Steve Jobs - What if he had taken on the HIT challenge?

Yesterday, I saw something that made me think of the difference between a "techy" and a "regular" doctor's approach to technology.

We were installing an upgrade to a popular medical dictation software.  The upgrade was over the network and was to occur seamlessly overnight.

Unfortunately, in the morning when providers logged in, they saw a big message in the middle of their screens saying the software would now be installed and during this process, they would not be able to use various software including MS Outlook.

To make matters worse, this was a long install process and the message would stay on top of all other windows.



When the IT person was told about the problem the response was,

"What's the big deal?  Just drag the message window down so it does not interfere with other windows, and use web Outlook.  What if you can't dictate you notes for a while?  Just use the keyboard!"

I am sure a number of docs had figured that out and went about their work.  But many were complaining...



The world is made up of 2 kinds of people (simplistic view with lots of assumptions):

1. Those who love Linux because it is open and they can tinker with it and troubleshoot it and they get a thrill out of making a difficult thing work.  Some of these same people would prefer a PC over a Mac because of similar reasons.  They love messing with the hardware and drivers and they know how not to get viruses.  They would hate a device where they cannot modify the OS or hardware!
   I would venture to suggest that these same people may also get a kick out of fixing their furnace and replacing a faucet.
   These might also be the folks in the IT industry.


2. Those who want to take a device out of the box and just have it work.  They want to use the device to do what it is bought for without worrying about trouble shooting the device.

Fixing things and finding workarounds is fun and gives the person satisfaction from having solved a tough problem.  But when time is short, when there is important work to be done, when the interface creates inefficiencies, it causes a lot of frustration.  Having worked on both sides of the fence (Clinical and IT) it is quite obvious that the 2 sides don't speak the same language, are clearly not on the same page.  Our current EHR systems are a classic example.



Physicians probably don't know what exactly they want but they know what they have is not ideal.  They want someone to figure out what their needs are and create something simple that works that actually helps them take better care of their patients in less time.



I really wonder if Steve Jobs ever got to see one of these EHR interfaces and work-flows, saw the chaos of a clinician's day, the frustrations, the inefficiencies, ....

An iPad is arguably the best media consumption device ever made.  EHRs have a ton of data, and docs need a device with the right form factor and data visualization to consume information about their patients as they walk from room to room.



Would he have taken on the challenge to fix it?  Would he have made a difference in people's lives by improving care via better HIT products?  Did we lose a huge opportunity in his untimely death?

Doc why are you asking me all these questions? All that information is in the computer!

Disclaimer: This is a hypothetical case - any resemblance to anyone is purely coincidental.

Addendum 8/28/2011 Link to G+ discussion on this post 



Students learn about patient centered interviewing and focusing on patient problems and complaints.  That is the point of HPI (History of present illness).  When they come to work with a primary care provider, who has know his/her patients for a long time, some of these question can be irritating to the patient who expects the physician to remember everything about their health history.



The HPI helps when approaching a patient with a new problem. Students are often not familiar with the patient who has 5 serious chronic problems but no complaints.  They start by asking something like, "So what brings you in today?" and they get something like "Oh, this is just a follow up.  I am fine!" and then they don't know what to do next.



Part of the problem is that many medical students get only an acute exposure to chronic diseases.  They do an 8 week rotation in Internal Medicine where they almost never see the same patient again.





Recently I had a patient who came in to establish care.  She was the first patient of the day and she was 15 minutes late.  I had come in earlier than usual as I knew I had a third year student with me in clinic.  Because of these reasons, I got time to review her EHR data in some detail.  She had received all her care at our institution and this meant all her data was in one system.



The student was very bright and very comfortable with history taking but new to EHRs.  The previous day, she had faced the typical patient scenario, "Why are you asking me all these questions?  Its all there in the computer!"



After that last encounter, we had discussed how a lot of information can be gleaned from the EHR.  So we had decided to spend some time going over the strategy of using the EHR prior to seeing the patient.



