Major enki features and products launched in 2016.
enki Telemedicine module lets you seamlessly connect to your patients wherever they are. Enable remote healthcare delivery in a secure and simple way using video and messaging based consults.
enki Patient Portal
The new and improved version of enki Patient Portal allows patients a convenient access to their medical records 24×7. The patient portal also integrates enki Telemedicine modules for virtual consults. Patients can interact with you, request appointments and medication refills directly through secure messaging modules.
enki EndoWriter helps you capture endoscopy images and document your procedures effortlessly. Cloud based technology frees you up from expensive hardware and provides access to your notes from anywhere. One platform integration with enki EHR greatly improves your efficiency.
enki EHR demonstrates complete ICD-10 integration across all clinical documentation modules. The simplified ICD-10 code selection interface guides you to the accurate diagnosis code for documenting your cases in a structured and compliant way.
One of the most valuable technology company in world, Apple, recently debuted their health management tool called HealthKit. The tool promises to provide a dashboard that integrates health and fitness data of the users. Apple is not the only company doing so. Over the years there has been an exponential growth in health and fitness monitors such asFitbit, Jawbone UP,Nike’s Fuelband, Adidas micoach series and many more. Electronic Health Record providers such as Mayo Clinic and Epic are partnering with Apple to integrate HealthKit with their EHR systems.
Technological trajectory can be predicted towards integrated systems, constantly providing valuable healthcare data. EHRs have the potential to transform from being medical storage softwares, to action oriented health enabling platforms. We ourselves at NextServices, have been experimenting with developing smart EHR functions for Google Glass and have laid down the technology architecture for integrating fitness data streams (from Fitbit) and genetic data streams (from 23andMe) into enki – our cloud based mobile electronic health record system.
Many debate that this boom in technology is a passing fad, but with major players diving into integrating systems and creating a connected network, the others are bound to follow. Patient-physician visits are completely orchestrated today. Diagnosis and course of treatment is solely based upon how the patient is feeling at that point in time. This is risky business, what if the patient has a different set of symptoms tomorrow? Moreover, how would a physician determine the changes in vitals if the patient is not physically present at the practice? Connected systems can constantly track patient wellness.
Imagine a world with continuous flow of data from different sources and EHRs being a central hub where data is constantly monitored, stored and interpreted. Any fluctuations in patients’ health are immediately flagged and notifications are sent to the concerned physician instantly. The physician then checks alerts on her iPad or Android tablet/phone and determines course of treatment. Treatment transparency is always maintained by sharing records with the patients and through educational resources.
Apart from the sheer coolness, the data generated by the integrated systems would be most useful and EHRs being available at the point of care would impart care that is progressive and longitudinal.
1) A group consult is very effective, even emotionally. Unlike the private nature of healthcare delivery we are used to in the developed world, a group consult can actually be highly effective – even emotionally. It helps patients realize that others are sick too and they are not alone. This somehow converts the group consult into a more supportive environment that can possibly increase patient compliance.
To describe a group consult, a patient in Trincomalee, Sri Lanka sits in front of a Skype camera and interacts with doctor(s) in Ann Arbor, Michigan while other patients wait in the background and observe. The doctor(s) go over key vitals, past history, medication list, dosages and examine latest data available and note what’s changed from the last time. They ‘look’ at the patient via Skype, ask questions (some general) with the help of a translator/ medical assistant on the Sri Lanka side. Naresh and the medical students arrive at a consensus on what to do and then they move on to the next patient.
2) One hour together is a lot of time. When a group of doctors go over each case methodically for a group of patients, a lot is actually accomplished. Time is saved. There’s a unique sense of transparency – everyone knows what is being done. Unlike in private practice medicine, there’s a different sense of teamwork among the doctors and among patients. Learning occurs both ways.
