Could a new note, the Football, help improve healthcare?

As I've mentioned in previous posts, the American government cannot set up a national patient identifier. So projects like NHIN Direct generally rely on a document push mechanism which, essentially, allows one healthcare provider to push an authorized, HIPAA-secure document to another healthcare provider.

I'll admit it - I wish we could have pull.

The reason I want pull? A centralized, patient-centric medical record (like in the #SpeakFlower model) would make it much easier for various providers to pull and update information in a virtually central location. Pushing documents is going to have its workflow challenges, and leave some with the question, "Where is the patient's real chart?".

So since I recently became involved in our Massachusetts discussion on Health Information Exchange, I'm struggling with the question of how to implement a state-wide HIE system that will allow providers, at least initially, to push documents to eachother.

So my first informatics question, on being given this challenge, is : What will people push? Who will push it? And to whom? And when?

To try to answer these questions, I invited folks to our last Interstate 91 Informatics dinner in January to discuss "Can we do better than SOAP?" by asking everyone :

1. What documentation do people want?
2. Could we develop any group standard templates for standardized documentation, to save us all development costs?
3. Could we develop any rudimentary, area-wide clinical governance so we can share documentation easier, and thus all benefit from a common language?
4. Ultimately, who will push what documentation to whom, and when?

And after a rousing discussion, the answer I heard was this : Everyone has a different opinion.

I guess it's entirely understandable... ICU docs, PCPs, surgeons, specialists, hospitalists, and everyone else has a common goal - making the patient healthier - but they have different training and thus they all have different needs. This is why when I hear docs say "I just need the important information!", I smile because ultimately, all of the information in a chart is important - It just depends on your context and clinical needs.

So I'm left with the ultimate Informatics challenge - How can we get the right information to the right person in the right place in the right time in the right way? Especially when everyone has a different opinion on what the right information is?

And is there any way we can develop a standard lingua franca that all doctors speak?

Is there something that all docs would know how/when to use, in a standard way?

THE CHALLENGE

So to better understand the challenge here, I looked to the most common issues I hear doctors, nurses, and administrators talking about :

1. Med Reconciliation (at virtually every stage of care)
2. Handoffs inside a hospital
3. PCPs wanting notification that their patient has been admitted
4. PCPs wanting discharge summaries when their patients are discharged
5. Quality
6. Waiting times

And given the push mechanism it looks like we are going to get, at least initially, how are we going to set any standards?

There is one thing issues #1-6 above share : They are mostly all caused by the lack of a common, portable, #SpeakFlower-type, patient-centered chart, which we currently lack in modern private healthcare. (Note : I say private healthcare because the Veteran's Administration/VA VistA system actually has a pretty seamless, continuous, portable patient chart that only works inside the VA system for various political and cultural reasons...) 

But in a private, push world, is there any way we could we start to approach some kind of a portable, patient-centered chart?

In other words, is there any way we could leverage our push system in a way that actually simulates a patient-centered chart?

And how would we implement this?

THE CURRENT STATE

Looking at the current buffet table of documentation, it's no wonder that every doctor has a differrent opinion of what they need. There aren't really any hard standards for clinical documentation. As I've mentioned in previous posts, most doctors learn about documentation from things like the Washington Manual Internship Survival Guide. So as a result, most physicians are familiar with things like :

1. Admission H&P
2. Progress Note
3. Discharge Summary
4. Transfer Note
5. Encounter Note
6. Procedure Note
7. Visit Note
8. Consult Note

And so when our Interstate 91 Informatics group got together, it's no wonder every doctor had a different opinion of which note they would want to get, and when.

So to look for inspiration on how to build a standardized document that every doctor would know how to use, and when to push to whom, again I thought : Could we make a standardized push document that approaches the portable, patient-centered chart we all want?

THE INSPIRATION

It dawned upon me that to solve this problem, we will need a new type of note. And so if it's something that's not in the Washington Manual Internship Survival Guide, it would have to be something that was so useful, so intuitive, and so desirable - like McDonalds French Fries - that every doctor would *want* to use this note, update it, and push it to the right person at the right time.

