8 years ago I got an awesome 12 inch Powerbook G4. It was $1500. When I bought it, it was the smallest Mac Laptop. It’s still beautiful. It runs web stuff. Has a 1024×768 screen, 1.5 Ghz Processor.

About 3 years ago, the iPad came out. People expected it to cost $1000. It was generally as fast as my Powerbook for most web tasks. It was actually $500.

I know, you think we’re doing a Moore’s Law discussion about how tech improves. Next I’m going to say that my iPad mini was only $330. Right? No…….

People think they understand that prices are going do. But then you go to a Chinese website like focalprice.com and your mind goes Poof.

You can get a tablet that approximates my Powerbook or iPad mini for $135 (as of this writing). But spend time looking at the prices and options. It’s easy to see that prices are dropping continuously. A tablet that would have blown minds 8 years ago might go for $52. It took years for Macs to go from single core to dual core to quad core. These prices are trending rapidly to zero. $50 will get you a quad core tablet in the near future. Definitely not years from now.

Who profits from disposable hardware?

Don’t get me wrong, I’m not making light of e-waste or the enviromental issues of hardware becoming disposable. But hardware is becoming disposable regardless.

In general when a product becomes commoditized, profits flow above or below in the value chain. (Sorry, jargon.) So, looking at PCs. As the IBM Desktop PC became more of a commodity, Intel was making money by supplying CPUs and Microsoft was making money by providing the Operating System. In the mean time, Dell and HP sell billions but can barely make a profit.

Let’s apply this to healthcare. Imagine using a tablet to check in for a well child check. If you did this 8 years ago on a Powerbook, say, Apple would have got a good chunk of profit. Now I could do check-in for $100 hardware instead of $1500. The hardware isn’t going to generate much profit. Profit now goes up a layer to the software interface maker.

So what’s on the market for check-in interfaces? If we bought a hardware kiosk that integrated with our EMR, one is currently priced at $10,000. Clearly the vendor isn’t spending more than $1000-$2000 on the hardware. So the rest of the cost is for software. Alternatively, another vendor offers multiple tablets for free. Oh, except they want to do your merchant services and charge fees. And they want to do collections on your patients. Oh, and they have targeted advertisements to your patients. Come for a headache, get an advertisement for an expensive medication. Ewww. If you try to turn things off, then the price again goes to $X000s.

Disposable hardware prices make it easier for software vendors to make a profit. In the end, any reasonable software vendor is going to price things to maximize overall profits. I can respect that. Their motivations aren’t about improving life as a physician or as a patient. If we want to make life easier/cheaper for patients, we can’t rely on interface vendors. Instead, we’ll need disposable software in healthcare.

Definition Cloned – To produce a copy of; imitate closely

Most of the EMRs we use today have templates, macros and/or the ability to copy and paste previous notes into current notes. The EMR I use can do all of the above. These options can help speed up documentation, allow more face time with patients, and if used properly can help accurately justify the level of coding (complexity) of the encounter. In the last 6-12 months though, CMS and the Secretary of Health and Human Services have decided they have a problem with these features. They believe that these features lead to upcoding (more income to the doc) and inaccurate medical records. (issues with patient safety). The use of these features also came up in a monthly physician meeting in our practice after an independent auditor looked at a sampling of charts.

Is CMS right about cloning?

There probably is some truth in there. It is easy to propagate a finding, complaint or disease state through future visits by using what they term cloning of notes. And there are probably some doctors out there that do inflate their notes, so they can bill a higher code and receive a higher payment, although I think this is a small minority. There is also an assumption by auditors that just because the visit notes look similar, that we are not doing the work documented. That we are automatically guilty of fraud. This is just a patently false assumption to make. I also wonder if auditors have problems with paper-based visit note templates that can look awfully similar from visit to visit.

