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Thursday, August 21, 2014

The Yeshi Dhonden dx, and other business

I first acquired and read this amazing book 40 years ago. It remains among my prized literary possessions.


Blessedly, it is now out in Kindle, with an update preface. A favorite excerpt I have quoted elsewhere:
On the bulletin board in the front hall of the hospital where I work, there appeared an announcement. “Yeshi Dhonden,” it read, “will make rounds at six o’clock on the morning of June 10.” The particulars were then given, followed by a notation: “Yeshi Dhonden is Personal Physician to the Dalai Lama.” I am not so leathery a skeptic that I would knowingly ignore an emissary from the gods. Not only might such sangfroid be inimical to one’s earthly wellbeing, it could take care of eternity as well. Thus, on the morning of June 10, I join the clutch of whitecoats waiting in the small conference room adjacent to the ward selected for the rounds. The air in the room is heavy with ill-concealed dubiety and suspicion of bamboozlement. At precisely six o’clock, he materializes, a short, golden, barrelly man dressed in a sleeveless robe of saffron and maroon. His scalp is shaven, and the only visible hair is a scanty black line above each hooded eye.

He bows in greeting while his young interpreter makes the introduction. Yeshi Dhonden, we are told, will examine a patient selected by a member of the staff. The diagnosis is as unknown to Yeshi Dhonden as it is to us. The examination of the patient will take place in our presence, after which we will reconvene in the conference room where Yeshi Dhonden will discuss the case. We are further informed that for the past two hours Yeshi Dhonden has purified himself by bathing, fasting, and prayer. I, having breakfasted well, performed only the most desultory of ablutions, and given no thought at all to my soul, glance furtively at my fellows. Suddenly, we seem a soiled, uncouth lot.

The patient had been awakened early and told that she was to be examined by a foreign doctor, and had been asked to produce a fresh specimen of urine, so when we enter her room, the woman shows no surprise. She has long ago taken on that mixture of compliance and resignation that is the facies of chronic illness. This was to be but another in an endless series of tests and examinations. Yeshi Dhonden steps to the bedside while the rest stand apart, watching. For a long time he gazes at the woman, favoring no part of her body with his eyes, but seeming to fix his glance at a place just above her supine form. I, too, study her. No physical sign nor obvious symptom gives a clue to the nature of her disease.

At last he takes her hand, raising it in both of his own. Now he bends over the bed in a kind of crouching stance, his head drawn down into the collar of his robe. His eyes are closed as he feels for her pulse. In a moment he has found the spot, and for the next half hour he remains thus, suspended above the patient like some exotic golden bird with folded wings, holding the pulse of the woman beneath his fingers, cradling her hand in his. All the power of the man seems to have been drawn down into this one purpose. It is palpation of the pulse raised to the state of ritual. From the foot of the bed, where I stand, it is as though he and the patient have entered a special place of isolation, of apartness, about which a vacancy hovers, and across which no violation is possible. After a moment the woman rests back upon her pillow. From time to time, she raises her head to look at the strange figure above her, then sinks back once more. I cannot see their hands joined in a correspondence that is exclusive, intimate, his fingertips receiving the voice of her sick body through the rhythm and throb she offers at her wrist. All at once I am envious— not of him, not of Yeshi Dhonden for his gift of beauty and holiness, but of her. I want to be held like that, touched so, received. And I know that I, who have palpated a hundred thousand pulses, have not felt a single one.

At last Yeshi Dhonden straightens, gently places the woman’s hand upon the bed, and steps back. The interpreter produces a small wooden bowl and two sticks. Yeshi Dhonden pours a portion of the urine specimen into the bowl, and proceeds to whip the liquid with the two sticks. This he does for several minutes until a foam is raised. Then, bowing above the bowl, he inhales the odor three times. He sets down the bowl and turns to leave. All this while, he has not uttered a single word. As he nears the door, the woman raises her head and calls out to him in a voice at once urgent and serene. “Thank you, doctor,” she says, and touches with her other hand the place he had held on her wrist, as though to recapture something that had visited there. Yeshi Dhonden turns back for a moment to gaze at her, then steps into the corridor. Rounds are at an end.

We are seated once more in the conference room. Yeshi Dhonden speaks now for the first time, in soft Tibetan sounds that I have never heard before. He has barely begun when the young interpreter begins to translate, the two voices continuing in tandem— a bilingual fugue, the one chasing the other. It is like the chanting of monks. He speaks of winds coursing through the body of the woman, currents that break against barriers, eddying. These vortices are in her blood, he says. The last spendings of an imperfect heart. Between the chambers of her heart, long, long before she was born, a wind had come and blown open a deep gate that must never be opened. Through it charge the full waters of her river, as the mountain stream cascades in the springtime, battering, knocking loose the land, and flooding her breath. Thus he speaks, and is silent.

“May we now have the diagnosis?” a professor asks.

The host of these rounds, the man who knows, answers.

“Congenital heart disease,” he says. “Interventricular septal defect, with resultant heart failure.”

A gateway in the heart, I think. That must not be opened. Through it charge the full waters that flood her breath. So! Here then is the doctor listening to the sounds of the body to which the rest of us are deaf. He is more than doctor. He is priest.

I know ... I know ... the doctor to the gods is pure knowledge, pure healing. The doctor to man stumbles, must often wound; his patient must die, as must he.

Now and then it happens, as I make my own rounds, that I hear the sounds of his voice, like an ancient Buddhist prayer, its meaning long since forgotten, only the music remaining.

Then a jubilation possesses me, and I feel myself touched by something divine.

Selzer, Richard (1996-04-15). Mortal Lessons: Notes on the Art of Surgery (Harvest Book) (Kindle Locations 302-320). Houghton Mifflin Harcourt. Kindle Edition. 
(BTW: That's not the cover; I did that in Photoshop from one of the illustrations in the book)

I have all of his books in hardback. What a writer. Rare erudition and passion.