3) The mind can’t really tell the difference. Video-conferencing even via a blurry medium (in this case Skype over a moderately paced Internet connection) is very effective. Patients (and doctors) forget after a point that no one is physically in front of each other. The doctors aren’t located in a formal office – in fact, some are on their bed, some in their studies, some in their kitchen. This provides a different sense of camaraderie and in a completely different way they are welcoming the patient into a personal space. After the initial minutes, the mind actually forgets what’s virtual and what’s real. The patient-doctor interaction can get as immersive and real as a video game.
4) Using evidence-based guidelines. Given the age of patients, the focus of care has been hypertension, followed by diabetes. Readings are captured by the assistant every other day and entered into the system. We are now programming enki EHR using JNC 8 guidelines for hypertension to automatically assist during care based on age and medical background of the patient. During the group consult, the guidelines keep care-givers in check based on evidence-based protocols. The evidence-based methodology provides great balance to the human interaction enabled through a virtual consult.
5) Sometimes, virtual is better than the real thing. This past week, Naresh shared the outcome of a short survey done amongst patients. They feel well taken care of and actually prefer ‘virtual care’ over a real one. While this may be early, it’s startling and very telling. But when you think about it, it’s actually not surprising. For some patients, the alternative to ‘virtual care’ is usually bad care or even no care.
Why this is the future and could change how healthcare is delivered
Every few decades, medicine undergoes a big shift – increasing access, life expectancy and so on. We are in the middle of another one – where medicine is becoming a more precise data science. There’s increasingly more data available about the human body – from a gross level (# of steps taken in a day to # of hours slept) to a deeper level (DNA testing to microbiome testing). Doctors are increasingly reliant on data (usually via lab tests) before making a medical judgment. Most data is always available via a patient’s electronic medical record. The ‘Internet of things’ is a very real trend (think, the Nest thermostat) and is becoming the ‘Internet of medical things’ where medical devices are Internet-enabled. Patients continue to live longer through the aid of medications and fixes at the hospital. Fewer and fewer doctors are getting into primary care where the basic flow chart of a patient’s diagnosis begins. Cost of care will continue to explode (even in the developing world) as science advances further within specialties and the influences of regulation, administration, insurance companies and law continue to rise.
The trends point to a world where access to quality and reliable healthcare will not just continue to be difficult but may also increase. The trends also point to a possible future where healthcare is accessible from anywhere through a mobile Internet connection with the aid of virtual consults and medical data through an EHR.
Just as driving a car takes time and becomes second-nature with practice, so would learning a new system. Good systems aren’t usually designed with the first time user in mind but are designed for the second-time, repeat user. It’s best not to expect that you’ll simply get it when you start using a system – anything that’s worthwhile takes a bit of time and interest to learn. Assuming that the system is designed well, here are a few tips to keep in mind while working with staff during an EHR rollout:
1) Develop a 3×3 matrix based on skill and resistance. On one side, divide the rows into High, Medium, Low skill levels. On the other side, divide the columns into High, Medium and Low resistance levels. Plotting staff in such a matrix helps you identify high skilled-low resistance ones, high skilled-high resistance ones, low skilled-high resistance ones and so on. This knowledge will help you take the right actions when issues occur.
2) Rollout in modules, not phases. Don’t attempt rolling out the entire EHR platform at the same time. Don’t think linearly (one after the other), instead think in concentric circles where modules build upon each other. At the center are the core modules that help document a basic chart, then expanding outward are modules with greater functional depth. Do not go to the next set of modules until you and your team have nailed (score a 100%) the core ones. For example, when you start the rollout don’t worry about Clinical Quality Measures of Meaningful Use – focus on documenting a basic SOAP note in the quickest, consistent way possible. This is important for ongoing success.
3) Identify champions. Early on in the process, identify who really wants to make it happen. Go across the hierarchy and create an informal rollout team that would help you during the process. Provide additional training opportunities.
4) Communicate. Have daily (10min), weekly (1hr) and monthly meetings (1hr) to align everyone’s goals, remove issues as they occur rather than letting them pile up.
