Don't let EMRs cut into your doctor-patient time Technically Speaking. By Pamela Lewis Dolan, AMNews staff. Posted Sept. 21, 2009. Paul Roemer is in the health care technology business, but even he had a hard time dealing with what a computer screen was doing to his doctor. Roemer, managing partner of Downington, Pa.-based consultancy Healthcare IT Strategy, noticed that his cardiologist, who normally looked him in the eye during a visit, instead barely glanced up from the computer resting on a small desk in the corner of his exam room. "We could have done the whole thing via WebEx," an online conferencing site, Roemer said. "It was disappointing." Roemer's complaint is common among patients whose doctors bring information technology into their practice, particularly when the systems require physician input. Studies have found that patients who feel rushed through an exam have lower satisfaction rates than those who feel their physicians spent an appropriate amount of time with them. And not maintaining eye contact is an easy way to make a patient feel rushed, experts say. The computer does not have to get in between you and your patient. Experts and doctors with technology experience have come up with various strategies to make sure the screen doesn't overtake the physician's attention. One easy-to-implement strategy: acknowledging the technological elephant in the room. Letting patients know that because of the computer you might not be making constant eye contact with them can make patients feel more at ease, said Lyle Berkowitz, MD, medical director of clinical information systems for Northwestern Memorial Physicians Group in Chicago. When he first started with EMRs in 2002, Dr. Berkowitz was on the other end of the experience Roemer had with his cardiologist. Dr. Berkowitz' patient stopped him in the middle of the exam and asked him to stop paying so much attention to the computer and focus more on her. Dr. Berkowitz said he used the opportunity to explain to the patient the advantages of having the computer and how it helped him do his job. He told her the computer was checking for possible drug interactions and was creating a record that could be accessed by another doctor if she ended up in the hospital. He also told her it was helping him create an accurate record of the care she received. His response satisfied the patient and he continued the exam. Even now, he says he will still occasionally say to a patient, "I promise I am listening to you very intently, I just need to need to look something up on here so go ahead and tell me what's going on." Using the computer for documentation tells the patient, "I am not just saying it, I am writing it down," Dr. Berkowitz said. Timothy Fiorillo, DO, a family physician at the Perkiomen Valley Family Practice in Collegeville, Pa., makes sure to divide his time between the patient and the computer. He typically allows the patient to talk for up to two minutes, while he looks at them and listens, before he types anything. At about 30 words a minute, Dr. Fiorillo thinks his typing abilities work to his advantage. If you feel your typing skills aren't up to speed, choosing an EMR system that allows the use of dictation may be the answer. But whatever type of program you choose, you still need to make an effort to become as proficient on it as you can be, Dr. Fiorillo said. Often, experts say, the reason physicians aren't making eye contact with their patients is that the doctors are unfamiliar and uncomfortable with their new systems. By practicing scrolling through the most commonly used screens, physicians will learn to navigate the system quicker, allowing more face time with the patient. Adopting an EMR also mean reorganizing the exam room or changing the order in which an exam is conducted, Dr. Berkowitz said. After his group's system was installed, some doctors found that their patients were sitting on exam tables that left them, literally, staring down physicians' necks. The solution was a triangle set-up, he said. The exam room is now set up to allow the patient, doctor and computer to form a virtual triangle so that the physician can look at the patient and the computer at the same time. At the beginning of an exam, Dr. Berkowitz says, he sits the patient on a bench in front of him with the computer screen in between them so eye contact can be maintained. Once the patient history is completed, it's on to the exam table. After the exam, the patient returns to the bench to go over instructions. This close proximity allows doctor and patient to share the computer screen, creating a more collaborative environment, Dr. Berkowitz said. He also can show patients previous lab values or educational material. "The vast majority of patients love the EMR as long as they don't feel ignored," Dr. Fiorillo said. Roemer agreed, saying he decided to give his own physician a break and not complain about the lack of eye contact during his last visit. The doctor was just trying to make it through the learning curve, he said. Dolan is a business reporter. She can be reached at 312-464-5412 or by e-mail (pamela.dolan@ama-assn.org). The print version of this content appeared in the Sept. 28, 2009 issue of American Medical News. healthspottr: Leading Minds. Leading Change. Leading Healthcare.  ISSUE 3 — September 10th, 2009   ExpectED: Light App That Automates Patient Hand-off To ER What: A web based software application that allows physicians to electronically notify an emergency room of an incoming patient, and advance case-critical patient stats -- the "expect report"-- to the urgent care team. When: Initial pilot launched, April 2008. Phase II, which will integrate ExpectED with EMRs, is currently underway. Where: Northwestern Memorial Hospital, an affiliate of the Feinberg School of Medicine at Northwestern University, in Chicago, IL. Who: Created by Dr. Lyle Berkowitz, a practicing internist with Northwestern Memorial Physicians Group (NMPG) in Chicago, IL. He is also a future health 100 member. Why:  Replaces the time consuming and error prone tradition for "handing off" a patient to the ER: a doctor-to-doctor phone call and lots of manual note taking. Web based ExpectED reports are easy for referring docs to produce. Sent electronically, they are also an efficient way to deliver critical patient data to a trauma team without interrupting ER workflow. Asynchronous communication between doctors improves quality; the patient report is produced when the information is fresh to the referring doctor, not an hour later in a call with the ER doc. The report is also accessed only when the ER doc is ready to focus on it; no interruptions, less confusion. This equates to more efficient