However, as we know, medical economics are much more complex. Barriers for entry into the EMR market are high (because of complexity), barriers to change EMRs within a practice or hospital are high (expensive). Doctors and other end-users will rarely be making purchasing for the EMRs they use. Hospital networks and large organization with complex needs will be making these buying decisions. Usability may not have the market moving power it deserves, and has in more elastic markets (like the choice of mobile phones or email systems).

We currently accept inefficiencies, poor human factor design, and unproven assertions in technology that would be quickly rooted out in other medical technologies and in other industries.

We need strong oversight to make sure that useful technology components and innovations do not find their way into clinical settings without baseline safety and usability requirements. Voluntary rules will likely be inadequate to achieve compliance with usability standards.

David Brick, MD

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Successful integration of EHRs into the DNA of healthcare delivery will facilitate health information exchange on a global scale with the goal of improving both coordination of care and public health but only if those EHRs are shaped around standards and best practices for capturing and managing patient health information in a practical, patient-centric manner. As the ONC turns its attention toward the usability of EHR systems, it will be critical to define usability from two important perspectives:

• Usability of the EHR system – Does the system complement the diagnostic process and practical work flow of care providers? Or does the technology ask providers to compromise the care process to “fit” the system?

• Usability of the information – Does the EHR system facilitate the capture of care encounters in a way that generates truly meaningful information? Or will the critical detail of that care encounter be forced through an EHR filter that results in data that, while capable of aggregation and analysis, is of no practical benefit to or legal support for the provider?

At great risk of extinction in our pursuit of health information exchange is the patient health story. Every patient has one, and it’s more than just an aggregation of care “data.” It is the chronicle of every care encounter, treatment decision, clinical conversation, and health outcome in a patient’s life from birth to death. Preserving that story will be critical to capturing an information-rich care record for coordinated care and treatment decisions, facilitating truly practical adoption and integration of electronic health record (EHR) systems, and engaging patients in their own care story in a way that empowers them to make better health decisions and meet care compliance goals. And if the goal is a meaningful NHIN, then the story has to matter. The sum is greater than its parts.

We are in danger of losing this story in the EHR. Physicians and other care providers need the freedom to record as much detail as they feel necessary when documenting a care encounter with a patient. Many EHR systems are forcing physicians into point-and-click entry that is radically changing the way they document patient care, and many are complaining that restricted “data” fields in EHR systems are prohibiting them from documenting the way they need to. (See New York Times article The Doctor vs. the Computer – http://well.blogs.nytimes.com/2010/12/30/the-doctor-vs-the-computer/.) EHR systems should not ask providers to compromise either the care process or the way they choose to document it simply to “fit” the system. This is not, on any level, usability.

EHR systems must be required to interface with dictation/transcription systems. The dictation-transcription process remains the preferred method of physicians for documenting healthcare encounters because it is easy to use and is time-efficient, allowing physicians to focus on reconnecting with and treating their patients. By making the dictation-transcription process a required component of “meaningful use,” physicians will be more likely to embrace the push for greater EHR adoption and to find the experience of using an EHR to be a positive one for them, their healthcare teams, and patients.

Required data elements can be tagged and exported from information-rich narrative notes into EHR systems. Contrary to what EHR vendors are reporting, physicians do not have to give up narrative dictation in order to comply with EHR adoption goals. The healthcare documentation/medical transcription sector is already deploying technologies to codify narrative reports, using established clinical nomenclature systems like SNOMED, to tag data elements in those reports and export them to EHR systems to meet meaningful use, core measures, and other clinical reporting criteria.

In December of 2010 the President’s Council of Advisors on Science and Technology (PCAST) released and discussed its report entitled “Designing a Digital Future: Federally Funded Research and Development in Networking and Information Technology.” Per the press release of December 16, 2010:

“But achieving the full potential of health information technology will require the development and adoption of a robust information-sharing infrastructure to facilitate the exchange of data among institutions, the report concludes. Unlike conventional electronic health records, which are effectively digital versions of paper charts that are trapped in the offices where they are created, such a
system would allow health data to follow patients wherever they are, with appropriate privacy protection and patient control, while giving patients’ various doctors a more complete picture of those patients’ medical conditions and needs.”

