle continues.

Electronic Medical Records 1.0 (EMR 1.0) is still in its early development and implementation stages. Out near the edges, EMR 2.0 may already be evolving. First a little context:

System development 1.0 — the process leading to EMR 1.0 — follows a methodology something like this:

• Define a user group
• Determine their requirements
• Develop a system that satisfies those requirements
• Deliver sequential improvement, i.e., versions

System development 2.0 uses a different methodology:

• Define a capability
• Develop a system that exploits that capability
• Deliver it to the market place as “beta” version
• Work in the marketplace to learn what is really wanted and needed
• Stay in beta and make evolutionary enhancements as fast as you can

For this discussion, let’s use Microsoft Word as an example of a 1.0 system. The team in Redmond Washington developed Word 1.0. They then made minor changes, e.g., 1.1., 1.2. and a series of major changes that they stopped numbering several years ago. They listened to customers but the emphasis appears to have been to incorporate advances in the state of PC technology and the results of their own usability labs. In its era that worked and MS Word is the dominant system solution for word processing worldwide.

Electronic medical records (EMRs) – the real topic of this post – started as version 0.1. Basically a large number of standalone systems, most of which were developed for a single client or small group of clients. The primary focus was data capture and delivery within a single office of complex. There is still a very large number of those systems in use and for sale.

As the data was being captured it became apparent that sharing the data among a patient’s doctors would be valuable to the doctors and the patient. Efforts to add networking and sharing of information led to the dawn of EMR 1.0. The 1.0 model says, in effect: “We are developing an integrated system you can use when it is ready.” That version represents most of what is happening with EMRs today including the Administration’s inclusion of EMRs as part of the economic stimulus package and health care reform. A recent Twitter post defined the current status as: “an endless barrage of information and discussions and debates regarding various combinations of information.”

Google and Microsoft are, individually, taking 2.0 approaches. From here on I will use Google as my example because as a user of Google Health, I know more about and have easier access to what they are doing.

Google has taken some basic capabilities of the Internet and developed a rather simple model of a Person Health Record (PHR.) This 2.0 approach says and then asks “Here are some applications that could be part of a larger system. How can we work with you – patients and service providers – to make this and future enhancements useful to you? What role should we play? What role will you play?”

The market place is responding with uses that are almost all outside the current definition of the 1.0 version. Patients now have the option of linking 47 services to their Google Health profile. Whether or not these uses are valuable will be determined by the patients and the providers of services, not in some executive office or committee. Patients and providers will vote with their money, yes or no.

Google Health links to additional services

“I want it all.” This sentiment is shared by nearly all of the clinicians we’ve met with, from the largest integrated health systems (IHS) to the smallest physician practices, in reference to what data they want access to once an aggregation solution like a data warehouse is implemented.  From discussions with organizations throughout the country and across care settings, we understand a problem that plagues many of these solutions: the disparity between what clinical users would like and what technical support staff can provide.

For instance, when building a Surgical Data Mart, an IHS can collect standard patient demographics from a number of its transactional systems.  When asked, “which ‘patient weight’ would you like to keep, the one from your OR system (Picis), your registration system (HBOC) or your EMR (Epic)?” and sure enough, the doctors will respond, “all 3”. Unfortunately, the doctors often do not consider the cost and effort associated with providing three versions of the same data element to end consumers before answering, “I want it all”.  And therein lies our theory for accommodating this request: Leave No Data Behind. In support of this principle, we are not alone.

By now you’ve all heard that Microsoft is making a play in healthcare with its Amalga platform. MS will continue its strategy of integrating expertise through acquisition and so far, it seems to be working. MS claims an advantage of Amalga is its ability to store and manage an infinite amount of data associated with a patient encounter, across care settings and over time, for a truly horizontal and vertical view of the patient experience. Simply put, No Data Left Behind.  The other major players (GE, Siemens, Google) are shoring up their offerings through partnerships that highlight the importance of access to and management of huge volumes of clinical and patient data.

