This is Part 2 of a three-part blog post. Emphasis of Big Data acquisition and analysis is supposed to improve healthcare. We emphasize that healthcare collaboration is a way to deal with the massive amounts of data considered to be medical knowledge that has grown beyond mastery of anyone. That said, we also are concerned that attempts to improve quality and profitability remove focus from care and caring. The first post described one source of errors. This second post will show how this error can happen in clinical practice -- with or without healthcare collaboration. The third will suggest a solution. The whole set of the three should bring fair warning to those who hear the sirens of Big Data which is done poorly, and help them look to solutions which are done well.

The past few weeks have brought huge attention to the analysis of data to health care. Much promise has been given to disease detection, epidemiology trends, bioterrorism, and business intelligence. Savings are promised as well as improved care.

iClickCare helps erroneous interpretation by including images, words, discussion and judgment.

EMR and EHRs with financial metrics are the foundations upon which Big Data is being built. They are taking up a considerable part, even a majority, of the day in the life of the provider. What of the rest of the day, a day like this one? To be kind in description, less than user friendly EMR's are being inserted into the office work flow. This process is called “Go Live” which is a stretch of definition of zombie-like software.

All of a sudden four exam rooms are filled and three more patients sit anxiously in the waiting room. The first exam room is occupied by an elderly, somewhat demented, 86 year old with black and blue eyes following a fall. His facial fractures are multiple, and not classic. There are fractures across and within the edentulous maxilla, the nasal bones are involved. There is an extension to the orbit on one side. The zygomatic arch is displaced. With difficulty, they could be classified as LeFort II and a half. Not exactly, but sort of close enough. For patient care, the classification does not matter, the treatment will be the same. We will need to code this visit properly, we know. Why? Because and it will take searching through lists of codes.

The second room corrals a crying 13 month old who has just been sent to the office from the emergency room with a dog bite of the left lower eyelid. She is accompanied by two distraught parents and one distraught grandmother. The next room in line finds a pleasant demanding 54 year old who has body dysmorphic syndrome and is very happy from the scar after the facial basal cell carcinoma that was removed but is also very concerned about her aging body, skin turgor, wrinkles and cheek bones.

The fourth room has another child with a facial deformity and what his mother describes as moderate to severe autism. He is accompanied on the visit by his brother who shares the same spectrum disorder. There are multiple sharp-edged drawers being opened and slammed closed. The mother’s third child is to be picked up from preschool in just a few minutes. Is surgery to be done?

The fifth room is quiet. Just a calm patient who is thankful for the care, and doesn’t mind waiting. Who would want to keep her waiting? Another form of pressure rests within.

We know that all who care for patients find themselves in similar storms. In part, this exacerbated by patient expectation, such as this Scrubs blog from one our Pinterest followers. In part, it is further caused by the frustration of not doing as smooth a job of healthcare delivery as was possible with less mechanical documentation.

Can you see the potential for error in this scenario? More to follow in Part 3 when we will describe the error and suggest a solution...

A second thought about Big Data, EMRs and healthcare collaboration.

Another plausible explanation is that the management of Big Data is doing what it is supposed to do. However, the unintended consequence is that billings increased.

Maybe what has been discovered is that a whole lot of free care is now being caught in the documentation sieve. Rightful reimbursement is given for work done now, it is just that no one was aware of it before.

Below is a non-medical analogy involving 3 ways to act when a stranger approaches and asks for directions. Assume the stranger is not a native speaker. 

#1. You tell him the directions -- walk one-half block until you see the store with the red front, turn right. You bill for Code ZDP994564.

#2. You quickly and sternly walk him to the corner, a half block away, and point down the street. You bill for the same code, and add the modifier -- 77 because you are completing the EMR form to exactly describe what you did.

#3. Or, you smile, ask him where he is from and how his visit is going, walk him down to the corner, turn right, and walk with him another half a block until he sees what he is seeking. Was there a modifier for that? Was that billable as “public relations," assistance at a higher level, or counseling? 

In either of the 3 ways, you provided a service. If you coded at different levels, isn't that what was asked for? The Garbage-In is just different. Are we as a society getting what we wanted or just getting what we have asked for -- more precise data? And what was free (free as a smile) is accounted and billed for.

iClickCare enables healthcare collaboration by combining words and images with discussion. 

