Telemedicine or telehealth?

I just returned from the American Telemedicine Association 2012 annual conference in San Jose, CA. The conference was packed with people who were excited to share how they were using telecommunication technologies to deliver care. Some amazing demonstrations were also available within the ATA exhibit hall. And, people were using #ATA2012 to send tweets about the meeting.

As I listened to presentations, I noticed that some people used the term “telemedicine” while others opted for “telehealth”. And though a majority used these interchangeably, there is a difference between “medicine” and “health”, and I wonder if we’ll start hearing discussions around this over the next few years.

Let’s start by looking at the words “medicine” vs. “health.” Some may argue that the term telemedicine is too physician-centric and that telehealth is a broader, better term that encompasses other health care professionals like nurses, dentists, pharmacists, psychologists, etc.  After all, physicians are the only ones who go to “medical” school. And, they’re the only ones prescribing “medicine.” The American “Medical” Association represents physicians. So, should we be using “health” to encompass a broader audience, or is it OK to stick with the term “medicine” as in telemedicine? I’m obviously biased, but I see this trend occurring in a number of areas.

To start, we can look at the common acronyms EHR and EMR. Docs still love using the term “EMR.” They have not adopted the phrase EHR, but this is the new “standard” term for the industry if you ask the U.S. government. We’re all creatures of habit, so EMR is still easier for people to say. But, over time, will EHR entirely replace EMR?

Here’s another example: schools that offer degree programs in informatics. Are they offering a degree in “medical” informatics, or “health” informatics? Is there really a difference?

Because of history and tradition, I anticipate that the ATA will always be the American Telemedicine Association. Likewise, AMIA will always be the American Medical Informatics Association (and I doubt we’ll see a new organization called AHIA competing against AMIA).

What’s going to happen in telemedicine? Will the phrase “telehealth” stick, or will it get swept away with everyone using telemedicine? Given that telemedicine is often used to treat patients or to deliver care for an active health condition, the term telemedicine seems more fitting. We also have terms like telesurgery, teleradiology, teledermatology, etc. So, maybe we’ll just get much more specific with our terminology in the future.

How do electronic health records (EHRs) impact medical malpractice risk?

Let’s face it: many physicians are not excited about adopting electronic health records (EHRs). Unless you trained in a hospital and “grew up” using EHRs all your life, it’s a big adjustment and a major change to switch from paper charts to computers. I realize that there are some physicians who love EHRs because of the e-prescribing, the legibility of the notes, the populated problem lists, the built-in clinical decision support, the automated templates, the “copy and paste” (which no one does, right?), and a variety of other functions that improve the clinical workflow. But, there are enough physicians who dislike EHRs that they may even believe that EHRs negatively impact their risk for medical malpractice. Do we have any data on that? Or, are these all theoretical discussions at this point?

In 2010, the New England Journal of Medicine had an article titled, “Medical Malpractice Liability in the Age of Electronic Health Records.” In that article, the authors explored the “implications for malpractice liability of four core functionalities of EHR systems: documentation of clinical findings, recording of test and imaging results, computerized provider-order entry, and clinical-decision support.” What did they find back in 2010? They stated:

“The liability implications of EHRs are likely to vary over the life cycle of the adoption of these systems.”

During implementation, all sorts of things may go wrong, so we may find more medical errors. After you’re up and running, the authors note that “EHRs have the potential to reduce injuries and malpractice claims but will also create opportunities for error and will alter the context for proving and defending malpractice claims with the use of electronic information.”

So, do EHRs increase or decrease your medical malpractice risk? I think the answer is “it depends.” It depends on how effectively you are using your EHR and how well you document your clinical encounter. It also depends on how legal standards evolve as digital records become the norm within the industry. EHRs are creating new legal risks. At some point, it will be considered medical negligence to document a patient’s health information on a paper chart. We’re not there yet.

So, what does that mean today? I think the critical component is to encourage clinicians to leverage clinical decision support tools effectively so that they are delivering the best evidence-based care for their patients. They ought to be thorough in their documentation.  The use of “copy and paste” or templates could get you into trouble if you are not careful about your documentation.  Finally, be prepared to pull up a LOT of records the next time you have to go to court. Chances are, you will have much more digital data on a patient compared to the days when outpatient charts just had a few illegible scribbles written on a blank page. Don’t plan to rely on the “we can’t read the doctor’s handwriting” defense either.  The evidence will be clear and it will be abundant. Of course, this also means that the medical malpractice attorneys will probably need to spend more time combing through all the chart records that get generated (and I bet they will get printed on paper, so we’re back to square one - paper records).

