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Doctors & EHR: Can This Shotgun Marriage Be Saved?
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David F. Carr
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David F. Carr,
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2/11/2014 | 10:26:27 AM
No dumb questions
I wrote this in keeping with the theory that there are no dumb questions ... or at any rate, that you ought to get your dumb questions out of the way so you can move on to better ones.
David F. Carr
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David F. Carr,
User Rank: Author
2/11/2014 | 1:23:45 PM
Re: No dumb questions
These surveys keep coming

70% of Providers Dissatisfied With EHR Systems, Survey Finds - iHealthBeat http://www.ihealthbeat.org/articles/2014/2/11/70-of-providers-dissatisfied-with-ehr-systems-survey-finds
Mark Braunstein
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Mark Braunstein,
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2/11/2014 | 4:36:09 PM
All EHRs Aren't Created Equal
As some of you know, I teach about HIT and try to do it from a real world perspective so this is something I've though about quite a bit.  (I'm also a "reformed" vendor.)

Frankly, I don't see the added value in surveys like this one.  The result should be obvious pre-survey, given where we are.  There are literally hundreds of EHRs and, from what I've been able to see (I've hardly seen them all), most aren't very good with respect to some key usabiliity issues.

Reader beware: Some of what follows may be a bit redundant with what David and others have already said:

1) They don't integrate well with workflow.  Rather than becoming a seamless component of seeing patients and documenting their care and one that actually improves productivity they are essentially an off-to-the side-extra activity that physicians resent for taking up too much of their valuable time.  This is partially do to poor EHR design and partially due to poor implementation.  In my  years as an HIT vendor it was rare for new clients to take the time to look at their manual processes and think through specifically how they wanted automation to improve them.  I would argue that only once that's been done is a healthcare organization (or any organization for that matter) ready to look at systems of any kind.  It is unfortunately at least equally rare that systems are designed around process.  Far too many EHRs are designed to mimic the paper world (so that sales people can tout how easy they are to use and how little training is involved in learning to use them) rather than provide a tool to improve and optimize office processes.  I won't name names but there ARE exceptions to this out there and physicians should be looking for them.

2) The vendors haven't thought creatively about data collection.  In the end most physicians are complaining that its taking too much time and/or its too hard to enter data.  Of course, in many cases, this is a false comparison between poor, inadequate documentation and forced, more complete documentation but that doesn't change the fact that there are creative EHR solutions out there with respect to data entry (again, I won't name names) and that, from what I can see, physicians really do like those systems.  Caveat emptor.

3) This one doesn't get nearly enough attention.  Once EHRs have the data they typically don't do much creatively to present it back to the physician in ways that both save time and help provide better patient care.   Here I really haven't seen an exceptional EHR and it is something serious vendors should be spending more time on.  The inception of EHR app platforms may offer real help to the extent that their APIs allow indendent developers explore creative approaches to visualization of the underlying clinical data.

BTW, many vendors will point to the high degree of user configurability as the "solution" to #2 and maybe even #3.  Let's get real. Very few end users have the talent or the time to do system configuration well.   The answer is better thought out system design and LESS user configurability -- just ask Apple!

Finally, wouldn't it nice if physicians -- who now are and forever will be essentially required to use EHRs -- were actually trained in health informatics?  I guess its easier for me to be critical since Georgia Tech doesn't have a medical school but I think the time is long past that we keep producing physicians, nurses and other health professionals whose only experience in health IT is learning to use whatever system the teaching hospital they trained in happened to have.  BTW, my hidden agenda here is smarter, more informed and more critical potential customers.  That's the one sure way to get the vendors to improve!
UsabilityPeople
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UsabilityPeople,
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2/11/2014 | 10:33:35 PM
Re: All EHRs Aren't Created Equal
It is so true that there are a number of EHRs out there with significant usability problems.

We are on a quest to change that, and so should be everyone else.  The ONC Meaningful Use Stage 2 certification requires that EHR vendors conduct and report on a summative usability test of their EHR (using a number of pre-defined typical tasks). That's a start.


