Can Hospitals in Mexico Avoid the Pitfalls of US EHR Systems?

Over the past 10 years, US hospitals have rapidly adopted Electronic Health Record systems because of federal mandates that included both carrots and sticks. The US federal government pumped 87 billion US dollars into the market by giving multi-million dollar rewards to hospitals that adopted EHR systems and, in 2017, hospitals that have failed to do so will be penalized up to 2% of their Medicare payments.

This rush to computerize clinical care has been both a blessing and a curse for US hospitals many of which have seen their costs for IT skyrocket in spite of large government rewards and watched their productivity falter as complex systems slowed work and required extensive training. While some are now seeing benefits from this transition, the ongoing costs are challenging in a period of shrinking reimbursements from federal and state health programs.

Can hospitals in Mexico avoid the high cost of US-based systems while achieving better care, improved productivity and better profitability? One California company thinks so and is investing heavily in building a Latin American client base in Mexico and beyond. E-Health Records International (EHRI) has begun to market HarmoniMD, a Hospital Information System, in Mexico, Guatemala, Chile, Argentina and other Latin American countries which replaces paper charting for all clinical care processes.

While most of the HIS platforms currently in Mexico are add-ons to locally built business systems, HarmoniMD, EHRI’s flagship system, was designed as a clinical management system that integrates with imaging, lab, pharmacy and other software and addresses business needs like billing and inventory by capturing data in the clinical environment. In this way, HarmoniMD is able to eliminate the need for paper charting of patient care entirely and move hospitals completely to digital records. This includes all aspects of physician ordering including nursing orders, medications, lab, imaging, respiratory therapy, physical therapy and other departments.

To accomplish this, the EHRI team has built a unique system of Electronic Clinical Documents (ECDs) that can be customized to any hospital without any programming. These digital documents replace paper exam forms, order sets, evaluations, consent forms, surgery checklists and any other forms that the hospital needs with an easy to fill out digital interface. Most importantly, every clinical process can be mapped onto the workflow of the hospital and have easy to enter buttons, checkboxes and lists to reduce the amount of typing necessary to record patient information.

HarmoniMD is designed to run on inexpensive mobile devices like the 7-inch Lenovo tablet, which retails for less than $100US. This puts all of the workflow for nurses and doctors into their pockets thus eliminating the need to write down information and then type it into a computer. It also allows doctors to review any clinical information and place orders over the cell network from any location. Physicians are often surprised to find out that they can view x-rays and CT scans, see lab results, read nursing notes, see photos of patient conditions and place orders from any location with WIFI or cell 3G!

The biggest innovation EHRI is bringing to the Latin American market is a Software as a Service (SaaS) model that allows hospitals to pay for the system based on their patient volume and pass the cost of the system onto patients. With no up front costs for the software other than training and implementation, hospitals can get the benefit of improved productivity, charge capture, patient billing and clinical care without having to buy software or pay for future upgrades.

Nick Smith, E-Health Records International CEO, sums up the company’s approach as follows: ‘We built HarmoniMD from the ground up with the Latin American market in mind. We knew that we would have to be fully featured and attain the highest standards for any EHR system. At the same time we have to provide a return on investment for Latin American hospitals within the first year. Our goal has always been to keep not only the cost of our system as low as possible but also the cost of hardware and IT support affordable.’

Will these innovations help hospitals in Mexico to be more productive and profitable and to provide better care? Only time will tell but it will certainly be worth watching the early adopters of this system.

$400 Million Boondoggle

Another Boondoggle.

As reported by the San Francisco Chronicle on 12/15/2016: “A huge project to modernize medical record-keeping for California prison inmates has more than doubled in cost from original estimates to nearly $400 million in just three years, the latest in a long string of computer projects that have befuddled state government.”

Even for those of us who are familiar with the high prices charged for health care software, this example of wasted taxpayer money is hard to fathom. The article goes on to report: “In court and budget filings, Kelso’s [the court receiver] office largely blamed problems with the medical records system on the contractor, Cerner Corp., which is being paid $177 million over the project’s 11-year life.”