Fast forward 40 years.

When I look at my career at midlife, I realize that in many ways I have become the kind of doctor I never thought I’d be: impatient, occasionally indifferent, at times dismissive or paternalistic. Many of my colleagues are similarly struggling with the loss of their professional ideals. Of course, the relinquishment of one’s ideals is standard fare in the midlife phase. In this period, fundamental questions about life often arise: What is its purpose? What is my ultimate aim? Depression and nostalgia can take hold as middle-aged adults struggle with responsibility, regret, and the nagging awareness that their lives are half over.

I used to think that my life would settle down when I got to this stage, but I was wrong. The insecurity and ambivalence of my youth have persisted, though in different forms. In my twenties, hamstrung by my passions, I yearned for consistency in my core beliefs. I obsessed about what I was going to do with my life. Those ruminations now seem like luxuries. The challenges I face now— supporting my family, navigating the precarious domains of job, marriage, and fatherhood while trying to maintain personal and professional integrity— seem so much bigger (if no less insoluble). As a young adult I believed that the world was accommodating, that it would indulge my ambitions. In middle age, reality overwhelms that faith. You see the constraints and corruption. Your desires give way to pragmatism. The conviction that anything is possible is essentially gone.

It occurs to me that my profession is in a sort of midlife crisis of its own. In the last four decades, doctors have lost the special status they used to enjoy. In the mid-twentieth century, at least, physicians were the pillars of any community. They made more money and earned more respect than just about any other type of professional. If you were smart and sincere and ambitious, the top of your class, there was nothing nobler or more rewarding that you could aspire to become. Doctors possessed special knowledge. They owned second homes. They were called upon in times of crisis. They were well-off, caring, and smart, the best kind of people you could know.

Today medicine is just another profession, and doctors have become like everybody else: insecure, discontented, and anxious about the future. In surveys, a majority of doctors express diminished enthusiasm for medicine and say they would discourage a friend or family member from entering the profession. In a 2008 survey of twelve thousand physicians, only 6 percent described their morale as positive. Eighty-four percent said their incomes were constant or decreasing. The majority said they did not have enough time to spend with patients because of paperwork, and nearly half said they planned to reduce the number of patients they would see in the next three years or stop practicing altogether. American doctors are suffering from a collective malaise. We strove, made sacrifices, and for what? For many, the job has become only that— a job.

Consider what a couple of doctors had to say on Sermo, the online community of more than 125,000 physicians:
I wouldn’t do it again, and it has nothing to do with the money. I get too little respect from patients, physician colleagues, and administrators, despite good clinical judgment, hard work, and compassion for my patients. Working up patients in the ER these days involves shotgunning multiple unnecessary tests (everybody gets a CT!) despite the fact that we know they don’t need them, and being aware of the wastefulness of it all really sucks the love out of what you do. I feel like a pawn in a money-making game for hospital administrators. There are so many other ways I could have made my living and been more fulfilled. The sad part is we chose medicine because we thought it was worthwhile and noble, but from what I have seen in my short career, it is a charade.
Another wrote:
I loved what I did, running an ICU. But I was on call 11 of every 14 days for more than 25 years. Over a third of my work weeks were 100 hours. I quit when I was 56 because my wife developed a terminal illness and I wanted to return all the lost hours I had promised her “when we retire.” In my last year of practice I asked the billing department to collect all the actual money we had collected on one particularly long and difficult weekend on call  … After overhead, I was actually paid $ 11.74/ hour. Who would do that again? Fool that I am, I probably would, but my wife and I brought up our sons from an early age to be totally against the idea of medical school. They were clearly bright enough, with full academic scholarships. And while they respect physicians, they are not doctors. And I am glad they are not.
The discontent is alarming, but how did we get to this point? This book, chronicling my experiences in my first few years as a new doctor, is my attempt to answer this question.

Jauhar, Sandeep (2014-08-19). Doctored: The Disillusionment of an American Physician (pp. 6-7). Farrar, Straus and Giroux. Kindle Edition.
A bit more:
Because insurers had been slashing reimbursement rates, that summer my LIJ colleagues and I were told we had to increase our “relative value unit” collections, or RVUs (the currency of medical payment). With all the cuts in reimbursements over the prior few years, academic medical departments across the country had suffered sharp downturns in revenue. Some physicians had responded by upcoding— claiming greater complexity in patient encounters than was in fact the case— and fraud investigations at some centers were under way. Obviously I wasn’t going to upcode, so what the department’s directive meant for me on a practical level was that I had to see more patients. I reduced the time in my schedule earmarked for new patients from sixty minutes to forty and for established patients from thirty minutes to twenty. With administrative tasks, conferences, teaching, chart reviews, and letters and phone calls to physicians, hospitals, and pharmacies increasingly gobbling up my day, I began to rush through visits, hurrying patients along in subtle and not so subtle ways. I stopped making small talk. I interrupted histories after a few seconds to get patients on point. I even urged my patients to breathe a little faster when I was listening to their lungs. “Doctor, I just want to know…” “One second, ma’am, please, one second…” (pp. 224-225).
Related readings of mine:


Another awesome book, reported on here.

Yet another:


Reported on here.

Periodical literature has been rife with recursive reports of the dismay in recent years.
The Root of Physician Burnout
RICHARD GUNDERMANAUG 27 2012


Incentivizing with money is a self-fulfilling prophecy of cynicism. We must promote compassion, courage, and wisdom among our physicians before we "make a sordid business of this high and sacred calling."

A colleague of mine in primary care medicine has decided to leave the practice of medicine. She is very well trained, has impeccable professional credentials, and works in a thriving practice. Over the past several years, however, she has noticed an unrelenting decline in the sense of fulfillment she derives from her work. She feels increasingly frustrated with what she calls the "bureaucratization" of medicine, and resents spending "more time filling out forms than caring for patients." My colleague is suffering from what is commonly described as burnout...

