EHR Implementation Update at 6 months

Surprisingly, it has already been 6 months since an enterprise EHR was implemented at the hospital where I work. Things should be going smoothly by now, right? I truly wish I could say that were the case. It may be an understatement to say that the EHR project has hit a few speed bumps. I hear that just a few weeks ago the medical executive committee considered a motion to turn off the EHR for 6 months while it is re-engineered to meet the demands of local practice and function in a more user friendly fashion. That must have been a really scary moment for administrators present at the meeting. I never imagined that a recapitulation of what happened at Cedars Sinai years ago would happen in Yuma. Instead of turning the system off, the decision was made to hire more consultants and IT staff to speed the "optimization" of the system. But I assert that the response of medical staff members was totally predictable.

Optimization is the process whereby the EHR is modified after go-live to correct unanticipated user issues. Above, I mentioned that user outcry was predictable. What did I mean? Adoption of an EHR goes through a well-known life cycle that has been validated by years of experience. First, the institution determines its EHR requirements and (often) produces a RFP (request for proposal) to be submitted to a battery of EHR vendors. Then a multidisciplinary committee sifts through the responses, selects a small group of finalists, makes site visits to hospitals where vendor products have been implemented, performs other due diligence activities and makes a final vendor selection. The next step is contracting for the software license and, often, vendor implementation support. Here, the hospital should take legally binding steps to protect its multimillion dollar investment. Once an agreeable contract is reached, the next steps are to refine local user requirements, perform work-flow analysis, set up governance structures to help manage the EHR, and begin implementation of change management strategies. Then the real fun begins.

Design and build of the software is carried out by local and vendor-provided IT staff based on data collected in previous steps. Testing of the software build in a simulated working environment is essential to verify interface function, safety of the build, stability and performance of IT infrastructure, and generally to make sure that everything works as designed. Everyone who will use the EHR must receive general and specialized training before go-live. Go-live is always a high stress time but really should go smoothly if all the preceding steps were done properly. Finally, optimization is really just part of the maintenance that all IT systems require after they are introduced. So where did the processes at my hospital go wrong?

First, I believe that the selection process was as good as it could have been. The selection that was made was the best that was available at the time. I think that many of those involved in the selection process now feel that we did not get the system or design support that we expected, however. I wasn't privy to the specifications and protections for the hospital built into the contract. Certainly, the investment required in post-implementation support is much greater than the administration expected. I hope the hospital was protected by an appropriate service level agreement.

I am disappointed that more user input specific to our local routines and workflow patterns was not incorporated by the design team. My impression has been that the design team did not do their homework. Governance structure for the EHR is still evolving. Even now, it is not designed to efficiently manage user feedback. The CMIO was almost the last IT staff member hired, a year after other major hires. There was little time to build a sense of team membership/ownership. Everything I have ever read has emphasized the importance of physician involvement from the earliest stages of EHR implementation. I think many of the current problems could have been mitigated had a qualified CMIO participated from the start. I made this point to medical staff leaders and administration members during the selection process; the consequences were predictable; and outcome could have been avoided. Communications have been poorly managed. It is hard to know if or when a help desk ticket has been acted upon and what the outcome is. There is no system of publishing institution wide lessons learned with the EHR. A few notes have been posted in physician's lounges and in mini-pamphlets of "tips and tricks." I would have liked to see ticket request information posted on the private intranet of the hospital. I would also have liked to have lessons learned posted to the intranet along with an index to help find information of concern. Finally, I cannot determine if we selected an unsatisfactory system. It does seem to have many inherent deficiencies but some of these may be design and build related. The next few months of EHR IT department work will see optimization steps that will seriously revisit the previous design and build activity, incorporating our nascent governance input. Hopefully, the future EHR will more closely fulfill the needs for functionality and usability our medical staff members demand.

Clinical Documentation Challenges

One of the most difficult tasks for EHR software is to capture clinical documentation. For many EHR implementers this is one of the last functions to be "turned on." There is a tremendous diversity in the breadth and depth of clinical notes. This is an area where "one size fits all" solutions usually do not apply. An advantage of EHR adoption purportedly has been reduction in transcription costs. This is achieved by clinical documentation software that eliminates the need for dictation and manual transcription. Often this accomplished through use of templates. Check boxes are filled in by the provider and then the narrative text representing the clinical note is generated by computer to provide a traditional-appearing note. Another method is the use of voice recognition software that in real-time converts voice to written text. As usual, I will relate my own experiences and thoughts:

Templates: I work with another surgeon who does mostly one type of operation over and over. He has a very standardized method with few variations. Previously, he dictated an operative report for each case. This task took at least several minutes of his time. That does no account for the time and expense of transcribing his dictations. I was able to create a template that accommodated almost all of his variations. There was one blank that required free text (the name of the anesthesiologist), two drop-down lists, and 5 fields that need to be completed with a typed number for the size of implants used. The surgeon is now able to complete an accurate operative with the template in about a minute. There is no doubt that this is a more efficient way for him to create his operative reports. In my experience templates work well for generally simple clinical documents where there are a limited number of possible variations.

On the other hand, templates do not work so well for me. I think it is hard to capture the nuances that are so important to recognize and report in clinical medicine. The majority of my surgical practice is individually tailored to each patient. The multiple types of conditions that I see and the complexity of co-morbidities make template-based documentation impractical. The types of procedures I perform are numerous and cannot be distilled down to simple templates. I need a tool like to dictation to complete operative reports for the surgeries I perform and the preparation of clinic notes for the outpatients that I evaluate.