If it is truly the goal of electronic health record integration and adoption to improve patient outcomes and quality of care as well as reduce the cost of care for the US healthcare delivery system, the considerations outlined here will be an important part of ensuring that health information, and not just health data, is the compelling objective. Narrative capture must be factored into the equation for generating a meaningful health record if the goal is to create one that truly provides that “more complete picture.”

You’ll find the position of the clinical documentation/medical transcription sector outlined in our official Comments on Meaningful Use Stage 2 (http://www.ahdionline.org/Portals/0/downloads/CommentsMeaningfulUseStage2CDIA_AHDI.pdf), submitted to HHS last month. We urge the ONC to make protecting the patient story a critical priority in these and future considerations of EHR standardization, integration, and usability.

Lea M. Sims, CMT, AHDI-F
Director of Professional Programs
Association for Healthcare Documentation Integrity &
Clinical Documentation Industry Association

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It is simply not possible to tell the entire patient story with point-and-click and check-boxes. Those technologies are really only suitable for a completely negative review of systems or physical examination. Here is an example of why. Suppose the patient complains of chest pain, so that is checked off as positive in the system review. But how long has the chest pain been going on? Is it of sudden onset, or has it come on gradually? Does anything exacerbate or relieve it, and if so, what? Is it intermittent, or constant? What was the patient doing when it first began?

In other words, the patient’s chest pain story simply cannot be told with a positive check box.

This reminds me of a meme that made the rounds at the height of the popularity of the movie “Titanic.” The meme? “The boat sank.” Well, yes, it did, but there’s a great deal more to the story!

I am similarly reminded of the time that one of my former doctor employers, when asked what was wrong with a patient, simply answered, “Cancer.” Another doctor, in answer to a similar question, said, “She’s sick.”

One final anecdote. Many years ago, one of our workman’s comp patients put in a claim for payment for a hearing aid. Naturally, the insurance carrier questioned this; but after they had reviewed the complete narrative (dictated by the physician and transcribed by the MT), they understood that the medication prescribed to treat the patient’s work-related injury had the rare but well-documented unfortunate side effect of hearing loss, and thus paid for the patient’s hearing aid.

Thank you for your consideration.

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I also urge you to take a step back and be sure the systems that are implemented do what we need them to do–improve efficiencies AND still protect the patient and provide for ways to assure quality patient care.

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Another thing I have learned is that what a doctor dictates and what I transcribe into a patient’s medical record provides so much information that is important to the care of a patient. When the doctor dictates, I am thankful that I have the knowledge to recognize and flag things that might be incorrect and have adverse effects on a patient’s care.

On the flip side, if I were the patient, I would be thankful that my health care team has this MT, this “X factor” to help make sure my documentation is the best it can be. Even though I know it is the doctor’s responsibility to treat me, prescribe my medications, etc., I know that it is possible that something could make it into my chart that might be harmful to me because it is an error that wasn’t caught before it went into my permanet record. I am grateful that my doctor/MT team, these are people who want to present my story accurately. As long as I am truthful in describing my symptoms, my history, my allergies, etc., then this team will make sure that my documentation is correct and that my care will be correct. I actually have less fear for my very life because the MT has a critical ear, a brain filled with knowledge, and the ability to at least question when something in my documentation could possibly be inaccurate.

