EHR and Health IT Consulting
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EHR and Health IT Consulting
Technical Doctor's insights and information collated from various sources on EHR selection, EHR implementation, EMR relevance for providers and decision makers
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Tips for Fixing a Botched EHR Implementation

Tips for Fixing a Botched EHR Implementation | EHR and Health IT Consulting |

Organizations face many challenges when implementing electronic health records platforms (EHR), but fixing a botched implementation can be among the most stressful.  Problems with EHR implementation can reverberate throughout a healthcare organization and must be recognized and fixed as soon as possible.

The first step of a successful remedy is to create an action plan that prioritizes the fixes that will have the most immediate impact in helping operations return to optimal performance. Once those pressing problems are solved, it’s time to address all of the other issues. Here are a few useful tips to help guide you through that process.

Establish A Task Force

It’s wise to establish a task force to deal with each particular problem. The task force should include members whose specialties overlap with the problem area. For example, someone directly involved with the revenue side should be involved with resolving all revenue issues.

The task force should closely analyze the problem, and look for the breakdowns in the system. One might start by looking at whether staff members are able to input data. If so, check to see where it ends up. By taking a systematic approach, the task force will be able to get to the root of the problem more efficiently.

Carefully Calibrate Staffing

It’s quite common for healthcare organizations to wonder whether outside resources should be brought in to help rectify problematic EHR implementations. There are a couple of different approaches that work quite well.

[Related: How “The RightFit” Process Guarantees You’ll Get the Best Quality Consultants]

One option is to remove the appropriate internal staff from their normal day-to-day duties and have them focus exclusively on fixing the EHR platform issues (staff augmentation). Outside resources would then be brought in to handle the day-to-day responsibilities of those internal staff resources until the issues are resolved and they can resume their normal duties.

Another option is to bring in third-party consultants to solve the EHR application problems and allow the internal staff resources to continue concentrating on their normal day-to-day duties.

Which option is better depends on a variety of factors, including the size of the organization, the nature of the EHR problems, and the level of expertise the internal staff resources have in regards to the EHR platform.

Ensure Sufficient Resources and Track Progress

It’s important to engage key stakeholders throughout this process. The financial side of the organization must be included in the decision-making, so that adequate support can be provided to execute the fixes. To help build trust with the financial side, it’s imperative to establish metrics for success. This not only serves to prove the business case for the implementation fixes, but also ensures the project stays on track throughout the process.

Engage with End Users

In a situation in which the EHR solution is not performing as expected, perhaps the most vital tip is maintaining some degree of buy-in among the clinicians and staff who use the application on a daily basis. It’s essential to work closely with key stakeholders and influencers, like the chief medical officer, the nursing leadership, and even the financial department to ensure that everyone is on the same page. Have them propagate the message that the problems are being worked on and will soon be fixed.

After a botched implementation, IT staff might encounter a lot of resistance, but it’s important to break through this and emphasize what the long terms benefits of the EHR project will be once it is done correctly. By making these benefits clearer, it will become easier to keep everyone on board during a period of difficulty.

By following these EHR best practices, organizations will be able to more effectively overcome botched implementations, and will be better situated to have more success once they start on their EHR optimization projects.

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Electronic health records and data abuse: it's about more than medical info

Electronic health records and data abuse: it's about more than medical info | EHR and Health IT Consulting |

On the heels of the recent announcement that medical insurance firm Anthem was breached, we look at the nuance and impact of a medical record breach versus a medical data breach. They are certainly related, but digging through troves of data containing primarily identity information is significantly different to an attack that focuses on specific treatment of a specific patient.

If an attacker can harvest name, social security number, phone, address, email and the like, that haul has a much wider potential audience than, say, whether or not a patient underwent a specific medical procedure. A stolen medical record containing a lot of detail may sell for a lot of money, but that market is more specialized than the broader market for general identity data.

To help folks visualize the different levels of data that thieves might want to swipe from a medical facility, and then abuse, my colleague, Stephen Cobb, created this diagram of a generic electronic health record.

Level one is pretty basic info, things that are fairly easily knowable about you without any hacking, normally sourced through Open Source Intelligence (OSINT) gathering. However, grabbing a big fat collection of such data might still earn a bad guy some black market bucks, say if a spammer needed fresh targets.