Voice to text. My hospital eliminated most of the transcription department when the EHR went live in May. Dictation is still permitted but transcription has been scheduled to be eliminated by January 2013. Transcribed dictations follow a different work-flow than notes entered directly into the EHR because they must be scanned. The hospital administration decided to license voice recognition software for use by clinicians to assist in their documentation. (Recall that our EHR implementation was a "Big Bang" so transition was from paper to all electronic without phased introduction of functions or any pilot projects.) For some clinicians, voice recognition works well, with acceptable accuracy. For me, the accuracy is somewhere less than 85%. Some of the mistakes that are made result in text that at best has a number of embarrassing errors and at worst is nonsensical even to the creator of the note. Optimization of software by "training" is not feasible. It takes too much time and disrupts workflow when attempted on the fly. The output rate for voice to text during a dictation is unpredictable so that it can sometimes be near real-time but at other times as much as a sentence or 3 are printed after a delay, then all at once. Corrections on the fly completely disrupt productivity. Besides, with all the extra work the EHR engenders, I do not have the time nor is it the best use of my training to function as a copyeditor to fix transcriptions. I hesitate to admit that I am now resorting to typing most of my notes. This, I think, is definitely an unintended negative consequence of the EHR adoption. A solution that I favor is to have the hospital hire transcriptionists to review and edit each report. They would have access to the original voice files to help with the editing/correction task. (By the way, I used an earlier version of the voice recognition software the hospital licenses for a year in my private office during 2005-2006. I abandoned the software because of the unacceptable number of errors in my reports. I was actually "happy" to spend $1,000 a month to hire a skilled transcription service whose work I could rely on to be accurate and provide a professional result.)

One advantage of voice recognition software that I am impressed with is its potential to orchestrate navigation functions by voice commands rather through use of a mouse. Macros can be developed to facilitate tasks such as user logon, application launches, and page navigation among others. Programming can be as simple as recording a sequence of mouse clicks or it may require specialized programming training. Watch for increased use of voice controlled functions by users of HIT devices in the near future. Here is an interesting article I just read as I was preparing this post.

EHR Implementation-My first thoughts

It is time for some reflection about the EHR system I have been using since go-live at the beginning of May. These impressions are uniquely my own but I think they mirror those of many on the medical staff. The most surprising conclusion (though it shouldn't be) is that I am finding that change is especially hard to accept. The question I pose is: Is change hard because it is innately so or were there design, training, and implementation flaws that exacerbated the situation? Introspective IT professionals would be wise to revisit these possibilities on a regular basis.


Going counter to my natural inclination, I will discuss the positives first. One of the most positive elements of the implementation was having well-trained EHR specialists easily available during the first few months of use. These folks, some internal, and some with special training with the EHR, were generally very knowledgeable and could answer most questions. They had access to resources to get quick answers when they were stumped. The hospital administration wisely extended its short-term commitment to keeping these people around when they recognized how much the service was needed even 6 weeks after go-live.

The most positive aspect for the inpatient EHR from my point of view is that I don't have to search the ward looking for a patient's chart. I can assess the record from any computer on the hospital network as well as remotely from home. It is a lot easier to locate incomplete charts that need additional documents or signatures. I have helped develop two operative report templates for a colleague does a few procedures over and over. He can now complete the operative reports just as accurately in about one third the time it would take to dictate. This doesn't work as well for me because I do so many different types of procedures. I will have more to say about my documentation difficulties later.

I have spoken to a few nurses about the system. Their assessments of the EHR seem generally much more positive than that of physicians.

Now I will discuss some of my criticisms. I don't the same as a lot of physicians that I have read about in EHR case studies. For a lot of things I do, I don't feel the EHR is an indispensable step forward and that I would never go back. A lot of my complaints stem from poor overall engineering of the system where usability and attention to clinician workflows could not have been high priorities of the design team. The system is clunky, makes us do things that don't make sense in a way that does not seem natural and that does not follow customs and patterns many have come to expect when using computer systems. A laundry list of my complaints would be too long for this post.

Patient Safety: I have run into the problem many times where a patient's medications cannot be fully documented. Only medications in the EHR data base can be used. That data base is not exhaustive by any means. For example Combivent inhaler is not on the list either generic or by trade name, as far as I can tell. Furthermore, that is no work around to enter a medication not in the data base by free text so that at least it shows even if it is not in structured format. True, you can enter the drug in a patient care note but unless someone searches for and finds this specific note it will not be apparent that the patient is taking the medication. To reiterate, it does not show on the patient's medication list and is not available to the system for clinical decision support when drug-allergy and drug-drug interactions are being checked. Finally, as far as I know, there is no policy that has been promulgated to clinicians to explain how one goes about bringing this to the IT department's attention and correcting the problem.

Order sets available at go-live in no way reflected local preferences. They were company generic sets and had a frustrating number of inadequacies. The third CMIO in 3 years has just started working at the medical center. The governance structure to deal with order set development and maintenance does not yet exist. There is no capability for clinicians to individually modify, amend, or add to the pre-determined list of order sets. Some parameters of existing order sets can be pre-selected and saved as favorites.

Results: Access to laboratory results is essential for patient care. Our system offers several options for locating and reviewing lab results. The trouble is that I am not sure where the best place to look is. Results are presented in directory format that requires one to open sub files to see all the results. I have found that I sometimes miss results that are important to me. I hate to say this but in the old days of paper or with our previous computerized lab reporting system, I could feel secure that I was viewing all the daily labs and cumulative summaries. Now-not so much. I am not alone among clinicians in voicing this concern.

Elements such as setting up in baskets to receive and show results were not configured individually with clinicians. It took me months to learn what I did not know about my personal work space-that I had not been set up to receive results. This was potentially dangerous for my patients and for me. I cannot understand why someone from IT did not sit down with each clinician and go through a checklist of options for how to configure the system to match their preferences. This seems like EHR 101 to me. I am still making discoveries about configuration issues at four months after the initial implementation where significant discrepancies in configuration result in differences in my screen views vs. how others in my same specialty.

Ease of Use/Efficiency of Care: Clinical documentation. The plan was to offer about one third of the medical staff the use of voice recognition (VR) software for dictation, once they completed creation of user files and had training in the use of the software. Many of the hospital transcriptionists were laid off. Some clinicians were expected to develop point and click templates; others were expected to continue to use dictation until the end of the year when dictation would be phased out completely. The number of VR licenses was rapidly increased due to unexpected demand by clinicians. A separate decision was that positions for transcriptionist/editors would not be created. Sole responsibility for accuracy of dictations rests on clinicians and spell check software. At first, I was an enthusiastic supporter of this enterprise version (but not the latest version.) Then I started reading some of my previously created notes. I found the number and types of errors to be unsatisfactory. I tried to solve this by running spell check on every note. This took time but did not significantly increase the accuracy rate. Some of the errors I were such a distortion of what I said that I would not be able to correct them without listening to the original voice file to discover what was really said. I have tried taking the time to train out the errors but this is time-consuming and did not seem to be achieving the desired effect. More and more, I am resorting to typing my notes to achieve the accuracy that I feel is needed for a medical document. It is that or proofread and correct every document. That is not efficient use of my time. Isn't that why voice recorders and transcription systems were developed in the last century in the first place?

