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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.

‘Escape Fire’ leaves out IT, ultimately disappoints

I finally got the opportunity to catch the documentary film “Escape Fire,” a good 15 months after it went into limited theatrical release and became available in digital formats. I thought it would be an eye-opening exposé of all that ills the American healthcare industry, particularly for those who somehow believe we have the greatest care in the world. I excitingly ran this graphic when I first mentioned the movie on this blog back in October 2012:

The well-paced, 99-minute film interviews some notable figures in the fight to improve American healthcare — safety guru and former CMS head Dr. Don Berwick, journalist Shannon Brownlee, integrative medicine advocates Dr. Andrew Weill and Dr. Dean Ornish — as well as some lesser-known people trying to make a difference. It goes through a laundry list of all the culprits in the overpriced, underperforming mess of a healthcare system we have now, and examines approaches that seem to be producing better care for lower cost.

I expected the movie to have a liberal slant, but it really stayed away from the political battles that have poisoned healthcare “reform” the last couple of years. About the only presence of specific politicians were clips of both President Obama and Senate Republican leader Mitch McConnell both praising a highly incentivized employee wellness program at grocery chain Safeway that reportedly kept the company’s health expenses flat from 2005 through 2009, a remarkable achievement in an era of escalating costs.

However, filmmakers Matthew Heineman and Susan Froemke did discuss all the lobbyists’ money presumably buying off enough votes in Washington and at the state level that has helped entrench the status quo. They even scored an interview with Wendell Potter, the former top media spokesman for Cigna, who became a public voice against abuses by health insurers because his conscience got the better of him. As Brownlee noted in the film’s opening, the industry “doesn’t want to stop making money.”

Other reasons given for why healthcare is so expensive, ineffective and, yes, dangerous include:

  • direct-to-consumer drug advertising leading to overmedication;
  • public companies needing to keep profits up;
  • fee-for-service reimbursement;
  • the uninsured using emergency departments as their safety net;
  • lack of preventive care and education about lifestyle changes;
  • a shortage of primary care physicians;
  • cheap junk food that encourages people to eat poorly; and
  • severe suffering among the wounded military ranks.

The filmmakers also kind of imply that there isn’t much in the way of disease management or continuity of care. Brownlee described a “disease care” system that doesn’t want people to die, nor does it want them to get well. It just wants people getting ongoing treatment for the same chronic conditions.

One physician depicted in the movie, Dr. Erin Martin, left a safety-net clinic in The Dalles, Ore., because the work had become “demoralizing.” The same people kept coming back over and over, but few got better because Martin had to rush them out the door without consulting on lifestyle choices, since she was so overscheduled. “I’m not interested in getting my productivity up,” an exasperated Martin said. “I’m interested in helping patients.”

Another patient in rural Ohio had received at least seven stents and had cardiac catheterization more than two dozen times, but never saw any improvement in her symptoms for heart disease or diabetes until she went to the Cleveland Clinic, where physicians are all on salary and the incentives are more aligned than they were in her home town. As Berwick importantly noted, “We create a public expectation that more is better.” In this patient’s case, she was over-catheterized and over-stented to address an acute condition, but not treated for the underlying chronic problems.

The film also examined how the U.S. military turned to acupuncture as an alternative to narcotics because so many wounded soldiers have become hooked on pain pills. One soldier, a self-described “hillbilly” from Louisiana, got off the dozens of meds he had become addicted to and took up yoga, meditation and acupuncture to recover from an explosion in Afghanistan that left him partially paralyzed and with a bad case of post-traumatic stress disorder. The only laugh I had in the movie was when he told the acupuncturist at Walter Reed Army Medical Center in Washington, “Let’s open up some chi.”

I kept waiting and waiting for some evidence of information technology making healthcare better, but I never got it. After leaving the Oregon clinic, Martin took a job at a small practice in Washington state where she was seen toting a laptop between exam rooms, but, for the most part, I saw paper charts, paper medication lists and verbal communication between clinicians.

What really bothered me, however, is the fact that there was no discussion of EHRs, health information exchange or clinical decision support, no mention of the problem of misdiagnosis, no explicit discussion of patient handoffs, continuity of care, medication reconciliation and so many other points where the system breaks down. You can’t truly fix healthcare until you address those areas.

 

January 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.

Things change pretty fast in health IT, don’t they?

Yes, things do change pretty fast in health IT. I realized this over the past couple of weeks when I updated my database of contacts by scanning and categorizing about 300 business cards I’ve collected over the past 2½ years. (I really let things pile up this time. Now that my desk is reasonably clean, I hope I never do that again. I can claim extraordinary circumstances in 2012, but that only accounts for one year.)

What really struck me, in addition to the amount of time I let this slide, is the number of new categories I had to create in the database and the number I had to modify. My contacts go back to when I started covering healthcare in October 2000, and I’ve had a card scanner for at least 10 years. I had “PDA” and “ASP” as two of the choices until I changed them to “smartphone” and “SaaS” within the last couple of years.

Here are a few terms that are new in my database since I last did a thorough update, probably early in 2011:

  • accountable care
  • analytics (as opposed to data mining)
  • business incubator
  • remote monitoring

I also can’t believe I didn’t have CIO as a category until this month.

