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Tuesday, July 22, 2014

Mission Statement

Mission Statement

[Verse 1:]
We must all efficiently
Operationalize our strategies
Invest in world-class technology
And leverage our core competencies
In order to holistically administrate
Exceptional synergy
We'll set a brand trajectory
Using management's philosophy
Advance our market share vis-à-vis
Our proven methodology
With strong commitment to quality
Effectively enhancing corporate synergy
Transitioning our company
By awareness of functionality
Promoting viability
Providing our supply chain with diversity (versity, ooooh)
We will distill our identity
Through client-centric solutions
And synergy (Oooooh oooh oooh)

At the end of the day (At the end of the day)
We must monetize our assets
The fundamentals of change
Can you visualize a value-added experience?
That will grow the business infrastructure and
Monetize our assets
Monetize our assets
Monetize our assets

[Verse 2:]
Bringing to the table
Our capitalized reputation
Proactively overseeing
Day-to-day operations
Services and deliverables
With cross-platform innovation
Networking, soon will bring, seamless integration
Robust and scalable, bleeding-edge and next-generation
Best of breed
We'll succeed
In achieving globalization

And gaining traction with our resources in the marketplace
It's mission-critical to stay incentivized
Against this purple-poster-flexible-solutions [?] for our customer base
If you can't think outside the box
You'll be downsized
It's a paradigm shift! (Hey, Hey! Look out!)
Well, it's a paradigm shift, now!
(Here we go! Here we go! Here we come! Here we come! Ha!)

Weird Al Yankovic, from his new CD "Mandatory Fun."

Monday, July 21, 2014

"There is no more wasteful entity in medicine than a rushed doctor."

From the New York Times:
Busy Doctors, Wasteful Spending

OF all the ways to limit health care costs, perhaps none is as popular as cutting payments to doctors. In recent years payment cuts have resulted in a sharp downturn in revenue for many hospitals and private practices. What this has meant for most physicians is that in order to maintain their income, they’ve had to see more patients. When you reduce the volume of air per breath, the only way to maintain ventilation is to breathe faster...
Indeed. "Productivity treadmill" and all that. He cites the Mayo and Cleveland Clinic models, in which physicians are ostensibly insulated from the Suits and all their MBA Worry Beads.

Read all of it. What do you think?

apropos, from Health Affairs (subscription firewalled):
‘Nothing Is Broken’: For An Injured Doctor, Quality-Focused Care Misses The Mark
Charlotte Yeh

It was just after 6 o’clock in the evening on Wednesday, December 7, 2011—Pearl Harbor Day—when I left my organization’s Washington, D.C., office to meet a colleague for dinner. It was dark and rainy, and I had one more intersection to cross to get to the restaurant. I was about a third of the way across the intersection when I heard a loud “thump” and felt a sharp pain squarely in my backside. A dialogue unfolded in my head: “Wow! I wonder what that was…. I think it was me. No, I don’t think it was me. Wait…I think I just got hit by a car! But there’s no way!” Before I could even make sense of the situation, I had flown through the air and landed on the street...

As a medical professional who became an accident victim and then a trauma patient, I was a participant-observer in emergency care, with a big-picture window into how well our health care system does or doesn’t work...

In my case, I was struck by the uneven nature of my care, marked by an overreliance on testing and a narrow focus on limited quality metrics such as pain management or catheter care processes. Looking back, I believe that this approach fostered an inattention to my overall well-being. Instead of feeling like a connected patient at the center of care, I felt processed and disengaged. This is disconcerting, especially at a time when patient-centered care—that is, care delivered with me, not to me or for me—is becoming the new normal.

The Oath of Hippocrates, the medical profession’s ethical creed, reads: “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.” This vow compels physicians to heed both the “science” and the “art” of medicine. The science often lies in defining the treatment regimens. The art lies in understanding what matters personally to the patient.

Even in an ideal world, this would be a high bar to clear. Despite some national consensus on quality metrics, we have continued struggling to measure “the good of the patient.” Still, quality metrics cannot alone advance the good of the patient. Focusing on clinical measures in particular is not enough as long as other measures that focus on patient-desired outcomes are ignored. If we don’t understand what patients’ expectations are, we can’t engage patients effectively in their care.

Through my experience as a patient, I observed a bias in what the metrics track: toward the clinical and away from the personal. To help restore this balance and reassert the “art” of care, I see three areas that the medical community should address...

The unintended consequence of our current approach is that the clinical measure can become more important than the patient. I am afraid that as a result, we may be training a new generation of practitioners to equate high-quality care with conducting a test. Instead of having the test be used to discover new information about the patient, it is being used to define if one even is a patient.

Personalizing care
After I’d spent four days in the hospital, it dawned on me that not once had anybody come by to ask how I was doing, what I needed, what I wanted, or whether I had any concerns. I then understood something that my own patients had been telling me all the time: They don’t feel engaged in their own care. There is nothing personal about it...

Patient-reported outcomes currently in development, such as asking for the patient perspective (“what do you want,” “what are your fears,” “what matters to you”) and equalizing the patient-provider dialogue, create shared partnership in the outcomes and might have made a difference in my care. Going forward, quality metrics should give more weight to patient-reported outcomes, if we want to truly assess care more effectively. As my experience suggests, we’re not quite there yet.