Why is the concept of No Data Left Behind important? Clinicians have stated emphatically, “we do not know what questions we’ll be expected to answer in 3-5 years, either based on new quality initiatives or regulatory compliance, and therefore we’d like all the raw and unfiltered data we can get.” Additionally, the recent popularity of using clinical dashboards and alerts (or “interventional informatics”) in clinical settings further supports this claim. While alerts can be useful and help prevent errors, decrease cost and improve quality, studies suggest that the accuracy of alerts is critical for clinician acceptance; the type of alert and its placement and integration in the clinical workflow is also very important in determining its usefulness. As mentioned above, many organizations understand the need to accommodate the “I want it all” claim, but few combine this with expertise of the aggregation, presentation, and appropriate distribution of this information for improved decision making and tangible quality, compliance, and bottom-line impacts. Fortunately, there are a few of us who’ve witnessed and collaborated with institutions to help evolve from theory to strategy to solution.

Providers must formulate a strategy to capitalize on the mountains of data that will come once the healthcare industry figures out how to integrate technology across its outdated, paper-laden landscape.  Producers and payers must implement the proper technology and processes to consume this data via enterprise performance management front-ends so that the entire value chain becomes more seamless. The emphasis on data presentation (think BI, alerting, and predictive analytics) continues to dominate the headlines and budget requests. Healthcare institutions, though, understand these kinds of advanced analytics require the appropriate clinical and technical expertise for implementation. Organizations, now more than ever, are embarking on this journey. We’ve had the opportunity to help overcome the challenges of siloed systems, latent data, and an incomplete view of the patient experience to help institutions realize the promise of an EMR, the benefits of integrated data sets, and the decision making power of consolidated, timely reporting. None of these initiatives will be successful, though, with incomplete data sets; a successful enterprise data strategy, therefore, always embraces the principle of “No Data Left Behind”.

One of the few places that appears to be keeping up with all the changes going on with the American Recovery and Reinvestment Act of 2009 , is the HIMSS Economic Stimulus website. I know. This is the same HIMSS that loved to misspell my company’s name year after year in their directory, yet here they are regularly updating things like timelines, FAQs, etc…

Whilst perusing, I ran across a well written white paper (warning: PDF) here on the impact of good/bad usability on EHR adoption. Since many of the EHR’s I’ve seen look like something written 10 years ago in MS Access or have funny dark screens with green letters, this is welcomed guidance.

We submit that usability is one of the major factors—possibly the 
most important factor—hindering widespread adoption of EMRs. 
Usability has a strong, often direct relationship with clinical 
productivity, error rate, user fatigue and user satisfaction–critical 
factors for EMR adoption.

In addition, HIMSS details several usability principals that I’ve found lacking in even mainstream EHR’s, like Simplicity, Minimal Cognitive Load, and (my personal favorite) Efficient Interactions. Seven ways to update a chart sounds great in a sales presentation, but try to implement that without cognitive overload.

They also reference the National Highway Traffic Safety Administration (NHTSA) Ease of Use rating program and FDA Human Factors as good guidance for developing products that make better sense.

Alright, now all of you EHR vendors out there, go back to your applications and ask this all important, enduring question: will our clients actually enjoy using our solution?

Health information technology (HIT) is a broad and extremely complex field, and I want to visualize it. I’m going to need your help to do it. But first it needs defining…

HIT could simply be defined as any information technology utilized within the healthcare industry vertical, but that would be too inclusive, because that means a MySQL database is considered HIT because it is sometimes used in a hospital. Brailer & Thompson, former ONC Secretary and former HHS Secretary respectively, define it as “the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making” (Thompson & Braile, 2004). The line between HIT and health informatics is fuzzy and we’ll ignore it for now.

