EHRs: The Bridge to Nowhere–other than despair. An investigative Must Read on ‘an unholy mess’.

If you hate your EHR, think it’s swallowing your information, adding hours to your day, and if you don’t watch it, you’ll make an error, you’re not a Luddite. You’re right. An exhaustive investigation by Fortune and Kaiser Health News (KHN) concludes that it’s ‘an unholy mess’. In fact, even if you are not a physician or clinical staff, it will make you wonder what was going on the collective brains of the digerati, Newt Gingrich, Barack Obama–and the US government–in thinking that EHRs would actually “cut red tape, prevent medical mistakes, and help save billions of dollars each year,” committing $36 billion to pursuing the ‘shovel-ready’ HITECH stimulus in the depths of the 2008-9 recession. Perhaps the shovel should have been used on a body part. Now if only those billions went towards an interoperable, useful, and national system rather than a money giveaway–which even Farzad Mostashari, then ONC deputy director and later director, now admits was “utterly infeasible to get to in a short time frame.” (Mr. Mostashari is now head of Aledade, counseling those mostly independent practices which lined up–hungry or terrified–for meaningful use EHR subsidies on how they can continue to survive.) Even the vendors were a bit queasy, but nothing was stopping HITECH. (Your Editor was an observer of the struggle.)

Now that we have been living with them for over a decade, EHRs have been found culpable of:

  • Soaring error rates, especially in medication and lab results
  • Increasing patient safety risks in lack of pass-through of critical information
  • Corporate secrecy, enforced by system non-disclosures, around failures
  • Lack of real interoperability–even with regional HIEs, which only exchange parts of records
  • Incomplete information
  • A very real cognitive burden on doctors–an Annals of Family Medicine study calculated that an average of 5.9 hours of a primary care doctor’s 11.4 hour working day was spent on the EHR
  • Alert fatigue
  • Note bloat
  • Plain old difficulty or unsuitability (ask any psychiatrist or neurologist)
  • A main cause of doctor burnout, depression, and fatigue–right up to high suicide rates, estimated at one US physician per day
  • Lack of patient contact (why the scribes are making a good living)
  • All those dropdowns and windows? Great until you click on the wrong one and find yourself making a mistake or in the wrong record.

Not even the head of the Centers for Medicare and Medicaid Services is immune. Seema Verma’s husband, a physician, collapsed in the Indianapolis airport. She couldn’t collect his records without great difficulty and piecing together. When he was discharged, he received a few papers and a CD-ROM containing some medical images, but without key medical records.

A long read for lunch or the weekend. Death by a Thousand Clicks: Where Electronic Health Records Went Wrong. Also the accompanying essay by Clifton Leaf

A diagnosis of why digital health startups die–an old (and new) story

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2015/11/upside-down-duck.jpg” thumb_width=”150″ /]For years now, your Editors have championed integration of data and system interoperability–search on these terms and you’ll find a wealth of articles and views. This Editor also included how data is integrated in patient records as the Fifth Big Question (FBQ) in 2012 [TTA 8 Aug 13]. Many digital health companies, not just startups, have failed at the data integration (and security) tasks, whether with EHRs, hubs, billing and practice management systems or with other devices. (Let us not forget that the initial impetus for Continua back in 2007, the US state/regional HIXs and for HL7 now, was to have common data and interchange standards.)

So there’s no real element of surprise here by John Sung Kim’s pleading in TechCrunch re ‘integrating into legacy systems’ and the troubles his own startup DoctorBase encountered in what he tactfully puts ‘political and technical hurdles’ encountered. But then the velvet gloves come off about EHRs and their less-than-scrupulous idea of ‘partnerships’. (more…)

The leaky roof of healthcare data (in)security–DARPA to the rescue?

This week’s priceless quote:

“A lot of the response was, ‘We live in a cornfield in the middle of Minnesota,’” he said. “’Who wants to hurt us? Who can even find us here?’”–Jim Nelms, Mayo Clinic’s first chief information security officer, 

We know where you are and what you do! The precarious state of healthcare data security at facilities and with insurers, plus increased external threats from hacking has been getting noticed by Congress–when you see it in POLITICO, you know finally it’s made it into the Rotunda. It was over the horizon late last summer with the FBI alert and legislators in high dudgeon over the Community Health Systems China hack [TTA 22 Aug 14]. It’s a roof that leaks, that costs a lot to fix, doesn’t have immediate benefit (cost avoidance never does) but when it does leak it’s disastrous.

