Free Healthcare IT Newsletter Want to receive the latest news on EMR, Meaningful Use, ARRA and Healthcare IT sent straight to your email? Get all the latest Health IT updates from Neil Versel for FREE!

Podcast: Care Innovations CEO Sean Slovenski on his company’s Validation Institute

PALO ALTO, Calif. — I’m out here in the Bay Area, in part because Intel-GE Care Innovations invited me to be one of six judges of its first-ever “hackathon” this past weekend. (Full disclosure: Care Innovations paid my travel expenses, but placed no editorial demands on me.)

On Saturday, I sat down with CI CEO Sean Slovenski to discuss a number of issues in digital health and health reform, but I found myself most curious about CI’s new Validation Institute, launched in late June, which looks to bring some truth to some outrageous claims made by entrepreneurs in the untamed world of digital health, telehealth and population health management. I turned on the voice recorder, and this short podcast is the result.

(Sorry for the bit of background noise. We both live in the Midwest, and just had to do this outside on a gorgeous California morning.)

Podcast details: Interview with Sean Slovenski, CEO of Intel-GE Care Innovations, on the company’s new Validation Institute. MP3, stereo, 192 kbps,  9.2 MB. Running time 6:38

September 22, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

APSO vs. SOAP, continued

A couple weeks ago, I had a story in Healthcare IT News about the growing use of the “APSO” notes for documenting patient encounters. APSO flips around the traditional SOAP format (subjective, objective, assessment, plan), ostensibly making it easier to view progress notes in electronic health records.

As I reported, APSO is in wide use at University of Colorado Health and at Lucile Packard Children’s Hospital in Palo Alto, Calif. Baystate Health in Springfield, Mass., found that hospitalists focused most of their attention on the “impression and plan” sections of patient records, essentially the AP part of APSO/SOAP. Physicians at Epic Systems, according to University of Colorado’s Dr. C.T. Lin, are recommending APSO as a best practice.

Yet, the inventor of the SOAP note, Dr. Larry Weed, still believes his format is superior. You saw his comments in the Healthcare IT News story. But every time I have the privilege of speaking to the nonogenarian Renaissance man, he always has more to say than I can fit into the average article. I often can’t keep up in my note taking, but, fortunately, in this case, Weed and his son/occasional co-author Lincoln, took the time to put their thoughts in writing for me.

I left most of their comments out of the story due to space limitations. I don’t have that problem here, so I present their entire statement to me:

The following represents our collective thoughts, including references to relevant portions of Medicine in Denial [their 2012 book].

The supposed advantage of the APSO alternative — that it begins with the physician’s assessment rather than data — is actually a failing. This sequence tends to make the note provider-centered rather than patient-centered, and judgment-based rather than evidence-based.  In contrast, beginning the progress note with data disciplines the provider’s assessment. The provider must think in terms of specific data, specific problems on the problem list to which the data relate, and the interrelationship of each problem to the other problems on the list. Moreover, it’s important to begin the progress note with subjective (symptomatic) data from the patient rather than so-called “objective” data,  As Medicine in Denial states (p. 168):
“… progress notes should begin with subjective data, because progress should be assessed from the patient’s point of view.  Practitioners should be alert to discrepancies between subjective and objective data (for example, where the patient does not feel better when lab results show improvement). These discrepancies may signal an error in data or misstatement of the patient’s problem.”
In short, provider thinking can be disciplined with problem-oriented SOAP notes as a standard of care. Yet, regulators and academics who are in a position to act on this issue have shied away from the whole notion of standards of care for organizing data in medical records. See our comments on ONC’s Stage 2 regs and our comments on the PCAST Report.
The need for standards of care in medical records goes far beyond the SOAP vs. APSO issue in progress notes. In fact, that issue is secondary. Two more fundamental issues for medical records are the following:
  1.  Determining initial inputs to the record. Initial inputs are determined by selection of data needed for the patient’s problem situation, and once the data are collected, analysis of the results.  Both selection and analysis are fatally compromised when determined by the physician’s clinical judgment. External standards and tools, based on a combinatorial standard of care, must govern the selection and analysis. Once that happens, then judgments of patient and practitioners (not just physicians) may supplement the combinatorial minimum standard.  See Medicine in Denial, pp. 53-61, 69-79, 136-37, 145-52.
  2.  Organizing the medical record around the problem list. Once initial data are collected and a complete problem list is defined, then care plans, orders, and progress notes should be problem-oriented, that is, labeled by the problem(s) to which they relate on the problem list. This disciplined practice is essential to justifying provider actions in terms of defined patient needs. Yet this practice is not followed or enforced with consistency. Indeed, some EHR systems do not even enable electronic links between the problem list and care plans, orders and progress notes. See Medicine in Denial, pp. 134-35, 144, 159-60, 166-67.
Like so much else in medicine, medical record practices are a Tower of Babel. Medicine need standards of care for managing clinical information (knowledge and data) no less than the domain of commerce needs accounting standards for managing financial information. This failing is a primary root cause of the health care system’s failures of quality and economy.

