Is a Universal Patient Record a Solution?

Posted by Paul Roemer

Today is the anniversary of the solving of Fermat’s last theorem. As a long recovering mathematician, these types of thing interest me so I sought a copy of the proof and began reading. The mathematics for librarians description of the proof is something like this:

The Pythagorean theorem states that for a right triangle the sum of the squares of the sides equals the square of the hypotenuse.
Fermat stated that the theorem only holds for a coefficient of 2, squaring, and that no other coefficient will work
This went unproven until recently

One might have thought that the solution could be solved by brute force using a computer. How many numbers are there to be dealt with? If you approach the problem this way you’ve got to do it for infinitely many numbers. So, after you’ve done it for one, how much closer have you got? Well, there’s still infinitely many left. After you’ve done it for a thousand numbers, how many, how much closer have you got? Well, there’s still infinitely many left. After you’ve done it for a million, well, there’s still infinitely many left. In fact, you haven’t done very many, have you? In fact, using this approach, you’ll never finish. This got me thinking about our EHR system.

I think something has been lost in the confusion about a national EHR system. After all, that’s the target right, a national system? We only unleash the power of EHR if we are able to make it work out outside of the provider’s four walls. Is it possible that perhaps the logic of how we have been viewing developing a solution for the problem is wrong? I think it is. Since the outset, the problem has been defined as how do we develop a system that will enable us to get everyone’s health records (let’s call an individual record A) to some arbitrary set of healthcare providers, call them P. There are some 350 million A’s and for simplicity let’s agree that there are 100,000 P’s. So now, the system to which everyone is working is the system that will enable all of the A’s to get to any combination of P’s.

See? Now what happens if we place a few hundred Rhios and health information exchanges (HIEs) in between the A’s and the P’s? Let’s label them G’s for gatekeepers. So, in the current framework all the A’s (everybody’s health records) have to pass through all the G’s, make it up to the national network, then back through all the G’s and then sorted through all the P’s to the correct P.

How can we know this design will work for every possibility? The only way is to test every combination of A’s, G’s and P’s. It’s a difficult problem. It becomes more difficult when we acknowledge that there are hundreds of EHR vendors supplying software to all of those P’s. Many of those P’s will have modified the software, meaning that there are probably thousands of variations of EHR systems. Oh, and did I mention that all of this is being done without any single set of standards? That means my stuff will look different from your stuff, and the G’s will have to move different stuff, and from an “IT” perspective the EHRs at the end of the food chain will have to interpret different stuff and then update your stuff with their stuff. That’s a lot of stuff.

So, if that is where things are, what can be done about it? My take on a solution is that the problem with this model lies with the word in italics, ‘everyone’. Every possible patient with every possible need getting to every possible provider. How to solve this or at least simplify the magnitude of the problem? One possible solution is to build out the EHR system and the network such that one patient’s record can go to one provider and have that record updated. Would it not make more sense to build it for a single patient, create a universal patient record (UPR) that can handle all instances? Do it right once. Prove that it works and then replicate it instead of building millions of different ones and hoping they work?

Is it time to rethink your approach?

Posted by Paul Roemer

So I’m making dinner the other night and I’m reminded of a story I heard a while back on NPR. The narrator and his wife were telling stories about their 50 year marriage, some of the funny memories they shared which helped keep them together. One of the stories the husband related was about his wife’s meatloaf. Their recipe for meatloaf was one they had learned from his wife’s mother. Over the years they had been served meatloaf at the home of his in-laws on several occasions, and on most of those occasions his wife would help her mom prepare the meatloaf. She’d mix the ingredients in a large wooden bowl; 1 pound each of ground beef and ground pork, breadcrumbs, two eggs, some milk, salt, pepper, oregano, and a small can of tomato paste. She’d knead the mixture together, shape into loaves, and place the loaves into the one-and-a-half pound pan, discarding the leftover mixture. She would then pour a mixture of tomato paste and water, along with diced carrots and onions on top of the two loaf, and then garnish it with strips of bacon.