Based upon the experiences that we have had working with a number of EHR vendors, we can say that there is a HUGE difference in the amount of time and effort that vendors put into adopting the "User-centered Design" philosophy that is required for the 2014 Certification from an ONC- ATCB.  They need to think ISO 9241-11: Efficient, Effective and Satisfying.


Healthcare IT (much like Enterpise IT was years ago) needs to focus more on the users, their tasks and their workflow.  The days of "Enginering-centric" design are over.  The innmates are NOT running the asylum anymore.

We run a blog site to keep up on Healthcare Usability issues, and often present about usability at Healthcare and UX conferences -- Hopefully we can help you help your users!
David F. Carr
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David F. Carr,
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2/12/2014 | 10:36:22 AM
Re: All EHRs Aren't Created Equal
In sympathy with the software developer, we should also acknowledge that it's a tough challente to create a system that is easy yet sophisticated, addressing a complicated scientific discipline while serving other masters like regulators and insurance companies.
Mark Braunstein
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Mark Braunstein,
User Rank: Moderator
2/12/2014 | 11:47:02 AM
Re: All EHRs Aren't Created Equal
David,

I completely agree and was remiss in not making that point in my earlier comment.

Mark
ZibdyHealth
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ZibdyHealth,
User Rank: Apprentice
2/12/2014 | 2:43:52 PM
Re: All EHRs Aren't Created Equal
David Carr,

 

"In sympathy with the software developer, we should also acknowledge that it's a tough challente to create a system that is easy yet sophisticated, addressing a complicated scientific discipline while serving other masters like regulators and insurance companies."

 

No one has served more than one master successfully for long time. We need to separate it out. Let patient manage their EMR....but from my personal conversations with many physicians ..there is a minorty group of physicians who feel that they created these records so they own it and they would like to get paid second time to share (give) records with patients. Talk about double dipping.
ZibdyHealth01
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ZibdyHealth01,
User Rank: Apprentice
2/16/2014 | 6:53:46 PM
Re: All EHRs Aren't Created Equal
David,

Here is a relevant article by Kevin Pho...EMRs are just not made for patient care. These software packages are for billing first approach. http://www.usatoday.com/story/opinion/2014/01/19/kevin-pho-electronic-medical-records/4649043/
DavidV992
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DavidV992,
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2/11/2014 | 9:53:01 PM
Re: No dumb questions
Can you read "Tiranny of the note?"

The reason Dentists and some other EHR systems (veterinarians comes to mind) are satisfied with their systems is they don't have to document the "leaves" in detail in order to get reimbursed.  As a result the signal to noise ratio is huge compared to most physicians who have sold their souls and now have to grind out excruciatingly detailed notes in order to get fairly reimbursed.

I'm sure if the dentists and vets had to record the same type of notes we physicians have to document there would be no penetration of EHR-like products in their offices.

Either change the reimbursement mechanism or change the rules around documentation and reimbursement so we can stop documenting notes and concentrate on improving the accuracy and integrity of the important parts of the patient's issues.

We also need to change the rules as to who can document what.  Forcing a physician to do everything doesn't provide any of the participatory process that used to exist in paper.  EHR's have taken away a paper based clinic's freedom to leverage the wetware of the employees as with a digital system audit trails can show who's putting in what.

Having said all of this it's still not hard to make things work.  I've been successful in eliminating a lot of noise by incorporating photographs within a large portion of my medical records.  Trouble is photographs are not part of the CCD or similar protocols that are the base for HIE's.  So some downstream readers see a very sparse note.  Fortunately our coders tick off the credits for complete exams when photos are part of the examination.

The more attention we can divert from clinical notes to improving the accuracy of the problem list, all of the past procedures and any of the JHCAHO 5 elements the more valuable the EHR becomes.  The more time and attention is spent on the clinical note the less valuable the EHR becomes.

