Survival


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So, the question has been raised: why am I doing this?  Why re-invent the EMR wheel?  What is so different about what I am doing that makes it necessary to go through such a painful venture?  I ask myself this same question, actually.
Here\’s my answer to that question:

What medical record systems offer

What I need

High focus on capturing billing codes so physicians can be paid maximum for the minimum amount of work.

No focus on billing codes, instead a focus on work-flow and organization.

Complex documentation to satisfy the E/M coding rules put forth by CMS.  This assures physicians are not at risk of fraud allegation should there be an audit.  It results in massive over-documentation and obfuscation of pertinent information

Documentation should only be for the sake of patient care.  I need to know what went on and what the patient’s story is at any given time.

Focus on acute care and reminders centered around the patient in the office (which is the place where the majority of the care happens, since that is the only place it is reimbursed)

Focus on chronic care, communication tools, and patient reminders for all patients, regardless of whether they are in the office or not.  My goal is to keep them out of the office because they are healthy.

Patient access to information is fully at the physician’s discretion through the use of a “portal,” where patients are given access to limited to what the doctor actively sends them.

A collaborative record, sharing most/all information with patients so they can use it in other settings for their care.  Also, I want patients to have edit privileges for things they better suited to maintain, like medication lists, demographics, insurance information, and past history items.

Organization of information is not a high priority, as physicians are not reimbursed for organized records.  The main focus is instead on meeting the “meaningful use” criteria, which gives financial incentive to physicians who use a qualified record system.

Since the goal is to share the record and to maximize care quality to make communication more efficient, organization of the record is crucial.  The goal is to put the most important information up front and to give easy access to the details sought.  I am the “curator” of the record, organizing it and prioritizing information in a way that is useful to both me and my patients.

Top priority is paid to billing workflow, with second billing given to in-office patient management (not apparent to most patients).  The least attention is given to clinical workflows for patients outside of the office.

My priorities are 180 degrees from this.  My top priority is keeping people outside of the office healthy and happy (which will keep them paying their monthly payments), so maximizing organization and communication need to be the focus of my records.  Certainly in-office care needs to be efficient, but not in the same way as the rest of the healthcare system (efficient documentation for payment); it must focus on getting the most accurate information into the system and making it easiest to get information out.  Billing is almost a non-issue, as it is very simple in my system.

Task management is again a low priority, as it increases potential non-reimbursed work for physicians (and staff) in the typical office.  For example, there is not much emphasis put on phone office follow-up or making sure the plan is communicated to the patient.  This is not strictly avoided, as most medical professionals do want to give good care, but the high-stress overworked atmosphere in most offices makes most medical personnel reject any tool that gives “extra work.”

Task management is near to the top.  I am focused on coming up with a care plan for each patient and making sure the patient understands that plan.  The goal is to reduce the chance of misunderstanding, as it increases my work and decreases the patient’s chance for health.  So an integrated task-management tool is very important, as is education resources which can be accessed directly from the patient record and given to the patient to keep (ideally) in an online “folder.”

Mobile communication is becoming more available, but it is very much system-centric, meaning that it is built by the EMR vendor to only be used by patients of physicians who use that EMR and to only be for viewing information from the physician, not as a patient-centered tool.

My goal is to give patient access to accurate medical information and access to me in a way that is easy and efficient.  Mobile technology is the most obvious means to this end.  I want patients to be able to access their entire record, not just what I generate, from a mobile application (or at least a web application).  I want any place they get information to also be the communications hub, as it allows them to communicate with as much information as possible.  In short, I am looking to have a “one stop shop” for all patients’ needs, not a “walled-garden” that only gives them access as long as they see a doctor that uses the system.

Payment for health services generally depends on two things: a problem being treated and a procedure code.  These are both, therefore the focus of the record system.  Problem lists are in the record, not primarily because they help with care, but to allow billing for services.

I believe we should focus far more on reducing risk factors than on treating “problems.”  My goal is to avoid problems and do fewer procedures when and where at all possible.  Problem lists should not be focused on code, but instead to give the most accurate information to lead to the best decisions, and to help understand the risks the patient faces so problems can be avoided.  If this happens, I will have less procedures, a fact that will make both me and my patients happy.

Optimistically, the ultimate goal of the typical EMR is to allow a physician to practice the best medicine possible while not going out of business.  It allows physicians to give good care despite the system that rewards them for bad care.

