At the HIMSS 2012 conference in Las Vegas this past February, Dr. Farzad Mostashari, National Coordinator of Health Information Technology, observed that while there is still a lot of work to do on the adoption and use of electronic medical records (EMR), the majority of physicians in the US will be using an EMR within the next two years.

And we like that. It shows progress.

It also means we are experiencing an acceleration of the paradigm shift from the “Old World” of paper-based health records to the “New World” of EMRs.

None of it feels like a small adjustment; more like a tectonic paradigm shift for the health care industry. Even as the Old World recedes around us and the New World emerges, Old World concepts of health records and record ownership do persist. They manifest themselves in some unusual ways, too, and with surprising staying power, persisting in laws, regulations, the way we think about records, the way we do business and, often, even in EMR offerings themselves.

EMR systems that have not fully transitioned to the new paradigm represent a “Middle Path” that slows down change and innovation. To move forward successfully from the Middle Path to the New World, we will ultimately need to resolve the conflicts between the paradigms.

Ownership vs. Use

So, what about these conflicts? In the Old World, records are regarded principally as physical items–paper files that contain information. Therefore, the Old World focuses on custodianship of the record, which then translates into the question of who “owns” the record and, therefore, the items (information/data) contained within the record. This is a property-based approach to health information. In the New World, the interest is the data itself and, more important, aggregated data across multiple records that:

• provides meaningful insight about what care protocols work
• enables caregivers to communicate better with patients
• enables researchers to more expediently identify patients to participate in studies
• achieves better public health reporting and analysis, among other uses…

Therefore, in the New World, how the data can be used and how it can be leveraged is more relevant than who owns it.

Are you still living in the Old World? Did you make the leap to the New World? Tell us about it.

Next week, we will explore static records vs. real-time records and ways that software-based EMR systems often represent the inertia of the Old World paradigm.

The buzz this week has been all about a new article in Health Affairs showing an association between electronic access to diagnostic radiology and laboratory studies and increased diagnostic test utilization.

The buzz was loud enough that Farzad Mostashari, MD, ScM, the National Coordinator for Health IT, felt compelled to set “some facts straight.”

The study, based on retrospective review of data from the National Ambulatory Medical Care Survey, would seem to fly in the face of conventional wisdom that electronic medical records (EMR) should reduce costs by providing doctors access to prior test results, thus reducing unnecessary and duplicative testing.

But it doesn’t.

It’s easy to misunderstand the study. However, it was not about EMR use, but rather the provision of electronic results and the images themselves. To quote the investigators: “other indicators of office computerization—computerized physician order entry and the use of an electronic medical records system—showed no association with test ordering.”

What the study did show is that among a host of potentially cofounding variables, the volume of test ordering is higher for practices and their practitioners if they got their results in an electronic form.

Why the paradox? Unfortunately, the study lacked the ability to actually slice and dice the data in a truly meaningful way.

• First, it is not clear that they controlled for the variability of practice types and locations. Back in 2008, the vast majority of physician’s offices that had already deployed electronic results reporting were large employed groups and academic medical centers. Don’t these docs order more studies than small offices?
• Second, the study doesn’t look at whether the diagnostic testing was appropriate. While the study specifically splits out MRI and CT (modalities that are rarely part of typical quality care gaps) it is difficult to really tell what’s going on without a deeper analysis of the indications for testing.
• Third, the study does not look at whether the differences of care were a result of differences in test ordering, or differences in test compliance. At athenahealth, we are sensitive to the fact that connecting the clinician’s intent to an outcome (i.e., the patient actually getting the test) is critical, because our real-time data show that a high percentage of all physician orders go unfilled, meaning a doctor can write for a completely appropriate test, and that patient, for whatever reason, just does not get it.
• Finally, the study provides no insight into the total economic picture. How many of these studies prevented death, disability or more severe complications? You can criticize test ordering, but not unless you know the whole story.

The real problem with the study is that it failed to recognize the effect of plain old e-commerce on the medical supply chain. They almost make the point in their discussion section:

“Perhaps physicians who order more imaging studies, for whatever reason, are more likely to acquire health information technology that facilitates the retrieval of imaging results or images.”

Bingo.

Say I’m a doctor who orders a lot of studies, a neurologist, an orthopedist, or a geriatrician who specializes in cognitive decline (think MRI). My fax machine is jammed up with results, so I ask that imaging center or lab for an interface, or just a way to log in online, rather than jam up my fax machine.

At athenahealth, this is what we do every day – take high volume transactions and make them electronic. It’s why we don’t charge for interfaces.

It’s what everyone was doing in 2008 – taking advantage of information technology to make their lives easier. And, so here we have a handful of folks trying to influence national policy on the basis of four-year-old data.

Believe what you want about the nation’s health IT strategy, but this study adds little to the dialogue.

So far in this blog series, I have talked about “the good” in health care IT. For example, EHR interoperability—when it exists—is really good. I’ve also shared some of “the bad,” like data entry and data access in light of a 400-page paper chart. Today’s entry focuses on “the promise” of health care information technology. That is, the potential of HIT to act as a foundational service in which to share research and protocols across providers, to benefit all patients, no matter where they are or who they know.