Finally getting the patient to help with the documentation is a clear winner. Not only do they wind up telling a better story but they get involved in improving the accuracy of the documentation.  We've remodeled our clinics around this so the patients and physcians can work in parallel in a way we could never do in a paper world.  Documented this a long time ago in a blog http://vorand1125.wordpress.com

David Voran, MD
ZibdyHealth
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ZibdyHealth,
User Rank: Apprentice
2/12/2014 | 2:38:00 PM
Re: No dumb questions
David Voran,

You hit the nail on the head. We need to involve patient in keeping their records. Care providers will get much better patient participation and hopefully this will improve outcomes. To do this we need to make these software packages very simple. Can our moms or grandma handle these records? Someone working in retail without any real knowledge of healthcare, can they manage it. It has been done for other industries and we are trying to do just that with our platform.

Another thing you mentioned, we need to separate out patient care from billing. We get it that billing is critical but so it patient care. One can't have two competing interests without compromising somewhere. Current commercial systems are build for billing. There is a spearate debate if providers need all the explanations to get paid for their work. You are correct with your assumptions why dentist like their EDRs.
Laurianne
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Laurianne,
User Rank: Author
2/12/2014 | 4:00:44 PM
Re: No dumb questions
I disagree that patients are dying to manage their own records. Anyone else agree with me?
ZibdyHealth
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ZibdyHealth,
User Rank: Apprentice
2/12/2014 | 4:47:02 PM
Re: No dumb questions
Hi Laurianne,

I did not say that patients are dying to manage their records. In most of the world with exception to 4-5 countries, patient manage their own records. It helps that records are on paper and everyone knows how to keep a folder full of papers. Healthcare apps make 40% of downloaded apps in Brazil.

If we keep making patient records so difficult to manage that one needs a Health-IT degree or MD then we failed from the start. I did mention here that we need records easy enough that my grandma should be able to manage. You remember how many smartphone and smartphone OS were there in the market prior to iPhone launch. We need to learn few things from Apple here.

I am the first one to accept that adoption of health records has been difficult and any company which solves this problem will own the market. Patients won't manage records unless they get some additional benefit from managing the records.

Alison Diana
IW Pick
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Alison Diana,
User Rank: Moderator
2/11/2014 | 12:21:00 PM
Belts and Suspenders
Ever since my doctor discovered what I write about, we seem to spend half my appointment time discussing technology. He's older -- probably in his 60s -- and loves his iPhone (one of his first questions after the iPhone 5 came out was whether he should upgrade). But when it comes to his office he's absolutely adament that his paper files are here to stay. The doctor is slowly -- too slowly for his staff -- adding an EMR, although he ruefully admits to missing the financial incentives by years. When I said he could then get rid of the paper files that fill the reception area and several unused examination rooms, his eyes flashed and he clasped my folder closer to his chest. "Never!" he roared, while his nurse shook her head. I cannot imagine he's alone in feeling that way. But having an EMR will make it easier for him to sell his practice when he decides to retire.
Joe Stanganelli
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Joe Stanganelli,
User Rank: Ninja
2/18/2014 | 12:37:20 AM
Re: Belts and Suspenders
@Alison: Yeah, but what will be the cost of the transition -- and, ultimately, his ROI -- on the sale?
DarrellP725
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DarrellP725,
User Rank: Moderator
2/11/2014 | 1:44:29 PM
Since dentists are not complaining about EDRs, they must be almost 100% satisfied. Right?
What aspect of EHR software most cries out for improvement? Electronic dental records - but the cries aren't being heard.

It seems obvious to me that far too many in the dental profession bought into EDRs far too soon, and now even the highest leaders in the profession refuse to acknowledge that EDRs are both more expensive and more dangerous than paper dental records.

Unlike physicians, very few in the dental community are complaining. It's quiet... Too quiet.

