Mahatma Gandhi

I think that most people don’t feel that they make much difference in the large scheme of things. The world seems much too big to really affect anything. So why really try or even care?

I’m just as guilty as anyone in this regard. But I now feel like individuals can and do make a real difference. And it isn’t just the larger than life people that matter. What I’ve come to realize is that choices we make have a consequence. For instance, our consumer decisions affect entire industries and markets. If no one did street drugs, than the violence we are seeing in Mexico related to drug cartels would go away. What types of foods we eat, grossly influence the market such as organic vs. nonorganic, farm raised salmon vs. wild caught. Americans don’t understand how much they influence the rest of the world. Every day we are faced with a myriad of decisions and choices. Every single one has a definite affect on the world. Are we making sustainable choices or are we choosing wasteful practices? We don’t have to be rich or famous to make a dent. Mahatma Gandhi freed the second most populous country through peaceful, nonviolent choices that led India into independence. His now famous quote above stands for all that he was about.

I think that it isn’t too late to change the course of human events. No one really knows the future. We need to choose what happens next. This is why I take a proactive approach to the small corner of the world that I can influence. So make good, thoughtful choices and reap the consequences!

It is not the critic who counts, nor the man who points out how the strong man stumbled, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena; whose face is marred by dust and sweat and blood; who strives valiantly, who errs and comes short again and again; who knows the great enthusiasms, the great devotions, and spends himself in a worthy cause, who at the best, knows in the end the triumph of high achievement; and who at the worst, at least falls while daring greatly; so that his place shall never be with those cold and timid souls who know neither victory nor defeat.

—Theodore Roosevelt

When I began developing ChartShare 5 years ago, I knew I faced nearly insurmountable odds. I wasn’t naïve to the fact that the big boys would get involved when they smelled the money. However, I was confident enough in my knowledge and experience with medical charting and their lack thereof that I should push ahead. I believed that the way medical professionals communicated was a highly evolved art. I knew that the large companies would largely ignore that fact. As programs have come out, I wasn’t disappointed. Large companies are driven by boards and committees, not visionary individuals. Development that has been designed and done mostly by software engineers creates feature-rich mazes. I jumped into the mix to interject an alternative that followed the lines of traditional medical model communications. Why should the learning curve for electronic medical records be so hard? The interface should be intuitive and complementary to traditional charting. With my program, I can plop a new physician down at the computer and have them charting and prescribing on their own within 30 minutes and no other training. They can access any part of the program within 1-2 clicks purely on their existing medical charting knowledge. They don’t have to have a lot of computer know how to use the system.

Whether or not I gain wide acceptance for my program is less important than the fact that I achieved many of my goals at the onset. I wanted an alternative choice that was medically familiar, comprehensive, fast and easy to use. After 5 years of pushing through the countless challenges, I can confidently say I have accomplished these goals. I hope to get the word out that there is a better choice available among the many vying for attention. My software website is not up to speed yet, but soon I will have a functional site that showcases its virtues and utility.

Software as a service has firmly planted itself into the very fabric of the internet and daily computing.  EMRs are beginning to venture into this new territory.  At first glance it makes logical sense. It is cheaper and easier to access in many ways. It sometimes comes free. It doesn’t take up valuable hard drive space and can be accessed from anywhere. What is there not to like about it?

Well for starters, beauty is only skin deep. When it comes to EMRs, there are some special considerations. Doctors are very busy people and speed and efficiency count. Using an internet based program presents some speed and reliability concerns. For now and into the foreseeable future, most practices will have a certain amount of paper to deal with. Scanning documents over the internet is a very slow process. Scanning documents directly into a server, bypassing the internet, is lightning fast. So if the EMR is an internet “service,” physician practices will likely be forced to keep a paper file due to the prohibitively slow upload ability of scanning documents in. This negates some of the appeal of EMR—going totally paperless. In my group of 12 psychiatrists who are using the paperless EMR ChartShare, it would take a fulltime scanner 2 ½ months (24/7) to scan all the paper documents currently in our system to an internet service program.  This is even if the documents were stacked in one continuous pile going in consecutively without concern for where they were stored. The speed of direct scanning into a local server is dependent mainly on the speed and capacity of the scanner.  Scanning across the internet is contingent on the capability of the internet connection speed, which is very finite. This may someday improve if everyone is on fiber optics, but that is a ways off.

