The Rand Study and the impact of EHRs on Healthcare Costs

Last week, Rand published a study in Health Affairs (ANALYSIS & COMMENTARY: What It Will Take To Achieve The As-Yet-Unfulfilled Promises Of Health Information Technology),  revising its original 2005 healthcare IT cost savings research.

The New York Times wrote about it.

Several publications asked me to comment and here's what I said:

"We're still at an early stage of EHR implementation, healthcare information exchange connectivity, and decision support.

Meaningful Use Stage 2 in 2014 will take us to a new level that will begin to reduce redundancy, over treatment, and waste.

Stage 3 in 2016 will take us even further by enhancing outcomes.

We're on a journey and I have every expectation we'll change the practice of medicine to improve its value (quality/cost).    We're moving as fast as we can to accomplish this and I believe by 2016 we'll realize the improvements we're seeking from the meaningful use foundation we've built.    Expecting significant cost reductions by 2013 is not realistic at this point in the process."

Many people are working tirelessly to implement EHRs, HIEs, and PHRs.   Think of our work like creating the interstate highway system.   Soon we'll be able to drive at high speed from coast to coast.  In the meantime we need to realize that every day gets us closer to our goal.   We need to keep our eyes on the prize and keep building.

Building Unity Farm - Managing Wood

Farm properties commonly include meadows, pastures, woodland, wetland, and rocky rolling hills.   Unity Farm has all of these ecosystems.  We've recently re-surveyed all our wetlands to ensure we comply with appropriate environmental regulations that guide where we can plant, farm, and raise animals.  

Our plans over the next year include adding year round growing capacity via a high tunnel/hoop house, adding an acre of high bush blue berries, creating a mushroom growing shed, expanding our orchard, and refining our kitchen garden.

All of these activities are ideal for the spring and summer.   Wintertime is perfect for managing wood.

Unity Farm has 12 acres of white oak, red oak, hard maple, cedar, and poplar.     Oak and maple make excellent firewood.  Cedar contains aromatic oils and burns hot/fast making it a great firestarter.   Poplar does not generate much heat, so it's not an ideal firewood.  However, it is excellent for cultivating oyster mushrooms (hence the mushroom growing shed)

How do you manage 12 acres of forest with multiple different woods harvested at different times?

I approached the problem just as I would approach data storage architecture.   First define requirements and input/output streams, then design the appropriate information lifecycle management infrastructure.  Here's how I thought about it

Cache - the wood you'll use today and later this week
Nearline - the wood you'll use this month and this season
Archive -  the wood you'll use next year and next season
Swap space - the wood you cut or moved today that needs to be stored before putting it in cache, near line, or archive storage.

With this model in mind, I organized the woodcutting area of the farm in .5 cord of cache, 1.5 cords of near line, 1.5 cords of archive, and .5 cords of swap space.    This ensures I have 2 cords for current use and 2 cords for long term use.

Each Saturday I take my farm wagon (holds 700 pounds of wood) onto the trails I've built into our upper forest (5 acres) and lower forest (7 acres).    Using a Stihl M290 chainsaw I cut a few hundred pounds of oak, maple and cedar from fallen trees, de-limbing using my Scandinavian Forest Axe and bucking them into 18" segments.   I secure the logs onto the wagon using ratchet tie downs.

I pull the wagon over our trails back to our wood processing area shown above.   I use a 24"x12" hard maple round as the base for log splitting with my splitting maul   For very thick logs, I use two splitting wedges and the hammer portion of the splitting maul.   I keep everything sharp with a file  and axe stone 

Once the logs are split, I stack them appropriately into the 4 areas listed above.    I have dedicated near line and archive storage for each type of wood - oak, maple, and cedar.

 My rule of thumb is that wood should age at least a year between cutting and burning.   The only exception is old fallen cedar which seems to burn well immediately, although I use it sparingly because the burning oils pop and spark in the fireplace.

 To avoid repetitive motion injury I limit my wood cutting to 1/2 cord per day and my splitting to 1/4 cord per day.    At present all my storage areas are full and we have a roaring fire at the farm every winter night.

