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Wednesday, November 26, 2014

Pardon the MU turkey?

RIP Meaningful Use Born 2009 – Died 2014???
BOB WACHTER, MD


The policy known as Meaningful Use was designed to ensure that clinicians and hospitals actually used the computers they bought with the help of government subsidies. In the last few months, though, it has become clear that the policy is failing. Moreover, the federal office that administers it is losing leaders faster than American Idol is losing viewers.

Because I believe that Meaningful Use is now doing more harm than good, I see these events as positive developments. To understand why, we need to review the history of federal health IT policy, including the historical accident that gave birth to Meaningful Use...

...I believe the policy decisions were sensible. And for a while, everything went pretty well. Meaningful Use Stage 1, implemented in 2010-12, consisted of achievable standards designed to ensure that EHRs were being used effectively. But it was not so prescriptive as to stand in the way of the primary goal, namely, wiring healthcare. Adoption rates soared and MU ensured that the computers were being used.

With Meaningful Use Stage 2 (2012-present), things went sour. The standards became far more aggressive, veering far more deeply into the weeds of clinical practice. MU now dictated how doctors should give out handouts to their patients (they must be prompted by the computer). It held doctors and hospitals responsible for ensuring that patients viewed and transmitted their data to third parties (most patients had no idea how to do this). It forced EHRs to meet onerous disability access requirements. All of these are noble goals, but all are bells and whistles – the kinds of changes you make after you’ve nailed the basics of getting the darned machines to work safely and efficiently...
Interesting post. Read the entire piece.
In the past six months, in fact, more than half of ONC’s senior personnel – its chief scientist, chief nursing officer, chief privacy officer, and director of consumer eHealth – have jumped ship.

I worked in the Meaningful use program for one of the RECs from its inception until I retired last year. I never liked the phrase "meaningful use" -- effective health IT use is what we need for improved patient outcomes, and the MU criteria comprise weak neonatal steps proxies for that. And, CHPL "certification" is an expensive joke. But, conversely, I find the overwrought whining about the putatively lethally onerous standardized data capture criteria equally fatuous. A typical 99123 outpatient encounter workflow, for example, will require the accessing, viewing, updating/editing/appending, perhaps transmitting, and evaluating (SOAP) of hundreds of variables (or more) in a patient's record. The numerator/denominator "structured data capture" MU criteria comprise about two dozen (including the CQMs), and most of those can be handled at the sub-MD support staff level, with minimal workflow adjustment (and, most of those MU vars you'd likely be capturing anyway, albeit in haphazard fashion). That's not theoretical for me; it was my job to help REC clients do precisely that.

Trying to shoehorn all of that necessary logistical and analytical work into a 20-30 minute patient visit is the real problem.

More from Dr. Wachter:
Rather than continuing to push highly prescriptive standards that get in the way of innovation and consume most of the bandwidth of health IT vendors and delivery organizations, MU Stage 3 should focus on promoting interoperability, and little else. Last month, an expert panel presented ONC with a reasonable set of recommendations calling for standardized, publicly available application programming interfaces (APIs), the EHR version of standardized light sockets. This change would allow EHRs to communicate with each other and developers to write apps that could link to the large systems like those built by Epic and Cerner. Promoting this kind of interoperability would be a judicious role for a smaller, less muscle-bound ONC, and for MU Stage 3.
"the EHR version of standardized light sockets?"

I've been making that type of analogy for a long time. See my "Interoperabbable" posts.
"Visualize going to Lowe’s or Home Depot to have to choose among 1,848 ONC Stage 2 CHPL Certified sizes and shapes of 120VAC 15 amp grounded 3-prong wall outlets."
Whatever.

I hope everyone has a safe and happy Thanksgiving holiday weekend, btw. Glad I don't have to travel. Happy 34th anniversary to my wife and best friend (this Friday).
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More to come...

Monday, November 24, 2014

"Big Data" and "surveillant anxiety"

"To control spiraling healthcare costs related to managing patients with chronic conditions, 70 percent of healthcare organizations worldwide will invest in consumer-facing mobile applications, wearables, remote health monitoring, and virtual care by 2018, which will create more demand for big data and analytics capability to support population health management initiatives."
From "Big HIT Changes May Be Coming Soon."

Saw an article in my Atlantic Monthly iPhone app recently. Tweeted it, and then read it and the links to which it led me.

Self-tracking using a wearable device can be fascinating. It can drive you to exercise more, make you reflect on how much (or little) you sleep, and help you detect patterns in your mood over time. But something else is happening when you use a wearable device, something that is less immediately apparent: You are no longer the only source of data about yourself. The data you unconsciously produce by going about your day is being stored up over time by one or several entities. And now it could be used against you in court.

The first known court case using Fitbit activity data is underway. A law firm in Canada is using a client’s Fitbit history in a personal injury claim. The plaintiff was injured four years ago when she was a personal trainer, and her lawyers now want to use her Fitbit data to show that her activity levels are still lower than the baseline for someone of her age and profession to show that she deserves compensation.

As an additional twist, it is not the raw Fitbit data that will be used in the courtroom. The lawyers are relying on an analytics company called Vivametrica, which compares individual data to the general population by using “industry and public research.” Vivametrica claims that they “define standards for how data is managed, bringing order to the chaos of the wearable.” In other words, they specialize in taking a single person’s data, and comparing it to the vast banks of data collected by Fitbits, to see if that person is above or below average.

Vivametrica says that they are doing more than just enabling consumers to get access to their own data. They are also working with wearable tech companies and healthcare providers, and seeking to “reimagine employee health and wellness programs.” But what happens when there are conflicting interests between individuals who want to monitor data about their body and employers, wearable manufacturers and healthcare providers, and now the law?

Vivametrica isn’t the only company vying for control of the fitness data space. There is considerable power in becoming the default standard-setter for health metrics. Any company that becomes the go-to data analysis group for brands like Fitbit and Jawbone stands to make a lot of money. But setting standards isn’t as simple as it may seem.