So then I thought - We are really asking for a portable, mini-chart that we can push around to the next provider.

And then I wondered, "What will we name it?" The "Mini-chart"? The "Patient Summary"?

What we're really talking about here is a "Patient Handoff Note" - The 'mini-chart' - And to make it extra-intuitive, I've decided to nickname it "The Football".

(Interestingly - "The Football" is also the nickname given to the "Nuclear Football" which the President of the United States carries around at all times, which according to Wikipedia is designed to be "a mobile hub in the strategic defense system of the United States" - A portable, role-centric tool for making important decisions... Huh! Talk about portable documentation!)

Also by nicknaming it "The Football", it gives users a visual clue about how to use it and when to punt it to the next physician.

THE PATIENT HANDOFF NOTE ("FOOTBALL")

The Patient Handoff Note ("Football") is basically a patient mini-chart, designed to be used in handing off care from one physician to another. In other words, physicians could think of the Patient Handoff Note ("Football") as a document that they update and push to the next physician expected to see the patient.

Who is the next physician expected to see the patient? Whoever is expected to see or cover the patient next. If you're a PCP expecting a specialist to see your patient, you'll update the football and send it to the specialist. If you're a specialist done with the consult, expecting the PCP to see the patient next, you'll update the football and send it back with the patient to the PCP. 

Of course, the key word here is expected - What if a patient has an unexpected trip to the ED?

I thought the note should be of such high value that, on arrival, the ED physicians would request the Football from the PCP. (By doing this, they would ensure the PCP knew about the visit.) And when the ED doc decides to admit the patient to the Hospitalist, they would update the football and push the patient and football to the expected Hospitalist.

And the admitting hospitalist could update and push the football to the expected hospitalist the next day. 

And the daytime hospitalist could update the football and push it to the expected overnight covering staff. 

And the overnight covering staff, if needed, could update the football and push it to the daytime hospitalist.

And the daytime hospitalist, on discharging the patient, could update the football and push the patient and football back to the PCP.

(To the patients reading this, I apologize - This is really referring to document management, not patients - I am definitely not endorsing pushing patients around!) :)

So anyway, back to the football - what could this Patient Handoff Note ("Football") look like?

Here's my first draft - As an example, I'll show how it could be used at the point of discharge :

[ DRAFT ] PATIENT HANDOFF NOTE ("FOOTBALL")

PATIENT NAME   :   VADER, DARTH A.

DATE OF BIRTH   :   Jun 06 1966

Emergency Contact :

Tarkin, Emperor

Relationship : Father

Cell (914) 555-1212

CODE STATUS : 

Full Code (last verified by Luke Skywalker, MD, PCP, Internal Medicine, Oct 30 2009)

DATE OF HANDOFF :

Feb 03 2012

HANDOFF FROM :

Dirk Stanley, MD (Hospitalist, Internal Medicine)

EXPECTED HANDOFF TO :

(   ) Overnight Coverage 

(X) Other : Luke Skywalker, MD (PCP, Internal Medicine)

AUTHOR : (Note : This is who is pushing the football today)

1. Feb 03 2012 - Dirk Stanley, MD (Hospitalist, Internal Medicine)

CO-AUTHORS : (Note : this is essentially everyone who has pushed the football in the past, with last date they pushed it, in reverse date order)

2. Jan 28 2012 - Han Solo, MD              (Attending, Emergency Medicine)

3. Sep 22 2005 - Beru Whitesun, MD    (Attending, Gastroenterology)

4. Apr 02 2004 - Luke Skywalker, MD (PCP, Internal Medicine)

5. Apr 01 2002 - Ben Kenobi, MD        (PGY-1, Internal Medicine)

6. Feb 22 2002 - Owen Lars, MD         (Attending, General Surgery)

7. Jan 11 1996 - Leia Organa, MD        (Attending, Cardiology)

ALLERGIES :