The Epidemic of Disillusioned Doctors
We all know medicine has become a frustrating profession. But surveys show that a younger generation of doctors are more resilient to burnout

By Danielle Ofri, MD


Last week I was ready to quit medicine. I was seeing a new patient with diabetes, heart disease, anemia, hypertension, osteopenia, hypothyroidism, reflux, depression and pain in every part of her body. From a bag she produced 18 pill bottles — from about as many doctors — and piled them onto my desk. She pulled out a form from her job that needed to be filled out, plus a prior-approval form that her insurance company required, as well as a stack of photocopied records from the other doctors. She didn’t speak English, so we waded through her complicated medical history via a telephone interpreter. I don’t like to write while I am talking with a patient, but I couldn’t afford to fall behind in my documentation, so I typed madly into the 50 required fields of our electronic medical record while the patient recounted her complex medical history.

In the middle of this, the computer seized up, then turned a shade of gray that in an ICU would elicit the code team. I didn’t want to lose the interpreter on the phone, so I fiddled with the control-alt-delete buttons while I continued the interview, moving on to the refresh buttons, the escape buttons, finally squatting awkwardly under the desk to yank the on-off switch of the computer.

Forty-five minutes into our 15-minute visit, with an interpreter telephone in one ear translating back and forth into Bengali, my office phone in the other ear, on hold to tech support, my desk swimming with insurance forms, pill bottles, MRI reports, and mammogram referrals, the computer flashing ominous error messages, plus six more patients waiting outside, eight phone messages from yesterday still to return, I thought: “That’s it, I quit!”...
I got off into thinking about this in particular after reading this on THCB:
An Open Letter to Primary Care Physicians
By JACK COCHRAN, MD AND CHARLES KENNEY


Dear Doctor,
The future is in your hands.


You have the opportunity to make primary care better.


More efficient.

More accessible.
And more affordable.

We know you and other primary care doctors have more responsibilities than ever. But you also have great influence, along with the ability and opportunity to change this country’s health care system for the better.


Primary care is essential to the quality of health care, and we need you now more than ever.


Maneuvering the Minefield


According to research firm Harris Interactive, “the practice of medicine is … a minefield. … Physicians today are very defensive – they feel under assault on all fronts.’’* Harris questions, “how much fight the docs have left in them. Some are still fired up … while others have already been beaten down.’’


Those who feel frustration, anger and burnout say they are squeezed by administrators, regulators, insurance companies and more. They worry about the possibility of a lawsuit that could destroy your career.


The question is: What can be done about it? Some of you may choose to remain in the status quo. Some of you have chosen to retire early or otherwise leave the field of medicine entirely. Yet some of you have said enough is enough and found specific solutions that mark a pathway forward. You sought – and found – specific solutions that mark a pathway forward.


If you’ve rejected the status quo and joined your fellows in search of innovations from other practices that you have applied at home, congratulations. You’re a physician leader who’s doing great things for your patients, your colleagues and yourself. You are undoubtedly more satisfied in your work than before, and you are quite likely providing better care.


To those of you who aren’t sure of how to proceed, there is a way out. But you have to act...
A lot to think about. The authors continue:
If you have the courage to stand up and lead, you will quickly find that identifying great practices from which to learn isn’t that difficult. Don Berwick, MD, former head of the Centers for Medicare and Medicaid Services (CMS) for the United States, puts it this way: “It’s not hard to describe the health care system we want; it’s not even hard to find it. … Among the gems and the jewels throughout our country… lie answers; not theoretical ones, real ones where we can go and visit these organizations and see how good they are.”

So, when we add these elements together, the pathway forward emerges:

  1. Step forward as a leader
  2. Identify problem areas within your practice
  3. Find practices that have done a nice job of solving those problems
  4. Learn from others
  5. Apply what seems like the best fit to your practice
Ah, that "Leadership" thingy I've been working on.

Which leads me to another book I have underway.

This book is about a naturally occurring pattern, a way of thinking, acting and communicating that gives some leaders the ability to inspire those around them. Although these “natural-born leaders” may have come into the world with a predisposition to inspire, the ability is not reserved for them exclusively. We can all learn this pattern. With a little discipline, any leader or organization can inspire others, both inside and outside their organization, to help advance their ideas and their vision. We can all learn to lead...

Sinek, Simon (2009-09-23). Start with Why: How Great Leaders Inspire Everyone to Take Action (p. 1). Penguin Group US. Kindle Edition. 
Got hip to him from that TED talk in my prior post. Again, "Talking Stick culture," anyone?

See also my citation of the book "When Doctors Don't Listen" in my post "Philosophia sana in ars medica sana." (scroll down)

Saturday morning, Jerry woke up with tightness in his chest. It hurt when he sat up and he figured he must have pulled something while he was moving. But his uncle or grandfather (maybe both?) had heart problems, and Jerry’s wife persuaded him to go to the ER to get it checked out.

A generation ago, a doctor might have heard Jerry’s story and told him that he had a muscle strain. He would have left and felt better. Not so on this particular day. The nurse who greeted Jerry noted his “chief complaint” of chest pain and called over a tech, who took off Jerry’s shirt and attached him to a monitor that beeped and displayed waves and numbers that made no sense to him, but Jerry trusted the folks around him to make sense of it all. He was given some aspirin to chew and another tiny pill under his tongue that tingled a bit and gave him a headache. He was brought to a treatment room where another nurse came in and asked a series of questions about his “chest pain” before proceeding to take several vials of blood and shuttling him off to the next destination, the radiology suite for X-rays. When he finally got back, a doctor stopped in and went over yet another checklist of questions, these seeming even less relevant to why he was there. (“ Why did it matter whether I had blood in my stool or slept on two pillows at night?”) But while long, convoluted, and confusing for Jerry, the whole process nevertheless appeared routine and procedural for the ensemble of medical professionals coming and going...

