Docnotes

John Faughnan

Hey - John's got a weblog -- er -- three.

• Faughnan's Notes.  - Friends and family
• Medical Notes - the medical version
• Quick Notes - quick notes blog

I missed John at AMIA this year.  His weblogs are great.  Hmm .. he's uing blogspot -- so no RSS.

Linux Medical News

Over at LMN: Live from the 2003 Fall AMIA Conference.  This is Ignacio's version of  the EHR session.  He types faster (and has better batteries) than I do.  Neither of us liked what we heard -- but for different reasons, it seems. 

I'm not bothered at all about the code.  Open source of the code that's behind the software is simply unnecessary.  Good software can be "closed source" and still be good.  The key is that our data be accessible.  With many EMR's the data is locked forever.  It's a real problem and dates back to the age of the dinosaurs. 

A key (and laudible) component of the AAFP project is that the data remain accessible.  

Colace does nothing

So it seems that Docusate Sodium (Colace) does rather little. Despite this, it remains the mantra for post-partum care (with the partner FeSo4).  This isn't recent news.   I wonder why it's still used so much?

Nonetheless -- I suggest it frequently -- for problems at the other end.

Teflon Flu

Here's an interesting piece on the Teflon Flu. It's better known as metal fume fever and/or polymer fume fever in the medical literature. It is real .. but seems to be a problem only if you cook your frying pan instead of the food.

AAFP EHR

An interesting letter from Rick Peters on the AAFP Open EHR from last April.  Much has changed since then.

Here's a pair (one  two) of press released from this week.

OK .. so we learned about who the vendors are:

• A4 Health Systems - EMR
• GE Medical Systems Information Technologies - EMR
• HP -Hardware
• MedPlexus - EMR
• MedPlus, Inc - Interfaces
• NextGen - EMR
• Physician Micro Systems  - EMR
• Siemens Medical Solutions - hosting, infrastructure
• Welch Allyn -  instruments

Most of these are no surprise. 

I didn't anticipate Medplus or Welch Allyn.

 

A Definition of the "ACID" test - as I described a few days ago:

• Affordability - Recognizing the limited capital available to family physicians in small medical practices, the AAFP's partnering firms will discount their prices and work with the AAFP to increase the volume of their sales for software and hardware.
• Compatibility - Compatibility will be achieved through efforts to standardize connectivity interfaces between office-based systems, such as the EHR, and key information resources for electronic prescribing, laboratory result reporting and hospital information systems.
• Interoperability - Interoperability standards, such as the Continuity of Care Record, will be jointly developed by the AAFP and partnering companies to permit seamless data exchange among physicians, other providers and patients.
• Data stewardship - Data stewardship will become an increasingly important challenge as larger amounts of physician-generated health information are collected, stored and managed in systems and databases across the country. These data must be protected, kept secure and used only for ethical purposes that support the highest values of the medical profession.

... and a search of google for "AAFP EHR" brings up Family Medicine Notes in the top five.

Soarian

Press release: Siemens Soarian Goes Live at Largest Customer To Date. I wonder what "Goes Live" means. This software will be good, but it's not there yet.

Paper as a User Interface

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.

 

Primary Care Office Information System

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.

AAFP and NAPCI

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:

AAFP EHR Project

Still at the AMIA meeting in Washingotn DC.  This afternoon there is good wireless access in the conference room -- unlike the morning.

I'm now at a session hosted by Alan Zuckerman.  Alan is a guy who seems to have lots of energy and is always working on yet another project.

Other presenters at this session include David Kibbe - who is the architect of the AAFP EHR project - and Michael Bainbridege.  Mike is from across the pond - and worked for Meditel (now Torex).  Mike is chair of the BCS Primary Health Care Specialist Group. 

The title of this session is:

"A phoenix Rises from the ashes of Open Source: Lessons learned and New Directions Taken"

I suppose this refers to the Oceana product I've discussed before ... that's the phoenix.  Now the product has been transferred to Medplexus.