Most of us are using these features so we can speed up our documentation, try to spend more time with patients, and also not get behind. Otherwise, documenting notes in EMRs can be onerous and time consuming. The alternatives to using templates, macros, and coping/paste features are hiring a scribe, typing out every encounter, or dictating. (I didn’t include handwriting recognition software because it is not ready for prime time at all.) Hiring a scribe is just another expense. Typing notes can be time consuming if you are not a speedy typist, and will also lead to less face time with the patient. Dictation can be quite beneficial but software isn’t cheap, and it means finishing notes either after hours or spending more time in between patients completing notes. Finally, both dictation and typing notes takes away the EMR’s ability to have structured searchable data, which is suppose to be one of the benefits of electronic records.

So do we do away with templates, macros, etc? That might happen, but how? Well, I could see hospital-owned practices, for fear of being audited and owing money, either disabling these features in their EMRs or banning the use of them. I could see the next stage of Meaningful Use including a measure where progress notes can NOT be generated using templates, copy/paste features or macros.

Is taking away these features the proper solution? I don’t think so. The proper solution is training. Training doctors to review their notes before signing off on them, and making sure the visit notes reflect accurately the work that was done that day and the codes used.
It is fitting though that the government has pushed really hard for physicians and hospitals to adopt EMRs, and now are looking to punish us when we use the benefits of those systems in which we invested.

So, don’t be surprised if templates go the way of Betamax. In the meantime, check those notes.

The top 4 browsers were IE, Chrome, Firefox and Safari. In that order. I find that interesting because for several years I have complained to e-MDs that Portal doesn’t layout appropriately in Modern Browsers. Less than half of my visitors use Internet Explorer. That campaign to convince e-MDs to fix portal usability was probably the first time SupportCenter had been used systematically to raise awareness with e-MDs. Interesting coincidence, a couple weeks later, the exact fix that I had recommended went out to Portal.

Google is now a significant source of traffic — I’ve had about a couple thousand visitors from Google links. (Comparatively: for me, Bing is 20x smaller. No other search engine shows up.) There are no advertisements (other than, I guess, stuff I advertise for myself.)

The Content…..

I wrote most of the posts here. I’ve definitely had help from a number of other people who’ve shared their work. Thanks Chris, Bill, Sara, John, Chat, Keith, and a few others. THere have been 120 posts. Some are articles, others are just placeholders for crystal reports or other downloads. Since I’ve started teaching on my ‘day off’ last July, the site has been less active.

My top posts:

• Unchart Visit Summary. (Which now has about 3500 uses/week!)
• Stage 2 Proposed Guidelines (the spike of traffic, handout was downloaded ~800 times)
• e-MDs Macros (My tool for making daily work faster)
• Where to Start with macros and e-MDs.

I spent some time optimizing the site. I like speed. A typical page loads in 2.5 seconds. Hopefully that makes browsing more enjoyable for people. 95% of visit are straight browsing (not using search.)

Year 3

The biggest news for the next year on the site is that John Crankshaw is joining me on this. He’s already on the sidebar! I’ve got some other project that I’m working on — in particular an app that helps new MAs do refills via protocol. More about that soon…..

Hey everyone!

I’m a third year medical student at Pacific Northwest University of Health Sciences, home of the Mighty Mustangs! I currently live in Mount Vernon, WA and am stumbling along as a Junior Doctor…my wife’s most endearing pet name…at Skagit Valley Hospital.

I am very happily married to my beautiful and creative wife, Laura, who gave me the world’s cutest and strongest-willed kid, Parker J. Life as a daddy, husband, medical student, friend, son, sibling and more…can be a bit hectic, but I love my life and am so blessed.

The great state of Washington has always been my home, living in Kent, Seattle, Yakima, and now in Mount Vernon. I did have a quick stint in Granada, Spain while a junior at the University of Washington…Go Dawgs!!…and subsequently got bit by the travel bug, which unfortunately isn’t too conducive with the med student lifestyle and non-existent salary.

I can’t claim the prestigeous title of Geek, like my Unchart.com superiors, but hopefully they can help me change that. I did grow up in the world of dial-up AOL, giving me madd middle-school AIM flirting skillz, and I was in undergrad when TheFacebook made its debut. I like computers and I kind of know how to use them. Let’s do this!