Wen, Leana; Kosowsky, Joshua (2013-01-15). When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Tests (p. 2). St. Martin's Press. Kindle Edition.
Issues at every turn. I'm sure physicians feel shot at from every direction every day.

UPDATE

"hypermetricosis"
...A third player is increasingly encroaching on the doctor-patient relationship, and more and more doctors are beginning to suspect that it may be the vector of much of contemporary healthcare’s pathology. Who is the third party? Its precise identity is often difficult to pin down, but its seat in the doctor’s office and at the patient’s bedside is often occupied by a hospital, a health insurer, or a government agency.
This third party usually does not see individual patients. Instead it sees aggregates, such as rates of mortality, disease incidence, and the utilization rates of particular tests, procedures, and pharmaceuticals. It tends to be particularly interested in parameters such as efficiency, safety, cost, and revenue.  Because it is largely blind to individuals, however, its risk of developing certain disorders is dramatically increased...
From THCB. Nice. Will there be an ICD-10 code for that dx?

But, wait! There's more...
Another such disorder is hypermechanosis. Many third parties envy the kinds of productivity and quality gains that have been achieved in other industries through the application of various forms of statistical process control. For example, six sigma focuses on reducing variation, usually treated as error. If only we could run medical practices the same way Toyota manufactures automobiles, Southwest flies airplanes, and Disney treats its theme park visitors, proponents argue, we could revolutionize healthcare...
Yeah, hahahaha.... Good for laughs among the Perpetually Pissed At Their Loss of Clinical and Business Autonomy, but, more than just a bit of Straw Man there.
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More to come...

Wednesday, August 20, 2014

@BobbyGvegas says...

A comment I just made over at THCB.
There are 3 fundamental aspects of workflow in the digital era: physical tasks, IT (EHR) tasks, and cognitive tasks. Every certified EHR has to have an audit trail to comply with HIPAA, given that every time ePHI is created, viewed, updated, transmitted, or deleted the transaction must be “date-time/who/what/about whom” captured in the audit trail log.
The ePHI audit log, to me, is a workflow record component. It can’t tell me WHY front desk Susie or Dr. Simmons took so long to get from one transaction element to the next — i.e., physical movements or cognitive efforts — but it can tell me a lot, adroitly analyzed.
I worked for number of years as a credit risk and portfolio management analyst in a credit card bank. We had an in-house collections department that took up an entire football field sized building, housing about 1,000 call center employees. I had free run of the internal network and data warehouse. One day I just happened upon the call center database and the source code modules (written by an IT employee in FoxPro, which I already knew at an expert level). I could open up the collections call log and watch calls get completed in real time. We were doing maybe a million outbound calls a month (a small Visa/MC bank).

(My fav in the Comments field was “CH used fowl language,” LOL)

It was, in essence, an ongoing workflow record of collections activity.
I pulled these data over into SAS and ground them up. I could track and analyze all activity sorted by any criteria I wished, all the way down to the individual collector level. I could see what you did all day, and what we got (or didn’t) for your trouble.

I was [able to] rather quickly show upper management “Seriously? You dudes are spending $1,000 to collect $50, every day, every hour” etc. The misalignment was stunning. I started issuing a snarky monthly summary called “The Don Quixote Report” with a monthly “winner.” …Yeah, we called this hapless deadbeat 143 times this month trying to get 15 bucks out of him…

Well, it didn’t take long to squelch all that. We saved the bank 6 million dollars in Collections Department Ops costs that year via call center reforms. Didn’t exactly endear me to the VP of Collections, whose bonus was tied to his budget.

Gimme a SAS or Stata install and SQL access to the HIT audit logs, and I will tell you some pretty interesting (Wafts-of-Taylorism 2.0) workflow stories.
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More to come...

Monday, August 18, 2014

Crappy Health IT reporting


Let a thousand non sequiturs bloom.
Survey: EHR use cuts into resident education, productivity
By: DOUG BRUNK, Family Practice News Digital Network


SAN DIEGO – Family medicine residents reported that documentation time increased by about 16 minutes per patient encounter following implementation of an electronic health record system at two academic medical institutions in Southern California.

"We have learned about how electronic health records are going to improve our patient care and our efficiency in the clinic but not a lot of studies have explored how the implementation of an electronic health record at academic centers is going to impact resident education," Dr. Maisara Rahman said in an interview during a poster session at the annual meeting of the American Academy of Family Physicians.


Dr. Rahman and her associates surveyed 122 family medicine residents, attending physicians, and other clinical staff from Riverside County Regional Medical Center (RCRMC) and Pomona Valley Hospital Medical Center (PVHMC) to assess their perceptions about the adequacy of EHR training, the amount of time spent on documentation, and the effects of EHRs on patient care and resident education. Of the 122 people surveyed, 99 responded, for a response rate of 83%.

Dr. Rahman, in the department of family medicine at Loma Linda University and an attending physician in the department of family medicine at RCRMC, reported that there was an overall decrease in resident productivity at both academic institutions following implementation of the EHR: a 30% decrease at RCRMC and a 20% decrease at PVHMC. Overall, respondents indicated that EHR documentation took about 16 minutes longer to complete compared with documentation by paper chart (an average of 37 vs. 21 minutes, respectively.)...
"Residents"? To the extent that this implies that health IT will negatively impact post- academic training clinical care, where most of the ambulatory primary care EHR documentation is done for the doctor by subordinate staff, it tells us nothing. Moreover, we would expect that those still in training will be episodically encountering halting upward steps on the leaning curve upslope. HIT competency is not "See One, Do One, Teach One." HIT training -- hel-LO? -- is a necessary part of medical training.

Little To Show For $26 Billion Health IT Investment
By Christine Kern


The advancement of HIT-related initiatives has been slow despite “considerable investments.”