We write a lot about healthcare collaboration. But this is interesting. An editorial in the Wall Street Journal, and report in the NY Times notes that EMRs and EHRs increase healthcare costs.

Design, promote, and sell something which is based on billing and regulations rather than on patient care.

Teach its efficient use over 10 to 20 hours.

Is there a surprise that billings increased? And productivity has decreased? 

Is this hyperinflation of big data?

Sometimes a well aimed gun misfires and explodes backward (the breech). Is this a breech explosion? Really, probably not, the gun may not have been aimed right to begin with. The best aim would be designing better care for the patient that is also cost efficient for the country. EMRs and EHRs are doing what they were designed to do -- bill and regulate.

Could iClickCare be a distraction?

On December 14, 2011 Mr. Matt Richtel in the NY Times wrote about electronic devices when placed (forced?) into the hands of medical providers resulted in unintended distractions.

Many, many comments followed. Some fearful, some indignant, but all observing use and misuse of computers and smartphones. A dramatic mention of a neurosurgeon who was involved in a malpractice suit after using a wireless headset during surgery... clearly typifies abuse. It is sad to see colleagues who have much training but little judgment. A humorous advertisement shows the absurdity of such practice.

Any tool can be used for creation or for destruction. The ball-peen hammer is a necessary part of a tool box, and an oft used prop in murder mysteries. The EMR/EHR is cited in the comments. The electronic medical record should be a help, but judging by the comments in Mr Richter’s piece which we agree with, it has become more than a distraction, it has become a liability.

That is ironic since the EMR/EHR was in part designed to “document” in an litiginous environment where appearance trumps reality. Could it be that this misapplication of technology is worsened by a subtle, but well advertised, push to document so billing can be justified (or maybe enhanced)?

We at ClickCare are heavily invested in using technology to make things better for both patient and provider. We also remember the student who is left totally behind by expensive costs of EMR/EHR “seats.”  We are aware of distraction, and we are dismayed by anything that interferes with the provider/patient relationship.

Our design principles follow this rule: that technology be assistive, simple and delightful. So when you see your doctor, your nurse, or yourself pull out an iPhone or stare at a screen and see iClickCare, be confident that you are involved in medical management that is supportive and exciting. Beeps, clicks, fields and page flips are minimized and distraction changes to problem solving.

California Telehealth Law advances the opportunities for care coordination.

Last week, we discussed the vision of the California Telehealth Advancement 2011 Law.

The telehealth law does more.  We will discuss:

• Do you know what the biggest challenge is for providers using telemedicine?
• Have you considered why email is so valuable, but what its limitations are?
• Why is California’s support of store and forward technologies is so important?

There is not enough time, and too much place. Telemedicine, traditionally videoconferencing and monitoring were designed to take care of the too-much-place problem.  But, neither videoconferencing nor monitoring do much about the not-enough-time problem.

Ask any provider about their biggest challenge. Invariably, the answer is not enough time. This is not a new problem, indeed.  Remember the doctor with the fancy car? He bought it because he could enjoy something while he drive from hospital to office, house-call-to-home over and over again.

Store and Forward telemedicine is the answer to this problem, but has not been pushed by vendors because it is a difficult sell: reimbursement has been offered only for video technologies, with the patient present. That has been described as "Face to Face."

That is why the foresight and vision of of the California Law is so exciting.

First, it is defined in Sec 4. 2290.5:

1. “Asynchronous store and forward” means the the transmission of a patient’s medical information from an originating site to the health care provider at a distant site without the presence of the patient.

Second, it requires payment to be made for store and forward services: 

(c) No healthcare service plan shall require that in-person contact occur between a health care provider and a patient before payment is made for the covered services appropriately provided through telehealth, subject to the terms and conditions of the contract entered into between the enrollee or subscriber and the health care service plan, and between the health care service plan and its participating providers or provider groups.