The 'North Star' of Care
If I resolved anything on my care journey, it is that the “North Star” guiding all care must be providers using “any means possible,” to know the patient, hear the patient, and respond to what matters to the patient. It should make no difference where you practice; any provider can do this. Emergency departments can’t hide behind the excuses of “we’re too busy” or “it’s too chaotic” to avoid connecting with every patient.

It is time to frame a new paradigm of care, a consumer-driven approach that concentrates attention on the art of medicine. This might begin with a reinvigorated focus on patient-centered care and mastering the skills of listening, empathy, and patient partnership...
Yes, but the "productivity treadmill" could not be more antithetical  to "listening, empathy, and patient partnership."

Dr, Yeh's article is a lengthy and thoughtful piece, poignantly so. I have cited only some small excerpts. Highly recommended.

I groused a bit about our obsession with "quality metrics" back in April.

Process measures like Meaningful Use, CQMs, PQRS, etc, as I've noted before, are tangential proxies for effectiveness in health care. It's assumed that if you are doing and reporting on X, Y, Z, A, B, C, D, E, and F, improved outcomes will eventually follow.

How about if we lay on a concerted effort to measure actual outcomes directly?
Yeah, like maybe to include actually listening to the patient at greater length and depth?

More to come...

Saturday, July 19, 2014

Medical Error, Interop, and the Patient Safety-Health IT nexus

"Preventable medical errors persist as the No. 3 killer in the U.S. – third only to heart disease and cancer – claiming the lives of some 400,000 people each year."
Wow. Where does Health IT fit into that?

I've been reviewing the recent RAND study (pdf).
Promoting Patient Safety Through Effective Health Information Technology Risk Management
Health information technology (IT) safety has several dimensions: using health IT to make care safer, ensuring that health IT is itself safe, and ensuring that health IT is used safely. The potential for health IT to improve the safety of health care delivery has been appreciated for decades, but the role of health IT in introducing safety risks has been recognized only more recently. As the use of health IT has grown, users have begun also to observe its fallibility. Hardware and software can malfunction. Data can be lost or corrupted during transmission. Deploying complex technologies in a complex organizational environment can introduce new hazards and safety risks. Identifying and mitigating health IT safety risks is a relatively new undertaking for most health care organizations. The introduction of health IT safety improvement initiatives could be expected to face many of the challenges that accompany introduction of any change to clinical practice. Introduction of new tools and practices can require substantial organizational effort...
None of these concerns are actually "news." And, the most strident critics of Health IT continue to angrily assert that EHRs are dangerous, unregulated "medical devices." I joust with them regularly on the major HIT blogs. Not that I summarily dismiss their concerns. Having commenced my white collar career writing apps code in a forensic-level radiation lab in Oak Ridge in the 80's, I know a thing or two about software QA and "usability" (dated as my keyboard-level experience may now undeniably be). Skeptics are a necessary and good thing, insofar as they don't wander off into "Perfectionism Fallacy" territory (sometimes called the "Nirvana Fallacy"). While there is indeed much merit in the HIT criticisms, I find a good bit of the anti-HIT carping as unscientific as the charges of lack of rigor they lob (usually from behind their untraceable troll screen names) at the industry and the regulators.

You gotta Walk your Talk, boys.

