Driving Dr. Daisy - Using Scribes to Drive Meaningful Use

In the movie Driving Miss Daisy, the lead character refuses to accept a driver despite her son's insistance and her inability to purchase car insurance. She eventually relents, agreeing to have Hoke drive her everywhere. The rest is Oscar history.

Physician groups and hospitals are hiring "drivers" to deal with the impact of EMRs on their practice of medicine. Unlike Daisy, who resisted a driver, physicians are willingly hiring scribes to input data into EMR systems. Some blame the perceived disconnect between provider and patient when an electronic system is introduced - the hypothesis is that patients feel the physician is paying attention to the computer rather than their needs. Turns out patients actually have greater confidence when their information is entered directly into a system. Similar studies and surveys have linked patient confidence to providers' use of technology. The larger reason for the growth in scribe use is because "new record-keeping systems, which are touted as a way to improve efficiency and quality, slow down" physicians so much that they hire others to input the data for them.

The largest scribe companies have doubled their employee base and provided greater than 6x the number of hours of coverage over the last few years. Some are even turing down more projects than they take. Is this a good thing? Other than providing gainful employment and invaluable exposure to pre-med students, I'm inclined to think this is a net negative development. EMR systems must better support physician workflow and minimize data entry burden.

Many systems expose physicians to additional fields and alerts that don't exist in their current clinical workflow - does the patient require a translator and does he/she need transportation are two relatively simple examples. Other examples include questions typically answered by a clinical pharmacologist rather than a general practitioner - transferring this from a pharmacist to a physician introduces new workflow. Unless these additional fields have clinical value that physicians should be expected to answer and/or would impact medical decision making, they only serve to decrease productivity thereby negatively impacting technology adoption.

EMRs also introduce new data entry requirements with the keyboard as the only option. Voice recognition, tablet and digital pen technology have all advanced to the point where data entry shouldn't disrupt the traditional physician-patient interaction.

Technology has slowly but steadily removed the need for transcriptionists - let's not introduce scribes as the transcriptionists of the HITECH era.

Santa's Gone Green - Happy Holidays from the Health IT Junkie and SecureGirl

 ‘Twas the night before our 13^th Christmas and I could barely hold open my eyes

Wondering if a sweater would be required for tomorrow’s pre-dawn ride,

My neoprene stockings hung drying by the chimney above the fire

But all I could wonder was whether I’d packed a spare tube and tire,

Major, our boxer of eleven years, looked up at me like any other dog

His only concern that I not step on him in my early morning fog,

K slumbered peacefully surrounded by stuffed animals and dolls

While T snoozed, protected by the superheroes adorning his walls,

When from outside I heard something land softly upon the frozen sod

It sounded like a low-pitched hum and was really quite odd,

I slipped out of bed, leaned in and pressed the window to my cheek

When all of a sudden I swore I heard the thud of a boot and a loud kick,

“Hybrid my ass” he yelled tersely and in anger tossed his sack down

It was at this very moment I knew Santa was indeed back in town,

“If I’m to deliver toys in this Go Kart I’d love to know how

This hybrid sleigh ain’t gettin’ it done; I’ll never make my deadline now!”

I couldn’t help but chuckle at the elf as he cursed his difficult situation

I soon realized what St. Nick needed was some stiff holiday libation,

“Pssst, Santa,” I whispered, hoping the neighbors wouldn’t awake

“Come inside, let’s talk it over, you clearly need a break,”

“Yes, I suppose I should stop, take inventory and talk beneath your tree

No use driving a sleigh led by Rudolph and his low voltage LED,”

Having downed his first pint of stout and now safely inside

I couldn’t resist asking him why he’d ditched his sweet ride,

“I have to limit my carbon footprint, at least that’s what I’m told

Now naughty kids get recycled plastic rocks instead of a lump of coal,”

“But enough global warming talk,” he said with newfound cheer

“What have the Umbachs been up to during this past year?”