Medical research on the relationship between exercise, sleep, diet, and health is moving extremely rapidly. The decisions about what is “normal” and “healthy” that these companies come to depends on which research they’re using. Who is defining what constitutes the "average" healthy person? This contextual information isn’t generally visible. Analytics companies aren’t required to reveal which data sets they are using and how they are being analyzed...
Pretty interesting. I have a Fibit. It was a freebie when I upgraded to my iPhone 5s. Used to use a Jawbone (what a shoddy, flimsy product that is; I bought one for my wife. Both hers and mine flamed out in relatively short order. More hassle trying to get warranty service than the damn things are worth). I've not been wearing the Fibit lately. Put it on the USB charge cable and then forgot about it. In light of this news I may have to inquire more closely of this vendor whether they capture my activity and sleep pattern data, and, if so, what they do with them.

Using customers' data against them is nothing new. It predates the "cloud," social media, and biometric wearables. Back in the late 1990's when I was caring for my terminally ill daughter in L.A., a dustup hit the news regarding a major grocery chain customer who'd slipped on some liquid in an aisle (the result of a broken container that had yet to be cleaned up) and injured himself. He sued. The chain responded by introducing his "customer loyalty discount card" purchase data in their defense, alleging that his history of alcoholic beverage purchases indicated that perhaps he'd been intoxicated while in the store, and that was the proximate cause of his misfortune.

Fast-forward 16 years. Now our "Digital Panopticon" is ubiquitous, going far beyond store loyalty cards (all the way, at it most extreme, to extraconstitutional blanket NSA surveillance). Unless you fastidiously turn off Facebook location permissions, you may find it announced on your page -- for all your friends (and skulking, data-mining others) to see -- that you'd just dined at Lindo Michoacan Mexican restauarant and that you were now at the veterinarian with your dogs.

Both of those things happened to me. Trivialities, in those two instances, to be sure, but tiny snips of a much larger concern.
"Already, the lived reality of big data is suffused with a kind of surveillant anxiety — the fear that all the data we are shedding every day is too revealing of our intimate selves but may also misrepresent us."
From The Anxieties of Big Data, by Kate Crawford, author of the aforementioned Atlantic Monthly piece. Kate continues.
The current mythology of big data is that with more data comes greater accuracy and truth. This epistemological position is so seductive that many industries, from advertising to automobile manufacturing, are repositioning themselves for massive data gathering. The myth and the tools, as Donna Haraway once observed, mutually constitute each other, and the instruments of data gathering and analysis, too, act as agents that shape the social world. Bruno Latour put it this way: “Change the instruments, and you will change the entire social theory that goes with them.” The turn to big data is a political and cultural turn, and we are just beginning to see its scope.
"With more data comes greater accuracy and truth?" Myth, indeed. The utility of any set of data is a function of its intended use. "Big data" shot through with inacurracies can still be handsomely profitable for the analytical user (or buyer), irrespective of any harms they might visit on the individuals swept up (usually without their knowledge or assent) in the data hauls and subsequent proprietary modeling.

A personal illustration. I worked for a number of years (2000 - 2005) in subprime credit risk modeling at a VISA/MC issuer. We routinely bought "pre-screened" prospect mailing lists for our direct mail marketing campaigns. Direct mail campaigns can be in the aggregate quite profitable at a one percent response rate or lower. Ours, being targeted to credit-hungry subprime prospects with blemished credit histories, typically had response rates of about 4%. Of those who responded, about half did not pass the initial in-house analytical cut for one reason or another (many owing to impossible, bad data in the individuals' dossiers). Of the remaining 2% that we actually booked, perhaps half of those would eventually "charge off" (default). These were our "false positives."

The surviving 1% were lucrative enough to pay for everything, including a nice net margin (we set new annual profit levels every year I was there). It's called "CPA" -- cost per acquisition. Ours were about $100 per new account. Fairly standard in the industry at the time.

Potentially creditworthy (and profitable) prospects that we passed on after they replied were our "false negatives." And, ~96% of our marketing targets didn't even respond, so were were "wrong" about them (the "unknown unknowns") at the outset.

To sum up; we were in, a material sense, routinely 99% "wrong," but, notwithstanding, incredibly profitable.

Now, "big data shot through with inaccuracies" is entirely another matter when it comes to, say, "terrorism surveillance" and getting it wrong. Recall the stillborn post- 9/11 federal proposal for "Total Information Awareness." I do. Wrote about it here.
From William Safire's NY Times editorial (11/14/2002)
"...Every purchase you make with a credit card, every magazine subscription you buy and medical prescription you fill, every Web site you visit and e-mail you send or receive, every academic grade you receive, every bank deposit you make, every trip you book and every event you attend -- all these transactions and communications will go into what the Defense Department describes as "a virtual, centralized grand database."

To this computerized dossier on your private life from commercial sources, add every piece of information that government has about you -- passport application, driver's license and bridge toll records, judicial and divorce records, complaints from nosy neighbors to the FBI, your lifetime paper trail plus the latest hidden camera surveillance -- and you have the supersnoop's dream: a "Total Information Awareness" about every U.S. citizen.

This is not some far-out Orwellian scenario. It is what will happen to your personal freedom in the next few weeks if John Poindexter gets the unprecedented power he seeks...."
I warned back then:
In addition to the warrantless law enforcement implications of HSA's envisioned data repositories, we must also recognize that a TIA database will also constitute a commercial data-miner's wet dream of scope heretofore unimagined. Vigilance with respect to HSA collaborative "public-private partnerships" had better be tireless.
While TIA was nominally killed off (proud to say I had a small hand in its demise), things inexorably got worse. See my July 9th, 2008 post "Privacy and the 4th Amendment amid the "War on Terror."

Today we have all manner of virtually unregulated big data mining, modeling, and aggregated and re-aggregated resale going on, using all of us as correlational grist -- e.g.,  Google, the overtly commercial Amazon and their lesser competitors, and "free" social media platforms such as Facebook, Twitter, Tumblr, Pinterest, etc, along with business sites such as LinkedIn. Digital gumshoe companies such as Palantir are hard at work quietly drilling in the tar sands of social media, modeling away and "scoring" individuals for their clients, far from any regulatory purview.

The Digital Panopticon.


UBER KNOWS IF YOU'VE BEEN NAUGHTY

The ride-sharing startup Uber has recently gotten mired in some fractious bad publicity over their privacy practices. See, e.g., "Uber’s PR stumble drives new privacy woes."
The ride-sharing app this week finds itself in the midst of a major public-relations nightmare after BuzzFeed captured an Uber executive suggesting the company might conduct opposition research on journalists — not to mention a second incident in which an Uber employee looked at a reporter’s travel history...
See also "What’s Really Wrong With Uber?