1. Mar 29 2002 - Bactrim (Rash/Hives)

PMHx/PSurgHx : (Note : This has all problems/history identified in reverse date order)

1. Feb 03 2012 - Aspiration Pneumonia

2. Feb 25 2002 - Cholecystitis, s/p cholecystectomy

3. Sep 22 2005 - Colonoscopy, s/p benign polyp removal

4. Jan 11 1996 - CAD s/p NSTEMI, no catheterization, medical management

5. Oct 12 1994 - Hyperlipidemia

6. Apr 03 1992 - HTN

SIGNIFICANT STUDIES : (Note : This is noted by docs, again in reverse date order)

1. Jan 28 2012 - 2-view Chest X-ray = (R)LL patchy infiltrate

2. Jan 04 2004 - PSA=0.06

WHAT I DID :

Patient admitted to Mos Eisley Hospital on 1/28 with cough, fever, purulent sputum approx 3d after being found asleep and intoxicated at a party. Chest X-ray showed (R)LL infiltrate, WBC=21k, PMNs=80%. Started Zosyn IV and after 3d patient improved. Changed to oral Augmentin on 2/2/2012. Now ready for discharge today 2/3/2012.

ACTIVE MEDS (AT TIME OF HANDOFF) :

1. Lisinopril 5mg PO daily

2. ASA 81mg PO daily

3. Metoprolol 25mg PO 2x/daily

4. Simvastatin 40mg PO daily

5. Augmentin 875mg PO 2x/day x7d, to complete on Feb 09 2012

TO-DO LIST :

1. Feb 15 2012 - PCP to follow-up with patient for routine follow-up visit

2. Mar 01 2012 - PCP to repeat Chest X-ray to ensure resolution of pneumonia

3. Apr 01 2012 - PCP to repeat lipid panel and LFTs to monitor Simvastatin dose

4. Apr      2015 - Gastroenterologist to repeat colonoscopy to follow-up benign polyps 

5. Jan       2020 - PCP to give repeat Tetanus vaccination 

SIGNED : __Dirk Stanley, MD_(Hospitalist, Internal Medicine)______ Date : Feb 03, 2012     

                                     

(My apologies to George Lucas - I'm obviously a big fan - Hope you don't mind me using characters to demonstrate this new medical note...!)

Anyway, I think the advantages of this drafted Patient Handoff Note ("Football") are this :

1. It would be a very high-value note that docs would look and ask for (like McDonalds French Fries!) when receiving a patient :)
2. After receiving the football from another physician, it makes creating your local documentation much easier.
3. After receiving the football from another physician, it makes it very easy for you to update the football for the next provider.
4. By making it something all doctors expected, it would drive ownership of the note by all physicians, so...
5. ... It encourages docs to own, review, and continuously update the full med list, problem list, to-do list, allergy list, etc
6. It makes med reconciliation easier for everyone.
7. It could virtually replace notes involved in the expected transfer of care such as the transfer note, overnight coverage signout, discharge note, and consult referral
8. Nicknaming it "The Football" makes it fairly intuitive about its importance and who to push it to and when
9. In a push environment, in an unexpected transfer of care, an ED doc or Hospitalist requesting this from the PCP would pretty much ensure the PCP was notified about the admission in a timely basis.

It's definitely an off-of-the-beaten-path idea, but I'm going to suggest it to my fellow physicians here in Massachusetts, as we start to warm up our state-wide HIE and get it running. Will let you know the results!

Is this note wishful thinking, or just crazy? Always interested in feedback and questions! Send me your thoughts and ideas! Love the discussion just for education's sake!

#SpeakFlower : A model for interconnectivity in US Healthcare

UNIQUE IDEA ALERT

So in my last post, I discussed the "patient identifier problem", and how it contributes to poor connectivity between systems. I discussed some of the political problems with sharing health information, and some common, differing perspectives. I also briefly discussed some of the models being developed, including NHIN/Direct (now officially called "The Direct Project").