I could go on but I will stop here. IT staff say they are committed to addressing clinician concerns, optimizing the systems, correction errors, and providing on-going user training. That remains to be seen. While I don't think clinicians will reject this system, the successful implementation of our EHR is a work in progress.

EHR/HIT Training-MyThoughts

These are some of my thought about EHR Training. I recently went through clinician specific training to use the EHR being installed in the hospital where I work. I wrote about my experience, which was not very satisfactory. I've had some time to process my impressions and hopefully will put together some useful conclusion in this post.


The training for physicians where I work consisted of two 4-5 hour classroom sessions. The training primarily was a lecture/demonstration format, although participants were assigned some exercises. Printed training aids were limited, poorly edited, had some confusing errors, and were only provided at the time of training, not before. Navigation instructions to accomplish basic tasks were few and often did not follow clinical workflows. My biggest complaint is that the training had few permanent artifacts that could be reviewed later. The sessions were repetitive for the trainers, who became very familiar with the system by conducting numerous classes, but not for the future users who had only one chance to learn information critical to their livelihood and the safety of patients. The result is that the trainers became excellent super-users to help clinicians after go-live but the clinicians were poorly prepared to use the system. This form of training was expensive for the institution because of the need for a large number of trainers and specialized classroom space required for the sessions. The pace was often determined by the trainers rather than the students and could not easily accommodate those with different levels of computer skills. My experience was that when I got stuck at some phase, often I missed a big chunk of training as the class moved ahead without me. Several of the clinicians received pages and phone calls during the classes that either took them out of the sessions or were distracting to other attendees. I'll say it again, there were almost no permanent guides to refer to later during go-live.

I envision a different approach. First and foremost, training should recognize and follow the workflows encountered in real clinical practice. This means that curriculum developers need to have a strong and broad-based clinical background. Next, as a clinician, I want to have the control to learn at my own pace, at a time I find convenient. I would like to be able to review training materials as many times as it takes to learn how perform essential tasks. Furthermore, training that is based on a set of training artifacts can be reused to train new staff members without the need for the institution or vendor to maintain and support a large staff of permanent trainers. Self-directed learning suits the needs of busy clinicians better than the options we were provided. I learned these lessons first hand in my graduate program for a master's degree in medical informatics.


One of the challenges of taking an online degree was the need to learn and rapidly master a variety of new computer applications. Here is a short list of the some of the applications we used at Northwestern when I was a student: WebEx, Backboard, Visio, Microsoft Word, Microsoft Excel, TreeAge, Microsoft Access, Microsoft PowerPoint, Microsoft SQL, Adobe Connect Pro, SimulConsult, and EndNote. One of the more difficult academic assignments was to create a database in Access from a schema we were given, in little over a week. I'd had no prior exposure to MS Access. The teaching assistant for the class created a WebEx recording and demonstrated each of the required tasks in a session that took her only about 45 minutes. I watched the recording a few times. I then broke out the tasks I needed to accomplish and created an index using the time code for the WebEx recording that correlated with the tasks. I used the indexed times to review relevant portions of the session until I could accomplish the tasks myself. This made it relatively easy to complete the assignment even though the software program was completely new to me. It turns out that this was one of the most valuable lessons learned in the graduate program.


The approach I recommend is applicable to many adult learning needs. First, you need to realize that not everyone is a good teacher. To create useful educational materials requires a team of skilled individuals. Curriculum development is a specialized skill set that is an essential element. Once a curriculum has been developed then a scripted teaching plan must be formally written out, much like a screenplay for a TV show or a movie. Those with creative skills to actualize the plan are needed next. This requires skill with special software that that has the ability to record screen movements, webcam output, capture voice over, and insert presentation graphics. Such software is readily available. Some sites even offer many functions at no cost. Indexing capability within the software is a must to make the materials accessible and user- friendly. Additional skills with video and audio editing are helpful as is the ability to utilize web resources such as video streaming optimization, etc. The final product can be distributed as free content on the Web (YouTube, for example), can be sold commercially as a training aid, or be made available over an organization's private Intranet. Realistic training exercises could be developed. Computerized scoring is an available tool.


I realize there are many approaches to teaching EHR use. The technology I have recommended is available now to enable user-friendly training that respects the learning needs and time restrictions of modern clinicians. Taking this approach can also limit training costs and improve the quality of EHR instruction for the sponsoring institution or vendor.

The First Approved HISP comes to Arizona

Arizona Health-e Connection recently announced the selection of the first health information service provider (HISP) for Arizona. This is exciting news because this is the first step that will enable use of the Direct Project specification. Direct enables secure exchange of health information using a "push" type mechanism much like email. Unlike typical email secure transmission utilizes encryption of messages through use of cryptographic protocols that are powered by digital certificates. The protocols are very similar to online banking and online purchasing services over the Internet, two examples with which we are all familiar. The HISP is needed to provision health care providers with special health care email addresses and provide and manage the digital certificates. The digital certificates are issued by a certificate authority and are needed for trusted identification of the endpoints of the information exchange pair as well as for use in the encryption/decryption process. The selected vendor, GSI Health will also offer a provider directory (needed to obtain health email addresses and digital certificate information needed to communicate with others) and a web portal (software as a service) to enable participation in HIE for those who use EHRs where Direct is not included as a native service and even those for clinicians without EHRs. The basic service is very affordable at $45 annually for the digital certificate and $15 monthly for HIE access using the available portal. Check out the GSI web site for fees associated with EHR interfaces.