Ever since the feds pumped $87 billion into the EMR software market, the US has been enamored with the belief that EMR software has to have a huge price tag to be any good. But the bloated systems that are being peddled by the billion dollar US software companies are often cumbersome and running on outmoded technology as the article states: “Employees struggle to learn the new record-keeping system.”

The article further states: “The biggest problem was a pharmaceutical records system so complex that it turned out to be ‘damn near unusable’ when it was tested last winter at three prisons, Kelso said: ‘The thing wasn’t designed or implemented properly.’”

Like other failed software projects, the state will likely continue to pour money into this one with the belief that they can’t afford to waste the dollars that they have already poured down the drain. This leaves the inmates and staff with the short end of the stick having to contend with a cumbersome system and not enough money to provide care.

Read the full article at SFGATE

 

Bridging the Communications Gap Between Healthcare and IT

One of the great challenges of Electronic Medical Records adoption is bridging the divide between clinic-speak and IT-speak. For those of us who have worked on both sides of the divide, it is easy to see that even experience cannot reconcile the abundance of information in healthcare and in information technology. What can help is maintaining a level of patience and respect needed to address the common needs of both industries.

Healthcare professionals, are you tired of feeling like IT professionals ignore your needs? Does your IT staff appear to adopt an attitude and treat you as if you know nothing when you are stuck on an IT issue? Information Technology professionals, do you find yourself brushed off by healthcare staff, when they call for assistance? Have you ever had the experience of building a piece of software to a user’s requirements that was then rejected due to miscommunication during the project?

Having left the field of direct patient care and transitioned to the Information Technology field, I have found that it does not benefit either side to assume our compatriots have anything but good intentions. Both IT and healthcare professionals can find a productive way to approach the common goals of accurate records and excellent patient care through collaboration, meeting etiquette, respect, and communication. Whether we are focused on a large-scale project, a customized feature, or a bug in the system, demonstrating basic courtesy in meetings builds goodwill in any team effort and makes the most of the time spent in those meetings.

Prepare in Advance for the Meeting

Healthcare professionals should prepare by:

  • Gathering the opinions and needs of coworkers their specific department.
  • Getting clearance from boards or committees.
  • Providing concrete examples.
  • Clearly communicating these needs as close to “step-by-step” instructions as possible.

IT professionals should prepare by:

  • Researching healthcare forms and requirements.
  • Providing visual examples instead of descriptive examples when possible.
  • Providing an assessment and timeline for project prioritization and completion.
  • If current projects and expertise required for the project will increase the time to completion, then prepare an estimate of the time and hindrances that may affect completion.

Showing up on Time

Timeliness is a common courtesy. We are all busy with full days, and none of us wants to be in the position of waiting for someone else. Demonstrating respect for another’s time goes a long way toward building trust and understanding on a project. Pick a time and write it on your calendar to avoid repeatedly rescheduling meetings and being late.

Avoid or Translate Technical Terms or Acronyms

Both the healthcare and IT industry have a plethora of acronyms and technical terms, many of which overlap. An example would be the acronym ACL which is ‘access control list’ in the IT world and ‘anterior cruciate ligament’ in the healthcare world. Clear communication dictates that we avoid the use of acronyms or clearly define them when acronyms are used.

Provide Your Full Attention

Another common courtesy is to focus on the presenter or discussion at hand. Checking your cell phone or other devices is distracting for you and the people with whom you are working. If you are waiting on a call or are on a call, please alert individuals in the meeting and leave the room to take any calls. While all of us have experienced the feeling that meetings distract from our “real” jobs, we all need to understand that meetings are critical to our success. The better we prepare, attend, and pay attention the greater our success will be.

Respect Competence and Initiative

Both IT and healthcare professionals should be treated with respect and appreciated for their commitment to attending meetings and answering questions. Both industries require dedication and competence to successfully perform job functions as well to develop solutions to project issues. The project may be frustrating and taking longer than you would wish, but as long as the commitment to attending meetings and making progress remains, avoid taking out frustrations on those working with you and doubting their competence.

