Family Medicine Notes

The last session in this afternoon's adventure is a discussion of how OCR was used to populate an EMR.

It's a good talk.

He reviews how a paper template can be used to provide decision support and improve the quality of data entry.

They developed the concpt of "adaptive turnaround documents."

Aftern the patient checks in, a form is generated (based on a patient questionnaire that the patient fills out -- and patient demographics) that the nurse and then the physician will fill out.  So the clinical staff get a custom developed form that helps them focus on issues that the rules engine thinks are important. 

Cool

So the kid with asthma gets a different form from the adult with diabetes.

Workflow:

1. Patient checks in
2. Patient gets the survey
3. Nurse gets the patient (with the form)
4. Nurse gets the form and scans it into the "Digital Sender" (HP4101mfp) and the device e-mails the scanned image to the OCR server.
5. System reads the form and determines it slevel of confidence about each item.
6. The system then creates a form based on the inputs from the patient survey

They did a fairily thorough of QA and observation of how the system worked from a workflow standpoint.  Research findings:

1. 224 forms completed in a 6 day study period
2. 98% or so were completed
3. 98% were accurately scanned
4. It took 25 seconds to generate the form
5. 43% of the forms required some correction
1. The software prompted the nurse for corrections and/or confirmation - the average was about 1 .4 fields per form. 
2. This took about 10 seconds per form.

Soooo ..

Here's the punch line .. they can now alert the doc to clincial problems.   The doc is prompted:  "John has a BMI of 12 - you may want to consider malnutrition."

Interesting.  He's got other thoughts about faxing forms to teachers for ADHD evaluation, etc.  Cool.  Medical Informatics with paper.

Posted by Jacob Reider, MD at 03:13 PM | Permalink | Comments (2)

Now I'm at Octo Barnett's session.  He's at MGH - the medical mecca back in Boston.  Indeed, he's an icon of Medical Informatics ... has been doing this work since most of us were toddlers.

It's an interesting talk on how they built an intranet for primary care physicians in Boston that was very successful.  No surprise there.  Formulary infomation, Up-to-date, referral forms, how-to, etc. etc.  To support this system, they have several FTEs - including a 1.5 FTE clinicians.  Big resources that only MGH or another big organization could afford.  They develop content, support old content ..

Then they did a cool thing:  they went out to places that had no such infrastrucutre - rural Maine, Rural Arizona, Nashville, etc. 

The goal of this was to see if it met Octo's three-pronged "reality test"

• Is it used by real people for real jobs?
• Is it supported by real money?
• Can it work somewhere else?

Now .. does an "intranet" with such clinical information work well in other environments?  The answer is maybe.  There are things that need to be localized:

• Formulary
• Patient Education Information
• Referral Information
• Guidelines

Other barriers included hardware and software availability.  Some of the sites had insufficient hardware, connectivity or technical resources to implement even the end-user side of this.  Without good Internet access - one certainly can't use web-based resources.

Overall - the session was a good descriptor for how one could succeed in implementing a clinical web resource - but many questions about sustainability (the project was funded by an NLM grant) remain.

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Next is a paper on whether the EMR is trustworthy.  This is interesting too.  The issue involves the ease with which one can copy stuff.

"It's very easy to use ctrl-c and ctrl-V to create your progress note"

The concern was bred from the observation that some progress notes in the VA EMR were VERY similar to previous notes.  Are the physicians generating real records .. or just copying the previous notes?

They uised to "Copyfind" by Louis Bloomfield, which is open source, and was customized to read records from the EMR.

Then they looked for notes that had exactly the same text for 40 words, and then scored these events on a scale of risk.

Of 167,000 notes, there were 90,000 "copy events" identified by the software.  Some of this is a product of templates - and so may not represent "real" copy events.  They "dug down to about 6,000 notes on ~250 patients to look closely at what was going on.

8% of notes had copied text in them

1% had copied text of some risk

0.1% had copied text of high risk.

The prevlance of copied text was rather high - roughly 10% of patients had copied text in their records.

What parts of the record was copied?

1. Problem list
2. HPI
3. PMHX
4. Meds

What was high risk copied sections of the chart?  Physical Exam.

Summary: 

1. bad copying does occur
2. We don't know why (not yet studied)

How can we stop it?

• Revide Templates
• Minimize inserted data
• Develop hx and exam objects for review and re-use
• Enhance problem list function
• Educate staff on the copying issue and how copying erodes trust of the medical record and that it can be detected
• Adopt policies that inappropriate copying in not acceptable

This was an interesting session that I really did enjoy.  He's honing right in on why/how the EMR needs to be well designted to optimize data entry.  The fact that physicians copied test into the record demonstrates that novel clinical observations are too time consuming to record.  While one may think that this paper is an indictment of the users ... I don't think that's the right way to look at it.  Remember Rule 1 of software development and implementation:  Don't blame the user.  If they are doing something wrong - it's the developer's responsibility to make the system better so that the proper use of the system is easier than using it "wrong."  

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Hmmm  Next paper is too dry for me.  Time for a nap.  I think I'll check my e-mail.

Posted by Jacob Reider, MD at 02:34 PM | Permalink

Yesterday we learned that the AAFP board decided not to join NAPCI.  Like many family physicians, I don't understand why. 

NAPCI, which was the brainchild of two family physicians, is an effort to unify the voices of primary care physicians.   Despite the fact that primary care physicians provide the majority of medical care in theis country, hospital information technology needs have been the primary drivers of most of the standards and policies that healthcare IT vendors attend to.  Without standards for primary care information technology - the mishmash that now exists will continue.   To say that it is challenging for a primary care physicians to make good choices about buying an electronic health record in their office would be an understatement.  Feature matrices, functional requirements, usability metrics .. etc etc etc .. it's all so complex and there is no unified message to the government on what primary care needs .. nor is there a unified message to the vendors.

But NAPCI - which now has been formally created - aims to change that, and I have high hopes for what it will accomplish.  Yet when David Kibbe explained to me that "AAFP has decided not to join at this time."  I realized that what seems so self-evident to most of us (that collaboration among the primary care specialities would be a good thing) is perhaps not so clear to some others.  

Here comes the hard part:  I can't help but wonder how much of the AAFP board's decision had to do with the messenger rather than the message.   What does David Kibbe have against NAPCI?  It's possible that in the context of his own efforts to play a role in the shaping of public policy and vendor policy through the AAFP's new Center, David wants to be the only such voice for primary care - rather than either sharing the podium with NAPCI or working through NAPCI. 

Perhaps he'll weigh in at some point and help us understand that - but it's ironic that he was rebuffed by the other primacy care specialities when he approached them about joining the AAFP EHR project last Spring .. yet now when they have all agreed to work together through NAPCI - he turns his back on them.  As a family physician and an AAFP member - I WANT the AAFP to join NAPCI - since I think that NAPCI is the best conduit for getting these groups to work together.  Indeed, had David engaged NAPCI last spring, it's possible that the EHR project may have been more readily embraced.

Alan Zuckerman told me last night that the AAP has been surprised that David hasn't continued to engage them in the EHR project - and I've heard that SGIM and ACP have similar feelings.  

It's all troubling because I do want the AAFP EHR project to flourish - and I suppose that working with other groups could be perceived as a potential roadblock in the path of moving the EHR project along swiftly.  

Who knows.  On my end -- along with this well-kown genius - I'm going to begin lobbying AAFP to reconsider their decision.  If you know an AAFP board member - or are active in your state Academy of Family Physicians - please do your best to send this message:

Posted by Jacob Reider, MD at 09:18 AM | Permalink | Comments (2)