 Also "7 reasons you may want to delete your Uber app."
1. Uber tracks riders’ hookups
In 2012, Uber said it was tracking user data to see which cities had the most one-night stands in a blog post titled “Rides of Glory.” Uber said it was analyzing data on its users’ car rides on Friday and Saturday nights between 10 p.m. and 4 a.m.

“The world has changed and gone are the days of the Walk of Shame,” the post says. “We live in Uber’s world now.” According to Uber’s analysis, Boston topped the list of cities with the most hookups. Uber took it a step further and even broke down its data by neighborhood. [slide 2]
If you don't have "Surveillant Anxiety," you've not been paying attention.

TRAFFICKING IN ePHI

Matthew Holt of Health 2.0 has a post up at THCB entitled "Is Deborah Peel up to her old tricks."
Long time (well very long time) readers of THCB will remember my extreme frustration with Patients Rights founder Deborah Peel who as far as I can tell spent the entire 2000s opposing electronic health data in general and commercial EMR vendors in particular. I even wrote a very critical piece about her and the people from the World Privacy Forum who I felt were fellow travelers back in 2008. And perhaps nothing annoyed me more than her consistently claiming that data exchange was illegal and that vendors were selling personally identified health data for marketing and related purposes to non-covered entities (which is illegal under HIPAA).
Dr. Peel (a psychiatrist) is the nation's pre-eminent alarmist regarding the putative perils of ePHI (electronic Protected Health Information). She apparently believes that her pure motives (and I have no doubt that they are) entitle her to being cavalier with facts and their conflation.

Matthew minces no words in conclusion.
It’s now put up or shut up time. Are personal health data resales a bigger industry than health IT? Are vendors really illegally selling identified health data? Is Deborah going to retract her statements? Or at least explain what she knows–with evidence please–that I’m missing?
See the accruing comments below Matthew's post.

I had a go at her during my October 27th, 2014 post "An Epic battle: Did the EHR kill Dallas Ebola patient zero? On the double-edged sword of Health IT."
In the immediate aftermath of the the Dallas Duncan dx debacle, sharp-elbowed HIT critics wasted no time assigning blame. The ever-strident patient privacy rights advocate Deborah C. Peel, MD posted a LinkedIn piece under a inflammatory click-bait headline "Why did Mr. Duncan have to die for the US to face flaws in EHRs?"

Nothwithstanding that [1] she's a psychiatrist, not an ER doc, [2] wasn't there in the Dallas ER, and [3] is not an Epic user...
Dr. Peel's recent awkward TEDx talk.


Make up your own minds. She asserts a lot of things that are in fact true. However,
Ms. Peel, @11:01,
“So, we know, for example, that physicians and their EHRs sell the [ePHI] data…”
Nice conjunctive conflation. Name some physicians who are selling ePHI?

Beneficent, public-minded motives don't grant you a pass on documentable specifics.
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A THOUGHTFUL BOOK ON PRIVACY

I read them all. This one is excellent.

In his essay “Commodities and the Politics of Value,” Arjun Appadurai has noted “the tendency of all economies to expand the jurisdiction of commoditization and of all cultures to restrict it.” The economy’s jurisdiction has now come to include human organs and genetic material, which are “mined” and “harvested” like minerals and crops. “We used to think our fate is in the stars,” says former Human Genome Project director James Watson. “Now we know, in large measure, our fate is in our genes.” So is the potential for making a lot of money, along with a new frontier for privacy abuse. A 2001 survey by the American Management Association revealed that 30 percent of large and midsize companies solicited genetic information about employees; 7 percent used the information in hiring and promotion. Meanwhile biotech companies “have flooded the federal patent office with applications to patent newly discovered genes” even though the genes occur naturally. One bioethicist has likened this trend to “patenting the alphabet and charging people every time they speak.”

Even when individuals manage to rise above a market mentality, they do not necessarily rise above the Market. In one especially disturbing instance, families whose children were victims of Canavan disease, a rare and fatal recessive disorder, donated their children’s tissue samples for research in the hopes that better prenatal diagnostics and new treatments would spare other families the suffering they had known. Later they discovered that researchers at Miami Children’s Hospital had patented the gene for Canavan and the hospital was charging royalty fees for diagnostic tests. In some cases, the same families whose donations had enabled the research were charged fees when they tested for the condition in other members of their households.

For scale of exploitation, few examples can match the story of Henrietta Lacks, a poor African American tobacco farmer, whose “immortal life” is recounted in a recent book by Rebecca Skloot. Prior to her death from cervical cancer in 1951, medical researchers at the “colored” ward of Johns Hopkins Hospital removed and cultured Lacks’s cells without her knowledge or consent. Since then more than 50 million metric tons of cells grown from this original “harvest” have been used for medical research, including the development of the polio vaccine, in vitro fertilization, and cloning. Of the millions in profits generated by Lacks’s unwitting donation, her family did not receive a penny. They did not even learn that her cells had been used until more than twenty years later, when they too became unwitting subjects of medical research.

In an effort to curtail such abuses, the state of Oregon passed the Genetic Privacy Act of 1995 , which mandated “informed consent for the collection , analysis, and disclosure of DNA information” and the destruction of DNA samples once testing was completed. The most controversial provision of the law was its “property clause,” stating that an “individual’s genetic information is the property of the individual.” Not surprisingly, the most vocal opposition to the property clause— in Oregon and in other states such as New Jersey and Maryland, which followed with genetic privacy statutes of their own— came from and on behalf of the biotechnical industry.

Sociologist Margaret Everett, who served on the Oregon Genetic Privacy Advisory Committee and whose son died as the result of a rare genetic disorder, opposed the property clause for different reasons. Though initially she had joined the committee with the aim of protecting the clause against legislative revision, noting that she felt “very‘proprietary’ about my son’s cells,” she eventually came to feel that “the proponents of individual property rights were encouraging, perhaps unwittingly, the very commodification and objectification that I found so troubling.” In other words, her son’s cells were not saved from economic exploitation simply by giving her an exclusive patent to exploit them.

Everett’s experience of wrestling with the property clause raises questions about how we construe privacy rights within the structures of a market economy. Even when we oppose the economic exploitation of our bodies, we find it difficult to do so in any way other than to turn them into salable property. To use Marx’s words, we cannot think of something as ours unless we “have it.” Is it possible that bodily integrity and personal privacy would find better fulfillment in a society where neither could be sold? Might our genetic material become most indisputably ours in a society that viewed its citizens— as the parents of the children with Canavan disease surely viewed themselves— as stewards of the common wealth of humankind?