and higher quality care. ExpectED's next pilot will experiment with integrating ExpectED reports directly with Northwestern Memorial's EMR platform (Cerner-based). Phase I ExpectED software is open source and available for free by contacting Dr. Berkowitz. Any doctor can try it -- we encourage you to do so. Cost: free When the internist known as "Dr. Lyle" isn't seeing patients at his Chicago-based primary care practice, he is directing the Szollosi Healthcare Innovation Program, a nonprofit incubator he co-founded in 2007 to develop healthcare technologies and IT tools for clinical use. An Associate Professor of Medicine at the Feinberg School of Medicine at Northwestern University, Dr. Lyle is also an expert in health informatics and has authored numerous articles on the topic. He likes technology, a lot. ExpectED is the first project to come out of the Szollosi program (SHIP). Berkowitz came up with the idea for replacing doctors handwritten "expect notes" based on his experiences sending patients to the emergency room at Northwestern Memorial Hospital. Dr. Berkowitz’s primary care practice is the largest in the Chicago area and he is known to his peers in the Northwestern ER as a “large volume referrer”. Berkowitz had grown frustrated with the old method: he'd make a phone call to a triage doctor or nurse who would then take down notes on the expected patient. (Hence, the term “expect note”.) But by the time Berkowitz’s patient arrived at the ER, often hours later, these handwritten notes were sometimes misplaced or even attached to the wrong chart. “ER's are chaotic places and little slips of paper are bound to get lost,” Dr. Berkowitz says. Time diverted or wasted trying to recover information on a patient by hunting a paper trail or by calling a referring doctor again, comes at a cost. “When I have to stop treating one patient to take an expect note on another the quality of information is degraded,” says Dr. Martin Lucenti, Vice Chair of Clinical Operations at Northwestern, and Dr. Berkowitz’s collaborator on ExpectED. “Ours is a system where delaying a person only delays the next. So anything you can do to help the patient in front of you, to make it more efficient, allows you to [work] better and faster -- with better outcomes." In April 2008, the pair launched a beta test of ExpectED, limited to physicians in Dr. Berkowitz’s practice and urgent care staff in Dr. Lucenti’s ER. Version 1.0 is a simple, web based application. A referring doctor logs into ExpectED’s secure site and creates a new note with the patient’s DOB, location of the recent evaluation and expected arrival time at the ER. The substantive data is in the SBAR section (“situation, background, assessment and recommendation”), where existing conditions, meds and the referring doctor’s opinion is recorded. Referring docs also include their “preferred consultants”, specialists’ names should any become necessary.  (Screenshot at left, below.) The one-page forms are electronically stored, but in version 1.0, they cannot be pulled off the web at the ER. ExpectED faxes them to an urgent care desk where they are printed and filed by a nurse.  (Screenshot at right, below.) It’s not ideal, as it still uses paper. But there are no more time-hording phone calls or error-prone scribbles. "It was a big process improvement, because it took the doctor out of the information exchange system," says Michael Schmidt, the current Medical Director of the Emergency Unit at Northwestern Memorial. Keeping doctors at the bedside matters in an ER like Northwestern’s, where, at peak volume, five attending physicians and 22 nurses will treat between 240 and 290 patients in a 24-hour period. Imagine the amount of data flowing through Dr. Schmidt’s ER at peak traffic. Getting the correct and prioritized information on a patient to the doctor at the moment when it is most valuable—as the patient is being examined, rather than hours before—is the difference between good care and sub-par care. This kind of information allocation requires high quality but asynchronous communication, which isn’t easy to achieve in a low-stress environment. (Think of the game telephone.) ExpectED makes high quality asynchronous communication between doctors just a bit easier. “Now we get information from a primary care doctor when we want it and we convey information [back] to them at our best time. They don’t have me calling them at 4 AM asking, ‘What do you think and why are you sending this patient to me?’” Dr Lucenti explains.  Sending and accessing information when it is most relevant saves time and prevents errors. In one recent case, a patient presented to his primary care doctor with extreme chest pain. An EKG indicated acute heart attack. From reading that expect note Dr. Lucenti mobilized the cath lab at the hospital ahead of time. “Essentially we started the whole process to open up his artery before we even saw the patient. We got him into the lab in rapid progression. It saved him as much as 30 minutes or an hour.” It also likely saved his life. Dr. Berkowitz now building out ExpectED 2.0: a version to integrate directly with Northwestern’s EMR system, so nurses will no longer need to print faxed versions of ExpectED notes, and the substantive data will flow directly into the patient’s complete medical record. He says referring physicians ought to be able to create ExpectED notes from within the EMR itself, or through the original web interface – meaning even physicians not on Northwestern’s Cement-based EMR could still use ExpectED when sending patients to the ER. ExpectED 2.0 will be ready by the end of September, and soon after, also available to non-Northwestern Memorial physicians. It will be compatible with many, but not all, EMR systems. "If you have a widely available EMR in both your outpatient and ER settings (Cerner, Epic, Allscripts, or NextGen), then it makes sense to go right to our Phase 2 and create notes that post right into the viewing window the ER docs will see,” Dr. Berkowitz says. “If your EMR is not in both settings, Phase 1 will still be helpful (web based notes that print out in the ER).” Dr. Berkowitz made the web based version open source, so other physicians and developers may build upon them to meet their particular needs. If you’d like to try ExpectED Phase I, simply email Dr. Berkowitz directly, and he’ll send you the code.  lyle@drlyle.com READ ARTICLE ONLINE HERE Rush for EHRs could ‘stick docs with bad systems’ By Joseph Conn / HITS staff writer Posted: April 30, 2009 - 11:00 am EDT Lyle Berkowitz is not an electronic health-record systems basher; far from it. Nor is he opposed to the federal government subsidizing hospitals and physician