With this definition, I tried to create a hierarchical list of the types of health IT software. I want the list to be comprehensive in breadth and don’t care quite as much about depth (3 or 4 levels should be sufficient). There are dozens of ways to structure this list and probably hundreds of items I missed. This is a work in progress, so please leave a comment and let me know what you would change/add/remove. I’ll keep updating it until everyone feels good about it. After that comes the visualization…

A special thanks to the Twitterers that have already helped me on this: @chadosgood, @oneofthefreds, @ChristineKraft, @ePatientDave, @MedC2, and my good friend Jake. And a shout out to Sam Adam’s HIT Primer on his blog, IT (R)EVOLUTION, that helped get me started.

A few other helpful sources:

• Thompson & Braile, 2004
• Wikipedia: List of open source healthcare software
• Meaningful Use Matrix

In the last week I have encountered a number of thought challenging, disruptive experiences and articles. Here’s a couple of items that illustrate my point:

I have been exploring the changes that electronic medical records are creating. The process is being driven as part of the Administration’s stimulus plan and their efforts to improve the quality and reduce the cost of health care. The current approach has been summed up by on Twitter poster as: “… an endless barrage of information (and discussions and debates regarding various combinations of information),” Meanwhile CVS is expanding into health care services though clinics in their stores and using the personal medical records systems of Google and Microsoft to improve service and communicate with the patient’s doctor. Today there is word that the British national system is so over budget and late that they may adopt a Google or Microsoft solution. Are we seeing some classic Clayton Christensen disruptive technologies for health care? Microsoft and/or Google rather than a government driven program?

Here’s an article from the July 2, 2009 issue of Business Week by Shoshana Zuboff who is regular contributor to Business Week. She points at some different but equally disruptive ideas.

I spent a quarter-century as a professor at the Harvard Business School, including 15 years teaching in the MBA program. I have come to believe that much of what my colleagues and I taught has caused real suffering, suppressed wealth creation, destabilized the world economy, and accelerated the demise of the 20th century capitalism in which the U.S. played the leading role.

We weren’t stupid and we weren’t evil. Nevertheless we managed to produce a generation of managers and business professionals that is deeply mistrusted and despised by a majority of people in our society and around the world. This is a terrible failure. … Margins have shrunk steadily for 40 years; return on sales for the Fortune 500 has been declining since the early 1960s.

Many companies reacted to this decline by finding new ways to cut costs. The Harvard Business School, along with other business schools, taught them how: outsourcing, off-shoring, downsizing, reengineering, and finding new overseas markets for old products.

… a return to real prosperity and long-term growth … will require a rebirth of business based on new rules for a new era.

The old rules that most B-schools have preached were invented a century ago for supplying mass consumers with affordable goods and services. They are poorly suited to the values of today’s new consumers, who want help to live their lives as they choose, with personal control, voice, and a practical sense of connection. Many smart people have spent decades trying—and failing—to adapt the old model to this new pattern of consumer demand.

New Rule No. 1: Race to I-Space
The old rules assumed economic value. That’s why Harvard Business School students have been trained for a century in the “administrative point of view.” The manager’s job was to oversee and control what was inside organization space, or what they were trained to view as “my company.” Everything else was a distraction. The “administrative point of view” reflects a simpler time when business was about selling a product. …. It’s a world of producers vs. consumers, my company vs. your company, us vs. them.

Business is no longer just about the product. Now it’s about solutions for the individual. Economic value is hidden in consumers’ unmet needs and is released by providing people with the means to fulfill those needs. But in order to release new value, you need to get out of organization space and into the subjective space where individuals live. I call it “I-Space.” This means shedding the “us-them” mentality. Now everyone is an insider.

…. Apple headed for I-space with iPod/iTunes and released massive quantities of value by giving people what they wanted on their own terms in their own space. Meanwhile, music industry executives were busy throwing tantrums in organization space and suing their most passionate customers. …

New Rule No. 2: Advocate, Don’t Alienate
The old rules taught you to ask, “What is my product or service, and how can I sell it to you?” With that question, adversarialism was baked into the DNA of the buyer-seller transaction.

