Meaningful Use Stage 3 Full Steam Ahead @Meaningful Use

Thanks to my colleague John Poikonen for the Meaningful Use Stage 3 update for everyone.  The Working Group met on August 1, 2012 and among other things set the timeline for upcoming events.  Get ready for things to heat up.  

•Aug, 2012 – present draft preliminary stage 3 recs

•Oct, 2012 – present pre-RFC preliminary stage 3 recs

•Nov, 2012 – RFC distributed

•Dec 21, 2012 – RFC deadline

•Jan, 2013 – ONC synthesizes RFC comments for WGs review

•Feb, 2013 – WGs reconcile RFC comments

•Mar, 2013 – present revised draft stage 3 recs

•Apr, 2013 – approve final stage 3 recs

•May, 2013 – transmit final stage 3 recommendations to HHS

I am also attaching the Presentation from the event.  Please feel free to download and review.  Time permitting I will review and summarize the preliminary recommendations soon.

MU Stage3 prelim 080112.pptx Download this file

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EHR use in Pediatric Populations by Anne Bobb et al

Another fantastic contribution to the informatics community on behalf of NIST and the always professional Anne Bobb.  Anne has been a long time colleague and one of the very best at quality measures in the field.

 

To put it in perspective, the word "medication" is used 82 times in the article.  Anne is the only Pharmacist on the team of 30.  Although I did not have time to read the entire 44 page article before writing this post, my comfort level with the outcomes and discussion are very positive.

 

 

 

My overall summary:

 

1.  EHR Adoption by pediatric providers has lagged behind their general adult counterparts.

 

2.  Overall usability is a seldom addressed but  critical piece to successful implementation in high risk populations such as pediatrics.  Current EHRs have a long way to go.

 

3.  Time pressure shouldered by healthcare providers makes usability all the more important in pediatric populations.

 

4.  Pediatric patients are unique, and small delays in care due to usability issues can have extreme consequences on patient care.

 

Thanks to Anne and the NIST team for putting together a wonderful and informative article on the impact of EHRs to pediatric medical practice.

 

Article Link and Download

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The quest for an organized peripheral brain

John's wonderful post on the Peripheral Brain sent on a quest to find tools to organize my life.  I spent a few hours this weekend looking over Springpad, and decided it is not ideal for those that manage documents.  At least for me, I am still getting the majority of my information in a document format.  Springpad is fantastic if you spend lots of time on the Internet, and if most of your cataloging comes from web pages.  In the Informatics world many of our articles and references are not mainstream (or behind a password protected site) so this makes it hard to conveniently add all articles in Springpad.  This coupled with the inability to add multiple documents to one "Spring", and one can see where it quickly falls behind. 

It seems as though Springpad might be good for someone that works in a smaller more amoebic type office, or one that deals with mostly internet based business relationships. 

After this revelation, I was obviously disappointed!  My attempt to make some sense of the email monstrosity, tweets, blog posts, RSS feeds, publications, and articles remained a mystery.  At this point I turned my attention back to Evernote.  It allows easy cataloging and even easier searches to find those old, obscure articles from years past.  Before Evernote I organized items into folders.  Before Spotlight on OS X, it was really difficult.  Folders had to provide all organization, so I ended up with hundreds of them.  Needless to say it was still difficult to find anything.  John and I have both been long time users of Evernote, using it on a daily basis.  I have a few thousand notes, and I am sure he has many more. Evernote is fantastic for its simplicity.  Evernote has no substitute for document cataloging, and it is comparable to other products for all other forms of digital media. 

You may be wondering why I was looking for an alternative if Evernote is so fantastic at managing my digital media.  Well, my focus this weekend was organizing my tasks and projects.  There are many methodologies available to the novice consumer such as myself.  One might fall upon GTD or Personal Kanban.  However, my goal was to find one product that could do both.    To accomplish this in Evernote, we typically rely on tags and notebooks.  My research brought me to an interesting system called The Secret Weapon.  This methodology uses tags to organize email based on who, what, where and when it needs to get done.   For instance, my “what” might be Projects, Informatics Consulting, and Expert Witness.  My “where” might be Home, Office, and Town.  My “when” could be represented by Now, Next, Later, Someday, and Waiting.  To organize the messages you tag each with as many of these categories as you can.  So an email about an expert witness report I need to finish might be tagged with Chad, Now, Office.  Then next time I am in my Office, I would look through Evernote and find tasks with these tags to work on.  This can also be used for home life, say remodeling a room.  You could use tags to set the who, what, where, when and organize them into a meaningful, prioritized plan. 

So my appetite for organization is sated right?  Not so fast.  The Secret Weapon is fantastic for organizing emails if you are using Outlook.  Where this fails is with simple tasks or lists for small things.  No one wants to create a new note in Evernote to say “get laundry”.  It just takes too much time.  Springpad was great at this type of simple easy to review list management, but weak on document cataloging.  Maybe I have yet to stumble upon a simple elusive feature in Evernote to accomplish this.  I ran across Nozbe, a GTD application that has promise.  It interfaces with the Evernote API and shows notes with related tags right in a task.  Nozbe has great reviews on the Apple App Store, as well as the web.  They offer versions for iOS products, OS X, as well as a very well designed web application.  However, all of this functionality does not come without a price.  Each version is a separate purchase, and there is a monthly subscription.  However, if Nozbe is the destination on my journey for GTD awesomeness, it is well worth the cost.  I am going to give it a try for a few weeks to see if it meets my needs.   I will report back on my quest for the best solution!