offices, although he says the proposed maximum payments of $44,000 for most office-based physicians like himself in the American Recovery and Reinvestment Act of 2009 won’t cover the true cost of installing an EHR. No, what gets Berkowitz going is the poor quality of the user interface of the current crop of EHR systems on the market. “I think the stimulus bill money is not worth it for the current EMR systems that we have,” said Berkowitz, a practicing internist, an EHR system user and medical director of clinical information systems with the Northwestern Memorial Physicians Group, Chicago, Berkowitz was also a presenter at the recent Healthcare Information and Management Systems Society convention in Chicago on “How to Improve EMRs and Incorporate Innovation In All We Do.” “The actual cost of buying and implementing these systems as well as factoring in the lost time and problems—it’s significantly more than $50,000,” Berkowitz said. “It’s probably more than $100,000. The systems alone are not the real cost, when you factor in the change management that has to take place.” One potential problem is the stimulus law, with its deadlines for purchasing an EHR system, and, eventually, penalizing them financially if they don’t, that could make physicians “buy something and rush into an inadequate system,” he said. “And they all are inadequate; they’re not all evil, but certainly none of them are perfect.” If that is all the federal IT subsidy program achieves, then, “all we’re going to do is stick doctors with bad systems,” Berkowitz said. “If the end goal is to just get doctors to use EMRs, that’s a bad end goal, a horrible end goal. If the goal is to increase quality and efficiency, we have to rethink our entire reimbursement system and reward quality and not quantity.” The key, Berkowitz said, will be federal interpretation of the “meaningful use” requirement in the stimulus law. The National Committee for Vital and Health Statistics, an HHS advisory panel, held two days of public hearings this week on the meaning of the phrase in advance of HHS rule-making on the stimulus bill to be completed this year. Everyone is still wondering what the phrase means, Berkowitz said, but “by putting in that language, I think they got some good advice from some people and they realize their end goal is not simply getting everybody to use an EMR.” Berkowitz is a board member of the Association of Medical Directors of Information Systems, a professional association for physician informatics. He also heads an IT consulting firm and serves as the program director of the Szollosi Healthcare Innovation Program, a not-for-profit organization working to improve information sharing among collaborating physicians as well as between physicians and patients. Better communication, according to an explanation on the organization’s Web site, includes a concept called “information visualization,” an exploration of ways to improve the interface between information source and the healthcare information user—both clinician and patient. So, Berkowitz has done a good deal of thinking in the past few years on the ideal physician/computer interface. “Any screen I see should essentially have two parts,” Berkowitz said. “It should have historical information or data I need to make a decision. And that data is going to be pulled in from all parts of the record, vitals, labs, meds history, evidence-based medicine guidelines. The other half should be today’s history, physical exam and plan. This is where I’m going to document what I see today and what I’m going to do today. There is no reason a computer can’t pull most of this information in and pre-populate everything I’m going to do. It significantly cuts down my work and leads me in the right direction.” “To get this information now, I have to jump to every different screen to find all this, or if it’s on one screen, it’s not an articulate screen, it’s just mashed all together,” he said. “I don’t know if the EHR vendors should be doing this, or whether they should be giving us the tools to do it, because they haven’t done it too well thus far.”  “I think we should create a single, iPhone-like platform on which everyone can create applications,” Berkowitz said. “Making it an open platform on which everyone can create applications and then you get the best of both worlds, a government platform for standardization and then you get everyone making the customized things that make your practice run. “That’s how you spend $20 billion,” Berkowitz said, referring to early estimates of the amount of the stimulus law’s subsidies for healthcare IT, a figure now estimated at about $36 billion. “That’s a much better way than rewarding vendors to make poor product.” Berkowitz said the further opening of IT systems under modification—a trend already under way—is likely to continue with or without the stimulus funds. “I am optimistic that we’re starting to see EMR vendors acknowledge they don’t have a one-size-fits-all “user interface” and they’re opening up APIs (application programming interface) so some people can create their own user interactions," Berkowitz said. "If we see more of that, I think it’s a good sign that we have a chance to bring innovation back into the EMRs and let doctors figure out creating the user interface that works for them and leave the underlying data schema to the vendor. “Right now, we have documentation as an end result as the focus of the EMR, and what we need is a workflow tool where documentation is an end result of those tools,” Berkowitz said. HealthLeaders 20: Twenty People Who Make Healthcare Better In our annual HealthLeaders 20, we offer profiles of individuals who are making a difference in today’s complex healthcare world. Healthcare faces a long list of daunting challenges, from spiraling costs to drug-resistant infections to millions of uninsured patients. Who is showing the courage, the creativity, the perseverance to meet those challenges? Who is truly making a difference in today's complex healthcare world? In our annual HealthLeaders 20, we offer profiles of individuals who are doing just that. Some are longtime fixtures in the industry; others would clearly be considered "outsiders." Some of them are revered figures; others would not win many popularity contests. But all of them are playing a crucial role in finding ways both large and small to make the industry better Lyle Berkowitz, IT innovator When internist Lyle Berkowitz, MD, was treating Chicago businessman and creative director Peter Szollosi for cancer, the two often discussed the fragmented state of healthcare. Szollosi's approach to problem solving meshed well with Berkowitz's background in biomedical engineering