The new rules ask, “Who are you? What do you need? How can I help?” This creates a dynamic of advocacy and mutual accountability. The more trust you build, the more value you release, and the more wealth you create.

… President Barack Obama gets it. In his proposed overhaul of financial regulations, brokers will be compelled to put their clients’ interests first. Trained in the administrative point of view, Wall Street executives are already preparing to fight the very changes that would put them on a path to new wealth creation.

New Rule No. 3: Collaborate and Federate to Compete
When you’re in I-Space, you need to collaborate and federate to provide the support individuals need. You can’t do it alone because the needs of individuals don’t conform to existing organizational and industry boundaries. This means learning how to manage what you don’t control or own. These economies of trust are becoming even more important than economies of scale.

… Amazon’s marketplace and eBay’s webs of buyers and sellers are early prototypes of these federated networks. Apple and Facebook are struggling to understand the rules of engagement that should govern relationships with their applications developers. You can see them climbing a new learning curve through trial and error as they figure out how to build and sustain economies of trust.

Are You Ready to Let Go?
After decades of working with adults on the challenges of transition, I know that letting go of the old rules won’t be easy. No one gives up what they know without a fight. …

Letting go is a Catch-22. You don’t want to let go until you have something new to cling to, but you can’t discover the new thing until you let go. In between, you must cross a mystery zone. Eventually you get to the point where you can’t stand the feeling of things not adding up for one more minute. That’s when you take a leap of faith, and the questions start to feel more important than the answers. You’re in a new place. The bad news: There are no maps. The good news? You are the mapmaker.

Sounds like we are living in interesting times. Stay tuned.

I’ve had a great start at my new clinic. The preceptors and staff are all super-friendly, forgiving me my constant foibles. I e-mail my main preceptor trying to figure out the nuances of my schedule. I whine to the MOA whenever the computer crashes, because she has to report errors to the company that makes our Electronic Health Record (EHR) software. Okay, well I only tell her about 1/4 of the time, since I wasn’t sure if it was the program crashing or just the angry laptop. Also I learned that logging in under certain domains will boot others off; I definitely (accidentally) did this to my preceptor. Twice. In a row. Oops!

Technical issues aside, the patients are great. Those I’ve met in the clinic have welcomed me with big smiles and many ask if I’m settling in to the city and if I’ll be staying for long. There must be an incredible demand for doctors in this world; while walking back from rounds at the nursing home, some people on the patio of a pub stopped me to say hello. That’s right, directly beside our clinic there is a pub. Oh yes, it’s our next-door neighbour in the mini-mall, and there’s a pharmacy and then a big liquour store on the other side of us! But I digress. I chatted for a bit with these nice people and explained my nametag. One older fellow said he saw a doctor at my clinic, hadn’t been for a year or so, but would come back just to see me (insert a wink here). The old-man pretending to charm me is nothing new. I’m used to being called ‘dear’ or ‘hun’ and was once hit on by a paramedic while I was doing CPR [honestly!], so I just had a good laugh and skittered away to the clinic. Moments later, I hear “Dr. Otte, are you accepting patients?” One of the other gents sitting at the table had followed me to make an appointment. Well, technically I’m not even a GP yet, but it is a testament to the need of the community that they are asking the young, naive, doesn’t-know-much-about-anything woman to care for them. [N.B. that is what I will continue to beleive so don't try to convince me otherwise!!*lalalala I'm not listening*]

On rounds at the nursing homes, it has become clear what a cult-of-the-personality surrounds physicians. Maybe that’s the wrong term for it, but boy, people over 60 sure show a lot of love and respect for the doc. A lot of that probably comes with the years of care that they have experienced, or maybe my preceptor really is as fantastic as he seems, but it is an incredible thing to witness. If I have a handful of patients that have unwavering faith in me one day, I’ll be equally heart-warmed and frightened to let them down.

