Docnotes

12 years of blogging .. about medicine, technology and their intersection ...

This post from November 26th, 1999 - was the first on this blog.  There were a few months of previous posts, but due to several platform changes back then - these seem to be lost.  

No matter.  12 years is a long time.  My blog is now officially an adolescent.  I wonder what it will be when it grows up!  Long-time readers are of course observant that I've been remarkably quiet for the past few years.  This is due to my evolving work for an HIT vendor and now the Federal Government.  

So I've been operating with this in the background for the past six years:

The opinions expressed on this blog are my own and do not represent the veiws of my employer.

And there is a rough "social media policy" (google docs - you have edit rights .. feel free to steal or enhance ... ) that I have in my head as well .. so in general I have done my best to observe and occasionally point to important publicly available information, but take care not to comment too deeply - for fear that others would interpret my commentary as a telegraph of my employer's next steps.  This wouldn't be appropriate for me to share - and increasingly - I am concerned that most of my public thoughts could be interpreted in this way - so I've been holding back from any public commentary.

So for now - here we are. 

I'll push the envelope a teensy bit and comment on some events of the past few months:

Tim HISTalk covered my arrival at ONC in a post about a month ago.    He asked the right questions about the topic at hand - but he didn't get to the one that I am hearing often these days - which is .. "Why did you leave your leadership role at one of the top health IT companies, choose to spend weekdays away from your family, AND (with two kids in college) take a giant pay cut?"  

The answer is easy:   It's the right thing to do.  

Health Care in the United States  is at a turning point.  It is well known that despite great advances - we don't provide the quality of care that we would.   It is also self-evident (to me) that technology - carefully applied - will improve both the quality of care - and the efficiency, sensitivity, and ease with which it is delivered.  Yes - some of those words may not be familiar to you - but why WOULDN'T we want it to be EASY to deliver great care?  Why shouldn't we deliver SENSITIVE care (sensitive to your hopes, religion, fears, preferences) - in addition to efficient, evidence-based and (of course) cost effective) care?

 So I have always tried to focus my work on helping others meet their true potential.   In my first career - as a 16 year old sailing teacher, I helped kids find the freedom and autonomy that a good breeze and a sunfish will provide.   As a teacher of junior high school kids - I witnessed breathtaking intellectual growth in a herd of 12 year olds who were otherwise distracted by adolescence and its daily challenges.  Working with (some say "caring for") patients as a family physician - I found that my most important work was not to take control and "fix" my patients (as some of my mentors had advised in medical school) but to partner with my patients - serving as a resource - without any judgment or critique.  As Bill Miller and James Prochaska have demonstrated (motivational interviewing, transtheoretical model) - people change when they choose to - and no sooner.  Can we facilitate growth in others?  Of course we can.  But "facilitate" and "cause" are inherently different.

As a leader in a large health IT software company - my role was often to help our teams align the software products we were producing with the needs of our customers.  This is not unlike the role of a good physician:  we need to listen carefully and critically so that we understand the needs (which will sometimes differ from the "wants") so that we can facilitate success.

And isn't that the role of government too?   Perhaps that's a political question.  Some would argue that government should get out of the way, while others would argue that there is an important role for government to provide an infrastructure with which success can be facilitated.  Is a healthy happy nation something that is important?  Are there ways that government can facilitate a migration toward these goals? 

I think so.  Keep an eye on my occasional tweets , g+ posts (rss), and posts here on this blog.  It will continue to be sparse here on the blog. 

EHR Incentive Program Registration Instructions

Registration opens today for the EHR Incentive Program.  The process is not so easy as one would like.  Here's an overview for how to register as an Eligible Provider.