The bubble will move from HIT to HIE

Right now, we’re experiencing an interesting bubble phenomenon. Physicians and hospitals all around the country and scrambling to establish meaningful health IT solutions so that they can achieve “meaningful use.” We still have a few years to go before we’re all going to be there, so we’re seeing rapid growth in EHR implementation and CPOE deployment. The bubble is growing rapidly and it’s going to burst, right? Maybe not quite. The bubble will move from simple, basic HIT to meaningful health information exchange (HIE). After all, what’s the point of digital data if you can’t share it and exchange it in a way that will improve clinical care efficiency and patient outcomes?

Right now, there are many doctors who are getting trained to be ready for the new world of health IT. There has been little discussion around HIEs unless you happen to live in a state where the HIE infrastructure is fairly robust and established. Most docs in private practice really don’t understand the concept of an HIE because they’re focused only on their immediate patient population.

When will the bubble start to shift? I think the movement will be slower than what the policy makers are predicting. The “meaningful use” of HIEs will be harder to measure and incentivize. We’ll eventually get there, but it’s going to take a long time because health care organizations are so slow to adopt technology and they have trouble staying current with the latest technology. So many organizations are still struggling to support legacy solutions and they are building on top of old infrastructures.

Finally, when will patients realize that they can gain access to their health data? So many patients remain frustrated because they lack access (or they think they lack access). We need a major PR campaign to let patients know that they can gain access to their health data wherever they go!

The Meaningful Use of Quantified Self Gadgets

There is a growing body of people who are very actively engaged in the quantified self (QS) movement and I have found myself more engaged with my own Fitbit. I got my Fitbit at a conference in Philadelphia where they were having a contest to see if all the attendees collectively could walk a large number of steps. They reached their goal and donated money to a charity. I did not become a regular Fitbit user until I went to the HIMSS conference in Las Vegas. There, I wore my Fitbit every day because I wanted to know how many steps I was walking as I roamed the exhibit halls and attended sessions. I found that it was easy to reach my daily 10,000 steps goals.

The quantified self movement isn’t simply about tracking your daily activity. There is a “meaningful use” behind this technology and I’m not sure if everyone gets it. On a simplistic level, the concept behind self-monitoring is that the feedback will fuel behavior change and motivate people who are not very physically active to become more active. If you are averaging only 2,000 steps each day and you have set a personal goal of 10,000, you will be motivated to make time to exercise. You will be deliberate and intentional about finding ways to increase your steps. As you see progress, you’ll be rewarded and you will continue to engage in healthy activity. However, it does not end there.

Once you have started uploading and sharing your activity statistics online, you’ll find that you can engage other users and enter competitions. This simple element of gamification actually has a powerful behavior modifying effect. People feel competitive and they want to win - whether that is winning a physical prize or simply earning bragging rights that you can tweet to all your followers. Gamification is becoming an essential element of sustained health behavior change and we are finding that QS devices have a powerful ability to engage all types of people. You don’t need to be a gamer to understand or appreciate that. We all have some element of a competitive drive within us.

Finally, QS devices can provide a layer of social accountability. When is the last time someone asked you about your level of physical activity? How do your friends and family members know your level of physically activity? If you tell people you went to the gym, you may have spent 5 minutes on a treadmill or you might have exercised for 60 minutes. By sharing your QS statistics online to your friends and family, you now build a layer of social accountability where people may ask you, “Why were you so inactive today? Are you not feeling well?” This type of social support structure is possible because the Internet connects people all over the world. Your exercise accountability partner may be thousands of miles away.

I see tremendous potential in the QS movement and I encourage you to explore it. Don’t just dip your toes in the water. Immerse yourself in achieve meaningful use. Your health will be glad you did.

A month after HIMSS

As I reflect on the HIMSS conference, I think about all the changes and innovations occurring in health IT. For one thing, I wonder if we will see ICD-10 delayed vs. implemented sooner. The physician community wants to delay ICD-10 for as long as possible because of the administrative burden they will face (and because they need to learn a new coding system that is much more complex). The health IT community wants to see ICD-10 implemented as soon as possible because they have developed solutions to help physicians and hospitals with ICD-10 and they want to sell these solutions and services. ICD-10 delay will only negatively impact their revenues this year.

I was also excited to see that HIMSS is growing in the mobile health or mHealth space. The acquisition of the mHealth Summit in December is one of the landmark steps that shows me that HIMSS is serious about becoming a leader in the mHealth industry. I wonder what type of impact this will have on all the other mobile health conferences and communities out there. Will they collaborate with mHIMSS or will they continue to operate independently? I anticipate that more local and regional mobile health meetings will attract HIMSS members who want to gain a better understanding of the rapidly evolving mHealth space.