There are some philosophical concerns as well. Physicians have typically always “owned” their records and have been their long term stewards. The idea of floating records out in cyberspace seems very foreign. There will be a greater need for trusting outside corporations to very private information.  I’m still not convinced that that is completely secure.  I still like owning my records, even if they are in digital form. I know where they are and how they are secured.

Having a local server is just plain faster. There is no internet lag. With multiple users, the servers can be scaled up to accommodate the load requirements. Comprehensive programs like ChartShare that do everything a clinical practice can throw at it, do better on a local server. On the business side, a good EMR tends to crunch a lot of data and perform extensive searches. This excels on well scaled local servers.

Until service software can match the speed and efficiency of local server based programs, I’m sticking with the ownership model, even if the initial cost is higher. In the long run, time is money and having a faster system will pay for itself.

With any government subsidy, strings are always attached. Reporting and rigid guidelines that may have nefarious motives will be required. Free market liberties may not be as available and will constrain innovative development. In an ideal world, finding an EMR that combines innovation and efficiency with government acceptance seems like the logical choice. But does such a choice exist? I think the rules are still enough in flux that caution is advised.

Physicians have become all too familiar with big brother. EMRs may be the perfect government tool for further scrutiny of everything documented. Keeping things at arm’s length should be a consideration.

Be cautious about handouts. Think before you leap! Keep some independence. It may cost more to take the stimulus money than it saves. Make sure the EMR is a good investment on its own. It should have enough efficiency to save on staff and supply costs to pay for itself.   Government “approved” software may or may not achieve this.

Has the government gone too far?   The newly enacted laws related to violations of privacy and security has reached unprecedented levels.  With penalties as high as $1.5 million dollars and 10 years in prison, one must take serious pause before installing an electronic medical record system.  The penalties for even inadvertent mistakes start at $250,000 for each incident!  On top of that the provider is required to be their own whistleblower to the public and patients.  I can imagine a lot of finger pointing between the vendor and the provider if something bad goes down.  It will be a lawyer hay day.

I don’t know many doctors that can absorb that kind of hit. On the one hand the current and previous administration has promoted the digitization of the medical records, but then they want to scare the crap out of us if there are any unforeseen glitches. Don’t get me wrong, security breaches are serious. But crucifying doctors and stoning them in public seems excessive.  I’m not saying there shouldn’t be penalties or consequences to poor design or a lack of precautions. I think that the size of the penalties is unreasonable and counterproductive. If we are to move forward in a new era of digital records, there needs to be some reassurance that we can still practice medicine without an overriding fear of catastrophic financial loss and criminal prosecution. All it would take is an employee who is either careless or disgruntled to allow a small or large breach and it would be game over! This gives employees a whole new retaliation tool. One can bet full well that if a breach occurs, the feds will be going after the doc and not the receptionist. This interjects a precarious dynamic within an office hierarchy.  Even if there are perfect internal rules in place to protect the privacy and security of the medical records, an employee could bypass them, causing irreparable damage to the physician. The new rule even penalizes for inadvertent breaches.  I would like to see some consideration given to circumstances and due process. There needs to be some fudge room. I would like to see the American Medical Association and other medical associations stand up to this absurd standard and repeal this one sided law in favor of more balance and equity.  I hope to see a ground swell of support to counter this government heavy handedness. Comments are welcome!

So far in my experience as an EMR developer, I’ve found that every customer has some unique wants and needs. I don’t feel that any out of the box solution can accomplish everything. EMR that is adaptable and flexible will always be in demand. This isn’t to say that there isn’t a place for out of the box programs, but a good company should be able to do both.

Consumers have come to expect custom products that can be individualized to their specific tastes. Car manufacturers, shoe companies, watch makers, eye glass vendors and bicycle brands are a few examples of this push. Apple prides itself on listening to its customers in shaping its product development. The companies that don’t do this become a thing of the past.

So in my estimation, customization is critical to EMR adoption and survival. Letting the customer be right, profits both parties. Be wary of overly rigid systems that can’t change quickly with ever evolving times.

                   

Although this seems self evident, many physicians struggle with time management. I see many doctors who say they will just do some of the office tasks to “save money.”  I recently read a blog from a psychiatrist in solo practice who had no support staff!  That means he is doing all of the office duties himself! Go ahead and do the math. If his employees made $20/hr, he would likely be losing on the order of $150-250/hr in lost revenue by virtue of missed patient billable time. Any physician who is doing any office work is leaving money on the table. Beyond just the financial loss, he or she didn’t go into medicine to be a bookkeeper! Besides, health care providers have enough on their plates trying to keep up with their clinical responsibilities.