Keizer, Garret (2012-08-07). Privacy (Big Ideas//Small Books) (pp. 89-92). Macmillan. Kindle Edition.
ERRATUM


Below: this is pretty interesting, my top 10 viewing countries the past 5 days.


Thanks for continuing to read.
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SPEAKING OF "SURVEILLANT ANXIETY"

How Medical Care Is Being Corrupted
PAMELA HARTZBAND and JEROME GROOPMAN, NY Times OpEd

WHEN we are patients, we want our doctors to make recommendations that are in our best interests as individuals. As physicians, we strive to do the same for our patients.

But financial forces largely hidden from the public are beginning to corrupt care and undermine the bond of trust between doctors and patients. Insurers, hospital networks and regulatory groups have put in place both rewards and punishments that can powerfully influence your doctor’s decisions.

Contracts for medical care that incorporate “pay for performance” direct physicians to meet strict metrics for testing and treatment. These metrics are population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice...


Physicians who meet their designated targets are not only rewarded with a bonus from the insurer but are also given high ratings on insurer websites. Physicians who deviate from such metrics are financially penalized through lower payments and are publicly shamed, listed on insurer websites in a lower tier. Further, their patients may be required to pay higher co-payments.

These measures are clearly designed to coerce physicians to comply with the metrics. Thus doctors may feel pressured to withhold treatment that they feel is required or feel forced to recommend treatment whose risks may outweigh benefits.

When a patient asks “Is this treatment right for me?” the doctor faces a potential moral dilemma. How should he answer if the response is to his personal detriment? Some health policy experts suggest that there is no moral dilemma. They argue that it is obsolete for the doctor to approach each patient strictly as an individual; medical decisions should be made on the basis of what is best for the population as a whole...


...the power belongs to the insurers and regulators that control payment. There is now a new paternalism, largely invisible to the public, diminishing the autonomy of both doctor and patient...

Medical care is not just another marketplace commodity. Physicians should never have an incentive to override the best interests of their patients.
I am not a fan of the "population health" thing. If every physician does what's best for her patients, the population health needle will move in the right direction in relatively short order.
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More to come...

Friday, November 21, 2014

A damning Health IT quote from Joe Flower

"A Medical Economics survey published last February showed that over 70 percent of physicians would not buy their current information system, if they had the chance to make that choice again, because they hate the way it works. Nearly 70 percent have seen no improvement in care coordination with the hospitals. And 45 percent believe it has actually hurt patient care."
From "Why You Should Ditch Your IT System."

So, three survey findings. The first one we can take at face value. The second and third, though, would be stronger with some underlying data having firm prior operational definitions, i.e., some scientific metrics going to adverse process "care coordination" and HIT proximate causes that "actually hurt patient care." Absent those, we're left mostly with partisan shouting-past-each-other points of contention. See, e.g., my prior post "An Epic battle: Did the EHR kill Dallas Ebola patient zero? On the double-edged sword of Health IT."

I am reminded of the saying "the plural of 'anecdote' is not 'data'."

Nonetheless, Joe's post is highly worthy of consideration. He's one of the most astute and charitable healthcare observers I've ever met. Read the entire post carefully.
So you spent millions to billions of dollars on information systems over the past few years, right?

How’s that working out for you?

For a large percentage of you, whether or not you admit it, not so well. What you bought needs some serious tweaks, re-engineering, re-thinking, re-vamping.

For an even larger percentage, maybe most of you, the best advice is: Junk it. Throw it out and start over.

Poorly designed and poorly implemented information systems are worse than useless, worse than a waste of those millions and billions of dollars. As we go through rapid, serious changes in health care, poor information systems will strangle your every strategy, hobble your clinicians, kill patients and actually threaten the viability of your organization.

A lot of health care executives dismiss the complaints about the new systems as the carping of stubborn technophobic doctors and nurses who should just get with the program. If you are tempted to do that, you need to take a step back. You need to get real. The complaints and concerns are too widespread, too deep and indeed too frightening for that kind of blithe denial. And they are not just coming from disgruntled docs...


In a recent Black Book survey, 98 percent of 13,650 registered nurses polled said nurses in their facility were never asked to help design the system; it was just imposed on them. As a result, 85 percent say the system is flawed and gets in their way, 94 percent feel that it has not improved communication among the care team, and 90 percent feel that it has damaged communication with the patient...

It’s Time
It’s not like this is new. It’s not like we didn’t see this coming. I have been writing about and advocating for the digitization of health care for 30 years, as have many others. I have to tell you: We knew back then that interconnectivity through industry standards — and smart user interfaces that assist clinicians in their normal workflow rather than hinder them — were hard problems that needed solving...
Yeah. "How's that working out for you?" Maybe Joe might inquire of Kaiser Permanente, users of the much-maligned Epic platform? See my Feb 6th, 2014 post "Meaningful Use 2013 review, ONC Working Group Stage 3 draft report, and discussion of KP's book "Connected for Health."

See also my May 28th, 2014 post on Joe, "Joe Flower on the Health tech revolution."

"It's not like we didn't see this coming." I return to my 2011 post "Use Case" and the observations of medical economist J.D. Kleinke, written nearly a decade ago.
HIT market failure. The underlying cause of Joe’s death is health information technology (HIT) market failure. If the state of U.S. medical technology is one of our great national treasures, then the state of U.S. HIT is one of our great national disgraces. We spend $1.6 trillion a year on health care—far more than we do on personal financial services—and yet we have a twenty-first-century financial information infrastructure and a nineteenth-century health information infrastructure. Given what is at stake, health care should be the most IT-enabled of all our industries, not one of the least. Nonetheless, the “technologies” used to collect, manage, and distribute most of our medical information remain the pen, paper, telephone, fax, and Post-It note.

Meanwhile, thousands of small organizations chew around the edges of the problem, spending hundreds of millions of dollars per year on proprietary clinical IT products that barely work and do not talk to each other. Health care organizations do not relish the problem, most vilify it, many are spending vast sums on proprietary products that do not coalesce into a systemwide solution, and the investment community has poured nearly a half-trillion dollars into failed HIT ventures that once claimed to be that solution. Nonetheless, no single health care organization or HIT venture has attained anything close to the critical mass necessary to effect such a fix.