The RAND methodology:
To learn about the sites’ experience with the process improvement strategy, including the resources and safety event reporting, an evaluation team from the RAND Corporation conducted in-person and telephone interviews with representatives of six of the hospitals and ambulatory practices. The evaluation team used a semi-structured interview protocol to elicit information about the sites’ experiences with identifying risks and implementing new health IT safety practices, as well as their experiences with the AHRQ Common Formats. The evaluation data were analyzed thematically and described in case study reports. A comparative analysis was performed to identify differences and similarities in sites’ implementation experiences; to develop a series of lessons learned; and to offer recommendations that may be useful to hospitals and ambulatory practices seeking to manage safety risks posed by health IT, policy makers, electronic health record (EHR) developers, and other stakeholders.
More excerpts:
Health IT Safety Risk Identification and Mitigation
Identifying and mitigating health IT safety risks is a relatively new undertaking for most health care organizations. The introduction of health IT safety improvement initiatives could be expected to face many of the challenges that accompany introduction of any change to clinical practice. Introduction of new tools and practices can require substantial organizational effort.11, 12 Health IT improvement poses unique challenges. Line authority over health IT–related risks within health care provider organizations is not well articulated or standardized. The multiple distinct lines of management authority over health IT, quality, and safety within organizations may create a hurdle to the systematic and coordinated identification and management of IT risk. For example, in hospitals and larger medical groups, operation of EHRs is typically managed by an IT department, efforts to improve safety may be carried out by a quality management group with a medical director and a patient safety officer, risk management is the purview of risk and liability managers, and regulatory compliance and reporting may be embedded in a compliance department. In ambulatory settings, one individual may be responsible for several of these tasks. Hospitals and ambulatory practices may be able to collaborate with health IT developers to reduce health IT–related safety risks, but it is unclear how developers and their customers should work together to identify and mitigate such risks...
Fostering Collaboration Among Departments and Disciplines
Health IT safety is a cross-cutting area that creates an opportunity for risk management staff, safety staff, and IT staff to collaborate. Each disciplinary perspective contributes distinct knowledge to the detection, analysis, and mitigation of health IT safety risks. Several enablers of collaboration could support future initiatives: (1) disseminating best practices (case study examples of organizations that have successfully tackled a particular problem) and project templates (step-by-step project guides for specific problems or checklists); (2) providing staff from distinct disciplines with training in core terminology and methods related to safe use of health IT; and (3) developing a cadre of experts who can provide consultation through regional extension centers (RECs), PSOs, or other organizations and can facilitate training programs. The SAFER Guides provide a valuable tool for multidisciplinary, multifunctional teams to optimize the safety and safe use of health IT, EHRs in particular...
Content I was most interested in finding is referenced in Table 2.1
  • Internal organizational features -- Policies, procedures, work environment, and culture.
Cutting to the chase,
Beyond expertise and infrastructure for quality improvement, staff at several sites emphasized the need for a “culture of safety” within the organization. A culture of safety (or “just culture”) implies that an organization treats error as an opportunity for improvement rather than cause for individual blame. Indicators of a culture of safety include a system for encouraging and rewarding staff for identifying risks and reporting adverse events and a non-punitive approach to addressing medical error...
OK, so far, so good. Recall my "Talking Stick" post. 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).
Summing things up:
The challenges and lessons identified in this pilot project point to several opportunities to increase the safe use of health IT systems. We draw several conclusions about the current state of health IT safety risks:
  1. With few exceptions, awareness of the safety risks introduced by health IT is limited. Many organizations sense that health IT is difficult to implement successfully, and some have experienced significant patient safety events, but organizations vary in their appreciation of the connection between those difficulties and events and their health IT installation. At the current time, engagement of front line clinicians in detecting and mitigating health IT–related safety risks appears to be limited.
  2. The traditional departmental “silos” between risk management, IT, and quality and safety management may impede the ability of organizations to recognize and respond to health IT safety risks. This is especially the case in hospitals. For some hospitals, this project represented the first time that staff from these different departments had worked in collaboration with one another.
  3. External facilitation appears to be important to hospitals and practices, but the model for providing consultation and technical assistance requires further elaboration. This model has to account for wide variation in the capabilities of most hospitals and ambulatory practices to take on health IT risk mitigation projects.
  4. Most ambulatory practices lack the risk management, IT, and quality and safety expertise that is available in hospitals. Ambulatory practices have limited staff capacity to address health IT safety, given the more pressing challenges of maintaining a financially viable ambulatory practice in a rapidly changing health care market.
  5. There is an urgent need for tools and metrics to enable project teams in hospitals and ambulatory practices to detect, mitigate, and monitor health IT safety risks. Tools available to project teams during this project were not adequate to fully support the needs of the organizations participating in this pilot project.
  6. The current structure of the EHR marketplace, and the low awareness of the risks introduced by health IT systems, lead to weak incentives for EHR developers and providers to invest in the type of joint effort required to reduce health IT safety risks. Because of that market failure, certification and standards will continue to be an important mechanism for ensuring that EHR products are designed to minimize the introduction of new safety risks.
The RAND report concludes:
The investment that is converting the U.S. health data infrastructure into a 21st century enterprise has the potential to improve care for patients in countless ways. However, “digitizing” the health system also has the potential for harm. In this project, we worked with 11 hospitals and ambulatory practices to evaluate a process improvement strategy and tools developed to help health care organizations diagnose, monitor, and mitigate health IT–related safety risks. While many of the health care organizations (especially the hospitals) had expertise in process improvement, we found a general lack of awareness of health IT–related safety risks (especially in ambulatory practices) and concluded that better tools are needed to help these organizations use health IT to improve care and to optimize the safety and safe use of EHRs. The SAFER Guides provide an excellent beginning, but until health care organizations have a better understanding of the safety risks posed by EHR use, tools like the SAFER Guides may not be used to their full potential. There may also be a need for additional tools and metrics (and further usability study of existing tools and metrics) to better support the needs of health care organizations. ONC could additionally support efforts in this area by strengthening incentives for EHR developers to make safer health IT products and to participate with providers in risk mitigation.
Yeah. One persistent limitation I find in all of these reform proposals is that we continue to have a near-exclusive "transactional / instrumental" view of people in the healthcare workforce. Maybe that works fine for Amazon or WalMart (see Simon Head's "Mindless"), but I would like to see more explicit "Just Culture" emphasis on what I have come to call the "psychosocial health" of care delivery organizations. Maybe I'm being naive, running the risk of becoming the butt of Dilbert Zone jokes.

I don't think so. I repeat once more:
A psychosocially healthy workplace is a significant profitability and sustainability differentiator.
Again, some of my recent recommended reading list on the subject:

To which I will add one more.

This book is an utter delight. An important read. I read it quite some time back, and am going back through it closely with the highlighter for further triangulation.
To err is human. Yet most of us go through life tacitly assuming (and sometimes noisily insisting) that we are right about nearly everything, from the origins of the universe to how to load the dishwasher. If being wrong is so natural, why are we all so bad at imagining that our beliefs could be mistaken – and why do we typically react to our errors with surprise, denial, defensiveness and shame?

