mTuitive, Inc. » blog

Structured Clinical Documentation

Peter O'Toole — Wed, 19 Sep 2012 17:25:27 +0000

ComputerWorld's Juergen Fritsch writes cogently on the failure of EHRs to transform physician clinical documentation from unstructured narrative text to structured data:

Not surprisingly then, at least 60 percent of all clinical documentation is still captured in unstructured narrative form – for example via dictation/transcription or a front-end speech recognition tool – and simply stored as text blobs in the EHR. While this keeps physicians productive and at the same time results in more meaningful and higher quality documentation, such unstructured documentation has not been very accessible to electronic systems in the past.

National Coordinator for Health IT Farzad Mostashari tweeted a link to the article:

Yes, integration of NLP (with voice front-end) into EHRs is the future (also helps w ICD10) bit.ly/PnOZTC
— Farzad Mostashari (@Farzad_ONC) September 19, 2012

It is refreshing that Stage 2 of Meaningful Use recognizes the need for structured clinical documentation. It is disappointing, however, that thought leaders in the US still relegate all future user interface enhancements for physicians to voice recognition. In practice, voice recognition can be very effective, and it is true that natural language processing (NLP) can extract meaningful data from free-form text after it is translated by a voice recognition engine. However, it doesn't have to be this hard.

In Canada, the province of Ontario has collected structured pathology reports on almost every type of prevalent cancer for years. They did not implement voice recognition, allow pathologists to dictate at will, and attempt to use artificial intelligence to translate all of this into the required data elements recommended by the College of American Pathologists and Cancer Care Ontario. They needed consistent, standard data to learn more and make decisions about cancer care. Instead, they issued a data standard, certified various vendors as effective implementers of that standard, and let pathologists choose structured clinical reporting tools. More than half of the hospitals chose mTuitive's structured reporting tool, xPert for Pathology. Physicians use a simple user interface to complete standardized checklists that result in apples-to-apples comparisons for cancers across the province. In comparison, using sophisticated artificial intelligence just to arrive at a standard set of data elements on a checklist looks like a Rube Goldberg machine.

Fritsch's claim that structured reporting modules built into EHRs "put the burden of creating structured patient data on the physicians by making them point-and-click through templates full of checkboxes, radio buttons and drop-down menus, thereby slowing them down significantly" is true about most structured reporting tools built into EHRs today. However, it does not mean that all user interfaces that use mouse-and-keyboard or touch are hard to use. He is also correct that many EMRs "encourage the use of one-size-fits-all forms and copy-and-paste behavior that often results in cluttered, lower quality clinical documentation that fails to represent the subtleties and uniqueness of each individual patient’s story." Using intelligent defaults that remember physician's most common answers, but with additional answers and more descriptive terms within easy reach, you can have the best of both worlds — speedy entry of structured documentation that is also personalized and specific to the patient encounter.

Applications like mTuitive's xPert for Pathology and OpNote bring fast, easy-to-use interfaces to pathology and operative reporting. Rather than forcing physicians to speak (and remember!) every data element in very detailed clinical protocols, a simple, checklist-style user interface replaces pathology and operative report dictation. By focusing on areas of deep domain expertise (pathology, surgical specialties) and using proven methods in usability design, smaller companies like mTuitive can create extremely usable point-and-click (and now tap-and-swipe) interfaces that are far faster and easier to use than voice recognition, without the need for Watson on the backend to translate speech into simple findings. We embrace the ideas behind Atul Gawande's Checklist Manifesto, and extend those ideas to clinical documentation. It is a lot easier to correctly report on 50 pathologic findings when you follow a standard checklist.

And as for that ICD-10 conversion? Synoptic, structured reporting helps with that too.

Unsolicited Feedback

Rob Dean — Wed, 05 Sep 2012 18:50:06 +0000

A new customer recently sent us the following feedback on his experiences with implementing mTuitive's pathology solution. With his permission, it's reprinted below:

It’s been almost 2 months since Markham Stouffville Hospital [MSH] went live with the Meditech Orders to mTuitive interface.

The saying is right, that “No news is good news”.