and healthcare informatics, and the two often debated how they would reengineer healthcare with a particular focus on technology and innovative thinking—if only there was enough time and money to be truly innovative. After Szollosi passed away in 2007, his friends and family approached Berkowitz about founding the Szollosi Healthcare Innovation Program. The charitable endeavor, which launched in January, adopted Szollosi's mantra—"I don't care what you can't do"—and the goal of using diverse technologies to improve the patient experience. Berkowitz's first project was a Web-based tool to revamp "expect notes" that doctors send to ED staff to notify them of a patient handoff. He rolled it out at Northwestern Memorial Physician Group, Chicago's largest primary care group where he practices and serves as the medical director of clinical information systems. His focus has since turned to creating a portal for patients and physicians to coordinate care at "inflection points"—scenarios where a new diagnosis transforms a patient into a high-level care user. His goal with IT innovation isn't necessarily to revolutionize the entire system. "It doesn't have to solve everything, but if it solves that problem, that's what we're focused on," he says. Fixing Health Care from the Inside Part One and Part Two By Richard L. Reece, M.D. (August, 2008) Lyle Berkowitz, M.D., a practicing physician, applies innovative thinking and information technology to health care conundrums. Efforts to improve quality of care and reduce expenses won’t succeed without a healthy dose of innovation. Lyle Berkowitz, M.D., a practicing primary care physician at Northwestern Memorial Physicians Group, Chicago, has made a study of health care innovation centers and now leads the nonprofit Szollosi Healthcare Innovation Program (SHIP). In the first installment of a two-part interview, he discusses the need for reengineering across the health care continuum, and how to support and encourage innovation. Next week, Berkowitz explains SHIP’s mission and initial projects. Richard L. Reece: Given your biomedical engineering background and your past work in software development and strategic consulting, how could health care benefit from reengineering? Lyle Berkowitz: There are three interrelated areas that need major reengineering: how we take care of patients, how we reimburse physicians, and how we design and use electronic medical record systems. First, good engineering means good efficiency and effectiveness. We need to recognize that we don’t have a shortage of physicians in America’s health care system; rather, we are not using physicians efficiently and effectively. Our current system is built on the premise that all care must be done via face-to-face visits between a patient and a doctor. The result is a system where a single primary care physician is limited to a patient panel of about 2,000 and is often rushed in visits with them. We therefore have to shift our paradigm to think about how we can most efficiently and effectively use each of the providers in the health care environment, including physicians, nurse practitioners, nurses, medical assistants, physical therapists and social workers. A good model to explore is the advanced medical home concept, in which a primary care physician serves as leader or manager of a team of providers. Consider the scenario where a primary care physician manages a team that provides both onsite and “virtual” care to a large patient population. In the office, a variety of physician extenders armed with evidence-based protocols could provide routine care for uncomplicated cases, such as colds, urinary tract infections and stable diabetics. As a result, a physician could spend more time with those patients who have more serious or complicated illnesses. And if some of the routine care could be performed virtually via the phone or Web, this system could combine the effectiveness of evidence-based medicine with the efficiency of non-office-based care. In fact, this type of model is already successfully employed by some West Coast organizations in capitated situations. However, to make this model successful for the rest of America, we need a reimbursement system based on how well this type of medical team could care for a large patient population, regardless of the method of patient interaction. In other words, a system that rewards value over volume and rewards providers for how well they take care of patients, not how often they see them. Finally, this type of model also requires an EMR system optimized to support protocol-based care, population health management and delivery of virtual care via the phone or Web. And, it must do so in an intuitive and cost-effective manner. I’m not the first person to talk about the need to reengineer the system. For example, one of my innovator idols is Larry Weed, M.D., the inventor of the SOAP note format. Back in 1968, he said, “It will be necessary to develop a more organized approach to the medical record, a more rational acceptance and use of paramedical personnel, and a more positive attitude about the computer in medicine.” That was 40 years ago, and he was spot-on, and yet we have not come very far. Unfortunately, there are plenty of cultural, technical and financial barriers making these transitions difficult. The good news is that providers, payors and patients all share the same goals of high quality and efficient care for all. Therefore, it should be no surprise that we are seeing the rise of a variety of innovation centers across the nation, which are starting to create new processes and tools to improve efficiency and quality, while also testing new models of care and reimbursement. We need to make sure these innovations are funded and supported, because the result will be a higher level of care that benefits everyone. Reece: How can health care providers and leaders support innovation? Berkowitz: Innovation in health care has traditionally focused on devices and medications. The result has been the rise of CT and MRI scans, implantable devices of all sorts, and an explosion of drugs for almost every condition. Now we need to apply this same level of ingenuity and innovative thinking to process improvement. Fortunately, more institutions are doing great work, and we need to share our knowledge so that better ideas will keep bubbling up. For example, the Innovation Learning Network, led by Kaiser’s Innovation Consultancy, connects innovation centers to foster collaboration and promote the exchange of ideas. Meanwhile, the Agency for Healthcare Research and Quality has created the Health Care Innovations Exchange as an online forum to share innovative strategies