1. Go to the Registration Program's login page.
2. You need a login.  This is your NPPES login.  Oh?  You don't have one?  Neither did I.  
3.  I do have an NPI.  So do most EPs.  If you have an NPI - you can create an NPPES login here.  If you don't have an NPI - you will need to apply for one here.
4. OK .. go back to the login page (link in #1 above) and log in.
5. Click on "registration"  (the tab at the top) and scroll down to the bottom.  Your name is listed and at the bottom-right is hyperlink:  "Register."  Click that.
6. Click through to the page that is going to stop most providers in their tracks.  There are several questions:  First - you need to select whether you are participating in the Medicare or the Medicaid program.  You should know.  Most providers will choose Medicare.  This next part is counter-intuitive:  you need to select the radio button - and then click "apply."  It's terrible design.  What does "APPLY" mean?  Am I applying for the program?  No.  In this case - what I THINK the web designers meant was that you are APPLYing your selection of the radio button.  When you choose "Medicaid" - a drop-down list appears so that you can choose your state.  Only a handful of states have competed their paperwork - so only a handful of state Medicaid programs are open for registration.  If you plan to register for the Medicaid program in one of the states not listed here, you need to wait days, weeks or months until the program is active.  There is a link to this page (ugh! pdf - more bad web design - here's a non pdf version) that lists the state programs and their expected ETA.  Don't know which program you qualify for?  Use this nice wizard to figure it out.
7. Once you select the program - you are asked whether you have a certified EHR - and if so, what the certification number is of that product.  This is an OPTIONAL question.  I assume that's because some products are not fully certified yet - or because in many scenarios - one needn't even have an EHR yet.  This is just registration for the program.  Note that this page requests a certification NUMBER but in fact - what they want is a "YOUR CERTIFICATION ID" - and NOT the "Certification # of the product.  Yes - this is confusing.
8. This page directs you to the CMS website here.  But that's not the right place to go.  What you need is the CHPL - the Certified Health IT Product List.  To create your certification ID (you don't really need this - recall that it's optional)  .. go to the CHPL here .. then browse the list or search for your vendor(s).  The second column is the PRODUCT's certification #.  Not what you want.  If you have one complete EHR - click on "add to cart" and follow step #9 below.  If you have several modules - add all of them to the cart.
9. At the top of the page - you will see a link to your "shopping cart."  Click on that link.  Now you see your list of modules.  You need 100% Certified EHR technology - so if you have modules that don't make you "complete" - you won't be able to create a certification ID.  Have 100%?  Great.  Now click.  There is your certification ID.  That's what goes in the optional field on the EHR Incentives registration page.  Let's hope they fix this soon so that it's more clear.

I didn't get past this page - (yet) as my state isn't one of the active ones - and I will apply for the Medicaid program.  If you got past this screen - please let me know if you encounter anything challenging. 

 

Mark is still dead

Last week I wrote about Mark. 

Unfortunately - the bad dream that he had died wasn't a dream - and it's been a surreal week - re-connecting with old friends, and re-living formative memories.

Mark was a passionate, thoughtful person who worked so hard to make things RIGHT – while doing his best to have fun - with a unique serene yet sardonic demeanor.

In 1982, I was Mark’s apprentice for 12 months on the 144’ sailing ship – the Barkentine r/v Regina Maris – where he was Chief Engineer (El Jefe) – and I was the Assistant Engineer (El Lacayo) - earning $1 / day.

It’s Mark’s fault that I am a physician.

As we diagnosed, disassembled (and reassembled) diesel engines, bilge pumps, de-salinators and generators together – Mark taught me the fine art of diagnosis, decision making, and careful, patient action. 

In healthcare we call this SOAP (Subjective Objective Assessment and Plan) – On Six Forks Road (and Toyota) – it’s called PDCA (Plan-do-check-adjust).

Medical Educators call it GNOME.

Regardless of the name/ framework/ religion we use – it’s about thinking carefully, calmly and strategically about where you want to end up – then having the knowledge, skill and attitude to get you there.