The electronic sharing of information (health information exchange) plays a critical role in improving the cost, quality, and patient experience of healthcare. However, there is very little electronic information sharing among clinicians, hospitals, and other providers despite more than $24 billion in incentive payments to hospitals and eligible professionals who "meaningfully use" electronic health records, and another $2 billion spent on interoperability standards and EHR certification over the past five years...
I'd like to know whether this author wrote the headline for this article. I also have to wonder about her chops for opining about the state of Health IT.
Christine Kern is a contributing writer for Jameson Publishing, featured in Health IT Outcomes, Integrated Solutions For Retailers, and Business Solutions magazines. She has a PhD in European history from Penn State University, is widely travelled, spent over 15 years in the college classroom teaching European and World history, and is a published author of both academic and creative works.
Her article is simply an uncritical report on the recent Health Affairs Policy Brief on interoperability. Fine. But, I have to quibble with the simplistic headline. While I am by no means an unreflective cheerleader for Health IT -- as my regular readers have long known -- it is way too early to summarily declare that there it "little to show" for the national effort.

My Clinic Monkey spoof site
How "little," relatively speaking? Where would we likely be today absent the effort? (See JD Kleinke).

Then there's good reporting:

Delegating tasks to practice staff enhances team-based care

Physician practice owners carry much more responsibility than they did in previous years. In fact, an avalanche of administrative requirements required to succeed, even survive, in healthcare is placing an even greater toll on morale. According to a Medical Economics web poll in December 2013, 41.9% of physicians say that administrative hassles threaten their relationships with patients. And while the challenges have been well documented, the solutions require a new approach to delegation and teamwork, experts say.

 “The notion of what it means to lead has shifted. We are moving to a team-based model of care—and it’s not just doctors,” says Andrew Morris-Singer, MD, president and founder of Primary Care Progress, a nonprofit organization that develops leadership practices amongst an interprofessional group of medical professionals. “There are different levels of credentials, expertise and diversity in the doctor’s practice right now. And we never taught physicians how to be on a team and lead a team that’s not all physicians.”

Morris-Singer adds that physicians no longer can have the mentality that they have all of the answers—and this is a good thing. Because of the increased complexity of patient care, especially surrounding chronic disease, it will be important for physicians to build a staff that can manage all areas of a patient’s needs.

The need for appropriate delegation can save a team time. According to a Health Affairs study primary care physicians could save 30 minutes per day by delegating routine functions to staff members. While it’s not a lot of time, it is a start.

“We aren’t able to know the exact answers anymore in terms of care delivery,” he says, adding that different staff members can assist physicians with getting patients to adhere to prescriptions and other guidelines.

“We have to work in a team with a unique, complementary set of skills. This is not substituting the doctor. There’s no one on the team who knows complex diagnoses and can build a therapeutic alliance better than the physician. But that’s not the only thing a patient needs.”...
Also, re "credibility,"
Why I Am Still Optimistic About the State of HIT
Jerome Carter, MD
MU stage 2 is making everyone miserable.  Patients are decrying lack of access to their records and providers are upset over late updates and poor system usability. Meanwhile, vendors are dealing with testy clients and the MU certification death march.  While this may seem like an odd time to be optimistic about the future of HIT, nevertheless, I am.
The EHR incentive programs have succeeded in driving HIT adoption. In doing so, they have raised expectations of what electronic health record systems should do while bringing to the forefront problems that went largely unnoticed when only early adopters used systems.  We now live in a time when EHR systems are expected to share information, patients expect access to their information, and providers expect that electronic systems, like their smartphones, should make life easier.

Moving from today’s EHR landscape to fully-interoperable clinical care systems that intimately support clinical work requires solving hard problems in workflow support, interface design, informatics standards, and clinical software architecture.  Innovation is ultimately about solving old problems in new ways, and the issues highlighted by the current level of EHR adoption have primed the pump for real innovation.   As the saying goes, “Necessity is the mother of invention,” and in the case of HIT, necessity has a few helpers...
I have reported on Dr. Carter's work before.
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LOOKING AHEAD

Re "analytics," and the "big data" Health IT nexus. HealthCatalyst offers another free eBook (downloadable PDF with registration). I am well into it, and will finish it today. A lot of good stuff, fairly technical.

CONTENTS
  • Introduction
  • Chapter 1: What Is a Data Warehouse?
  • Chapter 2: Why an EDW Is a Foundational Platform for Future Analytic Success
  • Chapter 3: Which Approaches Are Commonly Used in Healthcare before
  • Implementing an EDW?
  • Chapter 4: What Works Best For Healthcare? Introducing the Late-Binding Data Warehouse
  • Chapter 5: Alternatives to Late-Binding. The Star Schema Approach in Healthcare
  • Chapter 6: Alternatives to Late-Binding. Can a BI Tool Be an Effective Data Warehouse?
  • Chapter 7: Six Reasons Why Healthcare Data Warehouses Fail
  • Chapter 8: Four Phases of a Successful EDW Implementation
  • Chapter 9: Should We Build or Buy Our Data Warehouse?
  • Chapter 10: How to Evaluate a Healthcare Data Warehouse and Analytics Vendor
  • Chapter 11: Health Catalyst’s Solutions
  • Chapter 12: Success Stories: Reaching Goals Through Healthcare Data Warehousing
  • Appendix:
  • Further reading
  • Contributors
I cited their eBook HEALTHCARE: A BETTER WAY. THE NEW ERA OF OPPORTUNITY in a recent prior post. While these gratis eBooks are in fact "frisbees," -- marketing giveaways via which to promote their company, the information contained therein seems to be totally on the up-and-up and relatively unbiased (and rendered with great aesthetics).

to wit, Brian Ahier on "late binding" -
[The] third wave of analytics will enable large numbers of healthcare organizations to realize some significant returns on their IT investments and thrive in the healthcare marketplace of the future. Developing a consensus model for adoption of analytics capabilities could help healthcare leaders and vendors succeed by providing a common roadmap for the deployment of these capabilities. But much of the success of these analytics platforms will depend on the underlying architecture and I think the "late-binding" data warehouse model holds the most promise.