The benefits of using Direct are several. Information exchange using interoperable standards facilitate continuity of care, especially when transitions of care are needed and different providers are involved. Examples are discharge of a patient from a hospital with subsequent care by the primary care physician/clinician (PCP), referral from a PCP to a specialist, and transfer of a patient from an inpatient facility to a long term care setting. Other uses include reporting of clinical quality measures, communication with disease registries, public health reporting, and syndromic surveillance. Educated readers will note that many of these tasks are required in Meaningful Use Stage 1 or are included in the two Notices of Proposed Rule Making (NPRM) for Meaningful Use Stage 2. Some have criticized the Direct Project for not having all the bells and whistles of more robust information. Nevertheless, it is a potential game-changer for freeing up the flow of clinical information between authorized clinicians. Now let's review some of the barriers to use of Direct.

Probably the most significant barrier is the resistance to sharing information. Many clinicians and health organizations view patient data as a personal possession. They refuse to consider that the data belongs to the patient and that sharing of data is essential to provide the best possible medical care. Another barrier is that we are at a point where the technology for information exchange is not wide-spread. Think of the similar problem faced by early adopters of the fax machine. For electronic information exchange to make sense, we must of trusted partners who are willing to exchange information and have the necessary technology to do so. The greater the number of partners, the greater the value of the capability. The workflows to incorporate Direct in routine clinical care need to be developed and promulgated. Most vendors do not support Direct natively in their EHR systems. This will need to change in the next two years, unless a major change is made to the NPRM to preclude the proposed standards for interoperability and EHR certification, including the prescription for information transport via Direct. Many EHR vendors also need to work harder to enable preparation of summary documents (CCD) that facilitate transmission of essential clinical information between clinicians (in stage 2 this will need to comply with the consolidated CDA standard.) Finally, many state public health agencies are not prepared for the changing rules and will need to move forward rapidly to enable receipt of information from clinicians via Direct.

These are exciting times. Rapidly changing technology will eventually enable clinicians to provide higher quality medical care for reduced cost. Finally, it is important to remember that Direct is just one hammer in an arsenal of tools that will be available to help achieve the health care goals of the US.

EHR Implementation: Go-Live Week

I recently wrote about my experiences during training to use the EHR to be implemented at the hospital where I practice. That training has been put to practical use this week after Go-Live started in the early hours of Tuesday. Here are some thoughts about my early experiences. Admittedly, I am just one physician in a large organization and my use of the system to date has primarily been in an orthopedic outpatient clinic.


I want to start out with positive comments because I am wired to be critical rather than complimentary. We have had on site-support by engineers and other experts from the vendor, in addition to the local implementation team members. These folks were flown out to Yuma to help us over the "speed bumps" of early implementation, as it was couched by our CEO. The few vendor experts I have encountered have been quite impressive. They are knowledgeable about the software and seem to have efficiently connected with the local team to help solve problems. To their credit, they have been able to fix the majority of issues that have been raised in a most expeditious fashion. Although they were not experts in all modules of the enterprise software, they seemed to have sufficient breadth of knowledge to address almost every issue I had or knew who to go to for appropriate help. Also, their priority has clearly been to provide the one-on-one support that is so valuable at this point in an implementation. None of the pre-go-live activities was able to adequately simulate the daily record keeping needs of a busy clinician.


Now for my usual negative, critical, (?constructive) comments. Even though I have been told that every Go-Live is chaotic, I think many of the problems I have had this week were preventable. Stephen Covey in his The 7 Habits of Highly Effective People advises us to start with the end in mind. So in my opinion "the start" was not completed very effectively. One lesson learned from prior EHR implementations has shown that needs assessment is a very important step. In talking with the clinic staff, I have come to the conclusion that this assessment was carried out in a superficial fashion. Secondly, perhaps the biggest challenge in implementing EHRs is adapting the software to local clinical workflows. This requires in-depth understanding of current workflows and a clear concept of how this will change with EHR adoption. The workflow assessment for our clinic was too simplistic and in many was did not depend on actual, in-person, observation of existing workflows. You might refer to a couple of my previous posts in which I discussed workflow. Finally, I don't think the timeline for implementation allowed enough time for pre-go-live testing of the production environment. I am guessing that a lot of the glitches we have seen this week probably could have been discovered and corrected by following checklists developed based on lessons learned from prior implementations of this vendor's software.


Overall, I think that Go-Live week went about as well as could be expected. I have been impressed with the professionalism of the support team and their ability to rapidly resolve issues that have come up without needing to resort to a lot of administrative overhead. I look forward to developing proficiency and optimizing the EHR capabilities to improve my ability to deliver high quality patient care.

Electronic Prescription of Controlled Substances

The electronic prescription of controlled substances (EPCS) is a topic that has been in my thoughts lately. Next month my hospital and clinic go live with an EHR that has e-prescribing capabilities. During training I was told that electronic prescribing of controlled substances was not allowed. I recalled that an interim final rule (IFR) for prescribing controlled substances had been posted in the Federal Register in 2010. So I spoke up and said that electronic prescription of controlled substances was allowed. That started me on a search for up-to-date information about the subject. It turns out that in March 2012 in Arizona, I was only partly correct but that has changed in April 2012. Let me start by providing some information about EPCS.


EPCS offers a number of advantages over the current state of affairs. For current e-prescribers separate paper and electronic workflows are needed to prescribe the full spectrum of medications. For some specialties such as mine as an orthopedic surgeon, the majority of prescriptions I write are for controlled substances (narcotic pain medication.) Printing prescriptions for controlled substances from many eRx software arrangements requires that special alteration-proof paper be loaded into the printer. That is a disruptive workflow. Finally, EPCS could potentially help reduce the explosion of illegal use of prescription medications currently being experienced in the U.S. by providing better two-way communication of prescription history between prescribers and pharmacies .


Barriers to EPCS include lack of incentives to certify eRx software, need for identity proofing of providers to obtain a digital certificate, the relatively modest cost (less than $100 per year) of obtaining a digital certificate, and the need to modify workflow processes to integrate standard eRx and EPCS.