T still goes to Montessori having this spring turned four

He loves tumbling, being read to, and anything Star Wars,

K is now seven and thinks 2^nd grade is quite fantastic

She still plays soccer, rides her bike a ton and really loves gymnastics,

Deb’s still jogging & practicing yoga for exercise, but this year she’s found a new joy

Tweeting and blogging as SecureGirl (so different from all the boys)

I still ride regularly with a group of guys when it’s very early

At that hour and that pace, our mood is sometimes a little surly,

This spring we managed to fit in a last-minute trip to Disneyland,

And in the summer, we made our annual trips to Cape Cod and Storyland

Between us we attended 3 reunions spending time with old friends and having great fun

With a 10th b-school and two 20th high school reunions, we certainly weren’t feeling very young,

We continue to enjoy our work, often by night and by day

I’m now a director at PolyRemedy, while Deb is still managing at RSA,

With Deb now in her kerchief and me at the bottom of my mug

I looked at Santa, we bumped fists, and exchanged a big ‘olman hug,

Though his sleigh was fully charged and his belly full of beer

His fondness for more horsepower was still quite clear,

Then he shouted down from his hybrid as he reached for the starter switch

“Recycle and turn off unused lights, this global warming is a bitch!”

2010 was a record-breaking year for the Pan-Mass Challenge.  The PMC Kids rides (of which K is a 2-time rider) raised over $810,000!  The “adult” PMC raised $33M, and thanks to many of you, I was able to contribute$5,475 to that total (my largest amount to date)!  I sincerely thank you for your continued support.

@healthITjunkie

@SecureGirl

On Being Thankful

This year's ride is in the books and all donations are in - this post-ride recap, however, is woefully late, and for that I apologize (Debbie reminded me that the Christmas poem was just around the corner!).

Logan, Taylor and me at the finish in Provincetown, MA

PMC 2010 was as eventful and full of memorable moments as always - I even made the front page of the Boston Globe on day 1 (that's me in the very bottom left, seriously).  This year, I was able to ride, dine, and speak with senators Scott Brown (R) and John Kerry (D) as both rode form Sturbridge to Bourne on day one.  Senator Kerry was coming off hip replacement surgery (#2 I think!) and Senator Brown was headed out to the Middle East, after riding 110 miles, the very next morning.  Kudos to the senators for continuing to show their support by riding under those circumstances, although I'm quite certain both are well aware of the sacrifices that the patients for whom we ride are making, rendering the sentators' medical and travel "challenges" routine by comparison.

Together we raised $5,475 - eclipsing the $5k mark for the first time!  I am truly thankful for your support and humbled by your generosity.  As I often like to do, and with the benefit of more participation history under my saddle, I've taken a look at the fund raising numbers over the years, and here is what I've found.

With the exception of 2008, the total amount raised and the average donation has risen steadily.

The total number of donors has remained remarkably steady, and the number of repeat donors continues to increase.

I'm looking forward to the challenge of raising the fundraising bar in the coming years, in particular by leveraging social media.  I have a modest network of friends on Facebook and a slightly more modest list of followers (hopefully growing) on Twitter, but with each friend and follow my reach and opportunity to influence donations grows.  Social media is increasingly becoming a part of my job (anyone's in marketing for that matter), and it seems to have worked well for Doug Haslam, who has a nice summary of the impact of Social Media on his fundraising efforts.  I have some time to think it through, but it'll be here before I know it - registration comes in January!

As for the winner of this year's $200 donation challenge drawing - according to the accounting firm of Taylor and Logan, LLC - that bounty goes to Greg Greely!  Greg, the check is "in the mail."

The PMC is about many things to each of the 5,000+ riders who train and raise money year after year - I think this video captures it nicely.  For many it's the triumph over a dreadful disease - for others it's remembering those who weren't as fortunate.  Before sunup on day two of this year's ride, someone from the "Auburn Family" passed away after nearly 10 years of battling cancer.  We are constantly reminded of our daily grace and reasons to give thanks.

Thank you for your continued generosity, and see you on the road!

Why Doctors Need Marketing Now More Than Ever

I just returned from the Diabetic Limb Salvage conference in Washington, DC. I could end this post on that note. If there ever was an example that screamed for marketing help, it's a conference (or anything for that matter) that goes by the name of "Diabetic Limb Salvage." But that's actually not the entire point.