In Being Wrong, journalist Kathryn Schulz explores why we find it so gratifying to be right and so maddening to be mistaken, and how this attitude toward error corrodes our relationships—whether between family members, colleagues, neighbors, or nations. Along the way, she takes us on a fascinating tour of human fallibility, from wrongful convictions to no-fault divorce, medical mistakes to misadventures at sea, failed prophecies to false memories, “I told you so!” to “Mistakes were made.” Drawing on thinkers as varied as Augustine, Darwin, Freud, Gertrude Stein, Alan Greenspan, and Groucho Marx, she proposes a new way of looking at wrongness. In this view, error is both a given and a gift – one that can transform our worldviews, our relationships, and, most profoundly, ourselves.

In the end, Being Wrong is not just an account of human error but a tribute to human creativity – to the ways we generate and revise our beliefs about ourselves and the world. At a moment when economic, political, and religious dogmatism increasingly divide us, Schulz explores the seduction of certainty and the crisis occasioned by error with uncommon humor and eloquence. A brilliant debut from a new voice in nonfiction, this book calls on us to ask one of life’s most challenging questions: what if I’m wrong?
"Human factors," "culture of safety," "UX," etc, yeah, all fine and necessary. But, a more nuanced view of the breadth of the nature of error -- "being wrong" -- is warranted, in my view.


From a Journal of Quality and Safety in Healthcare paper cited in the RAND study:
Safety culture assessment: a tool for improving patient safety
in healthcare organizations

V F Nieva, J Sorra

...Professional and organizational cultures in health care must undergo a transformation in the interests of promoting safer patient care. Health care must come to see itself as a high hazard industry which is inherently risky. It must abandon the philosophy of requiring perfect, error free performance from individuals and focus, instead, on designing systems for safety. Healthcare systems must move away from the current ‘‘blame and shame’’ culture that prevents acknowledgement of error and therefore obstructs any possibility of learning from error. Safety improvement requires that healthcare systems have ready access to information that supports learning from experience in order to promote systems that both prevent errors and mitigate the impact of errors that occur. In contrast to a ‘‘pathological culture’’ where failure is punished or concealed and people refuse to acknowledge that problems exist, a positive safety culture recognizes the inevitability of error and proactively seeks to identify latent threats...

For example, adverse event reporting systems will not overcome chronic under-reporting problems within a punitive culture where acknowledgement of error is not acceptable. Analytical methods such as root cause analysis (RCA) and failure mode effects analyses (FMEA) will not succeed in uncovering latent sources of error if staff, bound by an implicit ‘‘code of silence’’ and a fear of challenging the institutional hierarchy, are uncomfortable with exposing weaknesses in processes for which they are responsible. Even benefits from new technologies designed to improve safety, such as computerized physician order entry, may not be realized if they are not accompanied by cultural and process changes...

OK, that was published in 2003! Are we just gonna study things to death forever, publishing an endless stream of papers for wonk audiences, redundantly advocating for that which has already been advocated multiple times? I know: maybe AHRQ can let an RFP for an $800,000 two-year research grant via which to study the RAND study (like they've done with topics such as workflow).


It's been a tough week for focusing attention on the issues pertinent to this blog. First, the renewed acute violence in Gaza, and then the astonishing atrocity of the shooting down of Malaysian Airlines flight 17 over the Ukraine. Very depressing.

More to come...

Wednesday, July 16, 2014

Pedant's delight

My crusty views on sloppy use of language are well known. It is at once a cause of and a reflection of sloppy thinking, for which we have no time.

This is great fun.

BTW: "Data ARE..." Grrrr.r...

Weird Al is the undisputed King of the send-up. I dabble in it, in my Other Life. See, e.g., here, and here (my latest, music video in progress). I just bought his new CD "Mandatory Fun." His spoof of "Royals" is very funny: "Foil" (mp3).


Layoff notice, Microsoft style.

More to come...

Saturday, July 12, 2014

"No clinical metric conforms to a six sigma standard"

Nortin Hadler, MD, posting on THCB:
"If patients were widgets, if care givers were production workers, and if caring conformed to “six sigma” principals [sic], even slight deviations from standards of care would be as easy to recognize, those responsible could be singled out for improvement, and remedies would be obvious. This is the mantra of the quality agenda that drives health policy. In a corollary exercise in linguistic determinism, health economists and hospital administrators are wont to speak of patients as “units of care”, physicians as “providers”, and clinical demand as “throughput.”  But manufacturing cell phones or producing fast food has little in common with managing the care of patients in all their variability and with all their unpredictability. No clinical metric conforms to a six sigma standard; we in medicine are barely comfortable defining “normal” with a 95% confidence interval and we are fully aware that “outliers” can be clinically normal and those in the normal range can be abnormal. Forcing the clinic into the six sigma paradigm is worse than an exercise in futility; it is an exercise in iatrogenicity."
When Dr Hadler speaks, we do well to listen. His criticism of Health IT goes beyond the usual UX carping:
"It was the end of a long day in clinic a couple of weeks ago. I found myself sitting next to a colleague, a young, talented and well-read academic orthopedic surgeon. Each of us was staring at a computer screen displaying our “Physician’s Dashboard”, the gateway to the granularity-generating Electronic Medical Record (EMR) purveyed by EPIC. EPIC is a privately-held, exceedingly profitable company that dominates the multi-billion dollar EMR marketplace. Both of us are novitiates with the interface; UNC Hospitals only recently “went live” with EPIC at great cost in terms of personnel time and in terms of hundreds of millions of dollars. I was grumbling as I fought with the program to create a clinically useful medical record for the sake of the patients I had been seeing that day. My surgical colleague urged me to create templates and “smart sets”; he found EPIC easily manageable thanks to these short-cuts to record keeping which took advantage of any and all aspects of patient care that were stereotypical.