5) Shadow, observe and give feedback as it occurs. Feedback is most valuable when it comes in the form of assistance. Shadow doctors and staff and help them resolve a mistake as it occurs.
6) Have a pilot phase. It helps to iron out the kinks with the system and staff when there are no real patients around. There’s no need to rush through a rollout.
7) Make it a game. Score points (e.g. on knowledge, helpfulness, speed etc.) and put the chart up on a big monitor for everyone to review by the end of the day. Thinking of the rollout as a game, will make it easier. Competition amongst staff members will help everyone get better.
8) Make the EHR vendor part of the team. Just because something doesn’t look familiar, may not mean that something’s wrong with the software. Have the approach of including the vendor as part of the team versus treating them as someone external to your environment.
9) Fall-back option. Think through on all the ways that the rollout could go wrong during a live patient scenario. Prepare staff on what to do when something like that happens (e.g. Internet downtime).
10) Celebrate. It’s important to celebrate with staff on the small wins during the rollout. This could be even a simple cheer or an ice-cream for everyone. It helps keep the atmosphere positive and engage everyone in the right direction.
Medicine undergoes shifts every few decades – from germ theory to medications to reliance on clinical trials. During the past decade, there’s been a slow but steady shift towards reliance on data. Nearly every treatment plan has associated tests – radiology tests, pathology tests and possibly DNA and microbiome tests in the future. Doctors rely on data to confirm their hunches and to also protect themselves from law suits. Over the next decade, the amount of data we will get from a patient’s body is going to be enormous – akin to the amount of data we are now generally exposed to everyday as consumers. According to Marty Kohn from IBM’s Watson, 90% of the world’s data was created in the last two years and 1 trillion connected devices are generating 2.5 quintillion bytes of data every day (quintillion is 1 followed by 18 zeroes).
Doctors have a dual relationship with data. On one hand, they use it clinically for treatment (e.g. lab tests) where the data is of high value. On the other, when they document medical charts – they enter minimal information and enter standardized information (e.g. an operative note – almost no one reads this). The main reason for this polar relationship is because they aren’t visualizing the use or the value of the data that they put in. They don’t combine and use it as a whole to analyze their patient population. They don’t use it to predict future outcomes. In the future, they will.
Medicine is gradually migrating from an art to a more exact science. IBM Watson has been trained by senior oncologists at Kettering Institute to assist in diagnosing patients. If these trends are amplified, it might not be so difficult to imagine that a part of medicine could even become a data science – where algorithms analyze data from inside (e.g. DNA tests) and outside (e.g. activity trackers) and present findings to a doctor, who then reviews and confirms a diagnosis. If this were to become even remotely true, the value of data in medical charts would go up. So may be we must pause for a moment to consider what we put into a medical chart everyday.
A couple of decades later, when we look back at this time, we would more completely understand that these were the early days of healthcare IT. While majority of Americans are just about getting on digital records, large pockets of the world are largely paper-based. While most of the hospitals in the US are using hospital management systems, almost no one takes a cloud-based approach. While several medical practices are migrating to the cloud, just a minority uses a mobile platform. While large healthcare systems have figured out how to implement and use an EHR, almost no one uses the medical record as a means to deliver healthcare. While early adopters are getting access to data from their insides through DNA and microbiome tests, most doctors aren’t yet accustomed to using this information to diagnose before a disease occurs. While several families use Skype to talk to loved ones, they have never used video calling to speak to a doctor.
There are 7.2 billion people in the world today, majority of them in urban areas. There will be 1.75 billion smartphone users in 2014. It’s easy to imagine that in just a few years, most of the world will be connected via smartphones that are Internet-enabled. It would be a failure of our health systems, if we don’t take advantage of this reach to provide healthcare access everywhere.
Despite requirements mandated by Meaningful Use Stage 1, providers are still hesitant to actively share their medical records with all of their patients – they possibly fear trouble with law suits. But I’ve met doctors not only are able to share their records with patients confidently (because the records are not templated and the care is thorough) and even get patients to participate actively in managing their health. Patients tend to respond by understanding their conditions better and I’ve noticed that they proactively rate such doctors highly on forums such as healthgrades.com. Going beyond such benefits, there are also business benefits by engaging patients over the Internet. Using a well-functioning patient portal, ambulatory surgery centers can save time for themselves.