Speaking of mHealth, what will be some of the major advances in the mHealth industry this year? One may think that a big focus area will be in electronic health records (EHRs), but we saw that Epocrates announced that they were abandoning their plans to develop an EHR. Meanwhile, physicians are expecting fully robust EHR capabilities on their mobile tablets where they can view, enter, and edit information and orders. CPOE may need to be renamed: MPOE for Mobile Physician Order Entry.

Another area that intrigued me this year was these Fitbit contests that were sponsored by various organizations. I had my Fitbit, so I tracked how many steps I was walking at HIMSS. I also entered one of those contests and won a digital pen! I think HIMSS converted me to be more devoted to my Fitbit and this small self-monitoring device has made me more engaged in the quantified self movement.

Finally, I’m grateful that some of those informal tweetups from HIMSS have continued in my geographic area. I’ve continued to meet with several physician executives (mainly when I’ve been in NYC) and we’ve continued our health IT discussions and we have grown our social communities by inviting others to our tweetups.

Enjoyed a great time at HIMSS 2012

For the past few years, I’ve been attending the HIMSS conference but this year I wasn’t sure if I was going to take the time to attend. At the last minute, a few things fell together in a nice way and I was able to attend the biggest HIMSS conference in the history of health IT. This year, there were over 37,000 people attending and the conference was huge! I didn’t even get to say hello to all my friends given that every time I would swing by one of the exhibit booths to say hello to someone, inevitably he/she was not present.

This year, there were many discussions around mobile health (mHealth). We recently saw that HIMSS had acquired the mHealth Summit and that they had launched mHIMSS last year. The buzz around mobile technology is growing every year as devices like smartphones and tablets become ubiquitous. Also, we’re seeing more computing horsepower in these small devices. Soon, physicians will be accustomed to using medical devices that attach to their mobile devices through wireless technology like Bluetooth or Near Field communication.

Another hot topic this year was Clinical Decision Support (CDS). We saw several sessions focused around discussions around the opportunities and challenges of using CDS in a way that will lead to improved clinical outcomes. Alert fatigue remains a valid concern. If physicians are receiving too many alerts on the computer screen, we may run into the opposite problem: alerts ignored. Therefore, it’s important for hospital executives to develop clear, effective strategies around the use of CDS so that physicians agree about the proper clinical workflow.

Finally, it was great to meet other folks from the SearchHealthIT community. We had a great tweetup on Monday night and then I constantly ran into editors, contributors, bloggers, and other community users from SearchHealthIT. This year at the HIMSS conference, I had the opportunity to meet and greet a number of people I had only met online via Twitter, LinkedIn, or Facebook. It’s always fun to put a real face behind that username!

Looking forward to HIMSS 2012 in Las Vegas!

It’s been amazing to see all the growth in the health IT industry over the past few years. The government launched things into motion with the HITECH ACT in 2009. It’s hard to believe that was roughly 3 years ago!

This year, we’re expecting over 35,000 people at the HIMSS conference. As usual, there are different parties and social events almost every night. There will be plenty of sessions focused on EHRs, meaningful use, CPOE, clinical decision support, HIEs, interoperability, and more.

Here are a few other highlights this year:

Consumer adoption of health IT is a newer focus for HIMSS – vocal patient advocates such as Regina Holliday will be speaking at the “Leading from the Future” event on 2/23.  @SeattleMamaDoc mommy blogger & patient health advocate Wendy Swanson will be speaking on social media in healthcare on 2/20.

Mobile health is a major focus at HIMSS12, echoed by the launch of mHIMSS (HIMSS mobile health project) this past Fall.  There are several sessions on mobile health – including one on 2/23 on how mobile health is saving lives in at-risk areas (Haiti, Africa).  Health eVillages is a unique foundation that is equipping clinicians in developing nations with mobile phones preloaded with health resources.

This year, I plan to spend more time focusing around consumer health, social media, and mobile health. We all know that we’re in the midst of an mHealth revolution, but many people don’t fully understand how mobile technology could be used to transform healthcare delivery. As patients and health care professionals embrace digital media and find ways to improve communication and workflow inefficiencies, we’ll find a very different health care landscape in this country (and the rest of the world). I’m particularly interested to see how health care delivery is evolving in other countries given that computer and communication technologies are becoming much more affordable, even in developing countries (emerging markets).

I look forward to seeing you at the HIMSS conference this year!

Confusion around graduate degrees in health informatics

I often encounter physicians who want to become a CMIO or a medical director of informatics. These physicians often ask, “should I get a graduate degree in informatics?” Then, the next question is, “which degree should I get?” A master’s degree in: Medical informatics? Health informatics? Clinical informatics? Biomedical informatics?