We started off by looking at a Patient summary screen (a snapshot of her problem list, medications and health maintenance alerts). We saw that she had the following issues noted in the EHR by her previous physician:



1.  Hyperlipidemia

2.  Goiter

3.  Smoker

4.  Hypertension

Her medications included

1.  HCTZ 25

2.  Pravastatin 40





So in this patient we went over her chronic issues (problem list) and dug into each one to see what we could glean from the EHR.  This is how the conversation went:



1.  Lets look at the hyperlipidemia.  What would you want to know?

• Last lipid level


• Target LDL (how do we calculate this?) 


• What medication, dose, is she compliant, tolerating?


• Liver test results


• Diet and exercise

So we click on Chart review >>; Lab results>> Select the last 2 lipid panels >> view in table form >> find that her LDL was about 150 1 year back.

We discuss ATP III >> go to the ATP calculator online >> put in her risk factors >> calculate that her LDL should be less than 130 mg/dL

We assume that whoever ordered that last lipid panel must have done something when the LDL came back above the target.  Go to Medication tab >> medication history >> sort by therapeutic class >> look for lipid lower meds >> find that she used to be on pravastatin 20 and had been increased to 40 mg after the date of the lab.  Did that work?  Lab results >> see that lipids and ALT had been ordered for 3 months after the change in dosage but not done.

So we create one agenda item: Find out if she is taking the 40 mg dose, and check lipids on that dose.

I recall reading about the new JAMA study on the dietary portfolio (oatmeal, soy and nuts) being better than just following a low saturated fat diet at lowering cholesterol.  Find it in Google Reader easily and share with student.

Create second agenda item: Discuss diet with patient and d/w her re' this study

2.  Goiter:  What questions do we have?

• Has this been worked up? 


• What was found?


• What was done?


• What is her thyroid status?


• She is not on any meds so is she euthyroid?

So we click on the problem "Goiter" in the EHR and find that it was first noted in 2007.

Chart review >> Imaging>> USG thyroid >> has one large nodule and rest diffusely enlarged.

D/w student what she would do>> FNA >> Who does this? Endocrinology>> chart review >> Encounter tab >> sort by department >>Endocrinology >> saw them in 2008 >> had an FNA done>> Lab results tab>> Sort by test >> Surgical pathology >> Thyroid bx>> Benign. Also check last TSH >> low normal 2 years back.

Create agenda: Update problem list with this information so next physician does not have to do this again! Another agenda item: Ask also about symptoms and recheck TSH.

3.  Smoker: What would you want to know?

• Is she still smoking?


• If so is she interested in quitting?

Create agenda to ask these questions.

4.  Hypertension:  What would you want to know?

• What is the BP today?


• Is she taking her medication?  and side effect?


• How has her control been?


• Any evidence of end organ involvement?

In EHR to go graphs>> BP >> see that she is usually <140/80 over last 4 years

Chart review >> Cardiology>> Echo >> none, EKG >> normal (no evidence of LVH)

Chart review >> Lab results >> BMP>> Creatinine normal, K normal; UA >> no Hb or protein.

Create agenda: Ask about home BP measurements, does she have a machine, do cardiovascular exam for murmur, gallop, heave, bruit, pulses and look at fundus.

The student looks at me amazed!  She did not know the EHR could hold the answers to so many questions. I tell her how she can create her own agenda before going into the exam room.  Once she has elicited the patient's agenda and addressed it, she needs to cover the items on her own agenda.  Hopefully both the agendas are the same.  Hopefully there is time to cover both the agendas.  

We have spent 30 minutes discussing and reviewing all these issues.  We are lucky we got an early start and the patient was late!

So what is the point of this story?

1.  EHRs can hold an amazing amount of important information

2.  Getting this information out of the EHR takes a lot of time, clicks and knowledge of where to find this information.

3.  These benefits are visible when all the data is in one system.  If the consultants and labs and imaging were all done at different places, this would not be possible.  Even when external reports are scanned in, this data is not easily accessible.  As we develop electronic data interfaces this should not be a problem.