Value Cases for Clinical Documentation Improvement

As BIDMC prepares for ICD10, we're examining the entire clinical documentation process and asking how best to leverage the work we must do to support ICD10 with the innovations we believe will transform our workflow.

As mentioned in a previous post, we're working with several innovators to re-examine assumptions we made for decades about clinical documentation.

Here's an analysis of the types of projects we could do, the challenges, and the proposals, stratified into documentation improvement, structured documentation, code capture, validation, billing, and audit/review categories.  

Imagine the following workflow:

An orthopedist sees a patient for a hip fracture and writes a comprehensive note using a fracture specific template to capture a combination of structured and unstructured data.  Upon saving the note, the clinician is reminded to add important details such as co-morbidities, anesthesia risk factors, and patient preferences for treatment to the note, assuming a guideline and computer assisted coding could be used to trigger such reminders.  As the note is signed, the clinician is presented with a short list of SNOMED-CT codes which capture the essence of the clinical information in the note.   The orthopedist checks the codes that apply.    An expert human coder reviews the chart and validates the codes, then a bill can be submitted backed by complete/codified documentation that supports future audit processes.

Our next step is continue to work with vendors to develop scope and budgets for these projects, then determine what we can implement/afford in the short/medium/long term.  

I'll let you know which of these many projects we decide to do on the path to ICD-10 go live.

Dinner at the Japanese Consulate

Last night I had dinner at the home of the Consul General of Japan, Akira Muto, to discuss Massachusetts/Japan economic development in the areas of healthcare IT, robotics and big data.

A dozen Massachusetts technology, government, and academic leaders spoke for 3 hours over elegant Japanese cuisine to brainstorm about win/win collaborations.

In 2011, I worked with Washington and Tokyo collaborators to craft a healthcare IT plan for Japan based on lessons learned from the earthquake and tsunami.

The United States experience with Meaningful Use coupled with Japan's knowledge of mobile technology and high tech innovation would be a powerful partnership.  

My specific recommendations for a national Japanese healthcare IT program included:

1. Widespread adoption of electronic health records (EHR) in hospitals and provider offices.

2. A national healthcare identifier that would enable linking of records among multiple facilities and the creation of a national emergency care database.

3. A privacy framework that would provide the policy guidance supporting the sharing of
electronic health records among all 47 prefectures as needed for care coordination, quality measurement, and clinical research.  Privacy concerns are paramount in Japan. Through the use of strong policies such as mandatory breach notification, civil penalties for privacy violations, a unified approach to consent, model data use agreements, and security standards, patient privacy preferences could be protected.

4. A security framework that would permit and encourage the use of the public Internet for transmission and sharing of electronic records, as long as appropriate standards, business practices, and controls are put in place. Japan has state-of-the-art wireless and wired networks, arguably the best in the world. However, few hospitals and clinicians now use this infrastructure to exchange healthcare information, coordinate care, or engage patients/families. The public Internet is appropriate for healthcare information as long as the proper, rigorous policies and technologies are in place before data is exchanged.

5. Data standards that would break down barriers to data exchange. These could include
international standards, such as clinical document architecture (CDA), continuity of care
document (CCD), and continuity of case record (CCR), as well as Japanese standards that have been successfully implemented, such as medical markup language (MML), which is utilized by Dr. Hiroyuki Yoshihara’s Dolphin Project at Kyoto University.

6. Decentralized implementation programs based at the prefecture level. These programs, organized on a regional basis, would assist hospitals, physicians and other providers to plan, install, and use electronic health records successfully. Iwate and Miyagi prefectures could be ideal places to initiate these decentralized programs given the need to rebuild healthcare infrastructure in these prefectures.

Our robotics discussion focused on the use of military robots in disaster recovery efforts such as Fukushima-Daiichi and the use of home healthcare robots to provide support for elders who live alone.

Our big data discussion emphasized the need to turn data into knowledge and wisdom, especially in the area of healthcare.

