Chris Notte, MD

The other day, I had to look up “whispered pectoriloquy” to be reminded of what it meant. The last time I had seen the term was when I was a third-year medical student.

I was motivated to look it up now as I was reading the review of systems in a patient note generated from an electronic health record. Interestingly, the note was written by a consulting urologist.

I have become accustomed to only glancing at the review of systems in most of the medical letters I receive, but this particular review of systems caught my attention. As I looked carefully at it, I noticed that the urologist documented that the patient denied chest pain, shortness of breath, double vision, and – oddly – loose stools. In fairness, the note also documented that the patient denied blood in his urine and nocturia.

I was quite doubtful that the physician actually asked the patient about chest pain and double vision, so I was facing a dilemma: believe all of the note, none of the note, or just the parts I felt confident were actually asked.

For a long time, I really did not think much about the problem. I just processed the observation with a sense of mild amusement and absurdity, and mostly with an acceptance that these kinds of observations were an annoying but unavoidable side effect of systems created by computer engineers and forced upon doctors.

But I became more concerned as I read further. The physical exam documented a detailed cardiac exam with no murmurs, rubs, or gallops, and the pulmonary exam showed no wheezing or whispered pectoriloquy. These documentation inaccuracies, while amusing, truly are a source of potential liability and ultimately detract from our ability to find the important information contained within a note.

Fundamentally, medical notes are written to document what occurred during a patient visit. They should allow the physician to recall what happened at the visit, whether the patient follows up in a day, a week, or 3 years later. They also need to communicate the details of the visit to any other clinician who may see the patient at some point in the future.

In recent decades, notes also have become the sole evidence required to justify physician charges. To bill at a certain rate, a physician must document a minimum amount of information, including a specific number of elements in the review of systems and the physical exam. Recognizing that compliance with billing requirements is an important goal of clinicians, many EHRs have made it too easy to “bloat” a note by including reams of irrelevant information – thereby making it difficult to find the important information the note was intended to communicate in the first place.

Notes from some EHRs remind us of the Wendy’s commercial from the 1980s: They force us to ask, “Where’s the beef?”

This is because many EHR implementations rely on default settings. These maximize documentation for billing but unfortunately leave the “beef” (in our case, the real information relevant to patient care) buried in lines of irrelevant, specious, and sometimes downright fictitious information.

We can do better. Virtually every EHR currently in use allows clinicians to customize fields so that notes can be easily written to reflect the realities of our differing practices.

Put more simply, you really can (and should) have a review of systems that is relevant to what you do.

If you always ask about chest pain, difficulty breathing, and abdominal pain, you can include negative responses to those questions with one click and then add in any positive aspects the patient may report. If you are seeing a patient with asthma and you generally ask the same questions – exacerbations in the last month, frequency of the use of albuterol, nighttime awakenings, symptoms with exercise, etc. – most EHR systems will allow you to set up the record to populate an asthma review of systems that includes defined responses you can individualize for each patient.

Electronic documentation of the physical exam also should reflect the examination that you routinely do by default. Then you can make simple changes to adapt your personalized predefined settings and correctly reflect what occurred with each patient.

For that same asthma patient, the physical exam should give the details of the heart and lung exam but should not include any mention of an abdominal exam unless one was actually done. A current high-quality EHR also should populate the appropriate physical exam areas with one click of a button.

It has been more than 3 years since the majority of practices transitioned to electronic health records, but we still see far too many clinicians struggling with systems and describing data that reflect things they have not done, all due to the use of default settings that have never been changed. It is important to understand how to customize your EHR to meet your needs and to make the individual efforts required to learn how to effectively use the current instruments of our craft.

As for whispered pectoriloquy, it is the increased loudness of a whispered word heard on auscultation over an area of lung consolidation. It is similar to tactile fremitus, where consolidation is noted by the vibratory feel in your hand placed on the chest of a patient. It should be a very rare event in our day and age that any description of whispered pectoriloquy should sneak its way into our record, particularly for a urology visit.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

The other day, I had to look up “whispered pectoriloquy” to be reminded of what it meant. The last time I had seen the term was when I was a third-year medical student.

I was motivated to look it up now as I was reading the review of systems in a patient note generated from an electronic health record. Interestingly, the note was written by a consulting urologist.

I have become accustomed to only glancing at the review of systems in most of the medical letters I receive, but this particular review of systems caught my attention. As I looked carefully at it, I noticed that the urologist documented that the patient denied chest pain, shortness of breath, double vision, and – oddly – loose stools. In fairness, the note also documented that the patient denied blood in his urine and nocturia.

I was quite doubtful that the physician actually asked the patient about chest pain and double vision, so I was facing a dilemma: believe all of the note, none of the note, or just the parts I felt confident were actually asked.

For a long time, I really did not think much about the problem. I just processed the observation with a sense of mild amusement and absurdity, and mostly with an acceptance that these kinds of observations were an annoying but unavoidable side effect of systems created by computer engineers and forced upon doctors.

But I became more concerned as I read further. The physical exam documented a detailed cardiac exam with no murmurs, rubs, or gallops, and the pulmonary exam showed no wheezing or whispered pectoriloquy. These documentation inaccuracies, while amusing, truly are a source of potential liability and ultimately detract from our ability to find the important information contained within a note.

Fundamentally, medical notes are written to document what occurred during a patient visit. They should allow the physician to recall what happened at the visit, whether the patient follows up in a day, a week, or 3 years later. They also need to communicate the details of the visit to any other clinician who may see the patient at some point in the future.

In recent decades, notes also have become the sole evidence required to justify physician charges. To bill at a certain rate, a physician must document a minimum amount of information, including a specific number of elements in the review of systems and the physical exam. Recognizing that compliance with billing requirements is an important goal of clinicians, many EHRs have made it too easy to “bloat” a note by including reams of irrelevant information – thereby making it difficult to find the important information the note was intended to communicate in the first place.

Notes from some EHRs remind us of the Wendy’s commercial from the 1980s: They force us to ask, “Where’s the beef?”

This is because many EHR implementations rely on default settings. These maximize documentation for billing but unfortunately leave the “beef” (in our case, the real information relevant to patient care) buried in lines of irrelevant, specious, and sometimes downright fictitious information.

We can do better. Virtually every EHR currently in use allows clinicians to customize fields so that notes can be easily written to reflect the realities of our differing practices.

Put more simply, you really can (and should) have a review of systems that is relevant to what you do.

If you always ask about chest pain, difficulty breathing, and abdominal pain, you can include negative responses to those questions with one click and then add in any positive aspects the patient may report. If you are seeing a patient with asthma and you generally ask the same questions – exacerbations in the last month, frequency of the use of albuterol, nighttime awakenings, symptoms with exercise, etc. – most EHR systems will allow you to set up the record to populate an asthma review of systems that includes defined responses you can individualize for each patient.

Electronic documentation of the physical exam also should reflect the examination that you routinely do by default. Then you can make simple changes to adapt your personalized predefined settings and correctly reflect what occurred with each patient.

For that same asthma patient, the physical exam should give the details of the heart and lung exam but should not include any mention of an abdominal exam unless one was actually done. A current high-quality EHR also should populate the appropriate physical exam areas with one click of a button.

It has been more than 3 years since the majority of practices transitioned to electronic health records, but we still see far too many clinicians struggling with systems and describing data that reflect things they have not done, all due to the use of default settings that have never been changed. It is important to understand how to customize your EHR to meet your needs and to make the individual efforts required to learn how to effectively use the current instruments of our craft.

As for whispered pectoriloquy, it is the increased loudness of a whispered word heard on auscultation over an area of lung consolidation. It is similar to tactile fremitus, where consolidation is noted by the vibratory feel in your hand placed on the chest of a patient. It should be a very rare event in our day and age that any description of whispered pectoriloquy should sneak its way into our record, particularly for a urology visit.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

The other day, I had to look up “whispered pectoriloquy” to be reminded of what it meant. The last time I had seen the term was when I was a third-year medical student.

I was motivated to look it up now as I was reading the review of systems in a patient note generated from an electronic health record. Interestingly, the note was written by a consulting urologist.

I have become accustomed to only glancing at the review of systems in most of the medical letters I receive, but this particular review of systems caught my attention. As I looked carefully at it, I noticed that the urologist documented that the patient denied chest pain, shortness of breath, double vision, and – oddly – loose stools. In fairness, the note also documented that the patient denied blood in his urine and nocturia.

I was quite doubtful that the physician actually asked the patient about chest pain and double vision, so I was facing a dilemma: believe all of the note, none of the note, or just the parts I felt confident were actually asked.

For a long time, I really did not think much about the problem. I just processed the observation with a sense of mild amusement and absurdity, and mostly with an acceptance that these kinds of observations were an annoying but unavoidable side effect of systems created by computer engineers and forced upon doctors.

But I became more concerned as I read further. The physical exam documented a detailed cardiac exam with no murmurs, rubs, or gallops, and the pulmonary exam showed no wheezing or whispered pectoriloquy. These documentation inaccuracies, while amusing, truly are a source of potential liability and ultimately detract from our ability to find the important information contained within a note.

Fundamentally, medical notes are written to document what occurred during a patient visit. They should allow the physician to recall what happened at the visit, whether the patient follows up in a day, a week, or 3 years later. They also need to communicate the details of the visit to any other clinician who may see the patient at some point in the future.

In recent decades, notes also have become the sole evidence required to justify physician charges. To bill at a certain rate, a physician must document a minimum amount of information, including a specific number of elements in the review of systems and the physical exam. Recognizing that compliance with billing requirements is an important goal of clinicians, many EHRs have made it too easy to “bloat” a note by including reams of irrelevant information – thereby making it difficult to find the important information the note was intended to communicate in the first place.

Notes from some EHRs remind us of the Wendy’s commercial from the 1980s: They force us to ask, “Where’s the beef?”

This is because many EHR implementations rely on default settings. These maximize documentation for billing but unfortunately leave the “beef” (in our case, the real information relevant to patient care) buried in lines of irrelevant, specious, and sometimes downright fictitious information.

We can do better. Virtually every EHR currently in use allows clinicians to customize fields so that notes can be easily written to reflect the realities of our differing practices.

Put more simply, you really can (and should) have a review of systems that is relevant to what you do.

If you always ask about chest pain, difficulty breathing, and abdominal pain, you can include negative responses to those questions with one click and then add in any positive aspects the patient may report. If you are seeing a patient with asthma and you generally ask the same questions – exacerbations in the last month, frequency of the use of albuterol, nighttime awakenings, symptoms with exercise, etc. – most EHR systems will allow you to set up the record to populate an asthma review of systems that includes defined responses you can individualize for each patient.

Electronic documentation of the physical exam also should reflect the examination that you routinely do by default. Then you can make simple changes to adapt your personalized predefined settings and correctly reflect what occurred with each patient.

For that same asthma patient, the physical exam should give the details of the heart and lung exam but should not include any mention of an abdominal exam unless one was actually done. A current high-quality EHR also should populate the appropriate physical exam areas with one click of a button.

It has been more than 3 years since the majority of practices transitioned to electronic health records, but we still see far too many clinicians struggling with systems and describing data that reflect things they have not done, all due to the use of default settings that have never been changed. It is important to understand how to customize your EHR to meet your needs and to make the individual efforts required to learn how to effectively use the current instruments of our craft.

As for whispered pectoriloquy, it is the increased loudness of a whispered word heard on auscultation over an area of lung consolidation. It is similar to tactile fremitus, where consolidation is noted by the vibratory feel in your hand placed on the chest of a patient. It should be a very rare event in our day and age that any description of whispered pectoriloquy should sneak its way into our record, particularly for a urology visit.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Sixty-six years after George Orwell penned his prophetic vision of 1984, many physicians are encountering tangible evidence that “Big Brother” is alive and well: Meaningful use audits are here, and we’ve heard from a lot of our readers that they are time consuming and disconcerting, if not a bit scary. We, too, have encountered Stage II audits and have helped physicians navigate audit mysteries, so we thought it would be a good idea to offer our insight into the process.

First, a disclaimer: The best advice for passing an audit should come from a consultant familiar with your unique situation and audit request. There are, however, a few general principles that everyone should adopt to make the process as smooth as possible. We will highlight them here, beginning with the following axiom:

Prepare, but don’t panic

The most important piece of advice we can offer to providers attesting for meaningful use is to plan carefully for an audit, even if an audit request never comes. The best way to do this is to maintain attestation documentation so it is readily available when needed. This might mean screenshots, “dashboard” reports, letters of intent from collaborating registries, or records of successful data transmission. If you are not sure what to prepare, your EHR vendor should be able to provide you with guidance; every EHR product needs to be certified for meaningful use, so vendors must have documentation on how you can prove you’ve achieved it.

It’s also worth pointing out that audits may encompass a multistep process. Once you respond to the request, the auditor may require additional documentation. This may become a two-way conversation and allow you to clarify what is needed, but preparation will make the process go much more smoothly. Thus, if an audit request materializes, you’ll have already done all of the hard work and will need only to provide it to the third-party auditor. A word of caution, though: Don’t believe that once you’ve received your meaningful use payment that you are completely out of the woods, because ...

Audits may come before or after payment

There are several types of audit requests. Auditors may simply ask you to prove you are using a certified EHR, or they may ask for a whole lot more. Furthermore, they may perform “prepayment” or “postpayment” audits. In the case of a prepayment audit, they will hold any incentive payments until after the audit requests are satisfied. Audits after payment is issued can be a bit trickier; if you don’t “pass” a postpayment audit, the Centers for Medicare & Medicaid Services will ask for the money back and typically won’t be too friendly about it. The appeal process isn’t easy and may involve lawyers and other complications, so make sure to take the audit request quite seriously, and cover yourself by remembering that when it comes to a Meaningful Use audit …

There is no such thing as TMI (too much information)

When submitting supporting documentation to an auditor, try to be as exhaustive as possible to avoid making the process lengthier than it needs to be. It is critical to make your case clear, and screenshots depicting the measure, source, and date can be one great way to do this.

For example, if you are sending attainment numbers from scored measures (e.g., ePrescribing, CPOE, or Clinical Summaries), be sure to include some evidence that the numbers were obtained from your certified EHR’s scorecard or dashboard (such as the software’s logo, etc.). If sending evidence of compliance for a yes/no measure (e.g., patient lists by condition or clinical support rule activation), be sure the date you generated it is clear so you can prove it was active during the reporting period. Finally, be sure to provide clear documentation that you are actively submitting data to immunization and disease registries (or at least have done your due diligence to set it up), and whatever you do ...

Don’t neglect the security risk analysis

This is one area that seems to become a focus point in every audit. It’s also something that may be taken for granted by providers, as it is a yes/no measure that can be easily overlooked. Don’t fall into this trap; the CMS takes data security very seriously and so should you. If you receive an audit request from them, they will want to know not only that the analysis was performed but also what potential risks were identified, what type of data was collected, and what your practice is doing to improve upon any deficiencies. If you need guidance on how to do this, you’ll find help here.