This article rounds up much of what these pages have pointed out for several years, including the Ponemon Institute/IBM study from earlier this week, the Chinese/Russian connections behind Big Hacks not only for selling data, but also IP [TTA 26 Aug 14] and how decidedly easy it is to hack devices and equipment [TTA 10 May 14]. Acknowledgement that healthcare data security is about 20 years behind finance and defense deserves a ‘hooray!’, but when you realize that on average only 3 percent of HIT spend is on security when it should be a minimum of 10 percent (HIMSS) or higher…yet the choice may be better security or uncompensated patient care particularly in rural areas, what will it be for many healthcare organizations?

The article also doesn’t go far enough in the devil’s dilemma–that the Federal Government with Medicare, HITECH, meaningful use, rural telehealth and programs like Medicare Shared Savings demand more and more data tracking, sharing and response mechanisms, stretching HIT 15 ways from sundown. At the cutely named Health Datapalooza presently going on in Washington DC, data sharing is It for Quality Care, or else. Yet the costs to smaller healthcare providers to prevent that ER readmission scenario through new care models such as PCMHs and ACOs is stunning. And the consequences may be more consolidated, less available healthcare. We are already seeing merger rumors in the insurer area and scaledowns/shutdowns/buyouts of community health organizations including smaller hospitals and clinics. Also iHealthBeat.

DARPA to the rescue? The folks who brought you the Internet may develop a solution, but it won’t be tomorrow or even the day after. The Brandeis Program is a several stage project over 4.5 years to determine how “to enable information systems that would allow individuals, enterprises and U.S. government agencies to keep personal and/or proprietary information private.” It discards the current methodology of filtering data (de-identification) or trusting third-parties to secure. Armed With Science  FedBizOpps has the broad agency announcement in addition to vendor solicitation information.

Pondering the squandering redux: $28 billion gone out the HITECH window

In 2009, the US Congress enacted the HITECH Act, as part of a much broader recovery measure (ARRA or ‘the stimulus’), authorizing the Department of Health and Human Services (HHS) to spend up to $35 billion to expand health IT and create a network of interoperable EHRs. Key to this goal of interoperability and seamless sharing of patient information among healthcare providers was achieving stages of ‘meaningful use’ (MU) with these EHRs in practice, to achieve the oft-cited ‘Triple Aim‘ of improved population health, better individual care, delivered at lower per capita cost. Financial incentives through Medicaid and Medicare EHR programs were delivered through multiple stages of MU benchmarks for hospitals and practices in implementing EHRs, information exchange, e-prescribing, converting patient records, security, patient communication and access (PHRs).

Five years on, $28 billion of that $35 billion has been spent–and real progress towards interoperability remains off in the distance. This Editor has previously noted the boomlet in workarounds for patient records like Syapse and OpenNotes. Yet even the progress made with state data exchanges (e.g. New York’s SHIN-NY) has come at a high cost–an estimated $500 million, yet only 25 percent are financially stable, according to a RAND December 2014 study. (more…)

Box.com’s odd swerve into healthcare cloud storage and PHRs

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2013/02/gimlet-eye.jpg” thumb_width=”150″ /] Both The Gimlet Eye (filing from a remote island) and Editor Donna have been pleased users of the Box.com file storage site for storing all sorts of files in the ‘cloud’ (a/k/a Somewhere Out There On A Whole Bunch Of Internet Servers), sharing and collaboration. It’s simple to use, it works and, for our needs, actually free. However founders Aaron Levie and Dylan Smith, who look barely old enough to shave (but smartly have A Touch of Grey in their management team), have their eyes set on far bigger prizes than our mediocre needs. Now they have added ‘special advisers’ Aneesh Chopra, first US CTO, and Glen Tullman, former CEO of Allscripts. Mr. Tullman certainly does add major luster (and connections) and Mr. Chopra, despite the Eye’s consideration of him as hyperbolic and politically, not technically, qualified for his previous positions in the Government and the state of Virginia, adds the inevitable political ones. Having them on the roster also adds heft to their imminently rumored IPO (TechCrunch; update, filed 24 March) and ultimately acing out other file sharers Dropbox in the enterprise area. Expectations are high; Box has $414 million in funding from a roster of investors (including Telefónica and Australia’s Telstra) through a Series F (CrunchBase) with a valuation of $2 billion (TechCrunch) and undoubtedly they’d like some of it back. Soon. (The completely overheated Castlight Health IPO only whets the appetite.)