First, I took him to task on behalf of my patients. I explained that for a rheumatologist like me, and all others who are labeled “cognitive” specialists, the care of the patient revolves around the “granularity” of the narrative. I needed to listen actively to my patient to understand the particular idioms that populate any narrative of distress. And I need to communicate the approach the patient and I would take to sorting out the illness and formulating management to all involved in this patient’s care. It is an exercise that takes advantage of individual differences and idiosyncrasies rather than pummeling narratives into common denominators. I never assume the average, nor do I ever presume the outcome. Templates and “smart sets” are anathema."
Read the entire post, including the comments. Lots to think about. For openers, it has me reaching back down in the Weeds'

Essential to health care reform are two elements:  standards of care for managing clinical information (analogous to accounting standards for managing financial information), and electronic tools designed to implement those standards. Both  elements are external to the physician’s mind. Although in large part already developed, these elements are virtually absent from health care. Without these elements, the physician continues to be relied upon as a repository of knowledge and a vehicle for information processing. The resulting disorder blocks health information technology from realizing its enormous potential, and deprives health care reform of an essential foundation. In contrast, standards and tools designed to integrate detailed patient data with comprehensive medical knowledge make it possible to define the data and knowledge taken into account for decision making. Similarly, standards for organizing patient data over time in medical records make it possible to trace connections among the data collected, the patient’s problems, the practitioner’s assessments, the actions taken, the patient’s progress, the patient’s behaviors and ultimate outcomes.

Two basic standards of care, and corresponding tools, bring order and transparency to medical decision making:
  • First, from the outset of care, relevant patient data must be chosen, and its implications determined, based on the best available medical knowledge, independent of the limited personal knowledge of the practitioners involved. Patient data must be systematically linked to medical knowledge in a combinatorial manner, before the exercise of clinical judgment, using information tools to elicit all possibilities relevant to the problem situation, while defining and documenting the information taken into account. Practitioners’ clinical judgments may add to, but must not subtract from, high standards of accuracy, completeness and objectivity for that information.
  • Second, in complex cases, particularly in cases of chronic disease, the organization of data in medical records must be optimized for managing multiple problems over time. This means that each medical record must begin with a complete list of carefully defined patient problems, and that other clinical information in the record must be linked to the problem or problems to which it relates. Without that structure for the medical record, decisions are made out of context, follow-up and coordination of care are haphazard, and records are not usable for rigorous clinical research.
With these two basic standards of care, and the information tools needed to implement them, practitioners and patients can manage the flood of detailed information required for sound decision making over time. With this detailed information, made usable for research in structured electronic medical records, medical care can become increasingly refined and individualized. In contrast, so-called “evidence-based medicine” is derived from large population studies that fail to account for the medical uniqueness of each patient.

Enforcing the necessary standards and tools depends on changing medicine’s culture of professional autonomy for highly educated physicians. Indeed, the concept of a physician as we know it is not viable. All practitioners must submit to meticulous definition and control of their inputs to care (a principle recognized by the patient safety movement). The primary barrier to this cultural change is graduate medical education and credentialing. These social institutions (1) fail to define, disseminate and enforce high standards of quality for provider inputs to care, (2) inhibit effective design and use of information technology to manage clinical information, and (3) suppress competition among providers who might otherwise exploit information technology to generate remarkable advances in patient care and medical knowledge.
“The consequences of that digitization of information in a reasonably systematic way, guided by meaningful use, will have enormous, difficult to predict, and generally positive effect on the American health system over a generation to come. That’s my view of it. I know that physicians find certain aspects of meaningful use problematic. Some find it too aggressive. Some find it not aggressive enough. But, I still think it was a reasonable way to proceed, and we’ll see the results over decades.”

- David Blumenthal, MD

The Misuse of Meaningful Use, Part II

Originally Certified EMRs and Meaningful Use policies were created so as to provide the financially incentive to encourage primary care physicians to adopt electronic medical record programs and then use these electronic medical record programs according to specified “meaningful use” mandates. It was the hope that the appropriate use of EMRs would improve the quality or reduce the cost of healthcare. Since the program’s introduction, Meaningful Use has been expanded to almost every medical specialty and subspecialty, regardless of the appropriateness/relevance.

There has now been a fair amount of data accumulated regarding the effectiveness of electronic medical record programs. Unfortunately, most of the published data is not high quality and the majority of clinical trials are now being funded by the EMR industry. As we have seen with clinical trial sponsored by the pharmaceutical industry, only an irrational person would accept the results of a vendor sponsored EMR trial on face value...

In recognition of the federal government’s desire to promote electronic medical record programs, and despite the lack of “proof of efficacy,” the Massachusetts insurance industry appears to feel that they too should promote the use of EMRs/ and Meaningful Use. As a result, some of the large Massachusetts insurers are including clauses in their contract which mandate that physicians use certified EMRs according to Meaningful Use standards, and they are applying these mandates both to primary care physicians and specialists.