Here goes …

I had a really good cry just after I was diagnosed with Stage 4 colon cancer. The tears were laced with fear—I was scared. I cried for me, my wife and our kids—I couldn’t think of anyone else during the first 12 hours. I felt better, temporarily, as if the tears washed away a bit of the fear. But then, by the following morning, the fear was back. I was less scared of the diagnosis, and more anxious about the unknown process of how to cure it. Or whether it was even curable.

When the poking, prodding and questioning finally stopped and my diagnosis was launched into the cosmos, my wife and I had to figure out who my doctor would actually be. More accurately, we had to figure out how to figure out who my doctor would be. Also, we obviously had to determine what my treatment plan would look like. In short, we needed a route back to health.

This, I soon came to realize, is where connections who possess both extreme compassion and access to leading edge research and physicians intersected to create my health care HOV lane—a channel in the vast highway system of health care options that the patient firmly believes gives them the best shot at arriving at a safe and healthy destination. And like an HOV lane (high occupancy vehicle for the uninitiated, a smooth-sailing highway lane), if I could find a way into it, I could get back to health faster than the rest of the traffic because I had a few friends on board with me.

Stay with me on the HOV lane. The analogy may not hold for everyone, but let me explain what I mean and how it relates to a larger problem in health care. This is a solvable issue greater than just me trying to overcome my diagnosis and get back to wellness.

First, we had a connection who exhibited an immense amount of compassion for us. A few short hours after awakening the day after my diagnosis, a distant family friend (the mother of my wife’s sister’s college roommate… I did say distant) and a veteran leader at the hospital, walked into my room. She advised us to meet with the medical and surgical oncology teams that I’ve already referenced (Dr. R and Dr. T). She is a strong woman and I took her words as gospel the second I met her. 

It was clear that, in advance of her visit, she had pulled my chart, seen that I was 39 years old, read about the state of my disease and decided she was going to help. In an unexpected turn of events, I went from crying over the fear of “figuring out how to figure out how to get a doctor” to being assigned to two of the hospital’s leading physicians—both of whom had already discussed a very progressive chemotherapy and surgical strategy to get me back to the “Kingdom of the Well.” 

And with that… I was officially in my version of health care’s HOV lane. I was comfortable with the team and the very aggressive plan of attack. We were on our way.

While unbelievably grateful for the connections and compassion exhibited by our physician friend, I thought  a lot about the other 20+ million current cancer patients who may lack proximity or any connection to a leading edge cancer institution. 

This led me to another set of questions: Do patients who receive care at more remote or less research-oriented hospitals question whether they’re getting the best care possible? Further, could these doubts somehow compromise the efficacy of their treatment? Further yet, do huge swaths of patients miss the opportunity to follow what leading research deems the most effective protocols for care?

I have to assume the answer to at least one of these questions is “yes,” at least some of the time, for some patients. But it doesn’t have to be that way.

This is where HIT companies, in collaboration with the world’s finest research institutions, have an amazing opportunity—and maybe a responsibility—to pave the way for cancer patients (and their families) on their often harrowing journey to beat this ravaging disease.  

If you watched any of the NFL playoff games, you saw several large corporations advertising that their “super computers” are being used to cure cancer. The commercials show huge 3D servers and scientists viewing holographic images of DNA—all with an eye toward unpacking the riddle that is cancer. 

Having all that information makes for impressive advertising but it needs to be deployed to huge numbers of physicians in order to see demonstrable results—such as people staying healthy.

Here’s what I mean. With any diagnosis, limitless amounts of information can be gathered and analyzed to guide treatment. Many of these data—tumor markers, for example—guide oncologists toward specific treatment protocols. However, when you couple clinical research advances and protocols with the ever-expanding vastness of personalized data for a cancer patient, I see an emerging disconnect. This disconnect relates to the ability to readily identify relevant information from these massive data structures and surface those data into the hands of the oncologist… and then, directly into the treatment protocol of the patient. 

The collaboration between HIT companies and research institutions needs to enable promulgation of cutting edge research using patient-specific markers. It needs to find its way into the hands of the physician.

In perfect alignment, the match of patient-specific markers against leading edge treatment protocols would be used to create situational awareness for a specific patient as a standard part of the care process. It’s possible; we’re just not there yet. But like my HOV lane, I can see there’s a road to get us there.   

I don’t believe this information or the situational awareness to guide care should come for free. Massive amounts of funding go into aspects such as research advancement and universal information access.

And there is most certainly a market for it.

Leading institutions are already beginning to market their care protocols, but merging these protocols seamlessly with the care process must happen to ensure a reliable entrance onto an HOV lane, not just from a research institiution, but from any physician’s office in the country. It can and should be done, in an economically rational way.

When we reach this point as an industry, and a nation, it will be possible for any cancer patient to be comforted in knowing that a region, nation or world’s worth of clinical research is behind him or her—even if location or a family connection doesn’t enable them to align with the most prestigious hospitals in the world. 