The conversation was stimulating, the energy was high, and the food/sake (Junmai Daigingo, Hana-no-Mai) was amazing.

Thanks so much to the Japanese consulate for organizing this amazing event.

Electronic Health Record Safety

On December 21, 2012, ONC issued its Health IT Patient Safety Action & Surveillance Plan for public comment

I was interviewed by the Boston Globe about the plan.

Although EHRs address a variety of safety concerns such as unreadable orders/prescriptions, drug/drug interaction checking, and fostering care coordination, they can create new problems that did not exist with paper.   These problems are rare (less than 1% of quality issues reported), but they are important.

For example, a clinician writing a paper prescription for Atenolol, a beta blocker used for cardiovascular diseases, would be  unlikely to accidentally write for Ativan, a benzodiazepine used for anxiety.

However, if an EHR presents medications in a pulldown or an AJAX style lookup list, you can imagine a physician selecting the wrong medication by simple slip of a mouse.

Atelvia
Atenolol
Ativan
Atorvastatin
Atovaquone
…

There have been several articles in the literature suggesting that badly designed software (or any software implemented poorly) can cause harm.

At BIDMC, we've used agile development techniques and rapid cycle improvement processes to  enhance usability of systems, especially in response to sentinel events or clinician concerns.    Our systems are developed by clinicians for clinicians.

It is challenging to define usability of applications and software quality, so writing regulation (such as FDA Device registration/approval) is hard.

Since it will take time to learn how to monitor the safety of EHRs and write enforceable regulation, what can we do in the short term?

The ONC report suggests
 *Learn - Make it easier for clinicians to report patient safety events and risks using EHR technology.  Engage health IT developers to embrace their shared responsibility for patient safety and promote reporting of patient safety events and risks.   Provide support to Patient Safety Organizations(PSOs) to identify,aggregate,and analyze health IT safety event and hazard reports.  Incorporate health IT safety in post-market surveillance of certified EHR technology through ONC-Authorized Certification Bodies (ONC-ACBs).  Align CMS health and safety standards with the safety of health IT,and train surveyors.  Collect data on health IT safety events through the Quality & Safety Review System(QSRS).  Monitor health IT adverse event reports to the Manufacturer and User Facility Device Experience (MAUDE) database.

 *Improve - Use Meaningful Use of EHR technology to improve patient safety.  Incorporate safety into certification criteria for health IT products.  Support research and development of testing, user tools, and best practices related to health IT safety and its safe use.  Incorporate health IT safety into medical education and training for all healthcare providers.  Investigate and take corrective action, when necessary, to address serious adverse events or unsafe conditions involving EHR technology.

 *Lead - Develop health IT safety priority areas, measures, and targets.  Publish a report on a strategy and recommendations for an appropriate,risk-based regulatory framework for health IT.   Establish an ONC Safety Program to coordinate the implementation of the Health IT Safety Plan.  Encourage state governments to incorporate health IT into their patient safety oversight programs.  Encourage private sector leadership and shared responsibility for health IT patient safety.

Some have questioned the wisdom of moving forward with EHRs before we are confident that they are 100% safe and secure.   I believe we need to continue our current implementation efforts.   I realize this is a controversial statement for me to make, but let me use an analogy.

When cars were first invented, seat belts, air bags, and anti-lock brakes did not exist.    Manufacturers tried to create very functional cars, learned from experience how to make them better, then innovated to create new safety technologies. many of which are now required by regulation.

Writing regulation to require seat belts depended on experience with early cars.

My grandmother was killed by a medication error caused by lack of an EHR.  My mother was incapacitated by medication issues resulting from lack of health information exchange between professionals and hospitals.   My wife experienced disconnected cancer care because of the lack of incentives to share information.     Meaningful Use Stage 2 requires functionality in EHRs which could have prevented all three events.

I am hopeful that ONC's thoughtful plan, which leverages the experience of EHRs in use, will appropriately accelerate the benefits of today's Certified EHR Technology while minimizing risks of future EHR products still in development.