and quality-related tools. Innovation is not a spectator sport. We need to acknowledge that our current system has to improve, and we need physicians and others to get involved in making change happen—whether that is joining a process improvement committee or simply being open to a new idea when others present it. Be inspired by the fact that some of the best innovation comes from single individuals who simply see things a bit differently. Take comfort in knowing that trying and failing may still lead to success if it creates an ongoing discussion about the topic at hand. William J. Mayo, M.D., said, “It is better to think and sometimes think wrong than not to think at all.” I encourage hospital leaders to set up small, independent innovation centers to experiment with improvements that could be made at their institutions and to learn as much from failures as from successes. I encourage physicians in small practices to devote at least an hour every month to figuring out how a certain workflow could be performed faster or better within their office or hospital. I hope that they will find that one hour invested could save them many more hours down the road. Finally, believe in your ideas. If you can figure out a way to do something faster, cheaper and better, then share your knowledge. As Margaret Mead said, “Never believe that a few caring people can’t change the world. For, indeed, that’s all who ever have.” Reece: Tell me about the Szollosi Healthcare Innovation Program. Berkowitz: In January, we launched the Szollosi Healthcare Innovation Program (SHIP), a nonprofit organization with a mission to use creative thinking and diverse technologies to produce a better health care experience for patients, others associated with their care and physicians. On a more concrete level, we intend to focus on real-world problems that have a significant impact on patients and physicians. Our plan is to create pragmatic solutions that are more efficient and consistent than the status quo and that can be used by all physicians regardless of their information technology infrastructure. Additionally, we plan to work with Northwestern University researchers to study these new tools and workflows. Finally, we hope to distribute any successful ideas and tools outside our own organization. We started this program by researching the topic of innovation in health care. This included talking to a variety of researchers at Northwestern and then studying some of the well-known health care innovation centers in America, including programs at Kaiser Permanente, Group Health, Johns Hopkins, Partners HealthCare, Geisinger Health System and the University of Pittsburgh Medical Center. Additionally, we studied a variety of other organizations, such as Virginia Mason Medical Center, the California HealthCare Foundation and the Institute for Healthcare Improvement. This research will be an ongoing part of what we do, but we are also planning to expand outside the health care sector and look at innovators in finance, publishing, travel and the arts—nothing will be off-limits. Reece: How does SHIP differ from other innovation centers? Berkowitz: First, our funding comes from philanthropic sources, so we have a bit more freedom compared to other innovation programs that are funded by their hospital organization or via research dollars. Second, I have some unique biases as a practicing primary care physician running the program. For example, my main interest is in the outpatient realm and because I have to use any system we develop, I will be particularly attentive to creating very pragmatic and user-friendly solutions. The third and perhaps biggest difference is that we are combining process improvement with product development, whereas most other centers reasonably focus on process change alone. While there is some risk, I believe there are three important benefits to this strategy. One is that by building simple, Web-based applications, we think we can improve adoption of new processes by making them easier, more consistent and more cost-effective to implement. The second is that we can freely or cheaply distribute any tools we develop. The final benefit is the ability to really think creatively and develop highly specialized tools and processes that could not be created if we had to work within the constraints of standard EMR or paper-based systems. In fact, I believe there is a growing role for innovators to create niche products that lead to an immediate impact on patients while encouraging commercial vendors to build similar functionality into their products over time. Alternatively, we might see an iPhone-like future, where a company creates a standard platform upon which independent developers can build anything they want. Reece: What are the philanthropic sources behind SHIP? Berkowitz: Our program was created to honor the memory of Peter Szollosi, a creative director in Chicago who knew how to bring diverse people together and do things others didn’t even dream about. He had a mantra we stand by: “Don’t tell me what you can’t do.” Peter was diagnosed with cancer in 2006 and had a variety of complicating factors that required him to see multiple specialists at Northwestern as well as seek out second opinions at a number of cancer centers nationally. As his primary care physician, I saw Peter often and guided him through the system. We talked a great deal about how to improve communication and coordination among these physicians and health care organizations. Even though he was not a health care expert, Peter’s underlying creative drive was both inspiring and educational, and he encouraged me to try to solve the coordination and communication problems that he and other patients often faced. Peter passed away in the fall of 2007 before we could take full advantage of his knowledge and experiences. To honor his memory and legacy, those who were closest to him decided to help carry out his intentions by funding the Szollosi Healthcare Innovation Program. Reece: How does SHIP work? Berkowitz: We have created a strategic model to identify problems, obtain buy-in from appropriate sponsors and develop real-world solutions that fulfill our mission of improving patient and physician experiences. Additionally, I am part of the largest primary care medical group in Chicago, and it has agreed to serve as the pilot site for the processes and tools we develop, thus making it easier to demonstrate success in the real world. We focus our efforts around dealing with complex and critical medical issues, particularly in the outpatient environment. The result has been the identification of two solution themes: information sharing and information visualization. Within