The Physicians New Assistant: An Electronic Patient Manager

1
The Physicians New AssistantAn Electronic
Patient Manager

• Massachusetts Software Internet Council
• Business Opportunities in Bio-IT
• Newton Marriott 10/18/02
• Thomas E. Sullivan, M.D.President-elect, The
  Massachusetts Medical SocietyChair, Partners
  Healthcare Confidentiality Committee Chair,
  AMA eMedicine Advisory Committee

2
Speakers Background

• 33 years of practice experience, both solo
  and group, Internal Medicine and Cardiology, in
  community hospital with academic affiliations,
  and leadership in managed care settings. Local
  and national involvement in organized medicine.

3
The Premise-A Software Developers Challenge

• Physicians are very busy and under constant
  pressure to perform. They will NOT change
  behavior, unless the new workflow is clearly
  more efficient on a personal, individual level

4
Incentives to Change Behavior

• Achieve greater efficiency (aka improves
  workflow - encompasses all others)
• Reduce error rate
• Practice better medicineimproved outcomes
  require the capacity to query personal practice
  patterns and benchmark individual performance.

5
Incentives to Change Behavior 2

• Increase patient satisfaction
• Automate collection of satisfaction surveys
• Develop automated patient history taking
• Group practice demands sharing information with
  multiple colleaguesmuch easier with an EMR.
• Managed care capitation demands for population
  based practice

6
Incentives to Change Behavior 3

• Comply with demands from statutory agencies and
  voluntary organizations
• New requirements for documentation of care
• NCQA National Committee On Quality Assurance
• AMAP/Physician Consortium for Performance
  Improvement
• HIPAA Health Insurance Portability and
  Accountability Act
• JCAHO Joint Commission for the Accreditation of
  Healthcare Organizations

7
A Typical Physicians Daily Workflow/Practice

• Follow the physicians footsteps and analyze each
  segment to determine whether its better to
  automate or remain manual
• The morning routine - The Computer is always on
  - broadband at home.
• The Hospital - rounds, new admits, meetings,
  surgery.. .
• The Office - the customized desktop, digital
  dashboard or my portal working seamlessly
  with patient visits.
• On Call - the need for ubiquitous computing
  -mobile devices - the wireless PDA as an option -
  cell phones on steroids.

8
Working with Nurses

• Success in getting physicians to use computers
  includes close collaboration in planning, design,
  implementation and revision of the system. IMHO
• Documentation leans toward tables, columns, and
  spreadsheets... versus..
• Communication - which leans toward narration and
  free text data entry.
• Flexibility is key!

9
Physicians..Why, the Internet?

• Information at your fingertips
• Anywhere, anytime on any device Sun
• Where do you want to go today? Microsoft
• The NLMs contribution to slogans
• The More You Know, the Better You Heal
• Beware, the Yahoo Factor
• Digital Daydreaming

10
Physicians, Why the Internet 2

• Clem McDonald, M.D. et al. On Canopy Computing
  
• The rain forest canopy is a seamless web through
  which arboreal creatures efficiently move to
  reach the edible fruits without any attention to
  the individual trees. Individual health care
  computer systems are rich with patient data, but
  rather than a canopy linking all the trees in the
  forest, the data fruit come from a diverse
  forest of individual computer trees --
  laboratory systems, word processing systems,
  pharmacy systems and the like. These different
  sources of patient information are difficult or
  impossible to reach by individual physicians,
  especially from their offices. The World Wide
  Web and other standardization technology provide
  physicians and

11
Physicians, Why the Internet? 3

• their institutions the tools needed for seamless
  and secure access to their patients data and
  medical information, when and where they need it.
  We and others have adopted these tools to
  combine independent sources of clinical data.
  Physicians who assist in the purchase of clinical
  information systems should demand products in
  their practice settings that are Web enabled, use
  standard coding systems, and communicate with
  other computers via broadly accepted protocols.
• JAMA 19982801325-1329

12
The Physician Portal an Internet Creature

• A Customized Front Page with many options, e.g.
  my Yahoo
• A Thumbnail view of the office schedule,
• Urgent alerts and reminders, lab, etc. results
• Medical or other news, investment info, weather,
  medical journal e-mailed TOC
• PubMed/Medline/other search window
• Is it affordable?

13
The MMS Committee on Information Technology

• Charter and Mission - not for profit - vendor
  neutral
• Annual Goals and Objectives
• The Internet Free
• The MMS Outpatient Formulary Guide
• The CPR Challenge aka bakeoff

14
MMS Mission Statement

• The Massachusetts Medical Society was established
  as a professional association of physicians by
  the Commonwealth of Massachusetts in an Act of
  Incorporation, Chapter 15 of the Acts of 1781.
  Section 2 of that Act states
• "The purposes of the Massachusetts Medical
  Society shall be to do all things as may be
  necessary and appropriate to advance medical
  knowledge, to develop and maintain the highest
  professional and ethical standards of medical
  practice and health care, and to promote medical
  institutions formed on liberal principles for the
  health, benefit and welfare of the citizens of
  the Commonwealth."

15
The Massachusetts Medical Society and NEJM
Approach

• The New England Journal of Medicine Online
• Web component available April 1996
• Full text launched August 1998
• 52,600 full text access - 65,000 TOC/e-mail -
  683,000 page views weekly (early 1999 stats)
• Free to developing nations free after 6 months
  elsewhere.

16
Internet/Medical Issues

• Quality, Access and cost efficiency of healthcare
• Physician work habits, lifestyle and satisfaction
• Secure e-mail
• Organizational attitudes, and priorities
• Major changes ahead
• Security and HIPAA Implementation

17
A Non Physician View

• The Massachusetts Medical Society CIO Perspective

18

• Administrative and financial transactions
• Online searching for health information
• Searches of medical literature
• Downloading of educational videos
• Search for a clinician or health plan
• Participation in chat and support groups
• Online access to personal health records
• Completion of patient surveys
• Routine care delivery (e.g., e-visits) and
  chronic disease management (e.g., periodic
  reports on health conditions to clinicians)
• Reminders and alerts decision support systems
• Consultations among clinicians (perhaps involving
  manipulation of digital images)
• Remote monitoring of patients in home and
  long-term care settings
• Transfer of medical records and images
• Remote and virtual surgery
• Videoconferencing with real-time sharing of
  documents
• Enrollment of patients
• Scheduling of appointments
• Billing for services, payment of providers
• Certain aspects of clinician credentialing

19

• Health services, biomedical, and clinical
  outcomes research
• Videoconferencing among public health officials
  during emergency situations
• Incident reporting
• Collection of information from local public
  health departments
• Surveillance for emerging diseases or epidemics
• Transfer of epidemiology maps or other image
  files for monitoring the spread of a disease
• Delivery of alerts and other information to
  providers and health workers
• Accessing reference material
• Distance education with real-time transmission of
  lectures or prerecorded videos
• Real-time consultations with experts about
  difficult cases
• Virtual classrooms, distributed collaborative
  projects and discussions
• Simulation of surgical procedures
• Virtual exploration of three-dimensional
  environments
• Health services research using administrative and
  clinical data
• Searching of remote databases and professional
  literature
• Collaboration among researchers, peer review,
  interactive virtual conferences
• Control of experimental equipment, such as
  electron microscopes, visual feedback from remote
  instrumentation
• Real-time monitoring of compliance with protocols
• Transfer of large datasets between computers for
  high-speed computation and comparisons