For that matter, Lin had more to say than what you saw in the story. He discussed the supposed importance of the subjective and objective elements. “That’s true in cases where there is diagnostic uncertainty,” Lin said. But he added that those components are still there for reference, jut not up front.

Lin called SOAP “a phenomenal innovation,” but suggested that EHR complexity sometimes makes it difficult to find the assessment and plan. For example, he said that a non-Epic EHR in the emergency department at UC Health has as many as 17 different screens for progress notes. “At least with APSO, you would collect the assessment or plan in the first half,” Lin said.

Because SOAP is so entrenched, Lin ran into much resistance when he proposed switching to APSO at 40 affiliated practices. He, of course, heard the tired, “But we’ve always done it this way” defense.

“I learned myself about culture change very acutely,” Lin said. “I was literally shouted out of the room by our physician leadership.” He had neglected to prepare the heads of various departments and clinics for the change in advance of the meeting where he announced the plan.

He subsequently had to have individual conversations with all 40 practice directors. And then Lin dropped a great quote from none other than Niccolo Machiavelli (speaking of Renaissance men): “Those who benefited from the old order will resist change very fiercely.”

Yes, that’s absolutely perfect for an industry as resistant to change as healthcare. But is APSO superior to SOAP? I’d love to hear your thoughts.

May 20, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Patient safety update

I’m passionate about patient safety. I’m happy to report a couple of things that aren’t exactly breaking news, but still worth bringing to your attention.

First off, there is a fairly new peer-reviewed journal called Diagnosis, and it’s about exactly what the title suggests. The first, quarterly issue, from German academic publisher De Gruyter (North American headquarters are in Boston), came out in January, so the second issue should be published soon. The online version is open access. That means it’s free. (A print subscription is $645 a year.)

A highlight of the premiere issue is a submission from the legendary Dr. Larry Weed and his son, Lincoln Weed, discussing diagnostic failure and how to prevent it. “Diagnostic failure is not a mystery. Its root cause is misplaced dependence on the clinical judgments of expert physicians,” they begin. The answer? Clearly defined standards of care and wider use of clinical decision support tools. It’s not anything new. Larry Weed has been advocating this for a good 50 years and saying that the unaided human mind is fallible for probably 60 years. Yet, medicine still largely relies on physicians’ memory, experience and recall ability at the point of care.

This doesn’t mean evidence-based medicine ,which is based on probabilities. Probabilities are fine when the patient has a common condition. They’re useless for outliers. No, Weed has long said that IT systems should help with diagnosis by “coupling” knowledge to the patient’s particular problem, and this starts with taking a complete history.

Weed, of course, created the SOAP (subjective, objective, assessment, plan). I recently talked to a CMIO who is advocating flipping that around a bit  into an “APSO” (assessment, plan, subjective, objective), which he said works better with electronic records. I’ll have more on that in an upcoming article for a paying client, and I’ll probably want to dive into that again in the near future.