One Page AAFP Infographic

Nurse practitioners have started to respond. CKRN wrote about Nurse Practitioners, Scope of Practice and turf. (Go ahead and read it, I’ll wait here. )

Dr Berstein says Patients should lead care.

Medical management ≠ Team Leadership

I think these discussions are confusing leadership and management. In the last 100 years since the Flexner Report, physicians have assumed leadership of much of healthcare. Nearly all physicians can get leadership roles if they are willing to commit time/energy.That’s a correlation, though. It’s not that medical school and residency trained us in team leadership.

The AAFP says, “Doctors bring broader and deeper expertise to the diagnosis and treatment of all health problems. Doctors are trained to provide complex diagnoses and develop comprehensive plans to treat them.” That’s technically true compared to Nurse Practitioners. But that’s confusing management of medical care and leadership of patient-centered care. (This is where I like Dr. Bernstein’s idea that patients should be leading — they should be the best advocates.)

Correlation is not causation. Physician training did not make me a team leader. The talents/skills/activities that helped me get into Stanford for college or ETSU for medical school are the foundations for being a leader now. Nearly everything I’ve learned about teamwork or leadership has happened outside of my formal medical education. I learned as a Peace Corps Volunteer or as a volunteer coordinator. In three years of residency I had lectures about practice management. But it was a tacked-on experience — we weren’t really going to get to practice any of those topics on the current residency clinic. (Who’s going to let a resident decide budgeting priorities?)

We don’t really need that much ‘leadership’. It’s ridiculously simple to see failure across modern healthcare. Healthcare teams need skills at getting things done for patients. Expanding roles for Nurse Practitioners is a non-sequitir for me. It’s unrelated to whether teams are well-run or not. Just like being a physician-owner is unrelated to whether a clinic’s business is efficient. Some are. Some aren’t.

So personally, this feels like protectionism and whining from the AAFP. Let’s provide exceptional care. Let’s keep advocating for innovation and limit the flaws of modern healthcare. If we excel, patients will choose with their feet. There’s more than one way to do things right — I respect Nurse Practitioners’ for trying to create their own way of patient-centered medical care.

Postscript

In the 1990s, I heard what I thought was a damning condemnation of the AMA and physicians in general. OK, this is unsourced. But in all the discussion of 1990s Health Care Reform, not a single statement from the AMA was about patient-centered issues. It was all about physician reimbursement. Protecting physician rights, etc. All about protecting turf. Hmm, why am I remembering this anecdote now?

When thinking home sleep monitors, I wanted to reveiew practice changes I’ve made in the past couple years.

None of these changes are about making money. The point is that I can increase the ways I help patients. And that they are viable as part of my practice as a Family Doc.

Small practice innovations cover their investment costs and expand scope of practice. Cocky Strategic Idea-Guy (that’s me!) would like to add one more innovation: Home Sleep Monitors.

Home Monitors

For patients with a moderate to high pre-test suspicion of OSA, full polysomnagraphy can reasonably be replaced by home sleep studies. It has > 90% sensitivity.

• Much shorter wait between diagnostic suspicion and evaluation. (Typically up to 2 months in my community now.) Could be a week.
• More comfortable/convenient than going to a lab.
• Much cheaper (No consult visit, Study price is ~1/4 a full night study)
• Allows some people who would refuse referral to still get evaluated.

Reimbursement/Costs

• Medicare 2012 Reimbursement for 95806: $183.80 (TC: $121.85; -26: $61.95)
• Local Commercial Payors: $234-273 (Source: Family Care Network, Bellingham)
• Device costs ~$2200.
• Supplies and interpretation and portal ~$100 per study.
• ROI: Need to do 10-15 studies to recoup cost.

Coordination

I talked with a local sleep doc about potentially collaborating on interpretation and followup. His office was starting home sleep studies as well. He wasn’t interested in coordinating. Understandable.