Given the lack of objective data about the effectiveness of EMRs, this is an outlandish overreach by the Massachusetts insurance companies which will interfere with the patient-physician interaction. As a practicing physician I am appalled to learn that the Massachusetts insurance companies seriously believe that they know how I should structure the use of my time in the exam room...
Read all of it, including the comments. Massachusetts is trying to be the first state to make Meaningful Use Certified EHR use a condition of physician licensure and insurance carrier acceptance. We'll see how that plays out.


The past decade has witnessed an explosion of electronic health data. Diagnostic images, lab results, and biometric information are generated and stored in digital form. Key elements of medical records are abstracted using natural language processing. Medical claims provide a treasure trove of longitudinal data. Those who bring these disparate threads together and apply them to real-life situations have created the next big thing in health care: big data.

Big data has the potential to improve clinical decision making at the point of care. Tapping into vast databases, a physician can access knowledge relevant to the individual patient, yielding better decisions and outcomes. Big data also has the potential to revolutionize research. Massive databases enable observational studies on a scale and at a speed randomized controlled trials cannot approach...
I now subscribe. Stay tuned...





Building Clinical Care Software Systems, Part I: Issues and Challenges

by Jerome Carter on July 14, 2014
Creating software is hard. The entire process, from deciding that a piece of software is needed to implementation, requires analysis and problem-solving–every step. I was reminded of this reality anew when I began the latest round of coding for my seemingly mythical startup. There are so many decisions to make that affect the final product, even though I consider what I am trying to build to be fairly straightforward in design and features. Building a good clinical care software system is many times more difficult.

Given the troubles that are plaguing EHR vendors in meeting MU stage 2 requirements, this seems like a good time to talk about what goes into building a system that supports clinical care...
Well worth your time. Jerome is definitely a SME. Below, I annotated his table of the components of Health IT architecture.

Recall my "standard data dictionary" rant:
One. That’s what the word “Standard” means -- er, should mean. To the extent that you have a plethora of contending “standards” around a single topic, you effectively have none. You have simply a no-value-add “standards promulgation” blindered busywork industry frenetically shoveling sand in the Health IT gears under the illusory guise of doing something goalworthy.

One. Then stand back and watch the private HIT market work its creative, innovative, utilitarian magic in terms of features, functionality, and usability. Let a Thousand RDBMS Schema and Workflow Logic Paths Bloom. Let a Thousand Certified Health IT Systems compete to survive on customer value (including, most importantly, seamless patient data interchange for that most important customer). You need not specify by federal regulation (other than regs pertaining to ePHI security and privacy) any additional substantive “regulation” of the “means” for achieving the ends that we all agree are necessary and desirable. There are, after all, only three fundamental data types at issue: text (structured, e.g., ICD9, those within other normative vocabulary code sets, and unstructured, e.g., open-ended free-form SOAP note narratives), numbers (integer and floating-point decimal), and images. All things above that are mere “representations” of the basic data (e.g., text lengths, datetime formats, Boolean/logical, .pngs, bmps, .tiffs, .jpegs etc)...

More to come.

Wednesday, July 9, 2014

Meaningful Use registrations and payments update

~$24.415 billion in cumulative MU payouts thus far. Stage 2 registrations count, attestations, and payments thus far (through May 2014) are indeed pretty puny. Off to a slow start. Full CMS summary tabular report here (pdf).


Everyone needs to understand the difference between "relative" and absolute" risk and "NNT" (Number Needed to Treat) in healthcare tx.

This is a great series. Clear and quick explanations acorss a breadth of clinical topics.

Meaningful use program: Code blue

Hit the button, call the crash cart: Meaningful use could be triggering a code blue.

Respected health IT leaders such as meaningful use guru Jim Tate and Beth Israel Deaconess Medical Center CIO John Halamka, M.D. may be right in painting a picture of the health IT incentive program as "in need of overhaul." Similar notions show up in letters issued earlier this year by the College of Healthcare Information Management Executives and American Medical Association calling for "flexibility" in stage 2 rules and last year's letter to HHS from six senators, who termed it a "reboot."

The word we're getting out of Washington D.C. in discussing recent events with sources on and off the record paints a far graver picture than a possible overhaul. Sources tell us that morale at the Office of the National Coordinator for Health Information Technology (ONC) has withered and Republicans will continue to call into question the existence of the meaningful use program as well as the ONC itself as election season draws closer...
A high-ranking EHR vendor executive familiar with D.C. machinations we spoke to hasn't heard anything about morale issues at ONC. This executive wouldn't be surprised, however, to hear of such problems, considering the barrage of criticism the agency endures from physicians, industry and political foes over the structure, execution and backtracking on meaningful use...

Even if we are stepping into a post-meaningful use world as of today, healthcare CIOs, as they like to put it, will have to keep the lights on: Data will need a place to be stored. Wi-Fi and wired infrastructure will have to work. Clinical data will need to be protected and backed up in compliance with HIPAA. Radiologists and cardiologists will keep cranking out pictures and videos at a record pace. Patients in remote areas will still need telemedicine visits. Payers will still demand that coders and billing departments create claims with ICD codes, documented just so.

