Tag Archives: engagement

EHR and quality? Murrow had it right: Otherwise it’s just wires and lights in a box

It’s been interesting to watch the fireworks from a recent study in the Archives of Internal Medicine, Electronic Health Records and Clinical Decision Support Systems. People taking sides. In one corner, electronic health record (EHR) advocates (thanks, ePatient Dave). On the other, those not fond of EHRs or investments in health IT. I find myself standing in the middle. Polarized views about EHRs aren’t good for anyone — especially patients. You know, the people who all the stuff in EHRs is all about?

I’m a researcher and sometimes review manuscripts submitted to journals, so I’ll comment on the study, in a minute. First I’ll pose a few thoughts about factors, going forward, critical to the quality-EHR connection.

If EHRs are perpetually seen as professional-facing tools at the heart of care, we’ll be challenged to solve quality. If seen only as conduits to document encounters, deliver reminders and place orders, then the power of EHRs is underestimated. Context and intention are everything.

Long before EHRs existed, Edward R. Murrow , renowned American broadcaster/journalist, forecast their limitations. He said,

The newest computer can merely compound, at speed, the oldest problem in the relations between human beings, and in the end the communicator will be confronted with the old problem of what to say and how to say it.

This instrument can teach, it can illuminate; yes, and even it can inspire. But it can do so only to the extent that humans are determined to use it to those ends. Otherwise it’s nothing but wires and lights in a box.

– Edward R. Murrow

To really get to EHR impact, then, their use has to be optimized in the context of delivering care in a busy clinical environment. The best way to do that is to figure out how to deliver care outside the visit. Further, we must design with consumers as intended users. Patients will increasingly access information now locked up in EHRs. Patient access to their health information expands decision support and the reach of reminders – by engaging patients. It makes sense that if EHRs push data to personal health records, then studying what happens at a single encounter won’t accurately measure quality. When patients are intended recipients of EHR contents, we’re likely to improve quality (that includes patient experience and health).

OK, back to the study, which was done between 2005 and 2007. Stanford authors reviewed 250,000 patient visits to outpatient clinics and emergency departments. They looked for differences in “quality of care” delivered by providers who used electronic health records (EHR) with and without computerized decision support. Meaning, EHRs reminding doctors to do certain things compared to EHRs that didn’t. What they ended up comparing was visits with and without an electronic record. They didn’t find a relationship between having an EHR and having a higher level of “quality” of treatment.

The methods seem pretty sound, and the results are worth a thorough review. Yes, there are limitations, like there are in every study. Several have been nicely described in a post by Bill Hersh, Oregon Health & Science University. I might add a few more. Sites using electronic and paper records were categorized as an EHR practice (possibly overestimating EHR use). Over half the visits were in an emergency room, a very different place to combine with primary care. Plus, “quality” was measured at a visit, rather than what is usually done: measured across a population over time. Finally, 40% of sites did not agree to participate, limiting generalizability across the U.S.

Even ignoring all the limitations, I think the reviewers let the authors take liberties in their abstract and conclusions. They state, “Electronic health records were used in 30% of an estimated 1.1 billion annual US patient visits.” They conclude, “Our findings indicate no consistent association between EHRs and CDS and better quality.” The science doesn’t support these statements. These are the type made by the lay media.

This time I can’t blame the press, always on the prowl for a good story. They found one. Problem is, they didn’t realize they were only talking about the “wires and lights in a box”.

Portland VA’s Patient-Facing Apps Through a Colleague’s Eyes: Getting to Great

I just had the pleasure of hosting Kaiser’s Ted Eytan (@tedeytan) at the Portland VA Medical Center for a few hours. He was in Portland doing a deep dive on population management at Kaiser Northwest. He’s been posting all week about his observations and the great work going on right in my backyard.

I’m a huge fan because he shines high beams on patient-centered care and consumer health IT. And he blogs often and with passion and heart. With my short experience in the blogosphere, I can’t imagine doing this without pioneers like Ted and ePatient Dave.

Ted asked me for the “full experience” and he’s already posted about it. So we met at the bottom of the Oregon Health & Science University (OHSU) Tram, took the 3-minute ride up then walked across the glass skybridge to the Portland VA. Of course, it couldn’t have been raining harder if it tried. Sigh. December in the Northwest.

He had a tour of some of our patient-facing applications. At the My HealtheVet office, we talked to Carol Kedalo, MHV Coordinator, who helps position the Portland VA as the highest-in-the-nation for patients fully enrolled in the personal health record. While national authentication rates are less than 10% of VA patients, the Portland VA boasts about 25% of patients authenticated. I think there are 2 factors responsible for this. The first is Portland’s Chief Health Information Officer, Dr. David Douglas, who single-handedly champions the PHR and who has garnered support to bring on staff to help patients enroll. The second is critical but not always made a priority: putting staff in places with high “foot traffic” where they can’t be ignored.

Ted and I were then joined by Shawn Adams as we stepped into a check-in area, where patients use touch-screen technology to update their information and reconcile their medications. Developed by a great local team led by Dr. Blake Lesselroth, this software presents pictures of medications (from the VA Formulary) to patients, and asks if and how they are taking each prescription or over-the-counter med. The VA has been so impressed with our local experience, that there are now plans to pilot and roll out point-of-service, touch screen kiosks nationally.