He went on to say that meatloaf night at home was one of his favorite dinners. His wife always prepared the dish exactly as she had learned from her mother. One day he asked her why she threw away the extra instead of cooking it all. She replied that she was simply following her mother’s recipe. The husband said, “The reason your mom throws away part of the meatloaf is because she doesn’t own a two-pound baking pan. We have a two pound pan. You’ve been throwing it away all of these years and I’ve never known why until now.”

Therein lays the dilemma. We get so used to doing things one way that we forget to question whether there may a better way to do the same thing. Several of you have inquired as to how to incorporate some of the EHR strategy ideas in your organization, how to get out of the trap of continuing to do something the same way it’s been done, simply because that’s the way things are done. It’s difficult to be the iconoclast, someone who attacks the cherished beliefs of the organization. It is especially difficult without a methodology and an approach. Without a decent methodology, and some experience to shake things up, we’re no better off than a kitchen table amateur (KTA). A KTA, no matter how well-intentioned, won’t be able to affect change. The end results would be no better than sacrificing three goats and a chicken.

So, we’ll talk about how to define the problem, how to find a champion, and how to put together a plan to enable you to move the focus to developing a proper strategy, one that will be flexible enough to adapt to the changing requirements. But keep the goats and the chicken handy just in case this doesn’t work.

Some good news to share

Posted by Paul Roemer

A lot of you have been generous with your time and knowledge in helping me learn a little something about healthcare.

I am pleased to share I have been invited to become a member of the Penn Medicine Cardiovascular Institute Leadership Council.

You now know which ERH you should have bought

Posted by Paul Roemer

This occurred to me while listening to a report on NPR that was comparing the Kindle to the iPad. The comparison made regarding a study conducted to assess the viability of using the devices in universities as e-Textbooks instead of paper textbooks. The Kindle was tested for a year; the iPad was tested next.

The traditional textbook prevailed over the Kindle; iPad may have reinvented the textbook. A winner and a loser for what many consider being the same device in different packages. Apple did the same thing for MP3 players and the cellular phone.

The conclusion about that Kindle was it was a bad imitation of its paper counterpart, saying it was simply a copy of what was on the paper but not as effective. To me, this sounds like the conclusion many physicians have made about their EHRs—a poor automation of a poorer set of processes. This is why user acceptance has been poor and why in many places productivity has fallen off the charts.

The study concluded some of the issues with the Kindle for both the students (think patients, and the professors (the physicians)—the analogous EHR function is noted within the parentheses has the following negatives. The Kindle:

is less interactive than a piece of paper
does not follow the layout of a textbook or the flow of the discussion (navigation)
cannot easily handle full color illustrations and photographs (imaging)
is more difficult to annotate (SOAP notes)
takes longer to load the material, input data, and to search for information (clicks and drop downs)
the users stopped reading Kindles as scholarly texts and began reading them as novels (how physicians read and chart)
the students learned less and required additional time to learn the same amount (productivity)
did not maintain pace with the discussion or activity (process)

The textbook winner, the iPad, creates multimedia functionality out of a book.

Just because you search for electronic book readers online, and up pop both the Kindle and the iPad, does not mean they are equal. You cannot expect a search engine to distinguish between them.

Here’s the punch line. Just because you Google EHRs and get a list of vendors does not make them equal. I know you know that.

I think most of EHRs are equal, equally dysfunctional. Sticking with the analogy of the Kindle and the iPad, most EHRs are Kindles. Most EHRs—in fact almost all of them; 99% of the 400—are to healthcare what Kindle is to textbooks; not much. For many, the chart is better.