In sum, health IT isn't going anywhere.

But meaningful use might be.
Policy ADHD? Will there even be a MU Stage 3?

Those pesky, troublesome end-users. From Politico:
INDUSTRY, MINUS DOCS AND NURSES, PLEASED WITH DIRECTION OF HEALTH IT RULES: The FDA and a diverse set of industry groups — and even Congress — have reached a high degree of consensus on how to regulate health IT. The only outliers seem to be the doctors and nurses who use the tools every day. As the comment period ended for the framework report on health IT regulation written by the FDA, FCC and the Office of the National Coordinator for Health IT, Hill sources pointed to the large overlap of FDA’s vision and that of industry, patient and research groups. “We don’t have any major differences,” says Janet Marchibroda, executive director of the CEO Council on Health and Innovation at the Bipartisan Policy Center, which is central to pushing the regulatory reform agenda. “We are excited because we see a convergence here. And we see agreement on the Hill too. Hooray!” Not everyone is so enthusiastic, including the National Nurses Union, whose director, RoseAnn DeMoro, blasted the FDA report as a “remarkable abdication of federal regulatory responsibility.”

More to come...

Tuesday, July 8, 2014

"Doctors have become a profession of whiners"?

A news feed headline I just saw.
Doctors have become a profession of whiners. Meetings, dinners, doctor’s lounge and blogosphere are flooded with physician complaint, tirade and anger. The volume of pained voices suggests that health Armageddon is only a few moments away.

It was not always so. Medicine is a career where idealism runs rampant. In medical school interviews young students really do answer that they want to help their fellow man.  Nonetheless, in recent years that has changed.

Instead of espousing the latest breakthroughs, preaching preventative care or carrying on collegial disagreement about research direction, doctors harangue about insurance company dominance, the intrusion of dehumanizing electronic records, ridged evidence-based-venn-diagram treatment regulations, lost autonomy, malpractice assault and of course plummeting reimbursement. Why has the mantra of the doctor moved from; I am here to help, to I am here to be harassed?

Pundits blame doctors for much that it wrong and therefore justify broad attacks on the profession. Doctor’s [sic] over-diagnose, over-treat, and over-charge, all resulting in massive cost overruns. They fail to use objective analysis and best standards, depend too much on pharma sales data, and rush lemming-like toward the next glittering breakthrough. Physicians are accused of making income their primary drive, with overblown salaries and even fraudulent billing. The power of the doctor’s order drives chaos.

Are physician complaints simply the response of a failed profession as it is bludgeoned with reality?  Should we hear their frantic words as bombastic, hubristic self-preservation, or is it a warning?  Whom are they trying to protect?  What are they trying to achieve?...
A prominent physician wrote that. My comment:
I will be citing this on my blog. Been thinking, reading, and writing a lot lately about what I call “psychosocial toxicity” in the healthcare workforce culture. At its worst, it poses patient safety issues. Beyond that, it’s enervating and counterproductive for everyone involved.

While there may be a (negative) “publication bias” (only the angry and frustrated docs get attention; happy ones don’t blog or comment as much), the problems are significant, and need remediation.
I recently challenged another physician's blog post definition of healthcare's "toxic workplace" as perhaps too narrow (given that it was simply a petulant litany of all the ways physicians are burdened by organizational and regulatory things they dislike). His response?
"Go to hell."
Yeah, that's real constructive. I replied that maybe he ought consider retiring. Medicine is not the only field with maddening requirements and professional frustrations.

Been giving a lot of thought to all of this lately. As I wrote in a prior post,
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).
My study continues.

More to come...

Sunday, July 6, 2014

On the bubbleliciousness of mHealth?

"We’ll put sensors in snow cones, aggregate all the data, optimize, and then we’ll know everything about who prefers what kind of snow cone, and we’ll correlate that with their health prospects and their career prospects, and then we’ll sell that [sic] data!"
Only kidding. It was just funny. Not that there's no grain of truth there. From "Nerds on the Knife Edge" in the current issue of The Baffler.

On the same riff, see Evgeny Morozov's trenchant "To Save Everything, Click Here."

...That smart technology and all of our social connections (not to mention useful statistics like the real-time aggregate consumption of electricity) can now be “inserted” into our every mundane act, from throwing away our trash to making tea, might seem worth celebrating, not scrutinizing. Likewise, that smartphones and social-networking sites allow us to experiment with interventions impossible just a decade ago seems like a genuinely positive development. Not surprisingly, Silicon Valley is already awash with plans for improving just about everything under the sun: politics, citizens, publishing, cooking...

Morozov, Evgeny (2013-03-05). To Save Everything, Click Here: The Folly of Technological Solutionism (p. 5). Public Affairs. Kindle Edition.

More to come...

Friday, July 4, 2014

Interoperababble update

From JAMIA: (pdf)

EHR adoption and Meaningful Use
EHR use in the USA has risen rapidly since 2009 with certified EHRs now used by 78% of office based physicians and 85% of hospitals. Meaningful Use (MU), a staged federal incentive program enacted as part of the American Recovery and Reinvestment Act of 2009, has paid incentive of US$21 billion to hospitals and physicians for installing and using certified EHRs pursuant to specific objectives. Stage 1 of the program (MU1) commenced in 2011, Stage 2 (MU2) in 2014, and Stage 3 is expected by 2017.