Family medicine is good. This city is good, and it’s great to be a learner here, and especially to be that in one place for 2 years. I feel a kind of ease that’s new to me, and I really hope all of my classmates from undergrad are feeling it too, wherever they are. [Although a little birdie told me that a classmate (and new resident in Vancouver) ran a code and did 24 CCU consults on his first shift on call]

For a real giggle, here’s a very brief (1.5 minute) funny I’ve come across lately: video of Bill Maher on Healthcare (in view of the US move to revolutionize their public/private system.

Although the idea of Electronic Medical Records, or EMR as they are commonly called, isn’t entirely new, it is still being integrated into many hospital groups at a rapid rate. The concept basically takes the paper records that medical offices have used for years and turns them into a digital record. This can be easily shared among physicians, pharmacies, and other healthcare providers, enabling them to see the patient’s history. This can alert providers to allergies, conditions, and other relevant information prior to treating them, which is particularly important for emergency care. EMRs have even become a priority for President Obama and his administration (http://www.tempdev.net/blog/?p=498). For more information on EMRs, visit http://en.wikipedia.org/wiki/Electronic_medical_record or http://www.himssanalytics.org/docs/WP_EMR_EHR.pdf.

Hi everyone.

So sad, today was Michael Jackon’s memorial service at Staples Center. Anyways, on other news, remember that OUTLINE that i mentioned in my first post that I said I would post up? Well here it is: if we actually do decide to make to REALLY make an app for mobile devices, here are some competitors: a lot of them do the same thing but some are better than the others.

Research – iPhone medical apps – what do they do, how much, who do they target, and etc.

1. 1. LifeRecord – this company allows doctors and patients to use the IPHONE as an EMR service:For physicians: this company offers one touch billing and one touch prescribing. Doctors can patent their records using the iPhone and also using Life Pax. LifePax prompts doctors and all they have to do is answer right on the question and that is how the information gets recorded into LifeRecord. It also allows doctors to directly communicate with their patients on the iPhone and can also use a direct video chat as well. When a patient in signed into an office, a doctor can automatically know which patient it is with LifeRecord due to their SMS Text Messaging service with the iPhone. For patients: patients can access anywhere, anytime, all of their medical records via the iphone. This can include their billing, x-rays, medical history, immunization records, ..pretty much everything that is in their medical life. They can also set up appointments with doctors via the iphone instead of going in person to the doctor’s office.
   2. Allscripts – Misys Healthcare Solutions has introduced Allscripts Remote, an application that allows physicians to read patients’ medical records, their relevant case histories and the medication that they’re on using their iPhone.
   3. Epocrates – this app is pretty much like a drug and disease information utility.
   4. Health Cloud – An iPhone developer created Health Cloud by using Google Health’s API. Targets Google Health’s users so that they can view their personal health record from their iPhone.
   5. iChart – contains “iprescribing” – which is to administer patient medications, ibilling – which is to organize and submit billing records, iLab reports – to manage lab data, and iNotes- write, organize, and transfer electronic notes.

   I also wrote some ideas down..but I don’t think they matter to what my project is on. I found some new links or links that i was reading last week about the 3 ways that Iphone can be used as a medical device. I have posted these links and you can see them on the right side.

Okay. I will post more later in the week with what I found today.

Leo Technosoft, a leading cloud computing solution provider in Product Engineering, I.T Services, and Infrastructure Support added one more new customer in the health care domain to design and develop the tele x-ray viewer for an USA based health care provider.

Leo Technosoft (www.leosys.in), a global service provider in the domain of custom software development, partnered product development and digital media and marketing added renowned a renowned US based healthcare provider to their portfolio of clients. Leo set up a qualified and experienced offshore development team to build the next version of their online x-ray tool. Working on latest technology platforms, the Leo team built a next generation image converter that integrates features of PACS and EMR, subscribing to healthcare standards laid down by HL7.

