First, do no harm.
Four simple words that are synonymous with healthcare. It’s a principle that everyone in the industry – not just physicians – should adhere to.
So shame on us all for our part in allowing an EHR vendor to shut off a practice’s access to their patients’ medical records and for recklessly putting patients at risk.
Background: Full Circle Health Care in Maine purchased an EHR from HealthPort in 2010. Originally the maintenance fees were $300 a month. A few months later CompuGroup Medical purchased HealthPort and increased the maintenance fees to $2,000 a month. The practice protested the price increase and claimed CompuGroup failed to deliver hardware upgrades that had been paid for. The parties spent several months arguing and for 10 months the practice did not pay its maintenance bills. Finally in July, CompuGroup shut off the practice’s access to its medical records.
The details as to why the fees jumped so much and whether CompuGroup had the legal right to do so are a little unclear. What is clear is that multiple parties are at fault for allowing such a mess to occur.
Let’s start with the government, which created the HITECH program and promised thousands of dollars for providers willing to adopt and meaningfully use EHRs. Though the objectives were admirable, CMS failed to adequately address all the “what if” scenarios in its rush to move the program forward. The legislation and final rule provide no guidelines for protecting patient records in the event of a vendor/provider disagreement, financial hardship, or business discontinuance. Undoubtedly we’ll see plenty more disputes like this one in the coming years.
The practice also gets a share of the blame. The owner should have invested in legal advice before signing a $72,000 contract for something as critical as an EHR system. Did she skip this step in her haste to achieve Meaningful Use and earn incentive payments? Furthermore, even if she disputed the increase in maintenance pricing, shouldn’t she, at a minimum, have continued paying the $400 a month fee she believed was the correct amount? Perhaps the vendor would have been more willing to come to an acceptable agreement if she hadn’t stopped paying altogether.
CompuGroup, of course, looks like the really bad guy here. The multi-national company has annual revenues of about $600 million. Did they really need to pull the plug on this practice over a piddling $40,000? The company’s general counsel says the situation is similar to an electric company shutting off power when a customer fails to pay. Perhaps, but many municipalities and some states have laws that prohibit the discontinuance of services under certain conditions, such as in extreme cold weather or when a child or sick person is in residence. In other words, there are laws to protect consumers against potentially harmful actions. (See: EHRs And The Law: When Interoperability Isn’t a Choice)
Which brings us to the seemingly forgotten patient, who arguably is – or should be – the owner of his or her own record. We do have federal and state laws that give patients the right to access and inspect their medical records. Perhaps the practice’s 4,000 patients should all send CompuGroup a written request for a copy of their records. Maybe an attorney who is smarter than me should look into that.
Until the mess is settled, we have a practice seeing patients without the benefit of medication and allergy lists, details on previous treatments, or lab and test results. And everyone involved is hoping that no patients are harmed.
Whether our role in healthcare is policy maker, technology developer, provider, or HIT geek, we really need to do better.
Industrial designer Marc Harrison suffered a brain injury while sledding when he was 11-years old. The injury and years of rehabilitation would provide Harrison with insight and inspiration for his future work in industrial design.
Harrison would go on to develop the philosophy of Universal Design – the idea that products should be developed for people of all abilities, not just for people of average size, shape, and ability.
Harrison’s study of people with disabilities led to the iconic design of the Cuisinart food processor, a design still relevant today after more than 40 years. The simple, clean design would also come to be a major influence for Steve Jobs in the development of the Macintosh computer.
If you put the original Mac in 1984 side-by-side with an early ’80s Cuisinart, the influence on the physical design of the Mac is immediately obvious. Not only is the Mac designed with software for accessibility and more universal design, but its physical design had this perhaps unknown influence as well. – Dean Karavite
I learned about Harrison from an exceptional interview with Dean Karavite, a Human Interaction Specialist in Clinical Informatics at Children’s Hospital of Philadelphia. Dean was interviewed by Whitney Quesenbery, co-author of the book, “A Web for Everyone”.
It is important to point out that people with disabilities are not all people in poor health.
People with disabilities use the health care system a lot and in many different ways. –Whitney Quesenbery
Among study participants with various levels of disability, Dean found that people with the highest level of needs – those also with many chronic conditions – were the source of “the most detailed, sophisticated, and innovative ideas on what an accessible PHR should do.”
Understanding what users want and the problem the application will solve should be the first step in any development process. How does user-centered design firm IDEO find people to interview for needfinding? While it is great to speak with average users, the most interesting interviews come from “extreme users.” This idea of extreme users is also explored in “Just Ask: Integrating Accessibility throughout Design” by Shawn Henry.