If you already implemented EHR you learned your EHR, how well is it performing? I am willing to bet more than half have not met expectations, or expectations have been lowered to meet the performance. Let us look at the same scorecard we used above. If your EHR…

is less interactive than a piece of paper
does not follow the flow of the patient/doctor narrative
cannot easily handle full color illustrations and photographs
is more difficult to annotate than a paper chart (SOAP notes)
takes longer to load the material, input data, and to search for information (clicks and drop downs)
does not allow doctors to review notes and images the way they read charts
requires additional time to read and document the same amount of information than paper charting (productivity)
does not maintain pace with the patient discussion or activity (process)

…you have quite a mess on your hands. If this makes you a little weak in the knees, what does this type of performance imply about your chances of meeting Meaningful Use? Having a certified EHR will not make these problems disappear; you will simply have certified problems.

If you disagree with this assessment, please tell me why. If you agree with the assessment, what are you doing to try to fix it? I am willing to bet you a bag of licorice that it will not make things better.

Those who have read this far did not need to read this to know your EHR has not done what you needed it to do. The strange thing is very few know what to do about it.

Those who have yet to complete their EHR or have yet to begin the process will come to the same conclusion unless they find the hidden jewels that make up the one percent of EHRs that actually function better than a paper chart.

Your brand ain’t what it was

Posted by Paul Roemer

Many brands have been redefined by a hospital’s patients through their patients’ use of social media. Your brand is now what their patients—their social mediaphiles—say it is. How’s that for a wakeup call?

Hospitals spend millions of dollars each year marketing to build their internal and external image; to what end? At best, a hospital’s only barometer for how well they are getting their message across is a metric for name recognition. Do more people know your name than they did a year ago?

I bet they do. I would also bet most hospitals would have the same recognition factor if they did not spend a dollar on marketing. Many organizations have no return on their marketing investment. Installing a billboard on a highway a mile away from the hospital depicting a picture of smiling urologists is not bringing new patients or helping you retain current patients.

It may be time to figure out what the market and your employees are saying about your organization. Chances are good that many of their messages are far different from your hospital’s vision statement and mission. Chances are also good that their bandwidth and access to your customer base is significantly higher than yours.

EHR: know when to ask for help

Posted by Paul Roemer

I was thinking about the time I was teaching rappelling in the Rockies during the summer between my two years of graduate school. The camp was for high school students of varying backgrounds and their counselors. On more than one occasion, the person on the other end of my rope would freeze and I would have to talk them down safely.

Late in the day, a thunderstorm broke quickly over the mountain, causing the counselor on my rope to panic. No amount of talking was going to get her to move either up or down, so it was up to me to rescue her. I may have mentioned in a prior post that my total amount of rappelling experience was probably no more than a few more hours than hers. Nonetheless, I went off belay, and within seconds, I was shoulder to shoulder with her.

The sky blackened, and the wind howled, raining bits of rock on us. I remember that only after I locked her harness to mine did she begin to relax. She needed to know that she didn’t have to go this alone, and she took comfort knowing someone was willing to help her.

That episode reminds me of a story I heard about a man who fell in a hole—if you know how this turns out, don’t tell the others. He continues to struggle but can’t find a way out. A CFO walks by. When the man pleads for help the CFO writes a check and drops it in the hole. A while later the vendor walks by—I know this isn’t the real story, but it’s my blog and I’ll tell it any way I want. Where were we? The vendor. The man pleads for help and the vendor pulls out the contract, reads it, circles some obscure item in the fine print, tosses it in the hole, and walks on.

I walk by and see the man in the hole. “What are you doing there?” I asked.

“I fell in the hole and don’t know how to get out.”

I felt sorry for the man—I’m naturally empathetic—so I hopped into the hole. “Why did you do that? Now we’re both stuck.”

“I’ve been down here before” I said, “And I know the way out.”

I know that’s a little sappy and self-serving. But before you decide it’s more comfortable to stay in the hole and hope nobody notices, why not see if there’s someone who knows the way out?