This leads us to one final important piece of advice:

Make sure you follow up

It is not uncommon for providers to submit information to auditors and then wait a little while for a response, but we have also heard of communications being lost to spam filters and misspelled email addresses. It’s therefore critical to follow up carefully on any audit request, as there are deadlines attached and financial incentives at risk. In our experience, auditors are not offended by providers “checking in” on the status of their audit, nor are they opposed to clarifying questions. So even though “Big Brother” may be watching, in this case he (or she) has a name and an e-mail address and is willing to answer your questions, should any arise. In summary, audits will happen, but with some preparation as described above, the process will be less intimidating and (hopefully) a lot less work.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Sixty-six years after George Orwell penned his prophetic vision of 1984, many physicians are encountering tangible evidence that “Big Brother” is alive and well: Meaningful use audits are here, and we’ve heard from a lot of our readers that they are time consuming and disconcerting, if not a bit scary. We, too, have encountered Stage II audits and have helped physicians navigate audit mysteries, so we thought it would be a good idea to offer our insight into the process.

First, a disclaimer: The best advice for passing an audit should come from a consultant familiar with your unique situation and audit request. There are, however, a few general principles that everyone should adopt to make the process as smooth as possible. We will highlight them here, beginning with the following axiom:

Prepare, but don’t panic

The most important piece of advice we can offer to providers attesting for meaningful use is to plan carefully for an audit, even if an audit request never comes. The best way to do this is to maintain attestation documentation so it is readily available when needed. This might mean screenshots, “dashboard” reports, letters of intent from collaborating registries, or records of successful data transmission. If you are not sure what to prepare, your EHR vendor should be able to provide you with guidance; every EHR product needs to be certified for meaningful use, so vendors must have documentation on how you can prove you’ve achieved it.

It’s also worth pointing out that audits may encompass a multistep process. Once you respond to the request, the auditor may require additional documentation. This may become a two-way conversation and allow you to clarify what is needed, but preparation will make the process go much more smoothly. Thus, if an audit request materializes, you’ll have already done all of the hard work and will need only to provide it to the third-party auditor. A word of caution, though: Don’t believe that once you’ve received your meaningful use payment that you are completely out of the woods, because ...

Audits may come before or after payment

There are several types of audit requests. Auditors may simply ask you to prove you are using a certified EHR, or they may ask for a whole lot more. Furthermore, they may perform “prepayment” or “postpayment” audits. In the case of a prepayment audit, they will hold any incentive payments until after the audit requests are satisfied. Audits after payment is issued can be a bit trickier; if you don’t “pass” a postpayment audit, the Centers for Medicare & Medicaid Services will ask for the money back and typically won’t be too friendly about it. The appeal process isn’t easy and may involve lawyers and other complications, so make sure to take the audit request quite seriously, and cover yourself by remembering that when it comes to a Meaningful Use audit …

There is no such thing as TMI (too much information)

When submitting supporting documentation to an auditor, try to be as exhaustive as possible to avoid making the process lengthier than it needs to be. It is critical to make your case clear, and screenshots depicting the measure, source, and date can be one great way to do this.

For example, if you are sending attainment numbers from scored measures (e.g., ePrescribing, CPOE, or Clinical Summaries), be sure to include some evidence that the numbers were obtained from your certified EHR’s scorecard or dashboard (such as the software’s logo, etc.). If sending evidence of compliance for a yes/no measure (e.g., patient lists by condition or clinical support rule activation), be sure the date you generated it is clear so you can prove it was active during the reporting period. Finally, be sure to provide clear documentation that you are actively submitting data to immunization and disease registries (or at least have done your due diligence to set it up), and whatever you do ...

Don’t neglect the security risk analysis

This is one area that seems to become a focus point in every audit. It’s also something that may be taken for granted by providers, as it is a yes/no measure that can be easily overlooked. Don’t fall into this trap; the CMS takes data security very seriously and so should you. If you receive an audit request from them, they will want to know not only that the analysis was performed but also what potential risks were identified, what type of data was collected, and what your practice is doing to improve upon any deficiencies. If you need guidance on how to do this, you’ll find help here.

This leads us to one final important piece of advice:

Make sure you follow up

It is not uncommon for providers to submit information to auditors and then wait a little while for a response, but we have also heard of communications being lost to spam filters and misspelled email addresses. It’s therefore critical to follow up carefully on any audit request, as there are deadlines attached and financial incentives at risk. In our experience, auditors are not offended by providers “checking in” on the status of their audit, nor are they opposed to clarifying questions. So even though “Big Brother” may be watching, in this case he (or she) has a name and an e-mail address and is willing to answer your questions, should any arise. In summary, audits will happen, but with some preparation as described above, the process will be less intimidating and (hopefully) a lot less work.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Sixty-six years after George Orwell penned his prophetic vision of 1984, many physicians are encountering tangible evidence that “Big Brother” is alive and well: Meaningful use audits are here, and we’ve heard from a lot of our readers that they are time consuming and disconcerting, if not a bit scary. We, too, have encountered Stage II audits and have helped physicians navigate audit mysteries, so we thought it would be a good idea to offer our insight into the process.

First, a disclaimer: The best advice for passing an audit should come from a consultant familiar with your unique situation and audit request. There are, however, a few general principles that everyone should adopt to make the process as smooth as possible. We will highlight them here, beginning with the following axiom:

Prepare, but don’t panic

The most important piece of advice we can offer to providers attesting for meaningful use is to plan carefully for an audit, even if an audit request never comes. The best way to do this is to maintain attestation documentation so it is readily available when needed. This might mean screenshots, “dashboard” reports, letters of intent from collaborating registries, or records of successful data transmission. If you are not sure what to prepare, your EHR vendor should be able to provide you with guidance; every EHR product needs to be certified for meaningful use, so vendors must have documentation on how you can prove you’ve achieved it.

It’s also worth pointing out that audits may encompass a multistep process. Once you respond to the request, the auditor may require additional documentation. This may become a two-way conversation and allow you to clarify what is needed, but preparation will make the process go much more smoothly. Thus, if an audit request materializes, you’ll have already done all of the hard work and will need only to provide it to the third-party auditor. A word of caution, though: Don’t believe that once you’ve received your meaningful use payment that you are completely out of the woods, because ...

Audits may come before or after payment

There are several types of audit requests. Auditors may simply ask you to prove you are using a certified EHR, or they may ask for a whole lot more. Furthermore, they may perform “prepayment” or “postpayment” audits. In the case of a prepayment audit, they will hold any incentive payments until after the audit requests are satisfied. Audits after payment is issued can be a bit trickier; if you don’t “pass” a postpayment audit, the Centers for Medicare & Medicaid Services will ask for the money back and typically won’t be too friendly about it. The appeal process isn’t easy and may involve lawyers and other complications, so make sure to take the audit request quite seriously, and cover yourself by remembering that when it comes to a Meaningful Use audit …

There is no such thing as TMI (too much information)

When submitting supporting documentation to an auditor, try to be as exhaustive as possible to avoid making the process lengthier than it needs to be. It is critical to make your case clear, and screenshots depicting the measure, source, and date can be one great way to do this.

For example, if you are sending attainment numbers from scored measures (e.g., ePrescribing, CPOE, or Clinical Summaries), be sure to include some evidence that the numbers were obtained from your certified EHR’s scorecard or dashboard (such as the software’s logo, etc.). If sending evidence of compliance for a yes/no measure (e.g., patient lists by condition or clinical support rule activation), be sure the date you generated it is clear so you can prove it was active during the reporting period. Finally, be sure to provide clear documentation that you are actively submitting data to immunization and disease registries (or at least have done your due diligence to set it up), and whatever you do ...

Don’t neglect the security risk analysis

This is one area that seems to become a focus point in every audit. It’s also something that may be taken for granted by providers, as it is a yes/no measure that can be easily overlooked. Don’t fall into this trap; the CMS takes data security very seriously and so should you. If you receive an audit request from them, they will want to know not only that the analysis was performed but also what potential risks were identified, what type of data was collected, and what your practice is doing to improve upon any deficiencies. If you need guidance on how to do this, you’ll find help here.

This leads us to one final important piece of advice:

Make sure you follow up

It is not uncommon for providers to submit information to auditors and then wait a little while for a response, but we have also heard of communications being lost to spam filters and misspelled email addresses. It’s therefore critical to follow up carefully on any audit request, as there are deadlines attached and financial incentives at risk. In our experience, auditors are not offended by providers “checking in” on the status of their audit, nor are they opposed to clarifying questions. So even though “Big Brother” may be watching, in this case he (or she) has a name and an e-mail address and is willing to answer your questions, should any arise. In summary, audits will happen, but with some preparation as described above, the process will be less intimidating and (hopefully) a lot less work.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Eighteenth-century French philosopher Voltaire – amongst his many other pithy and lasting axioms – notably wrote: “God gave us the gift of life; it is up to us to give ourselves the gift of living well.” Almost 300 years later, his observation seems more salient and timely than ever. In the 21st century, we find ourselves in an era of technology unimaginable by Voltaire – one that empowers individuals to live better than ever, with tools no longer limited to the intellectual or aristocratic elite.

Accordingly, this month we thought it would be refreshing to take a break from looking back at the trials and tribulation caused by Meaningful Use in 2014, and look forward to the advantages and challenges promised by the consumer-focused health care technology market of 2015 and beyond. After all, we need only walk into the local Wal-Mart to be confronted with devices aimed at improving everything from sleep to diabetes, and our patients are clearly starting to take notice. Much more disruptive than the Internet revolution of the past 20 years, emerging technology promises not only to educate, but also diagnose, leading to an entirely different definition of “informed patients.” Like it or not, this is the new generation of “connected health,” and it is poised to reshape health care delivery in the very near future. We’ll review some of the recent innovations here.

‘Steps’ to achieve better health

While you might be challenged to recall the introduction of the mechanical pedometer by Thomas Jefferson in the 1700s, you no doubt recall the digital pedometer revolution of the 1990s. Seemingly overnight, these small belt-worn novelties began showing up on waistbands everywhere, easily confused for small pagers. Initially, the goal of owning a pedometer was simple: get to 10,000 steps a day to achieve better health. But the pedometers of today are far from simple. Now, they are worn on the wrist, or embedded in our phones, and track everything from calories burned to hours and quality of sleep. What’s more, they are integrated with health and wellness smartphone apps and often form the center of diet and fitness plans.

It’s hard to argue with the value of devices such as Fitbits and FuelBands as they encourage our patients (and even ourselves) to engage in more healthful and active lifestyles, but these are really just the beginning of the connected movement. Things really become interesting for physicians when patients choose to advance to the next level of technology and move from wellness tracking to disease management and diagnosis.

Beyond the Fitbit: Personal diagnostic technology

All of us encourage patients to monitor their blood pressures and blood glucose levels at home, as this can provide multiple data points crucial for proper management and medication dosing. But patients are no longer limited to just taking measurements and recording them on a paper log. Like the modern pedometers described above, BP cuffs and glucometers can now fully integrate with smartphone apps, leading to a whole new world of data integration. What’s more, the software can help patients self-manage their conditions, make recommendations on lifestyle modifications, and even suggest treatment options.

But personal medical gadgets are not just limited to upgraded versions of time-honored devices. Advancement in sensor and cloud-based technologies have paved the way for entirely new categories of diagnostic equipment. One such device, the S+ by ResMed (a respected respiratory equipment manufacturer), is a small box that sits on a bedside table. It is billed as “the first non-contact sleep sensor,” and ResMed claims it will “track and better understand your sleeping patterns, and then create personalized feedback and suggestions to help improve your sleep.” Not surprisingly, the S+ integrates with your smartphone, and even includes multiple sensors, smart alarms, and other tools to improve your sleep experience.

Another device currently in clinical trials is the Scanadu Scout, described by creators as a “medical tricorder” (an intentional reference to Star Trek). Integrating a thermometer, blood pressure sensor, pulsometer, pulse oximeter, and 2-lead EKG into a device about half the size of a hockey puck, the Scout collects and communicates data to a smartphone via Bluetooth. This could make it easier than ever for patients to compile cardiovascular data to share with their physicians, especially as a growing number of ambulatory EMRs offer the ability to submit these readings directly into the medical record through a web portal.

On a final note, we would be remiss if we didn’t mention the growing range of home blood-testing kits that offer everything from hemoglobin A_1C measurements to complete genome sequencing. All of these innovations signal a shift away from the idea of the medical home being the physician’s office, while keeping the patient squarely at the center of care delivery.

Shifting the data paradigm

Try as we might to avoid it, it is difficult for us to discuss emerging trends in medicine without mentioning Meaningful Use. Thus we feel compelled to mention that the MU Stage III proposed rule (which we will be discussing at length in future columns) includes language about connected medical devices. Under the header of “Active Patient Engagement,” the rule requires that physicians incorporate health data from nonclinical settings for 15% of patients. This leads us to ponder several questions. First, how will we handle this new onslaught of health information? How should it affect our medical decision making? And finally, what is our role as patients embrace these new technologies to take increasing ownership of their own care. Returning to the words of Voltaire we find comfort in this: “The fine art of medicine consists of amusing the patient while nature cures the disease.” Perhaps the paradigm hasn’t changed much at all. Perhaps patients have simply found new ways to be amused.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Eighteenth-century French philosopher Voltaire – amongst his many other pithy and lasting axioms – notably wrote: “God gave us the gift of life; it is up to us to give ourselves the gift of living well.” Almost 300 years later, his observation seems more salient and timely than ever. In the 21st century, we find ourselves in an era of technology unimaginable by Voltaire – one that empowers individuals to live better than ever, with tools no longer limited to the intellectual or aristocratic elite.

Accordingly, this month we thought it would be refreshing to take a break from looking back at the trials and tribulation caused by Meaningful Use in 2014, and look forward to the advantages and challenges promised by the consumer-focused health care technology market of 2015 and beyond. After all, we need only walk into the local Wal-Mart to be confronted with devices aimed at improving everything from sleep to diabetes, and our patients are clearly starting to take notice. Much more disruptive than the Internet revolution of the past 20 years, emerging technology promises not only to educate, but also diagnose, leading to an entirely different definition of “informed patients.” Like it or not, this is the new generation of “connected health,” and it is poised to reshape health care delivery in the very near future. We’ll review some of the recent innovations here.

‘Steps’ to achieve better health

While you might be challenged to recall the introduction of the mechanical pedometer by Thomas Jefferson in the 1700s, you no doubt recall the digital pedometer revolution of the 1990s. Seemingly overnight, these small belt-worn novelties began showing up on waistbands everywhere, easily confused for small pagers. Initially, the goal of owning a pedometer was simple: get to 10,000 steps a day to achieve better health. But the pedometers of today are far from simple. Now, they are worn on the wrist, or embedded in our phones, and track everything from calories burned to hours and quality of sleep. What’s more, they are integrated with health and wellness smartphone apps and often form the center of diet and fitness plans.