the information sharing theme, we plan to create new workflows and tools to enable better communication and coordination between patients and physicians, as well as among physicians taking care of the same patient. This is especially important for complex patients who have multiple providers and are more likely to have critical and urgent issues. Within the information visualization theme, we plan to develop ways to more easily view and understand the massive amounts of information presented to both patients and physicians. Our initial goal will be to develop prototypes of what EMRs could look and act like in the future. Reece: What projects has SHIP undertaken since its inception? Berkowitz: Our first project, ExpectED, has been in beta-testing since April 2008. It is a Web-based tool that allows a physician to notify the emergency department about an incoming patient. The physician fills out an online form which then prints at the ED triage desk for use when the patient arrives. Lessons learned from this project are already being used in a bigger project involving computerization of the whole ED system. Our second project, the Inflection Navigator, combines the idea of health advocates with a Web-based registry empowered by issue-specific protocols. These protocols will focus on coordination of care in the midst of acute inflection points in a patient’s health, such as receiving a diagnosis of cancer. The vision is for this to allow for a concierge-like level of care for patients who really need it but do so in a cost-effective manner by focusing only on the area of highest need and by ensuring the most efficient use of both human and technical resources. Reece: Tell me about your plan to improve user interfaces for EMRs and patient portals. Berkowitz: One of the main complaints about EMR systems is that they are not easy or intuitive for physicians to use, which can lead to inefficiencies and problems with quality of care. We want to develop prototypes for a wide range of user interfaces to better support the real-world needs of care providers. We plan to explore the fields of information visualization and video gaming to come up with ideas that are both unique and useful. We hope that these prototypes will encourage commercial vendors and others to think about how they might evolve their systems. We plan to have initial prototypes released by the end of 2008 and available on our Web site. Richard L. Reece, M.D., is a pathologist, author, editor and speaker. He is the author of 10 books, most recently Innovation-Driven Health Care: 34 Key Concepts for Transformation, and a blog. Pulse + IT Australia’s First and Only Health IT Magazine -- August 2008 Is Technology a Critical Tool to Avert Healthcare Crisis? “A smart future will see an increased use of paramedical personnel in the delivery of basic healthcare, supported by innovative information technology before medical specialists get involved, “ So says Dr. Lyle Berkowitz, keynote speaker at the recently held Health Informatics Society of Australia (HISA) Health Informatics Conference (HIC ’08).   Lyle Berkowitz, MD. FHIMSS, is a practicing internal medicine physician and healthcare informatics expert with a passion for creating innovative solutions that improve the quality and efficiency of the healthcare system for both physicians and patients. “If we don’t adopt new technology and change the way we deliver care, it will be harder and harder to get to see a doctor, it will cost more, the rich will cope, the poor will suffer. Many will die earlier than they would have if cost effective treatments were available. We have to act now before the healthcare system goes into meltdown.” “In America we are facing the same healthcare problems as every developed nation. An ageing population, an obesity epidemic, increasing levels of diabetes and other related problems and huge growth in treatment options. So therefore we are seeing a demand increase, at the same time there is a supply decrease, fewer physicians, fewer nurses, fewer healthcare professionals everywhere, not just in the US.” Dr. Berkowitz is a quietly spoken unassuming bloke, yet his message rings loud in the ears of those who understand the serious situation healthcare systems face in the developed world. He serves as the Medical Director of Clinical Information Systems for the largest primary care group in the city of Chicago, he is the Program Director for the Szollosi Healthcare Innovation Program (SHIP), and the president of an independent healthcare IT strategy consulting firm. Dr. Berkowitz has researched and consulted in the field of medical informatics with a focus on creating tools and strategies to ensure physician and patient adoption of clinical information systems. He is an author, public speaker and a self confessed media junkie; he’s a physician advisor to the ABC Medical news Unit and works with a wide variety of movie, television, and theatrical productions in Chicago. He’s also a Dad with two kids: although where he finds time to do that job I’m not sure. Lyle Berkowitz and other speakers at HIC ’08 were all singing from the same hymnsheet, we: that is you and I, can no longer expect all our visits to the Doctor to be face to face. A lot will be virtual, online, maybe to a nurse practitioner first, then if they reckon you are seriously ill, a face to face consultation. To complicate matters. Medicare with its rebates and payments systems will have to find innovative ways to cope with the changing world. “We are more similar than we are diverse; we all suffer from the same medical problems of cost, quality and access to care. We have the same shortages of healthcare professionals, we don’t have enough money to fund healthcare. We all deal with the same pain, we need to develop and use new technologies to make the systems work more efficiently.” Lyle’s mind works in interesting ways, not only does he have substantial formal medical qualifications as a specialist physician, he has an enquiring mind and an ability to think like an engineer. It’s classic left and right side brain activity.   “Technology is fine but in the end these are only tools, they need to add value, they need to do that by improving the health system, making it work better. It’s all about establishing where we are now, where do we want to be in ten years and how do we get there with the help of new technology.” “In our relatively small Innovation Centre, with limited budgets, we ask ourselves, ‘what can we do that will improve healthcare delivery in our hometown of Chicago? " We work in niche areas, ones where we can afford to develop technology that will solve local problems and also make out health system better. Then we can export that technology to the nation and beyond.” “We have concentrated on outpatient care for those people who need a lot of attention, where right now, a lot of time, money and resources are spent on a small number of individuals. We know that a smart future will see an increased use of paramedical personnel, supported by information technology, delivering basic healthcare before medical specialists get involved. Doctors will have to let go of a lot of ‘stuff’ they do now and quite honestly nurses and others are much better at following protocols than many doctors. If we don’t do this, there will be worse medical shortages than there are now, it will be harder and harder to get to see a doctor, it will cost more, the rich will cope, the poor will suffer and many will die, earlier than they would have if cost effective treatment was available. The worst example of that is already apparent in the USA with some medical specialists in Florida establishing VIP care clinics. Patients have to pay an annual retainer of $2000.00 per year just to be on the clinic’s books. They also pay fees when they access services. These doctors see fewer patients and keep their income high. They might see 200 patients a year instead of 2000. What happens to the other 1800 who cannot afford the retainer fee? They have to find doctors in an already overstretched system. The implications of this sort of change are scary for ordinary Americans, “says Lyle. I asked him if politicians in the US understand the seriousness of the healthcare crisis? He said, “I don’t think so, they all say we need more doctors, but that isn’t the answer, it’s not the answer in Australia wither. We have to change our payment systems; in Australia that means changing the way Medicare pays doctors, that will provoke another healthcare debate. Care does not mean a face-to-face consultation with a doctor every time you feel ill. You may need to see a nurse practitioner first, the consultation may be online, yet the practice still has to be paid even if it’s an online consultation or the appointment and treatment is with a nurse in the medical clinic.” “If we don’t adopt new technology and change the way we deliver care, the system simply will not cope, we have to act now before the healthcare system goes into meltdown.” -Mike Swinson  How curbing clicking may boost benefits of EMRs CAP (College of American Pathologists) Today  (May, 2008)  www.cap.org “Clicking takes much longer than flipping.” And that, says Lyle Berko­witz, MD, is why electronic medical records should be redesigned to be more efficient. EMR systems do not take full advantage of the organizational functionalities, search proficiencies, or visual capabilities of computers, says Dr. Berkowitz, clinical associate professor of medicine, Feinberg School of Medicine, Northwestern University, and medical director of clinical information systems, Northwestern Memorial Physicians Group, Chicago. (Dr. Berkowitz spoke about EMR inefficiencies at the Physicians’ IT Symposium at the 2008 Healthcare Information and Management Society conference, in February.) Doctors are comfortable with paper charts, Dr. Berkowitz explains, because they can be reviewed so easily. Lab results, for instance, are often printed and clipped to a paper chart, so the physician can quickly review the results and look at the last note or compare them to old results by simply flipping through a few pages. “A lot of analysis and scanning is going on during this process, but it is all at virtual speed in the physician’s brain,” he says. The physician finishes the review by initialing the front page of the results, writing or stamping an interpretation on it, and putting it into an outbox for an assistant to complete and file. “In a typical EMR scenario, however, the same workflow may take much longer because each step requires extra clicks and scrolling,” Dr. Berkowitz continues. The physician must first execute a series of clicks to reach the results section in his or her EMR. Then he or she may have to click several more times if the results for various tests are grouped separately for the same patient. And if the results section does not clarify whether the tests are finished or pending, the physician will have to go through another series of clicks to verify that all orders have been completed, Dr. Berkowitz says. Additional clicks may be necessary to access a flow sheet that allows the physician to view past lab results and compare them with current results. Then the physician must document what he or she will tell the patient and the method of notification by clicking to access another page and typing in the information. “Finally, even more clicks are added if the physician decides to write something in an electronic sticky note so the information is readily available for the next patient visit,” he adds. “This is quite simply a waste of our time,” Dr. Berkowitz says. This workflow process may even hurt quality, he continues, since a physician’s analytical thought process will be interrupted by the effort of repeatedly clicking to access information from different areas of the EMR. So how to solve this problem? “Create a system that gives the physician everything they need in one place and that emulates the thought flow they use to make a decision,” Dr. Berkowitz says. The EMR system should have a “results dashboard,” which would allow a physician to immediately visualize lab results, prioritize them, and act on them. The physician should be able to quickly clarify which test results are completed for each patient and which are pending, perhaps by holding a cursor over a designated area or having a color-coded icon appear next to the patient’s name, Dr. Berkowitz explains. A second color-coded icon could represent whether results are normal or have minor or critical abnormalities. EMR systems could also help prioritize lab data by comparing the test results to normal ranges or weighting certain tests as more important than others, or both, he says. For example, a hemoglobin abnormality would be weighted as more important than a chloride abnormality. “The result is that the EMR has helped the physician easily see how to prioritize the results—all with no extra clicks,” Dr. Berkowitz says. Furthermore, a physician should be able to click on a patient’s name to see—all at once—current and old test results, current medications and diagnoses, and perhaps even a summary of the most recent office visit. Rather than appearing as numbers, the test results might appear in graphical format, making it easier to put such data on one easily accessible page, Dr. Berkowitz says. This expanded results dashboard, he continues, would