1. No healthcare service plan shall limit the type of setting where services are provided for the patient or by the healthcare provider before payment is made for the covered services appropriately provided through telehealth, subject to the terms and conditions of the contract entered into between the enrollee or subscriber and the healthcare service plan, and between the healthcare service plan and its participating providers or provider groups.

iClickCare is developed specifically to free the provider to provide the right care at the right time. If it were emergent care, then it has to be now. If it were much more consultative and chronic, the appropriate time for research and management is preferred.

We are inspired by the creativity and the signing of the law. We trust that other states, and CMS itself, will follow soon. Until they do, reimbursement issues are greatly diminished by doing the right thing and sending the data and not the patient. It makes for a happier and more satisfying work day.

The next step is for providers to acknowledge their responsibility to do more than send data, but to discuss and change based on experience, protocol and conversation. That very process is why and EMR/EHR is not a coordinator of care. Artificial intelligence and hopeful advances aside, providers still need to collaborate. This Law makes it easier and more efficient. It is truly an advance in patient care. 

We have put together a concise guide and references to, guess what?, save you time:

Standardization is Nirvana to many, particularly regulators and payors. But, there are unintended consequences, one of which is called de-skilling. De-skilling is a process driven by a need to extract maximum value from labor. It occurs primarily by separating planning from execution and using technology to create efficient workflows.

In a paper titled, "De-skilling and adaptation among primary care physicians using two work innovations" Timothy Hoff, PhD, thoroughly analyzes primary care physician behaviors as they adapt to clinical guidelines, pay for performance, and EMR/EHRs.

There are at least 3 unexpected consequences:

1. Less patient-specific information from specialists
2. Visits become "checklist visits"
3. Record completion dominates "over all else"

The implications of these unexpected consequences are huge. Providers talk to their laptops. Drugs are administered at the bedside with a scan of the wrist bracelet and without an explanation. Conversations are thrwarted. Medical providers at all levels have both implicit and explicit, ethical and moral, commitments to put the patient first.  That the patient should always come first is undeniable, but what is one to do?

We incessantly seek an answer. We are not naive enough to suppose that all of this de-skilling will go away.  We do know a couple of things that help:

1. Slow down to speed up. Collaborate with your colleagues and supervisors.
2. Find other ways to collaborate and coordinate care.
3. Don't even try telephone tag and tardy written report.
4. Collaborate: provide better care and enjoy satisfaction and peace.

We thank Kevin Pho, MD and Stephan Wilkens, MPH  for bringing this to our attention.

He called, we answered, and he asked us some interesting questions. We did our best to bring some insight about ClickCare and iClickCare. Here is a link: Expert Interviews, For any of you who would like some more background about why we do what we do, we answered these questions:

• After long careers as physicians, why did you start?
• Give me an example of how a patient would benefit?
• If the internet is involved, how can privacy be assured?
• Everything’s expensive in medicine, how does ClickCare save?
• How does iClickCare fit into other healthcare IT initiatives?
• How soon will I see this in my doctor’s office?

These questions are very commonly asked of us. Is there anything that we left out? Do you agree? We welcome your comments.

There is a lot to talk about. Year end is for reflection. Year beginning is for looking forward. We are reticent to predict (as in Doctor, “how long does she have to live?”), but it seems as if all the buzz of stimulus monies, of EMRs, of personal health, of debate over health care, some fundamentals have been forgotten. Forget fundamentals, disregard principles, abandon commitments, but if you do so, you will be reminded that you “Can’t Fool Mother Nature”.

So we want to look forward to where ClickCare will fit in.

Three diverse concepts relate to each other: EMRs, Twitter with information overload, and the Cloud.

Many of us have made large, very large, investments in licensing, infrastructure and workflow for EMR/EHRs. We have spent a lot of human capital to be sure that we get on the wagon with meaningful use. We have kept a very close eye on stimulus money. Why would we want to challenge ourselves even more? Why, then, are we unsure of ourselves?. Perhaps, we feel that the fable of the Emperor’s New Clothes might come true. Perhaps, we can see no end in sight.

The Emperor's New Clothes

First, we should feel satisfied and confident that the EMR is already advancing. Electronic subscribing and fewer scattered repositories of patient information are most valuable. So while we worry that the “truth might come out”, all is not lost. The team at ClickCare is very committed to being sure that the EMR becomes an even more valuable resource because ClickCare and iClickCare can magnify it and fill the gaps that most fear to mention. There are limits to the EMR. Dr. Alok A. Khorana eloquently and wisely describes them in his brief essay, Physician as Typist, in the Journal of Clinical Oncology.