The illegal earnings potential goes up a notch if you can grab Level 2 data. Scammers can use that to carry out several kinds of identity theft, creating fake IDs, opening credit card accounts, committing tax fraud (filing fake returns to get a refund) or even use it to answer challenge questions to online accounts, thereby pivoting the attack to new digital beachheads. Even Level 2 data is enough to commit some types of medical ID theft, though the bad guys have no clue how healthy or sick you really are (here’s a pretty scary case of what can be done with just a stolen driver’s license).

Level 3 data just makes all of the above that much easier; plus, it enables new forms of badness. Some crooks prefer taking over an established account to opening a (fake) new one. the number of electronic records or EHRs that actually contain financial or payment data is not clear, but obviously a lot of healthcare entities do handle it at some point, making them a target for digital thieves who turn around and sell it on carder forums.

When you get to Level 4 data, the badness takes on a new dimension. If an attacker has a patient’s full (or partial) history, it’s easy to imagine matching up a willing bidder who has a need for a similar medical procedure with a donor record to (roughly) match, in an attempt to get pinpointed specific services they would otherwise have difficulty receiving.

But the options for selling medical history-style Level 4 records may be much narrower in scope than, say, bulk repackaging and resale on the underworld markets of lower levels, appealing to any buyer who wants to assume an identity, spread a wider net and attack other properties, or engage in fraudulent activity which is then blamed on you (if it’s your record that was compromised).

Of course, the threatscape may well change as the EHR becomes more universal. With the proliferation and sprawl of third party providers who are somehow tapped into a cohesive health ecosystem, there will always be various specialized smaller providers whose business is targeted to a specific subset. That’s not bad, it’s just how the health segment does business; in many cases it leverages strengths of one organization to help another. But it does imply a larger potential attack surface, which has implications for security if the data sprawl is not carefully managed. For example, if an attacker can gain a beachhead in one of the providers in the ecosystem, will they then have an elevated trust relationship with other systems within this ecosystem?

And here’s the rub: having instant digital access to all of a patient’s medical data (or other sensitive information) wherever a doctor happens to physically be is a wonderful tool, but now we have many more endpoints in question with security environments to understand and corral. This implies an ongoing need, not just for really smart endpoint protection, but also strong encryption, and authentication, as well as sane network segmentation, vigilant network monitoring and reliable disaster recovery.

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Keeping Up With Technology: A Must for Medical Practices | Physicians Practice

Keeping Up With Technology: A Must for Medical Practices | Physicians Practice | EHR and Health IT Consulting |
Still carrying around that BlackBerry you've had for the last five years? Still using Microsoft 2003 on that XP machine of yours? Still think the "cloud" is a fad? You might be doing yourself and your business a disservice if you answered "yes" to one or more of those questions.

Keeping up with the ever-changing world of technology is tough. Change can be hard. It's much easier to keep the status quo and ignore all the technological advances happening around you. The problem is, if you don't adapt and keep up with technology, you'll miss out on all the advancements and benefits it has to offer.

That trusty BlackBerry took too long to embrace touch-screen technology and missed out on creating a robust app store. The result is you can't check into your American Airlines flight on your phone, you can't use Hailo to get a cab, you can't access your Google Drive documents, and you can forget about looking up restaurant reviews on Yelp. Basically, even though switching to an Android or iOS device may be inconvenient in the short-run, the long-term benefits are well worth it. You'll have to learn how to use a new tool but that took has far more uses.

Technology in the workplace can mean the difference between a successful business and a failing business. Capable hardware and efficient software will keep your office running in tip-top condition and will allow your employees to focus on their jobs instead of troubleshooting their computers.

Look into Web-based programs that can be accessed remotely and that have export features that allow you to easily extract the data you need. Productivity suites like Google Documents are free and offer a comparable experience to the costly Microsoft Office standard (Google documents are compatible with MS Word). If you have to use Microsoft Office, don't skip on more than one major update. The difference between Word 2007 and Word 2010 is probably greater than you think.

The anxiety in introducing new technology to your office staff lies in the assumption that each employee has a different adoption threshold; some will "get it" and others will struggle. That's not as big of a hurdle as it's been in the past, as technology has become more uniform. Most people have a smartphone of some design, and many have households with smart TVs, multiple computers, and other universal technologies. Like all things, it may take a day or two for your staff to become comfortable with the new work flow, but your bottom line...and talent pool...will appreciate it.