Finally, I demonstrated VA’s secure messaging application. I’m communicating online with many patients in my primary care clinic, and it’s been great. It’s efficient, it’s valuable (for all of us). One great bell & whistle is the ability to attach files to a secure email. I’ve used it several times, and know that it’s helped reassure patients, and reduced travel for office visits. I’m excited about pushing this out nationally across the enterprise.

I enjoyed hearing first-hand from Ted about Kaiser’s journey with patient empowerment through kp.org. What really struck a chord is that now it’s the clinicians who get frustrated when a patient s NOT using the PHR and portal. Now that’s transformation..

Thanks for taking a side trip to the VA while you were in Portland, Ted. It’s great hanging out with a consumer informatics rock star!

Dear ONC: Nothing about me without my input. Design with me.

The Office of the National Coordinator has asked for input as they develop strategies to “Empower Consumers to Better Manage Their Health through Health IT”. To kick it off, they are seeking public response to specific objectives, including:

Objective A. Engage consumers in federal health IT policy and programs
Objective B. Accelerate consumer access to electronic health information
Objective C. Foster innovation in consumer health IT
Objective D. Drive consumer-provider electronic communications

These are a great start. To get to truly meaningful, ONC should use its position to get to truly transformational. The aim of electronic records in every clinic is a must. As the focus now shifts to patients and caregivers, we need thinking that’s way out of the box. This opportunity is unprecedented. With Health 2.0 at our disposal, let’s not look at our electronic records as partly “facing consumers”, let’s figure out how to design our health records and exchanges in the context of patients’ lives. I’ll offer modified objectives.

A. Practice participatory design in federal health IT policy and programs.
Rather than a media campaign to “help consumers understand” HIT policies, stakeholders should gather more information about consumers, and practice participatory policy design. Patients and caregivers want policies that give access to all their information and allow them to contribute to their health record. We need to leverage untapped consumer power to drive policies that make sure we go beyond face-to-face encounters. Healthcare won’t be transformed until we get away from the tyranny of the visit. Here’s our sweet spot: both clinicians and patients want telephone and online care mainstreamed. Yet another example of how consumers are the #1 underutilized member of the team.

B. Ensure consumer access to all health information and ability to input information.
Patients can get access to notes, but rarely do. Electronic access will be ground-breaking (See Open Notes post). Yet we need more than unidirectional pushing information out. We need sea change, where patients and caregivers enter content directly, not have it transcribed by clinicians. Valuable patient-centered data, such as: a picture, a nickname, what clinicians should to know about them, their social support, self-reported use of medications and health risks, and whether they agree or disagree on problems and assessments. Yes, this will alter our notes, but what’s wrong with that? (see next objective) Patients and caregivers can work with HIT stakeholders about how notes should change and where greater accuracy will be gained if people input their own information.

C. Use consumers and other HIT users to transform how we document and deliver care.
Let’s think Blue Sky and use this opportunity to change how we use HIT to interact with patients, how we document interactions and share information. Let me offer an example. I work with internal medicine residents. After a clinical encounter, they “present the case”. I’ve heard the same thing for over 20 years: a 53 year old woman with diabetes and hypertension.…a 79 year old man with heart failure and depression who frequently no-shows and is non-compliant. I often ask “context” and perception questions — Does he live alone? Is there a support network? Does he use the Internet? What does he think he has? Often these questions haven’t been asked. While the resident sees value in these questions, it seems there’s little time to ask so many. Meticulous notes are written, which focus on diagnosis and treatment. Who is the patient? Mostly, our notes ensure proper documentation for coding and billing. We need patient-entered information that increases our knowledge and builds trust that’s so critical to outcomes. We need to re-structure our notes to gain meaning for everyone – clinician and patient. (who reads the social history, anyway?)

D. Get all the right people on the bus to tackle consumer engagement.
We have lots of work to do here, and focus on people and behavior. It’s easy to think about cool tools and widgets to “get patients more engaged”. We need to work with non-IT folk, like anthropologists and behavioral and social scientists, to crack this nut. There’s great science on how to engage people (see post on bringing behavioral scientists into HIT development and adoption). Make it fit into people’s beliefs. Provide things people want. Meet people where they are. Make sure shared decision-making really means people participate. Importantly, don’t believe people “will get engaged” if they just take advantage of HIT. Finally, let’s go outside medicine and healthcare. We have parallel consumer-engagement-and-information grid development happening in energy and sustainability. I posted about this recently. These worlds should collide and conquer together. I’m sure there’s other parallel intelligences happening.

E. Drive the provision of services with greatest consumer value, while mitigating disparities in care.
ONC Objective D. identifies secure email and telemonitoring as serving to engage consumers in their care. Slam dunk. These tools have been shown to improve satisfaction and health outcomes. While systems should support clinician participation, we should think more about how we can drive consumer demand which in turn can drive the use of services. Above all, our policies need first to support (see A) offering these services. Our educational programs must ensure clinical staff understand appropriate use of these tools. Our marketing programs must learn about value to the consumer then increase awareness. Our built environments must be modified so all patients and caregivers can learn about consumer HIT and use it to their advantage. Our researchers must prove we’re not creating more disparities as some but not all patients access these services. And we must put great innovators in our communities so that these likely disparities are minimized because point-of-care provides services of comparable quality.

Thanks, ONC, for asking. Let’s make sure the consumers are co-piloting the ship as well as helping pick the destination.