The orders interface has been a resounding success, both from an IT perspective and a user perspective.

There has not been a single issue with the actual interface between Meditech and mTuitive.

Complaints by the pathologists have dropped to zero.

We would like to take this opportunity to thank mTuitive for agreeing to develop the orders interface in conjunction with MSH. The interface replaces a very “clunky” solution for linking Meditech and mTuitive. The interface is a real plus for the pathologists and the hospital. The user interface is simple and streamlined. Pathologist training took literally minutes, and as noted previously, there have been virtually zero complaints. Remote reporting using Citrix is also working well, which had not been possible previously.

We would strongly recommend any new customer, or any Meditech 6.0 conversion site, purchase both the HL7 orders and results interfaces.

Again, thank you for supporting our efforts to improve the technical and business processes related to pathology synoptic reporting.

And congratulations on a development job well done.

Rick Lambert

Systems Integration Consultant

Markham Stouffville Hospital

Want to learn more about the products Rick and the rest of Markham Stouffville Hospital are enjoying? Contact us today!

Digital Pathology Fears Debunked

Rob Dean — Fri, 31 Aug 2012 14:53:29 +0000

President of Digital Pathology Consultants Addresses Common Concerns

The Digital Pathology blog recently published Amanda Lowe's post, "Digital Pathology Misconceptions Debunked by Digital Pathology Consultant." In it, Ms. Lowe examines the various fears and concerns that have held people back from adopting digital pathology solutions in their own laboratories. Most of these misconceptions are centered around the costs of digital pathology and the impact it will or won't have on workflow and a laboratory's infrastructure. Ms. Lowe sums it up best in her own subhead - "Yes, you can be reimbursed, and no, it won't slow you down."

Many of the points Ms. Lowe makes are about the unfounded fears that users will not receive the same reimbursement and certification for adopting digital pathology solutions. Or, worse yet, will somehow be penalized for using digital pathology instead of current or even obsolete methods. Ms. Lowe is quick to point out that these worries are not based in fact - just rumors that are born of anxieties whenever any innovation arrives. She is quick to debase and debunk each of these objections and there is one particular point that she makes that really resonated due to my similar experiences encouraging synoptic reporting adoption in pathology. Ms. Lowe writes

Digital pathology disrupts my laboratory workflow. How do you break something that is already broken? Many laboratories have a workflow that is manual, fragmented and extremely inefficient. Digital pathology will not be disruptive, instead digital pathology will make these workflow inefficiencies more apparent. These inefficiencies will need to be addressed to be a more productive and progressive laboratory.

There is always room for improvement and there are ways of increasing your lab's efficiencies. Neither digital pathology nor synoptic reporting are the silver bullet that will instantly make your lab run correctly. But they are powerful tools that can streamline processes, ensure consistency of results and output and assist physicians in making important decisions about administering care. Digital pathology and synoptic reporting are means to organize your lab's activities and promote best practices. Of course there exists a possibility of people doing it incorrectly or there might even be a slight learning curve with new technology. But if you use them correctly, they can be powerful aides to help curb inefficiencies, adhere to industry standards like the CAP Cancer Checklists and meet the increasing demand for results that pathology labs are facing.

Again, here is the link to Ms. Lowe's post, "Digital Pathology Misconceptions Debunked by Digital Pathology Consultant." For more information on mTuitive's pathology solutions, visit our Pathology page.

New CAP eCC Release – June 15

Rob Dean — Tue, 12 Jun 2012 14:53:37 +0000

Hey everyone - we just received this from College of American Pathologists (CAP) today in their CAP PS mailing list. There was a lot about the new release of the electronic cancer checklists. Here's a brief summary of the background and changes expected in those checklists. Some of this was posted earlier on CAP's website, but there's some newer and more detailed information below. Be sure to join the CAP PS mailing list to stay informed about all these changes, and if you have any questions contact us at mTuitive.

New CAP eCC Release Available June 15th

A new release of the CAP electronic Cancer Checklists (eCC) will be available for download by current licensees on June 15, 2012. This eCC release contains all 81 cancer checklists, and incorporates user feedback from the previous releases.