This online tool offers the most comprehensive EMR system for tele radiologists, providing a secure hosting service to track, monitor and verify the x-ray process. This web-based technology helps maintain patient information, stores digital images, creates radiology reports and manages online accounting functions like billing and payment.

Fully HIPPA compliant, with multiple layers of security protection, the online tool is housed in a protected information environment. The radiologist can view the images on anything with WEB access like a full blown PACS, a PC, or even a PDA! The radiologist’s diagnosis is converted into an electronic report that is permanently attached to the patient record and can be web accessed, faxed, or emailed.

“We are very pleased that our client has chosen Leo Technosoft as their product development partner. With Leo Technosoft’s proven track record of implementing successful SAaS solutions for clients’ world-wide, supplemented by our expertise in the health care domain, we are confident of providing a versatile application that effectively optimizes RSO.” observed Mr. Satyen Jain, Managing Director of Leo Technosoft   .

About Leo Technosoft

Based out of Pune, India with offices in Orlando, Florida, Leo Technosoft is an outsourced technology, digital media and development firm specializing in the development and deployment of Business & System Applications and Web-based SAS Solutions. Leo specializes in different technology platforms and has partnered with clients from different geographies to achieve their business goals by leveraging immense project management expertise with the highest quality standards to make every project they partner an assured success.

Two really interesting developments are occurring with the all important EHR stimulus package. Check out the following two EMR news items:
Definition of Meaningful Use sent back to HIT Policy Committee by David Blumenthal
Alternative EHR Certifications to CCHIT Meeting with ONC

It’s going to be a busy summer for those interested in EMR and EHR. It’s amazing what a few billion dollars of EHR stimulus money will do.

On the eve of our nation’s Independence Day, it is a good time to reflect on what this truly means to us, the US citizen and even reflect upon what this means within the context of healthcare and future reform efforts.

From the beginning, the writings of Chilmark Research have tried to steer clear of broad healthcare policy discussions. Lord knows there are more than enough Blogs and posts addressing that subject.  But healthcare is, by its very nature, directed by policy at all levels and one can not look at issues in the HIT market without some reflection on the policies in place or being developed that may drive technology adoption and use or hinder it.

Originally, we also intended Chilmark Research to focus on consumer-facing technology, but how naive we were to think that we could look at only these applications without considering their context, use and ultimately, the data they would gather and present to help a consumer better manage their health.  Thus, applications such as EMRs, or the new buzzword, “certified EHRs” which create some of the richest and most useful health data as well as future exchange architectures/platforms (NHIN, RHIOs, HIEs) have fallen into our area of coverage.  In doing so, however, we always keep the thought in the back of our minds: How will this technology, how will its use be reflected within future consumer applications?

Now within the context of healthcare is a smoldering issue that could ignite into a firestorm, the issue: health data access and ownership.  A little over a week ago we did a post of the Health Data Rights declaration, a simple declaration stating  the consumer has basic rights to their health data.  Chilmark Research, along with some 950 others, endorsed this declaration and encourage you to do so as well.

Honestly, the declaration is not that revolutionary as it simply restates rights already supported by HIPAA in simpler, more understandable terms. What is surprising though is the lack of endorsements by providers and payers of this simple declaration, which is it not fundamental to our rights as individuals?  After all, is not personal health information (PHI), be it claims, lab data, medication data (PBM data), images, and other clinical information not ours? Does it not fundamentally belong to those for which it is about?  Is it not an individual we are talking about and without that individual, this data would not exist?

This is the smoldering issue underlying basic questions such as:

• Who ultimately has access and control of the data?
• Who decides who sees the data?
• Who has the right to add notes to a record, to suggest corrections?