As part of our project exploring accessible Personal Health Records, one of the methods we have applied was performing a survey with 150 people with different disabilities. In that survey, we had our participants rate over 20 health topics in two ways.
First, in terms of how important the particular topic was to their health and healthcare, and second, their current level of satisfaction with a particular issue or topic.
The number one, most highly rated issue in terms of importance was the ability to share medical information between different providers’ offices, and hospitals.
The real underlying issue here isn’t just the transfer of data, but care coordination, which is the collaboration, not just communication, but collaboration between multiple healthcare providers. – Dean Karavite interview with Whitney Quesenbery
Another part of the “Accessibility Designs” project looked to assess the current state of PHR systems for accessibility, functionality and usability.
Unfortunately, vendors were reluctant to participate.
These results came from systems project team members used to manage their own health including a hospital PHR, an ambulatory PHR, and a consumer PHR.
According to the project, “The hospital PHR was the least functional and least usable, yet was the most accessible. Meanwhile the ambulatory PHR was the most functional and most usable, yet failed to meet basic accessibility standards. The consumer PHR was quite usable despite failing to meet accessibility criteria, and failed one crucial accessibility requirement: the entry of dates by people with visual and/or physical disabilities, a critical action required by almost every task managed by the system.”
Many of the technologies used today are the result of work used to meet the needs of people with disabilities:
“For example, touch screens, on-screen keyboards with word prediction, zoomable displays, speech recognition, text-to-speech. Think about it. It took about 10 to 15 years, and now we all have it on our computers, our phones and other devices, and we absolutely love it.” – Dean Karavite
Get out of your little box and look for inspiration all over the place.
Good ideas can come from anywhere!
I’ve been writing a lot about the benefits of patient-centered-care and patient engagement.One study published in Health Affairs examined the relationship between “patient activation levels” (which could also be called patient engagement) and care costs. In a companion piece to the study, the authors wrote that “patients who were more knowledgeable, skilled and confident about managing their day-to-day health have lower health care costs than those patients who lacked this type of confidence and skill.”
One great example of patient education not exactly hitting the mark and leaving the patient not fully engaged was told to me by a diabetic educator. I had gone for a consultation and education on how to manage a gestational diabetes diagnosis. After going over all the blood glucose values, when and how to test, when to be alarmed, etc., she asked me what I would do if I had three readings with numbers above my blood glucose level goal.
“Call my doctor,” I said. Her reply, “Excellent. You’d be surprised how many people keep great logs of their glucose readings but don’t call anyone when their levels are too high.” They understood that they were to track their glucose levels but didn’t realize they needed to report abnormal results to someone.
How can clinicians get patients to understand the nuances of their care so they will make those necessary phone calls? How can we educate patients so they understand the “whys” of the interventions and the steps they need to take to achieve their goals? To me, explaining they need to do a certain task or get a certain reading isn’t enough. They need to have some rational behind why it is important and what will be done with the information they gather.
Here are four interesting ways I found to help patients better understand care, interventions and concepts. I hope clinicians find these useful in educating and engaging their patients.
I hope you find these tools useful in engaging and education your patients. And please share your favorite tools for increasing patient engagement in the comments section.
Case in point: A few months ago I bought a one-cup coffee maker—not the style that has been around awhile but a newer model that has additional settings to make the coffee stronger. The coffee is still not quite as good as my all-in-one grind and brew coffee machine, but I love the convenience. Unfortunately the model is so new that none of my local grocery stores carry the proper-sized coffee packs, so I have resorted to buying the coffee packs online. It’s not that buying online is that big of a hassle, but I may have selected a different model if I had realized that online was my only option.
Of course anyone working in health IT understands the phenomenon of unforeseen wrinkles with new-and-improved solutions. Many moons ago I sold billing systems to physician offices. At one point my primary job was to convince customers on an older legacy platform to upgrade to the latest product. NewProduct had many more bells and whistles than OldProduct so initially customers were eager to make the switch.
A few months into the migration project, however, we realized that NewProduct was missing a few of the nifty functions that customers had loved in OldProduct. We couldn’t move the clients back to OldProduct so we had to suggest various workarounds until the missing features could be incorporated in a later release of NewProduct. Despite all the enhancements in NewProduct, I am sure quite a few customers would have delayed upgrading if they had been aware of the loss of functionality.
More recently, a physician shared some of her concerns with her practice’s new patient portal. While she recognized and appreciated the many benefits of online scheduling, secure patient communication, and patient access to test results, etc., she disliked how the portal added more “noise” to her electronic in-box. She already received a steady stream of various electronic tasks generated by her EMR; having the portal feed her additional tasks left her feeling frustrated and overwhelmed. She had underestimated how much she personally would be impacted by the portal’s implementation.