It’s hard to argue with the value of devices such as Fitbits and FuelBands as they encourage our patients (and even ourselves) to engage in more healthful and active lifestyles, but these are really just the beginning of the connected movement. Things really become interesting for physicians when patients choose to advance to the next level of technology and move from wellness tracking to disease management and diagnosis.

Beyond the Fitbit: Personal diagnostic technology

All of us encourage patients to monitor their blood pressures and blood glucose levels at home, as this can provide multiple data points crucial for proper management and medication dosing. But patients are no longer limited to just taking measurements and recording them on a paper log. Like the modern pedometers described above, BP cuffs and glucometers can now fully integrate with smartphone apps, leading to a whole new world of data integration. What’s more, the software can help patients self-manage their conditions, make recommendations on lifestyle modifications, and even suggest treatment options.

But personal medical gadgets are not just limited to upgraded versions of time-honored devices. Advancement in sensor and cloud-based technologies have paved the way for entirely new categories of diagnostic equipment. One such device, the S+ by ResMed (a respected respiratory equipment manufacturer), is a small box that sits on a bedside table. It is billed as “the first non-contact sleep sensor,” and ResMed claims it will “track and better understand your sleeping patterns, and then create personalized feedback and suggestions to help improve your sleep.” Not surprisingly, the S+ integrates with your smartphone, and even includes multiple sensors, smart alarms, and other tools to improve your sleep experience.

Another device currently in clinical trials is the Scanadu Scout, described by creators as a “medical tricorder” (an intentional reference to Star Trek). Integrating a thermometer, blood pressure sensor, pulsometer, pulse oximeter, and 2-lead EKG into a device about half the size of a hockey puck, the Scout collects and communicates data to a smartphone via Bluetooth. This could make it easier than ever for patients to compile cardiovascular data to share with their physicians, especially as a growing number of ambulatory EMRs offer the ability to submit these readings directly into the medical record through a web portal.

On a final note, we would be remiss if we didn’t mention the growing range of home blood-testing kits that offer everything from hemoglobin A_1C measurements to complete genome sequencing. All of these innovations signal a shift away from the idea of the medical home being the physician’s office, while keeping the patient squarely at the center of care delivery.

Shifting the data paradigm

Try as we might to avoid it, it is difficult for us to discuss emerging trends in medicine without mentioning Meaningful Use. Thus we feel compelled to mention that the MU Stage III proposed rule (which we will be discussing at length in future columns) includes language about connected medical devices. Under the header of “Active Patient Engagement,” the rule requires that physicians incorporate health data from nonclinical settings for 15% of patients. This leads us to ponder several questions. First, how will we handle this new onslaught of health information? How should it affect our medical decision making? And finally, what is our role as patients embrace these new technologies to take increasing ownership of their own care. Returning to the words of Voltaire we find comfort in this: “The fine art of medicine consists of amusing the patient while nature cures the disease.” Perhaps the paradigm hasn’t changed much at all. Perhaps patients have simply found new ways to be amused.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Eighteenth-century French philosopher Voltaire – amongst his many other pithy and lasting axioms – notably wrote: “God gave us the gift of life; it is up to us to give ourselves the gift of living well.” Almost 300 years later, his observation seems more salient and timely than ever. In the 21st century, we find ourselves in an era of technology unimaginable by Voltaire – one that empowers individuals to live better than ever, with tools no longer limited to the intellectual or aristocratic elite.

Accordingly, this month we thought it would be refreshing to take a break from looking back at the trials and tribulation caused by Meaningful Use in 2014, and look forward to the advantages and challenges promised by the consumer-focused health care technology market of 2015 and beyond. After all, we need only walk into the local Wal-Mart to be confronted with devices aimed at improving everything from sleep to diabetes, and our patients are clearly starting to take notice. Much more disruptive than the Internet revolution of the past 20 years, emerging technology promises not only to educate, but also diagnose, leading to an entirely different definition of “informed patients.” Like it or not, this is the new generation of “connected health,” and it is poised to reshape health care delivery in the very near future. We’ll review some of the recent innovations here.

‘Steps’ to achieve better health

While you might be challenged to recall the introduction of the mechanical pedometer by Thomas Jefferson in the 1700s, you no doubt recall the digital pedometer revolution of the 1990s. Seemingly overnight, these small belt-worn novelties began showing up on waistbands everywhere, easily confused for small pagers. Initially, the goal of owning a pedometer was simple: get to 10,000 steps a day to achieve better health. But the pedometers of today are far from simple. Now, they are worn on the wrist, or embedded in our phones, and track everything from calories burned to hours and quality of sleep. What’s more, they are integrated with health and wellness smartphone apps and often form the center of diet and fitness plans.

It’s hard to argue with the value of devices such as Fitbits and FuelBands as they encourage our patients (and even ourselves) to engage in more healthful and active lifestyles, but these are really just the beginning of the connected movement. Things really become interesting for physicians when patients choose to advance to the next level of technology and move from wellness tracking to disease management and diagnosis.

Beyond the Fitbit: Personal diagnostic technology

All of us encourage patients to monitor their blood pressures and blood glucose levels at home, as this can provide multiple data points crucial for proper management and medication dosing. But patients are no longer limited to just taking measurements and recording them on a paper log. Like the modern pedometers described above, BP cuffs and glucometers can now fully integrate with smartphone apps, leading to a whole new world of data integration. What’s more, the software can help patients self-manage their conditions, make recommendations on lifestyle modifications, and even suggest treatment options.

But personal medical gadgets are not just limited to upgraded versions of time-honored devices. Advancement in sensor and cloud-based technologies have paved the way for entirely new categories of diagnostic equipment. One such device, the S+ by ResMed (a respected respiratory equipment manufacturer), is a small box that sits on a bedside table. It is billed as “the first non-contact sleep sensor,” and ResMed claims it will “track and better understand your sleeping patterns, and then create personalized feedback and suggestions to help improve your sleep.” Not surprisingly, the S+ integrates with your smartphone, and even includes multiple sensors, smart alarms, and other tools to improve your sleep experience.

Another device currently in clinical trials is the Scanadu Scout, described by creators as a “medical tricorder” (an intentional reference to Star Trek). Integrating a thermometer, blood pressure sensor, pulsometer, pulse oximeter, and 2-lead EKG into a device about half the size of a hockey puck, the Scout collects and communicates data to a smartphone via Bluetooth. This could make it easier than ever for patients to compile cardiovascular data to share with their physicians, especially as a growing number of ambulatory EMRs offer the ability to submit these readings directly into the medical record through a web portal.

On a final note, we would be remiss if we didn’t mention the growing range of home blood-testing kits that offer everything from hemoglobin A_1C measurements to complete genome sequencing. All of these innovations signal a shift away from the idea of the medical home being the physician’s office, while keeping the patient squarely at the center of care delivery.

Shifting the data paradigm

Try as we might to avoid it, it is difficult for us to discuss emerging trends in medicine without mentioning Meaningful Use. Thus we feel compelled to mention that the MU Stage III proposed rule (which we will be discussing at length in future columns) includes language about connected medical devices. Under the header of “Active Patient Engagement,” the rule requires that physicians incorporate health data from nonclinical settings for 15% of patients. This leads us to ponder several questions. First, how will we handle this new onslaught of health information? How should it affect our medical decision making? And finally, what is our role as patients embrace these new technologies to take increasing ownership of their own care. Returning to the words of Voltaire we find comfort in this: “The fine art of medicine consists of amusing the patient while nature cures the disease.” Perhaps the paradigm hasn’t changed much at all. Perhaps patients have simply found new ways to be amused.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

With 2014 behind us, we are finally able to assess the implications of Meaningful Use Stage 2 for Eligible Professionals. It is now clear – as anticipated – that the updated criteria have presented a significant challenge to many. In fact, it is predicted that only a fraction of those who attained Stage 1 of Meaningful Use will attest for Stage 2 for the 2014 year. As a result, physicians who have received financial incentives under the program will now face penalties, and may see a real impact on their bottom lines.

If it’s any consolation, there is hope (and even some evidence) that the Centers for Medicare & Medicaid Services will make a few amendments to the Meaningful Use program over the next few months. This will allow for additional flexibility for providers, and with any luck, will mean more people qualify in 2015. In this column, we’ll highlight the proposed changes and share a few observations from the first year of Stage 2.

Here’s what’s new

On Jan. 29, 2015, CMS released a proposed rule that would adjust the reporting period for 2015 – currently set for the entire year – to 90 days. While this is the same length as 2014, it would give providers an extra 9 months to upgrade software, systems, and work-flows to attest for Stage 2. For those who were able to take advantage of the CEHRT [certified EHR technology] Flexibility and continue Stage 1 in 2014, this may be just the reprieve needed to stay on track. For those who made an unsuccessful attempt at Stage 2 last year, this just makes the second try a bit easier.

In case you are wondering, if you “miss” a year of Meaningful Use, you simply continue as if you made it. In other words, under the current rule, if you are due to start a full year of Stage 2 reporting in 2015, you are still obligated to do so even if you were unsuccessful with 90 days of Stage 2 in 2014. The proposed rule would change that, and keep everyone’s reporting period at 90 days regardless of stage or year. (Remember: A 1% per year penalty is assessed for every year an eligible professional fails to meet the requirements, up to a maximum of 5%. These penalties continue indefinitely.)

CMS is considering other changes as well. Specifically, their press release states they are looking to “modify other aspects of the program to match long-term goals, reduce complexity, and lessen providers’ reporting burdens.” As of now, it is unclear what that might include, but a review of the challenges from 2014 may point to some strong possibilities. We’ll start with a principle we’ve dealt with previously:

Interoperability is hard

The most noteworthy changes from Stage 1 to Stage 2 are all requirements to pass information into and out of the EHR. These include: making records available through a secure patient portal, the ability to communicate with patients through electronic means, and the transmission of “summary of care” documents between providers. These requirements also happen to be the most challenging for physicians, because they rely on other systems and individuals to make the connections possible.

Up to this point, EHR vendors have not prioritized adopting established standards for data transmission, and Stage 2 really brought this shortcoming to light. So much so, that CMS considered it a valid reason to invoke the CEHRT Flexibility. By “limited exception” providers could continue with Stage 1 this past year if “their referral partners [did] not upgrade to 2014 Edition Certified EHR Technology” (i.e., doctors are given a pass on the need to send “summary of care” data if there’s no one around to receive it). But secure and reliable electronic communication with other physicians is just one area of struggle. Another that is arguably more difficult is communicating electronically with patients. Compared with the challenges of interoperability, we’ve observed that:

Patient care is even harder

It’s one thing to incentivize (or penalize) physicians for adopting Health Information Technology, but it is an entirely different thing to hold them responsible for whether or not their patients choose to embrace it. Unfortunately, the 2014 Meaningful Use measures seem to do just that. With quotas for providing “secure electronic access” through a patient portal, the MU program forces physicians to engage patients on a new virtual “playing field.” This may seem like a good thing on the surface, but it has been riddled with headaches for providers and patients alike.

With the dawn of EHR portals, physicians suddenly perceive a new level of exposure. Patients can now peer into their charts and uncover unfiltered diagnosis terminology or slightly abnormal lab values that may raise unwarranted concern. As a result, physicians have become much more conscientious about documentation, but most feel this is just one more layer of complexity to slow them down. Additionally, as patients discover the convenience and immediacy of secure e-mail, more care is now being delivered outside the context of an office visit. This requires a huge time commitment from physicians and, in most cases, provides no income – and this time demand is not limited to just the doctors! Office staff have the new and unwelcome task of providing technical support to patients for website problems, lost passwords, etc. All of these underscore this final observation:

This isn’t getting any easier

We realize this last point is self-evident, but its impact is hard to quantify. With every new stage of meaningful use, new requirements aimed at making care more efficient for patients only seem to make delivery of care much less efficient for physicians. As physicians become mired in regulations and visit volumes drop, care will ultimately become less efficient for everyone. In response to these and many other issues, we are hopeful to see some significant adjustments made to the timeline and requirements of meaningful use. In the meantime, we certainly acknowledge the challenges and as always invite your feedback and comments.

Dr. Notte is an FP and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

With 2014 behind us, we are finally able to assess the implications of Meaningful Use Stage 2 for Eligible Professionals. It is now clear – as anticipated – that the updated criteria have presented a significant challenge to many. In fact, it is predicted that only a fraction of those who attained Stage 1 of Meaningful Use will attest for Stage 2 for the 2014 year. As a result, physicians who have received financial incentives under the program will now face penalties, and may see a real impact on their bottom lines.

If it’s any consolation, there is hope (and even some evidence) that the Centers for Medicare & Medicaid Services will make a few amendments to the Meaningful Use program over the next few months. This will allow for additional flexibility for providers, and with any luck, will mean more people qualify in 2015. In this column, we’ll highlight the proposed changes and share a few observations from the first year of Stage 2.

Here’s what’s new

On Jan. 29, 2015, CMS released a proposed rule that would adjust the reporting period for 2015 – currently set for the entire year – to 90 days. While this is the same length as 2014, it would give providers an extra 9 months to upgrade software, systems, and work-flows to attest for Stage 2. For those who were able to take advantage of the CEHRT [certified EHR technology] Flexibility and continue Stage 1 in 2014, this may be just the reprieve needed to stay on track. For those who made an unsuccessful attempt at Stage 2 last year, this just makes the second try a bit easier.

In case you are wondering, if you “miss” a year of Meaningful Use, you simply continue as if you made it. In other words, under the current rule, if you are due to start a full year of Stage 2 reporting in 2015, you are still obligated to do so even if you were unsuccessful with 90 days of Stage 2 in 2014. The proposed rule would change that, and keep everyone’s reporting period at 90 days regardless of stage or year. (Remember: A 1% per year penalty is assessed for every year an eligible professional fails to meet the requirements, up to a maximum of 5%. These penalties continue indefinitely.)

CMS is considering other changes as well. Specifically, their press release states they are looking to “modify other aspects of the program to match long-term goals, reduce complexity, and lessen providers’ reporting burdens.” As of now, it is unclear what that might include, but a review of the challenges from 2014 may point to some strong possibilities. We’ll start with a principle we’ve dealt with previously:

Interoperability is hard

The most noteworthy changes from Stage 1 to Stage 2 are all requirements to pass information into and out of the EHR. These include: making records available through a secure patient portal, the ability to communicate with patients through electronic means, and the transmission of “summary of care” documents between providers. These requirements also happen to be the most challenging for physicians, because they rely on other systems and individuals to make the connections possible.