One thing I forgot to mention that makes this all more complicated are the myriad of privacy laws - Not just HIPAA, but also various state laws about transmitting or even storing data about HIV and other transmissible diseases.

The challenge is then, how do we overcome these issues in the US?

There are a lot of issues to be worked out, clearly, but I think one of the major issues is simply making organized change with all of these political, financial, and technical obstacles in place.

I. WHO'S THE BOSS?

So let me first ask - Who's the most powerful person in healthcare?

I sometimes ask friends and family this question, and it's interesting to hear people's guesses. "Obama?" "Hillary Clinton?" "The insurers?"

My response : It's the patient.

I think people forget : The patient is the boss. They are the ones who pay the tab for healthcare, whether it's the insurance premiums they pay, or the taxes they pay... They are the one making the choice about where to go, and so they have enormous influence about who succeeds in healthcare.

When it comes to healthcare reform, there is often talk about laws, and doctors, and insurance companies, and nursing unions, and medicare and medicaid - But I think patients are an untapped resource in the healthcare reform discussion.

The problem is that, from my experience, a lot of patients are sort of like the substitute teacher we all had in grade school - Even though they are technically in charge, they're new, they just showed up today, they don't entirely understand the routine, and so they sometimes lack confidence and can be subject to "But-Mrs.-Smith-we-ALWAYS-have-three-hours-of-recess"-type arguments that sometimes steer them.

So I've often wondered - What if a group of coordinated, informed patients could really assert their power?

II. COORDINATING A CHANGE

The problem is, as I said, most patients are too new, or too inexperienced to know what to look for. When doctors and nurses become patients themselves, they can be some of the most challenging patients - Why? Because they know what to look for and how to assert their power.

So then I wondered - Could we somehow train all patients to know what to look for? Could we get patients to ask for different care? How would they know what to ask for?

So I thought - To help patients assert their power to make change, we need to make it easy for them to ask for change. 

So then I thought of solutions. For those readers who are multi-lingual, or amateur linguists, you'll appreciate this : Language is fluid. It's not as precise as most people think. Even though modern English has been around since about 1550, linguists know this : words enter and leave the lexicon all the time.

So what if we employed a linguistic feat and came up for a new word for this new type of healthcare? Something evidence-based, efficient, affordable, and connected?

How could we get patients to ask for this type of healthcare? What if we could get lots of patients to ask for this type of healthcare?

III. DEVELOPING THE STANDARD FOR INTERCHANGE

The first trick is, defining a standard for this future model. From the ground up, the new healthcare paradigm has to be built. The informational framework for healthcare has to be laid to allow hospitals to run efficiently, and for patients to be able to - only if they wish - bring their data with them. That is, one patient = one chart. So when a patient moves from one office to another, the systems will talk to each other and allow true data portability - Without having to push or pull the data.

Why would a patient want a standard for data portability? Why would they care that other doctors can read their chart from another hospital?

• It reduces errors (because doctor A knows what doctor B has been doing)
• It reduces unnecessary tests (because doctor A knows what doctor B already ordered)
• It reduces costs (because fewer tests means lower bills)
• It reduces waiting times (because doctors don't have to spend time trying to research your history)

What if we could make a standard for data portability? Obviously, many patients would refuse, citing personal privacy reasons - But would other patients ask for this?

IV. THE SPEAKFLOWER PROPOSAL

The next trick would be, naming the standard something easy. A lot of "Health IT standards" have names like HL7, CCR, CCD, LOINC, DRG, ICD-9, etc.... Not too tangible to the average patient.

But what if we named this standard something really warm and friendly and tangible... Like "SpeakFlower"?

In other words, "SpeakFlower" is a placeholder for a standard that allows a patient to ask for a doctor/hospital/office to have all of their medical records transferred to a central site that the patient controls, so that other doctors could look at it in the future. It means not only building a particular HealthIT standard into the EMR, but also adopting the practices needed to employ it.