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Healthcare software: Thoughts on usability

Yesterday at the Build developer conference, Microsoft unveiled the next version of Windows to developers from around the world.  Windows 8 has received a great deal of press over the past few months, with usability among the mantras.  I am always interested in finding ways to improve the user interface for consumers.  In the case of electronic health records (EHRs), organization and simplicity are thought to play a role in improving safety and productivity.  Reviewing the general layout of some of the top certified EHRs in the country has left me desirous of a cleaner user experience. 

We expect the systems to check for allergies, allow documentation of clinical impressions, or display critical lab values.  However, we haven't really provided input to the vendor community on how these things should be shown.  There are a number of lessons everyone in healthcare technology can learn from our counterparts in mainstream operating systems. This 90 minute developer video does a great job of showing just how much thought and resource IT companies are giving to the user interface.  Some might argue the certification criteria should include usability measures, and we will most likely see healthcare software migrate to this thought process in the future.  After all, it has taken the largest software company in the world over 25 years to gain the necessary experience.   

Certainly we need to understand more about who needs to see it, where/when should it show,  and what should it say.  The information has to be meaningful and actionable, but it also needs to be clear.  We try to show so much information to providers and clinical staff, sometimes we may be doing more harm than good.  In Pharmacy Informatics, missing one piece of information in a sea of text can have dire consequences.  it is our job to help vendor's understand just how important the user experience is to safe and effective patient care.  I personally am looking forward to the journey with our vendor and clinical partners. 

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When should we teach students about Pharmacy Informatics?

The timing of student Informatics exposure came up in a recent discussion with Doina Dumitru, an Informatics colleague and editor of The Pharmacy Informatics Primer.  We were approached by a well known college about the possibility of offering an elective Pharmacy Informatics course to students.  You can imagine our excitement and enthusiasm for this request.  We started charting out the curriculum and lecture topics, as well as appropriate class timelines.  Initially we hoped to offer this during the summer of the student's second professional year, but quickly came to realize some challenges.  

First, students lacked the pharmacy practice experience to understand much of what we taught.  Informatics is an extension of the clinician, a way to take our experience and build it into computers.  Students just don't possess the knowledge to absorb the implications or reasons for Informatics decisions.  Informatics is about our practice experience, not about being an IT person.  The IT skills are necessary, but secondary.  Pharmacy workflows, regulations, and clinical practice play a big part in our decision making process.  Paralleling the importance of these points to pharmacy curricula, we realized the students would not be ready for an entire Informatics course until a portion of their final clinical rotations were complete.  While there may be an exemplary example with years of pharmacy technician or externship experience, it was not enough to justify a course.  

Integrating a handful of lectures on Informatics topics into a required management course might be a better alternative, but what about the lecture content?  The topics should focus on well known, high impact subjects such as Meaningful Use, the HITECH portion of ARRA 2009, and the overall impact of technology on pharmacy practice.  How has technology shaped our profession over the past 30 years?  What does Meaningful Use "mean" to the practicing pharmacist?  How can pharmacists help their institutions and colleagues in healthcare with adoption of medication use methodologies in information systems?  What is an electronic health record and how do medications flow through them?  Topics such as automation technologies, downtime, data mining, and report writing came up in our discussions, but the group felt like they would be perceived as low impact lectures.  In student speak "we will watch the lecture on video and sleep in a few hours."  

The next topic was on how many hours of content the lectures would provide.  The topics need to be targeted, high impact discussions that spark interest in the profession.  They need to grab the student's attention and flip a few light bulbs to the "on" position.   This is still an open discussion, but I would estimate 6 hours to cover the high impact topics.  

Students are a precious resource, and represent our legacy.  It is important for us to develop their exposure to Informatics in an interesting and paced manner.  I welcome your comments and questions.  

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Do we see only what we want to see in EHRs?

I was recently informed of a situation in which a high alert medication was programmed incorrectly, causing a gross rounding error to occur. Certainly the system could have been checked more carefully before implementing the changes, but what about the physician, pharmacist, or nurse? In this case the physician missed the rounding calculation (although shown on the ordering screen below the ordered dose). The pharmacist, our medication expert in the hospital setting also checked the order in the EHR without question. Luckily the discrepancy was caught by a completely unrelated test order, or ADEs could have resulted. Have we become so trusting of what shows on a computer screen that we don't question the content?
The power of the suggestive mind is not new to humans. It helps us fill in the blanks on those fun crosswords and MadLibs, and with those difficult co-workers. However, when it comes to the power of suggestion in electronic health records, seeing what we want to see may potentiate errors. This lab order is always twice daily, why should I pay attention to it after ordering it 15 times? The TPN order has always defaulted to 2000ml, can't I just skip review of the field? On rotation, my students are informed of this critical vulnerability in the healthcare computing age. We must use our minds to be sure what we see in a computer, in a book, or on the news makes sense. In our profession, we cannot take the computer's word for it. After all, it was programmed by a human and we are all aware of our nature. As we continue to learn more about technology adoption in healthcare, we will become aware of these pitfalls. In the meantime, we must remain diligent and ever questioning.

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When does the journey begin?

To Meaningful Use, of course :)  

This piece on HCR Blog provides some wonderful insight into what it really means to use EHR technology.  Think of a long hall with a doorway at the end.  Although the implementation of EHRs might be that long journey down the hallway, and the door is golive..........   Once we step through we "see the light" and the real task at hand:  Turning this technology into better patient care.  

After golive your journey is just beginning, and organizations should put more emphasis on this than the implementation itself.  How do we make things more efficient and safe for healthcare providers?  How can we leverage technology to solve logistics issues and improve patient throughput?  How can the pharmacist use CPOE to communicate formulary and safe medication choices to providers at the right time and place?  

It was just an outstanding revelation for me to hear this again.  It is so important to this transition.  We must keep it in perspective.