In summary, don't be afraid to try new technology. If there's a hot new device or productivity program, there's probably a reason for it being so popular. Don't turn your practice into a technological ghost-town. Think about what your competition is doing.

In regards to technology, it’s good to be a leader and it’s also good to be a follower ... just make sure you’re one of them versus neither of them.
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Physicians Must Lead the Charge to Improve Patient Care | Physicians Practice

Physicians Must Lead the Charge to Improve Patient Care | Physicians Practice | EHR and Health IT Consulting |
Communication, coordination, and follow-up are highly prized entities in patient care. Indeed, without these entities, little can be accomplished, and the more complex the issues are, the more important these entities become.

Sadly, great communication, coordination, and follow up become less and less evident in patient care the more complicated the patient's care becomes. This is especially true when the case entails a high degree of social issues as well as health issues. It is clear to any experienced physician and case worker that the more complex the patient's condition is, the stronger the need becomes for optimal communication, coordination, and follow-up.

I maintain that ensuring optimal communication, coordination, and follow-up requires a system that motivates physicians and healthcare systems with positive incitements. There is an urgent need for clear and obvious mechanisms that create negative feedback loops every time communication, coordination, and follow-up care are inadequate, and that strongly encourage the opposite.

Until now, no practical guidelines have existed that define how to establish and maintain such motivation at the system level. Good practice guidelines exist for specific diagnosis groups, but even here, the motivations are most often less than clear.

This is by no means to belittle many good practices that see traction in specific communities, such as Patient-Centered Medical Home recognition criteria, but these are predicated rather by top down mandates from entities such as the National Committee for Quality Assurance and enthusiastic practitioners than by concerted and positive financial and motivational structures.

For these reasons, it falls on physicians to lead the charge to improved communication, care coordination, and follow-up care in their own practices. Here are a few small changes that I recommend that all physicians begin making:

1. Ensure that all nurses active in your practice and visiting nurses have cell phones. Having these numbers for ready access 24/7 can mean the difference between coordinated care and catastrophe for the patient.

2. Gather your ranks, and get a town hall meeting going where physicians proclaim their willingness and energy to make things improve for those in most need of optimal communication, coordination, and follow-up.

3. Bring in experts who can help define what is doable within the given financial framework to make primary prevention and health promotion front seat drivers instead of passengers on an evidence-based express train that no one knows where it is going.
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New Calls for Meaningful Use Reporting Changes, ICD-10 Delay |

New Calls for Meaningful Use Reporting Changes, ICD-10 Delay | | EHR and Health IT Consulting |
HIMSS is seeking less stringent 2015 meaningful use reporting requirements while the Medical Society of the State of New York is petitioning for another ICD-10 delay.
While one industry association is calling on its members to support legislation that would make changes to 2015 meaningful use reporting, another is urging Congress to consider legislating an additional two-year delay for ICD-10 compliance.
As first reported by the Journal of AHIMA, the Medical Society of the State of New York began passing around a letter to members of Congress asking to delay the ICD-10 transition until October 2017 “in order to allow for physicians to work thru the myriad of new government regulations that face us.”
The provider association has highlighted the financial implications of a failed industry-wide ICD-10 implementation on Oct. 1, 2015.
“The onerous penalties tied to these mandates add to the hysteria that is running through physicians’ offices and is generating many early retirements,” the letter states. “If every entity in the complex medical payment pyramid does not function perfectly on October 1, 2015 then physicians’ income goes to zero which is a steep price to pay for a new imperfect coding system.”
The medical society is calling on members of the House Energy and Commerce Committee to include the two-year delay as part of “must pass piece of legislation during the upcoming Lame Duck Session in 2014.”
The move by the Medical Society of the State of New York mirrors that of the Texas Medical Association, which is advocating for a similar two-year ICD-10 delay.
Also calling for legislative action is HIMSS which has put out a message to its members to contact their representatives in Congress about the Flexibility in Health IT Reporting (Flex-IT) Act of 2014. The bill (HR 5481) introduced in September by Representatives Renee Ellmers (R-NC) and James Matheson (D-UT) would replace the full-year reporting for meaningful use in 2015 with a quarterly one.
HIMSS, which supports the bill, is looking to galvanize support among its constituents. “Members of Congress are not hearing from their constituents about 2015 Meaningful Use Reporting Period and that is where you can help! HIMSS is engaged in an effort to let members of Congress hear from their constituents about this important issue.”
Falling short of the bill’s passage, the industry association foresees the potential for Congress to consider other legislative avenues in the future. “Even without this bill passing, with enough Congressional support CMS may be persuaded to change the current policy,” the group maintains.
This legislation also has the support of the College of Healthcare Information Management Executives (CHIME), which has repeatedly called on the Centers for Medicare & Medicaid Services to reconsider meaningful use requirements in 2015 just as the federal agency showed a willingness to do in 2014.
“The misstep by officials to require a full-year of reporting using 2014 Edition certified EHR Technology (CEHRT) in 2015 puts many eligible hospitals and physicians at risk of not meeting Meaningful Use next year and hinders the intended impact of the program,” the organization stated in September. “To date; only 143 hospitals have met Stage 2 to date, representing a very small percentage of the 3,800 hospitals required to be Stage 2-ready within the next 14 days.”