D. Kellus Pruitt DDS

 
DarrellP725
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DarrellP725,
User Rank: Moderator
2/11/2014 | 6:02:10 PM
Re: Since dentists are not complaining about EDRs, they must be almost 100% satisfied. Right?
Dear David F. Carr,

I was curious if there had been any responses to my comment about electronic dental records when I noticed that I failed to offer a balanced report. As I said, public mention of electronic dental records in the dental community is suspiciously rare. Nevertheless, I have located two independent articles which both assure dentists that they can expect substantial savings from EDRs over paper records. What's more, the long-awaited claims were published by two of the most respected and revered dental authorities in the nation: Dr. Gordon Christiansen's Clinicians Report and the American Dental Association. These are the experts dentists, as well as lawmakers, turn to for advice.

In an undated DentistryIQ article touting the benefits of new technology, Dr. Paul Child, CEO of Clinicians Report says EDRs offer dentists a "high return on investment." (See: "Digital dentistry: Is this the future of Dentistry?" by Paul L. Child Jr., DMD, CDT, CEO CR Foundation).

http://www.dentaleconomics.com/articles/print/volume-101/issue-10/features/digital-dentistry-is-this-the-future-of-dentistry.html  

But unlike the Medical Economics survey you mentioned, in which "almost two-thirds of respondents (65%) indicated that their EHR system was responsible financial losses," Dr. Child offers no evidence supporting his savings claim. The absence is particularly surprising since the Clinicians Report is a research foundation which investigates the cost and benefits of new dental technology... including digital.

Elsewhere, on December 6, the ADA News posted an article titled, "EHRs provide long-term savings, convenience" (no byline).

http://www.ada.org/news/9435.aspx   

Once again, there is no evidence offered supporting the savings claim. However, it is worth noting that the anonymous author points out that The Dental Record is "the only ADA Business Resources-endorsed EHR provider." Later in the same article, she adds, "ADA Business Resources has chosen PBHS Inc. as its endorsed website design and practice marketing firm" - with similar sincerity.

Nobody wants to think about dentists until they cannot put it off any longer.

D. Kellus Pruitt DDS
David F. Carr
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David F. Carr,
User Rank: Author
2/12/2014 | 2:54:36 PM
Re: Since dentists are not complaining about EDRs, they must be almost 100% satisfied. Right?
I didn't mean to ignore you, but I haven't done any research on the software for dentists and don't have much to add. It may be something for us to follow up on. I'm finding that there are many EHRs designed for specific healthcare specialties, all with their own quirks.
DarrellP725
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DarrellP725,
User Rank: Moderator
2/12/2014 | 7:34:09 PM
Re: Since dentists are not complaining about EDRs, they must be almost 100% satisfied. Right?
Dear David Carr:

You said "I haven't done any research on the software for dentists and don't have much to add. It may be something for us to follow up on."

Please do. As you will see sooner or later, transparency is direly needed in dental IT. However, I should warn that searching for evidence-based value of EHRs in the secretive niche of dentistry is a tough and unpopular task. The rare pieces I shared yesterday - independent press releases written by the CEO of Clinicians Report and an anonymous American Dental Association author - are as close as you will come to peer-reviewed studies. As I said, it's quiet... too quiet.

The fact that EHRs in dentistry are far more expensive than paper dental records is only one reason unresponsive stakeholders are hiding. In addition, they have known for years that EDRs are simply more dangerous than paper records as well. What's more, false claims of encryption never before seen in EHRs (as far as I know), empower the harm. Even though Dentrix - the nation's most popular dental software - advertises on DentistryIQ that it is encrypted, the US Department of Homeland Security says it is not:

DentistryIQ - "The move to make Dentrix G5 an open platform for third-party applications was made possible by its new SQL database with encryption that improves performance while adding advanced security to patient data." - from "Henry Schein Dentrix G5," no byline, DentistryiQ, undated.

http://www.dentistryiq.com/articles/2012/03/henry--schein-dentrix.html

DHS - "Vulnerability Note VU#948155 - Henry Schein Dentrix G5 uses hard-coded database credentials shared across multiple installations," April 26, 2013, and "Vulnerability Note VU#900031 Faircom c-treeACE database weak obfuscation algorithm vulnerability," June 10, 2013.