Now that I have established the need for the physician to just practice medicine and leave the details to the low wage staff, what else would help keep the physician’s time efficient?  This is where quality practice management software comes into play. The next area of savings is to have a program that captures as much of the human workflow as possible. The biggest expense in a medical practice is payroll. Though there will likely always be a need for some humans in the office to do reception and call backs, the software program can take over many of the mundane human steps and processes. This then would save considerable overhead costs.

Lastly, the EMR should speed up the clinician’s practice, allowing an increase in productivity and satisfaction. This may be one of the harder challenges as many programmers do not understand the intricacies of a physician’s workflow. Only another physician can really understand that. A user driven development process is critical and takes a considerable amount of time and testing to pull off. In my experience doing this, it requires a lot of patience and give and take with the existing users. At the end of the day, it is rewarding to see how fast and efficiently the clinicians can use the program and enjoy practicing again.

There is a subset of psychiatrists that are sort of like cats; they resist herding.

Psychiatrists tend to be fiercely independent and solitary.

However, like other specialties, they also will form cohesive groups. Designing practice software for this demographic presents some unique challenges as a result.  Any EMR program for psychiatrists must be adaptable and flexible. The development must be driven by an insider who is intimate with the needs of the group.

Canned programs seem destined to struggle for acceptance. ChartShare was created to overcome these challenges and provide an alternative to the mass produced products currently on the market.

ChartShare was designed and created by a full time practicing psychiatrist, myself.  I took no short cuts in the development phase, which took over 5 years. The result is a program that can be used as is or be tweaked to the needs of the individual user. It is based on the experience of a large group of psychiatrists and support staff.  No software is ever finished, it will always be a work in progress, but all the major components are now in place for the consumer market. As it rolls out, the user base will continue to provide valuable feedback on its design and use. This is an exciting process for me and has been fun from the start.

The other side of cloud computing

Cloud computing is all the buzz these days!  Various entities are jumping on the bandwagon, touting its virtues. It is the next great thing. Well, in attempting to understand cloud computing, I discovered it still is in the process of being defined and comes in many forms and varieties.  If there is still a lot of vagueness to a concept, what is one jumping to?

In terms of healthcare, rapid adoption of cloud computing is a mine field waiting to happen. If EMRs were to go in this direction, I have the following questions:

1.   Who actually owns the records?

2.   Where is the physical location of the records, since by definition they exist in a virtual space?

3.   If EMR is a service, what happens if the service ends? Does the clinician lose those records?

4.   What happens if the service cost becomes prohibitive, does the clinician get the records back?

5.   Who is responsible for breaches in the cloud computing environment, the clinician or the service provider?

6.   How can the clinician be sure of the integrity, security and privacy of the cloud computing service?

7.   Who regulates cloud computing?

8.   With such a vast network, how can a cloud computing provider prevent a hacker from breaches?

9.   How fast can cloud computing handle bulk scanning of medical records?

10.                  What happens when the internet connection fails? How does a clinician access his/her records and chart then?

These are just a few of the important questions that still need to be answered. I certainly won’t be the first to venture into this arena, until some serious bugs are worked out on the design and implementation. With federal breach penalties and fines approaching  $1.5 million and prison time, I’m going to let someone else be the guinea pig.

Call me old fashion, but I still like to have the records in my possession, albeit in server form. By owning the server and the data therein, no one can take away my records (provided it is backed up). If the internet goes down (which it has), I can keep on charting via the direct connection to the local server. I can also perform high speed scanning directly to the local server at high capacity. Even when power has gone out in the building, I could keep on charting due to the backup batteries. There is nothing worse than having no charts when one is seeing lots of patients or having your business support staff grind to a halt.

Don’t get me wrong, I’m all in favor of technology and progress. I do think that we need to act cautiously as technology advances to make sure it doesn’t compromise healthcare’s integrity and security. Patients and providers get very nervous if this is eroded in any way. I will be the first to embrace advances in technologies when they have a proven track record of user friendliness, security, privacy and well defined ownership. These were high on my list when designing and implementing ChartShare.

Design is everything!