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Securely Disposing Medical Practice Equipment

Securely Disposing Medical Practice Equipment | EHR and Health IT Consulting |

It goes without saying that computers are expensive. Medical practices will often gift used office equipment to employees or family members; or donate them to vocational programs. Risk management attorney Ike Devji says that donating old equipment like scanners, fax machines, and computers at the end of the year is very common. "At the end of the year practices will rush to spend money so that it is not taxable. They buy [new] equipment … and computers are replaced."

There's just one small problem. Deleting sensitive patient data will not permanently eliminate it from the hard drive of the device. And if you've donated your practice's scanner to the local thrift store, it still contains sensitive patient data that "a well-trained 12-year-old kid with access to YouTube can get … off the hard drive," says Devji.

Devji points out that a high-end digital scanner can store up to 10,000 pages of patient data. And equipment that is synched to your EHR, even smartphones and tablets, needs to be destroyed or disposed of in a secure manner.

If you have old equipment that you'd like to get rid of, contact your IT consultant. He should be able to point you in the right direction. Or you could follow Devji's approach: He uses his old equipment for target practice in the Arizona desert.

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Top 10 EHR vendors in physician offices

Top 10 EHR vendors in physician offices | EHR and Health IT Consulting |

There's little question that Cerner and Epic are the giants in the EHR field. Epic is dominant not only in the scope of its market share but also in the depth of its client base. Mayo Clinic announced last month that it would be abandoning its three current EHR systems in favor of a new contract with Epic, which will now be the healthcare icon's sole EHR provider and strategic partner. Jilted in the deal were GE and Cerner, who were the providers of Mayo's current systemsalthough if you tallied the figures when Cerner acquired Siemens' EHR unit for $1.3 billion, it still had the largest US market share of any vendor, with 1,132 acute care hospitals. 

But a more granular look at market share amongst physician offices shows a slightly different market picture.

Epic is still on top, but only by a percentage point (eClinicalworks is close on its heels). And as you might expect, Epic's client base skews heavily towards larger practices, dominating the 41+ practice market at 54%. On the lower end of the scale (1 - 3), Epic, eClinicalworks, Allscripts and Practice Fusion are all within a percentage point or two of one another. 

Cerner, notably, is way down the list across the board in the physician practice world, taking just 3.5% of the overall market. So is athenahealth, at 3.3% overall and just 0.4% and 0.8% in the 26 to 40 and 41 and up segments. This tallies with the cloud-based vendor's ongoing investments in the inpatient market, however: In January, the cloud-based provider purchased start-up RazorInsights to move into the 50-bed and under sector, a niche that accounts for one-third of all hospitals in the US; and last week the company announced that it has purchased WebOMR, Beth Israel Deaconess' cloud-based, stage 2-certified EHR, for commercial development in the hospital setting.