Physicians get a bad rap for a number of reasons often characterized generally as being more Dr. Evil than Patch Adams. A common explanation (not excuse) cited is that doctors walk out of med school with triple-digit debt - and that's only from four years of study - forget that most go on to additional years of training at salaries not in-line with their level of expertise or responsibility. That would certainly challenge my disposition.

But it goes beyond simple salary implications. For the first time in history doctors are being forced to purchase and use electronic medical records (EMRs). You might think this is a good thing given the rest of the world stands in line for hours to buy the next "iThing" that Steve Jobs dreams up. But EMR technologies have not been designed the way Apple designs their products - that is to say, they have not been designed to serve the end user above all else. In addition, all specialties are at financial risk going forward, and the delta between them is shrinking. Finally, healthcare reform aims to provide benefits to nearly everyone, thereby guaranteeing an oversupply of patients for a chronically under-supplied pool of physicians. We need doctors, now more than ever.

Two things stood out to me at the DLS conference this week. First, doctors are "wicked smaht." Yes, I always knew this having spent my career working with and/or designing products for their use. But if everyone could sit in a packed conference room watching a surgeon operate on a patient while simultaneously discussing (and debating) the merits of his approach before a panel of world-renown experts, you would get a new appreciation for just how much they really know. Secondly, doctors care very deeply about their profession and their patients. The winner of this year's Georgetown Distinguished Achievement Award in Diabetic Limb Salvage went to Dr. Gary W. Gibbons. Dr. Gibbons was one of the more, shall we say, challenging physicians on the expert panel. Yet not five minutes later, while accepting the award, he gave an impassioned, emotional speech not about his career achievements (which are quite lengthy and impressive) but about their collective calling. He challenged everyone in the room to work together like never before on behalf of their profession, but more importantly on behalf of their patients. His conviction was as clear as the crystal award he held at the podium.

The themes of Dr. Gibbons' speech and the dedication of those in attendance at the DLS conference should be part of the broader healthcare debate. See you at next year's "Diabetic Limb Preservation" conference!

When Will mHealth Become Standard Practice in Medicine?

How about when an iPhone replaces a stethoscope?

Long the symbol of the medical professional, this is exactly what's starting to happen with an iPhone app designed by a researcher at University College in London.  More than 3 million users have downloaded this app that turns an iPhone into a stethoscope.  Need more evidence?  Google "mHealth conferences" and see how many results are returned.  Search "#mHealth" on Twitter and admire the minefield of tweets.  Even consider the fact that physicians have adopted smartphones at a greater rate than consumers.

Now that device quality (e.g., form factor) and connectivity have essentially been removed as barriers, what are some of the key factors that will continue to accelerate or potentially slow this fast-paced train? I'll throw out a few of them.

Accelerating Factors:

• Physicians.  As mentioned previously and in many articles of late, physicians love mobile health.  This should not be surprising if only because medical professionals are inherently mobile. Whether rounding in the hospital or shuttling between offices or simply taking a call from a colleague, physicians are always on the go.  If they can access important clinical information upon which to base their decisions all the better.  Despite popular (though fading) opinion, physicians are also technology enthusiasts.
• Consumers.  For better or worse, the largest portion of apps in the "Medical" category on iTunes are really more health and wellness the medical apps.  To the extent these and other apps begin to connect with or take on some of the functionality of a mobile Personal Health Record (mPHR), consumers will be a major driver in the mHealth movement.  Hospitals, practices and vendors will ignore connectivity with consumers apps at their peril (not to mention this kind of functionality will increasingly become required as part of the Meaningful Use requirements).
• Vendors and App Developers.  To date, the most popular apps used by physicians have been drug reference and medical calculators/resources like Epocrates and Medscape.  These will no doubt continue to be popular, but for deep and sustained penetration, physicians will (and have already begun to) demand access to clinical information on their patients - direct access to EHRs and any other system that contains information on their patients.  EHR and mobile devices vendors have been more than happy to oblige and will likely continue to dip their entire leg into the mHealth pool.