For those who still believe American healthcare is safe, effective and efficient, ProPublica worked with PBS Frontline and marketing firm Ocupop last year to produce a video “slideshow” called “Hazardous Hospitals.” It’s worth a view for healthcare industry insiders, and definitely merits sharing with laypeople. I recommend that you share it. Please. Do it. Now. I’m serious. Patient safety is a problem that doesn’t get enough attention. :)

 

March 25, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Breaking: ONC releases proposed 2015 EHR certification criteria

If you want something buried, release it late on a Friday so it doesn’t hit people’s desks until Monday morning. If you really want something buried in health IT, put it out there late on the Friday before the annual HIMSS conference because nobody will get any real work done for another week.

I’m not sure if ONC is trying to hide anything, or just wanted to get this done before all its top people head to Orlando, Fla., for HIMSS14, but this afternoon, the office issued proposed criteria for the 2015 edition of EHR certification. This is the first time certification criteria haven’t accompanied Meaningful Use standards, which means ONC wants to tighten certification requirements in the midst of Meaningful Use Stage 2, rather than waiting for Stage 3, which won’t start before 2017.

However, the plan is to make the proposed 2015 standards voluntary; vendors would be just fine with 2014 certification and providers would not have to upgrade their systems to achieve or maintain Stage 2 Meaningful Use, according to ONC.

ONC says the proposal will officially appear in the Federal Register on Wednesday, triggering a 60-day comment period that will run through April 28. Expect a final rule this summer.

UPDATE, 5:11 pm CST:  It appears that they’re just happy to have it done and to be able to talk it up. In fact, ONC’s Steven Posnack seems downright giddy.

 

Also, self-described HIT standards geek Keith Boone is reading through the whole thing and posting real-time updates on his observations.


 

February 21, 2014 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

The ‘Hospital of Tomorrow’

WASHINGTON—I’ve just finished 2 1/2 days of helping US News and World Report cover its inaugural Hospital of Tomorrow conference. My assignment was to sit in on four of the breakout sessions, take notes, then write up a summary as quickly as possible, ostensibly for the benefit of attendees who had to pick from four options during each time slot and might have missed something they were interested in. Of course, it’s posted on a public site, so you didn’t have to be there to read the stories.

Here’s what I cranked out from Tuesday and Wednesday:

Session 202: A Close-Up Look at EHRs — ‘Taking a Close Look at Electronic Health Records”

Session 303: The Future of Academic Medical Centers — “Academic Medical Centers ‘Must Become More Nimble'”

Session 305: Preventing and Coping With Infections — “How Hospitals Can Better Prevent and Cope With Infections”

Session 401: Provider and Patient Engagement — “Hospitals Grapple With Patient Engagement”

The one on infection control was particularly interesting, in large part due to the panel, which included HCA Chief Medical Officer and former head of the Veterans Health Administration Jonathan Perlin, M.D., Johns Hopkins quality guru Peter Pronovost, M.D., and Denise Murphy, R.N., vice president for quality and patient safety at Main Line Health in suburban Philadelphia.

The session on patient engagement was kind of a follow-on to my first US News feature in September.

If you want to read more about the whole conference, including US News’ live blog, visit usnews.com/hospitaloftomorrow

November 7, 2013 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

More on Blue Button Plus and MU2

My last post, based on comments from Frost & Sullivan health IT analyst Nancy Fabozzi at last week’s Healthcare Unbound conference, has generated a bit of controversy. Fabozzi said that “Blue Button Plus is totally disruptive,” possibly eliminating the need for some providers to get full-fledged patient portals in order to meet Meaningful Use Stage 2 standards.

In the comments under that post, David Smith of HealthInsight.org, a health improvement consortium in three Western states, correctly pointed out that MU2 requires not just that providers give 50 percent of patients electronic access to their records, but also that 5 percent of patients actually view, download and/or transmit information back to their doctors or hospitals. I also got an e-mail from a GE Healthcare executive reminding me that of the view/download requirement as well as the fact that EHR technology had to be certified by an ONC-approved certification and testing body.

The viewing and downloading certainly can be accomplished with Blue Button Plus apps or widgets. In fact, ONC’s Lygeia Ricciardi has said Blue Button Plus could be part of the Stage 3 rules.