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Electronic Health Record Copy and Paste - Issue at Hand

Electronic Health Record Copy and Paste - Issue at Hand | EHR and Health IT Consulting |

Healthcare personnel are using the copy/paste function in the EHR systems which are a cause for concern.  It has created a serious compliance and payment problems. The technology allows information to be quickly copied from one document into another with the idea being to reduce the time a physician spends typing.  This copy/paste action is also known as ‘cloning’ . The EHR copy and paste function is leading to fraud and abuse of the EHR system. Here are some of the

  • The Electronic Health Record copy and paste technique is being used to get higher reimbursement by upcoding patients’ medical conditions. Medicare is being overcharged and this abuse is running into millions of dollars.
  • Another issue is that as doctors are routinely copying information from one file to another to save time, it may happen that the data they enter is not relevant or even erroneous. A recent article in Healthcare IT News reported on the case of a patient who had a “family history of breast cancer” wrongly entered as “a history of breast cancer”. She almost lost her health coverage because the payer thought she had lied on her initial forms.
  • There have been cases when a physician copied information from one patient record into another patient’s record.

According to the inspector general’s office, Medicare has failed to provide proper instructions to the contractors who handle payments on how to ascertain fraud arising from EHR implementation. It also found that up to 75% of hospitals surveyed had no formal policy regarding the use of cloning.

Efforts to Resolve Medical Billing Errors and Fraud

The American Health Information Management Association says that cut and paste is one of the best ways to manage the documentation process.

Right now we need to find ways to address the flaws in the Electronic Health Record System. Medicare is proposing the following ways to address this cloning issue:

  • Creating better standards and systems for validating electronic health records, which ensures the proposed benefits and at the same time protects taxpayers from fraud and abuse.
  • Developing guidelines and systems for Medicare contractors to identify cases of  fraud by closely reviewing changes to specific patient documents.

It is important to educate and alert staff on the appropriate use of the copy/paste function. It can be used for copying patient regular medications, chronic allergies, demographics, problem lists and labs and treatments – if these are ongoing and the same from visit to visits. The use of internal audits is also a tool to help find errors so that they can be corrected right away.

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CureMD Selects DrFirst for Electronic Prescribing of Controlled Substances (EPCS)

CureMD Selects DrFirst for Electronic Prescribing of Controlled Substances (EPCS) | EHR and Health IT Consulting |
CureMD has selected DrFirst to provide controlled substance e-prescribing (EPCS) capability to users of CureMD EHR, its cloud-based electronic health record system.

CureMD is adding DrFirst’s EPCS GoldSM 2.0 controlled substance e-prescribing functionality as part of its effort to help providers nationwide curtail the epidemic of prescription drug abuse in the U.S. Additionally, CureMD EHR is used by a significant number of providers in the state of New York and its EPCS functionality will support compliance with New York’s Internet System for Tracking Over Prescribing Law (I-STOP), which requires electronic prescribing for all legend and controlled drugs beginning March 27, 2015.

“Before implementing EPCS Gold, many of our providers wanted to be able to send controlled substance scripts electronically,” said Bilal Hashmat, CEO of CureMD. “We chose DrFirst’s solution because the technology was easily integrated into our EHR, is cost-effective, and allowed our users to begin using EPCS quickly. DrFirst also manages provider onboarding and identity proofing for individual users and ensures they complete the necessary steps to start sending controlled substance prescriptions.”

While many doctors have access to or are familiar with e-prescribing for legend drugs, e-prescribing for controlled medications (Schedules II through V) requires additional components as governed by the Drug Enforcement Agency (DEA), including provider identity proofing, two-factor authentication functionality, and enhanced audit capabilities.

Controlled substance prescriptions represent approximately 10 percent of all prescriptions issued in the U.S. This coupled with greater technical requirements have historically slowed provider adoption of EPCS capability. However, EPCS offers significant social benefits to the greater healthcare system as it has been proven to assist providers in reducing prescription drug abuse and drug diversion, as well as in identifying ‘doctor shoppers’ attempting to attain controlled medications, such as hydrocodone combination drugs which are abused at epidemic levels.

DrFirst currently processes over 60 percent of all controlled substance electronic prescriptions nationwide, making it the leader in this field. The company’s recent data shows that provider adoption of EPCS is now increasing significantly. In the last three-month period, August through October 2014, EPCS prescription volume has jumped by more than 200 percent compared to the same period one year ago. Growing provider recognition of the benefits of EPCS, the rising number of pharmacies nationwide that are EPCS-enabled, and the greater number of EHR, EMR and HIS systems that are ready to handle EPCS, such as CureMD EHR, have all contributed to the large increase in EPCS volume. However, New York’s I-STOP law is seen by many as a leading indicator that similar initiatives will be pursued by other states and many healthcare organizations and providers have been encouraged to pursue EPCS in recent months as a result.