Up to this point, EHR vendors have not prioritized adopting established standards for data transmission, and Stage 2 really brought this shortcoming to light. So much so, that CMS considered it a valid reason to invoke the CEHRT Flexibility. By “limited exception” providers could continue with Stage 1 this past year if “their referral partners [did] not upgrade to 2014 Edition Certified EHR Technology” (i.e., doctors are given a pass on the need to send “summary of care” data if there’s no one around to receive it). But secure and reliable electronic communication with other physicians is just one area of struggle. Another that is arguably more difficult is communicating electronically with patients. Compared with the challenges of interoperability, we’ve observed that:

Patient care is even harder

It’s one thing to incentivize (or penalize) physicians for adopting Health Information Technology, but it is an entirely different thing to hold them responsible for whether or not their patients choose to embrace it. Unfortunately, the 2014 Meaningful Use measures seem to do just that. With quotas for providing “secure electronic access” through a patient portal, the MU program forces physicians to engage patients on a new virtual “playing field.” This may seem like a good thing on the surface, but it has been riddled with headaches for providers and patients alike.

With the dawn of EHR portals, physicians suddenly perceive a new level of exposure. Patients can now peer into their charts and uncover unfiltered diagnosis terminology or slightly abnormal lab values that may raise unwarranted concern. As a result, physicians have become much more conscientious about documentation, but most feel this is just one more layer of complexity to slow them down. Additionally, as patients discover the convenience and immediacy of secure e-mail, more care is now being delivered outside the context of an office visit. This requires a huge time commitment from physicians and, in most cases, provides no income – and this time demand is not limited to just the doctors! Office staff have the new and unwelcome task of providing technical support to patients for website problems, lost passwords, etc. All of these underscore this final observation:

This isn’t getting any easier

We realize this last point is self-evident, but its impact is hard to quantify. With every new stage of meaningful use, new requirements aimed at making care more efficient for patients only seem to make delivery of care much less efficient for physicians. As physicians become mired in regulations and visit volumes drop, care will ultimately become less efficient for everyone. In response to these and many other issues, we are hopeful to see some significant adjustments made to the timeline and requirements of meaningful use. In the meantime, we certainly acknowledge the challenges and as always invite your feedback and comments.

Dr. Notte is an FP and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

With 2014 behind us, we are finally able to assess the implications of Meaningful Use Stage 2 for Eligible Professionals. It is now clear – as anticipated – that the updated criteria have presented a significant challenge to many. In fact, it is predicted that only a fraction of those who attained Stage 1 of Meaningful Use will attest for Stage 2 for the 2014 year. As a result, physicians who have received financial incentives under the program will now face penalties, and may see a real impact on their bottom lines.

If it’s any consolation, there is hope (and even some evidence) that the Centers for Medicare & Medicaid Services will make a few amendments to the Meaningful Use program over the next few months. This will allow for additional flexibility for providers, and with any luck, will mean more people qualify in 2015. In this column, we’ll highlight the proposed changes and share a few observations from the first year of Stage 2.

Here’s what’s new

On Jan. 29, 2015, CMS released a proposed rule that would adjust the reporting period for 2015 – currently set for the entire year – to 90 days. While this is the same length as 2014, it would give providers an extra 9 months to upgrade software, systems, and work-flows to attest for Stage 2. For those who were able to take advantage of the CEHRT [certified EHR technology] Flexibility and continue Stage 1 in 2014, this may be just the reprieve needed to stay on track. For those who made an unsuccessful attempt at Stage 2 last year, this just makes the second try a bit easier.

In case you are wondering, if you “miss” a year of Meaningful Use, you simply continue as if you made it. In other words, under the current rule, if you are due to start a full year of Stage 2 reporting in 2015, you are still obligated to do so even if you were unsuccessful with 90 days of Stage 2 in 2014. The proposed rule would change that, and keep everyone’s reporting period at 90 days regardless of stage or year. (Remember: A 1% per year penalty is assessed for every year an eligible professional fails to meet the requirements, up to a maximum of 5%. These penalties continue indefinitely.)

CMS is considering other changes as well. Specifically, their press release states they are looking to “modify other aspects of the program to match long-term goals, reduce complexity, and lessen providers’ reporting burdens.” As of now, it is unclear what that might include, but a review of the challenges from 2014 may point to some strong possibilities. We’ll start with a principle we’ve dealt with previously:

Interoperability is hard

The most noteworthy changes from Stage 1 to Stage 2 are all requirements to pass information into and out of the EHR. These include: making records available through a secure patient portal, the ability to communicate with patients through electronic means, and the transmission of “summary of care” documents between providers. These requirements also happen to be the most challenging for physicians, because they rely on other systems and individuals to make the connections possible.

Up to this point, EHR vendors have not prioritized adopting established standards for data transmission, and Stage 2 really brought this shortcoming to light. So much so, that CMS considered it a valid reason to invoke the CEHRT Flexibility. By “limited exception” providers could continue with Stage 1 this past year if “their referral partners [did] not upgrade to 2014 Edition Certified EHR Technology” (i.e., doctors are given a pass on the need to send “summary of care” data if there’s no one around to receive it). But secure and reliable electronic communication with other physicians is just one area of struggle. Another that is arguably more difficult is communicating electronically with patients. Compared with the challenges of interoperability, we’ve observed that:

Patient care is even harder

It’s one thing to incentivize (or penalize) physicians for adopting Health Information Technology, but it is an entirely different thing to hold them responsible for whether or not their patients choose to embrace it. Unfortunately, the 2014 Meaningful Use measures seem to do just that. With quotas for providing “secure electronic access” through a patient portal, the MU program forces physicians to engage patients on a new virtual “playing field.” This may seem like a good thing on the surface, but it has been riddled with headaches for providers and patients alike.

With the dawn of EHR portals, physicians suddenly perceive a new level of exposure. Patients can now peer into their charts and uncover unfiltered diagnosis terminology or slightly abnormal lab values that may raise unwarranted concern. As a result, physicians have become much more conscientious about documentation, but most feel this is just one more layer of complexity to slow them down. Additionally, as patients discover the convenience and immediacy of secure e-mail, more care is now being delivered outside the context of an office visit. This requires a huge time commitment from physicians and, in most cases, provides no income – and this time demand is not limited to just the doctors! Office staff have the new and unwelcome task of providing technical support to patients for website problems, lost passwords, etc. All of these underscore this final observation:

This isn’t getting any easier

We realize this last point is self-evident, but its impact is hard to quantify. With every new stage of meaningful use, new requirements aimed at making care more efficient for patients only seem to make delivery of care much less efficient for physicians. As physicians become mired in regulations and visit volumes drop, care will ultimately become less efficient for everyone. In response to these and many other issues, we are hopeful to see some significant adjustments made to the timeline and requirements of meaningful use. In the meantime, we certainly acknowledge the challenges and as always invite your feedback and comments.

Dr. Notte is an FP and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Turning and turning in the widening gyre

The falcon cannot hear the falconer;

Things fall apart; the centre cannot hold;

Mere anarchy is loosed upon the world.

–William Butler Yeats, The Second Coming

The end of this year was dizzying. As we sat and watched the ball drop on TV, announcing the New Year, we thought about the past year in practice. The year 2014 ended with a unsatisfying bang, with the new year ringing in the news that almost half of all doctors eligible for Meaningful Use bonuses on meeting Stage 2 criteria did not meet the government’s standard for the program, so instead of bonuses these physicians will have penalties. It is estimated that over 250,000 physicians will receive penalties of a 1% reduction in Medicare payment. Many physicians left the year feeling like the government had played a fancy game of three card Monte with them, getting them to pay hard-earned money for expensive EHR systems, initially letting them win a little bit, then through some slight of hand, having them lose significant amounts of cash.

While we are champions of EHRs and clearly believe that their benefits outweigh the problems they bring, we continue to empathize with our colleagues and recognize that to use the EHR efficiently and effectively requires an incredible amount of work. While we will continue to go over EHR issues large and small, as well as specific strategies for success, we thought that it would be appropriate to start the year by letting the voices of some of our readers who have taken the time to email us their thoughts express the concerns of many from whom we have heard.

Dr. Sanjay Raina, an internist from Slidell, La., wrote: “In my opinion, EHRs are still not ready for prime time. I have practiced for 18 years as a primary care physician. I was not raised in the computer/electronic gaming era nor did I type very much growing up. EHRs have many benefits, but they are cumbersome. It seems that transmission of datasets and data mining is the main use of present EHRs and that information is used to determine payments and perform reporting of quality measures.

“The main problem I have is the lack of efficiency of the systems. I have heard people say that notes take a few minutes longer now to complete. In my opinion, to claim a chart note, which would take 1-2 minutes now takes 3-5 minutes per patient, as Dr. Depietro said in a previous column, is wishful. It is also more difficult to navigate through past records in electronic charts, compared with flipping pages in a paper chart.

“The EHR seems to have made communication more difficult. Reading through consultant notes that have been generated with an EHR is cumbersome, and the main point of the consultation is often hidden. I miss the days of typed consultations mailed on professional paper that addressed the patient’s problems and made clear recommendations.

“Younger-generation physicians, if they can maintain eye contact with the patient while touch typing, will do well. Those not so familiar with touch typing have to concentrate on putting in information and will be distracted from the patient.”

Dr. Raina’s comments are reflective of many we heard – a disappointment that the EHR has not realized its potential and neither improves quality nor saves time. Another common theme is that the EHR takes more time, that it makes it difficult to find the important information in consultant notes, increases practice expenses, and makes it more difficult to connect with patients.

Dr. Melvin Monroe, a family physician in Lima, Ohio, wrote: “I recently retired after 50 years in practice, and the computer was part of the reason why. The most important negative was losing face time with the patient. To minimize the effect on patient interactions, I would write in a note pad while seeing the patient then go to the computer to do my documentation. This approach greatly reduced my productivity.”

Clearly, the sentiment expressed by our colleagues is that EHRs have not been a net positive for doctors or patients. The year ended on a frustrating note, with over 250,000 smart, capable, caring physicians – people who work hard to do the right thing – being told that they would receive government penalties for not meeting stringent criteria that they do not see as helping either them, their practices, or their patients. That is both insulting and costly, and we are not sure which feels worse. The second stanza of Yeat’s poem quoted at the beginning of this column starts off with the phrase, “Surely some revelation is at hand.” That is what we can all wish for this coming year.

Dr. Notte is an FP and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Turning and turning in the widening gyre

The falcon cannot hear the falconer;

Things fall apart; the centre cannot hold;

Mere anarchy is loosed upon the world.

–William Butler Yeats, The Second Coming

The end of this year was dizzying. As we sat and watched the ball drop on TV, announcing the New Year, we thought about the past year in practice. The year 2014 ended with a unsatisfying bang, with the new year ringing in the news that almost half of all doctors eligible for Meaningful Use bonuses on meeting Stage 2 criteria did not meet the government’s standard for the program, so instead of bonuses these physicians will have penalties. It is estimated that over 250,000 physicians will receive penalties of a 1% reduction in Medicare payment. Many physicians left the year feeling like the government had played a fancy game of three card Monte with them, getting them to pay hard-earned money for expensive EHR systems, initially letting them win a little bit, then through some slight of hand, having them lose significant amounts of cash.

While we are champions of EHRs and clearly believe that their benefits outweigh the problems they bring, we continue to empathize with our colleagues and recognize that to use the EHR efficiently and effectively requires an incredible amount of work. While we will continue to go over EHR issues large and small, as well as specific strategies for success, we thought that it would be appropriate to start the year by letting the voices of some of our readers who have taken the time to email us their thoughts express the concerns of many from whom we have heard.

Dr. Sanjay Raina, an internist from Slidell, La., wrote: “In my opinion, EHRs are still not ready for prime time. I have practiced for 18 years as a primary care physician. I was not raised in the computer/electronic gaming era nor did I type very much growing up. EHRs have many benefits, but they are cumbersome. It seems that transmission of datasets and data mining is the main use of present EHRs and that information is used to determine payments and perform reporting of quality measures.

“The main problem I have is the lack of efficiency of the systems. I have heard people say that notes take a few minutes longer now to complete. In my opinion, to claim a chart note, which would take 1-2 minutes now takes 3-5 minutes per patient, as Dr. Depietro said in a previous column, is wishful. It is also more difficult to navigate through past records in electronic charts, compared with flipping pages in a paper chart.

“The EHR seems to have made communication more difficult. Reading through consultant notes that have been generated with an EHR is cumbersome, and the main point of the consultation is often hidden. I miss the days of typed consultations mailed on professional paper that addressed the patient’s problems and made clear recommendations.

“Younger-generation physicians, if they can maintain eye contact with the patient while touch typing, will do well. Those not so familiar with touch typing have to concentrate on putting in information and will be distracted from the patient.”

Dr. Raina’s comments are reflective of many we heard – a disappointment that the EHR has not realized its potential and neither improves quality nor saves time. Another common theme is that the EHR takes more time, that it makes it difficult to find the important information in consultant notes, increases practice expenses, and makes it more difficult to connect with patients.

Dr. Melvin Monroe, a family physician in Lima, Ohio, wrote: “I recently retired after 50 years in practice, and the computer was part of the reason why. The most important negative was losing face time with the patient. To minimize the effect on patient interactions, I would write in a note pad while seeing the patient then go to the computer to do my documentation. This approach greatly reduced my productivity.”

Clearly, the sentiment expressed by our colleagues is that EHRs have not been a net positive for doctors or patients. The year ended on a frustrating note, with over 250,000 smart, capable, caring physicians – people who work hard to do the right thing – being told that they would receive government penalties for not meeting stringent criteria that they do not see as helping either them, their practices, or their patients. That is both insulting and costly, and we are not sure which feels worse. The second stanza of Yeat’s poem quoted at the beginning of this column starts off with the phrase, “Surely some revelation is at hand.” That is what we can all wish for this coming year.

Dr. Notte is an FP and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Turning and turning in the widening gyre

The falcon cannot hear the falconer;

Things fall apart; the centre cannot hold;

Mere anarchy is loosed upon the world.

–William Butler Yeats, The Second Coming

The end of this year was dizzying. As we sat and watched the ball drop on TV, announcing the New Year, we thought about the past year in practice. The year 2014 ended with a unsatisfying bang, with the new year ringing in the news that almost half of all doctors eligible for Meaningful Use bonuses on meeting Stage 2 criteria did not meet the government’s standard for the program, so instead of bonuses these physicians will have penalties. It is estimated that over 250,000 physicians will receive penalties of a 1% reduction in Medicare payment. Many physicians left the year feeling like the government had played a fancy game of three card Monte with them, getting them to pay hard-earned money for expensive EHR systems, initially letting them win a little bit, then through some slight of hand, having them lose significant amounts of cash.

While we are champions of EHRs and clearly believe that their benefits outweigh the problems they bring, we continue to empathize with our colleagues and recognize that to use the EHR efficiently and effectively requires an incredible amount of work. While we will continue to go over EHR issues large and small, as well as specific strategies for success, we thought that it would be appropriate to start the year by letting the voices of some of our readers who have taken the time to email us their thoughts express the concerns of many from whom we have heard.