Background

The CAP eCC files are computer-friendly renditions of the Word and PDF versions of the CAP Cancer Protocols. The files are produced in XML format to facilitate integration into information systems and to foster interoperability. Reference implementations are provided, incorporating common Web technologies such as HTML forms and JavaScript. Extensive documentation is provided to aid implementation into computer systems.

Changes Included in This Release

The June 2012 release includes approximately 58 checklists with changes to the pathology content.
The release will also include 60 checklists updated to indicate items that may be omitted from reports when certain answers are selected. These items are marked with the “?” symbol, and are called “Conditionally Reported” (CR) items.
The asterisk symbol “*” that was used to denote non-required items has been changed to the plus “+” symbol in all CCPs and eCCs. This should help to eliminate some confusion for new users, since the “*” since generally denotes required items in web-based forms.
Thousands of additional improvements are included, covering more than 90 independent issues raised by pathologists, cancer registrars and the CAP eCC Team. These improvements were vetted by the CAP Pathology Electronic Reporting (PERT) Committee and the CAP Cancer Committee (CCC).
This eCC release is also synchronized with content changes in the CAP Cancer Protocols (CCPs). 47 updated CCPs, 37 of which have been updated for clinical content, will be available on the CCP web site in coordination with this release.

SNOMED CT, ICD-O3, and Short Names Maps

Updated maps for SNOMED CT, ICD-O3 and Short Names will be released approximately 6 weeks after the main eCC release.

CAP eCC Implementation Help

CAP Professional Services (PS) offers a wide range of consulting services to support optimal implementation, customization and integration of the CAP eCC into your workflow. If you have any questions regarding this or any upcoming releases, please call (847) 832-7700 or email capecc@cap.org.

Of course, mTuitive's xPert for Pathology will be kept up to date with any changes made to any of the eCC or CAP requirements. Be sure to join the CAP PS mailing list to stay informed about all these changes, and if you have any questions contact us at mTuitive.

New: Three Features Surgeons Will Love

Peter O'Toole — Thu, 26 Apr 2012 21:19:44 +0000

Start Over, Change Procedure, Repeat Procedure

Usability is our number one priority at mTuitive. (Our original slogan was "Usability by Design!") So when we kept hearing three requests from our surgeons recently, we looked at what was bothering them and quickly designed and developed three new features that we think smoothly address their problems.

Wrong Default?

We know that no surgeon would ever hit the wrong button! But occasionally we do get a call asking how to start over if someone selects the wrong default report. The old workaround was to delete the report and start over — cumbersome, and even trickier if the report was an amendment. Now, simply click "Wrong Default?" at the bottom of the screen and select the default you really want to use.

Change Procedure

Sometimes, you want to select a slightly different procedure code to describe the operation performed, but your usual description is still adequate or only needs minor edits. In this case, you don't want to return to the procedures screen to modify the list of operations performed and then have to re-do the description. For this reason, there is now a "change" link right next to the procedure above its operative description. Click it to load the procedure chooser on the right hand side of the screen. Selecting a new procedure changes the existing one in place, and keeps the operative description exactly as it was.

Office staff will also like this feature when helping surgeons complete amendments because they can quickly change to the desired code without modifying the surgeon's description, and then send it back to the surgeon for signout.

Repeat Procedure

Another common frustration occurs when surgeons may perform the same procedure multiple times. For example, a procedure may be performed on 1 to 5 fingers. In this case, it is annoying to have to keep a default report around for every possibility. Now, you can just have 1 and click "repeat" next to the procedure to add a copy of the procedure and its operative description right in the report.

We're Listening

Please contact us using live chat while you are using the product, or by email or phone (508-771-5800) and let us know what other new features would make signing out operative reports (even) easier for you. In the meantime, check out these hot new features!

New: OpNotes as Word Documents

Peter O'Toole — Thu, 22 Mar 2012 14:18:51 +0000

We've had several surgeons ask if they can download their completed operative reports as Word documents rather than PDFs. Some EMRs only allow Word uploads and some offices just prefer this format. Last Friday we shipped this feature in OpNote.

As a user, you'll see this option in several places.