This is the textbook definition of a market failure. All but the most zealous free-market ideologues recognize that some markets simply do not work. Indeed, reasoned free-market champions often deconstruct specific market failures to elucidate normal market functioning. The most obvious examples of such failures (such as public transit and the arts) are subsidized by society at large because such subsidies yield benefits to the public that outweigh their costs. Economists refer to these net benefits as “positive externalities,” defined as effects that cannot be captured through the economic equation of direct cost and benefit.

The positive externalities of an HIT system approaching the functionality of our consumer finance IT system include reduction of medical errors like the one that killed Joe Wilson; elimination of tens of thousands of redundant and expensive tests, procedures, and medications, many of which are not only wasteful but harmful; and the coordination and consistency of medical care in ways only promised by the theoretical version of managed care. These public health benefits are well beyond the reach of a health care system characterized by the complexities of medicine and conflicts of multiple parties working at economic cross-purposes. They are trapped outside the economic equation, positive externalities of a stubbornly fee-for-service health care system that inadvertently rewards inefficiency, redundancy, excessive treatment, and rework...
Back to Joe:
"[For] maybe most of you, the best advice is: Junk it (your EHR). Throw it out and start over."
Interesting. Maybe a small shop ambulatory practice will have that luxury, but I don't see larger acute care institutions going there, absent crushing exigent circumstances.

Joe in the comments (and my reply):


I subseqently went on with more.
“Meaningful Use,” btw, is a red herring whipping boy. The typical ambulatory EHR houses close to 4,000 variables in its RDBMS, with hundreds or more having to be accessed, viewed, updated, transmitted, synthesized etc during a conventional pt visit (and, yeah, to your point, a lot of them just to get paid). The subset numerator/denominator MU vars comprise less than 2 dozen (including the CQMs), most of which can be handed at the sub-MD support staff level.

Just to be clear: I’m no big MU fan, btw. I mocked the bozo-ness of it even while working in the MU program. See my Clinic Monkey (a “Survey Monkey” riff) ClinicMonkey.blogspot.com


The fact that it may take 5-8 clicks to get to a MU data target is stupid (e.g., in eClinicalWorks there are 4 different workflows for doing CPOE, ranging from 5 to 8 clicks). EVERY MU criterion should be macro-accessible in 1 click (or Dragon voice command). It’s not much to have to learn. I’d have insisted on macro capability within every ONC certified system as a condition of cert. Windows no longer has a macro utility, but there are 3rd party vendors of inexpensive macro utilities. Still, no one wanted the added expense and hassle of going 3rd party macro. And, in fairness, even optimizing MU workflows might still result in an additional $4,000 a year in labor cost (even if it only added minute or less to a note; I could show you the math).
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apropos of all of the foregoing, let's fast-forward up to late 2014. Where might we be headed? Jerome Carter, MD, at EHR Science:
A Question for EHR Vendors: What Is a “Real” Computer?

This might seem like a silly question with an obvious answer, but is it really? The solution to any problem grows out of the environment in which it appears and from the mindset in which it was conceived. In 1970, the answer to this question would have been a mainframe system. By 1981, after the Apple II and a few other microcomputers had been around for a few years, the answer for most people at that time would still have been mainframes (or maybe minicomputers as well)  because microcomputers were still considered to be toys. When IBM released the IBM PC AT in 1982, microcomputers began to be taken seriously as computers—that is, computers that could be used for real business applications.  The arrival of reliable local area networking technology cemented the status of PCs as real business computers.

Initially, local area networks (LANs) were used to share printers, disk storage, and applications.  However, as servers became more powerful and disk storage more dense and affordable, database management systems and sophisticated client/server software appeared...


Personal computers had to mature for a few years before they could tackle real problems, and smartphones and tablets are following the same pattern. Among other things, mobile computers add new user interface options and portability to the computing mix in ways that no other computing platform can match.   Solutions to clinical information management problems must now embrace mobile computing capabilities: touch-based interfaces, multi-media data management, communications functionality, and location/ movement awareness. Without question, the iPad Air 2 is a real computer, and it and other tablets with similar specs can be used to solve real problems.

Most current EHR software was designed well before tablets and smartphones existed, and many were born before the Internet really caught on. These EHR systems were designed back when LANs were state-of-the-art computing platforms, the cloud did not exist, Wi-Fi was painfully slow, and pointing was done with a mouse. The computing platform and development tools dictated how developers approached clinical information management problems...


Looking at clinical care and its computing needs, I see requirements that are distinct when compared to standard business computing.  Clinical data are varied and numerous. Clinical work consists of interacting with patients to obtain information, consulting information sources  (e.g., chart, guidelines, articles, other clinicians), making decisions, recording information, and moving on. Support for clinical work requires large, searchable data stores, fast networks, sophisticated communications functionality, and portable computers capable of displaying text, pictures, sound and video.  Tablets and smartphones are the first computers to meet all of these requirements.

Writing for mobile means stepping back from web and client/server applications and being willing to see a problem purely from the standpoint of mobile computing; that is, adopting a “mobile first” attitude.

Mobile first requires a willingness to rethink past approaches. At the top of the list is use of cloud capabilities. Like mobile computers, the cloud is a new way of doing things. Building mobile applications that link to cloud storage and use APIs to interact with other applications is a new way of delivering functionality.    There is no reason to have local terminology services if they can be obtained via a cloud application. The same is true of workflow engines or another service that supports clinical work. Mobile first also means not taking a client/server app and putting a mobile face on it.  That will not work any better than putting a browser interface on a standard desktop app. It might work to some extent, but the original design limitations will show through...
How many EHR vendors will bite the bullet and start serious mobile-first projects? Few, I imagine, because if the past is prologue, most will cling to the prevailing wisdom that mobile devices are not real computers. And we know how that story ends…
'eh?

OK, where will we get the requisite top gun HIT programming / UX design talent seemingly in short supply? From the current issue of The New Yorker:
THE PROGRAMMER’S PRICE
Want to hire a coding superstar? Call the agent.