The IFR for prescribing controlled substances can be found here. A number of succinct summaries have been published to help understand this somewhat complex regulation. I will provide links to some websites that I have found useful. A few of the key points are discussed below. A specially certified electronic prescribing system must be used at both the provider and pharmacy ends of the transaction. (For now, the certification is separate from that for the Medicare and Medicaid EHR incentive programs of CMS.) The IFR did not specify approved certifying agencies so this was problematic. In September of 2011 InfoGard was uniquely approved for this role. It has been hard at work certifying systems since. Next, prescribers must have digital certificates and use two factor authentication to sign and submit prescriptions. The eRx vendor was supposed to provide names of Certificate Authorities (CAs) or Credential Service Providers (CSPs) with whom they work to help providers verify their identity and obtain the necessary digital certificates. The CAs and CSPs should be cross certified with the Federal Bridge. I believe this step presented a barrier because the process is fairly new in the health IT world and participating CAs and CSPs are not easily identified. Continuing, at least two individuals must be involved in setting access controls to the controlled substance eRx software. Also, the software must be able to provide an audit trail of electronic prescriptions submitted. (These two requirements seem straightforward.) Loss of a hard token (a piece of hardware used for two factor identification such as a fob or smart card) must be reported immediately. Finally the workflow specified for preparing and submitting the electronic prescription of the controlled substance is flexible enough to permit a variety of individual prescribing routines.


So almost two years after the IFR was published, what has been the real-world experience with electronic prescription of controlled substances? Remember there are times when state law takes precedence over federal regulations. (This constitutional conflict between federal and state's rights continues all these years later.) Now that a certification body has been approved by the DEA, Surescripts has worked with EHR vendors and pharmacies to offer support for EPCS in CA, TX, and VA. There must be other pilots in states where the law does not prohibit electronic prescribing of controlled substances. I don't offer a comprehensive list. I have looked into electronic prescribing of controlled substances in my state of Arizona. Last week I called a local pharmacy and the representative said the EPCS is illegal in Arizona. I looked at the State Pharmacy Board website. They had a page with resources about EPCS but stated that it was not authorized in Arizona. Then, just this past Friday, the weekly newsletter published by the Arizona Medical Association announced that the governor signed a bill that legalizes electronic prescription of controlled substances on April 4th. Now we will have to wait to see how quickly EPCS is adopted in Arizona.


Coincidently, I was listening in on a meeting of the Health Information Technology Policy Committee Privacy and Security Tiger Team last week. They were discussing the comments they plan to submit to the full committee regarding the NPRM on Meaningful Use stage 2. They decided not to comment on the lack of requirement for EPCS in the proposed regulation. I was surprised because they often talk of aligning regulations and incentives. Contrary to this decision, I think a federal regulation would present vendors with a strong incentive to spend the extra time and money to redesign their eRx software and obtain the separate certification required and move this initiative forward.

The 2011 EHR User Satisfaction Survey

One of the best sessions I attended at HIMSS 12 was the roundtable on EHR user satisfaction. The session was based on a survey of 2,719 family physicians published by the American Academy of Family Physicians in 2011.

The presentation stimulated a lot of audience interaction. I think this publication is a worthwhile reference for both those in the market for an EHR and for those who are already EHR users. Only a relatively small number of physicians participated in the survey so it doesn't represent a complete analysis of the EHR marketplace. Nevertheless, a substantial cross-section of the more popular products was evaluated. Some of the findings will be discussed below.


Practice size was an important determinant of the products being used. In other words, smaller practices tended to select vendor solutions that were distinct from those utilized in larger practices. Respondees from the smaller practices also tended to be more satisfied with their EHR products than users from larger practices. The survey did not provide a definitive answer as to why this was the case. Responses to individual questions where some of the elements of usability were broken out provide a strong clue. Some factors contributing to high EHR satisfaction included overall ease of use, ease of customization, vendor training and vendor support. Among other factors studied were documentation, ordering labs and x-rays, reviewing results, electronic prescribing, patient engagement, meaningful use tools, and communications capabilities both within and outside the practice. Some of the most popular products were unknown to me. I spent several hours visiting the websites of a number of the products discussed to garner some additional insight. The time was well-spent.


The sophistication of the website design and information available was variable. The best were transparent about pricing, offered product information and demonstrations in video format, were up-front about product certification, and provided interesting information about company history and management.


Surprisingly, one of the highest rated products is available free. Advertising is the revenue source although for a relatively small subscription fee the software is available sans advertisements. This is a web-based product that is very attractive because it requires very little local IT expertise. Also, access to the EHR is available anywhere there is Internet access.


Several of the products were distinct in having robust real-time meaningful use tools and easy-to-use reporting tools needed for attestation such as reporting core and menu requirements and clinical quality measures including numerators and denominators. Several of the companies have incorporated advanced neural network concepts in their designs to facilitate documentation and improve quality of care. This is an interesting alternative to templates or dictation for documentation and patient management. One of the companies excelled at ease of delivery of care summaries in the form of the CCD. Few vendors were upfront about how they meet this meaningful use requirement. All the vendors appeared to support electronic prescribing. Some of these modules appeared easier to use than were others. It was rare to find information about health information exchange capabilities, specifically whether the Direct Project specification and associated workflows had been incorporated natively into the EHR product. This will need to change because the use of Direct is headed for a new stage 2 Meaningful Use requirement.


The most alarming conclusions of the survey were that only about 50% of users were satisfied with the systems they were using. Frank dissatisfaction was nearly 30%. Finally, just 38% agreed or strongly agreed that they would purchase their system again. HIMSS has sponsored usability workshops at previous annual meetings. I attended two years ago and learned a lot. The Office of the National Coordinator supports a group looking at usability issues also.

EHR Training, the Hard Way

My hospital is preparing to go live with a major vendor's EHR system the first of May. Hospital staff and clinicians have been busy going to training to prepare. Most of this post will be about my experiences during this training. Anyone who has read this blog knows that I tend to be on the critical side. Most of my experience has been unpleasant, perhaps because I, more than most other clinicians, know how it should/could be done.

First, you should know that I volunteered to become a physician superuser. Based on my training and preparation to teach a class on EHR adoption at the master's degree level, I had certain preconceived notions about how this would go. I was greatly disappointed to find out that most superusers being trained were not physicians. I was in a class that included no physicians in fact. Most of my fellow students were already familiar with the system because they had been enrolled in earlier courses so they had a head start on me. I was doubly frustrated because I had a lot of difficulty searching for my assigned patients. The search was done on the last name, case sensitive, and grammatically incorrect small case letters for the entire last name. It was hard to get over a life time of capitalizing the first letter of proper names. I am sure my 9th grade English teacher is turning over in her grave even now.