4.  Some patients expect that just because all the information is in the computer, it is also in the physician's brain!  Wish they could realize how much effort it takes to dig all this information out.

5.  As physicians use EHRs and spend time reviewing and summarizing the information, they should take time to encode it in a way that makes it easy for the next provider or the subsequent visit.

6.  Students learn how to get the history from the primary source but will also need to get comfortable getting the data from the EHR in a meaningful manner.  While looking up the information in the EHR prior to talking to a patient can create a huge bias and a kind of filter bubble, it is a great way to look up chronic problems.

7.  The time that it takes to review all the information occurs outside the exam room and it can become non-reimbursed care.  Doing this review is very important for patient care.  Will this become a non-issue once we move to ACO's?

Addendum 8/28/2011 Link to G+ discussion on this post.

Meaningful Use of Meaningless data - Lesson from the Teachers in Atlanta.

People are shocked by the story that teachers who are supposed to be setting good examples for school kids were involved in cheating.  The teachers were erasing incorrect answers on students standardized tests and entering the correct answers.

From CBS evening news:

 " It was to show phony progress at often troubled schools, what the report calls "the pressure to meet targets in the data-driven environment." Educator Diane Ravitch, author of "The Death and Life of the Great American School System: How Testing and Choice Are Undermining Education," blames it on a federal law that links funding with test performance.

"We have a terrible federal law called No Child Left Behind that says that all schools have to have 100 percent of their students proficient in reading in math by the year 2014 or their schools will be shut down," Ravitch said.

From CNN

"I think the overall conclusion was that testing and results and targets being reached became more important than actual learning for children," (Gov. Nathan) Deal said. 

So is anyone surprised that this would happen?  When a single number becomes more important that the process, in high stakes situations, people will do what it takes to improve that target number rather than improve the process that the number is supposed to measure.  



Why is this an important lesson for Medicine?

1.  We have for long struggled with the USMLE scores as being a single number that is used to measure the quality of a medical student.  This is what is used as one of the most important criterion for selection to residency training programs.  This is in spite of there being no good data that scoring high on the USMLE equates to potential to be a good doctor.  Recently there was a an article in the leading journal on medical education highlighting this problem.  The USMLE has 3 steps.  Students who score well on Step 1 will postpone taking step 2 till they have finished interviewing for residency programs - just in case they get a lower score on step 2 and jeopardize their chances!  Many medical schools give students dedicated time to prepare for the USMLE.  So students who have been getting a curriculum that medical educators believe is appropriate to make them good doctors for 2 years take a couple weeks off to read for a test!  USMLE is a test of medical knowledge and it also tests whether a student can apply this to the clinical environment.  But it cannot measure a lot of other important competencies like communication skills, professionalism, ability to be lifelong learners etc.



2.  The recent mandate for Meaningful Use (HITECH Act) of EHR data has the risk of falling into the same trap.  While well-intentioned, it has several measures of very important clinical processes.  If done right, these processes have the potential of improving healthcare.  The problem is that these measures are linked to incentive payments from the Center for Medicare and Medicaid Services which make them high stake for doctors working on razor thin margins.  Doctors who fail to use EHRs meaningfully with their Medicare patients are at risk of penalties. Let us take an example:

One of the 25 measures of meaningful use is to show that doctors are doing reconciliation of medications (checking what patients are taking and where there are discrepancies, updating the medical record or educating the patient appropriately).  One popular EHR system has a system for putting a check mark against each medication as you confirm it or to delete it if the patient is not taking it.  Doctors and nurses go over this exercise with the patients and it can be extremely time consuming.  One would assume that after you have gone through the entire list of medications, you should have complied with the meaningful use requirement.  Unfortunately, after doing all this, to record in the database that you reviewed the medications, you have to click a button that marks that you reviewed the medications.  As doctors get pressured to see more patients in less time, guess what is going to happen?  Yes, they may be tempted to click that button whether or not they went through the process of reconciling the medications.  This is an example of how poorly designed software will lead to physicians targeting a number (% of office visits where reconciliation occurred) rather than do what is a critical part of a visit - making sure the patient is taking the right medication.  