BY LIZZIE WIDDICOMBE


Not long ago, Stephen Bradley, a New York tech entrepreneur, was looking to expand his company, AuthorBee, which aggregates tweets and Instagram posts and puts them together in story form. Instead of following people, readers can follow their interests—“Breaking Bad,” for example, or the New England Patriots. Bradley is not a stereotypical startup founder, a hoodie-wearing college dropout; he’s been working in tech and media for decades. To launch AuthorBee, he raised three-quarters of a million dollars from angel investors and hired programmers in Pakistan and Bangladesh to build a prototype. Now he wanted to build a bigger, better version of the site, so he had to find someone to write the code that would form AuthorBee’s DNA. The guys in Pakistan and Bangladesh were O.K., but the cultural differences and the language barriers slowed things down. He needed “one really good developer” with a mastery of all the coding languages and frameworks that AuthorBee uses: Python, Django, Angular, JavaScript, the Twitter A.P.I. The search for programming talent was the part of building a startup that Bradley most dreaded. “It is a nightmare,” he told me. “And I’m as plugged in as you can be to the New York tech scene.”

He put up a job posting on the Web site AngelList, and was immediately flooded with calls from headhunters and e-mails from offshore companies wanting to set up a “short online telephonic meeting.” “I could have had two hundred résumés on my desk,” Bradley said. But he knew that the people behind those résumés weren’t the ones he was looking for. His dream developer might be buried in there somewhere, but Bradley had come to think that developers were like social media itself: “Ninety-nine per cent of them suck.” He added, “The entire problem is wading through the noise.”...


The world is being rebuilt in code. Hiring computer engineers used to be the province of tech companies, but, these days, every business—from fashion to finance—is a tech company. City governments have apps, and the actress Jessica Alba is the co-founder of a startup worth almost a billion dollars. All of these enterprises need programmers. The venture capitalist Marc Andreessen told New York recently, “Our companies are dying for talent. They’re like lying on the beach gasping because they can’t get enough talented people in for these jobs.”

The computer science taught in colleges still focusses more on theory than on commercial application; the business of teaching practical coding skills has the whiff of trade school. So-called coding “boot camps,” such as General Assembly, founded in 2010, are trying to fill the gap, teaching crash courses in how to design Web sites and write code. But Jake Schwartz, the co-founder and C.E.O. of General Assembly, told me, “There’s simply not enough senior people in the system.”...
Well worth your time. Ponder the ramifications for Health IT.

More Joe Flower:
Zane Burke, the president of Cerner (which just bought Siemens), made a strong point about interoperability in a recent interview with H&HN Daily’s Matthew Weinstock:

“We all owe it to the country … to really perform true interoperability and create openness…. You need platforms that don’t just open up your APIs [application programming interfaces] but actually create ecosystems for other players … to perform well. We can’t use the operating system at the EHR lever as a competitive advantage. It just can’t be that way.
Yeah. See my posts on "Interoperababble" See also "Interoperability solution? HL7® FHIR® -- We ® Family."
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More to come...

Tuesday, November 18, 2014

When HHS (via ONC and AHRQ) publishes two spiffy documents announcing major long-term Quality Improvement initiatives,

Link (pdf)
Link (pdf)
you might confidently assume that you'd encounter some detail regarding fundamental priority cultural, tactical, and strategic terms and phrases such as
  • workforce;
  • workplace;
  • staff;
  • high-performance;
  • team-based;
  • burnout;
  • turnover;
  • CQI;
  • Deming;
  • Lean;
  • PDSA;
  • Six Sigma (or 6 Sigma);
  • DMAIC;
  • Agile.

You would be WRONG.

Zero. Zip. Zilch. Nada. Nyet. Don't take my word for it. Search the documents yourself.
 

Re-read my little recent trilogy:

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More to come...

Monday, November 17, 2014

Physician, Heal Thy System

OK, I finished this book this weekend.


Many, many dots to connect. Notwithstanding my many churlish blog comment critics ("BobbyG is an EHR vendor shill," "how many patients have you treated? You're not a doctor, your views are irrelevant"), I have always been a physician champion, for deeply personal reasons going far beyond the academic and theoretical. This book provides ample support for that view.
I love being a physician. I love it for many reasons, but the main one is because of what I am able to do for people like Antonio. And the incredible thing about being a doctor is that every one of the almost one million physicians in the United States has a similar story— not a cleft lip necessarily but a story in which the physician changed someone’s life in a magnificent way. Countless specialists and primary care physicians alike have stories in which they literally saved a life— reached in and rescued the patient from the edge of the precipice. Or they saved many lives— of children, expectant mothers, and aging grandparents. The joy and satisfaction in those moments for physicians is unlike any other experience.

To reach the point where we can do these things requires years and years of hard work, including the rigor of a heavy science load in college followed by the unrelenting demands of medical school. Academic work combined with clinical training builds the skills that gradually transform the student into a clinician who advances to residency training and fellowship, ranging from three to eight years. Only then comes the great reward: the ability to care for people who need you.

This is the heart of the matter. Physicians love being doctors because we have the privilege of being able to calm fears and alleviate suffering— to change and save lives. This is what motivates doctors virtually every single day of their lives. When the structure and culture in which physicians work are well aligned, it is a most rewarding job.
But something has gone wrong in the physician world, and it is urgent that we fix it. Fundamental flaws in our system make it more difficult and less rewarding than ever to be a doctor... 
We ask the question “What is a physician?” because the doctor’s role has evolved over time, with a particularly rapid evolutionary acceleration in recent years, and many physicians feel confused or resentful about the direction that health care has taken. The deal is not what they signed up for. It is not only the ever-expanding volume and complexity of the clinical work that they face. Far too many physicians also find themselves working amid circumstances characterized by chaos and waste, being encouraged to practice defensive medicine, and being pressured by excessive regulation and hectoring insurance companies...
THE EVOLUTION OF THE PHYSICIAN’S ROLE
The physician’s evolution requires shifting from an Industrial Age model of care to an Information Age model of care. In the Industrial Age model, the doctor focused on illness. He (nearly always he), worried about each patient, one at a time, making his clinical decisions in conditions of virtually total autonomy. There were wonderful aspects to this care. It was often highly localized and intensely personal. There was a warmth to it that was derived from a sense of a physician’s responsibility to family, friends, and community.

But there was no information technology, there were few sophisticated diagnostic techniques, and there was a limited use of other team members able to provide highly valuable care. Doctors knew what they knew. There were fewer sources of information and knowledge about new medical techniques, and innovation spread at a glacial pace.

