Yet only a few diagnostic support systems are on the market and installations are “minuscule,” said Jason Maude, cofounder of Isabel Healthcare, who developed one such system after his daughter nearly died from an infection similar to Copeland's in 1999.
Among the provider organizations that do make the systems available, “getting the staff to use them is the biggest challenge they face,” said Coray Tate, vice president of clinical research for KLAS Enterprises, a health IT product research firm in Orem, Utah. But once they do, “those that are using them think they are awesome,” Tate said.
The federal government, meanwhile, has paid hospitals, physicians and other providers more than $5 billion in incentives to adopt “certified” electronic health-record systems. And while the feds—including Congress—required EHRs to have e-prescribing functionality as a condition of certification, they didn't mandate diagnostic support tools in the Stage 1 meaningful-use criteria, won't require them in Stage 2 and probably won't even in Stage 3, which could take the program to 2018.
“It's a little too far out there,” said Dr. Paul Tang, vice president, chief information and technology officer at the Palo Alto (Calif.) Medical Foundation. Tang is vice chairman of the Health Information Technology Policy Committee, which advises the feds on the EHR incentive program. Diagnostic support technology has not been pilot tested sufficiently to ensure its efficacy, he said.
Broad acceptance of diagnosis support is at least five to eight years off, said Dr. Lee Jacobs of Atlanta, who worked on the rollout of the Kaiser Permanente EHR and continues as an IT consultant there.
Jacobs described the Kaiser EHR, based on software by Epic Systems, as “a powerful tool,” but it's such a “gigantic monster” of a task to collect and present the data at hand, “to go to the next level and do more thinking through the EMR, that's too big,” at least for now.
Healthcare visionaries “can make a business case for an accurate diagnosis, and I think the Kaisers will go down that road,” he said. “But even the good groups are still in the pioneering stage of bringing these things together.”
Developers and true believers in the technology, however, see shame in not having widespread adoption already.
Count among them Dr. Lawrence Weed, 88, whose problem-knowledge couplers, a diagnosis and care management tool introduced in 1984, are an extension of his
earlier work on problem-oriented medical records. Weed founded PKC, which markets couplers as diagnosis support tools. He left the firm in 2006.
“People have been saying to me since the 1960s, you're ahead of your time,” Weed said. “I say, my God, you want me to live to 160? How long are you going to take?”
According to Weed, physicians' minds no longer are capable of memorizing and recalling all the medical knowledge in a fast expanding universe of new clinical information and matching that to patients' needs. Physicians and medical education establishments are unwilling to acknowledge this reality, he said. “It's easy to see why you're having so much trouble getting over it. You've invested half a million dollars in your education, you're full of prestige,” Weed said.
Medical schools, Weed said, need to recruit students not based on their ability to memorize and regurgitate facts, which will reside in the computer systems, but on hands-on and interpersonal skills, and train them to be competent in discrete skills and procedures. But that, too, is threatening to the status quo, he said.
Thirteen years ago, Maude's daughter Isabel, then age 3, nearly died after a delayed diagnosis of necrotizing fasciitis, further exacerbated by toxic shock syndrome, both complications of chicken pox.
“Healthcare doesn't seem to regard diagnosis as important,” Maude said. “The fact that we have these cases that are absolutely tragic, the case of Aimee Copeland, they're happening all the time, even though the solutions are readily available and cheap and effective.”
Maude said he's confident his system, named for his daughter—had it been available and used by Copeland's physicians—would have red-flagged them about necrotizing fasciitis. “All they had to put in was leg cut and intense pain,” he said. “Necrotizing fasciitis comes up as the No. 1 suggestion.”
About 70 physicians at 118-bed Children's Hospital & Medical Center, Omaha, Neb., have been using the Web-based Isabel system for about three months. Though not fully integrated, a link to the tool is embedded in the hospitals' ambulatory EHR, where “it's literally a right click off the problem list,” said Dr. George Reynolds, the hospital's chief medical information officer. Isabel is also available to clinicians with iPhones, iPads and Android mobile devices, he said.
“Can I verify Jason Maude's statement, had the docs had a tool like this available, they would have used it and made things better, I can't say,” Reynolds said. “You can't guarantee it's going to change behavior every time, but I have evidence that we do change behavior with our CDS tools.”
Front office workers in a group practice in Bangor, Maine, use a “triage coupler” to direct patients who call in or arrive with a new problem, said Dr. Charles Burger, a family practitioner there.
The triage system “helps our front staff take patient complaints and sort them as to what needs to be done, how soon they need to be seen, or should they go to the emergency room or do they need lab work to be done before they come in,” he said.