Know the Basics

Understanding the basics of both Healthcare and IT assists tremendously with accurate and efficient communication when working as a team. IT professionals need to research and understand the needs and requirements that Healthcare professionals must meet. Most data that Healthcare professionals use focuses on efficient patient care, accuracy, and measuring that accuracy for oversite and compliance. Whenever possible gather examples of forms, research the necessary requirements for patient care, and ask the Healthcare professional for clarification of terms or requirements.

In turn, healthcare professionals must also understand the basics of their facility’s IT system, being sure to take advantage of training offered by their facility and/or the IT department so that there is a basic working knowledge of the hardware and software that healthcare professionals are using. It is also helpful to write down steps taken when tech support is required. Tech support staff often start with basic techniques that are useful in many situations, not just in the workplace.

The challenge of the communication divide can be successfully traversed through the use of proper communication skills. Taking steps to remember basic etiquette and preparation can increase the success of projects and future collaboration. Many hurdles to project completion can find resolution through a commitment to communication, clarity, research, and attention.

Ta-blet or Not Ta-blet, That is the Question

In a recent article in Becker’s Health IT & CIO Review, Jessica Cohen reports that according to a report done by IBM Institute for Business Value of healthcare CIOs and other executives, findings indicate that 71% of CIOs and only 59% of other executives believe that mobile solutions will have a significant impact on their organizations over the next five years.

The question this raises is, what is wrong with the 29% of CIOs who don’t recognize that mobile solutions will affect their work environments significantly? From our perspective, the inevitable change from desktop to mobile application is bound to have a profound effect on the healthcare environment in almost all circumstances, and particularly in the hospital realm.

Mobile devices such as tablets and cell phones still lack a few important capabilities to become the ubiquitous interfaces that they promise to be but once these capabilities are integrated, there will be little need for desktop computers or rolling workstations. One shortcoming with current mobile technology is high-quality voice recognition like Dragon Naturally Speaking is currently available only as a desktop interface. Once this system is successfully migrated to the mobile environment, physicians and nurses will be able to dictate reliably into a mobile device making keyboards mostly obsolete.

Consider the current capabilities of mobile devices offering many advantages over computer workstations:

  • Bar code scanning: Tablets and cell phone cameras can scan any kind of bar code for patient ID, drug ID, charge capture, equipment usage and a variety of other functions.
  • Photo Capture: The camera can capture photos of patient conditions, documents, surgery procedures and many other clinical processes.
  • Notifications: Because mobile devices are generally used by one person during a shift, they can provide real-time notification of changes in individual patient care.
  • Image Viewing: With mobile devices, it is easy to view radiology images from any location and to show patients the results of X-rays, CT scans and MRIs at their bedside.

Mobile devices also offer the ability to connect to clinical databases through the cell network, which is an important redundancy to hospital-based WIFI networks and extends the reach of clinical systems for physicians.

We see the future connecting mobile devices with medical monitors and other clinical devices for automated capture of vital signs and other information. With an ‘untethered’ approach to clinical informatics, clinicians will not be hampered with having to be wired to one location and have more capability in their pocket than on their desk.

Are Computers Getting Ready to Supercede Doctors’ Diagnoses?

A recent small scale study by Harvard Medical School indicates that software symptom-checkers still have a long way to go when identifying the reasons for medical conditions. This result seemed fairly consistent across different software so it is more a statement of the readiness of these systems rather than the accuracy of any one in particular.

The study concluded that, ‘Doctors are much better than symptom-checker programs at reaching a correct diagnosis, though humans are not perfect and might benefit from using algorithms to supplement their skills’. Because computers can’t perform a physical exam, the trial compared the performance of physicians based solely on the information provided. Even in this case, physicians performed markedly better than symptom-checker software, getting the diagnosis right 74% of the time versus only 34% for software systems. This poor showing for software systems leaves one to question whether these software systems should be in use at all as having an inaccurate diagnosis can be very harmful at times.