Design occurs either intentionally or unintentionally. Read the following except from Cradle to Cradle by William McDonough & Michael Braungart, Chapter One p18:

“Imagine that you have been given the assignment of designing the Industrial Revolution—retrospectively. With respect to its negative consequences, the assignment would have to read something like this:

Design a system of production that

·        Puts billions of pounds of toxic material into the air, water, and soil every year

·        Produce some materials so dangerous they will require constant vigilance by future generations

·        Results in gigantic amounts of waste

·        Puts valuable materials in holes all over the planet, where they can never be retrieved

·        Requires thousands of complex regulations—not to keep people and natural systems safe, but rather to keep them from being poisoned too quickly

·        Measures productivity by how few people are working

·        Creates prosperity by digging up or cutting down natural resources and then burying or burning them

·        Erodes the diversity of species and cultural practices

Of course, the industrialists, engineers, inventors, and other minds behind the Industrial Revolution never intended such consequences. In fact, the Industrial Revolution as a whole was not really designed. It took shape gradually, as industrialists, engineers, and designers tried to solve problems and to take immediate advantage of what they considered to be opportunities in an unprecedented period of massive and rapid change.”

This is not unlike what is going on in the race for EMR supremacy. Many programs are created out of immediacy with less thought given to the overall design. If we are not careful we could end up with solutions we didn’t bargain for. We may have workflows that make little sense to the end user. We may waste valuable resources, money and time with faulty design.

Design should be thoughtful and calculated. The end users should drive the process, not the other way around. This is what motivated me to spend the last 5 years developing ChartShare, a user driven EMR. The final design is relevant to clinicians and is simple to use. In all fields, the best software programs are easy to use, even if they are feature rich. The best programs all seem to have one thing in common—they are built around the user. This is Apple’s core philosophy.

Unlike the Industrial Revolution, we still have time to get this one right. I have put my program out there as an alternative choice to the mass produced versions we have been inundated with. I don’t think the new industrialists necessarily have it right either.

I hope we don’t repeat the mistakes of the past. We need to make sound choices now that reward good design over piece meal and rushed development.

1. You are losing a ton of money staying in the paper world.
   Practice overhead can be an unchecked plague. In the paper world, it takes a lot of time and money just to understand the time and money. Paper based systems are prehistoric and it amazes me how inefficient medical businesses are. I don’t think many physicians even know their true numbers very well and can’t generate them in real time. Business decisions are heavily influenced by the office staff, rather than the commander and chief. It is the tail wagging the dog. I wanted to know what my numbers were in their entirety, in real time! That is how a business is run. Overhead is the biggest single expense to a practice.
2. You are dependent on programs and methods dictated by large hospitals.
   Autonomy was one of the primary appeals to me for going into medicine, which afforded me the chance to have my own business and be my own boss. I recognized the movement towards electronic paperless systems, which on the one hand I embraced, but was leery of the trends. I saw vendors popping up that were designed and driven by the IT community and larger hospital interests that didn’t fulfill my needs as an independent practitioner. I felt very small when I began to review existing programs. My way of life seemed threatened.
3. Your current electronic system was not designed by a seasoned practitioner.
   I’m fiercely independent and loyal to the time honored medical model. I definitely wanted a say on how the bold new world of electronic health records were used and accessed. I felt that only seasoned clinicians were qualified for such an endeavor. I was appalled by the number of programs that ignored this critical piece. I felt somewhat like a deer in headlights. I was determined to not take a passive role, but to commit to developing a relevant program for the clinical environment. I wanted a program that was an intuitive reflection on how we actually practice and communicate in medicine. My design relied more on my unconscious practice habits, than on copying existing flawed programs. My template for design was mapped out based on years of user pathways, look and feel. I wanted any trained clinician to login and go.
4. You waste a lot of time looking for patient information.
   One of my daily consternations is the useless, wasteful search for patient information. I’m a highly (somewhat) paid specialist, that is reduced to meaningless hours of clerical time. I get to ask constantly on the chart’s whereabouts, or where is that lab again? Timeliness of notes and signatures is another source of irritation. Managed care and for profit models demand more for less. Getting back some of that time is precious.
5. You are a slave to your practice.
   For as much time as I spent away from home and pleasures, I wanted my job to be fun! I wanted technology to be MY slave, not the other way around. When I’m with a patient, I want my notes and other’s notes at my finger tips. I wanted to generate prescriptions in the most efficient way possible. I wanted to create notes in the fastest, most flexible ways possible in real time. I didn’t want just one path. I also wanted to easily recognize the chart and have the same look and feel that I had become accustomed to for many years. I had become cynical with medicine and I think it reflected back to my patients. I wanted to be genuinely happy with being there.