Building Unity Farm - Managing Snow

We had a foot of snow last week and got our first experience with managing significant snow and ice on the farm.

Our previous home had a 30 foot driveway, which I shoveled by hand during and after each snow fall.

The farm has a quarter mile entry and 15 acres that need paths to support feeding/watering/animal management.

We maintain 4 cords of oak/maple/cedar stacked neatly in wood racks we designed (next week's Thursday post will be about managing wood) and we need paths between our wood processing area and the forest.

Finally there are about a mile of walking paths that we use for exercising the Great Pyrenees and for managing the property.

What did we do during our first major snowfall?

We hired a farm hand with a plow from the farm next door to clear our lane and driveway.  We mapped out the best location for snow piles so that predators would not use them to jump our fences into the llama/alpaca paddocks.

We hand shoveled paths through/around all the paddocks, wood processing area, chicken coop, forest border, and trailheads.

We cleared the areas around the hay feeders and created a broad area for the chickens/guinea fowl to gather.   We placed several logs upright in the snow for the birds to perch on during the day, keeping their feet out of the snow and ice.

We found that the alpaca/llama created their own paths from the barn to the feeders and their favorite places to congregate.

The dogs loved the snow - they rolled in it, jumped in it, ate it, and had no problem navigating even the deepest snow drifts.

It's clear that the guinea fowl do not like snow.   Last night, they veered off the paths we cut for them and decided it was too uncomfortable to come back, so they roosted overnight in a nearby tree on the coldest night of the season thus far (0 degrees F).  Luckily they are cold hardy and this morning we convinced them that the warmth and food of their coop was more appealing than an ice covered tree.

Finally, I built two sand stations on each end of the driveway, so we can easily spread sand on the entire approach from the highway to the barn.

So, we successfully completed the cleanup of our first major snowstorm.   We learned about each animal's reaction to snow and the steps to take after each storm to keep everything running smoothly.   We're ready for whatever nature brings us over the next few months.

Sharing Orders with Patients

In previous posts, I've talked about the perfect storm for innovation - alignment of an idea, policy, technology, people, and incentives.    Roni Zeiger, a world class informatician who provided physician leadership for the Google Health project in the past,  recently suggested an idea which I think has the potential for significant innovation in the world of patient and family engagement - Patient Friendly Orders.

Here's an analogy.

Last night I went to a neighborhood grocery store, Roche Brothers, to purchase a few vegetables.    They were having a sale on romaine lettuce and a special bar code on each lettuce reminded the checker to give a dollar off per head.

Next to the cash register, a "consumer friendly display" showed each item scanned in plain english, not some odd abbreviation like Rmne Lttc, and its price.   At the end of checkout, I noticed she forgot to scan the dollar off discounts, so I pointed to the display, identifying the problem.   She immediately corrected it.

Imagine if every patient had access to a web page of their current hospital orders in patient friendly terminology i.e.

You are receiving an antibiotic called Ceftriaxone to treat your lung infection.  It is being given once per day in your IV.

You are receiving Tylenol for your fever.   It will given every 4-6 hours as needed for fever.   You may requested it for pain but note that no more than 8 tablets will be given per day because more could adversely affect your liver.

You may request Benadryl as a sleep aid in the evening

I've posted the story of my mother's recent hospitalization for a broken hip and the challenge I experienced trying to obtain a list of the medications she was given (a total of 22, instead of the 2 she was actually supposed to take).     Such a problem would not have occurred with Patient Friendly Orders.   I could have scanned her orders from the airport before the flight to visit her and could have called the hospitalist with corrections.   My mother would have immediately recognized the inappropriate nature of the treatment she was receiving since the vast majority of medications were discontinued years ago.

There are informatics, educational, and policy challenges to implementing Patient Friendly Orders, but I do not see it as much more complex than the Open Notes project we recently completed.

Maybe the National Library of Medicine, with it's wonderful vocabulary/code set resources and patient friendly educational materials could lend a hand.

Definitely worth a pilot and maybe even a new product development opportunity for a start up!

Thanks, Roni, for a great suggestion.