Invite patients to use a patient portal – a common area that providers can share medical records, including lab results, medications, operative notes and so on. Once patients use the portal regularly, have them periodically track and document basic vital signs such as BMI, blood pressure, insulin readings. Have them complete checklists, scoring sheets (e.g. such as a Crohn’s Disease Activity Index), manage their demographic information, scan driving license or update photographs. This would save enormous amount of time for the front desk and nursing staff of the surgery center or medical practice. As a doctor, explore having virtual meetings for return visits through the patient portal. Your patients would greatly appreciate the time you’d save them by willing to have a virtual conversation.
The next logical step for the surgery center would be to actively monitor care across groups of patients via a dashboard that collates data from the patient portal. Using such information, clinical staff can track health across a group of patients and when things seem to deviate from the norm (e.g. high BP for 3 continuous days), then the practice can call the patient to schedule a check-up proactively, even before they fall sick. This reverses the expectation that patients need to call a doctor after they fall sick.
I think it’s a good thing that we work in an industry that’s in transition – we get to see the extremes and these could become stories to recount later. At sessions at FutureMed (now called Exponential Medicine), I recall extracting my own DNA and experiencing firsthand the role that data from DNA might play in the future of care. And on the other end, I visit medical practices that run really old software with archaic interfaces.
The typewriter is the quintessential icon of bygone technology. It opened up a new era in the industrial age and created countless jobs. But upgrading a typewriter doesn’t make it different. This reminds me of present day software. The original EHR systems did a great job in creating the market for digitized records. But simply documenting medical records electronically is not the end of the road – it’s the beginning. The real story occurs when we do something interesting with the data that we store.
We chose a typewriter for our ad in Becker’s ASC to call out all the software upgrade requests that salespeople extend to doctors and administrators. An upgrade is usually more of the same – it doesn’t change the basics. What we are calling for is a change – a new way to look at EHRs and management systems for ambulatory surgery centers.
Yesterday, I demonstrated enki EHR to one of our billing customers. In passing, I told him that someone else used a transcriptionist on our platform by creating limited-use logins – after listening intently, he told me that might be the perfect idea for everyone like him who disliked operating a computer in front of patients. It made sense. As a senior gastroenterologist, his time is better spent with patient care than with a computer. But that doesn’t mean that they cannot benefit from an EHR – the most powerful benefit from a mobile-based EHR is that he can pull up a patient record even in his car (if he wanted to). It’s accessing patient information at the right time that brings meaning to implementing an EHR.
Here are other ways you could use an EHR without needing to operate a regular computer:
a) Use an iPad/ Android-based EHR where you can tab your way through patient information – if you are comfortable with tabbing.
b) Integrate Dragon Medically Speaking and speak your way into the EHR.
c) In front of patients, use the iPad to access information just as you would use a paper file. Pull up vitals, chief complaints, medication lists, document basic data such physical exam and review of systems. But don’t document the History of Present Illness, Assessment and Plan. Write the final plan on a piece of paper and have your staff complete the final part of the note for you – on their computer. The iPad and computer would sync and keep the medical note current.
d) If you are used to using a transcriptionist – continue doing so. Create a separate login (with limited use) for the transcriptionist so that he/ she could login to the EHR and complete the note for you inside the patient chart.
e) Use a template for repeatable consults and teach your staff to edit key areas of the Note.
f) Use a combination of the above – when needed document (e.g. for complex cases) but for the common ones, continue practicing as you are used to and letting the system, process and staff take care of computer-based documentation.
However, you will need to go through the chart, approve and digitally sign before a Note is complete. Go ahead and start using the EHR – the benefit of giving better care to your patients will outweigh the hurdle of getting started.