I had a lot of trouble following the training. It did not take me long to realize that the major reason for this was that the training was not following clinical workflow. They might train how to manage orders in the recovery room, then a discharge, and then a history and physical. I have written a post about workflow and my observations about workflow have not changed a bit. It was enlightening to learn that one of the trainers had a background in sales and never worked in a clinical environment. This does not excuse the designers of the training who should have known better. I rightly or wrongly attribute this to lack of provider input. But that ignores the fact that best practices for clinician training are well-recognized and widely promulgated.


Many of the major tasks clinicians do routinely were not covered at all. Basic things like how to order an x-ray (I am an orthopedic surgeon after all) or how to view an x-ray in the new system, how to incorporate dictation into a note ( turns out a few clinicians will use voice recognition, most will use the current dictation system if they choose) or create a hybrid note, how patients will be consented for surgery (an electronic signature device will be used) how to transfer a patient to an outside facility, how to prescribe controlled substances, how to ensure a patient receives an electronic visit summary, how to provide patient education materials, how a clinician handles the patient portal- patient emails, release of lab information, and the list goes on.


Back to being a superuser. I found the plan for training superusers was to have them take the course twice and maybe help out with people having trouble on the second go around. There was no special one-on-one or small group training, and short cuts, tips, in depth training, best practices, etc. were not covered. The executive plan appears to me to have non physician superusers help physicians during the go-live. Given the lack of physicians trained in the role this is inevitable. The question is whether it will work well. There is substantial experience to indicate that there will be a problem. Physicians do better taking advice from physicians. Even experienced nurses or unit clerks really don't know physician workflows and likely are not aware of some special needs of physicians. I will wait and report back on the success of the strategy being implemented.


I had a cloud-based practice management system a number of years back. Training was carried out via live webinars for me and my staff by the vendor's trainers. I set up my scheduling system including role based permissions, appointment types and times with this training alone. Physicians were provided very little training about the schedule function of the new software. I was not even aware of the courses that trained on the scheduling module. I like to make my own appointments when I see a patient after hours, or discharge a patient from the hospital on a weekend. I think this provides better continuity of care at a care transition. With the new system, I will not be able to utilize this functionality-by design. I get upset about such things. I dislike wasted potential to improve care and I don't like being harnessed to a receptionist or medical assistant to carry out essential tasks. It turns out that this enterprise system actually is broken up into a number of silos as far as training goes-inpatient, outpatient, financial, patient portal, administration, etc.


A number of asynchronous learning sessions were offered to doctors. I never heard about them before class even though they were assigned as prerequisites. They were accessed through an employee portal. I had never used the portal because I was not an employee of the hospital and did not have user credentials to get into the system anyway. This oversight was clear up at the end of the first class. I think it happened less frequently for physicians taking classes after me. The e-learning sessions were actually quite helpful. They were produced by the vendor using professional trainers who were experts with the system. Each session covered a vignette, an element of clinician workflow. I liked being able to watch these videos several times. Unfortunately, there were quite a number of e-sessions available. Because of the numbering system for the sessions it was apparent that only a few of the available sessions were assigned for review. Communication for physicians about the menu of available sessions was only available upon request if one figured out there had to be more available somewhere.


Everyone had to pass a test to be able to be cleared to use the system. The first time I took the test I found out I was going to be tested at the end of the course during the final hour of 9 hours of training (after hours and after a full day of work.) The test was given on paper and answers were not discussed. I failed the first time but did not know what I missed. Later, trainers covered all the questions before the test (and gave correct answers) and the test was electronic and provided the correct answers for all questions missed so that when one retook the test it was hard not to pass. I could go on with a few more complaints but I think I'll end with one more thought.


Finally, I found it surprising that there was not a single point of contact for questions about training. I didn't know whom to call for help. The trainers were so focused on their individual areas that they did not have an overview of the whole system. I did find one trainer who was able to answer a laundry list of questions I prepared after my first few classes. I appreciated his help but I was lucky to find him.

Interoperability Showcase 2012 Thoughts

The Interoperability Showcase at HIMSS 12 was a popular exhibit floor destination again this year. It was a little hard to locate being situated at the back of the ground floor in the two level exhibit arrangement. There were more independent events making the Showcase more like the three ring circus of the convention itself. Taking a stroll around the site was well-worth the effort.

This was the fourth year that I worked as a volunteer docent. Interoperability demonstrations are based on clinically relevant use cases. This year's menu had fewer but more complex use cases that integrated the services of a larger group of vendors and more deeply highlighted the mechanics of health information exchange. This worked so well in most cases that it was easy to overlook the tremendous effort that vendors and others invest to make interoperability a reality. Health information exchange is enabled by standards produced by standards development organizations and harmonized by others such as Integrating the Healthcare Enterprise (IHE) and the Standards and Interoperability Framework (S&I Framework.) Vendors must qualify for the Interoperability Showcase by successfully completing live interoperability testing at the annual IHE Connectathon that is held for North America in January in Chicago.


Wisely, I think, the organizers shrunk down the number of use cases to just eleven or twelve. Also, teams of vendors that were part of each use case were clustered sequentially in individual pods. This eliminated the docent task of leading tours around numerous pods to complete the use case demonstrations. It also nearly eliminated even the need for docents. Tours worked much more smoothly for sure but my pleasure serving as a volunteer docent was adversely affected. Each group of tours is introduced by a "barker talk" designed to attract attendees to the site. This year the barker speakers saw much of their work taken over by an introductory video that covered much of their previous content territory.


A large section of real estate was reserved for Health Information Exchange this year. There was a pod for early pilots of the Direct Project and another for adopters of NwHIN Exchange, mostly federal partners is various Beacon Grant activities. I had expected more representation HISPs (health information service providers) and more information about digital certificate management.


I often take a critical view of the world I discuss. At this point I would like to take a positive (mostly) turn and look at what I thought was exciting at the Showcase. First, there was a new pod called the Digital Visualizer that featured a series of large flat displays that showed real-time the flow of electronic transactions in a number of the use cases being demonstrated. This was a well-thought out demonstration of the wiring diagram of the information flows from EHRs and patient care devices to HIEs and even across communities of HIEs. The standards being used to support the transactions were also shown. The only problem is that the visualizer stood alone away from the pods where the use cases were carried out so there was a serious disconnect there. Also, since the displays were set up to show real-time data flow, things happened too fast to be meaningful to most observers. My advice would be to enhance the value of this important teaching work by bringing the display information to each Use Case Pod. Also, by creating a slow motion recording or movie of the information flow, the attendees would really get a chance to understand the miracle of standards-based health information exchange that is possible although rarely implemented today.