These are critical questions that require thoughtful, meaningful discussions among all stakeholders to address fears, and concerns. But let us not needlessly bog-down (this industry sector seems famous for that) in meetings that go in circles. Reach a level of consensus and move ahead.

When we celebrate the brilliance of our founding fathers tomorrow, the Declaration of Independence and Bill of Rights they created which have held up so well for these 200+ years, let us also begin reflecting on a citizen’s right to their personal health information. No longer should a consumer be held hostage, it is time to storm the barriers and take personal control of one’s most personal details, their PHI.

Today we had our training in the new, read-only hospital records system. We use something called PowerChart which is employed in almost all of the hospitals run by the Vancouver Island Health Authority (VIHA). Various sub-programs are used to input pathology info, lab values, medical imaging reports and transcribed patient encounters. We are still meant to do phone dictations to the typing pool, but they’ll appear in the chart. We hand write orders, but they are faxed to someone in the magical basement who enters them into the system (or maybe the unit clerk does it). ER triage forms are included in the system. I’m not sure how much will be in paper format, but for now, we are to have both the electronic and paper charts open in front of us when doing any record perusal.

The ‘hybrid’ system exists because we are transitioning from paper to pure digital charts. Unfortunately, I’ve seen this elsewhere, and I have yet to encounter a service that is 100% digital. The St. Paul’s Hospital Emergency Department, in Vancouver, is getting close. But doctors and nurses still use paper forms for triage & notes, even if they are scanned in eventually.

To view radiology, we still rely on InteleViewer for PACS. It’s quite nice, because we can log-in from home… if I could just figure out what my proxy account is!

Tomorrow or Monday, I’ll find out what my Family Practice preceptors’ clinic is using. Most that I’ve encountered in the past use some blend of paper histories and progress notes with digital labs, consults, and radiology. This isn’t uncommon across the country; according to the CBC, Canada is still pretty retro when it comes to the format of medical records. Digitizing can be an expensive and cumbersome process, though the government of British Columbia has started to inject funding into the area. There are so many companies manufacturing Electronic Medical Records software; partly, this is because they are trying to build the ‘perfect’ system (many of these are physician-created) and partly, they can make good money doing so. Competition and capitalism allow for consumer choice, but I’ve got to say that here is one place where I would really love a national, standardized system. It would need a lot of health-care provider input and would have to be adequately customizable to make it acceptable to most people. But I can fathom it. Maybe we’ll get there in my lifetime.

Hey everyone.

My first post for simple-hit.com

Here is my A.G.E.N.D.A. run down for this month.

Last month (End of May – June 26th) = I mostly did extensive research on the different types of EMRS for iphones. I came up with a list of them and what their functions / targets are. I will post the outline I made in the office when I go in next week.

From now to maybe mid July-ish this is what I will be doing: hopefully I will come out with enough ideas to actually put together for a app that works about everything related to what we are doing that is health emr related.

Health Apps in Mobile Devices

Here are a few questions for me to consider while doing my even more specific research. I hope to gain enough knowledge about the electronic health world and my goal is try to help my father who is a internal medical doctor to switch his information into electronic data (he has massive amounts of charts and stuff everywhere in his office! its a complete MESSS!!!!!!)

1. Who uses the data?
2. WHo inputs data (Maintains/ updates data?)
3. What are the costs associated with using the service?
4. Who is paying for it?
5. (i will be working on more questions to ponder myself..)

EMRS on mobile devices – I’m primarily FOCUSING on the iPhone. the most popular smartphone that i came to use        and love.

Some examples are Health Cloud, Life Record, and iChart (I will post my outline next week.)

Remote Monitoring (for example blood pressuring, controlling glucose levels…interesting eh?)

I will also incorporate some business ideas such as Porter’s 5 Forces into my research. Hopefully I will also come up with a good statement on how to tie this all in together.

Well, that is my agenda for now. On the right side of my blog you will find useful links well i hope useful.

I have to finish or try to finish my KGB training now. Post later~~~~