This week we’re taking a break from all things serious and complex, specifically MACRA and MIPS. The big players Terry Ketchersid and Diana Strubler are going to rest in the fieldhouse and this week will be a fun, halftime pause in the MACRA Super Bowl. Think of this blog post as Katy Perry singing “Roar” on a golden lion puppet or maybe old school Paul McCartney singing “Hey Jude”. Put your feet up and get ready for Thanksgiving turkey, fun family time, and backyard football. All you have to think about while reading the blog this week is your cell phone; so, don’t worry, be happy.
Old school EHR
Recently I was on a call with a group of nephrologists as they began the transition to a new EHR. The nephrologists were looking at templates for HPI and ROS documentation, but the templates were not helping them say what they wanted to say. One physician finally asked for a large text box to type out sentences. While that seems more natural, it doesn’t facilitate clinical data capture. During this EHR call the physicians were taught how to custom-build macros to drop into templates. Documentation in the new EHR seemed cumbersome, uninspiring, and—at the end of the day—not a completely accurate documentation of the encounter.
Vital new directions
The October 25 issue of JAMA published 19 viewpoint articles from the National Academy of Medicine’s (formerly the Institute of Medicine) Vital Directions for Health & Health Care policy initiative. The policy documents 19 “priority focus areas” for U.S. health care reform with these 3 overarching themes:
- Better health and well-being
- High-value health care
- Strong science and technology
The U.S. spends 25% of the federal budget on health care, exponentially more than is spent on education, the environment, and energy combined. Not only is this expense unsustainable, the quality of care is not commensurate with the expense. The National Academy of Medicine (NAM) committee notes that U.S. healthcare is “reactive, isolated, episodic care” suited to acute care, but integrated continuous and holistic care delivery is needed to support wellness and chronic care. The NAM identifies 5 domains that influence health and wellness:
- Biological predispositions
- Social circumstances
- Physical environment
- Behavioral patterns
- Access to health care
Health Information Technology (HIT) is key to continuous care that touches all of these health determinant domains, but so far HIT is falling short of supporting such care. EHR incentives have pushed health systems and providers to electronic data capture, but key attributes are missing, including connecting health care data across a continuum of services, being patient-centered, and engaging patients. Today HIT lacks accessibility, functionality, and interoperability. Writing in JAMA about the next phase of HIT, Jonathan Perkins identifies key HIT features:
- Data standards for interoperability
- The ability to incorporate patient-generated data
- A common, universal patient ID
- Web-based services that accept “layers” of software applications
- A large, strong HIT workforce to collect, locate, analyze, and use data as part of a “learning health system”
An apple a day
Layering software applications (apps) onto a base EHR and incorporating patient-generated data may be just what the doctor ordered for HIT. As part of a commentary in Cell Systems, prominent health informatics experts note that apps may revolutionize the functionality of traditional EHRs. Instead of relying on a single vendor to provide ongoing enhancements, third-party IT innovation from many and varied vendors can offer modular IT solutions. Apps can enhance data mash up and visualization and facilitate intake and incorporation of data from patient devices. Imagine adding functionality to your EHR by shopping from an app store.
Healthcare services, software, and apps from IBM, Google, and Apple are already impacting the HIT space in refreshing ways. Released in 2015, the Apple ResearchKit is open source software that enables medical researchers to create iPhone apps. This video shows how it works and how it solves some research problems, including making patient recruiting more robust, supporting a shift from subjective to objective data, increasing the frequency of data collection, and improving communication flow with patients. By leveraging a personal mobile device like an iPhone, patients can input data and the mobile device can capture data second by second if desirable.
One year after the ResearchKit release this video shows the use of iPhone apps to enhance research in interesting and compelling ways. Duke researchers note that autism is apparent at 18 months, but the median age of diagnosis is 5 years. They created an “Autism and Beyond” app, with questionnaires and videos. While a child watches the video, the iPhone camera records facial features. For research purposes the data input and video are paired with an algorithm that is designed to predict the likelihood of autism or other developmental disorders. The hope is that a simple mobile device may become a screening tool for autism.
The Parkinson’s mPower app developed by Sage Bionetworks with the Robert Wood Johnson Foundation funding allows Parkinson’s disease patients to contribute to research without a clinic visit. The app includes a tapping activity on the phone that measures tremors and a voice-recording app that can measure vocal cord function. By putting the iPhone in a pocket while walking, the accelerometer can be used to record gate impairment.
The Johns Hopkins research team created the EpiWatch app for the Apple Watch. This research supports patient tracking of medications as well as capturing physiologic data to monitor seizure activity for people with epilepsy. The aim is to develop app tools that anticipate seizures, estimate duration, and notify family or caregivers using the mobile device.
Today you can use your iPhone to manage your health without participating in a formal research project. The Apple Health app helps you collect data about fitness, sleep, nutrition, and mindfulness, and it facilitates uploading medical records and storing or sharing them with other health care providers.
Imagine many people contributing to research using a personal mobile device. Imagine all of us tracking our own health and bringing data into the health system EHR. Imagine having intuitive health care apps for physicians that capture data quickly and clearly. Imagine finishing your day with insightful data visualization of your patient population that highlights patients who are outliers and need more support. Imagine sending those patients a secure message to make sure they take their morning meds and reminding them to send you their morning weight and blood pressure. It may all come true. Enjoy a restful, hopeful Thanksgiving holiday and don’t worry, be ‘app-y!
Dugan Maddux, MD, FACP, is the Vice President for CKD Initiatives for FMC-NA. Before her foray into the business side of medicine, Dr. Maddux spent 18 years practicing nephrology in Danville, Virginia. During this time, she and her husband, Dr. Frank Maddux, developed a nephrology-focused Electronic Health Record. She and Frank also developed Voice Expeditions, which features the Nephrology Oral History project, a collection of interviews of the early dialysis pioneers.
Top image from www.canstockphoto.com