Potential Retarding Factors:

• FDA.  The FDA has already begun to drop not so subtle hints that they are at the very least exploring what their role could and should be with respect to regulating mobile health devices.  The degree to which this crosses over into smartphones running "medical" apps or stays primarily focused on devices used to remotely monitor patients remains unclear and developing. Suffice it to say, this bears watching and could help continue the growth of mHealth to the extent it gives hospitals, providers and patients comfort that someone is looking out for their interests. There will of course need to be a balance struck between regulation and innovation.
• Privacy and Security.  Are mobility, privacy, and security mutually exclusive?  They shouldn't be, yet there are still many people who feel they are.  Still others remind us that our mobile devices may already be transmitting information about us that is equal to or perhaps beyond the scope of some PHI.

What factors do you think will influence mHealth positively or negatively?

Fines Do Not Matter, Transparency Does

I don't normally write about patient safety or risk management issues directly, but the news in today's Boston Globe about a potential whistle-blower lawsuit by a fired Jordan Hospital nurse grabbed my attention. I actually think this story is as much or more about transparency than anything else. Fortunately, in this instance, it appears both mother and newborn twins (born premature) are doing well. I choose to believe this is due to a combination of factors including the talent and care provided by the receiving hospital staff (South Shore Hospital), the mother and her infants, and perhaps even grace.


The Infractions in question relate to a federal law that prohibits hospitals from transferring patients without first making sure they are stable and have been examined by a physician. The plaintiff has been a nurse at Jordan for 38 years, most recently as director of occupational health and risk management - so she is presumably intimately aware of federal and state laws attendant to transfers as well as reporting violations to proper authorities when they occur. Nurse O'Connor accuses Jordan Hospital of terminating her employment because she reported a violation of the aforementioned federal law.


What is most concerning about this alleged incident (now that mother and children have recovered) is the focus on fines (of the hospital) and punishment (of the hospital and the nurse, assuming it contributed to her termination) rather than on transparency. The protections afforded to whistle-blowers stand as an important example of the great strides the healthcare industry has made over the last decade toward the issue of transparency. Public reporting of healthcare costs, outcomes and quality improvement by providers (including hospital leadership, example Paul Levy's popular blog), payers (including CMS) and vendors (including WebMD) alike will continue contributing to this movement. An environment that celebrates and encourages transparency will ultimately have a far greater impact on quality and safety than fines and punishment.

How Do You Get 5,100 Cyclists to Ride 190 Miles & Raise $31M?

Give them free food and drink, of course! There are few topics as serious or important as cancer research and treatment - except maybe research and treatment of pediatric cancer. But the Pan-Mass Challenge is much more than just a hugely important fundraiser. For many, it's a vehicle to sacrifice in a comparatively small way and take part in something bigger than the individual. For these people, the ride is a way to jump in with both feet (or wheels) and try to make a difference for friends, family members or even themselves if they too are battling the disease.

Whatever your reasons for raising funds and putting in the miles, every rider will take away at least two things from this year's edition of the Pan-Mass Challenge:

1. unbelievable memories from the stories, signs and shared spirit among fellow cyclists, volunteers, and survivors, and
2. fee food and beer

Yes, due to the annual and very generous donations of sponsors like Cape Cod Potato Chips, Harpoon Brewery, Stop & Shop, Whole Foods, and many others, riders will enjoy some of the following goods over the 3-days of PMC:

• 19,000 bananas
• 14,000 bags of trail mix
• 9,800 hamburgers
• 7,000 Cliff bars
• 6,800 slices of pizza
• 5,500 hotdogs
• 3,000 bagels
• 3,000 lbs of chicken
• 1,600 loaves of bread
• 1,400 lbs. of pasta
• 1,300 lbs. of peanut butter
• 500 lbs. of sliced turkey
• 500 lbs. of sliced ham
• 275 watermelons
• 160 kegs of beer

Thanks and cheers to ALL the sponsors and volunteers, all 3,000+ of you!