The term late-binding dates back to at least the 1960s, where it can be found in Communications of the ACM. The term was widely used to describe languages such as LISP, though usually with negative connotations about performance. In the 1980s Smalltalk popularized object-oriented programming (OOP) and with it late binding. Alan Kay in History Of Programming Languages 2 laid out the fundamentals of OOP and late-binding architecture in The Early History of Smalltalk section. In the early to mid-1990s, Microsoft heavily promoted its COM standard as a binary interface between different OOP programming languages. COM programming equally promoted early and late binding, with many languages supporting both at the syntax level.

The late-binding data warehouse model is a just in time method and is more adaptable to new analytics use cases and data content than those that make use of early binding and tightly coupled enterprise data models. Late-binding is a method of assembling data from disparate sources just in time for particular analytic use cases, known as the late-binding model of data warehousing, is starting to gain traction in healthcare as many provider organizations gear up for population health management. The advantage of this approach is that it allows users to combine disparate data very quickly for targeted analyses without locking data warehouses into a predetermined data model...
See also "late binding" in the Wiki for a more geeky discussion.

During my stint in credit risk modeling and portfolio analytics (pdf) a decade go, we established an Oracle platform "EDW" (Enterprise Data Warehouse), so all this stuff rings true to me. I routinely hit against ours using SAS Proc SQL to pull in "late bound" data for exploratory drilling and modeling (after cleaning up the crap they never ceased to let into the EDW).

AUG 19th NEWS UPDATE
Dignity Health goes big for data
Bernie Monegain, HealthCare IT News

Dignity Health, one of the largest health systems in the country, with a 20-state network, will build a cloud-based data analytics platform.

The health system tapped Cary, N.C.-based SAS to lead the big data and predictive analytics project.

The platform will be powered by a library of clinical, social and behavioral analytics, according to Dignity Health executives.

The initiative is aimed at helping doctors, nurses and other healthcare providers better understand each patient and tailor care to improve health while reducing costs.

In the short term, Dignity Health and SAS will use the big data analytics platform to reduce readmission rates, determine best practices for addressing congestive heart failure and sepsis, manage pharmacy costs and outcomes and create tools to improve each patient's experience.


"In order to deliver the right care at the right place, cost and time for every patient, we must connect and share data across all our hospitals, health centers and provider network," said Dignity Health CIO Deanna Wise, in announcing the move. "The SAS cloud-based analytics platform will help us better analyze data to optimize and customize our treatment for each patient and improve the care we deliver."...
Pretty interesting. An "EDW," eh? Bears watching.

I wonder whether SAS will be exhibiting at Health 2.0 in Santa Clara next month? I've long been a SAS user and enthusiast.
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More to come...

Thursday, August 14, 2014

"If you're 10 feet ahead, you're a 'Leader.' If you're 100 feet ahead, you're a Target." - Brent James, MD, M.Stat

Props to FierceHealthcare.com.

The changing role of leadership in healthcare
3 great leadership talks for healthcare executives



Love that Brent James quote. See my prior observations about "leadership" in healthcare.

Dympna Cunnane (1st video), at 2:02:
I know that when I go into a senior manager's office, into a senior team, I know that the behaviors in that team will be replicated everywhere in the organization. So, if that's an atmosphere of distrust, if that's an atmosphere of bullying, that will be replicated throughout the organization. So, leaders on their own can't do anything, but they are very influential in creating a culture and a climate within which people work...
"Talking Stick culture," anyone?

Simon Sinek (3rd video) at 5:12:
I was flying on a trip, and I was witness to an incident where a passenger attempted to board before their number was called, and I watched the gate agent treat this man like he had broken the law, like a criminal. He was yelled at for attempting to board one group too soon. So I said something. I said, "Why do you have treat us like cattle? Why can't you treat us like human beings?" And this is exactly what she said to me. She said, "Sir, if I don't follow the rules, I could get in trouble or lose my job." All she was telling me is that she doesn't feel safe. All she was telling me is that she doesn't trust her leaders. The reason we like flying Southwest Airlines is not because they necessarily hire better people. It's because they don't fear their leaders.

You see, if the conditions are wrong, we are forced to expend our own time and energy to protect ourselves from each other, and that inherently weakens the organization. When we feel safe inside the organization, we will naturally combine our talents and our strengths and work tirelessly to face the dangers outside and seize the opportunities. 

The closest analogy I can give to what a great leader is, is like being a parent. If you think about what being a great parent is, what do you want? What makes a great parent? We want to give our child opportunities, education, discipline them when necessary, all so that they can grow up and achieve more than we could for ourselves. Great leaders want exactly the same thing. They want to provide their people opportunity, education, discipline when necessary, build their self-confidence, give them the opportunity to try and fail, all so that they could achieve more than we could ever imagine for ourselves...
Dr. Smith (2nd video), at 13:09 (on the 4th of his 7 imperatives):
...learning to work in teams, and to maximize the potential contributions of everybody who's part of the care system -- including patients.
Which can only sustainably happen through adroit (i.e., technical competence + Just Culture) leadership.
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HEALTH 2.0 2014 CONFERENCE IN SANTA CLARA


Link to the Conference site here. My press credential was approved the other day. I will be there. Bringing my own half & half this time; later for the soy milk and rice milk. Ugh.
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More to come...

Wednesday, August 13, 2014

3rd leading cause of death?

Preventable medical error. From a recent congressional hearing:


apropos, see my prior post, Medical Error, Interop, and the Patient Safety-Health IT nexus. to wit:
"My recent posts have ruminated on what I see as the underappreciated necessity for focusing on the "psychosocial health" of the healthcare workforce as much as focusing on policy reform (e.g., P4P, ACOs, PCMH), and process QI tactics (e.g., Lean/PDSA, 6 Sigma, Agile), including the clinical QI Health IT-borne "predictive analytics" fruits of ""Evidence Based Medicine" (EBM) and "Comparative Effectiveness Research" (CER). Evidence of psychosocially dysfunctional healthcare organizational cultures is not difficult to find (a bit of a sad irony, actually). From the patient safety-inimical "Bully Culture" down to the "merely" enervating emotionally toxic, I place it squarely within Dr. Toussaint's "8th Waste" (misused talent)."