Whether the new-and-improved product is a coffee maker, billing system, or patient portal, end users don’t like discovering issues that decrease the product’s perceived value and efficiency. Even when workarounds are available, and even when the advantages of the new outweigh the old, no one likes to be surprised by a negative. Unfortunately many wrinkles are unforeseen by those developing, selling, or using the products.
In a perfect world, end users would be fully aware of any product limitations before making a purchase. Since the world is not perfect, often the best course of action for technology developers, suppliers, and users is to figure out how make the best of the situation. Most wrinkles can be ironed out – unless, of course, your coffee maker only makes tea. A few quick tips, should your new-and-improved solution include any surprises:
I admit that on occasion I miss my old and non-enhanced coffee maker – especially when I run out of my fancy coffee packs and can’t run to the grocery store to buy more. Thank goodness there’s always Starbucks.
I feel like we’re at almost the same place with Apple Watch as we were when we were concerned the first iPhone wouldn’t have a keyboard.
At first I didn’t quite get it with the Apple Watch: a computer on a wrist. I don’t like wearing a watch, what’s it going to do for me? At the same announcement where Apple was going with larger versions of the iPhone, Apple debuts a much smaller screen and perhaps the smallest interface yet. How could the interface get smaller and this be so revolutionary at a time when interfaces are getting bigger?
But, in fact, the interface just got a lot bigger.
It’s the combination of NFC, iBeacon and Bluetooth 4.0, along with the fact that the device knows where it is (on the wrist) and can communicate with a phone and many other things. Apple is mapping our physical world and making our close physical environment the interface, and it’s largely transparent to the user.
From Business Insider on Apple Watch Tracking our Movements:
“Specifically, the tracking mechanism on Apple Watch will be similar to the little-understood mechanism currently used in Apple’s iPhones. It combines Bluetooth 4.0 (the localized wireless signal system that lets you transmit or receive data from a nearby device), iBeacon (signal-emitting beacons that Apple is seeding all over stores and other physical locations in the real world) and NFC (another wireless transmitting system that Apple has incorporated into iPhone 6 and iPhone 6 Plus, and the Apple Watch).”
The Watch will be able to close the loop on activity between you, messages you receive and payments you make (via Apple Pay) and even how different environments, messages and products make you feel, and how your respond in terms of activity.
In other words, it will not only allow Apple to monetize the immediate context and environment, but it will be able to amass a wealth of data on both your bodily activity and even emotion and place in the world. Your responses and activities have just become part of the network, a part of the economy. Apple is building a behavioral economy.
And it’s going to happen fast. Banks are already heavily advertising Apple Pay, and Apple has a jump on mapping all of our internal spaces. When you want to make the world an interface, you need a very detailed map of it.
How Apple manages all this information will determine whether it’s convenient or creepy. They’ll need to maintain very tight trust with consumers. In the post-Jobs era of Apple, will Apple be able to resist the temptation to share this wealth of behavioral economic data?
Putting the World into a Health Context
Apple is seeking to map our our worlds both physically and via several other contexts. It says it right in the press release “the most personal device ever”. When Apple says personal, they mean they understand your context. They know who you are, what you’re doing, and even what you want to do within that context. Apple acquired Topsy last year for $200 million, a company big on contextual awareness algorithms around twitter. Think of it as digital psychology, and they’ll be able to run these tests almost every moment of every day.
There are many different ways to view a person’s context and they’ll often wind up in dimensions. Wellness organizations often talk about the “8 dimensions of wellness”: Emotional, Environmental, Financial, Intellectual, Occupational, Physical, Social and Spiritual.
With the Watch, Apple could have a pretty good map of each of these for any individual. As we make the move from patient to consumer, and from health care to health, this kind of contextual awareness will become critical.
With HealthKit and Apple Watch together, there’s not only going to be an environmental interface, but also a body interface, sensing the user’s internal state. Tying that internal state (heart rate as an example) to objects in the real world could be the next step toward the internet of things around consumers, as Tim Cook hinted. What will the world be like when we are in constant, transparent communication with the physical world around us?
At VivaPhi we identify several different contexts and environments of influence in consumer’s lives and how they make decisions. The Watch will be able to say more about these various contexts and exactly how these contexts, messages and tools are able to influence behavior. We see the potential as a contextual platform on a wrist. We’ll see what app developers create before we have much of an idea of what it can do, whether it’s convenient or creepy. What happens over the next few years will be as surprising or more so than the iPad apps.
The Apple Watch has little to do with telling time, it’s about contextual awareness. It’s a step toward our entire world becoming an interface. Let’s hope Apple can keep the streak alive creating devices that are more about what the consumer wants the world to do, rather than what the world wants the consumer to do.