Transmitting would seem to necessitate a portal since HIPAA demands — and patients should expect — security when sending protected health information over the Internet. Standard e-mail doesn’t cut it, but e-mail following Direct Project protocols does. MU2 already sanctions Direct Project for health information exchange between healthcare entities. There is no reason why it can’t work for individuals as well, as Dr. Deborah Peel’s Patient Privacy Rights Foundation is trying to facilitate.

This might be a bit unwieldy, asking each patient to set up a Direct e-mail address, but remember, providers only need 5 percent to do so in Stage 2. I see it as perfectly feasible that some small physician practices could bypass the portal and just make do with freely available resources like Blue Button Plus — though Blue Button Plus app developers likely will charge fees — and open-source Direct standards.

UPDATE, July 18, 12:40 a.m. CDT:

HHS itself says Blue Button Plus meets MU2 standards.

From http://www.hhs.gov/digitalstrategy/open-data/introducing-blue-button-plus.html:

Blue Button Plus is a blueprint for the structured and secure transmission of personal health data. It meets and builds on the view, download, and transmit requirements in Meaningful Use Stage 2 for certified EHR technology in the following ways —

Structure: The recommended standard for clinical health data is the HL7 Consolidated Clinical Document Architecture or Consolidated CDA. The C-CDA is a XML-based standard that specifies the encoding, structure, and semantics of a clinical document. Blue Button Plus adopts the requirements for sections and fields from Meaningful Use Stage 2.

Transmit: In alignment with Meaningful Use Stage 2 standards, Blue Button Plus uses Direct protocols to securely transport health information from providers to third party applications. Direct uses SMTP, S/MIME, and X.509 certificates to achieve security, privacy, data integrity, and authentication of sender and receiver.

It sounds to me like compliance is just a matter of making sure that a Blue Button Plus app is certified as an EHR module.

July 17, 2013 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Comprehensive coverage of WTN Media’s Digital Health Conference

As you may know from at least one of my earlier posts, I was in Madison, Wis., last month for a great little health IT event called the Digital Health Conference, a production of the Wisconsin Technology Network and the affiliated WTN Media. In fact, WTN Media hired me to cover the conference for them, so I did, pretty comprehensively. In fact, I wrote eight stories over the last couple of weeks, seven of which have been published:

I still have an overview story that should go up this week.

Why do I say it’s a great little conference? The list of speakers was impressive for a meeting of its size, with about 200 attendees for the two-day main conference and 150 for a pre-conference day about startups and entrepreneurship.

Since it is practically in the backyard of Epic Systems, CEO Judy Faulkner is a fixture at this annual event, and this time she also sent the company’s vendor liaison. Informatics and process improvement guru Dr. Barry Chaiken came in from Boston to chair the conference and native Wisconsinite Judy Murphy, now deputy national coordinator for programs and policy at ONC, returned from Washington. Kaiser Permanente was represented, as was Gulfport (Miss.) Memorial Hospital. IBM’s chief medical scientist for care delivery systems, Dr. Marty Kohn, flew in from the West Coast, while Patient Privacy Rights Foundation founder Dr. Deborah Peel, made the trip from another great college town, Austin, Texas. (Too bad Peel and Faulkner weren’t part of the same session to discuss data control. That alone would be worth the price of admission.)

July 2, 2013 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Don’t forget D.0

While everyone’s scrambling to comply with ANSI X12 5010 standards for HIPAA transactions by Jan. 1—or whenever CMS gets around to enforcing them—there’s another piece of the upgrade that hasn’t been talked about much. That’s the National Council for Prescription Drug Programs’ version D.0 standard for pharmacy transactions.

I got an inadvertent reminder this week when I picked up some prescription refills. One of my meds was out of refills, so my doctor sent a refill electronically (woohoo). Inside the bag of meds was a printout that may not have been intended for me to see, or perhaps I was supposed to mention it to my doctor. The notice contained a “reject message” with the note, “VERSION D.0 REQUIRED AS OF 1/1/2012.