Finally, there were two demonstrations that completely knocked my socks off and were the most impressive examples of interoperability at this year's exhibit. The first was an example of an automated operating room suite. The anesthesia machine, patient monitors, and infusion pumps (from disparate vendors) all sent information to a central processor that then fed the data, real-time to the EHR. There the data is permanently recorded but could also be monitored remotely, say by ICU staff waiting to receive the patient post-op. The system relieves the anesthesiologist from the mundane tasks of periodically recording vital sign information, IV fluid flows, and drug administration and frees up time to devote to monitoring a patient's status in the OR. The second impressive use case, one for cardiology, showed exchange of information between several different EHRs. During the presentation information was retrieved via HIE using a hybrid structure. The federated approach was used to retrieve x-ray images from the native PACS archive (because of the large file size for radiographs, CT scans, and especially MRI.) The EKG was retrieved from the registry/repository for viewing by both the primary care physician and the cardiologist. Thus documents, images, and other types of graphical information were exchanged seamlessly using sophisticated HIE architecture, even across different information exchanges. I think this example represents the moving puck those involved in health information exchange are trying to track.

Thoughts about HIMSS12

The HIMSS12 Conference in Las Vegas last week had the highest attendance ever. Even the large convention facility seemed crowded and at times claustrophobic. Nevertheless, I'd say it was a very successful meeting. I came away with a lot of ideas for future posts. For now I'll just discuss first impressions of what I thought were major themes I identified, as filtered through my one of 35,000 minds that attended this year's meeting.

Data mining was a very hot topic. Secondary use of data will be facilitated through the expected increase in health information exchange. Vendors, government agencies, researchers are looking forward to a 21st century gold rush of clinical data-not only to improve the quality and efficiency of health care but also for anticipated financial gain in some cases. The drive for health data is almost alarmingly commercialized. This recent report, unrelated to HIMSS12, epitomizes what I mean.


Clinical decision support (CDS) also got a lot of play. Clinical decision support systems are ubiquitous for checking for drug-drug interactions and allergy checks and even to promote guideline adherence. Order sets are a good way to implement CDS rules. But the safety and efficacy of CDS are still questioned. The challenge of decision support is to deliver information the clinician or patient needs at the time the information is needed with actionable choices in a manner that harmonizes with workflow. Strides in the development of artificial intelligence to filter data, generate information, and offer timely suggestions should be expected.


In the last paragraph I mentioned patient safety. The intention to deliver safe care is never far from a clinician's thoughts while practicing medicine. In fact, improvement in patient safety is one of the characteristics used to promote EHR adoption. Published reports on the use of EHRs to improve the safe delivery of care however are contradictory. Several speakers mentioned the Institute of Medicine's report published late last year on EHR safety. An article in Health Affairs was also mentioned several times.
I think these publications point the way toward enhanced scrutiny of the safety of HIT systems, better studies of the current state of the industry, and easier, more efficient, and systematic methods of collecting data on the safety risks of EHR technology.


Health information exchange was a popular topic of discussion. ONC representatives and others touted the successes of the Direct Project, NwHIN Exchange and Connect activities, State HIE grant programs, and health information exchange pilots in the Beacon and SHARP communities. There are a lot of stakeholders in this area with different viewpoints and different criteria for success. I don't think many are fully satisfied with the amount of health information exchange taking place today in the U.S. Vendor preparedness, provider acceptance, and infrastructure are barriers to "push" transactions such as Direct. Federal policy, local governance issues, consumer consent issues, vendor readiness, and infrastructure inhibit robust exchange. Progress is being made in incremental steps but much more needs to be accomplished to reach the full potential of HIT. This leads to the next topic-consumer empowerment.


More and more, patients want facile access to their health information. The "Blue Button" initiative of the VA
is leading the way to opening up the flow of data to patients. There should be easy ways to upload information to a personal health record or to a file on a home computer for patients to use to communicate with their multiple physicians and to enhance their ability to participate in promotion of their health. The ONC has made consumer engagement one of its strategic priorities and has developed a new web site to disseminate information to patients and families.
Last but not least, mobile health was a ubiquitous theme. Mobile health applications are being developed to empower providers and patients alike. The use of mobile technology to facilitate the use of patient care devices, both external and implanted, to facilitate patient care was particularly noteworthy. This technology is advancing like a tidal wave. This field offers perhaps the greatest opportunities for innovators today. Issues with FDA regulation of medical devices are a potential risk. Even the definition of a medical device seems to be in flux. We will have to be nimble to keep up with all the developments in this realm of health IT. Here is a good HIMSS resource.I haven't even touched upon the NPRMs released during the week. I will wait for the dust to settle a bit before I offer my thoughts. The coming months should be interesting for health IT participants.

Is the view only option for HIE worthwhile?

I watched the NeHC University online presentation- an introduction to the HIE Landscape early this month. The results of a survey of active HIEs were presented. Findings were that about half of the responders plan to offer the view only data option while just a quarter plan to support document sharing. In a similar vein, AZ HIMSS offered a state of the state update for HIT in Arizona at the end of January. It turns out that largest HIE in Arizona also plans on providing view only access to data. As a physician as well as a strong proponent of electronic information exchange, I am disappointed that more robust ways of freeing up patient information flow is not the goal of most HIE programs around the country.

The "view only" option for HIE has numerous limitations. If the user wants to retain the information in a more permanent format, there is no convenient way to do this. The receiver must re-enter the data in their own EHR, PHR, or other information system. This relies on memory and human typing skills, both of which are subject to error. The process is time consuming and does not fit well with the workflow of busy clinicians and patients. I suppose screen shots could be saved but the data is still basically constrained in a silo. Worse yet, for those with information privacy concerns, it would be hard to keep an accurate audit trail for this method of copying patient information. Also, it would be difficult to support the creation and maintenance of a longitudinal health record for the patient. Furthermore, the data would be in a format that would not allow ready use of clinical decision support tools to improve the quality of patient care.