While the term interoperability can refer to messages, documents, and services, MU provides several objectives that prioritize document interoperability. Although multiple document standards existed prior to MU1, providers with installed EHRs rarely had the capability to send structured patient care summaries to external providers or patients, as noted by the President’s Council of Advisors on Science and Technology and the Institute of Medicine. MU1 advanced document interoperability by requiring Continuity of Care Document (CCD) or Continuity of Care Record (CCR) implementation as part of EHR certification. Many vendors chose the CCD, which was created to harmonize the CCR with more widely implemented standards. In MU2, the C-CDA, an HL7 consolidation of the MU1 CCD with other clinical document types, became the primary standard for document-based exchange...
Putting aside the "interoperability" misnomer (it's really just about data exchange among 2014 CEHRT systems; no one's remotely operating another's EHR from across town or from the other side of the nation), the unsurprising answer to the title question is "no."
Background and objective Upgrades to electronic health record (EHR) systems scheduled to be introduced in the USA in 2014 will advance document interoperability between care providers. Specifically, the second stage of the federal incentive program for EHR adoption, known as Meaningful Use, requires use of the Consolidated Clinical Document Architecture (C-CDA) for document exchange. In an effort to examine and improve C-CDA based exchange, the SMART (Substitutable Medical Applications and Reusable Technology) C-CDA Collaborative brought together a group of certified EHR and other health information technology vendors.
Materials and methods
We examined the machine-readable content of collected samples for semantic correctness and consistency. This included parsing with the open-source BlueButton.js tool, testing with a validator used in EHR certification, scoring with an automated open-source tool, and manual inspection. We also conducted group and individual review sessions with participating vendors to understand their interpretation of C-CDA specifications and requirements.
We contacted 107 health information technology organizations and collected 91 C-CDA sample documents from 21 distinct technologies. Manual and automated document inspection led to 615 observations of errors and data expression variation across represented technologies. Based upon our analysis and vendor discussions, we identified 11 specific areas that represent relevant barriers to the interoperability of C-CDA documents.
We identified errors and permissible heterogeneity in C-CDA documents that will limit semantic interoperability. Our findings also point to several practical opportunities to improve C-CDA document quality and exchange in the coming years.
"615 observations of errors and data expression variation"? In one small study? Now, perhaps some of the data expression "variability" is nominally trivial (the errors are certainly not), but this is pretty disturbing.

I refer you to my February 23rd post, "The Interoperability Conundrum: Arguing for a std data dictionary."

I've pretty much lost that fight, I know. Nonetheless...



Interesting paper. Free, but registration required for access.
While Big Data enjoys widespread media coverage, not enough attention has been paid to what practitioners think — data scientists who manage and analyze massive volumes of data.
We wanted to know, so Paradigm4 teamed up with Innovation Enterprise to ask over 100 data scientists for their help separating Big Data hype from reality. What we learned is that data scientists face multiple challenges achieving their company’s analytical aspirations. The upshot is that businesses are leaving data — and money — on the table...
  • We’ve all heard how hard it is to analyze massive and rapidly growing data volumes. But data scientists say variety presents a bigger challenge. They are at times leaving data out of their analyses as they wrestle with how to integrate and analyze more types of data such as time-stamped sensor, location, image and behavioral data as well as network data.
  • For complex analytics, data scientists are forced to move large volumes of data from existing data stores to dedicated mathematical and statistical computing software. This time-consuming and coding-intensive step adds no analytical value and impedes productivity.
  • While Hadoop has garnered widespread media coverage, 76 percent of data scientists have encountered serious limitations using it. Hadoop is well suited for embarrassingly-parallel problems but falls short for large-scale complex analytics.
  •  Incorporating the diverse data types into analytical workflows is a major pain point for data scientists using traditional relational database software.
The overwhelming volume of corporate and organizational data continues to generate headlines but it’s the diverse types of data that pose a bigger challenge. Nearly three-quarters of data scientists — 71 percent — said Big Data had made their analytics more difficult and data variety, not just volume, was the challenge.
Many new analytical uses require significantly more powerful algorithms and computational approaches than what’s possible in Hadoop or relational databases. Data scientists increasingly need to leverage all data sources in novel ways, using tools and analytical infrastructures suitable for the task. As we have already seen in this survey, organizations are moving from simple SQL aggregates and summary statistics to next-generation analytics such as machine learning, clustering, correlation, and principal components analysis on moderately sized data sets. The move from simple to complex analytics on Big Data presages an emerging need for analytics that scale beyond single server memory limits and handle sparsity, missing values and mixed sampling frequencies appropriately. These complex analytics methods can also provide data scientists with unsupervised and assumption-free approaches, letting all the data speak for itself [sic]...
Well, at the end of the day, BI and clinical users of data are still only interested in three types of data: [1] text (both "structured" and unstructured narrative), numbers (integers and floating-point), and [3] images (both static and dynamic). How they originally get defined, and the interop problems of such heterogeneity, points directly back to the issue of dictionary standardization. It is indeed less of problem of data magnitude and more one of the n-dimensional translation issues inherent in the heterogeneity.


More to come...