Some of the changes reflect a shift in what I’ve covered, but some terms are pretty new. Did you know what accountable care was prior to 2010? Were there many business incubators or accelerators in healthcare before Rock Health started up in 2011? I don’t know of any.

By the same token, when was the last time anyone talked about a PDA, an ASP or RHIO? Perhaps it’s just been a change in semantics, but the real change has been in the technology and the focus of healthcare executives. (Come to think of it, some of the tags on this blog are a bit out of date. I’ve been blogging since 2004. You get the picture.)

On another note, thanks to Healthcare Scene guru John Lynn, who hosts this blog for me, for, without my prompting, promoting the fact that I’m cycling 100 miles in an event called the Wrigley Field Road Tour on Sunday, Aug. 25, for the third year in a row. The ride supports an organization called World Bicycle Relief, which provides specially made bikes to remote villages in Africa so people who are otherwise without transportation can get to school and jobs. It also benefits Chicago Cubs Charities, which funds a number of youth programs in the Chicago area. (The ride’s co-founders are World Bicycle Relief founder F.K. Day, whose family owns bike component maker Sram, and Todd Ricketts, whose family controls the Cubs.)

Within the last two weeks, I suddenly got a surge of donations from people within the health IT community, and I couldn’t figure out why. Now I know. If you’d like to help, here’s my fundraising page.

One unexpected donor was Todd Stein of healthcare PR firm Amendola Communications. I’d be remiss if I didn’t mention that he is fundraising to help offset medical expenses of a colleague whose 3-year-old son faces surgery for a brain tumor. From that page:

Kathy C., a friend and colleague (who has always been the first to help but the last to ask for help and so wants to remain anonymous) is a single mother of three children all under the age of 7. Her 3-year-old son “James” was recently diagnosed with a brain tumor.

The surgery will cost hundreds of thousands of dollars. Unfortunately, Kathy has a $10,000 deductible on her health insurance plan and stands to pay out of pocket costs that are estimated at three times that amount. James is going in for the first of a series of surgeries this week and paying tens of thousands of dollars in medical expenses is a hardship for anyone, especially a hard working single mother of three young children.

Please keep Kathy and James in your prayers and give whatever you can to support their urgent need. Just giving up a daily coffee for one week and giving that amount would make a world of difference.

And now, it’s just about 5 o’clock here in Chicago, so please enjoy your weekend.

 

 

August 16, 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.

My HIMSS will be all about quality and patient safety

As regular readers might already know, 2012 was a transformative year in my life, and mostly not in a good way. I ended the year on a high note, taking a character-building six-day, 400-mile bike tour through the mountains, desert and coastline of Southern California that brought rain, mud, cold, more climbing than my poor legs could ever hope to endure in the Midwest, some harrowing descents and even a hail storm. But the final leg from Oceanside to San Diego felt triumphant, like I was cruising down the Champs-Élysées during the last stage of the Tour de France, save the stop at the original Rubio’s fish taco stand about five miles from the finish.

But the months before that were difficult. My grandmother passed away at the end of November at the ripe old age of 93, but at least she lived a long, full life and got to see all of her grandchildren grow up. The worst part of 2012 was in April and May, when my father endured needless suffering in a poorly run hospital during his last month of life as he lost his courageous but futile battle with an insidious neurodegenerative disorder called multiple system atrophy, or MSA. (On a personal note, March is MSA Awareness Month, and I am raising funds for the newly renamed Multiple System Atrophy Coalition.)

That ordeal changed my whole perspective, as you may have noticed in my writing since then. No longer do I care about the financial machinations of healthcare such as electronic transactions, revenue-cycle management, the new HIPAA omnibus rule or reasons why healthcare facilities aren’t ready to switch to ICD-10 coding. Nor am I much interested in those who believe it’s more worthwhile to take the Medicare penalties starting in 2015 for not achieving “meaningful use” than to put the time and money into adopting electronic health records. I’m not interested in lists of “best hospitals” or “best doctors” based solely on reputation. I am sick of the excuses for why healthcare can’t fix its broken processes.

And don’t get me started on those opposed to reform because they somehow believe that the U.S. has the “best healthcare in the world.” We don’t. We simply have the most expensive, least efficient healthcare in the world, and it’s really dangerous in many cases.

No, I am dedicated to bringing news about efforts to improve patient safety and reduce medical errors. Yes, we need to bring costs down and increase access to care, too, but we can make a big dent on those fronts by creating incentives to do the right thing instead of doing the easy thing. Accountable care and bundled payments seem like they’re steps in the right direction, though the jury remains out. All the recent questioning about whether meaningful use has had its intended effect and even whether current EHR systems are safe also makes me optimistic that people are starting to care about quality.

Keep that in mind as you pitch me for the upcoming HIMSS conference. Also keep in mind that I have two distinct audiences: CIOs read InformationWeek Healthcare, while a broad mix of innovators, consultants and healthcare and IT professionals keep up with my work at MobiHealthNews. For the latter, I’m interested in mobile tools for doctors and on the consumerization of health IT.