“Controlled substance management should be top-of-mind for EHR, EMR and HIS system vendors,” said G. Cameron Deemer, president of DrFirst. “For those with New York providers, they must allot time not only for the integration and implementation of the EPCS functionality itself, but also for the identity proofing process that each provider must complete. CureMD moved quickly to ensure its New York users will be ready to meet the requirements of the I-STOP mandate, which means CureMD is also ready to support providers in any of the 49 states and the District of Columbia where EPCS is now legal.”
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EHRs Should Automate the Business of Medicine

EHRs Should Automate the Business of Medicine | EHR and Health IT Consulting |

EHRs should automate the business of medicine and eventually the science of medicine, while protecting the art of medicine. Margalit Gur-Arie shares her insights. 

By the time the next decade rolls in there will be no paper charts. There will probably still be paper floating around in various capacities, but there will be no one charting on paper. The term “charting” itself may become obsolete, like yonder or popinjay. The term EHR, which is what replaces the paper chart, won’t last either because it doesn’t roll easily off the tongue like say, email instead of letter or missive. EHRs don’t do anything else easily, so chances are EHRs themselves won’t last much longer, relatively speaking. Sooner or later, the national spotlight will shift to something other than health care, and other electronic critters will emerge from the shadows.  What will they be? What should they be? Those could be two very different answers.

What Should Be

Have you noticed how people advocating for EHRs use the word quickly in practically every sentence? Mega EHR allows you to quickly document XYZ, and Super EHR can quickly gather all historical data and display it in a summary dashboard which allows you to quickly assess the status of the patient. You can quickly send prescriptions to pharmacies, quickly order a bunch of tests, and quickly print out (the horror!) education materials. Your staff can quickly schedule patients, quickly answer questions, quickly verify eligibility and quickly drop claims. Your patients can quickly get answers, quickly schedule visits and quickly have their concerns resolved.

Of course, most of these things are aspirational at this point, but the language is indicative of the thought process behind EHR design: hurry up and get it over with. Time is money and quickly disposing of each patient is absolutely imperative in a high functioning health system. You could argue that there is nothing wrong with speeding up, or even eliminating, administrative tasks, and you would be right. But is reviewing historical information on a patient and documenting today’s encounter an administrative task? When reviewing histories is compressed into briefly glancing at a bunch of sparklines like they have for the stock market, it may seem like you are engaging in an administrative task. Buried somewhere deep in the dark chart though, there may be a note you made about Mary’s difficulties to navigate the front porch stairs last year.

Why did you make that old note? It’s not required for billing. It’s not demanded by insurers. What made you type that in? Do you usually make notes about irrelevant things that you fully expect to never see again? When you used paper charts, you had to flip through many pages to gather the information you can now quickly glean from your infographic patient dashboard. And while you were paging back and forth through that chart, chances are you would have stumbled upon that little note that seemed important enough for you to scribble down last year. And maybe you would discover other little notes too.

Is reading a book the same as reading the SparkNotes? Oh, you will pass the test either way, and may even get better scores with the SparkNotes version, but is it the same? Is reading this: “Ultimately, he is unable to bear the psychic consequences of his atrocities”, the same as reading this: “Tomorrow, and tomorrow, and tomorrow, /Creeps in this petty pace from day to day, /To the last syllable of recorded time; /And all our yesterdays have lighted fools /The way to dusty death. Out, out, brief candle! /Life’s but a walking shadow, a poor player, /That struts and frets his hour upon the stage, /And then is heard no more. It is a tale /Told by an idiot, full of sound and fury, /Signifying nothing.”? Which version leaves you better equipped to address the story at hand, and the story-teller himself as a whole person? And which version makes you, the reader, feel more like a whole person?