FROM HEALTHCARE: A BETTER WAY. THE NEW ERA OF OPPORTUNITY
John L. Haughom, MD
 
Avoidable error and harm categories
Safety experts including Lucian Leape, Robert Wachter, Peter Pronovost  and others have organized the causes of avoidable errors and harm into the following logical categories:

Medication errors. Adverse drug events (ADEs) are a significant source of patient harm. The medication delivery process is enormously complex. On the inpatient side alone, it generally represents dozens of steps, and it is only marginally less complicated in the ambulatory environment. Taken appropriately, the thousands of medications available in clinical care today offer huge advantages to patients. Still, the thousands of available drug options and their complicated interaction with human physiology and each other leads to a significant incidence of near misses (5 to 10 percent) and actual adverse drug events (5 percent) in hospitalized patients.

The incidence of ADEs is significantly higher for high-risk medications like insulin, warfarin or heparin. In addition to patient harm, the cost of preventable medication errors in hospitalized patients in the U.S. is substantial, estimated at $16.4 billion annually. In the ambulatory environment, the incidence of harm and the costs are even higher.

Multiple solutions are required to address the issue of adverse drug events. These include several well-implemented technological solutions: computerized physician order entry (CPOE), computerized decision support, bar code medication administration, and radio-frequency identification (RFID) systems. It will also require addressing a number of process issues, including standardization, vigilance with respect to the “Five Rights” (right patient, right route, right dose, right time and right drug), double checks, preventing interruptions and distractions, removal of high-risk medications from certain areas, optimizing the role of clinical pharmacists, addressing the issue of look-alike and soundalike medications, and implementing effective medication reconciliation processes, particularly at hand-off points.


Surgical errors. There are over 20 million surgeries annually in the U.S. In recent years, a number of advances have resulted in significant improvements in the safety of surgery and anesthesia and reductions in harm and death. Still, a number of surgical safety challenges persist. These include persistent anesthesia-related complications, wrong-site surgeries, wrong patient surgeries, retained foreign bodies and surgical fires. One study indicated that 3 percent of inpatients who underwent surgery suffered an adverse event, and half of these were preventable. Studies have also shown that there is a strong relationship between volume and safety. That is, surgeons need to perform any given surgery a certain number of times to attain a level of skill required to minimize adverse surgical events. Addressing surgical safety will require a number of measures, including widespread adoption of safety principles already largely implemented by anesthesiologists (e.g., systems thinking, human factors engineering, learning from mistakes, standardization and comprehensively applying the “Universal Protocols” — including site signing and time outs), along with teamwork training, checklists and the use of best practices for minimizing retained foreign bodies and avoiding surgical fires.


Diagnostic errors. While they have received less emphasis, diagnostic errors are relatively common. For example, in the study that served as the basis for the IOM’s estimate of 44,000 to 98,000 annual deaths from preventable errors, 17 percent of the deaths were attributed to diagnostic errors. Furthermore, autopsy studies have demonstrated that 1 in 10 patients suffer a major antemortem error. Addressing this problem will require a number of measures, including avoiding fatigue, avoiding overreliance on past experience, improved training in cognitive reasoning and computerized decision support systems.

Person-machine interface errors (human factors engineering)
. Human factors engineering is an applied science of systems design that is concerned with the interplay between humans, machines and their work environments. Its goal is to assure that devices, systems and working environments are designed to minimize the likelihood of error and optimize safety. As one of its central tenets, the field recognizes that humans are fallible — they often overestimate their abilities and underestimate their limitations. This is particularly important in the increasingly complex healthcare environment, where fallible care providers are being overwhelmed by increasing complexity. 


Many complex care environments have little or no support from modern technology for care providers, and in those that do have such support the devices often have poorly designed user interfaces that are difficult and even dangerous to use. Human factors engineers strive to understand the strengths and weaknesses of human physical and mental abilities. They use that information to design safer devices, systems and environments. Thoughtful application of human factors engineering principles can assist humans dealing with complex care environments and help prevent errors at the person–machine interface.

Errors at transitions of care (handoff errors). Transitions of care between care environments and care providers are common in clinical care. These handoffs are a common source of patient harm. One study demonstrated that 12 percent of patients experienced preventable adverse events after hospital discharge, most commonly medication errors. Because they are so common, healthcare provider organizations increasingly are focusing on this type of harm.
 

Policymakers are also paying more attention to this type of harm. In 2006, the Joint Commission issued a National Patient Safety Goal that requires healthcare organizations to implement a standardized approach to handoff communications including an opportunity to ask and respond to questions. Because of studies showing very high 30-day readmission rates in Medicare patients (20 percent overall, nearly 30 percent in patients with heart failure), Medicare began penalizing hospitals with high readmission rates in 2012. All of this attention has stimulated a growing body of research focused on handoffs and transitions. This research is providing a deeper understanding of best practices, which have both structural and interpersonal components. These practices include standardized communication protocols (including “read backs”) and more interoperable information systems.

Teamwork and communication errors. Medicine is fundamentally a team sport. There is an overwhelming amount of evidence that the quality of teamwork often determines whether patients receive appropriate care promptly and safely. There are many clinical examples of this, including the management of a cardiac arrest (a so-called “code blue”), a serious trauma case, a complicated surgery, the delivery of a compromised infant or the treatment of an immune-compromised patient in isolation.
 