It also raises the question of how physicians would have performed if they had done a physical exam, which is the gold standard for any diagnosis. While the development of computer analytics continues to make great strides in many fields, there are clearly limits when the problem being solved is more nuanced than might first appear to be the case. Another limitation of an Artificial Intelligence application is the ability to question the value or accuracy of certain data, something that only experience and thinking outside of the box can accomplish.

Creating medical diagnostic software is much like creating self-driving cars in that there are layers of complexity that the human mind takes for granted but that software might miss. This is especially true with an environment that is constantly changing as in operating a motor vehicle or in medicine. That being said, both doctors and drivers make mistakes and likely both can benefit from computer systems that augment decision making instead of replacing humans.

That being said, it is hard to imagine the replacement of the physical exam and questioning of a trained physician, which can uncover additional symptoms, eliminate others, and make sense out of contradictory data. Something as simple as a rash might mean very little to a computer system but point the trained physician to an underlying cause.

As a technology provider, it might seem odd that we would be pointing to the limitations of software in clinical decision support but experience has led us to conclude that the human mind has abilities that computers can’t come close to, at least in their present incarnations. While the promise of Artificial Intelligence has been around for a long time, the applications of it remain elusive. At least for now, we will go see our doctor if we are having medical problems (after using a symptom checker).

Escaping the EHR Trap

In a recent article in the New England Journal of Medicine titled “Escaping the EHR Trap – the Future of Health IT“, Dr. Kenneth Mandi and Dr. Isaac Kohane present a strong argument for disruptive change in the EHR space as follows:

“Health IT vendors should adopt modern technologies wherever possible. Clinicians choosing products in order to participate in the Medicare and Medicaid EHR Incentive Programs should not be held hostage to EHRs that reduce their efficiency and strangle innovation. New companies will offer bundled, best-of-breed, interoperable, substitutable technologies — several of which are being developed with ONC funding — that can be optimized for use in healthcare improvement. Properly nurtured, these products will rapidly reach the market, effectively addressing the goals of ‘meaningful use’, signaling the post-EHR era, and returning to the innovative spirit of EHR pioneers.”

The full article is available here: New England Journal of Medicine

This article reads like an indictment of the EHR industry as a whole and the constraints that meaningful use and old technologies have brought to healthcare. The authors point out that technology in other industries has rapidly evolved to utilize cloud-based systems, mobile devices and connected architectures while the multi-million dollar EHR platforms dominating the US market remain bound to local servers, big IT budgets, and cumbersome hardware like Computers on Wheels (COWS).

As a startup in the Hospital Information System space, Electronic Health Records International (EHRI), a California company, is focused on the developing world instead of the US market. ‘While the US market is focused on big-dollar systems that are cumbersome to implement, the rest of the world is looking to bypass these technologies and jump to mobile applications’ says Nick Smith, CEO of EHRI. ‘We are able to innovate in this market and work toward a mobile, connected health record.’

‘The first step in this process is to move away from expensive computers for clinicians and to utilize mobile devices like tablets and cell phones. We should remember that the cell phone in your pocket has more computing power than the PC on your desk and can do a lot more tricks than your PC, not the least of which is to be connected anywhere in the world. This includes taking pictures, scanning bar codes, and running on the cell network if you are out of wifi coverage. With tablets now under $100, we can put 100 devices into the clinical environment for the cost of one COW. For a little more, these can be SIM-enabled so that they can run on the cell network if they are out of the hospital or the hospital’s network is down.’

In a recent discussion with a hospitalist using HarmoniMD, EHRI’s hospital electronic health record, the hospitalist pointed out that she keeps her tablet by her bedside in order to place orders and review labs and imaging when she is on call at night. In the developing world, this connectivity is even more important than in the US where desktop computers are more prevalent.

‘In the developing world, they still believe in return on investment (ROI) when it comes to technology instead of rewards from the feds. This forces software providers like us to build systems that are cheaper than paper’ Smith adds. ‘We like this approach because we have to innovate or die.’ As Charles Darwin pointed out ‘It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.’