Signed out reports have PDF and Word download icons on their summary cards. For PDF, this is a change from the text link "pdf" to a familiar graphical icon. You don't need to open the report to download in either format. Simply click on either icon to download the report in the desired format.

In addition, we've offered the ability to batch download all reports for a date of service in a zip file. This option now has PDF and Word flavors, as well:

Lastly, the final report page displays a link to download the Word document below the existing option to download the PDF.

As always, you don't need to do anything to upgrade; new features appear automatically thanks to our hosted, software-as-a-service delivery.

We hope you find the Word download useful! We always try to find ways to make life easier for our customers. If there are other formats that would help you with your own workflow, please let us know.

5 Things Health IT Can Learn from Twitter

Rob Dean — Wed, 22 Feb 2012 15:15:25 +0000

The Healthcare Information and Management Systems Society (HIMSS) is currently having their annual conference and exhibition. Biz Stone, co-founder of Twitter, was the keynote speaker today. CDW Healthcare took Mr. Stone's presentation as an invitation to reflect on the "5 Things Health IT can Learn from Twitter." Here are the five lessons, which can be found in full on this site - http://industryview.cdwcommunit.com/index.php/2012/02/21/5-things-healthit-can-learn-from-twitter/. I'll post some of my commentary after.

1) It’s about people, not technology. We know this instinctively by the nature of our organization, but sometimes the forest perspective loses out because we have to spend so much time on the bark that falls off the trees. Similarly, twitter gets a lot of hype and all of its nuanced features. But it’s really just a tool. A technology. As Biz said, “Humanity moves forward with help from technology – it’s all about the people, it’s not about the technology.” A good reminder that ICD-10, meaningful use, telemedicine, PACS, and all those other acronyms are all about the patients we serve.

2) Technology utilized correctly inspires spontaneous, coordinated action. Twitter enables groups of people to swarm together (like birds) and move together as one organism to get things done. Biz also told a great story back when Twitter was in prototype phase. A tech guy at a pub after a long conference day tweeted that it was too loud in there and that he was moving to another pub. Within 8 minutes (and lots of retweets), 800 people had lined up at the other pub. How can healthIT do that for our clinical teams? “Code RED” on the PA system works very well, but are there new ways to think how our cross-functional teams work together?

3) Technology utilized correctly takes the firehose of information and turns it into actionable wisdom. Twitter enables people to take infinite information, turn it into understanding, and turn it into action. It’s not about information, it’s about knowledge/wisdom. The Arab Spring twitter story is a great example of that. With the boatloads of data that’s being stored up in our servers (and this is just the tip of the very beginning), how do we make all that information so easy to digest, analyze, and act upon that data for multiple user types?

4) Not Invented Here. Baked into Twitter’s culture is this core value: “there are more smart people outside our company than inside.” Especially for the complicated, ever-evolving field of HealthIT, we’ve learned this lesson time and again – we rely on the fellowship of colleagues, friends, and experts and attend events like HIMSS.

5) Technology enables culture change. Think about how smartphones has changed the nature of work and of family. As more sophisticated healthIT technologies continue to emerge, addressing the emotional/cultural aspects of the implementation of the technology may very well be just as important as the technical side of things. As we enter into an era of wearable devices and other health-awareness devices (Biz has a scale at home that shoots his weight information into a cloud where his friends can keep him accountable), demands for better, faster, more accurate, and more actionable information will only grow. This will continually moving the patient/provider relationship, and in turn, change the role that we in HealthIT play – not just as technical experts, but culture change agents.

All good points to remember and apply to Health IT, but numbers 3 and 4 resonate with me in particular.

Technology utilized correctly takes the firehose of information and turns it into actionable wisdom. This is an issue that we've really tried to impress on health facilities. As evidence-based medicine grows in popularity and practice, it will become increasingly important that the correct information is collected in its entirety. Structured data collected in electronic synoptic reports expedites the process of moving this information into the necessary places. We at mTuitive think it's a better method than recording the information without any sort of rules or structure, and therefore requiring more processes (and more time and more resources) to then get that data out of the records and where ever they need to be. So much information is collected but set adrift amidst an ocean of text - text that has no bearing on healthcare - or else the data is in a format which prevents easy access for other healthcare providers.