It took collaboration on my care team—my fellow passengers in that HOV lane—to get me to where I am today. Someday soon that same collaboration and the connection and compassion coupled with access to leading edge research and physicians, will be writ large across health information technology. And the HOV lane will be wide enough for everyone. It needs to be.

Great news!

athenahealth hired our first Director of Ecosystem Development.

This may be great news… but what does it mean exactly?

Right now, the only people making stuff for athenahealth’s clients are… well… athenahealth people. This is good… but it would be better if there were thousands of other people making stuff, too! The most obvious and painful example is that those thousands of cool people who develop apps and work for Apple on iPads, iPhones, iTunes, and Safari are NOT benefitting the athenaNet user experience. This needs to change.

There is countless other stuff our clients need that we won’t get to soon enough or well enough. There are companies that serve up cloud-based RIS-PACS systems that allow every doc to have instant access to every image he or she has ever needed or ever read WITHOUT having to remember which hospital, center, etc., it originally came from. There are dozens of cool sites where patients can complete part of their office visit rather than doing so in the exam room or waiting room! There is no really good inventory management app for docs… and the list goes on!

I don’t want to wait for our amazing dev and product teams to build all these and I don’t want the only versions to be those made by us. If our vision is to be a national backbone of health information to help make health care work better, then we need to be a lot better about being a national marketplace for apps that need a good backbone! For example, I would love it if, in five years, there were a wide variety of competitive services participating in our “ecosystem” as well… with only a couple of them written by us.

Why, you ask?

It’s kind of the same reason why we have been going down to DC to try making it easier for other companies to compete with us on electronic coordination of care. Earlier this week, those efforts paid off.

In business—as in nature—a diverse, bubbling ecosystem is more resilient and nimble than a homogenous one. Any change in government or fashion can wipe the latter out. The former experience a change in dominant species, but the system as a whole survives shocks more easily. In short, we need to make sure that our backbone and services get as strong as possible and have the best chance of growing and surviving. We need everyone to play… and to get paid for it. 

So would this be an iTunes-like store?  Kinda, but less so. First, we are playing to a very small audience, so we don’t expect MILLIONS of developers like Apple, whose audience exceeds a billion people. Also, as enablers of health care, we have an ethical obligation to go a little slower than the average Internet player. We are, in a serious way, subject to the same Hippocratic Oath that docs are; “first, do no harm.”

Our ecosystem will contain only vetted, secure providers of health care information service. They will have their own HIPAA security teams and a strong sense of their ethical obligations as participants in the care chain. Thus there will be way fewer options, and they will evolve way slower than, for example, Angry Birds. But there will be way more than just one… and they will evolve way faster than, say, certain legacy software systems.

How are things in your ecosystem?

In a recent blog post , our VP for User Experience, Mary Kate Foley, kicked off a discussion about the status of UX in health IT as well as the role of UX here at athenahealth. We take usability very seriously and lately we’ve been working with industry thought leaders to move the needle for users of patient-facing tools such as the Continuity of Care Document (CCD).

Earlier in November, fellow UX designer Luis Gutierrez and I attended a cross-industry collaborative EMR workshop hosted by the California HealthCare Foundation and IDEO. With a wide swath of the health IT industry—and not to mention a lot of doctors—neck deep in Meaningful Use, the timing could not have been better for this first-of-its-kind gathering.

This is how Glen Moy, senior program officer at the California Healthcare Foundation, set the stage: “HITECH and Meaningful Use provide a unique opportunity to more fully engage patients in their care through health information technology. The workshop will bring together a select group of health IT leaders to collaboratively begin to make electronic health records more usable for patients and consumers.”

We were thrilled to be able to collaborate with designers and colleagues from companies (competitors, really!) such as Epic, Cerner, McKesson, Siemens and others, as well as members of the HIMSS Usability Task Force and the Blue Button project, an initiative we took part in to provide better record portability for veterans.

The goal of the workshop was to “re-imagine” the CCD, so we viewed the document through a patient-centered lens to improve the overall visual, interactive and informational experience. We’re trying to make patient health records more accessible to providers, caregivers, and patients themselves.

Guided in various design exercises by IDEO’s project team, ideas were formed for creating interactive, easy-to-use displays of medical information for patients. Ranging from the unconventional to the practical, the ideas served to inspire us to launch from the current standards and also explore interface possibilities. The ideas also exposed the tough questions important to the interconnected health care system of the future:

• Who owns the data?
• How can we use technology to get patients more engaged in their own care?
• How can one’s medical record be a bi-directional, dynamic dialogue between patient and provider while maintaining scientific integrity?

While these questions still linger, this workshop served best as a precedent to industry collaboration with competitors working toward a common goal to tackle hard problems.

By sharing inspiration, acknowledging constraints and even throwing out some wild ideas in an open source workshop, we continue in our mission to help inform and lead the industry. We need to keep improving the usability of products and services in health IT.

Look for more about UX in the coming months. In the meantime, what thoughts can you share about EMR usability? We are always looking for valuable feedback and new ideas.