The goal of my record system is to promote the success of a new business model: pay doctors more to keep people well and to keep people out of the rest of the health care system.  The ultimate goal of this record system is not to make money for me as software I can sell, but to make it so I can extend the model efficiently to a larger population, ultimately making this new system of care an attractive enough alternative to physicians, employers, and patients to make the switch.  Perhaps in doing so the “do more, spend more” system can be replaced by a welcome alternative.

So here is the goal:

  • Create a prototype of a system that allows me to give my system of care efficiently to a large population.
  • Use that prototype to “prove concept” – that the care I give is better for patients, better for me, and saves money.
  • Create enough interest in the model that people are willing to develop the system. I think this is best done through making it open source and setting up a foundation to fund the program (and let me gladly hand it off to people who are better at this than I am).
  • This will ultimately lead to more adoption of the practice model (by making it easier to make the transition), which will in turn lead to more interest and funding in the software.

I don’t believe we can retro-fit a standard EMR product to do this job; I think their focus is too different from the goals of this practice model. I may be wrong, but I looked at numerous systems and found that they fought against my goals instead of enabling them. I turned to this idea not out of ambition, but out of a desire to survive and see my practice model succeed.

12 thoughts on “Survival”

  1. Rob, This is amazing. This is the type of software project I’d love to work on (or even lead development!) I. The future. I think the open source, open platform, model could be a huge win. Other HIT vendors have been successful at giving away the software and source code and then charging for premium support and sometimes premium features (see Mirth as an example).
    I currently lead software development for an HIT vendor than sells self-service patient kiosks and other registration workflow solutions, http://www.clearwaveinc.com. The whole ROI of our software and hardware is to improve the accuracy and efficiency in which patient information is collected for billing and collect more money from the patient during office visits. And it’s a huge win. But when working with EMR and practice management vendors, it’s striking how little focus there is on patient care from an IT perspective. Everything you’ve noted in this article resonates with my experience. (As a side note I wanted to mention how many of these vendors also fail in the user experience; the software is hard to use and doesn’t always solve their billing and patient management problems.)

    I also think you’ve give us an important observation in that the payment model of healthcare is key. And as a result virtually no existing software or platform is good enough to use as a starting point.

    I love these posts. They get my mind churning and my entrepreneural spirit energized.

  2. Thanks! I am hoping to pique enough interest with these posts to be able to set up a foundation to build this platform which ultimately promotes the system of care. I actually see the product being a lot like WordPress in that there could be a marketplace of add-ons or plug-ins that could enhance the product so it could be customized (widgetized?) to meet needs or preferences of different doctors while still having the overall same structure. I personally have no desire to do software support, but feel that the heart of this has to come from a physician actually doing it – it has to come out of true necessity, not just perception of need. That has caused it to end up looking much different than expected.

    I do have a group of folks around me believing in this project because of the potential of what it can do for health care in the bigger picture. We shall see, but I would tell you to stay tuned and in touch as this develops. We want as many hands on deck as possible once it gets rolling. We’ve just got to do it right (which is why it’s taken me so long up to now).

  3. hopefully helpful

    Dr. Rob, you might want to contact a direct primary care practice in Wichita, Kansas, called Atlas MD. I believe they have created their own EHR system that might meet some of your needs

  4. AN EHR focussing on chronic care- which takes 70% of my time and 20% reimbursement would be heaven.!

  5. What you have toward your advantage is some of the literature behind EHR usability that wasn’t there when EHRs were first (superficially) incentivized by HITECH & ARRA/MU. That and a better picture of MU requirements (which need to be accounted for in a new app to avoid penalties). There’s a lot to learn from the failures (and few successes) of EHRs currently on the market. I’m subscribed! If you see room on your team for an EHR/data viz person, let’s get in touch.

    Cheers!

    Bogdan

  6. Dr. Josh, AtlasMD

    All great ideas indeed! We share a very similar goal and vision. We’re already integrating with a number of consumer products like fitbit and more to come on board fast and furious! Keep it up.

  7. Dr. Josh, AtlasMD

    You’re absolutely right!! The end user, the physician/staff is the last person that is considered in a typical emr. That is why we built http://www.atlas.md on modern iOS-technology to maximize the for physicians and ultimately patients.