Paper, Paper Everywhere but Not a Drop of Ink

A recent article on medium.com titled “UCSF Nurses Want Someone To Build These Products” By Fiahna Cabana, Desiree Matloob, and Priyanka Agarwal includes the following:

‘Frontline nurses attend to almost all of a patient’s basic needs. In doing so, they often juggle up to 25 pieces of paper with critical information. Ideally, nurses could use charting software that would help manage and streamline all this information.’

While hospital EHR software has gone a long ways toward eliminating paper, there are still a lot of paper forms populating the average hospital environment. A survey during an implementation of an EHR system in a small California hospital showed that the busiest area in the hospital was the medical records room in which many documents were added to patient charts using high speed scanners.

While EHR systems have done away with CPOE and many other functions, these instances would indicate that there is still a ways to go if we are going to truly be paperless. One of the big problems is that every hospital has its own set of paper forms, some of which are difficult to develop in software and there is a constant need to add new ones or reformat existing ones. This makes building computer screens to replicate them a never-ending job for programmers.

At least one EHR company, EHRI Inc. has developed a technology that takes a big step toward solving this problem in what they describe as Electronic Clinical Documents (ECDs). The underlying concept for ECDs is that any clinical document can be made into a computer process without programming and share information with any part of the clinical database. This includes reading information from the database into the document and placing any kind of order from within the document. It also includes capturing drawings, patient signatures, and pretty much any kind of data. Furthermore, the data captured in an Electronic Clinical Document can be reported on as discrete elements even if the document structure changes over time.

This is not like filling in a PDF file, but more like building a custom software app for a mobile device that has its own internal logic without having to write any software code. The underlying technology for this is an XML interpreter written by Kiko Taganashi, one of the EHRI programmers and has many unique capabilities not the least of which is the data storage itself. When a clinical document is complete (a partially complete one can be stored on the mobile device), the data is stored as part of the XML structure so that any document will appear in its original form.

While the user sees a very simple-to-navigate format, the underlying technology is quite complex and took a number of years to perfect. Today, it is serving the needs of a wide variety of documents including order sets, nursing assessments, exams, evaluations, patient consent forms, and many others.

VA Ready to Junk Vista

For as long as anyone can remember, the US Dept. of Veterans Affairs (VA) has managed patient data on VistA, their EHR system that was started in the 1970s. VistA consists of 180 different applications for clinical, financial, administrative and infrastructure functions in the VA. The Computerized Patient Record System (CPRS) represents the common clinical graphical user interface started in the 1990s.

The VA has released an RFI for companies interested in bidding on the process management of a migration from VistA to an ‘off-the-shelf’ application. The primary reason given for the change is that VistA has been customized into ‘130 unique instances making modernization and standardization efforts extremely complicated, expensive and time consuming’.

So basically, the VA is throwing in the towel on being a software developer (wisely in our view) and realizing that the architecture of VistA (MUMPS) may also not be the best development system to be on in a web 2.0 driven world. While some systems like Epic have stayed in the MUMPS universe, newer systems that utilize mobile devices are being developed in more modern languages and have a much bigger pool of programmers to choose from.

But whatever the cause for the VA’s decision, it is clear that the future for VistA will be dramatically different; unless the VA selects another MUMPS-based system like Epic, there will be a lot fewer MUMPS programming jobs. Like COBOL programmers of old, there are many that continue to carry the MUMPS torch including those that have implemented Open VistA, the open source version of VistA.

Given that open source software is free, one might asks why anyone would pay millions of dollars or even hundreds of millions for a system like Epic, which is also a MUMPS-based system. The answer is the same as why aren’t we all running our computers on Linux? Free is not really free, especially over the long run. And with the VA now set to abandon a software project that they have spent billions on for an ‘off the shelf’ platform, we can see that even they realize that free is not really free.