AS THAT MT, I look forward every day to being that “X factor.” I am the one who is the buffer between what the dictator says should go into the documentation and what finally ends up in there, with signatures stating that everything there is accurate and must be believed. It is important to me that I have been required to update my education so that I might recognize discrepancies that could have an effect on a patient’s care and, in fact, not only their comfort but also their survival. I’m not against the use of new technologies. I want to know all about them. I want to know that nothing will be “lost” when it comes to the patient’s story, but I really believe that NOTHING will ever be as accurate and as complete as what we get when the patient/doctor/MT team do the job. Whatever else happens in this industry, “the bottom line” is NOT measured by dollars and cents but rather the cost in treatment errors and even loss of life when documentation is accurate and complete and the fewest adverse situations arise. MTs have helped save patient lives, and I’m convinced they will continue to do so for many years to come.

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With the move to an EHR and the requirements to meet meaningful use criteria, many healthcare providers are moving to things like click box systems. This leaves out the narrative part of the health care record that we have always seen through transcribed reports. Reports from physicians have said that sometimes even when there is room for a narrative, it is limited to so few characters they have to leave something out of the patient’s story. The narrative in a record tells the patient’s story. Without how, how can we, as patients (which we all are at one time or another) begin to trust that our care will be complete or meaningful.

In addition, the attempt to remove the humans who actually understand the health care documentation process has the potential to lead to even greater errors in the documentation. That cannot possibly serve a patient well. Medical transcriptionists correct and/or flag these kind of errors on a daily basis, working as a part of the health care team to assure that those things that are erroneous do not end up in the final record. In the end, this offers a greater protection to the patients we all serve in health care.

The medical transcriptionists that are a part of the community at the MT Tools Online site are quite supportive of moving to an electronic health record. What we do not wish to see is the loss of the patient’s story simply to implement technology that, in the end, provides only a part of the story necessary to truly treat the patient. In addition, we have grave concerns that removing the humans who touch those records now will result in even greater discrepancies and misinformation in the healthcare record.

When physicians find themselves in a situation where doing data entry becomes a major portion of their day, it’s not uncommon to see frustration, and now we have a new emerging “profession” of scribes, who document for the physician. In most training programs for these roles, the training is very short, way too short to truly understand the medical language and adequate document a patient encounter.

Systems should be planned out with all of the stakeholders involved. It does not seem this is happening as things are being done now. I would urge that we take a step back and be sure the systems we implement indeed do what we need it to do–improve efficiencies and still protect the patient and provide for ways to assure quality patient care.

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Specified Context – First a clear delineation must occur between inpatient EHRs and ambulatory EHRs. To date, ONC, CMS and NIST have lumped these two very different products into one unified concern for the definition of Meaningful Use. Providing medical care in a hospital, particularly an ED, is very different than providing medical care in a physician office. What may be considered acceptable, even desirable, in one setting, will often have no value, or become a hindrance in the other.
Additionally, various users are operating in multiple particular contexts, which differ by institution type, institution size, institution policies & procedures, and in any given institution users operate in multiple sub contexts based on department, role, specialty, terms of employment, and sometimes time of day.

Specified Goals – Obviously, in each of the above contexts, there will be multiple users attempting to achieve multiple goals, and sometimes conflicting goals. The glaring example is the blatant conflict between billing departments and clinicians goals. So far, administration and billing have had the upper hand in EHR functionality design, mainly because these are the stakeholders responsible for paying for the software, and thus one of the largest “usability” issues has been created.
Example: A physician would define a clinical documentation screen as being highly usable if he/she could quickly and succinctly make notes summarizing the visit. An administrator would define such screen as being useful if a) all the boxes required for maximizing billing codes are displayed (and sometimes required), and b) if all the clickable gizmos for obtaining Meaningful Use incentives are similarly positioned. How is ONC, or any certifying authority, planning on resolving such conflict?

Specified Users – As some have testified, until one attempts to collect usability data from actual users, there are very few assumption one can make. Physicians, as we all know are unique; practices have unique work-flows, hospitals have unique processes, and all various specialists have unique needs. It is not uncommon to receive directly conflicting requests for enhancements to software. Some prefer their Assessments and Plan sections at the top of the page, some prefer them on the bottom and others want nothing to do with histories in an encounter note. Some want to click, others want to type or copy-and-paste, and the rest want to dictate. The only consensus I ever found was that everybody wanted all of the pertinent information (as they define pertinent) on one page and no scrolling. Preferable on a little tablet.
EHR vendors respond to this diversity by providing hundreds of options to customize and configure the application per individual user preference. How is ONC proposing to test the millions of permutations possible in any given product?