In the Information Age, physicians take responsibility not just for individual patients but also for managing populations of patients— those with diabetes, for example— to make sure patients are fully up to date on all of the treatments and measures that improve their overall condition. Information Age physicians skillfully use electronic medical records, clinical registries— data on large numbers of patients and the internet— to help determine the most effective treatments and provide a great deal of care outside the doctor’s office. In the Information Age, metrics are central to delivering the best care to patients, many of whom engage in deep research related to their conditions on a nearly endless variety of websites dedicated to diseases, cures, and treatments. Too often, the question in health care for physicians is how many patients you can see today. But in the Information Age, the better question is how many patients’ problems you can solve today— and this speaks to the role of physician as leader in the Information Age.

It is not just physicians who are operating within the Information Age. Increasingly, it is, as we have noted, patients as well. The Information Age model requires disruptive innovation to the health care system by holding doctors responsible for all six of the Institute of Medicine’s essential elements of quality care: that it is safe, timely, effective, efficient, equitable, and patient-focused.

But is this fair? Is it reasonable to ask doctors to become something more than they have been? Some physicians chafe at the Information Age model. Most physicians already feel overwhelmed—understandably so. They are asked to do too much in a system that too often thwarts their efforts as much as it enables them.

We have no illusions about how difficult change in health care can be, especially among doctors. Dr. Gene Lindsey, former CEO of Atrius Health in Boston, has worked diligently in recent years to shift the culture of his organization, and he has found this to be exceedingly difficult work. “There is so much anxiety in the physician community,” says Lindsey. “Adaptive change is enormous work. It means giving up things we thought were bedrock.” He cites the example of a physician who is a true expert in his clinical field and then must go through lean training— learning a variety of lean management tools and methods to improve quality , safety, and efficiency. “So you go from being completely competent in an area to being a novice in a new domain. There are a lot of heated conversations.” Many doctors argue that the essence of their job is clinical: that a good doctor focuses on the condition with which a patient presents and then uses her or his skill and training to cure the problem. And many physicians will always cling to that definition exclusively, insisting that matters such as access, cost, and such are better left to administrators and policy makers.

Cochran, Jack; Kenney, Charles C. (2014-05-06). The Doctor Crisis: How Physicians Can, and Must, Lead the Way to Better Health Care (pp. 30-33). Public Affairs. Kindle Edition.
Episodically, you come across a book that inspires tremendously and adds serious value. This is one of them. Like these. And these. And these. And this. (I could, -- and will -- go on.) The Doctor Crisis is optimistic and documentably informed, all while painfully candid (it contains a sobering lookback into the public CusterFluck that was the Kaiser-Permanente Colorado experience). Not Polyanna-ish in the least.
Most physicians already feel overwhelmed—understandably so. They are asked to do too much in a system that too often thwarts their efforts as much as it enables them.
That is simply true. Recall another of my recent posts wherein I cite this book (below).

The healthcare workforce today. Where do we stand, and what should we do to expand and improve it?
Dr. Jauhar's book was widely panned for being "whiny." While I would not agree with that (I found it to a great degree quite forthright), I would categorize it overall in line with the Dr. Cochran's comparison of "cynic vs dissenter."
...I did not offer solutions to the problems that the physicians raised. I did not commiserate with “yeah, everything sucks.” I just listened. And what I heard at clinic after clinic, from physician after physician, was that they were deeply unhappy and often angry.

At one clinic in particular , I found that the staff was not angry so much as they were infused with a sense of futility. It was as though they were at a dead end and there was nothing they could do.

During the Listening Tour, I learned a critical lesson: the difference between cynicism and dissent. Cynics are characterized by a sense of hopelessness and futility and do not present alternative solutions along with their criticism. A dissenter, however, wanted to work to make the organization more effective. Thus, I learned a valuable lesson: Dissent has value, while cynicism has none.

Dissent can be just as angry as cynicism but comes with engagement: I care enough to be angry about the situation here. Dissent comes with ideas for change and solutions for improvement. Dissent is forward thinking and solution oriented. Cynicism is futile, hopeless, and negative [ibid, pp. 56-57].
HEALER-LEADER-PARTNER

This, below, is the crux of the Cochran-Kenney case.
In a paper titled “Physician Leadership in Changing Times,” authors Jack Cochran, Gary Kaplan, and Rob Nesse, pose a critical question: Who shall lead, and why?
The notion of joint or system wide accountability is gaining prominence, but which stakeholder— physicians, hospitals, health plans, or others— will lead delivery system transformation? We believe it must be physicians (emphasis added). Among all providers, physicians have a disproportionate impact on the health care system, and therefore have a disproportionate opportunity and responsibility to lead change. Patients experience their own health and the health care system in many ways: physically, socially, psychologically, and financially. As the first and primary point of contact with the health care system for most patients, physicians must therefore act as caregivers , teachers, trusted information sources, and fiduciaries for their patients . They cannot and should not opt in and out of accountability toward their patients in any one of these roles.
This powerful statement serves as a redefinition of a physician’s role— perhaps a broader definition than ever before. The authors insist that “physicians are ideally positioned, and in fact compelled, to take responsibility for helping shape the health care system— not just their own practice— to better serve patients’ physical, social, psychological, and financial needs. That is a huge task, and it cannot be accomplished with passivity or indifference.” 
Some doctors will respond by saying that they already lead— they lead their office staff, their practice, their specialty, and so on. There are also many outstanding physician leaders at major medical centers, medical schools, professional societies, research institutes, and more— examples that demonstrate the potential of physician leadership. Yet throughout the profession an enormous amount of leadership potential remains untapped, and this cannot continue. Talented physician leaders must come off the sidelines and assert themselves more broadly, for never before has the health care industry so urgently needed vision and leadership... [ibid pp.33-34]
"The Doctor Crisis" is an excellent, thought-provoking read. It had me immediately reaching back to, among many others, Maccoby's "Transforming Health Care Leadership."

Improving health care organizations means changing cumbersome bureaucracies into dynamic systems that are patient-focused, cost-effective, and propelled by collaborative learning. This requires culture change, and the first change will be with leaders throughout the organization. No one can do it alone. Leaders need to work together and enlist willing partners and collaborators to achieve these goals.