http://www.kb.cert.org/vuls/id/948155

http://www.kb.cert.org/vuls/id/900031

False security is worse than no security. Agreed? And the more dentists who read on DentistryIQ that Dentrix is encrypted, the more breaches of dental patients' unencrypted identities will go unreported. This is not going to end well for dentists, patients or Dentrix. I've done everything I can to get the ad deleted, maybe someone who is not a dentist might have better luck with DentistryIQ and Dentrix officials.

Yea, David. Please look into it. If I can be of any help, let me know.

D. Kellus Pruitt DDS
DarrellP725
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DarrellP725,
User Rank: Moderator
2/13/2014 | 8:08:30 PM
Re: Since dentists are not complaining about EDRs, they must be almost 100% satisfied. Right?
This just in: Dentrix acknowledges their error about encryption, but is not ready to give up on the misleading DentistryIQ ad.

An article titled, "Update: Does Dentrix need to send individual notification letters rescinding its 'encryption' claim?" was posted today by Dissent Doe on PHIprivacy.net.

http://www.phiprivacy.net/update-does-dentrix-need-to-send-individual-notification-letters-rescinding-its-encryption-claim/

While Rhett Burnham, Dentrix's Director of product management seems sincere in his plans to notify HIPAA-covered customers that G5 is not encrypted as advertised, that is little consolation for dental patients who don't yet realize that their dentists innocently failed to notify them of breaches of their unencrypted identities - months ago in some cases. Let's not forget that Justin Shafer warned Dentrix about this security weakness almost two years ago and was indignantly ignored by Dentrix officials.

As Dissent Doe suggests in her article, it's not over. Burnham tells her, "As you mention, we will not be able to remove or edit all old press releases or articles." Whom does that hurt, and whom does that help? Follow the money.

Until the DentistryIQ press release claiming that Dentrix G5 is encrypted is removed or corrected, dentists will always be misled into purchasing a faulty product, breaches of dental patients' identities will always go unreported, and Dentrix will always sell at least a few systems based on a lie. What's more, if DentistryIQ and Dentrix are unable to come to a monetary agreement that includes changing or deleting the undated press release, the encryption lie will always be current news.

For national security reasons alone, Rhett Burnham should weigh the cost of paying off DentistryIQ, versus the cost of a class action lawsuit brought by thousands of really pissed off dentists and dental patients blindsided by identity thefts - all involving Dentrix software their dentists were told was encrypted in a timeless ad.
David F. Carr
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David F. Carr,
User Rank: Author
2/12/2014 | 10:32:32 AM
Are scribes the answer?
1Simon
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1Simon,
User Rank: Apprentice
2/14/2014 | 10:38:39 AM
Are Younger Doctors Better Suited for EHR?
An ideal EHR system should deliver top-level usability and facilitate greater efficiency for anyone—no matter his or her age or technological background. I personally have seen both younger and older physicians embracing EHR systems that make them more efficient. This is done by finding the sweet spot between functionality and simplicity. Even the most tech savvy digital natives don't want to deal with a complicated EHR system that makes accomplishing simple tasks more tedious and unfortunately there are systems guilty of that. The solution is to listen to the real users and be prepared to make continuous improvements.

EHR systems can be made easy-to-use and ideally are flexible enough that one client interface can offer seamless access to all the different record types via one intuitive interface. The goal is one system where all users can easily access records generated in any department using any file type. This will reduce time lost and frustrations among physicians while improving overall efficiency and making strides toward meeting meaningful use requirements."

 

And regarding getting physician participation in an EHR system:

Giving doctors a voice in selecting systems is also of vital importance.  Rather than being critical,  you can create champions for the new system, greatly aiding its adoption success.

 — Simon Wieczner, Snowbound Software
lpop679
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lpop679,
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2/16/2014 | 11:24:06 PM
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