What I’ve learned so far

I got a Midmark Sleepview and it’s been pretty easy to setup and to use. I’ve done 4 studies so far and the average turnaround has been 5 business days for the interpretation. I don’t have it automated yet; it’s taking me about 10 minutes to set up the machine and 10 minutes to upload results. It’ll get faster. The results so far have made sense but it’s too early to see how effective I am with CPAP training, etc. I’m working on it….

CGM Overview

Continuous Glucose Monitor (CGM) allows for better understanding in hard to control insulin-dependent diabetics. It checks a reading every 5 minutes for 3 days, it’s then downloaded and we can use it to adjust isulin and improve diabetic control.

This is a disruptive technology — as a Family Doc I potentially can do a better job with complicated diabetes control because I have better data from the patient. This is a technology that allows me to broaden the scope of problems I manage before I get to referral.

Nuts and Bolts

• Why: A1c control is one of our main clinical benchmarks for Meaningful Use.
• Cost: Machine is ~$1200. Sensors are $40 each.
• Coverage: Our carriers cover it. There’s $120-200 charge for patient training/explanation (that’s outside of the visit E&M). There’s also a $30 interpretation fee after it’s removed.
• ROI: The first ~7 patients cover the cost of the machine, if we have ~$200 charges and $40 costs per patient.
• Quality: Allows better diabetic management in insulin patients.
• Time: Most of the process will be nurse driven, like, say, PFTs.

I bought a Meditronic iPro Continuous Glucose Monitor.

Since I’ve been doing it, I’ve found it to be very useful for seeing exactly where/how sugars are out of control. Essentially every patient has had one significant insight that helped improve diabetes. In Washington State, I think about 70% Private Insurance has coverage. So that’s been a barrier to doing it. For patients who don’t have coverage, if they might do it several times, I suggest that they consider buying a personal CGM out of pocket. Like Dexcom Seven Plus. It won’t be long for someone to make an iPhone compatible personal CGM…..

Spot Vitals LXi

• Connects directly into e-MDs
• Takes about 15 seconds to do BP/HR vitals
• Can connect to a electronic scale so weight gets imported, too.
• Costs $2000 – $3500 (quick googling, not comparison shopping.)

Direct ROI

• In setting of possible MA turnover, reduces BP variability
• Assume it saves 30 seconds (fast BP, less manual transcription), that translates to more than 2 full days of staff work. About 2000 vitals per side of the clinic monthly.

(ROI 1.5 years. More or less depending on how much time it actually saves. I think 30 seconds is low)

Indirect ROI

• More efficient MAs would mean nurses would not have to room as many patients.
• Reduce Doctor waiting on rooming patients
• Improve pt satisfaction (quicker rooming)
• Improve eye contact/friendliness of rooming (MAs wouldn’t have to look at computer nearly as much.
• Thigh cuffs would reduce temptation for MAs to get inaccurate BPs in order to save time of walking to central pod.
• Eliminate transcription errors
• Improve MA/Nurse Morale with less ‘scut work’.

(ROI 3-6 months given all the ripple benefits.)

Automated vitals addresses a few different issues for my practice:

• Using an interface eliminates typo errors (which can cause embarrassing mistakes graphing, say, weight.)
• By checking blood pressure on the way up, the SpotVitals is faster.
• By speeding up vitals it can allow the nurse/MA to focus more on the person
• Clinical Research shows that labile blood pressure readings are improved with automatic vitals over manual vitals.
• Reduces inter-staff variability in blood pressures.
• By having a central station, it’s much better stocked (every single cuff size is handy, no having to walk for a thigh cuff.)

So, sweet, right?

Unfortunately, reality hasn’t quite worked that way. The SpotVitals is expensive so you don’t just order one per nurse. We got our first one (without O₂ Sat) for about $1700. It’s an extra $1300 to add O₂ Sat. WelchAllyn’s milking this, if you ask me. The price is off by an order of magnitude. This is the same problem with Welch-Allyn’s Ambulatory Blood Pressure Monitor.

e-MDs has an interface — that’s why we bought this specific mdoel. It’s supported. But it’s not really. The interface is a hack outside of e-MDs.It adds enough friction to eliminate the usefulness. The process is: Open Interface, Find Pt, Get Vitals, Close Interface, Open e-MDs, Find Pt, Drop in vitals. If the interface was within e-MDs you could cut the number of steps in half. And although documentation says the interface also works with compatible scales, it’s been broken for a few years according several users. (Thanks Keith for saving me money on a wasted scale!)