Garbage in Ratings Out

As CMS continues to evolve quality reporting requirements for hospitals and nursing homes, the law of unintended consequences can come into play as administrators struggle to raise their ratings. In a recent article on Bloomberg News titled New CMS Nursing Home Ratings Don’t Solve Accuracy Issues, Senator Michael Williamson reports the following:

“Increasing the number of measures on which nursing homes must report offers seniors and people with disabilities, along with their families, more information when picking a nursing home, Sen. Bob Casey (D-Pa.) said. However, these changes don’t “impact the accuracy and reliability of the measures reported,” Casey said, adding that he and Sen. Ron Wyden (D-Ore.) in 2015 asked the Government Accountability Office to examine the nursing home five-star rating system and help determine its accuracy (167 HCDR, 8/28/15).”

In addition to concerns about the accuracy of CMS ratings, health careproviders are sometimes struggling to make sense of the CMS quality reporting system. With the addition of new requirements, many nursing homes would see their ratings drop even though there has been no change in their reporting, as reported below:

“The February 2015 changes “caused an estimated 4,777 of 15,500 centers nationwide to lose one or more stars in their individual quality rankings even though nothing about the quality of care those centers offered changed,” Greg Crist, senior vice president of public affairs at the AHCA,told Bloomberg BNA in August 2015.”

While the quality of care that is delivered in a healthcare setting will directly affect the ratings, other outside factors may prove more important. Hospitals and nursing homes in areas with patients with more lifestyle issues will likely see lower ratings even though the quality of care they are delivering is equal to those in more affluent areas. Smaller institutions may also be hit by ‘black swan’ events that don’t average out in their ratings.

The quality of data captured can also have a big effect on ratings causing hospitals and nursing homes to spend a lot more to make sure they are capturing information in a way that demonstrates quality outcomes. While this can be a positive influence, it can also detract from care delivery if documentation takes precedence over care.

As regulations for quality reporting change, training and system changes add to the expenses of hospitals and nursing homes at a time when increasing financial pressure is on them due to lower reimbursements. EHR software vendors also have to stay current with the changing landscape and will pass the cost on to hospitals.

Goldilocks and the Three Bears

In a recent article on emrdailynews.com titled “EHR Re-evaluation and Replacement is on the Rise”, Stephen Campbell reports that the replacement market for EHR systems is being driven by ‘systems that are too complex (in form and function)’ and the trend to cloud-hosted systems that run on mobile devices. He defines the ‘Goldilocks’ Principle as finding the right application for a hospital or clinic.

The three bears implied in this article are:

• Cumbersome user interfaces that are not easily adaptable to the needs of a hospital or clinic. Older systems that were built on top of billing platforms tend to have more clicks and screens to get the job done than are needed and add up to expensive clinical employee time.
• Server-based applications that require a high degree of internal IT support, regular updates, and maintenance of firewalls and other security measures require sophisticated IT staff who expect generous salaries and can be difficult to recruit in a tight job market.
• Extensive training requirements that make it difficult to integrate new staff and can cost more than the software. When the learning curve for the EHR is steep, employee turnover becomes even more expensive.

The rapid introduction of EHR systems under the Hitech program left a bad taste for many hospitals and physicians once the real cost of maintaining systems became known. According to Campbell, 24% of EHR users says that their current system is too cumbersome. Of those that look for an alternative, 60% switch to another system.

These trends are likely to continue as hospitals and clinics are faced with shrinking margins and lower reimbursement. Campbell also points out that mergers of software companies will often eliminate products and push customers into having to migrate, which in turn pushes them back into the market to examine their options.

Another trend that is about to hit the EHR market is the inevitable disruption as new startups look to dethrone the expensive EHR systems with more affordable and customizable applications that run on mobile devices and move IT maintenance into the cloud, allowing hospitals and clinics to focus on providing clinical care instead of maintaining hardware and software systems. IT budgets that bloomed because of Hitech rewards are now under increasing pressure to provide a ROI; complex, expensive to maintain systems will eventually have to change or be thrown out like a bowl of cold oatmeal.