Whatever else the EHR of the future might do, it should quit trying to quantify, summarize, highlight and decontextualize the soul out of the medical record. Disposing of patients quickly should not be our goal. Other than being demeaning and dehumanizing for all involved, seeing patients quickly is the root of all our health care woes. In an environment increasingly hostile to human interaction, EHRs should ferociously fight to create more time for patients to spend with their doctors. EHRs should automate the business of medicine and eventually the science of medicine, while protecting the art of medicine. And by art, I don’t mean compassion and advocacy. I mean the application of professional judgment, without which the science is incomplete and will always be incomplete, regardless of how many genes we can map or how many bots we can implant in ourselves.

Assuming that the business of health care will be marching along the glorious path currently laid out by our betters, the EHR of the future should endeavor to become a silent background processing machine. Natural language processing should be the first and foremost feature to be implemented to perfection. The EHR should parse and extract useful information from doctor-patient interactions to maximize physician reimbursement by maximizing claim values (yep, I just said that), and by scouring all opportunities to obtain incentives and bonuses from the overlords, and automatically applying for all, without user intervention. Not an easy task, but IBM Watson could drop out of medical school and take this on.

The flip side of maximizing revenue is to cut overhead. No practice needs a scheduler. Let patients schedule themselves online or on the phone. Let them check in and let them room themselves (think about those little restaurant gizmos that beep when your table is ready). Let them take their own vitals and answer all those preliminary questions on their own. For the outliers, the frail and the elderly, one medical assistant can cover these tasks for bigger practices. It doesn’t sound much like an EHR because it isn’t.

What else costs money, but has practically nothing to do with medicine? All the school notes, the back to work notes, the disability forms, trade forms and all other forms, authorizations, pre-authorizations, eligibility checks, statements and everything in between, can be delegated to computerized self-service. Get the medical records online and let patients have at it. Make it user friendly like all other trivial consumer facing apps that have absolutely no bearing on enterprise technologies. Make them colorful and fun. Show pictures, animations and ads. Put them on the iPhone. Monetize the heck out of everything, and remove this purely administrative burden from the practice.

And then comes a moment when restraint needs to be religiously exercised. Stay the heck away from the exam room. Let people say whatever they want to say. Let doctors ask whatever they want to ask. Forget about boxes, no matter how useful they look. Forget about structure too, because Watson will be taking care of that. Don’t make documentation easy, because taking notes is not just about documentation. It is mostly about the background thought process that makes one decide what to note and what to discard. Remember, the way you would use different styles of handwriting and text of different sizes or boldness, and how you added critical notes in the margins, or big pointy arrows? Actively taking notes helps you synthesize information, internalize, memorize and understand the narrative (programmers, think back to your college days).

If EHRs want to be helpful, let them be secretaries. Arrange the notes in a way conducive to better information retrieval. Don’t summarize and don’t impose your (or your machine’s) notions of what is or is not important. Collate and bind everything into a patient book. Remember that this is a reference book and the user can read at a 30th grade level. It is not a cookbook and it is certainly not a picture book. Add a table of contents. Use the computer to make it dynamic. Make it easy to flip pages in an electronic context. Make the fonts nice and large, and do learn from beautifully maintained old paper charts. Go out and look at some before they are extinct. You can’t improve that which you don’t know.

What Will Be

Of course none of the above is going to materialize in a meaningful way, except maybe the infantilized consumer facing EHR. Health care is going retail and health care will care about its customers precisely as much as Walmart and Amazon do. And health care will care for its employees as much as Walmart and Amazon do. When providers are all transitioned to having their employer paid for value, EHRs will become very easy to use. A few big buttons, at the bottom of pages prefilled with stereotypes and sprinkled with colored sparklines, should quickly do the job (i.e. Order, Refer, or Deny). There will be nothing for you to document and nothing for the patient to convey because the system already knows everything there is to know. Eventually, it will dispense with the buttons altogether, and your job will be to quickly explain to your customer why the system did what it did. And you will never have to use a computer ever again. Mission quickly accomplished.

Clipping Path's curator insight, December 9, 2014 1:31 AM
Photoshop Image Masking Service        

Photoshop Image Masking Service is mostly used for creating product catalogs. Photoshop Image Masking is used with Clipping Path technique to knockout the background of complex image to be placed for advertisement display in e-commerce website or photo manipulation. Photoshop Masking is further useful when clipping path alone is not applicable on hair (hair masking), fur (fur masking), or semi transparent or translucent images like glasses, feathers, smoke, flames, highlights, lighting, chiffon & muslin, etc.

<a href=>Image Masking</a>