Healthcare one key to a rich IPO. Box’s healthcare moves point in the enterprise direction. (more…)

DrChrono and Sermo’s ‘Blue Blazes’ moments

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2013/08/blue-blazes.jpg” thumb_width=”150″ /]Neil Versel in his personal blog Meaningful HIT News notes meaningful lapses in accuracy and good communications taste from two reputable companies targeted to US medical professionals. DrChrono is a mobile ambulatory EHR tweeting about ‘cashing in’ on the HITECH Act–the program that rewards practices for achieving stages of Meaningful Use with EHRs. Sermo is a physician social networking platform that has staged a contest called ‘The Pro Football Injury Challenge’  where one will go ‘head-to-head’ with other doctors in ‘making predictions about how injuries will affect pro athletes this season.’ This Editor felt in her comments below the article that this promotion’s communication crossed the line into, on the usual two-second read, a message that it is OK to ‘play for glory’ and win prizes out of players’ real pain, injury and career disaster–a misbegotten effort to gamify real-world medical situations ostensibly for learning. Yes, both have sound messages at the core, but how they were communicated…regrettable. Both DrChrono and Sermo are nominated for ‘Blue Blazes’ because, to paraphrase Neil, ‘what are their marketers thinking?’ What do you think? And this Editor would be more than open to comments from representatives of these two companies. DrChrono and Sermo, what are you thinking?

Editor’s Update: Sermo has provided an important response and clarification blazingly fast in their blog here. (more…)

Is nothing private in your EHR? Another disturbing trend out of Swampland.

According to a solicitation posted by the Department of Health and Human Services (HHS-Ed.) on Sept. 4, the CMS (Centers for Medicare and Medicaid Services) is commissioning the National Academy of Sciences (NAS) to study how best to add social and behavioral factors to electronic health record reporting.  Washington Free Beacon

So a non-profit online publication, which one would site on the conservative or libertarian side (part of the Center for American Freedom), breaks a huge story, way ahead of the mainstream media, which has major implications for privacy, data security, public health, how goes your doctor or hospital visit and the level of care you receive. Is this EHR TMI (too much information)? The Federal inclusion is being linked to Stage 3 of the Meaningful Use program and reimbursement under Medicare, Medicaid and the Children’s Hospital Insurance Program (CHIP). The NAS already is working on this with the Institute of Medicine to draft suggestions for collecting this behavioral data and identifying “core social and behavioral domains to be included in all EHRs.”

With linking the data to outside Nosey Parkers agencies such as public health entities, the possibilities for identified data becoming insecure or compromised increase dramatically. Will it be accessed (abused) by other entities involved in ACA such as the IRS, state Medicaid databases and Social Security? How much of this data will accidentially leak out in non-deidentified files? Will breaches of millions of non-encrypted records become the norm? Another important and oft-overlooked factor is the additional workload on already overworked hospital and clinical staff, who presently struggle to get comprehensive vital data correctly into multiple fields and screens on present EHRs–a major pain point among many speakers and participants at this past week’s iHT2 Health IT Summit. Finally, there’s the patient. He or she will be pressed to answer, due to penalties baked into the ARRA/HITECH MU3 incentives, the most personal questions about their life and behavior particularly if the diagnosis is one of what euphemistically was called a ‘social disease’. Having spoken this week to those in public health both at iHT2 and at Health 2.0 NYC, this Editor can see it as a deterrent to getting the care they need–or choosing evasion rather than truth with their doctor because there are no more confidences. Even the California Healthcare Foundation, hardly on the right wing, sounds an alarm in iHealthBeat.