Although these terms may seem similar and interchangeable, they are actually different. However, I don’t want to get into those technical details right now. Rather,  the issue I want to discuss is more around the various graduate programs that offer degrees in health or medical informatics. Biomedical informatics stands apart on its own.

The world of graduate degrees in health information technology is confusing if you do an Internet search and compare various programs. You’ll find some universities offering online programs and others offering live programs. Some programs are titled “medical informatics” and others call their programs “health informatics.” Why the different names? Wouldn’t it be less confusing if we could all agree to use the same names for all these similar programs?

Let’s take an example by looking at the city of Chicago:

The Master of Science in Medical Informatics Program at the School of Continuing Studies of Northwestern University is an online program. In contrast, the University of Illinois at Chicago offers an online Master of Science in Health Informatics. Why does one Chicago school use the term “medical” while the other school uses the term “health”? Is there really a difference if we’re talking about health IT?

To take the confusion further, the American Medical Informatics Association (AMIA) has recently come up with a medical sub-specialty for physicians called “clinical informatics.” I don’t know why they didn’t call it “medical informatics.” After all, they are the American Medical Informatics Association and not the American Clinical Informatics Association (ACIA). They’re also not the American Health Informatics Association (AHIA). I also don’t see them changing their name anytime either.

Currently, the most common graduate program you’ll find is the MS in Health Informatics. Some schools may call it MS in Health Care Informatics. There are currently only a few schools that offer an MS in “Medical” or “Clinical” Informatics.

These programs are being filled with physicians, nurses, pharmacists, technicians, computer programmers, program managers, consultants, researchers, and various other types of professionals. You couldn’t have a more diverse set of students in a single classroom!

I think we need standardization around graduate degree programs in health information technology. Why should we have so many different degrees? In the world of business, everyone recognizes the MBA. In the world of public health, the common degree is an MPH (although some schools offer an MS in public health, hence we see some people with an MSPH). In the world of health IT, shouldn’t we have a standard graduate degree?

Will 2012 bring greater confusion or clarity around meaningful use?

I speak with physicians about “meaningful use” all the time. So many are very confused about the rules, the incentives, the penalties, and even the definitions. Most physicians are not trained to think about these types of things. Also, many physicians don’t have enough background in EHRs so they’re struggling to understand how much work is going to be required to get them to meaningful use.

Let’s start with the simple word “attestation.” What does this word really mean? The dictionary may define this word as, “to affirm to be correct, true, or genuine.” Or, ” to certify by signature or oath.”

Attestation for the Medicare Electronic Health Record (EHR) Incentive Program opened April 18th, 2011. Do physicians understand the attestation process? This seems to be a significant area of confusion among many physicians.

Physicians need to attest that they are using EHRs and achieving “meaningful use.” Is it that simple, or do they need to provide a lot of documentation to essentially prove that they are meeting meaningful use criteria?

CMS indicates: “A complete EHR system will provide a report of the numerators, denominators and other information. Then you will need to enter that data into our online Attestation System.” This is where many physicians are getting confused. They may be using a certified EHR system, but they don’t know how their system provides this report.

Physicians are trained to document things in great detail so that they can effectively defend themselves if they find themselves in a lawsuit. They’re comfortable with that process and they’ve mastered the art of documenting each clinical encounter, each procedure, each visit, etc. Now, they feel they need to add a level of documentation that shows that they’re using EHRs in a meaningful way.

I hope that 2012 brings more clarity around “meaningful use” and encourages more physicians to go after the financial incentives that the government has set aside for clinicians who treat Medicare or Medicaid patients. I also hope that these incentives are enough to motivate physicians to use EHRs routinely on all patients, not just those who are tied to these financial incentives.

Careers in Health IT

These days, everyone is looking for a job in health IT. How do you go about finding a job in Health IT? Where do you go to gain experience if you’ve never worked in health care? The government has funded a number of educational and training programs to build the health IT workforce.

I frequently speak with physicians about health IT careers and I share my insights on NonClinicalJobs.com

Today, I participated in the webinar titled, “Careers in Health Information Technology” from the National eHealth Collaborative (NeHC). The faculty included:

• Norma Morganti, Executive Director - Midwest Community College Health Information Technology (HIT) Consortium
• Tammy McNeil, RHIA, CPHIT, CPEHR, HIT Clinical Advisor - Wide River Technology Extension Center (TEC)
• Todd Searls, Director of REC Operations - Wide River Technology Extension Center (TEC)
• Angie Agage, EHR Coordinator - Dialysis Center
• Charles Friedman, Ph.D, Director, Health Informatics Program - Schools of Information and Public Health, University of Michigan