Dr. Sanjay Raina, an internist from Slidell, La., wrote: “In my opinion, EHRs are still not ready for prime time. I have practiced for 18 years as a primary care physician. I was not raised in the computer/electronic gaming era nor did I type very much growing up. EHRs have many benefits, but they are cumbersome. It seems that transmission of datasets and data mining is the main use of present EHRs and that information is used to determine payments and perform reporting of quality measures.

“The main problem I have is the lack of efficiency of the systems. I have heard people say that notes take a few minutes longer now to complete. In my opinion, to claim a chart note, which would take 1-2 minutes now takes 3-5 minutes per patient, as Dr. Depietro said in a previous column, is wishful. It is also more difficult to navigate through past records in electronic charts, compared with flipping pages in a paper chart.

“The EHR seems to have made communication more difficult. Reading through consultant notes that have been generated with an EHR is cumbersome, and the main point of the consultation is often hidden. I miss the days of typed consultations mailed on professional paper that addressed the patient’s problems and made clear recommendations.

“Younger-generation physicians, if they can maintain eye contact with the patient while touch typing, will do well. Those not so familiar with touch typing have to concentrate on putting in information and will be distracted from the patient.”

Dr. Raina’s comments are reflective of many we heard – a disappointment that the EHR has not realized its potential and neither improves quality nor saves time. Another common theme is that the EHR takes more time, that it makes it difficult to find the important information in consultant notes, increases practice expenses, and makes it more difficult to connect with patients.

Dr. Melvin Monroe, a family physician in Lima, Ohio, wrote: “I recently retired after 50 years in practice, and the computer was part of the reason why. The most important negative was losing face time with the patient. To minimize the effect on patient interactions, I would write in a note pad while seeing the patient then go to the computer to do my documentation. This approach greatly reduced my productivity.”

Clearly, the sentiment expressed by our colleagues is that EHRs have not been a net positive for doctors or patients. The year ended on a frustrating note, with over 250,000 smart, capable, caring physicians – people who work hard to do the right thing – being told that they would receive government penalties for not meeting stringent criteria that they do not see as helping either them, their practices, or their patients. That is both insulting and costly, and we are not sure which feels worse. The second stanza of Yeat’s poem quoted at the beginning of this column starts off with the phrase, “Surely some revelation is at hand.” That is what we can all wish for this coming year.

Dr. Notte is an FP and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

The debate over the future of meaningful use seems to have found its bellwether issue: interoperability. For the uninitiated, this is the concept of sharing patient information across systems with the promise of improving the ease and quality of care. As you might expect, it is full of challenges, not the least of which is standardization. Competing vendors of electronic health record (EHR) software and technological hurdles have made the goal of true interoperability quite elusive, and there is no clear path to victory. Meaningful use and other incentive programs have set requirements for widespread rapid adoption of data sharing. Unfortunately, instead of encouraging innovation, they seem only to have created more stumbling blocks for physicians. Now providers are facing penalties for noncompliance, and national physician advocacy groups are taking notice.

On Oct. 15 of this year, a letter from key stakeholders including the American Medical Association (AMA), American Academy of Family Physicians (AAFP), and Medical Group Management Association (MGMA) to the Department of Health and Human Services laid out a “blueprint” for revamping the meaningful use program. The center point of this communication was a call for more emphasis on interoperability, as well as flexibility for both vendors and physicians. We tend to agree with these ideas, but wonder on a global scale what this interoperability should look like. In this column, we’ll address the essential pieces to making this a reality, and how physicians and patients can benefit from enhanced information exchange.

 Information should be standardized

One of the fundamental challenges standing in the way of true interoperability is standardization: allowing data to be shared and viewed anywhere, independent of hardware or software. This is an idea that has allowed the World Wide Web to flourish; websites are readable by any computer or mobile device, using any operating system or browser. As of now, very little standardization exists in the world of medical data, in part because EHRs have been developed and promoted by private corporations, all competing for market share.

This evolution is quite unlike the history of the Internet, which was developed by government and educational institutions, with the express intent of connecting disparate computer systems. EHRs have essentially been developed in isolation, with much more emphasis placed on keeping information private than on making it shareable. Now meaningful use is forcing vendors to share data across systems, and – not surprisingly – each vendor is attempting to create their own method of doing so.

Some argue that EHR companies would prefer not to share, as this might threaten their hold on the market. In fact, Epic Health Systems, the world’s largest EHR vendor, has recently faced accusations of limiting interoperability to encourage physicians to use its software exclusively. Epic has fired back with statistics pointing to its accomplishments in data exchange. Both sides clearly disagree on what true interoperability should look like. This underscores a critical point: The concept of interoperability and what the standards should look like may mean different things to different parties.

One attempt at standardization that is commonly referenced is the continuity of care document (CCD), a key requirement for data exchange outlined in Stage 2 of meaningful use. This document, endorsed by the U.S. Healthcare Information Technology Standards Panel, has gained popularity as it can contain large amounts of data in one file. Unfortunately, it too is still limited and often isn’t user friendly at the point of care. It is in many ways merely a jumping-off point that will hopefully facilitate improved data accessibility and ease of sharing.

To improve usability and confidence in data exchange, many practices and health systems have joined together to create Regional Health Information Organizations and provide some governance structure to the process of data exchange. We strongly recommend getting involved in such an organization and engaging in the process of standardization. Regardless of your position on the usefulness or practicality of sharing patient records, a few notions are indisputable: Interoperability is coming, and point-of-care data availability – if accurate, secure, and useful – can ultimately usher in the promise of better patient care.

Information should be secure

In the process of seeking easier data exchange, we cannot lose sight of the importance of data security. Health care entities need to feel confident the information they are sending electronically will stay private until it reaches its ultimate destination. An attempt to address this issue led to the development of the “direct” encryption standard in 2010. Also known as Direct Exchange and Direct Secure Messaging, it specifies a secure method for the exchange of Protected Health Information. Providers can take advantage of the security offered through Direct by developing their own infrastructure or engaging the services of a Health Information Service Provider. These are private, HIPAA-compliant data exchange services that serve a health care community and facilitate direct messaging between health care settings. Ultimately, the goal is to create a robust Nationwide Health Information Network and achieve true widespread health information exchange. But before we actually achieve this, there is one more element essential to interoperability and improving patient care.

The information should be useful

In the preliminary stages of EHR interoperability, attempts at meaningful information exchange have led to only modest success. Outside of private health systems that have developed their own proprietary interfaces, data extraction and sharing between disparate electronic platforms have yet to have a meaningful impact on patient care. In part, this is because the information is not provided to clinicians in a useful format. Even the CCD described above is often confusing and replete with extraneous information – filtering through it during a patient encounter can be tedious and frustrating. Also, ensuring data integrity can be a real challenge, not only technically, but also practically. Questions occur regularly, such as “Did the data come through in the correct fields?” or “Did the medical resident remember to include all of the medications or allergies associated with the patient?” Ultimately, physicians need to decide whether or not to trust the information they receive before making it a permanent part of a patient’s health record.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

The debate over the future of meaningful use seems to have found its bellwether issue: interoperability. For the uninitiated, this is the concept of sharing patient information across systems with the promise of improving the ease and quality of care. As you might expect, it is full of challenges, not the least of which is standardization. Competing vendors of electronic health record (EHR) software and technological hurdles have made the goal of true interoperability quite elusive, and there is no clear path to victory. Meaningful use and other incentive programs have set requirements for widespread rapid adoption of data sharing. Unfortunately, instead of encouraging innovation, they seem only to have created more stumbling blocks for physicians. Now providers are facing penalties for noncompliance, and national physician advocacy groups are taking notice.

On Oct. 15 of this year, a letter from key stakeholders including the American Medical Association (AMA), American Academy of Family Physicians (AAFP), and Medical Group Management Association (MGMA) to the Department of Health and Human Services laid out a “blueprint” for revamping the meaningful use program. The center point of this communication was a call for more emphasis on interoperability, as well as flexibility for both vendors and physicians. We tend to agree with these ideas, but wonder on a global scale what this interoperability should look like. In this column, we’ll address the essential pieces to making this a reality, and how physicians and patients can benefit from enhanced information exchange.

 Information should be standardized

One of the fundamental challenges standing in the way of true interoperability is standardization: allowing data to be shared and viewed anywhere, independent of hardware or software. This is an idea that has allowed the World Wide Web to flourish; websites are readable by any computer or mobile device, using any operating system or browser. As of now, very little standardization exists in the world of medical data, in part because EHRs have been developed and promoted by private corporations, all competing for market share.

This evolution is quite unlike the history of the Internet, which was developed by government and educational institutions, with the express intent of connecting disparate computer systems. EHRs have essentially been developed in isolation, with much more emphasis placed on keeping information private than on making it shareable. Now meaningful use is forcing vendors to share data across systems, and – not surprisingly – each vendor is attempting to create their own method of doing so.

Some argue that EHR companies would prefer not to share, as this might threaten their hold on the market. In fact, Epic Health Systems, the world’s largest EHR vendor, has recently faced accusations of limiting interoperability to encourage physicians to use its software exclusively. Epic has fired back with statistics pointing to its accomplishments in data exchange. Both sides clearly disagree on what true interoperability should look like. This underscores a critical point: The concept of interoperability and what the standards should look like may mean different things to different parties.

One attempt at standardization that is commonly referenced is the continuity of care document (CCD), a key requirement for data exchange outlined in Stage 2 of meaningful use. This document, endorsed by the U.S. Healthcare Information Technology Standards Panel, has gained popularity as it can contain large amounts of data in one file. Unfortunately, it too is still limited and often isn’t user friendly at the point of care. It is in many ways merely a jumping-off point that will hopefully facilitate improved data accessibility and ease of sharing.

To improve usability and confidence in data exchange, many practices and health systems have joined together to create Regional Health Information Organizations and provide some governance structure to the process of data exchange. We strongly recommend getting involved in such an organization and engaging in the process of standardization. Regardless of your position on the usefulness or practicality of sharing patient records, a few notions are indisputable: Interoperability is coming, and point-of-care data availability – if accurate, secure, and useful – can ultimately usher in the promise of better patient care.

Information should be secure

In the process of seeking easier data exchange, we cannot lose sight of the importance of data security. Health care entities need to feel confident the information they are sending electronically will stay private until it reaches its ultimate destination. An attempt to address this issue led to the development of the “direct” encryption standard in 2010. Also known as Direct Exchange and Direct Secure Messaging, it specifies a secure method for the exchange of Protected Health Information. Providers can take advantage of the security offered through Direct by developing their own infrastructure or engaging the services of a Health Information Service Provider. These are private, HIPAA-compliant data exchange services that serve a health care community and facilitate direct messaging between health care settings. Ultimately, the goal is to create a robust Nationwide Health Information Network and achieve true widespread health information exchange. But before we actually achieve this, there is one more element essential to interoperability and improving patient care.

The information should be useful

In the preliminary stages of EHR interoperability, attempts at meaningful information exchange have led to only modest success. Outside of private health systems that have developed their own proprietary interfaces, data extraction and sharing between disparate electronic platforms have yet to have a meaningful impact on patient care. In part, this is because the information is not provided to clinicians in a useful format. Even the CCD described above is often confusing and replete with extraneous information – filtering through it during a patient encounter can be tedious and frustrating. Also, ensuring data integrity can be a real challenge, not only technically, but also practically. Questions occur regularly, such as “Did the data come through in the correct fields?” or “Did the medical resident remember to include all of the medications or allergies associated with the patient?” Ultimately, physicians need to decide whether or not to trust the information they receive before making it a permanent part of a patient’s health record.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

The debate over the future of meaningful use seems to have found its bellwether issue: interoperability. For the uninitiated, this is the concept of sharing patient information across systems with the promise of improving the ease and quality of care. As you might expect, it is full of challenges, not the least of which is standardization. Competing vendors of electronic health record (EHR) software and technological hurdles have made the goal of true interoperability quite elusive, and there is no clear path to victory. Meaningful use and other incentive programs have set requirements for widespread rapid adoption of data sharing. Unfortunately, instead of encouraging innovation, they seem only to have created more stumbling blocks for physicians. Now providers are facing penalties for noncompliance, and national physician advocacy groups are taking notice.

On Oct. 15 of this year, a letter from key stakeholders including the American Medical Association (AMA), American Academy of Family Physicians (AAFP), and Medical Group Management Association (MGMA) to the Department of Health and Human Services laid out a “blueprint” for revamping the meaningful use program. The center point of this communication was a call for more emphasis on interoperability, as well as flexibility for both vendors and physicians. We tend to agree with these ideas, but wonder on a global scale what this interoperability should look like. In this column, we’ll address the essential pieces to making this a reality, and how physicians and patients can benefit from enhanced information exchange.

 Information should be standardized

One of the fundamental challenges standing in the way of true interoperability is standardization: allowing data to be shared and viewed anywhere, independent of hardware or software. This is an idea that has allowed the World Wide Web to flourish; websites are readable by any computer or mobile device, using any operating system or browser. As of now, very little standardization exists in the world of medical data, in part because EHRs have been developed and promoted by private corporations, all competing for market share.

This evolution is quite unlike the history of the Internet, which was developed by government and educational institutions, with the express intent of connecting disparate computer systems. EHRs have essentially been developed in isolation, with much more emphasis placed on keeping information private than on making it shareable. Now meaningful use is forcing vendors to share data across systems, and – not surprisingly – each vendor is attempting to create their own method of doing so.

Some argue that EHR companies would prefer not to share, as this might threaten their hold on the market. In fact, Epic Health Systems, the world’s largest EHR vendor, has recently faced accusations of limiting interoperability to encourage physicians to use its software exclusively. Epic has fired back with statistics pointing to its accomplishments in data exchange. Both sides clearly disagree on what true interoperability should look like. This underscores a critical point: The concept of interoperability and what the standards should look like may mean different things to different parties.

One attempt at standardization that is commonly referenced is the continuity of care document (CCD), a key requirement for data exchange outlined in Stage 2 of meaningful use. This document, endorsed by the U.S. Healthcare Information Technology Standards Panel, has gained popularity as it can contain large amounts of data in one file. Unfortunately, it too is still limited and often isn’t user friendly at the point of care. It is in many ways merely a jumping-off point that will hopefully facilitate improved data accessibility and ease of sharing.

To improve usability and confidence in data exchange, many practices and health systems have joined together to create Regional Health Information Organizations and provide some governance structure to the process of data exchange. We strongly recommend getting involved in such an organization and engaging in the process of standardization. Regardless of your position on the usefulness or practicality of sharing patient records, a few notions are indisputable: Interoperability is coming, and point-of-care data availability – if accurate, secure, and useful – can ultimately usher in the promise of better patient care.