One point is the lack of focus on communication–his EMR author with him as the typist:

“I stare at the primary care physician’s note in front of me. I have been concerned about our mutual patient’s hypertension. I believe it has been exacerbated by the use of bevacizumab, and I have referred her back for additional management. All I need is an acknowledgment of the problem and a treatment plan. The note that I have received is three pages long and is filled with unrelated laboratory values, scan results, and jumbled-up text.”

In contrast were other notes, generated “by hand”:

I get other notes, too, from providers that haven’t yet adopted an EMR system. I made a recent referral for a patient with hematuria to a urologist. In a day or two, I received a one-page summary of the problem, including a differential diagnosis, the findings on cystoscopy, and the plan for additional surveillance. It was, really, all I needed. Another oncologic surgeon with whom I share patients always mentions the patient’s profession in the first sentence of the letter. It tells me something about the care that a surgeon who cares to find out such details will provide. However, as our institution transforms from a hybrid to a completely EMR system, these unique styles are likely to disappear.

What is the reason there is a difference between man and machine? Dr. Khorana perceptively notes:

“Recall that there are two major narratives associated with the physician-patient encounter. The first is the narrative told by the patient to the physician. The starting point of this narrative is relatively uniform: the complaint that brought the patient in. From here onward, however, the narrative can be remarkably free flowing and often tangential. To make sense of this free-flowing story, we as providers resort to a second narrative. The physician’s narrative repackages the patient’s tale, but in a format that serves the scientific goal of the note, which is to reach a diagnosis and treatment plan. Of necessity, it requires the act of listening closely and mindfully to the patient first.”

This article is clearly and cogently written. Reading it is highly recommended.

The reaction

What we would add is that ClickCare takes that very “act of listening closely and mindfully to the patient first”, and allows the listener to act upon it subsequently and cooperatively with other colleagues. Not with every patient, not with every visit, but when necessary and appropriate, to do so easily and quickly. Indeed, ClickCare offers the patient an audience of more than just one.

Another way of looking at this, is that there is too much information, and that communication is not taking place. Here are excerpts from an interview on the blog GIGAOM.

Om Malik, the blogger is interviewing Evan Williams, the cofounder of Twitter:

Om Malik: Ev, when you look at the web of today, say compared to the days of Blogger, what do you see? You feel there is just too much stuff on the web these days?,

Evan Williams:I totally agree. There’s too much stuff. It seems to me that almost all tools we rely on to manage information weren’t designed for a world of infinite info. They were designed as if you could consume whatever was out there that you were interested in.

Om Malik:Do you think that the future of the Internet will involve machines thinking on our behalf?

Evan WIlliams: Yes, they’ll have to. But it’s a combination of machines and the crowd. Data collected from the crowd that is analyzed by machines. For us, at least, that’s the future. Facebook is already like that. YouTube is like that. Anything that has a lot of information has to be like that. People are obsessed with social but it’s not really “social.” It’s making better decisions because of decisions of other people. It’s algorithms based on other people to help direct your attention another way.

They also discuss immediacy and relevancy.

Om If you were starting Twitter today – same service, but in a world that is very mobile, very multi-touch driven and a very portable web – what would it look like?

Ev: I’d have to think about that for a while but i don’t think it looks that different than what we have today. Twitter is a natural fit for mobile – it has the immediacy. There is nothing significantly missing, but (we) need to really boost relevancy. If you can’t read everything, then (what is that) you really do need to know right now.

Immediacy creates a need for mobility. Mobility creates a need for immediacy. Again, ClickCare supports and enables the EMR by enabling both immediacy and mobility regardless of which EMR was purchased.

Which brings us to the Cloud, and our last prediction about where ClickCare fits in. Many will become comfortable with the Cloud, immediacy and access. There are some who already expect it. The last mile of internet access not with standing (ClickCare can use 3G and Edge), communication with pictures and words can be the norm. We will expand more on this in another post.

In the meantime our prediction is that the patients will begin to get better care this year. We just need to look ahead and beyond.