While the importance of teamwork is widely accepted, the evidence that it exists and that team members feel free to speak up if they see unsafe conditions is not strong. Over the last three decades, the aviation industry has learned the importance of teamwork and implemented state-of-the-art teamwork concepts which have had a dramatic impact on safety performance  Healthcare patient safety advocates have appropriately turned to the aviation industry to adapt their teamwork concepts to clinical care.

In addition, the JCAHO has provided evidence that communication problems are the most common root cause of serious medical errors...
 

Well-functioning healthcare teams should employ appropriate authority gradients that allow people to speak up, utilize aviation’s crew resource training communication model (CRM), use effective methods of reviewing and updating information on individual patients, employ accepted strategies to improve communications including SBAR (Situation, Background, Assessment and Recommendation) and so-called “CUS words” (I am Concerned, I am Uncomfortable and I feel it is a Safety ssue) to express escalating levels of concern, and constantly maintain situational awareness.

Healthcare-associated infections (HAIs). Healthcare-associated infections (HAI) are infections that people acquire in a healthcare setting while they are receiving treatment for another condition. HAIs can be acquired anywhere healthcare is delivered, including inpatient acute care hospitals, outpatient settings such as ambulatory surgical centers and end-stage renal disease facilities, and long-term care facilities such as nursing homes and rehabilitation centers. HAIs may be caused by any infectious agent, including bacteria, fungi and viruses, as well as other less common types of pathogens.
 

These infections are associated with a variety of risk factors, including:
  • Use of indwelling medical devices such as bloodstream, endotracheal and urinary catheters
  • Surgical procedures
  • Injections
  • Contamination of the healthcare environment
  • Transmission of communicable diseases between patients and
  • healthcare workers
  • Overuse or improper use of antibiotics
HAIs are a significant cause of morbidity and mortality. The CDC estimates that 1 in 20 hospitalized patients will develop an HAI, that they are responsible for about 100,000 deaths per year in U.S. hospitals alone and that HAIs are responsible for $30 to $40 billion in costs. In addition, HAIs can have devastating emotional, medical and legal consequences.
 

The following list covers the majority of HAIs:
  • Catheter-associated urinary tract infections
  • Surgical site infections
  • Bloodstream infections (including central line-associated infections)
  • Pneumonia (including ventilator-associated pneumonia)
  • Methicillin-resistant Staph aureus infections (MRSA)
  • C. difficile infection
As they are to other common sources of harm, federal policymakers are paying attention to HAIs. The U.S. Department of Health and Human Services (HHS) has identified the reduction of HAIs as an agency priority goal for the department. HHS committed to reducing the national rate of HAIs by demonstrating significant, quantitative and measurable reductions in hospital-acquired central line-associated bloodstream infections and catheter-associated urinary tract infections by no later than September 30, 2013. The final results of this program are yet to be published.
By using a variety of well-tested policies and procedures, there is encouraging evidence that healthcare organizations can significantly decrease the frequency of HAIs.

Other sources of errors. There are a variety of other sources of significant patient harm in clinical care. These include patient falls, altered mental status (often due to over sedation), pressure ulcers and venous thromboembolism, harm related to inadequate staffing ratios, harm resulting from nonstandardization, errors due to lack of redundant systems, harm resulting from inadequate provider training, harm caused by caregiver stress and fatigue, etc.
Following that, I found this next item interesting:
The role of information technology and measurement in safety 
Advanced information technology is playing an increasingly important role in patient safety. Technologies involved include Electronic Health Records (EHRs), CPOE, clinical decision support systems, IT systems designed to improve diagnostic accuracy, analytical systems, bar coding, RFID, smart intravenous pumps and automated drug dispensing systems. It is important to note that skill is required to implement these systems in a manner that promotes safety while not increasing the rate of harm.
The most aggressive Health IT critics routinely pooh-pooh HIT, calling it "dangerous, unproven technology that kills patients."

Regarding my ongoing "workplace toxicity" rant of late,
There is an overwhelming amount of evidence that the quality of teamwork often determines whether patients receive appropriate care promptly and safely...While the importance of teamwork is widely accepted, the evidence that it exists and that team members feel free to speak up if they see unsafe conditions is not strong.
Indeed. Health care delivery, particularly in the acute care space, will continue to be an irreducibly high cognitive burden, intractably time-stressed environment. Add into that any significant level of undue workforce stress stemming from culture dysfunctionality, well, as I've argued repeatedly, you are not going to Lean/Six Sigma your way around it. And, teaching "critical thinking" skills is, perversely, likely to make matters worse in some instances (where one speaks truth to power at one's peril).

See my earlier post addressing the High Engagement Workforce, Just Culture, and Leadership.

Also from this book:


Only ~TEN percent of our wellness factors are the result of healthcare system interventions. See my prior post about "the Upstream Factors."

UPDATE

Regarding Health IT "Usability" (UX), from EHR Science:
[C]linical work is role-based, collaborative, non-linear and integrative. These attributes of clinical work must be reflected in software designs.

See Building Clinical Care Systems, Part V: Supporting Clinical Work

As more clinical groups make their wishes known, the next step is turning them into real software—no small feat. It is certainly not something I expect the average EHR vendor to tackle single-handedly. The cost and resources required would be too much because there are so many basic research issues here. There are no models for clinical work and no reference user interface designs. Turning desired features into real software will require deep, long-term collaborations between clinicians, informaticists, software engineers, workflow specialists, usability experts, and many others. It is certainly more involved than adding a few features to current systems, or exchanging electronic documents.

So much time and energy have been put into systems conceived as electronic replacements for paper charts that we have lost track of the fact that care delivery, not updating a chart [emphasis mine -BG], is the goal of clinical work. Electronic charts have their place, but support for clinical work requires more...

Yeah, but, how long will MU, the proxy CQMs, and "productivity treadmill" tails continue to wag to clinical dog?

CODA

"Big Data"? LOL...


Tuesday, August 12, 2014

Rest in peace


Another genius, tragically gone too soon. My heart aches for his family. Song by Venice.