While every EMR claims to be “developed by physicians,” the real truth is that the vast majority of EMR’s are built by computer engineers according to their own vision of the patient management process. Conversely, the thrust behind ChartShare is Dr. David Kent, MD, a veteran psychiatrist who has spent the past several years in searching for the right EMR for his clinical and hospital practice. Because our development process has strictly adhered to the “medical model,” you will see the difference immediately. ChartShare understands that there are no shortcuts in patient management and has effectively enhanced the logic of the current methodology in an incredibly powerful software tool.

Chartshare is the most comprehensive patient management system on the market:

• Familiar Charting interface to anyone practicing medicine.
• One click and hotkey access to critical chart locations.
• Innovative dictation methodology allows user to peruse entire chart while simultaneously dictating, pausing or rewinding when needed, mimicking what occurs with paper chart reviews.
• Option of typing, writing or dictating notes. Voice recognition software easily integrated.
• Paper conversion to electronic is fast, direct and easy to learn with its integrated scanning program..
• Printing is intuitive with every page having a print function.
• Medications are easily organized and prescribed. Prescriptions can be handled via printout, fax or e-prescription. Current medications, past medications and med logs are all features fully integrated in the program. Past prescriptions can also be duplicated with one click to create a new prescription.
• All documentation activities of any kind are time stamped with date and time.
• When a patient chart is opened, it automatically opens up to the last completed progress note, paralleling what naturally happens with paper charts.
• Labs can be scanned in or interfaces with current lab providers created. Lab requisitions are integrated in the program and electronic interfaces can be created with contracting labs.
• Patient photos can be stored and displayed in the chart. Facesheets are easily updated and populate where needed in the chart.
• Billing, collections and scheduling are fully integrated.
• Permissions are granted by an assigned security administrator and can be updated at any time. ChartShare has extensive security and privacy levels, all customizable to the user.
• Audit logs provide detailed information on logins, chart access and any unsuccessful login attempts.
• Patient lookup can occur in multiple ways, even with only partial information.
• Psych evals can be produced via dictation, typing or writing depending on the preference of the user.
• Progress notes also can be dictated, typed or handwritten directly via tablet pc or scanned in. A time saving formatted progress note option also allows some shortcuts with the current meds, side effects, diagnosis, allergies and most commonly used billing code already integrated in the note. Audio files are visible upon dictation, providing a real time note until dictation returns.
• ChartShare has an internal, private, e-mail like messaging system that allows efficient communication between all system users. The message system is visible across the top of the screen and a ticker tells the user at all times how many read and unread messages, needed authentications and deleted messages are present. A split screen appears when the message box is open, with authentications on one side and messages on the other. As authentications are selected, they link directly to the patient and record type that need a signature. When the note is signed and saved, it automatically removes it from the authentication list. Signature pads are utilized to provide real signatures in the patient record which are then time stamped. The messaging system has more security than regular e-mail which are subject to hackers. Staff can alert providers about patient communications, thus eliminating paper messages.
• Outside records can be scanned into the Outside Records tab.
• Letters generated either by the provider or from an outside source can be stored in the Letters tab.
• Insurance cards can be easily scanned in to Insurance tab and continuously updated as needed. Notes can also be created by staff when needed.
• A Patient Education tab allows links to needed information either for the provider or the patient such as med education, APA website pamphlets, etc.
• Group call schedules can be posted in the On Call tab for easy access by those who need to know.
• Clinic rules, bylaws, protocols, community resources can be posted for easy access.
• Coverage of patients can be easily reassigned when needed.
• Accidental duplicate charts can be closed.
• Inactive, deceased, terminated, self-terminated and one time consults can be placed on an inactive list of charts.
• Secure remote access allows complete charting from anywhere when needed.
• Session logout can be set for a period of inactivity.
• An acknowledgement and addendum tab appears on every page where notes are possible allowing needed authentication and additional notes.
• Patient signatures can be obtained for prescription pickups, consents and releases and any other needed acknowledgements.
• Reports can be generated on any text based data.
• Medical and psychiatric problem lists can be stored, displayed and modified.
• Allergy/Adverse reactions list can be stored, displayed and modified.