More than likely, ONC or NIST, will be forced to devolve usability testing to “the basics”, in a similar fashion as Meaningful Use testing was devolved to the lowest common denominator, which by the way, has severely amplified the usability problem by creating hundreds of ONC approved products with less than optimal quality, usability included, and a false sense of security for potential buyers.
If ONC elects to go down a similar path with usability certification, it will probably end up with a process similar to what CCHIT is offering in that area today. Most every vendor has 5 star usability rating. If ONC decides to actually check if, for example, every mutually exclusive choice is represented by radio buttons instead of checkboxes, the task will become insurmountable, since serious EHRs have thousands of screens. The alternative would be code reviews, and here we are talking about millions of lines of code. By definition, ONC will have to sample several “basic” usability features and process indicators. If this sounds vaguely familiar, please think about clinical quality measures, and how we select those, how we measure those, what amount of work is involved and what the benefits are at this point.

As an aside, I would also like to address the frequent comments related to usability work in fields such as Aviation.
The best aviation comparison for Health IT is the introduction of digital displays in the cockpit. Just like EHRs, glass-cockpits are means to distill vast amounts of information and present them to the user in a way that maximizes efficiency and facilitates better decision support. And just like EHRs, digital instruments from different manufacturers vary drastically in appearance and behavior. Basically, glass-cockpits are to analog flight instruments what EHRs are to paper charts. Unlike the EHR industry, the aviation folks, and NASA in particular, have engaged in methodic and rigorous human-computer interaction research and applied the results to digital flight controls, although according to the Federal Aviation Administration (FAA), much more is needed:
• “Not all airplane and avionics designers have considered the pilot-machine interface by using good human factors practices. General aviation needs airplanes that are intuitive to operate, requiring as little training as possible”.
On March 10, 2010, the National Transportation Safety Board (NTSB) published the results of its safety studies regarding glass-cockpits in small aircraft and here are the findings.
• The statistical analysis found that for 2002–2008, light single-engine aircraft equipped with glass cockpit displays experienced lower total accident rates—but higher fatal accident rates—than the same type of aircraft equipped with conventional analog instrumentation.
• Accident pilots flying glass cockpit equipped aircraft were found to have higher levels of pilot certification and more total flight experience than those flying conventional aircraft.
• In addition, the FAA has no specific training requirements for pilots operating glass cockpit-equipped light aircraft. The lack of equipment-specific training requirements from the FAA results in a wide range of initial and recurrent training experiences among pilots of glass cockpit aircraft. With the exception of training provided by airframe manufacturers with the purchase of a new aircraft, pilots must currently seek out and obtain equipment-specific glass cockpit training on their own.
• The results of this study suggest that the introduction of glass cockpits has not resulted in a measurable improvement in safety when compared to similar aircraft with conventional instruments. The analyses conducted during the study identified safety issues in two areas:
• The need for pilots to have sufficient equipment-specific knowledge and proficiency to safely operate aircraft equipped with glass cockpit avionics.
• The need to capture maintenance and operational information in order to assess the reliability of glass cockpit avionics in light aircraft.
http://www.docstoc.com/docs/55369154/Part-23—Small-Airplane-Certification-Process-Study
http://www.ntsb.gov/publictn/2010/SS1001.pdf

Sounds familiar? If we are to learn from other industries, then let’s learn the correct lessons: adequate training is imperative to success and post-market surveillance is the best instrument for understanding and improving safety. Other than that, market competition should take care of propagating quality and usability. I am certain that ONC can help, and others (particularly the gentleman from Epic) have outlined multiple non-prescriptive suggestions, which I believe will prove more beneficial than another watered-down certification.

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