Posts filed under ‘Uncategorized’
Meaningful Use Rant 3: ICD-9 Coding of the Problem List
I am all for standards. The more we define and codify the practice of medicine, the better and more interoperable our EHRs become. But a standard, for the sake of a standard, takes us backwards.
I believe the writers of the Final Rule that defined Meaningful Use of an EHR took us backwards when they specified two different standards for coding the problem list (SNOMED and ICD-9). Most organizations appear to be using ICD-9 to code the problem list. I believe that this is because SNOMED is way too complicated and there is no decent implementation reference.
But ICD-9 coding of problem lists does not make sense. Firstly, this country is in the process of migrating away from ICD-9 codes. Why make that process more laborious by creating one more conversion? Let’s skate to where the puck will be.
More importantly, ICD-9 codes do not describe problems in the hospital. ICD-9 codes are medical billing codes. Sure, they are based on a disease classification system, but problems are not always analgous with a disease or condition. For example, an important problem to note during a hospital stay is that the patient is “at risk for fall” based on a fall assessment. What is the ICD-9 code for this?
ICD-9 codes collected as part of creating the problem list will not provide any additional data beyond the ICD-9 codes that are already abstracted as part of the billing process. So, this pseudo-standard does not provide any new insights. Furthermore, I don’t believe this codification will do anything to improve the interoperability between providers and systems. In the end this is work for work’s sake. Busy work keeps us from implementing the rest of meaningful use that has true benefit to the patient and those that pay for care.
At least this is the way I see it. Am I missing something?
Augmenting the IT Department’s Offerings
I think that part of being a productive employee in the 21st century is finding online services and mobile appps to meet your needs that are not met by the IT department’s standard offerings. Since Internet service and a modern browser are typically standard offerings, this opens up a whole world of offerings. Browsing simplespark.com gives you a sense for the IT services that are available.
Using web based services is not the same as asking the IT department to install software on corporate devices. That ultimately creates a support burden on the IT department. People don’t understand why we don’t want to buy and install their $100 application. It isn’t the $100. These are the things that IT managers hate about one-off software installs:
- we need to reinstall that ap every time we upgrade or fix the user’s PC.
- the help desk team members need to have knowledge of the applications when they call the user
- in a short period of time we will get a call telling us the software version is no longer supported and we need to purchase the upgrade, convert the data and train the user
But more importantly, locally installed software is increasingly unneccessary as Software as a Service (SaaS) makes everything accessible from the browser. Our corporate QuickBase account gives our user base a simple but powerful way to meet many of their needs for dabases and basic workflow. This is why our employees have created over 7,000 applications. This is 7,000 times that employees were able to meet their own needs instad of requesting software and services from IT.
One of my favorite web-based services is Toodledo. Toodledo.com is a web based to do list (there are iPhone and iPad apps) to. I like it betther than Outlook tasks. I like the usability and there are some cool features like automatic prioritization based upon due date and prioirty. Mostly I like that I can access it anywhere without launching a Citrix session. This is important becuse I use it to manage my work tasks and my personal life too. I use the paid version because it allows me to store attachments with my tasks. But the free version is impressive.
Meaningful Use Rant 2: Hospital Growth Charts
So this is the second in a series of rants regarding some of the more silly aspects of the Meaningful Use Stage 1 Final Rule. Let’s visit core obective 7 for hospitals (pg 257 Fed Reg):
(7)(i) Objective. Record and chart changes in the following vital signs:
(A) Height.
(B) Weight.
(C) Blood pressure.
(D) Calculate and display body mass index (BMI).
(E) Plot and display growth charts for children 2–20 years, including BMI.
The writers of the Meaningful Use rules were on a good roll there. A through D are totally reasonable. I believe every EHR should capture these things and hospital should be document these vital signs for most inpatient stays.
My best friend’s Dad ran a manufacturing plant. I remember him saying that the way to find the optimal setting on a piece of equipment is to turn the dial until it breaks, then go back one setting. I kind of feel that is what happened with this objective. They should have stopped at (D). Growth charts are great, every pediatric practice should maintain one for each child, and in this day and age they should be computerized. But why would a growth chart be a requirement for a hospital stay? Does that make any sense? I have spoken to a few pediatricians and none of them have stated that there is a medical need for a growth chart in the hospital stay.
This looks like a sloppy cut and paste from the Eligible Provider Objectives to the hospital objectives without thinking through the different environments.
The Live Huddle
Affinity Medical Group’s EHR pilot went live on GE Centricity EMR this week. It has been a well run project throughout and I had the honor of joining our bright, hard-working team for their end of day huddle. They did a few things that I really liked. This is not exhaustive list. I would love to hear from others on their ideas to run the Live Huddle.