Since the machine is expensive, we’ve been re-working clinical processes. Lately we’ve been trying doing vitals out in the waiting room. There are some communication issues between staff. On our next pilot, we’re going to add a few ‘rooms’ to our clinic dashboard. There will be ‘Vitals-Room’ and ‘Vitals Done’ so clinical staff can tell where a pt is in the process (and if there’s a backup, they can route around it.) My goal has been to help my staff decide what they want (not tell them.) So we’re still trying different things out.

Since the interface doesn’t work for efficient workflow, I’m building a new ‘pseudo-interface’. This will pop up from within a patient’s chart in e-MDs. I’m working with my staff to figure out the best place to put this. I’m trying a couple different things to make this work. First, much larger font-size so they can see typos better. The left side of this maps to where the vitals are on the machine. (Faster for staff, less cognitive-load so less error prone.) Tabbing through fields works in the order that they work (Again, faster). The results will be put into e-MDs where there’s full details — for example, which arm for the blood pressure. So we simplify input for reliability.

If you’d like to help test this, you can drop me an e-mail.

Over the years I’ve struggled with Dragon. I think I’ve failed half a dozen times. With honest attempts — where I tried something different to make it work. A newer version. A better microphone. More training. More customized vocabulary. A newer version. A better microphone. etc.

Enunciation still is the key.

Dictation will never be complete magic for me because I misspeak and slur. But a few years of typing has helped me dicate better — I’m more telegraphic and less rambly. Within the limits of my enunciation, I thought my setup was working pretty darn well:

• Dragon 11.5 (Not Medical)
• Samson C01U microphone on a stand. (Respected for Podcasting. Great bang for buck)
• Custom Vocabulary made from my old dictations.

Chris takes a different approach: He uses Dragon Medical Version (which costs > $1000) and has a SpeechWare 3-in-1 Microphone (the highest rated table mike.) I prefer a table microphone, like Chris, because I hate taking the headset on and off.

So I decided to buy a $279 Speechware Mic from Knowbrainer.

I have to say, I was surprised. I recreated a profile (pro tip: Any time you change Dragon Versions, your computer or your microphone, start a new profile. It’s work but it makes sure that each part is being maximized.) And the performance is much better. I still slur certain words but it felt that nearly all of my errors are either slurring or words that aren’t in my custom dictionary.

Now Dragon 12 is out with better accuracy. I’m using some of my Meaningful Use money to optimize my Dragon setup. A newer computer (mine’s pushing 5 years old) and newer Dragon, I’m hoping this will really rock….

I’d recommend the Speechware TableMike for Docs using Dragon daily.

The biggest problem with side projects like this, is finding time to do them. Yesterday afternoon I had a few hours while I was on call and so I got a table and have put it together.

This crystal report for e-MDs has 4 different tables that you can use to determine the answers to those questions.

The first table has the number of distinct patients assigned to a doctor with visits/invoices in the last 2 years. (People use different timeframes from 1-3 years typically when defining active patients.) So, for our practice certain types of visits, like prenatal visits, don’t show up here.

The second table shows the number of visit/invoices that the patients had in the past 2 years (regardless of continuity.)

The third table shows the number of visits/invoices that the provider gave in the past 2 years (regardless of continuity.)

And the last table shows the number of continuity visit/invoices for the providers and patients.

Ideal Panel Size Report

The real question for a group: Could you use this kind of data to make decisions about how to manage panel sizes?