I’m not doing a whole lot of feature writing at the moment, so I’d like to see and hear things I can relate in a 500-word story. Contract wins don’t really interest me since there are far too many of them to report on. Mergers and acquisitions as well as venture investments matter to MobiHealthNews but not so much to InformationWeek. And remember, I see through the hype. I want substance. Policy insights are good. Case studies are better, as long as we’re talking about quality and safety. Think care coordination and health information exchange for example, but not necessarily the technical workings behind the scenes.

And, as always, I tend to find a lot more interesting things happening in the educational sessions than in that zoo known as the exhibit hall. I’m there for the conference, not the “show.”

Many of you already have sent your pitches. I expect to get to them no later than this weekend, and I’ll respond in the order I’ve received them. Thank you kindly for your patience.

February 13, 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.

My first portal experience

Yes, after all these years of writing about EMRs, EHRs, PHRs, patient portals and the like, I have had my first real personal experience with a patient portal, courtesy of my internist.

He still has a small practice, with four other physicians, including one fresh out of residency. Those small practices are a dying breed, but this doctor is changing with the times, too. He recently offered a concierge option for a few hundred patients. I declined because I don’t need to reach him that urgently.

The portal has been in place for a couple of years, and I may have logged in once or twice before to set up an account, but didn’t really do anything other than look around. This time, prompted by an e-mail informing me of a new URL, I logged in and checked my medication list. I remembered that another doctor had changed the dosage of one of my medications a while back, so I fired off a secure message informing this practice of the change. (It was a new URL presumably because the EHR vendor formerly known as Sage Healthcare adopted the Vitera Healthcare Solutions name a year ago and was switching its customers to a common, white-labeled portal.)

I also looked at some of my test results from a year and a half ago just to confirm that everything was more or less OK then, though I did see one abnormality with my HDL cholesterol. I last went for a physical in March 2011, about a month after I ungracefully cut my face open on a bathtub in Orlando during HIMSS11, so I was probably due. This practice lets patients request appointments — not actually choose open slots — online, so I sent my request. Tonight, about 24 hours later, I got my confirmation, and I’ll be seeing the doc in a couple of weeks.

It’s not a perfect system, but it was convenient enough for a night owl like myself who might not remember to call during business hours to make an appointment or simply not want to wait on hold or press a bunch of buttons to navigate a telephone menu. I did not see the Blue Button option to download my record that the federal government is pushing private vendors to adopt, but I’m sure that will be there by the time the practice is ready for “meaningful use” Stage 2 in a year or two. I don’t have a PHR anyway, so I wouldn’t be able to do anything with the data other than print it.

I suppose I should set up an emergency PHR at some point, even though I doubt any hospital or specialist I might get referred to would take the time to download my data from a USB drive or log into someone else’s portal. Untethered PHRs simply don’t fit physician workflow. That might change in MU Stage 2 when providers will have to send electronic discharge statements and patient summaries during transitions of care, but I’m still not convinced a patient-controlled PHR will be the right vehicle for these data transfers.

 

October 31, 2012 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: Gartner’s Vi Shaffer on HIE, ACOs and meaningful use

Back in June, I covered the Wisconsin Technology Network’s Digital Healthcare Conference in Madison. That conference featured a panel with Vi Shaffer, research vice president and industry services director for healthcare providers at Gartner, Judy Murphy, vice president of information services at Aurora Health Care in Milwaukee, and Epic Systems CEO Judy Faulkner, based in nearby Verona, Wis.

The panel discussed the question, “Is meaningful use a floor or a ceiling?” as I reported for WTN News. The conference also featured several sessions on how business intelligence and health information exchange can support Accountable Care Organizations.

A month later, I saw Shaffer again at AMDIS Physician-Computer Connection meeting in Ojai, Calif. There, she presented preliminary data from Gartner’s annual survey of CMIOs. After the conference ended, I got a chance to sit down with Shaffer for this podcast. Since the fog and clouds finally lifted on the final day, we decided to record this outdoors at the beautiful Ojai Valley Inn, which is why you will hear some birds and other (human) creatures in the background. We don’t care, it was too nice to sit indoors.

We mostly discussed how HIE can support ACOs, but we also touched on meaningful use and health reform in this lively interview. Enjoy.

Podcast details: Interview with Vi Shaffer, research vice president and industry services director for healthcare providers at Gartner. Recorded July 15, 2011, in Ojai, Calif. MP3, mono, 64 kbps, 7.9 MB. Running time 17:14.

1:35 ACO as a business model and a fundamental change in the needs of patients (chronic disease)

3:00 Interoperability for care coordination 3:50 Will ACO model be better than disease management as it exists today?

4:50 Nature of proposed rules

7:30 Importance of innovation because “meeting the metrics is average.”

9:05 Is meaningful use a floor or a ceiling? Is an ACO a floor or a ceiling?

10:46 Ambulatory services growing faster than hospital services

12:38 “Oligopolies” in healthcare building interoperability and continuums of care

14:40 How far can you go with interoperability in this changing healthcare climate?

15:19 Targeted panel management rather than population health

August 12, 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.