  8. Rob,All of the points you mentioned in your post are valid and prescient, especially in these times when we need an infusion of new ideas in our healthcare system to improve care and lower costs. I stand with your philosophy and as a fellow physician who has been in your shoes as a solo independent primary care physician, I’d like to offer an opportunity to see my project that happens to also be a tool. Firstly, as opposed to other EHRs, mine is open source (as you indicated a preference of how such a prototype would be conceived). I’ll go over a brief checklist to show you that such a prototype already exists and let’s combine our cognitive efforts to make this even better. I’ll be referencing some these comments to my blog (google NOSH ChartingSystem) and you’ll see what I’m talking about.
    “No focus on billing codes, instead a focus on work-flow.” – NOSH is designed to be workflow aware from a physician’s point of view. Billing is secondary and billing companies don’t like my system for just that reason (I’ve had to work with some of them and they are certainly confused because it’s not like any other EHR they have seen).
    “Documentation should only be for the sake of patient care. I need to know what went on and what the patient’s story is at any given time.” – I agree. NOSH isn’t designed to make sure you bill correctly and have all the documentation needed to meet the level of service, etc. It was designed to allow a physician to view pertinent clinical data in as little steps as possible to get it.
    “Focus on chronic care, communication tools, and patient reminders for all patients, regardless of whether they are in the office or not.” – NOSH has a built-in reminders system (for any orders you make for instance, automatically without additional input, so that you don’t lose track of orders that were made and needing results). NOSH is completely web-based so that you can access it from anywhere, securely, as long as you have a web browser.
    “A collaborative record, sharing most/all information with patients so they can use it in other settings for their care. Also, I want patients to have edit privileges for things they better suited to maintain, like medication lists, demographics, insurance information, and past history items.” – NOSH has a built in patient portal that does most of what you just mentioned. Patients can message to your provider securely within its own network with this portal feature, schedule appointments, review results, and pretty soon, patient forms that get incorporated into your chart/encounter without having the extra step of re-entering data from paper to digital.
    “Since the goal is to share the record and to maximize care quality to make communication more efficient, organization of the record is crucial” – Check out my live demo (the real thing, not a screenshot or a need to contact me to schedule a meeting). You’ll see that organization of the record is geared to a clinical first and foremost in a simple, uncluttered interface.
    “Task management is near to the top.” – The first screen you see when you log into NOSH is a task list.
    “My goal is to give patient access to accurate medical information and access to me in a way that is easy and efficient. Mobile technology is the most obvious means to this end.” – NOSH is totally usable for mobile devices (iPads, tablets, and phones) out of the box because it is web-based.
    “I believe we should focus far more on reducing risk factors than on treating “problems.”” – I totally agree. One of the new features being developed currently is the ability to do tagging of any element of the chart and encounter. Tagging allows physicians (like the way tags work on blog systems) to categorize any aspect of the chart so that it can be analyzed later for any reason. It the tag is not restricted to diagnoses codes or problems (it can if you want). That is the total power of personalization that NOSH can accomplish.
    “I think this is best done through making it open source and setting up a foundation to fund the program (and let me gladly hand it off to people who are better at this than I am).” – I agree. The cool thing about open source is the ability to collaborate openly. And there is no right way to do it and open source gives anyone the ability to agree to disagree about how a product should work. I give full license to anyone who wants to fork my project for other purposes because I know that every health care provider is different. As an open source project leader, software coder, developer, and a practicing physician, I totally get what you are looking for. I’m already working with some other health care providers that get this too (locally in Portland and all across the world and through this project, we are building a community. Come join us. Google “nosh chartingsystem indiegogo” to know more about my project and my current Indiegogo crowd funding campaign to spread the word about my quest to change the health care IT landscape for the benefit of independent and outpatient health care providers of any specialty.

  9. Dr. Lamberts,

    Great posts — and great blog. I’m President of Physicians Angels, and we provide virtual medical scribes to clinics throughout the U.S. (“virtual” means remote, off-site). We work with over 50 EMRs now. We’re also deep into developing a new and better EMR, along with a PHR, for the U.S. and certain international markets. Would love to speak more with you. I’m at .

    Regards,
    Kevin Brady

  10. Dr. Federico Pedernera

    Dear Robert
    I came to your Blog by a friend’s recommendation of this post.
    As a doctor I agree 100% with you, it’s about go back to the roots. And as a specialist in Medical Informatics I’ve been working along with other colleagues to creat a product/service to meet step by step with your espectations, our espectations. Thus we created a startup to offer a Web-based solution focused on doctors needs.
    So thank you again for spread in a such good way what we’ve thinking.

    Best regards from Argentina
    Federico Pedernera.
    http://www.epicrisisweb.com

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