We're on our way to Mark's memorial service now.  Marcie sent me this last night - which does a better job than I ever will in telling a short story about our friend:

 

Informatics Comeptency Evaluation

Let's say you want to evaluate the Medical INformatics Competency of a group of students, IT staff or physicians.

I'm working on an evaluation tool that should be EASY for anyone with these skills .. and a true challenge for those without.   

Take a look at it here. It's a Google spreadsheet so you will have to log in to Google Docs to edit it .. but feel free to do so.

Physicians, Patients, and the Electronic Health Record: An Ethnographic Analysis

When Bill Ventres and his colleagues published their paper last year on this topic - I was impressed, but for some reason I didn't write about it here or forward a link to all of my colleages as I should have done. Bill presented the paper at this year's STFM - and of course he uploaded his powerpoint to FMDRL. Required reading.

Customer Service - Heathcare, IT and Cell Phones

Sam's cellphone ws not working (again) so we spent 90 minutes at the Sprint store getitng it fixed (again) last night. As we walked away - he observed: "Dad - everyone in that store was angry."

He was right - we wondered together who had the stronger point - the angry lady who hadn't gotten her rebate check yet - or the clerk who kept insisting that the check "comes from corportate - I can't help you." Of course it was the angry lady. the clerk didn't take any ownership of this problem. All he did was insult her and do his best to push the problem away.

Bad bad bad.

Joel's got seven steps:

Seven steps to remarkable customer service - Joel on Software

In healthcare - we can't always fix a problem - but at the very least - we need to build an alliance with the patient/customer so that there is shared understanding of the problem - and shared investment in solving it.

Google Calendar for office schedules

A few days ago I made a comment about how the building blocks were there to pull together some "mashups" in medical practice.   I said it wasn't rocket science.   Here's a short description of how I solved a real-life problem in my practice. 

Problem:

• Dr Reider isn't as well organized as he could be.  Duh.  this is a common problem in healthcare.  Physicians work too much - we'd much rather spend time with our patients than at our desks reviewing paperwork, writing notes, etc.  Perhaps I'm worse than many others.  So be it.  Not going to change this old dog. 
  
• Sometimes I'm not scheduled to see patients in the office (yes - I have too many jobs - but let's keep on track here!) but I agree to see someone anyway.  Perhaps I am on the phone with someone who tells me that they can't get an appintment to see me for a few weeks .. and I say "well, Bob .. how about we see each other at 8:30 next Tuesday?"  So Bob gets scheduled .. and next Tuesday rolls around and Bob shows up .. but I'm not there because I forgot. 
  
• oops.  Office calls me.  I rush to the office .. see Bob.  All is well.   We hope.
  
• My attempt @  human solution was to have the office staff look @ tomorrow's schedule .. see if there are patients scheduled to see me on a day that I'm not usually "in" - and call to remind me.  Short version: this didn't work. 
  
• Enter technology:

Requirements:

• The system will be able to determine when the provider is scheduled to see a patient on a day that he is not otherwise scheduled to see patients.
• The system will be able to cause the provider to be reminded about the appointment(s) with enough warning to be able to be in the office on time - yet not so early (1 week) that he will forget.
• The system should - if possible - be able to add the appointment(s) to his calendar in google calendar, 30Boxes, or Outlook.

Implementation:

• I'm using the webservices that I created for our Misys Vision practice management system to get the information about the scheudle.  Easy.  Scheduled Task that runs on the server @ 6 PM
  
• GetSchedule("JMR",BeginDate,EndDate)  .. in this case - I get 1 day - tomorrow.
  
• I parse the data and decide if it's a "usual" day or a day I'm not supposed to be in
• If # rows returned > 4 .. End
  
• If $ rows returned < 4 .. then it's probably not an "in-office" day - so let's keep going
• Push the data to Google's API - to add an event for each visit
• Sending: BeginTime, EndTime, no patient identifier, description "patient scheduled"
• The scheduled visit is now on my google calendar.  I can now receive an alert from google via SMS .. or sync with my PDA, outlook, 30Boxes, etc.  Easy.  Google this - there are so many options these days .. from SyncML free solutions - to commercial products.   Perhaps that topic deserves another post ...
  