Could we get patients to ask for SpeakFlower? What if they did?

V. SELLING THE CONCEPT

The joke goes, "Standards are like toothbrushes - Everyone knows what they are, but nobody wants to use yours." We have lots of different EMRs, and a few standards, and yet there doesn't seem to be universal agreement on which standard to use, and how to use them.

Why? I think there are a lot of reasons - Complexity of our healthcare system is one, but there's also privacy issues and a lot of competing financial interests. In the end, fighting for a national standard is very challenging.

So what if a coordinated group of patients developed a 100% optional, national standard and how to use it? And what if they called this optional standard SpeakFlower?

Could we sell this concept of an optional national standard? I think so.

After developing the SpeakFlower technical framework (HealthIT standards, central servers, HIPAA-secure gateways, etc.) - You then need to teach patients about SpeakFlower. And how to do this?

Imagine a commercial on the Superbowl, where Wilford Brimley comes out and says :

"You know, my primary care doctor almost ordered something that interfered with something my cardiologist gave me last week, because she didn't know what my cardiologist had prescribed. And my cardiologist almost ordered a test I had last week in the ED because he didn't know what the ED doctor had done. And all of these extra tests, bills, and waiting time are really getting me down... But now, with SpeakFlower, all of my doctors can share my information easily and I get to keep track of it. So ask your doctor... Do you SpeakFlower?"

Why Flower? Because flowers are ubiquitous. They come in every shape and size, are found in every country in the world, and no matter what it looks like, it's still a flower. Flowers are friendly, peaceful, and represent growth, life, and vitality. This optional standard that patients might ask for should represent peace and life.

Oddly enough, if you diagram the model that puts the patient at the center of the medical record, and have all of the providers/hospitals/labs/pharmacists as connections to the patient in the center - The diagram almost invariable ends up looking like a flower.

Why speak it? Because like a person trying to communicate in a foreign language, we might ask for someone to speak the language we know. Asking to SpeakFlower is asking a doctor/hospital's EMR to speak a particular language - It says, "Please have your EMR speak the language I need to accomplish the goal I'm asking for."

VI. REALLY?

The hope would be that simply discussing an optional, national standard for healthcare data interchange would be enough to get all vendors, doctors, and hospitals to adopt the standard and implement it for those patients wanting their charts to be portable. It would also help simplify the privacy discussion, because patients would actively seek out SpeakFlower - Makes the whole discussion on "opt-in-or-opt-out?" much simpler. It would also allow docs and hospitals to generally keep their legacy systems - Implementing SpeakFlower does not require painful amounts of programming, just adherence to the SpeakFlower standards.

But if the discussion wasn't enough, then the hope is that the Wilford Brimley commercial on the Superbowl could spur the discussion - in the same way pharmaceutical companies have gotten patients to ask for drugs, patients could start showing up saying, "Dr. Stanley, do you SpeakFlower in your office?" and have an understanding of the benefits of SpeakFlower.


And even if 30% of my patients asked me to SpeakFlower,  I'd probably have little choice but to make sure my EMR SpokeFlower, for those patients requesting it. So I'd speak to my vendor and ask them to make sure my EMR can SpeakFlower.

VII. SPEAKFLOWER TODAY

If only...

There is a SpeakFlower.org web site, which I started to develop with two colleagues in our spare time,  but you'll notice the web site is outdated and quite frankly, we realized planting SpeakFlower in our national garden would require much more time and capital than we currently have. (Namely, weekends and nights.)

But we're still trying to build it and transplant it to the right FlowerPot. Our hope is to make SpeakFlower a force of good in healthcare. We also have a #SpeakFlower hashtag on Twitter that we apply to tweets that discuss patient-centered electronic medical records.

Healthcare needs innovative ideas. If you're interested, follow @SpeakFlower on Twitter, feel free to use the #SpeakFlower hashtag, and look for the SpeakFlower gardening team as we look for the right pot to plant in. :)

As always, I welcome any comments and thoughts. 