Information should be secure

In the process of seeking easier data exchange, we cannot lose sight of the importance of data security. Health care entities need to feel confident the information they are sending electronically will stay private until it reaches its ultimate destination. An attempt to address this issue led to the development of the “direct” encryption standard in 2010. Also known as Direct Exchange and Direct Secure Messaging, it specifies a secure method for the exchange of Protected Health Information. Providers can take advantage of the security offered through Direct by developing their own infrastructure or engaging the services of a Health Information Service Provider. These are private, HIPAA-compliant data exchange services that serve a health care community and facilitate direct messaging between health care settings. Ultimately, the goal is to create a robust Nationwide Health Information Network and achieve true widespread health information exchange. But before we actually achieve this, there is one more element essential to interoperability and improving patient care.

The information should be useful

In the preliminary stages of EHR interoperability, attempts at meaningful information exchange have led to only modest success. Outside of private health systems that have developed their own proprietary interfaces, data extraction and sharing between disparate electronic platforms have yet to have a meaningful impact on patient care. In part, this is because the information is not provided to clinicians in a useful format. Even the CCD described above is often confusing and replete with extraneous information – filtering through it during a patient encounter can be tedious and frustrating. Also, ensuring data integrity can be a real challenge, not only technically, but also practically. Questions occur regularly, such as “Did the data come through in the correct fields?” or “Did the medical resident remember to include all of the medications or allergies associated with the patient?” Ultimately, physicians need to decide whether or not to trust the information they receive before making it a permanent part of a patient’s health record.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

In the constantly advancing world of health information technology, the buzzwords are always changing. In the 90s, HIPAA dominated the literature. In the past few years, meaningful use took over. Most recently, a great deal of attention has been paid to telemedicine. For the uninitiated, telemedicine, a.k.a. telehealth, is not simply returning patient phone calls after hours. Telemedicine is the idea of substituting in-person patient encounters with virtual ones, typically using a secure video interface. In this column, we will explore a general overview of telemedicine and consider how this new medium fits into the ever-changing landscape of patient care.

The patient will ‘see’ you now

As evidenced by the feedback we have received on previous columns, many of our readers are still reeling from the arduous task of implementing an EHR and shudder at the thought of introducing even more technology into their office workflow. Others who enjoy being on the cutting edge of medicine are eager to embrace these virtual visits. We’ve spoken to several early adopters and have learned that it can be a rewarding way to handle certain patient interactions, but telemedicine obviously isn’t right for every patient or condition. Some feel that the lack of physical presence is not conducive to handling personal conversations or conveying sensitive information. Others have met with resistance from patients who just can’t get used to the idea of hands-free care. As with anything else, there will be patients who remain skeptical, but there will also be those who prefer it.

One patient we engaged saw his physician’s choice to offer virtual visits as a huge benefit, saying that "the idea of saving the 30 minutes of driving in each direction to visit the doctor, along with avoiding the hassle of taking time off work, makes [telehealth] a perfect way to handle my blood pressure control." In this case, as with others, patients use information from devices such as home blood pressure monitors or glucometers to supplement the visit and provide objective data. As home technology advances, connected devices are becoming more sophisticated and allowing more complicated diagnostics to be done remotely. Smartphone-connected otoscopes and ECG machines are just two examples of what’s to come, and we plan to highlight some of these in an upcoming column.

Getting started: Is it safe?

There are several things to consider when getting started in telemedicine in your practice. First is hardware. In general, this is fairly straightforward as most practices are now set up with broadband Internet and computers or tablets. Obviously, a good quality webcam is essential to ensure quality communication with patients. Beyond this, it’s critical to think about the security of the video interaction.

Standard consumer video-conferencing software such as Skype and Apple’s FaceTime are not HIPAA-compliant and can’t be used for patient communications. An encrypted video portal is essential to maintain patient privacy and make sure the patient interaction remains secure. The good news is that several easy-to-use software packages exist to allow this, if the functionality is not already built in to your EHR. A quick web search for "HIPAA-compliant video conferencing" returned several low-cost examples – some that are even free for a few interactions per month. This may be a good way to see if there is interest from patients prior to a large outlay of money. But what about the question of liability?

Unfortunately, physicians in the 21st century are wired to always be concerned about the threat of litigation, and there is no question that telemedicine offers a new opportunity for scrutiny of our clinical decisions. In addition, many rightfully fear the idea of diagnosis and treatment without the laying on of hands. As of now, there is little-to-no legal precedent for the malpractice implications of telehealth visits, but Teledoc, the country’s largest purveyor of telemedicine, advertises 7.5 million members and zero malpractice claims. Whether or not this is enough to convince the skeptics remains to be seen, but so far telemedicine has seemingly managed to fly below the radar of the courts. Following the pattern of all areas of medicine, this is likely to change, but it may be prevented if physicians limit the kinds of services offered through virtual visits. Many providers, such as Teledoc, for example, do not prescribe Drug Enforcement Administration–controlled or so-called nontherapeutic medications. (If you’re wondering, Viagra and Cialis are both on this list.) In this way, they are able to avoid becoming confused with illegitimate drug fulfillment warehouses and limit encounters that might raise questions of legality.

Can I get paid for this?

Although there are many conceivable benefits to telemedicine, such as access to patients who are homebound or live in isolated rural areas, it is hard to imagine setting off down the virtual path without the promise of reimbursement. According to the American Telemedicine Association, 21 states and Washington, D.C., require coverage of telemedicine services with reimbursement at a rate on par with in-person visits, while providers in the others are left wanting. Currently, 120 members of the U.S. Congress support various bills to expand the reach and acceptance of telemedicine, according to the telemedicine association, but it’s clear there is a long way to go before telemedicine receives the full support of insurers. In the meantime, its only financial benefit may be as a marketing advantage for practices. Those who leverage this may be able to draw new business from patients seeking more options in the delivery of their care.

Are you ready?

As with all burgeoning areas of health IT, telemedicine in its early stages appears at best like science fiction and at worst like just another headache. Unlike the other buzzwords of the past few years, adoption of telemedicine seems to be less of a requirement and more of an option. It may or may not work in your practice or for your patient population. Most importantly, though, it represents one point on the continuum of care that will take on an increasingly prominent role in the consumer-driven health care market, and it may represent a boon to both patients and providers alike.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

In the constantly advancing world of health information technology, the buzzwords are always changing. In the 90s, HIPAA dominated the literature. In the past few years, meaningful use took over. Most recently, a great deal of attention has been paid to telemedicine. For the uninitiated, telemedicine, a.k.a. telehealth, is not simply returning patient phone calls after hours. Telemedicine is the idea of substituting in-person patient encounters with virtual ones, typically using a secure video interface. In this column, we will explore a general overview of telemedicine and consider how this new medium fits into the ever-changing landscape of patient care.

The patient will ‘see’ you now

As evidenced by the feedback we have received on previous columns, many of our readers are still reeling from the arduous task of implementing an EHR and shudder at the thought of introducing even more technology into their office workflow. Others who enjoy being on the cutting edge of medicine are eager to embrace these virtual visits. We’ve spoken to several early adopters and have learned that it can be a rewarding way to handle certain patient interactions, but telemedicine obviously isn’t right for every patient or condition. Some feel that the lack of physical presence is not conducive to handling personal conversations or conveying sensitive information. Others have met with resistance from patients who just can’t get used to the idea of hands-free care. As with anything else, there will be patients who remain skeptical, but there will also be those who prefer it.

One patient we engaged saw his physician’s choice to offer virtual visits as a huge benefit, saying that "the idea of saving the 30 minutes of driving in each direction to visit the doctor, along with avoiding the hassle of taking time off work, makes [telehealth] a perfect way to handle my blood pressure control." In this case, as with others, patients use information from devices such as home blood pressure monitors or glucometers to supplement the visit and provide objective data. As home technology advances, connected devices are becoming more sophisticated and allowing more complicated diagnostics to be done remotely. Smartphone-connected otoscopes and ECG machines are just two examples of what’s to come, and we plan to highlight some of these in an upcoming column.

Getting started: Is it safe?

There are several things to consider when getting started in telemedicine in your practice. First is hardware. In general, this is fairly straightforward as most practices are now set up with broadband Internet and computers or tablets. Obviously, a good quality webcam is essential to ensure quality communication with patients. Beyond this, it’s critical to think about the security of the video interaction.

Standard consumer video-conferencing software such as Skype and Apple’s FaceTime are not HIPAA-compliant and can’t be used for patient communications. An encrypted video portal is essential to maintain patient privacy and make sure the patient interaction remains secure. The good news is that several easy-to-use software packages exist to allow this, if the functionality is not already built in to your EHR. A quick web search for "HIPAA-compliant video conferencing" returned several low-cost examples – some that are even free for a few interactions per month. This may be a good way to see if there is interest from patients prior to a large outlay of money. But what about the question of liability?

Unfortunately, physicians in the 21st century are wired to always be concerned about the threat of litigation, and there is no question that telemedicine offers a new opportunity for scrutiny of our clinical decisions. In addition, many rightfully fear the idea of diagnosis and treatment without the laying on of hands. As of now, there is little-to-no legal precedent for the malpractice implications of telehealth visits, but Teledoc, the country’s largest purveyor of telemedicine, advertises 7.5 million members and zero malpractice claims. Whether or not this is enough to convince the skeptics remains to be seen, but so far telemedicine has seemingly managed to fly below the radar of the courts. Following the pattern of all areas of medicine, this is likely to change, but it may be prevented if physicians limit the kinds of services offered through virtual visits. Many providers, such as Teledoc, for example, do not prescribe Drug Enforcement Administration–controlled or so-called nontherapeutic medications. (If you’re wondering, Viagra and Cialis are both on this list.) In this way, they are able to avoid becoming confused with illegitimate drug fulfillment warehouses and limit encounters that might raise questions of legality.

Can I get paid for this?

Although there are many conceivable benefits to telemedicine, such as access to patients who are homebound or live in isolated rural areas, it is hard to imagine setting off down the virtual path without the promise of reimbursement. According to the American Telemedicine Association, 21 states and Washington, D.C., require coverage of telemedicine services with reimbursement at a rate on par with in-person visits, while providers in the others are left wanting. Currently, 120 members of the U.S. Congress support various bills to expand the reach and acceptance of telemedicine, according to the telemedicine association, but it’s clear there is a long way to go before telemedicine receives the full support of insurers. In the meantime, its only financial benefit may be as a marketing advantage for practices. Those who leverage this may be able to draw new business from patients seeking more options in the delivery of their care.

Are you ready?

As with all burgeoning areas of health IT, telemedicine in its early stages appears at best like science fiction and at worst like just another headache. Unlike the other buzzwords of the past few years, adoption of telemedicine seems to be less of a requirement and more of an option. It may or may not work in your practice or for your patient population. Most importantly, though, it represents one point on the continuum of care that will take on an increasingly prominent role in the consumer-driven health care market, and it may represent a boon to both patients and providers alike.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

In the constantly advancing world of health information technology, the buzzwords are always changing. In the 90s, HIPAA dominated the literature. In the past few years, meaningful use took over. Most recently, a great deal of attention has been paid to telemedicine. For the uninitiated, telemedicine, a.k.a. telehealth, is not simply returning patient phone calls after hours. Telemedicine is the idea of substituting in-person patient encounters with virtual ones, typically using a secure video interface. In this column, we will explore a general overview of telemedicine and consider how this new medium fits into the ever-changing landscape of patient care.

The patient will ‘see’ you now

As evidenced by the feedback we have received on previous columns, many of our readers are still reeling from the arduous task of implementing an EHR and shudder at the thought of introducing even more technology into their office workflow. Others who enjoy being on the cutting edge of medicine are eager to embrace these virtual visits. We’ve spoken to several early adopters and have learned that it can be a rewarding way to handle certain patient interactions, but telemedicine obviously isn’t right for every patient or condition. Some feel that the lack of physical presence is not conducive to handling personal conversations or conveying sensitive information. Others have met with resistance from patients who just can’t get used to the idea of hands-free care. As with anything else, there will be patients who remain skeptical, but there will also be those who prefer it.

One patient we engaged saw his physician’s choice to offer virtual visits as a huge benefit, saying that "the idea of saving the 30 minutes of driving in each direction to visit the doctor, along with avoiding the hassle of taking time off work, makes [telehealth] a perfect way to handle my blood pressure control." In this case, as with others, patients use information from devices such as home blood pressure monitors or glucometers to supplement the visit and provide objective data. As home technology advances, connected devices are becoming more sophisticated and allowing more complicated diagnostics to be done remotely. Smartphone-connected otoscopes and ECG machines are just two examples of what’s to come, and we plan to highlight some of these in an upcoming column.

Getting started: Is it safe?

There are several things to consider when getting started in telemedicine in your practice. First is hardware. In general, this is fairly straightforward as most practices are now set up with broadband Internet and computers or tablets. Obviously, a good quality webcam is essential to ensure quality communication with patients. Beyond this, it’s critical to think about the security of the video interaction.

Standard consumer video-conferencing software such as Skype and Apple’s FaceTime are not HIPAA-compliant and can’t be used for patient communications. An encrypted video portal is essential to maintain patient privacy and make sure the patient interaction remains secure. The good news is that several easy-to-use software packages exist to allow this, if the functionality is not already built in to your EHR. A quick web search for "HIPAA-compliant video conferencing" returned several low-cost examples – some that are even free for a few interactions per month. This may be a good way to see if there is interest from patients prior to a large outlay of money. But what about the question of liability?

Unfortunately, physicians in the 21st century are wired to always be concerned about the threat of litigation, and there is no question that telemedicine offers a new opportunity for scrutiny of our clinical decisions. In addition, many rightfully fear the idea of diagnosis and treatment without the laying on of hands. As of now, there is little-to-no legal precedent for the malpractice implications of telehealth visits, but Teledoc, the country’s largest purveyor of telemedicine, advertises 7.5 million members and zero malpractice claims. Whether or not this is enough to convince the skeptics remains to be seen, but so far telemedicine has seemingly managed to fly below the radar of the courts. Following the pattern of all areas of medicine, this is likely to change, but it may be prevented if physicians limit the kinds of services offered through virtual visits. Many providers, such as Teledoc, for example, do not prescribe Drug Enforcement Administration–controlled or so-called nontherapeutic medications. (If you’re wondering, Viagra and Cialis are both on this list.) In this way, they are able to avoid becoming confused with illegitimate drug fulfillment warehouses and limit encounters that might raise questions of legality.

Can I get paid for this?

Although there are many conceivable benefits to telemedicine, such as access to patients who are homebound or live in isolated rural areas, it is hard to imagine setting off down the virtual path without the promise of reimbursement. According to the American Telemedicine Association, 21 states and Washington, D.C., require coverage of telemedicine services with reimbursement at a rate on par with in-person visits, while providers in the others are left wanting. Currently, 120 members of the U.S. Congress support various bills to expand the reach and acceptance of telemedicine, according to the telemedicine association, but it’s clear there is a long way to go before telemedicine receives the full support of insurers. In the meantime, its only financial benefit may be as a marketing advantage for practices. Those who leverage this may be able to draw new business from patients seeking more options in the delivery of their care.

