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The HIT innovator’s challenge: Knowing when to lead and when to follow

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Dr. John Halamka
I've written many blog posts about our efforts along the path to ICD-10 that will enhance our inpatient clinical documentation.  We're hard at work planning the improvements we think are foundational to support care coordination, compliance, and quality measurement goals.

It's very challenging to create tools which simultaneously enable rapid, accurate, and complete clinical documentation.   We've deferred radical redesign of inpatient documentation for several years awaiting the alignment of technology, policy, and urgency to create the perfect storm for innovation.

BIDMC has had many firsts - early personal health record adoption, first in the country attestation for meaningful use, innovation in the use of web-based provider order entry, rapid adoption of iPads, and one of the first vendor neutral image archives.

Sometimes we're a leader and sometimes we're a follower.  Deciding which to be is the innovator's challenge.

BIDMC decided to ignore the entire client/server era in the mid 1990's.   As others were creating Visual Basic, Filemaker Pro, Delphi, and Access front ends to applications, we continued the use of roll and scroll terminal emulators.  When the web appeared, we jumped in with both feet and moved all our clinician facing applications to thin client, cloud hosted, web-service architectures in 1998.  That approach has served us well.   It still feels modern in 2013.

Recently we completed the implementation of a next generation electronic medical administration record (EMAR) using iPhones, iPads, and an Amazon-like shopping cart motif for choosing medications.   In the past, other organizations were first with EMAR designs, but they had to use computers on wheels and cumbersome user interfaces because the technology was not quite ready for a more streamlined approach.

We feel the same way about clinical documentation.   Offering clinicians an enhanced word processor does not result in orderly, complete, and readable documentation.   On the other hand, forcing structured input of every clinical observation may yield high quality data but usability will be poor.   We're working with 4 different companies to create next generation documentation tools that we think will benefit inpatient documentation the same way that waiting for the iPhone/iPad benefited EMAR.

Characteristics of this new approach include:

  • Natural Language Processing - the ability to prospectively or retrospectively identify key concepts in unstructured text
  • Clinical documentation improvement - the ability pop up templates just in time that offer structured input in the middle of unstructured text i.e. laterally and specific bone names for fractures
  • Vocabulary crosswalks - linkage between problem lists, documentation, and billing diagnoses based on mapping SNOMED-CT to ICD-9,ICD-10, and CPT.
  • Metadata markup - near real time SNOMED-CT markup of unstructured data so that structured clinical concepts are embedded within typed or dictated documents
  • Computer assisted coding - suggesting ICD-10 codes to clinicians or coders based on the markup in current notes combined with structured data extracted from past notes

Also, we've considered social documentation  (group authoring) and patient generated data.

As with many IT innovations our stakeholders will feel that we lag existing commercial products while we're in the midst of developing these new ideas.   However, once we go live with the finished product, incorporating cutting edge built and bought technologies, no one will remember the days of the hybrid medical record that today includes many electronic features but paper-based progress notes.  

Although the paperless hospital is about as realistic as the paperless bathroom, we will substantially reduce paper on our inpatient units in the next 18 months.  As a CIO, I look forward to the day when we've closed the last gap in our self built systems compared to commercial EHRs so that our users can revel in the innovation rather than describing the greener grass available elsewhere.   Luckily, we're as good as our latest go live and we're confident now is the time to implement advanced approaches to clinical documentation.  Tolerating impatience until technology, policy, and urgency align is what makes an innovator successful.

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Dr. John D. Halamka

By Dr. John D. Halamka

Dr. John D. Halamka is chief information officer and dean for technology at Harvard Medical School who writes at Life as a Healthcare CIO.
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