For the last four years I have served as a volunteer monitor at the IHE North American Connectathon. Most of the profiles I have tested belong in the Patient Care Coordination domain. To make a long story short, we test the ability of different vendors to conform to various clinical document summary specifications (medical summaries, ER referrals, Labor and delivery records, and ED physician notes to name a few. For further information see this site) and exchange those documents with information trading partners. The testing plan offers options of: view only, document import, section import, and discrete data import. The view only option allows one vendor to view another vendor's summary document on their computer screen, like pulling up a web page. As discussed above, this information is not in an easy to use format. The document import option allows the vendor to import the entire document and attach it to a patient's medical record. The workflow is similar to filing outside records received by mail or fax in a patient's paper chart, as many clinicians do today. Section import allows attachment of a section of a summary document to the patient's chart-for example the allergy section, problem list, medication list, demographic data, etc. This capability only has limited uses currently but could be used as a data source to drive a medication or problem list reconciliation engine. Discrete data import has the greatest potential to change how we do medicine. As the name implies, information at the data element level can be imported and inserted in the patient's chart. This information could then be used support CDS, prepare graphical representations of patient data, and for reconciliation activities such as reconciling a medication list. Unfortunately, the bar to pass the tests at the Connectathon has been set too low. Vendors only need to be able to support the view option. I have had conversations with fellow monitors and others and many agree it would be a valuable step forward to require vendors to support the discrete data import option. It is my belief that this is the most useful way to drive innovation and improve information exchange capabilities among different EHRs. There could be other incentives as well.


The federal government made a commitment to encouraging HIE through the State HIE Grant program. Federal policy has a considerable influence on the strategies the states are adopting. For example, it was made clear that The Direct Project specification should be adopted and implemented. I wish the ONC would put greater pressure on the state grantees to adopt options for data import as opposed to view only health information exchange. One only needs to look to the popularity of the VA sponsored "Blue Button" initiative to see that download technology is desired and used by patients and other stakeholders in the health care marketplace.

Cumulative Index through December 2011

I have prepared a cumulative index to posts for this blog from its beginning.
A Commercial Web-based HIE Offering from Verizon                                                            July 20, 2010
A Peeve: The auto-log off in HIT                                                                                           Dec. 27, 2011
Breach Notification-Part 1                                                                                                     Oct. 15, 2009
Breach Notification-Part 2                                                                                                     Oct. 26, 2009
Certification                                                                                                                            July 29, 2009
Certification Follow-up                                                                                                          Aug. 19, 2009
Clinical Decision Support Systems                                                                                         Mar. 23, 2011
Clinician Workflow                                                                                                               April 11, 2010
Consumer Preferences                                                                                                            Nov. 2, 2009
Digital Certificates-uses in HIE                                                                                               June 15, 2011
Dr. Blumenthal--An Inspirational Keynote Address at HIMSS10                                             Mar. 7, 2010
EHR's for Surgeons/specialists                                                                                               Nov. 19, 2010
EHR Safety                                                                                                                           Feb. 21, 2010
EMR Certification Revisited                                                                                                  Nov. 17, 2009
EMR Usability                                                                                                                      Nov. 22, 2009
Future Role for HITSP?                                                                                                          Dec. 2, 2009
Handheld Devices-the Mobile Clinician                                                                                     Jan. 9, 2010
Health Information Exchange                                                                                                 Aug. 18, 2009
Health IT Ontologies of the Future                                                                                           Jan. 12, 2011
Health IT Workforce Training                                                                                                Dec. 27, 2009
HIMSS 11 ARRA Usability Symposium                                                                                  Mar. 2, 2011
HIMSS Virtual Conf. 2011:
           Closing keynote-an exceptional presentation                                                                June 14, 2011
HIT Outlook for 2012: a crystal ball                                                                                         Dec. 2, 2011
HIT Workforce Training                                                                                                        Dec. 14, 2009
Imaging and Meaningful Use Debate                                                                                        Jan. 27, 2011
Information Exchange Patterns                                                                                               May 28, 2010
IFR on Standards and NPRM on Meaningful Use                                                                  Feb. 16, 2010
Introduction                                                                                                                            July 17, 2009
Introduction to electronic signatures and digital certificates                                                         June 9, 2011
It's all about workflow                                                                                                           Mar. 31, 2010
Looking forward to 2012                                                                                                      Nov. 27, 2011
Meaningful Use and Incentives to adopt HIT                                                                           July 21, 2009
Messages vs. Documents                                                                                                       June 16, 2010
More Thoughts on Documents                                                                                                Sept. 6, 2010
My Favorite Day at HIMSS 11                                                                                               Mar. 3, 2011
NA Connectathon 2011                                                                                                          Jan. 22, 2011
Online Education                                                                                                                    Sept.10, 2009
Online Graduate Degrees-My Experience                                                                              Nov. 18, 2009
Optionality and Interoperability in Health Care Software                                                           Dec. 6, 2010
Outlook for New Workforce Trainees                                                                                     July 25, 2010
Patient Portals                                                                                                                       Mar. 30, 2011
PCAST Report Thoughts                                                                                                       Feb. 11, 2011
Planning for HIMSS11                                                                                                            Dec. 1, 2010
Provider Directories                                                                                                              Mar. 31, 2011
Quality Reporting                                                                                                                 Sept. 30, 2009
Reasons Specialists should consider Regional Extension Centers                                               May 8, 2011
Recommendations for HIMSS 2012                                                                                      Dec. 12, 2011
Reconciliation-an unmet challenge                                                                                         Sept. 14, 2009
State Grants for Health Information Exchange                                                                         June 18, 2010
Summary of the HIT Policy Committee Workgroup hearing on EHR Safety                            Mar. 15, 2010

The Direct Project Goes Live                                                                                                  Mar. 1, 2011
The Perfect Storm Barometer:what are the greatest HIT risks for clinicians                              June 20, 2011
Thought on the NHIN                                                                                                           Mar. 18, 2010
Trusted Identities                                                                                                                   May 25, 2011
Where are the HIT Experts?                                                                                                  Aug. 26, 2011