So much information is being recorded in so many different programs, products, sheets, venues and machines. It leads to number 4, Not Invented Here which is important in healthcare - and to us - because everyone needs to collaborate better. To quote The Wire, "Everything is connected. Everything matters." What is entered in System X about a patient needs to be available for System Z about that same patient. We need to accept that there are other solutions out there, and we need to learn to work together. Because, ultimately, Health IT is about the patients, the people, and about helping everyone. We need to be more open to making these introductions to other organizations, creating partnerships with each other and come together to improve health IT on every level.

Empowering data - making it easier to find the data you want - is only helpful if it can be shared and used for better research and better care. Integration, interfacing and collaborating needs to be an easy process between vendors that doesn't put the onus on facilities or providers. Everyone believes in his or her own product, but everyone knows that his or her own product is limited in some way. That's OK - together we compliment each other and make a better experience and therefore ensure a better outcome for all patients.

Here is Biz Stone's site/blog and be sure to follow him on Twitter.

HIMSS 2012 is still going on RIGHT NOW in Las Vegas - from February 20th to the 24th - so stop on by if you're in the area. To find out more about it, be sure to check out the site.

To read more of CDW Healthcare's excellent posts, they are highly recommended and very insightful, please go to their page.

Updated iPad Experience for OpNote

Peter O'Toole — Thu, 19 Jan 2012 16:26:11 +0000

Earlier this week, one of our doctors found a problem using OpNote's write-in textboxes on the iPad. We quickly replicated the problem here and fixed it. At the same time, we took the opportunity to enhance OpNote's iPad experience.

Apple has done a great service for web applications running on the iPad with iOS 5. Among other improvements for web developers in the mobile safari browser, Apple now provides that native, kinetic scrolling you've come to love on your iOS devices to web apps.

Wait, you may say, I already use flick gestures to scroll up and down when using OpNote! However, you were using a simulation of the native iOS scrolling effect that we implemented with an open source code library. It was never quite as good as the real thing, and also turns out to be the cause of our surgeon's bug, above. Removing the code that simulated native scrolling fixed our problem, and gave us the chance to upgrade to native scrolling using the new features in iOS 5. Anywhere you scroll in OpNote when using the iPad, you will experience high-performance, smooth touch scrolling.

While working on this, we noticed a few things that could be smoother on the OpNote Edit screen. Traditionally, OpNote-on-iPad required users to tap "Edit" in order to select and edit a section of the report. Now you can tap anywhere on a section's current answers to select it. In addition, flick scrolling could be confused with dragging and dropping answers to reorder them. Now, flick scrolling only happens on the left where the section labels are, and drag-drop or selection happens over the answers.

In short, touch behavior on the Edit screen is now redesigned and improved:

Users can flick anywhere in the left column where the labels are to scroll. (purple rectangle below)
Users can tap anywhere on the answers or edit button to select the section. (red rectangle below)
After a section is selected and green arrows become visible, users can touch-and-drag to reorder answers. (purple oval below)

What do customers need to do?

Customers who want the best possible iPad experience should upgrade to iOS 5. OpNote will still work with older iOS versions, but you won't have kinetic scrolling and will have to use the non-kinetic, 2-finger scroll gesture (a real pain when you are used to the real thing!). iOS 5 if a free update that is available to all iPad 1 and 2 owners. Simply plug your iPad into your computer and follow the instructions in iTunes to upgrade.

We hope you enjoy these changes!

Are Surgical Objectives Important Enough to Document?

Rob Dean — Tue, 11 Oct 2011 16:50:25 +0000

In the latest Becker's Hospital Site Review, readers can find a great piece by Dr. Jared Ament that asks if surgical objectives are important enough to document? Dr. Ament used mTuitive OpNote as an example of an electronic way to easily and effectively capture important information for outcomes measurement and surgical research. But, Dr. Ament asks, should the original surgical objectives of those procedures be included in that research? What insight can be gained from comparing the objective with the outcome? What harm could come from documenting the original intent?

