{"id":1,"date":"2014-06-16T16:28:10","date_gmt":"2014-06-16T16:28:10","guid":{"rendered":"http:\/\/healthcare.davidstates.net\/?p=1"},"modified":"2014-06-16T16:59:26","modified_gmt":"2014-06-16T16:59:26","slug":"hello-world","status":"publish","type":"post","link":"http:\/\/healthcare.davidstates.net\/?p=1","title":{"rendered":"EHRs are awful, we can do better"},"content":{"rendered":"

Medical records have always been about communication. \u00a0Communication with\u00a0<\/span>yourself across time, communication with other providers and yes,\u00a0<\/span>communication with billing and finance. \u00a0Categorical data is necessary,\u00a0<\/span>particularly for the latter, but communicating uncertainty and alternative\u00a0<\/span>interpretations has always been an important aspect of medicine, and it is\u00a0<\/span>very difficult in the context of a modern EMR.<\/span>

Informatics is in a hole with administration because most\u00a0<\/span>EMRs do not increase provider productivity. \u00a0There is some evidence the EMRs\u00a0<\/span>increasing billing per encounter, but too often this does not offset the\u00a0<\/span>increase in time required for providers to complete an EMR note. \u00a0Billable\u00a0<\/span>encounters per provider hour is a critical administrative metric. \u00a0When informatics\u00a0<\/span>proposes enhancements and additions to the EMR, administration is thinking is “You have\u00a0<\/span>already whacked encounters per hour by 20% and now you want to add more?”<\/span>

But, for all the enormous resources devoted to IT in a modern healthcare\u00a0<\/span>organization, a surprisingly small fraction of the compute power is actually\u00a0<\/span>devoted to the central task of communicating among providers about patient\u00a0<\/span>care. \u00a0Most of the money going to IT is about security, billing, scheduling,\u00a0<\/span>inventory management and other necessary but ultimately administrative\u00a0<\/span>tasks. \u00a0And most of the big\u00a0dollars going to all those consultants\u00a0<\/span>is about maximizing reimbursement rather than optimizing care. \u00a0By\u00a0<\/span>comparison, the task of hosting a form based web interface for providers to\u00a0<\/span>view history and test results and to enter EMR data is a trivial task\u00a0<\/span>requiring only modest compute resources.<\/span>

We can do better. \u00a0Much better. \u00a0Advanced natural language processing should\u00a0<\/span>be capable of holding an intelligent conversation with a provider about a\u00a0<\/span>patient. \u00a0Think Siri with a \u00a0database focused centrally on the patient at\u00a0<\/span>hand. \u00a0Note that this is a greatly restricted space compared to what generic Siri deals with now. \u00a0Forget stock markets, sports scores or the weather, just hold a conversation about a specific patient’s medical conditions. \u00a0Smaller scope of interest translates improved accuracy, basic multiple hypothesis testing. \u00a0This would still require a lot of compute power you say, but if it\u00a0<\/span>increased billable encounters per hour by 10%, it would easily be worth\u00a0<\/span>$10\/hr per provider, and for $10\/hr you can rent half a dozen maximal\u00a0<\/span>configured high performance compute systems on the Amazon EC2 cloud\u00a0<\/span>aggregating to hundreds of CPUs with hundreds of GB of RAM and terabytes of\u00a0<\/span>SSD disk PER PROVIDER. \u00a0That is a lot of compute power. \u00a0Are you seriously\u00a0<\/span>telling me we cannot implement:<\/span>

Siri: How is Mrs. Doe doing this month?<\/span><\/p>\n

Doc: She seems to be doing well.<\/span><\/p>\n

Siri: So the UTI for which you prescribed Macrobid has resolved?<\/span><\/p>\n

Doc: Yes.<\/span><\/p>\n

Siri: Her blood pressure has been close to 140 over 90 on the past two\u00a0<\/span>visits. \u00a0Do you want to increase the dose of her Lisinopril or metoprolol?<\/span><\/p>\n

Doc: \u00a0How much metoprolol is she on now?<\/span><\/p>\n

Siri: Extended release 25 mg a day.<\/span><\/p>\n

Doc: Increase to 50.<\/span><\/p>\n

Siri: Changing metoprolol extended release to 50 mg daily.<\/span><\/p>\n

Siri: Her glucometer dump showed a median blood sugar of 138 with no\u00a0<\/span>readings above 252 or below 83. \u00a0Continue her current diabetes regimen?<\/span><\/p>\n

Doc: Yes.<\/span><\/p>\n

Siri: Any new problems?<\/span><\/p>\n

Doc: No.<\/span><\/p>\n

Siri: Standard outpatient physical exam?<\/span><\/p>\n

Doc: Yes, no concerns.<\/span><\/p>\n

Siri: She is due for an A1c and annual diabetic eye exam. \u00a0Go ahead and\u00a0<\/span>schedule those?<\/span><\/p>\n

Doc: Yes.<\/span><\/p>\n

Siri: So we are going to bill for a moderate to high intensity visit<\/span>
addressing follow up on the UTI, hypertension management and diabetes\u00a0<\/span>management?<\/span><\/p>\n

Doc: Sounds good.<\/span><\/p>\n

Siri: Here is the chart note for your review and signature.<\/span>

And perhaps at some point, Dr. Siri will be speaking directly to the<\/span>
patient.<\/span>

We need a vision of informatics as enhancing communication\u00a0<\/span>and productivity. \u00a0No excuses for forcing people to work for the computer.\u00a0<\/span>With the compute resources available in modern environments, the computers\u00a0<\/span>can let the people work in the ways people are most comfortable and\u00a0<\/span>productive. \u00a0And yes, we can do better on billable encounters per provider\u00a0<\/span>hour.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

Medical records have always been about communication. \u00a0Communication with\u00a0yourself across time, communication with other providers and yes,\u00a0communication with billing and finance. \u00a0Categorical data is necessary,\u00a0particularly for the latter, but communicating uncertainty and alternative\u00a0interpretations has always been an important aspect of medicine, and it is\u00a0very difficult in the context of a modern EMR.Informatics is in a … Continue reading EHRs are awful, we can do better<\/span> →<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-1","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"_links":{"self":[{"href":"http:\/\/healthcare.davidstates.net\/index.php?rest_route=\/wp\/v2\/posts\/1","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/healthcare.davidstates.net\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/healthcare.davidstates.net\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/healthcare.davidstates.net\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/healthcare.davidstates.net\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1"}],"version-history":[{"count":5,"href":"http:\/\/healthcare.davidstates.net\/index.php?rest_route=\/wp\/v2\/posts\/1\/revisions"}],"predecessor-version":[{"id":8,"href":"http:\/\/healthcare.davidstates.net\/index.php?rest_route=\/wp\/v2\/posts\/1\/revisions\/8"}],"wp:attachment":[{"href":"http:\/\/healthcare.davidstates.net\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/healthcare.davidstates.net\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=1"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/healthcare.davidstates.net\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=1"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}