Patient Relationship Management (PRM)

Posted by Paul Roemer

If you watch too much television your brain will fry. Sometimes I feel like mine is in a crepe pan that was left sitting on the stove too long. Two nights ago I’m watching Nova or some comparable show on PBS. The topic of the show was to outline all the events that took place that helped Einstein discover that the energy of an object is equal to its mass times the speed of light squared, better known as E=mc². It was presented to the audience at a level that might best be described as physics for librarians, which was exactly the level at which I needed to hear it. It’s physics at a level that is suitable for conversation at Starbucks or any blog such as this.

So here’s what I think I understood from the show. It tracked the developments of math and physics in 100 years prior to Einstein’s discovery. The dénouement appeared to occur when Einstein and his fiancée were riding in the bow of the small boat. Apparently, he was leaning over the side of the boat and noticed that the waves generated by the front of the boat moved at the same speed as the boat. He then noted that fact only held true for those persons in the boat, who were in fact, traveling at the same rate of speed. However for those persons watching from the shore, that same wave was not only moving slower than the boat it got further behind over time. Some other things occurred, yada, yada, yada, and there you have it. Clearly, the details are in the yada, yadas.

So here’s what happens when you watch too much television. As I’m running this morning somehow my mind takes pieces from that show and staples them together to yield the following. Let’s go back to the equation E=mc². For purposes of this discussion I’ll redefine the variables, so that:
E = the percentage of Patient Complaints/Inquiries.
m = Patient in-bound calls.
c = number of Patients
If this were true–this is an illustration, not an axiom–the percentage of complaints in the call centers of an healthcare provider is equal to the number of in-bound calls times the square of the number of patients. So as the number of calls increases the number of complaints/questions increases and as the number of patients increases the number of complaints increases exponentially. Of course this is made up, but there appears to be a grain of truth to it. As a number of calls increase the percentage of complaints is likely to increase, and as the number of patients increases there will probably be an even greater increase in the percentage of complaints incurred. I think we can agree that a reasonable goal for a healthcare provider is to decrease the percentage of complaints and perhaps to shift a hefty percentage of inquiries to some form of internet self-service vehicle.

I think sometimes the way providers like to assess the issue of Patient Relationship Management (PRM) is by looking at how much money providers throw at the problem. I think some people think that if one provider has 2 call centers, and another provider has 3 call centers, that the provider with 3 must be more interested in taking care of the their patients, and might even be better at PRM. I don’t support that belief. I think it can be demonstrated that the provider with the most call centers, and most Patient Service Representatives, and the most toys deployed probably has the most problems with their patients. I don’t think it’s a chicken and egg argument. If expenditures increase year after year, and resources are deployed continuously to solve the same types of problems, I think it’s a sign that the provider and its patients are growing more and more dysfunctional.

How does this tie to Einstein and his boat? Perhaps the Einsteins are those who work with the provider; those who are moving at the same speed, those in lockstep. From their vantage point, the waves and the boat, like the provider and its patients, are all moving forward at the same speed. Perhaps only the people standing along the shore are able to see what is actually occurring; the waves distance themselves from the boat in much the same way that the patients distance themselves from the provider.

PRM is such an easy way to see large improvements accrue to the provider, especially using social media.

Interoperability-this is the problem

Posted by Paul Roemer

How does one depict the complexity of the mess being presented as the national roll out plan of electronic health records (EHR) via the national health information network (N-HIN) using Health Information Exchanges (HIEs) designed by Regional Health Information Organizations (RHIOs), with the help of regional extension centers (RECs) without Standards (Standards) and with N too many vendors?

Class? Ideas? Class?

If this looks dumb, undo-able, unimplementable, uninteroperable–it’s because it is. your vision is fine.

Remember the idea behind all this is to get your health record from point A to point B, any point B. It’s that little word ‘any’ that turns the problem into a bit of a bugger.

Find yourself in the picture below, pic a dot, any dot (Point A). Now, find your doctor, any doctor (Point B). Now figure out how to get from A to B–it’s okay to use a pen on your monitor the help plot your course. That was difficult. Now do it for every patient and every doctor in the country.

Now, do you really think the DC RHIO-NHIN plan will work? If EHR were a Disney park, who’s playing the Mouse?