Curious what counts as a visit/invoice? No list is perfect. But here’s the CPTs embedded in the report:

 '99245','99201', '99202', '99203', '99204','99205',
 '99381','99382','99383','99384','99385','99386','99387'
 ''99211','99212','99213','99214','99215','99391',
 '99392','99393','99394','99395','99396','99397'
 '99253','99254','99255','99231','99232','99233','57410',
 '56605', '56606', '56620', '56625', '56630', '58120', '58558',
 '57065','57500','57505', '57520', '57522', '57155','56630',
 '56631', '56632', '56633', '56634', '56637', '58150','58200', 
 '58720','58943', '58951','58953','58954','58956','44005',
 '50715','44955','57531','58210'

That’s definitely me.

Our group is starting to think about re-investing Meaningful Use money. We’re trying a simplified process of deciding (it’s time-consuming to get a large consensus). My thought was to make it “innovative but not foolish.” Now, when I start talking about innovation, people think I’m talking about tech. I do love tech but I like how Bell Labs President Mervin Kelly described innovation: Cheaper, or Better or Both.

So I’m looking for things that make our care cheaper or better (or both) and are not foolish.

First Plan: WelchAllyn Spot Vitals LXi helps making rooming faster (that’s cheaper via less time) and has the potential to reduce variability of readings (that’s better) and our clinic has about 4000 visits a month (so it’ll be really used. Practical!) There have been some questions about reliability of readings at Mid-State Health but I’ve got to try one.

Second Plan: Bigger Monitors for our Receptionists (23 inch Dell Monitors for $180). By seeing more allows receptionists to work slightly faster. (Cheaper Checkins). Screens are more energy efficience (cheaper). Larger screen will allow showing multiple schedules. More monitor space will be nice for morale, too. Not Foolish: These will be used continuously.

But my third idea is my doozy. Since i spend most of my time with my laptop near my nurse (intentional plan to allow better interuption and informal conversation), I’m not sure I really need my offices. So I’ve decided I should make a consultation theater.

The Consultation Theater

There are several parts to this idea. Back in the day, doctors used to use their offices to have conversations and consultations. After a lengthy consultation, you might go the the exam room to continue the visit and back to the office for the final plan. Not super ‘lean’ but it allows a more comfortable discussion. HIPAA has long killed the old version — at least for me. I could never keep a completely privacy-aware desk space. I’ve been interested in doing a better job with patient education via videos. But not everyone has youtube or internet. Thus the consultation theater is born.

I’m imagining my desk in a corner (I have a Dragon Dictation Setup with my desktop PC). The main space will have a kitchen table with 4 chairs — enough for the vast majority of discussions I do. I’m hoping the make the feel ‘homey’ where we can sit around a table and discuss what to do. Maybe I’ll have a way to brew Tea or Coffee. Or possibly pop popcorn. I’ll use this room for certain types of visits (Follow up from an MRI Scan, Follow up starting an antidepressnant, etc).

Theater-wise, I plan a large TV mounted on the wall for video or to show Digital XR. I’ll get an iPad and an AppleTV to wirelesly show info on the TV. On the iPad I’ll sometimes mirror over e-MDs from my desktop, when it’s needed. The iPad will be loaded with videos that I commonly recommend. Sometimes I’ll use the theater for some simple brief education (Ambulatory Blood Pressure Monitor, Info about starting certain types of medications.) In some visits I’ll try to start the education part earlier and go work on great patient instructions in my Visit Summary.

So, Consultation-Theaters aren’t as well known as clock-radios or camera-phones or chocalate-peanut butter. But I think this combo has some real potential.

Bill Sweeney of Mid State Health wrote this report.

This shows normal vs new patients per month. It also includes distinct patients in that time.

Appointment Status by Month

Bill creates awesome flat file reports. This is just begging for some simple list work in Excel (See my Data-Driven Practice page).

In my practice we didn’t fully realize how expiration dates worked. We used 1 year later — now patients portal is expiring. We need to change the date to a later one. I think we’re going to use a macro to loop through and update expiration dates. It’ll be the same technique I used to add preventive flowsheet by looping through a list of accounts.

Portal Patients (with email and expiration dates)