Obviously, the script went through and I got my refill, but I sure hope people don’t start getting prescriptions actually rejected for being in the old NCPDP 5.1 format after the first of the year. Prescribers, get in touch with your vendors. Vendors, remind your e-prescribing clients. It’s not a big change like 5010 and the forthcoming ICD-10, but it’s significant. So get it done.

November 18, 2011 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Podcast: mHealth Initiative’s Peter Waegemann

In 2009, after 25 years of moving “Toward an Electronic Patient Record” (TEPR), the Medical Records Institute disbanded and its founder, Peter Waegemann, shifted his focus to mobile healthcare by creating the mHealth Initiative.

TEPR had grown into a rather substantial event, peaking at 3,800 attendees in 2004, when newly appointed national health IT coordinator Dr. David Brailer was the featured speaker. But attendance and vendor square footage rapidly declined after that, as much of the action in the realm of EMRs either moved to medical specialty societies or the huge HIMSS conference.

Taking a more content-driven than vendor-driven approach, the mHealth Initiative has tried its hand at conferences since last year. (I spoke and served on a panel at the organization’s 2nd mHealth Networking Conference last fall.) A week ago, the group held its third such event in that paradise for lovers of jet noise, Rosemont, Ill., and I sat down with Waegemann to record this podcast.

Podcast details: Interview with Peter Waegemann, chairman and founder of the mHealth Initiative. Recorded March 30, 2011, at the mHealth Initiative’s 3rd Networking Conference in Rosemont, Ill. MP3, mono, 64 kbps, 6.0 MB. Running time 26:02.

0:20     Transition from e-health to m-health after 25 years of running TEPR
1:50    “Total paradigm shift” for documenting and accessing information at the point of care
2:20     No country he’s seen has a complete, effective EMR yet
2:40    Movement from an industrial society to an “information society” of knowledge workers
4:40    Beyond voice communications
6:20    Behavior change in healthcare and adapting to technology
7:20    Lack of connectivity among mobile devices and shortcomings in current technology
8:55    The politics of standards for m-health devices and systems
10:40    Always “five years away”
11:20    Searching for the iPhone of home monitoring
12:00    iPad’s role in healthcare and its shortcomings
13:00    Apps
14:20    EMR vendors discovering mobile devices
15:25    Distinctions between wired health, wireless health and connected health
15:50    “Three pillars” of m-health
16:40     “Communication-enhanced healthcare”
17:35    Better care for less money
19:05    Cell phones in hospitals
20:30    Integration issues
21:00    Patients and younger physicians driving change
22:00    “Unified communications”
22:42    Payment for home monitoring
24:30    European approaches to m-health

April 8, 2011 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.

Big health systems to promote connectivity

Geisinger Health System, Group Health Cooperative, Intermountain Healthcare, Kaiser Permanente and the Mayo Clinic will join together to promote sharing of electronic health data as part of a new organization called the Care Connectivity Consortium. The formal launch is set for 9 a.m. EDT Wednesday at the National Press Club in Washington, and the event will be webcast here.

According to a media advisory, the Care Connectivity Consortium is “a historic interoperability collaboration among five of the nation’s leading health systems to securely share electronic health information and best practices.” Executives from the organizations will be on hand to “will discuss the goals of the consortium, how sharing electronic health data supports high quality, patient-centered care, and the possibility of sharing electronic data in a secure environment.”

It sounds intriguing, but the five participants don’t have much geographic overlap, save for Kaiser’s reciprocal care agreement with Group Health in the Seattle area. Don’t expect any overnight miracles.

That aside, I’d really like to know the standards they’ll be using for data sharing. If they pick something that’s unformatted text, à la Blue Button, this initiative might be doomed to failure.

UPDATE 12:30 p.m. CDT: A publicist for the consortium tells me that the health systems will be following NHIN protocols for data sharing.

April 4, 2011 I Written By

I'm a freelance healthcare journalist, specializing in health IT, mobile health, healthcare quality, hospital/physician practice management and healthcare finance.