Click below to read Dr. Ament's article:

http://www.beckershospitalreview.com/or-efficiencies/measuring-surgical-outcomes-are-surgical-objectives-important-enough-to-document.html

Why Your Facility Needs Updated Browsers

Rob Dean — Wed, 05 Oct 2011 14:34:01 +0000

mTuitive OpNote is a web-based operative report - so the issue of web browsers is of great importance to us. Those browsers that you use to wander the Internet - using Facebook, buying items on Amazon, even reading these words right now - are programs that are constantly updated by their developers. Mozilla Firefox, Google Chrome, Internet Explorer, Opera, Apple Safari; their names and icons may just mean "Internet" to you - but they are important pieces of software that need to be kept up to date.

Many times when we're speaking with ASCs, hospitals or other facilities that wish to use OpNote, we find out that these places are using Internet Explorer (IE) 6 or 7. It then becomes an issue where we have to start begging them to upgrade their browsers. So while it is definitely and patently in our product's best interest that all facilities use the latest versions, I'd like to discuss why it's in the best interest of your facility, your doctors and your patients to use the most updated browser.

Why are so many facilities using outdated web browsers in the first place?

The problem tends to be a mixture of bureaucratic lethargy - the long slow Bataan march of death to affect change in a large organization like a hospital or a health partnership - and technological necessity.

The maddening bureaucracy of medical facilities means even something as easy as "update all web browsers" becomes an issue for committees to discuss, action items to be voted upon, and authorized personnel to execute in a broad rollout strategy. Something that takes maybe 15 minutes at most to do, per computer, now necessitates weeks of planning and coordination.

Meanwhile, many of the IT programs installed (or built) at hospitals or ASCs are built for stability, reliability and security. They are not intended to be flexible or easy to update or upgrade. So if new Document Manager Program X or Homegrown Software Y is installed, it will probably only work with whatever was currently on it at the time, meaning that if you want to update to IE9 or install Firefox or Chrome - that might cause a problem. And by the time IT developers have tweaked this product, newer web browsers will already be out. Everyone is running as fast as they can just to lag behind.

Now we know why facilities don't, won't or can't update. But, and here's the most important question, why should you care?

You should care because the security of your information, and your patients' information, is at risk. You should care because the efficiency of your workflow is being undermined and resulting in taking more time to do simple tasks. You should care because the speed of delivering this information, the speed to do these tasks, will directly impact the time and quality of the care you are providing to your patients.

Old browsers lack many technological updates and abilities in today's versions. Lines of code are absent in old browsers; but in those lines of letters and numbers lie many hours of developers working to make the browser go faster, be smarter, respond correctly to commands. Without these updated lines of codes, sometimes without whole programs, browsers remain sluggish and unable to fulfill crucial tasks needed to get your work done in a timely fashion.

When you update web browsers, you are also getting an updated library of security measures to protect your computer and its information. Hackers tend to be a few steps ahead of developers, exposing new vulnerabilities and gaps in security; so when they are faced with old software and outdated security precautions - it's much easier for them to take advantage. With new updates, you get the latest security changes as well as the most recent list of known viruses and types of attacks. Without these, your entire organization is vulnerable - and so is your patients' data.

What makes this even more maddening is that Microsoft, makers of Internet Explorer, are trying to phase out IE6 and 7. IE6 will stop receiving any updates or any support soon - and IE7 is starting on that path to exile as well. In fact, developers are eagerly anticipating IE6's abandonment. They are gleefully tracking its plummeting number of users on sites and forums. Firefox, Safari and Chrome tend to automatically update - which means that they also automatically remove the old versions. The makers of these programs are glad you're using them - but would prefer you use the latest ones, to improve not only your experience but so that users don't think the negative aspects of their earlier versions persist.

It's not hard to update or install these browsers. It tends to be a click of a mouse and running a simple program. Less than 30 minutes to ensure your data is protected and your information is moving as fast as you are. There are other reasons - newer browsers have more programs, greater abilities, and can perform better tasks faster. But efficiency, speed and security of your information and your work are the most important. Your time is too valuable to waste and your work is too important to jeopardize. Make sure your facility agrees and is using updated web browsers.