Are you ready?

As with all burgeoning areas of health IT, telemedicine in its early stages appears at best like science fiction and at worst like just another headache. Unlike the other buzzwords of the past few years, adoption of telemedicine seems to be less of a requirement and more of an option. It may or may not work in your practice or for your patient population. Most importantly, though, it represents one point on the continuum of care that will take on an increasingly prominent role in the consumer-driven health care market, and it may represent a boon to both patients and providers alike.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Life is short, and the Art long to learn.

–Chaucer

If you are anything like us, you still hold firmly to the notion that medicine, at its core, is an art. Sure, medicine is informed by cutting-edge sciences, such as biochemistry and molecular biology. But one can’t capture the nuances of the patient interaction by studying the Krebs cycle, nor define the motivating forces driving physicians by looking through a microscope. On the contrary, physicians are artists, much like musicians, sculptors, or dancers. And, like any of these artists, it would seem that a physician’s craft should improve through "practice," not by studying data or using a computer. So how do we reconcile this in the era of "Big Data"? How can the "ones and zeros" living deep in the "guts" of our electronic health records (EHRs) promise to revolutionize an art that has relied solely on the judgment – or gut sense – of physicians for centuries? Here we will attempt to answer these questions and ponder whether or not we really can improve the art of medicine with the help of data.

It’s more than the ‘ones and zeros’

With the right information and the proper tools to analyze it, it is possible to conceive of an improvement in our ability to care for patients. Take, for example, the prevention of malignancies. Currently, early detection of cancer relies heavily on a physician’s knowledge of – and compliance with – current cancer screening guidelines. Success also depends on a patient’s willingness to come in for annual visits to receive the instruction. If the patient doesn’t show up for a physical, or if the provider neglects to mention the need for a colonoscopy when the patient does appear, the test may go unordered (much to the patient’s relief, perhaps!). But the right tools and analytics won’t let that happen. Instead, the technology will identify the highest-risk populations with ever-improving accuracy and notify both physician and patient of the need for action. With enough data, we may even be able to make observations in trends of cancer inheritance never before possible and predict cancer long before it might be detected by conventional screening protocols.

It pays to care about the data

Physicians may not realize it, but data can have a significant financial advantage, by improving reimbursement and decreasing the overall cost of care. This can be achieved in two ways. The first way is by using the data to paint a more accurate picture of patient complexity. Medicare assigns a risk-adjusted score to patient cohorts based on the severity of their diagnoses and reimburses Medicare Advantage plans based on that score: the higher the score, the better the reimbursement. Occasionally, those additional dollars are passed along to the treating physicians. But all too often physicians do not use ICD-9 codes properly on their claims, making their patients appear less complicated and thereby receiving lower reimbursement. Through emerging data collection tools, improper coding can be identified and corrected, and missed opportunities can be discovered early enough to capture additional funds.

The second way these tools can be used leads to direct benefit to the health care system in general, through improved medical cost management. By interfacing with insurers and analyzing claims, the software can identify patients who are high utilizers and can show trends in medical costs across a community or health system. This allows providers to target certain patients or disease states around which to build cost-containment strategies and create win-win scenarios that decrease hospital readmissions, limit cost, and improve patient quality of life.

We recently learned of a great example of this. Using a population management data tool, a community health system was able to identify a geographic area in their region with a large uninsured population. This group had a disproportionately high utilization of emergency medical services and very low care quality markers (such as diabetes control, vaccination rates, etc.). Through targeted outreach based on these data, the system was able to direct individuals into low-cost, high-quality primary care sites and reduce emergency service utilization to levels below the surrounding neighborhoods. Simultaneously, the health of the community improved through better disease management and care coordination. Finally, data analytics tools uncovered additional opportunities for savings by identifying expensive brand-name drug prescriptions that could be replaced with generic drug alternatives.

A reluctant revolution

As we have lamented on previous occasions, the adoption of health care information technology is often driven by artificial external forces, such as stimulus programs or regulatory requirements. The government has routinely used incentive payments and reimbursement adjustments in order to spur widespread acceptance of EHRs. Most infamously, the Meaningful Use Regulations program has become the poster child for government involvement in direct patient care. Through the use of annual payments over a 5-year period (combined with the threat of penalties for lack of compliance), Meaningful Use has almost single-handedly enabled the Big Data revolution in health care by requiring physicians to purchase electronic health records systems and use them for population management. While seemingly a good thing, most physicians would hardly regard these systems as "meaningful." In fact, many question if there is any value in having an electronic record at all.

Whether or not their detractors admit it, EHRs do form the backbone of a new and very powerful information network – one which many believe has the power to revolutionize health care. While we certainly do not view the "data revolution" as the panacea others have claimed it to be, we do recognize that the right tools are emerging to enable physicians to learn from data and implement new, novel, and "disruptive" strategies to improve patient care.

Art is not static; the canvas, the paints, and the viewpoints change over time as experience evolves. Leonardo da Vinci furthered the world’s understanding of perspective. Pablo Picasso led a revolution in modern art. Each was different from his predecessors, and each expressed a human need to understand and portray the world in a manner consistent with his age. The same is true of our age and the art of medicine. The science has changed, as has the viewpoint and perspective from which we provide care. Our ability to record, retrieve, and understand health and disease will never be the same. But the attention to the patient is ever present. The necessity of interpreting the shifting world of health and disease to provide an empathic understanding of each patient’s individual and unique place in the world will never go away. Therein lies the Art.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference Inc., a software company that creates mobile apps.

Life is short, and the Art long to learn.

–Chaucer

If you are anything like us, you still hold firmly to the notion that medicine, at its core, is an art. Sure, medicine is informed by cutting-edge sciences, such as biochemistry and molecular biology. But one can’t capture the nuances of the patient interaction by studying the Krebs cycle, nor define the motivating forces driving physicians by looking through a microscope. On the contrary, physicians are artists, much like musicians, sculptors, or dancers. And, like any of these artists, it would seem that a physician’s craft should improve through "practice," not by studying data or using a computer. So how do we reconcile this in the era of "Big Data"? How can the "ones and zeros" living deep in the "guts" of our electronic health records (EHRs) promise to revolutionize an art that has relied solely on the judgment – or gut sense – of physicians for centuries? Here we will attempt to answer these questions and ponder whether or not we really can improve the art of medicine with the help of data.

It’s more than the ‘ones and zeros’

With the right information and the proper tools to analyze it, it is possible to conceive of an improvement in our ability to care for patients. Take, for example, the prevention of malignancies. Currently, early detection of cancer relies heavily on a physician’s knowledge of – and compliance with – current cancer screening guidelines. Success also depends on a patient’s willingness to come in for annual visits to receive the instruction. If the patient doesn’t show up for a physical, or if the provider neglects to mention the need for a colonoscopy when the patient does appear, the test may go unordered (much to the patient’s relief, perhaps!). But the right tools and analytics won’t let that happen. Instead, the technology will identify the highest-risk populations with ever-improving accuracy and notify both physician and patient of the need for action. With enough data, we may even be able to make observations in trends of cancer inheritance never before possible and predict cancer long before it might be detected by conventional screening protocols.

It pays to care about the data

Physicians may not realize it, but data can have a significant financial advantage, by improving reimbursement and decreasing the overall cost of care. This can be achieved in two ways. The first way is by using the data to paint a more accurate picture of patient complexity. Medicare assigns a risk-adjusted score to patient cohorts based on the severity of their diagnoses and reimburses Medicare Advantage plans based on that score: the higher the score, the better the reimbursement. Occasionally, those additional dollars are passed along to the treating physicians. But all too often physicians do not use ICD-9 codes properly on their claims, making their patients appear less complicated and thereby receiving lower reimbursement. Through emerging data collection tools, improper coding can be identified and corrected, and missed opportunities can be discovered early enough to capture additional funds.

The second way these tools can be used leads to direct benefit to the health care system in general, through improved medical cost management. By interfacing with insurers and analyzing claims, the software can identify patients who are high utilizers and can show trends in medical costs across a community or health system. This allows providers to target certain patients or disease states around which to build cost-containment strategies and create win-win scenarios that decrease hospital readmissions, limit cost, and improve patient quality of life.

We recently learned of a great example of this. Using a population management data tool, a community health system was able to identify a geographic area in their region with a large uninsured population. This group had a disproportionately high utilization of emergency medical services and very low care quality markers (such as diabetes control, vaccination rates, etc.). Through targeted outreach based on these data, the system was able to direct individuals into low-cost, high-quality primary care sites and reduce emergency service utilization to levels below the surrounding neighborhoods. Simultaneously, the health of the community improved through better disease management and care coordination. Finally, data analytics tools uncovered additional opportunities for savings by identifying expensive brand-name drug prescriptions that could be replaced with generic drug alternatives.

A reluctant revolution

As we have lamented on previous occasions, the adoption of health care information technology is often driven by artificial external forces, such as stimulus programs or regulatory requirements. The government has routinely used incentive payments and reimbursement adjustments in order to spur widespread acceptance of EHRs. Most infamously, the Meaningful Use Regulations program has become the poster child for government involvement in direct patient care. Through the use of annual payments over a 5-year period (combined with the threat of penalties for lack of compliance), Meaningful Use has almost single-handedly enabled the Big Data revolution in health care by requiring physicians to purchase electronic health records systems and use them for population management. While seemingly a good thing, most physicians would hardly regard these systems as "meaningful." In fact, many question if there is any value in having an electronic record at all.

Whether or not their detractors admit it, EHRs do form the backbone of a new and very powerful information network – one which many believe has the power to revolutionize health care. While we certainly do not view the "data revolution" as the panacea others have claimed it to be, we do recognize that the right tools are emerging to enable physicians to learn from data and implement new, novel, and "disruptive" strategies to improve patient care.

Art is not static; the canvas, the paints, and the viewpoints change over time as experience evolves. Leonardo da Vinci furthered the world’s understanding of perspective. Pablo Picasso led a revolution in modern art. Each was different from his predecessors, and each expressed a human need to understand and portray the world in a manner consistent with his age. The same is true of our age and the art of medicine. The science has changed, as has the viewpoint and perspective from which we provide care. Our ability to record, retrieve, and understand health and disease will never be the same. But the attention to the patient is ever present. The necessity of interpreting the shifting world of health and disease to provide an empathic understanding of each patient’s individual and unique place in the world will never go away. Therein lies the Art.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference Inc., a software company that creates mobile apps.

Life is short, and the Art long to learn.

–Chaucer

If you are anything like us, you still hold firmly to the notion that medicine, at its core, is an art. Sure, medicine is informed by cutting-edge sciences, such as biochemistry and molecular biology. But one can’t capture the nuances of the patient interaction by studying the Krebs cycle, nor define the motivating forces driving physicians by looking through a microscope. On the contrary, physicians are artists, much like musicians, sculptors, or dancers. And, like any of these artists, it would seem that a physician’s craft should improve through "practice," not by studying data or using a computer. So how do we reconcile this in the era of "Big Data"? How can the "ones and zeros" living deep in the "guts" of our electronic health records (EHRs) promise to revolutionize an art that has relied solely on the judgment – or gut sense – of physicians for centuries? Here we will attempt to answer these questions and ponder whether or not we really can improve the art of medicine with the help of data.

It’s more than the ‘ones and zeros’

With the right information and the proper tools to analyze it, it is possible to conceive of an improvement in our ability to care for patients. Take, for example, the prevention of malignancies. Currently, early detection of cancer relies heavily on a physician’s knowledge of – and compliance with – current cancer screening guidelines. Success also depends on a patient’s willingness to come in for annual visits to receive the instruction. If the patient doesn’t show up for a physical, or if the provider neglects to mention the need for a colonoscopy when the patient does appear, the test may go unordered (much to the patient’s relief, perhaps!). But the right tools and analytics won’t let that happen. Instead, the technology will identify the highest-risk populations with ever-improving accuracy and notify both physician and patient of the need for action. With enough data, we may even be able to make observations in trends of cancer inheritance never before possible and predict cancer long before it might be detected by conventional screening protocols.

It pays to care about the data

Physicians may not realize it, but data can have a significant financial advantage, by improving reimbursement and decreasing the overall cost of care. This can be achieved in two ways. The first way is by using the data to paint a more accurate picture of patient complexity. Medicare assigns a risk-adjusted score to patient cohorts based on the severity of their diagnoses and reimburses Medicare Advantage plans based on that score: the higher the score, the better the reimbursement. Occasionally, those additional dollars are passed along to the treating physicians. But all too often physicians do not use ICD-9 codes properly on their claims, making their patients appear less complicated and thereby receiving lower reimbursement. Through emerging data collection tools, improper coding can be identified and corrected, and missed opportunities can be discovered early enough to capture additional funds.

The second way these tools can be used leads to direct benefit to the health care system in general, through improved medical cost management. By interfacing with insurers and analyzing claims, the software can identify patients who are high utilizers and can show trends in medical costs across a community or health system. This allows providers to target certain patients or disease states around which to build cost-containment strategies and create win-win scenarios that decrease hospital readmissions, limit cost, and improve patient quality of life.

We recently learned of a great example of this. Using a population management data tool, a community health system was able to identify a geographic area in their region with a large uninsured population. This group had a disproportionately high utilization of emergency medical services and very low care quality markers (such as diabetes control, vaccination rates, etc.). Through targeted outreach based on these data, the system was able to direct individuals into low-cost, high-quality primary care sites and reduce emergency service utilization to levels below the surrounding neighborhoods. Simultaneously, the health of the community improved through better disease management and care coordination. Finally, data analytics tools uncovered additional opportunities for savings by identifying expensive brand-name drug prescriptions that could be replaced with generic drug alternatives.

A reluctant revolution

As we have lamented on previous occasions, the adoption of health care information technology is often driven by artificial external forces, such as stimulus programs or regulatory requirements. The government has routinely used incentive payments and reimbursement adjustments in order to spur widespread acceptance of EHRs. Most infamously, the Meaningful Use Regulations program has become the poster child for government involvement in direct patient care. Through the use of annual payments over a 5-year period (combined with the threat of penalties for lack of compliance), Meaningful Use has almost single-handedly enabled the Big Data revolution in health care by requiring physicians to purchase electronic health records systems and use them for population management. While seemingly a good thing, most physicians would hardly regard these systems as "meaningful." In fact, many question if there is any value in having an electronic record at all.

Whether or not their detractors admit it, EHRs do form the backbone of a new and very powerful information network – one which many believe has the power to revolutionize health care. While we certainly do not view the "data revolution" as the panacea others have claimed it to be, we do recognize that the right tools are emerging to enable physicians to learn from data and implement new, novel, and "disruptive" strategies to improve patient care.