Medicine Reconciliation and Chaos Theory

So a lot has been written about "What is Medicine Reconciliation?"....

What exactly is this beast?

Yes, medication errors have been reported (such as in this article) to affect 1.5 million people every year (according to the Archeives of Internal Medicine), costing between $77 billion and $177 billion a year.

How do these medication errors occur? Because little is actually known about the information flows for medicine reconciliation.

Here's the problem : Nobody has a good plan for organizing enough to answer the question, "What meds is the patient actually on?"

Here's the scenario : A 60-year-old male shows up in the Emergency Room needing urgent care.

You're the doc responsible for this patient. How are you going to figure out what meds the patient is actually taking?

Potential sources of data include :

1. The patient - Works for some patients, but many don't know the details of their meds.
2. The family - Works for some, but many don't know the details of the patient's meds.
3. The PCP - Works sometimes, but may not know what the specialist prescribed last week.
4. The Specialist - Works sometimes, but may not know what the PCP prescribed last week.
5. The Pharmacy - Works sometimes, but many pharmacies close after 5pm, many aren't electronic, and a lot of patients go to many pharmacies (including mail-order)
6. Electronic "Insurance databases" - Works sometimes, but mainly only with insured patients - Doesn't work if the patient pays out-of-pocket
7. Herbal medications - Often missed as a data source
8. The old hospital record - Sometimes helpful, but sometimes out-of-date. Also remember, except for the VA, virtually no hospital shares pharmacy data with the outside PCPs.

So which of these data sources are you going to use?

What you start to realize is - It's almost impossible to know with 100% accuracy what meds a patient is on.

(Well, maybe in a best-case scenario : A well-educated, non-intoxicated patient, only on one or two medications - Maybe then, you can achieve 100% accuracy. Outside of this scenario, you're generally working at 95% accuracy or less.)

So for the majority of patients, you will never achieve 100% accuracy.

So you have to ask yourself - What level of accuracy is acceptable?

I'm proposing a new standard, which I lovingly call : The Mother Standard.

The Mother Standard is "The amount of data you would collect to achieve a level of accuracy that you would find acceptable for your own mother, knowing that 100% is impossible." I figure, for most people, this is a level of accuracy of >95%.

And this is my proposal, for an acceptable way to perform Medicine Reconciliation to the degree of the Mother Standard (>95%) :

Step 1 : Ask the patient what meds they are on - Including herbal medications. If you, as a clinician, do not feel you've met the Mother Standard - Proceed to step 2.

Step 2 : Ask the family what meds the patient is on - If still not the Mother Standard, proceed to Step 3.

Step 3 : Ask the pharmacy(ies) what meds the patient is on - If still not the Mother standard, proceed to Step 4.

Step 4 : Ask the PCP what meds the patient is on - If still not the Mother Standard, proceed to Step 5.

Step 5 : Ask the specialist what meds the patient is on - If still not the Mother Standard, proceed to step 6.

Step 6 : Check the old hospital/office chart for what meds the patient is on - If still not the Mother Standard, proceed to step 7.

Step 7 : Check the electronic insurance report - If still not the Mother Standard, then at least you can say you made every attempt to achieve the Mother Standard, and were unsuccessful.

So why are there so many errors nationally, every year? Because patients who don't have their meds clearly tracked require an enormous amount of work, just to try to get to the Mother Standard - And in some cases, it's just impossible.

Looking at the coordination of care among multiple specialists, sometimes even multiple PCPs, and hospitals - If the patient, or their family, does not keep track of the meds - Then achieving the Mother Standard is virtually impossible.

Fortunately, doctors are trained to work with incomplete information, but when incomplete information isn't enough, we have to ask ourselves : Who can fix this?

I'm hoping that SpeakFlower (http://speakflower.org) helps our country move into this realm, gradually.

Anyway, I'm hoping to do some research into the time it takes to reach the Mother Standard. Will try to publish what I can shortly. Stay tuned.