Issues
The primary focus of the Live Huddle is the issues that have been surfaced during the day. The issues are typically categorized something like this:
- Critical infrastructure or application problem that is having a negative impact on business operations (bad)
- Unanticipated issues that need a near term resolution
- Workflow issues
- Suggestions for improvement
As always the documentation of the issues is key: detailed descriptions, good examples and no abbreviations. One day I will blog about what constitutes a good issues list (tip 1: you can’t use Excel to manage issues). A great issues list is one of a handful of key project controls required for project success.
During the AMG huddle today I saw the team was using paper forms so they could jot down issues on the fly. Later they entered them into the project issues tool. Ultimately the live issues need to get into the same tracking tool as the rest of the project issues.
Statistics
During AMG’s huddle they shared some key stats about the day. I really loved this because it made the use of the system more tangible, building on the sense of accomplishment. Here are some stats from today’s huddle:
- refill requests processed: 27
- labs ordered: 64
- phone notes: 125
- visit notes: 129
Mood
The other creative thing that this group did was create a form that gauged everyone’s mood. Everyone was encouraged to complete the VERY SHORT form, including IT, managers and especially users. I think this can serve as a good early warning sign if the project is heading south.
What are your tips for a goo Live Huddle?
EHR Certification is a Black Box
The EHR vendors have not been sharing HOW their products are being certified. Currently, it is a black box. This is VERY frustrating. Especially since hospitals and doctors are supposed to be using the EHRs as cerified. Often there are many ways for an EHR to accomplish a testing objective. The current certification just produces a check box and a pretty certificate. How do we deploy and use the product in a certified way is a mystery. My EHR vendors have not been forthcoming with this informtation (slippery is a term that comes to mind).
During a HIMSS meeting with an ONC official, it became apparent to me that ONC now realizes this is a problem. There was a discussion that the vendors should provide screen shots for each step to share this with their customers. ONC can compel them to do this, but I would like to see the vendors do this on their own.
For me, this is one more reason to take the self certification route.
Replacing David Blumenthal
It appears everyone was surprised by the announcement from ONC HIT Coordinator Dr. David Blumenthal that he will be departing his government post to return to academic life. By all accounts he is a great guy and I wish him all the best.
[edit: One of our Clinical Informaticians pointed out that this has been rumored for some time and Blumenthal himself said his stay would be limited. So, in the sentence above when I say "everyone was surprised" - I guess I meant I was surprised]
I would suggest that when Dr. Blumenthal is replaced, the administration should appoint someone that has a more intimate knowledge of the reality of health care IT operations and what it really takes to achieve healthcare IT objectives. Another candidate from academia would not be the right choice. I would suggest someone with hands-on, in the trenches, implementation experience in a variety of healthcare provider settings is what is needed now.
Many of the current rules for EHR incentives just don’t make sense or lack necessary definition. There is too much focus on alphabet soup, and not enough on common sense. Just to be clear I support the implementation of standards, but they have to be relevant standards and they have to further the goals. Let me give you some examples of EHR incentive rules that seem to be rules, for rules sake:
- Problem lists are great and needed. But the certification requirement that problem lists use ICD-9 or SNOMED coding is wrong-headed. There is a ton of time being spent mapping ICD-9 codes to problems for no true benefit. The mapping is highly subjective and the end result does not create something that is reliably shared between providers that are not sharing the same EHR implementation. This time could be better spent developing care plans and interventions that help patients get to goal reliably and less expensively.
- I love the patient portal concept and the notion of giving patients access to their medication list, allergy list, problem list, etc. But, the certification requirement that one must do this using the emerging CCD or CDR formats is using the wrong tool for the job. These standards, once mature, should be great for sharing records between providers. However, this is useless to a patient and another place where we are spending time on something that is not getting us closer to the goal.
- Why are the NIST specifications for quality reports written using SNOMED codes? Nobody has this information in their EHR coded in SNOMED. Now the burden is on each hospital and doctor to map these codes to ICD-9. A total waste of time.
I am hopeful that an ONC HIT Coordinator with more direct experience can:
- write sensible rules, that are not ambiguous;
- keep the scope of the objectives achievable in the set time frames; and
- make sure all of the work required is work that gets us closer to the goals of more safe, effective and efficient care.
Since I am posting this on Super Bowl Sunday, I have to say: Go Pack Go. This is a big day here in Wisconsin.