Homeland security reaches the anus

This note in the Lancet (sorry - free registration required) tells a compelling story about the state of our Homeland security.  I'll admit I've never seen a Seton .. so I would have been just as confused as the Homeland security physician (did you know we had homeland security physicians?)

MySpace for Healthcare?

Matt's Article in Health-IT World got a nice little article on social networking in healthcare.  It's a good little review of what's out there.  I'm not convinced that this stuff is going anywhere.  Physicians have too little time ...

What makes a good doctor = what makes a good plumber.

Medical Decisions are hard to make.  Even when they seem easy.  

I'd say that the TV show "House" is popular because Dr House seems to focus on giving patients what they need (honesty, transparency, certain treatments) and not necessarily what they want.   In his case - the difference between the two are entertaining.   Does that make him a good doctor? 

In real life - this is much harder.   There's ample evidence that physicians' decisions are based on many factors.  What's best for the patient is simply one of these factors. 

We've had a medical student working on our office recently - and it's been interesting to see my practice style mirrored in her eyes:

• I "actually listen" to my patients (who doesn't?   I wonder ...)
• I spend lots of time with my patients (no wonder I come home late every day!)
• I hear what they mean - not just what they say (the hardest part)

I re-told this story to her - in abbreviated form.  I posted it nearly 5 years ago - but the principles I tried to highlight then remain important yet under-represented on the Internet today.  Medical blogs are now far greater in quantity - yet I still think there are rather few of them  that express the transparency that the initial work a few of us were striving for back then.   There are so many competing interests - for our time, our money, and our attention.  Without good principles - I'd argue that there is no way for physicians to stay the course - and really make the best decisions for our patients.

The National Physicians Alliance is a relatively new organization that's building steam - based on good principles.  It's great to see an organization that is committed to "Advancing the core values of the medical profession: Service, Integrity, and Advocacy."   You can also read the NPA’s ISSUE BRIEF outlining reasons why physician prescribing data should not be made readily available to pharmaceutical companies.  The issue brief mentions describes how to opt out of pharmaceutical industry data gathering by enrolling in the AMA's Physician Data Restriction Program (PDRP).  Cool.  Check.  Done. 

Integrity is so important - yet so often suspect when there is opacity.  Exposing our patients to the uncertainties of our profession is a cornerstone of shared decision making - yet it takes so much more effort - and so much more time - I'm not surprised that so few physicians actually do it. 

The same goes for plumbers.  We had a "free" cleaning of our furnace performed by these folks last week.  The service rep called my wife at work and told her we needed a new humidifier element for $45.  He happened to have one.  Said OK.  We also needed a new solenoid for the humidifier for $89 "on order."   Turns out - I replaced the humidifier element about 6 months ago (should be done once/year) and the solenoid seems to work just fine to me.  You can listen to  his explanation - left on our voicemail.   Now -  look at the picture. Water running pretty well, if you ask me!   I filled an 18 ounce cup in under 30 seconds.  If that's a "very small amount of water" - I think Gary needs to go back to plumbing school.

Either Gary is stupid - or he's lying.  Either way - I can't trust him or his company ever again - as I suspect that he's got his interests above mine.  I could buy the solenoid (see link above) for $45 if I really needed one.  And I'm a little mad that he took my 6 month old humidifier element with him when he sold me the new one (it's the honeycomb thing in the picture).  Either way - he can't be trusted.

We need trustworthy plumbers, doctors, bankers, lawyers, software developers, etc.    The principles of the profession  must guide our decisions.  If not - we will always be distracted or seduced by the many other choices on our path.  Plumbers who invent problems, doctors who self-refer, and software developers focus more on the icing than the cake - all compromise their integrity in the same way - and will ultimately lose.