The teachers in Atlanta has taught us a valuable lesson.  Even people who are expected to set examples of high moral values, when forced to meet requirements that are measured by numbers without actually getting the support they need to do their job right, will take shortcuts to make the numbers look better.  In today's data-driven society, this is a valuable lesson.

Making EHRs More Meaningful for Physicians - Part II

Peer rating of EHR notes!



One of the biggest problems with the profusion of meaningless data in EHRs is separating the wheat from the chaff, finding the proverbial needle in a haystack.

Something that the Web 2.0 has taught us is that the users who create data can also help to make it more meaningful.  Thus we have tags in Flickr and "likes" in Facebook.  How can we apply that to EHRs?

Every physician who has seen a patient for follow up after a long hospital admission knows what a relief it is to see a meaningful note that succinctly summarizes the hospital course.  For every useful note providing meaningful information there are tens of notes with meaningless words and phrases that don't add to patient care in any substantial way.

What if we have a thumbs up and thumbs down option next to every note?  What if anyone reading the note could give it an anonymous rating?  What if we let physicians see statistics of how many people had opened their note and how many of those rated it up or down?

Then users could filter the notes in the EHR by their ratings.  Also we could recognize the excellent work done by our infectious disease docs who document the best notes among all clinicians.  Maybe we could link this with a bonus just like we do for the meaningful use of EHRs!  

Making EHRs More Meaningful for Physicians - Part I

Using Social Media/Networking and Web 2.0 Ideas for EHRs.



While EHRs have a lot of potential, their design could be much better. There is a feeling that the needs of the physicians have been ignored during the design process. It is high time, physicians spoke up loud and clear on their needs.



As more information is collected within the EHR, it becomes progressively more difficult to review it in an efficient manner. This is due to several factors but I am going to focus on just 2 right now:

• The office visit notes tend to be very long with the meaningful portions buried amongst all the requirements for medico-legal and billing and coding needs.


• The information is not appropriately tagged or categorized.  For example, when I am managing a patient's reflux disease, I like to look at all the related notes, medications, tests etc. in one place. This would prevent overlooking something and provide better care while saving the physician time.

Web 2.0 means that users create content and help create meaning from the content by appropriately tagging and curating it.  In EHRs while care givers create content, it is not at present easy to make sense from it.  We rely on various system solutions like ICDs and CPTs which are often like fitting square pegs in round holes.  They serve the purpose for everyone but the physicians taking care of the patient.  It is high time, physicians did something to make sense of the EHR data for themselves.  So here is a proposal.

1. With every note, the care giver will create a short Twitter-like post to summarize the thoughts and plans.


2. This summary will be tagged with the appropriate organ-system or category (one or more)


3. The patient's EHR will have an overview page with the (reverse) chronologically arranged Twitter-like summaries from every encounter.  These could be sorted/filtered/searched.


4. The tags from these summaries would be used to create a wiki where each tag would be a topic and all summaries created by various physicians tagged by that topic would be automatically collated under that header.

Here is a mock-up of what this could look like.  To explore how this works, pause the presentation and click on the various tabs, hyperlinks and tags to see the proposed functionality.

Social EHR

View more presentations or Upload your own.

Click here to see the slide set as a flipbook.

Or just take a quick look at the non-interactive images below:

A twitter feed of summaries from encounters.  Each summary is linked to the full note.

Office visit note with Summary at top.  Appropriate tags added.

A Wiki for the GI topic with all encounter summaries tagged with [gi].  Additionally has timeline for GI related decisions.

Medication tab showing timeline of medication changes with links to encounters notes when changes were made.

These are "back of the envelope" designs and clearly need to be thought through in detail.  The concept though should be quite obvious from these.  Any EHR company out there listening?  Someone want to build an open-source EHR based on these principles that will truly help the physician and the patients?  

The astute reader must have noticed the "Part-I" next to the title of this post.  Yes there is more to come.