Thoughts About The Cloud
There is a lot of buzz about “the cloud,” as there should be. Still, it is amazing to me how the hype, especially IT company advertising, seems to miss the mark. Here is an example, the Microsoft commercial with the couple stuck in the airport.
They are able to use “the cloud” to remote into their home PC to watch a video. I think this commercial sucks for the following reasons:
- In my opinion, this is not using the cloud. I will explain my definition below.
- Watching video over a remote connection is like taking a shower with your clothes on. It sort of works, but the experience is awful.
- Few people use Microsoft technologies to record TV. It would have been more realistic (and more cloud-like) if they downloaded TV using iTunes, or Amazon.
- If you want me to empathize with this beautiful couple, don’t have them watch “Celebrity probation.” I have my share of guilty pleasures, but still…
Worst of all, this ad obfuscates what the cloud means. I suspect Microsoft’s only goal is to associate their name with the cloud. What the couple is actually doing may be irrelevant to Microsoft marketing types.
Nothing Microsoft does in this commercial helps us better understand “the cloud” and why is it noteworthy.
Everyone has their own definition of the cloud and typically they are written in a way that justifies their interests. To me The Cloud is a means to deliver an application as an IT service, where:
1. the service is hosted on servers and storage that are not on our private network
2. those servers and storage are connected to our private network via the Internet
3. the application is accessed by the user using a standard browser without any plug-ins, active-x controls or java requirements. Just HTML5.
I don’t believe in private clouds, or other variations. That strikes me as market-speak that organizations use to make their products and services seem like they are part of the hype. The cloud is not about watching bad TV with a massive latency and audio synch problems while we are sitting on airport carpet.
The cloud is about buying IT as a service to shift time and focus away from:
- deploying and managing data centers; and
- installing and troubleshooting desktop software.
Spending less time on these technical things should allow a business to focus on leveraging IT to drive even greater business value.
What about Care Planning?
In the world of hospital information technology, automated care planning is as under-appreciated and Computerized Physician Order Entry is over-hyped. Typically care planning software was used outside of the care process to produce documentation for Joint Commission (JCAHO) surveys. This is not the promise of good care planning software.
The care plan should be the plan produced by all disciplines, and led by the physician, that defines the goals of the patient stay and ensures that all of the key interventions take place at the optimal time in order to achieve those goals as quickly as possible (shortest length of stay) with the least amount of resources (lowest cost). The care plan is the hospital’s assembly line. I believe it is the most important element of nursing informatics.
Focusing on medication process automation and Computerized Physician Order Entry (CPOE), to the exclusion of good care planning automation, is like a car company that wants to build really good tires and engines, but does not have a way to build a car in a timely, defect-free manner.
I believe nurses, no – all care givers, need a single dashboard where they can see every intervention (including administering post-operative antibiotics, ambulating patients, assessing skin, patient education, etc,). That dashboard can function as the caregivers worklist presenting the tasks to be completed in the most efficient sequence by the most appropriate member of the care team
Additionally, all of the care plans could be monitored centrally to identify key interventions that have been missed (think population management for inpatients). This would allow interventions of key quality indicators before it is too late, as opposed to the status quo where the quality indicators are available 6 weeks after the patient is discharged and coded.
Why isn’t care planning an element of meaningful use? In my opinion, It holds more promise to manage cost and achieve outcomes than CPOE.
Getting Your EHR and Eating It Too
For year’s EHR vendors created EHR shells with functionality that lacked all of the creamy goodness of evidence based medicine. Instead they have left it up to the hospitals to do this.
This has not worked well. Who wants to buy the cream puff shells at the bakery then go home to make your filling? I just want a damn cream puff. Adding the evidence-based medicine to an EHR is an amazing amount of work that literally takes a decade before the average health care organization can scratch the surface.
I read this blog post today that describes Cerner’s plans to use British Medical Journal (BMJ) clinical content: http://bit.ly/9vJEfb. Dale Sanders, CIO, Cayman Island Health Authority has written an excellent post with exuberance.
This seems to be much more connected and thought out than the pseudo-partnerships we see today between EHR vendor’s and tools such as Zynx.
This is the kind of thing that can be disruptive to the EHR market. That is, it could knock Epic off the top of the mountain.
Home Phone Challenges in Patient Registration
I was speaking to some of the folks that head up admissions and registration at Affinity Health System this week. They shared with me that recently it has become very common for patients to have to look up their home phone numbers when registering. Usually they look it up on their cell phones.
I can think of a couple of times recently when I could not rattle off my home phone number like I had my entire life. I am glad to hear that this is the result of the shift in reliance to mobile phones, rather than my approach to age 50 (at least that is my claim).
In the future we will all be like Einstein.