also allow the physician to sign off on lab results, choose the appropriate interpretation (normal or abnormal results), and make a notation of the next step, such as notifying the patient, changing a medication, or scheduling an appointment. “And, of course, performing any of these action items creates automatic documentation that is recorded in the chart,” he adds. So how to get there? Vendors need to view workflows not as individual tasks, but as a series of related tasks combined with thought processes that allow users to interpret data, draw conclusions, and make decisions, Dr. Berkowitz says. And they need to pay more attention to the wants, needs, and frustrations of their current clients, rather than focusing on the requests of potential customers who use paper-based systems. Also shaping the future of EMRs are organizations such as the nonprofit Szollosi Healthcare Innovation Program (www.TheSHIPHome.org), of which Dr. Berko­witz is program director. The orga­ni­zation is “creating prototypes of new user interfaces to help stimulate vendors and others who are developing the EMR systems of the future,” he says. The end result, Dr. Berkowitz concludes, may be an EMR that looks very different from current paper or electronic systems. “This may be scary for vendors used to showing physicians something that looks familiar,” he says, “but vendors will be much more successful if they can move away from the paper-based paradigm and take real advantage of computers.”  MedInnovation Blog--Thursday, April 3, 2008  Innovation Centers - List of Health Care Innovation Centers I recently interviewed Lyle Berkowitz, MD, a 42 year old internist who is program director of the Szollosi Healthcare Innovation Program at the Feinberg School of Medicine of Northwestern University in Chicago. Dr. Berkowitz believes innovation offers America the surest and best chance of offering better health care for patients and physicians alike. He is now touring America, visiting various innovation centers. As part of our interview, he supplied me with the following list of major centers of healthcare innovation in the U.S. with some of their contact information. Innovation Centers • Kaiser Garfield Innovation Center: http://xnet.kp.org/innovationcenter/index.html • Group Health’s MacColl Institute for Healthcare Innovation: http://www.centerforhealthstudies.org/research/maccoll.html • Johns Hopkins Center for Innovation (Peter Provonost) – www.hopkinsquality.com • MGM Innovation in Primary Care – www.mgh.harvard.edu/stoecklecenter • Vanderbilt Innovation team: http://www.mc.vanderbilt.edu/vcbh/index.html • Ascension Health: http://www.ascensionhealth.org/ht_works/innovative_advancements.asp • Geisinger Ventures: http://www.geisinger.org/professionals/ventures/about.html • The Innovation Program at Partners HealthCare • Innovation Center at University of Pittsburgh Medical Center • Northwestern’s Szollosi Healthcare Innovation Program (SHIP): www.TheShipHome.org • IHI Institute for Healthcare Improvement: www.ihi.org • California Healthcare Foundation: www.CHCF.org Posted by Richard L. Reece, MD MedInnovation Blog--Monday, March 17, 2008  Clinical innovations, systems thinking - Short Take on Disseminating Innovation  What - Dr. Lyle Berkowitz, a practicing internist, chief medical information office of 120 person primary care group at Northwestern Memorial Hospital in Chicago, and program director at Szollus Innovation at Northwestern, called to discuss status of medical innovation in the U.S. – how to spot it, encourage it, spread it, teach it, embed it. Why – If U.S. health care is to improve, cost less, and get better outcomes, it must innovate to crawl out of its present rut and fixed ways of looking at things. When - It’s happening fast now as we seek ways and as innovation centers spring up to “fix” the “broken system,” or “mess,” whichever term you prefer. How – To spread, innovations must be perceived as benefit with risks outweighing risks; must be compatible with values, beliefs, past histories, and current needs of doctors; must be relatively simple; must find ways to test validity; and be observed and tried out by early adopters. Where -- Innovation centers have been set up at Kaiser, Virginia Mason, Northwestern, Cleveland Clinic, Minnesota state government, Mayo, and University of Pittsburgh – and no doubt others. Who – Personalities who spread the word and make it stick include : 1) innovators (venturesome, risk tolerant, novelty seekers, who are willing to venture outside to learn); 2) early adopters (those who see the opportunity and seize it early); 3) the early majority (who see the light shed by innovators and early adopters and climb on the bandwagon); 4) the late majority (who see the success stories and view change as inevitable); 5) the laggards (who refuse to change under any circumstances and are chained to the past by social, organizational, or political constraints) To make innovation work , rules are: 1) Find a sound innovation. 2) Support innovation. 3) Invest in early adopters. 4) Make early adopters’ activities observable. 5) Trust and enable those who want to modify or reinvent original innovation. 6) Give those who fail some slack time to re-energize their risk-taking zeal. 7) Lead by example, 8) Read Donald Berwick, MD, MPP, “Disseminating Innovation in Health Care,” JAMA, volume 289, pages 1969 -1975, 2003, for details. 9. Never, never, never give up. Posted by Richard L. Reece, MD EHR Vendors Making a Mistake? Health Data Management Breaking News (February 24, 2008) Vendors that sell electronic health records systems are making the critical mistake of organizing their electronic records just like paper records, one physician who specializes in information technology contends. Most EHR systems do not take full advantage of the organizational and search capabilities of a computer, says Lyle Berkowitz, M.D., medical director of clinical information systems at Northwestern Memorial Physicians Group in Chicago. “An EHR system requires too many steps” to complete the equivalent task of quickly scanning pages in a paper record, he contends. Instead, they should emulate a physician’s “thought flow,” he adds. Rather than presenting “a bunch of static pages,” the electronic record should enable a physician to easily follow a multi-step protocol for completing a task, such as making the decision to refill a prescription or analyzing lab test results, he argues. Most records systems, however, make it far too difficult to locate all the information to complete the protocol steps, Berkowitz contends. The physician made his comments Feb. 24 at the Physicians’ I.T. Symposium of the 2008 HIMSS Conference in Orlando.