Art is not static; the canvas, the paints, and the viewpoints change over time as experience evolves. Leonardo da Vinci furthered the world’s understanding of perspective. Pablo Picasso led a revolution in modern art. Each was different from his predecessors, and each expressed a human need to understand and portray the world in a manner consistent with his age. The same is true of our age and the art of medicine. The science has changed, as has the viewpoint and perspective from which we provide care. Our ability to record, retrieve, and understand health and disease will never be the same. But the attention to the patient is ever present. The necessity of interpreting the shifting world of health and disease to provide an empathic understanding of each patient’s individual and unique place in the world will never go away. Therein lies the Art.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference Inc., a software company that creates mobile apps.

Our past several columns have focused on the challenges presented by EHR technology, as viewed through the experience of our readers. The response to our request for feedback has been truly astounding, and in spite of an attempt to present a balanced perspective, there has certainly been a bias toward frustration with the current state of health IT.

But even with the challenges of today, we’ve always believed there are better days ahead. We constantly find ourselves asking: What will the future of EHRs look like, and how will the questions of today be answered by the innovations of tomorrow? Will the questions even still apply? As health care continues to evolve, will it lead the change in technology, or will advancements in technology shape the future of health care?

Recently, we had the opportunity to catch a glimpse of that future and find some answers to our questions, while attending a users’ conference presented by a major EHR vendor. As the company laid out its vision for tomorrow, several core themes were woven throughout it. We’ll attempt to highlight some of those here but will also offer this disclaimer: We left feeling encouraged overall by what we saw but certainly recognize that many might find their ideas challenging or even threatening to the way they practice. If the ideas below become reality – and it appears many already are – the landscape of medicine will be changed dramatically and hardly resemble the way it appears today. In other words, regardless of whether or not we are ready for it, change is coming and will redraw the map for the next generation of health care delivery. Here are some of the ways that will happen.

Patient engagement: Giving your patients the wheel

One of the most significant themes that ran through the conference was the idea of patient engagement. This has long been a "holy grail" in medicine, and one that seemed – at times – impossible to achieve. Any success was completely dependent on the talents of the physician and willingness of the patient, and no tools existed to help make it happen. That has completely changed. Enhancements to existing EHR software are finally putting patients at the very center of their care.

We have spoken before of web-based patient portals that allow patients to view labs and medication lists, but this is just the beginning. Now, vendors have created "apps" for iOS and Android devices, that completely integrate with the EHR. With these, patients are able to both view information and interact with their physicians in new ways. From a mobile device, a patient can now schedule an appointment, check in upon arriving at the office without interacting with the front desk, and even receive a text message when the doctor is ready to see them. They can also upload readings from connected devices, such as BP cuffs or glucometers, and see those data filter directly into the electronic medical record automatically.

Now we realize that some might see the EHR revolution as detrimental to the physician-patient relationship and accuse it of dehumanizing care. Throughout the last few months, we have received and repeatedly published those concerns. But there is no question that patients who are more engaged in their care have better overall outcomes and improved satisfaction. Also, the current generation of patients uses their smartphones for everything, eschewing paper and even their PCs for organization and communication. EHR vendors have decided to leverage this in an attempt to enhance care. For example, the new applications can remind patients about important health interventions (e.g., "You’re due for a mammogram."), and automate the process of communicating appointment reminders and health campaigns (e.g., "Get your flu shot now!").

Data: The new engine of progress

In almost every industry, information has become the currency of success. Headlines declaring that we are living in the era of "Big Data" assault us on all fronts, and health care is no exception. So many of our colleagues resent this idea, believing that the EHR has forced them to become glorified "data entry technicians." Adding to the frustration has been a limited ability to mine the data for salient information and manipulate it to improve outcomes and care outreach. But this is changing rapidly, and health IT vendors are finally placing a high priority on data collation tools to address these concerns. In response to changing trends in health policy, such as accountable care organizations and value-based care delivery, companies have developed tools that allow users to not only sort through their own data but also harness the power of a connected health network, and finally deliver on the promise of true population management and community health.

Quality: Passing the driver’s exam

Much of the confusion in health policy today stems from the seemingly countless quality incentive programs that exist at both the federal and state levels. From Meaningful Use and PCMH, to PQRS and HEDIS, it is easy to become overwhelmed by the myriad ways our care is being evaluated and monitored. Enhancements in EHR software are focusing in on quality, with the goal of streamlining and automating the process of reporting. Bringing all of those measures together, highlighting overlap, and simplifying data collection are just the first steps. Many new tools also offer suggestions for improvement and cost-benefit analyses to help providers determine which programs make financial sense, and which will end up being more trouble than they are worth.

Follow the map or take the road less traveled?

We want to again acknowledge the controversy in all of these concepts. Issues like patient empowerment and quality assessment seem in many ways to fly in the face of medicine’s tradition of physician autonomy and respect. Certainly there are those who will continue to resist complying with the above trends, and for many – especially those close to retirement – that might make good sense. But for the rest of us who are fearful that health care is becoming a commodity, we have to at least acknowledge that patients are consumers and are increasingly able to make informed decisions about how and where they purchase care. If for no other reason, that should force us to consider getting rid of our "maps" and investing in a new "GPS"; with how fast things are moving, soon there may not be time to stop and ask for directions when we get lost!

Dr. Notte practices family medicine and health care informatics at Abington (Pa.) Memorial Hospital. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial and professor of family and community medicine at Temple University, Philadelphia. He is editor-in-chief of Redi-Reference, a company that creates mobile apps. They are partners in EHR Practice Consultants. Contact them at [email protected].

Our past several columns have focused on the challenges presented by EHR technology, as viewed through the experience of our readers. The response to our request for feedback has been truly astounding, and in spite of an attempt to present a balanced perspective, there has certainly been a bias toward frustration with the current state of health IT.

But even with the challenges of today, we’ve always believed there are better days ahead. We constantly find ourselves asking: What will the future of EHRs look like, and how will the questions of today be answered by the innovations of tomorrow? Will the questions even still apply? As health care continues to evolve, will it lead the change in technology, or will advancements in technology shape the future of health care?

Recently, we had the opportunity to catch a glimpse of that future and find some answers to our questions, while attending a users’ conference presented by a major EHR vendor. As the company laid out its vision for tomorrow, several core themes were woven throughout it. We’ll attempt to highlight some of those here but will also offer this disclaimer: We left feeling encouraged overall by what we saw but certainly recognize that many might find their ideas challenging or even threatening to the way they practice. If the ideas below become reality – and it appears many already are – the landscape of medicine will be changed dramatically and hardly resemble the way it appears today. In other words, regardless of whether or not we are ready for it, change is coming and will redraw the map for the next generation of health care delivery. Here are some of the ways that will happen.

Patient engagement: Giving your patients the wheel

One of the most significant themes that ran through the conference was the idea of patient engagement. This has long been a "holy grail" in medicine, and one that seemed – at times – impossible to achieve. Any success was completely dependent on the talents of the physician and willingness of the patient, and no tools existed to help make it happen. That has completely changed. Enhancements to existing EHR software are finally putting patients at the very center of their care.

We have spoken before of web-based patient portals that allow patients to view labs and medication lists, but this is just the beginning. Now, vendors have created "apps" for iOS and Android devices, that completely integrate with the EHR. With these, patients are able to both view information and interact with their physicians in new ways. From a mobile device, a patient can now schedule an appointment, check in upon arriving at the office without interacting with the front desk, and even receive a text message when the doctor is ready to see them. They can also upload readings from connected devices, such as BP cuffs or glucometers, and see those data filter directly into the electronic medical record automatically.

Now we realize that some might see the EHR revolution as detrimental to the physician-patient relationship and accuse it of dehumanizing care. Throughout the last few months, we have received and repeatedly published those concerns. But there is no question that patients who are more engaged in their care have better overall outcomes and improved satisfaction. Also, the current generation of patients uses their smartphones for everything, eschewing paper and even their PCs for organization and communication. EHR vendors have decided to leverage this in an attempt to enhance care. For example, the new applications can remind patients about important health interventions (e.g., "You’re due for a mammogram."), and automate the process of communicating appointment reminders and health campaigns (e.g., "Get your flu shot now!").

Data: The new engine of progress

In almost every industry, information has become the currency of success. Headlines declaring that we are living in the era of "Big Data" assault us on all fronts, and health care is no exception. So many of our colleagues resent this idea, believing that the EHR has forced them to become glorified "data entry technicians." Adding to the frustration has been a limited ability to mine the data for salient information and manipulate it to improve outcomes and care outreach. But this is changing rapidly, and health IT vendors are finally placing a high priority on data collation tools to address these concerns. In response to changing trends in health policy, such as accountable care organizations and value-based care delivery, companies have developed tools that allow users to not only sort through their own data but also harness the power of a connected health network, and finally deliver on the promise of true population management and community health.

Quality: Passing the driver’s exam

Much of the confusion in health policy today stems from the seemingly countless quality incentive programs that exist at both the federal and state levels. From Meaningful Use and PCMH, to PQRS and HEDIS, it is easy to become overwhelmed by the myriad ways our care is being evaluated and monitored. Enhancements in EHR software are focusing in on quality, with the goal of streamlining and automating the process of reporting. Bringing all of those measures together, highlighting overlap, and simplifying data collection are just the first steps. Many new tools also offer suggestions for improvement and cost-benefit analyses to help providers determine which programs make financial sense, and which will end up being more trouble than they are worth.

Follow the map or take the road less traveled?

We want to again acknowledge the controversy in all of these concepts. Issues like patient empowerment and quality assessment seem in many ways to fly in the face of medicine’s tradition of physician autonomy and respect. Certainly there are those who will continue to resist complying with the above trends, and for many – especially those close to retirement – that might make good sense. But for the rest of us who are fearful that health care is becoming a commodity, we have to at least acknowledge that patients are consumers and are increasingly able to make informed decisions about how and where they purchase care. If for no other reason, that should force us to consider getting rid of our "maps" and investing in a new "GPS"; with how fast things are moving, soon there may not be time to stop and ask for directions when we get lost!

Dr. Notte practices family medicine and health care informatics at Abington (Pa.) Memorial Hospital. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial and professor of family and community medicine at Temple University, Philadelphia. He is editor-in-chief of Redi-Reference, a company that creates mobile apps. They are partners in EHR Practice Consultants. Contact them at [email protected].

Our past several columns have focused on the challenges presented by EHR technology, as viewed through the experience of our readers. The response to our request for feedback has been truly astounding, and in spite of an attempt to present a balanced perspective, there has certainly been a bias toward frustration with the current state of health IT.

But even with the challenges of today, we’ve always believed there are better days ahead. We constantly find ourselves asking: What will the future of EHRs look like, and how will the questions of today be answered by the innovations of tomorrow? Will the questions even still apply? As health care continues to evolve, will it lead the change in technology, or will advancements in technology shape the future of health care?

Recently, we had the opportunity to catch a glimpse of that future and find some answers to our questions, while attending a users’ conference presented by a major EHR vendor. As the company laid out its vision for tomorrow, several core themes were woven throughout it. We’ll attempt to highlight some of those here but will also offer this disclaimer: We left feeling encouraged overall by what we saw but certainly recognize that many might find their ideas challenging or even threatening to the way they practice. If the ideas below become reality – and it appears many already are – the landscape of medicine will be changed dramatically and hardly resemble the way it appears today. In other words, regardless of whether or not we are ready for it, change is coming and will redraw the map for the next generation of health care delivery. Here are some of the ways that will happen.

Patient engagement: Giving your patients the wheel

One of the most significant themes that ran through the conference was the idea of patient engagement. This has long been a "holy grail" in medicine, and one that seemed – at times – impossible to achieve. Any success was completely dependent on the talents of the physician and willingness of the patient, and no tools existed to help make it happen. That has completely changed. Enhancements to existing EHR software are finally putting patients at the very center of their care.

We have spoken before of web-based patient portals that allow patients to view labs and medication lists, but this is just the beginning. Now, vendors have created "apps" for iOS and Android devices, that completely integrate with the EHR. With these, patients are able to both view information and interact with their physicians in new ways. From a mobile device, a patient can now schedule an appointment, check in upon arriving at the office without interacting with the front desk, and even receive a text message when the doctor is ready to see them. They can also upload readings from connected devices, such as BP cuffs or glucometers, and see those data filter directly into the electronic medical record automatically.

Now we realize that some might see the EHR revolution as detrimental to the physician-patient relationship and accuse it of dehumanizing care. Throughout the last few months, we have received and repeatedly published those concerns. But there is no question that patients who are more engaged in their care have better overall outcomes and improved satisfaction. Also, the current generation of patients uses their smartphones for everything, eschewing paper and even their PCs for organization and communication. EHR vendors have decided to leverage this in an attempt to enhance care. For example, the new applications can remind patients about important health interventions (e.g., "You’re due for a mammogram."), and automate the process of communicating appointment reminders and health campaigns (e.g., "Get your flu shot now!").

Data: The new engine of progress

In almost every industry, information has become the currency of success. Headlines declaring that we are living in the era of "Big Data" assault us on all fronts, and health care is no exception. So many of our colleagues resent this idea, believing that the EHR has forced them to become glorified "data entry technicians." Adding to the frustration has been a limited ability to mine the data for salient information and manipulate it to improve outcomes and care outreach. But this is changing rapidly, and health IT vendors are finally placing a high priority on data collation tools to address these concerns. In response to changing trends in health policy, such as accountable care organizations and value-based care delivery, companies have developed tools that allow users to not only sort through their own data but also harness the power of a connected health network, and finally deliver on the promise of true population management and community health.

Quality: Passing the driver’s exam

Much of the confusion in health policy today stems from the seemingly countless quality incentive programs that exist at both the federal and state levels. From Meaningful Use and PCMH, to PQRS and HEDIS, it is easy to become overwhelmed by the myriad ways our care is being evaluated and monitored. Enhancements in EHR software are focusing in on quality, with the goal of streamlining and automating the process of reporting. Bringing all of those measures together, highlighting overlap, and simplifying data collection are just the first steps. Many new tools also offer suggestions for improvement and cost-benefit analyses to help providers determine which programs make financial sense, and which will end up being more trouble than they are worth.

Follow the map or take the road less traveled?

We want to again acknowledge the controversy in all of these concepts. Issues like patient empowerment and quality assessment seem in many ways to fly in the face of medicine’s tradition of physician autonomy and respect. Certainly there are those who will continue to resist complying with the above trends, and for many – especially those close to retirement – that might make good sense. But for the rest of us who are fearful that health care is becoming a commodity, we have to at least acknowledge that patients are consumers and are increasingly able to make informed decisions about how and where they purchase care. If for no other reason, that should force us to consider getting rid of our "maps" and investing in a new "GPS"; with how fast things are moving, soon there may not be time to stop and ask for directions when we get lost!

Dr. Notte practices family medicine and health care informatics at Abington (Pa.) Memorial Hospital. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial and professor of family and community medicine at Temple University, Philadelphia. He is editor-in-chief of Redi-Reference, a company that creates mobile apps. They are partners in EHR Practice Consultants. Contact them at [email protected].