Knowledge leaders are also needed to network with people outside the organization to bring new ideas and knowledge into the system. A destructive myth that is all too common in many health care organizations is: “We know best.” A not-invented-here syndrome rejects thinking from outside the organization and makes life miserable for able knowledge leaders. In one well -known health care organization, they either reject ideas that come from outside the system or, if they adopt an idea, they rebrand it with their own name. They have a habit of not referencing the original author. Learning organizations pride themselves on the ability to learn from many sources and also understand the need to recognize original contributions to their thinking, both from within and outside the organization.
Another commonly believed myth is that physicians will only follow physicians , and as one MD hospital director commented , “When MDs become administrators, they are no longer considered physicians.” However, physicians and other health care professionals will follow a leader with the knowledge and personality qualities essential to change bureaucracies into learning organizations. It is a myth that these leaders need to be caring ombudsmen. The leaders we need sometimes pull people outside of their comfort zones. It is also a myth that a good leader has all the answers . The leaders we need are able to make use of the knowledge and learning of all collaborators.
Maccoby, Michael; Norman, Clifford L.; Norman, C. Jane; Margolies, Richard (2013-07-29). Transforming Health Care Leadership: A Systems Guide to Improve Patient Care, Decrease Costs, and Improve Population Health (Kindle Locations 645-659). Wiley. Kindle Edition. 
Indeed. I've studied both of the Maccoby leadership books. An invaluable repository of the multifacted psychological and cognitive characteristics of "leadership."

One aspect of "The Doctor Crisis" had me jumping for joy -- the authors' recurrent citation of variations on the word "toxic" in the context of healthcare workforce culture.
Partner Physician as partner means being a great team member and recognizes that the surest route to sustained quality care is through effective teamwork. An essential component of teamwork is not only how team members band together to care for the patient but also how team members treat one another. Physicians who have collegial professional relationships often get the most out of their teams. Partnering is about stepping up and addressing challenges that impact the ability of the team to care for patients; it is about identifying and eliminating barriers to excellent care. It is also about understanding information technology systems and making sure all team members are using the system effectively.

Physicians need to be central to the development of strong teams and to work with nurses, pharmacists, medical assistants, and others to ensure that they too have careers that are relevant, interesting, and satisfying. Some physicians condescend to nonphysician leaders from both hospitals and health plans. Yet a true physician partner— working closely with these leaders— can accomplish a great deal. Arrogance and condescension are toxic elements in a team setting. ["The Doctor Crisis," pp. 40-41]

Play to Win had a powerful emotional impact on many at KP Colorado. One was Dr. Ellsworth (not his real name), a charming, popular physician. But over time, with the toxicity and dysfunction of the medical group , his outlook deteriorated along with that of many other physicians. It was not uncommon for Ellsworth to complain about one aspect of the medical group or another. [ibid, pg. 84]

Too often, the medical culture in the United States tolerates bad behavior by doctors. The culture permits some doctors to be rude, dismissive, and condescending to anyone without an MD after their name. This egocentricity is toxic. What if Dr. Smyth (not his real name) creates an intolerable atmosphere in the clinic? By creating an environment of fear and instability, patients are at risk. It’s 3 a.m., and a patient is having a problem. The nurse is unsure what to do. She believes that there might be an issue, but she knows that Dr. Smyth is on call and that he can be trouble. The nurse thinks it through: If I call Smyth at 3 a.m. it could be ugly, so maybe we’ll just see if we can get the patient through the night until the hospitalist is on at 7. [ibid, pg. 87]


...Dr. Woodley (not the physician’s real name), a new hire, was highly talented and technically proficient. But early on it became clear that Woodley was often condescending and dismissive to staff members. Nothing like this had emerged during the recruitment and orientation periods, yet Woodley was persistently difficult from day one.

Staff members complained, and we— the leadership team— listened. Staffers told us that they were intimidated by Woodley and were routinely belittled, made to feel incompetent. A couple of staff members were so deeply shaken by the mistreatment they received from Woodley that they went on medical leave.

Leaders sat down with Woodley. “This is what we stand for,” we said, “and these are our expectations. We told you this when we hired you, and we told you this at orientation. And this is how you’re going to get evaluated, and it’s not going to go well.”

Woodley replied that it was all about efficiency. “I’m just efficient, and if these people are slow, they’re going to have to get faster, because I’m efficient.”

Efficiency is great, we agreed, but collegiality and effective teamwork are critical as well. We set up a formal performance evaluation and gave Woodley a six-month improvement plan with crystal-clear standards and expectations. Incredibly, the behavior did not change. Woodley continued to abuse staff members, creating a toxic environment in the clinic. So, a high-quality, highly functional clinical doctor who just simply couldn’t— or wouldn’t— treat staff well was dismissed. [ibid, pp. 92-93]
I have repeatedly used the phrase "psychosocial toxicity" on this blog while discussing what I feel to be key elements of "high performance healthcare delivery teams." e.g.,
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).
I repeat yet again:
A psychosocially healthy workplace is a significant profitability and sustainability differentiator.
I stand by that view. See my July 19th, 2014 post Medical Error, Interop, and the Patient Safety-Health IT nexus.

Lots more to think about and report (there's so much good work out there in the literature). Need more coffee at the moment. Buy the Cochran-Kenney book. I get nothing for touting it, btw.
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THE "QUADRUPLE AIM"

Just as Dr. Toussaint added an "8th waste" (misused talent) to the traditional Lean methodology's "Seven Wastes," In The Doctor Crisis we encounter "The Quadruple Aim," which supplants the traditional "Triple Aim" of the progressive healthcare reform ideal.
Dr. Bodenheimer and his University of California San Francisco colleague Rachel Willard made a valuable contribution to “In Search of Joy in Practice,” conducting seven of the twenty-three primary care site visits covered in the report. After studying the seven practices, Bodenheimer and Willard authored a paper titled “The Building Blocks of High-Performing Primary Care: Lessons from the Field” for the California Health Care Foundation in which they observed that primary care in the United States “is undergoing a transformation— from physician-centered practices to patient-focused teams.” Bodenheimer believes so strongly in the importance of clinician morale that, he says, “the Triple Aim should be a quadruple aim, with clinician and staff satisfaction a necessity to achieve the other three aims.”...
The work by Drs. Sinsky, Bodenheimer, and their colleagues is instructive and inspiring, for they have broken out of the narrow definition of a physician as healer and embraced the concept of physician as healer-leader-partner. In doing so, they have taken on broad accountability for their patients’ health care, going beyond the clinic in search of improvements and joining together with others in a collaborative process that enhances the strength and power of their recommendations. They have identified improvements that seek to summon the idealist and enable the healer in all physicians to alleviate suffering and save lives..
We need a new deal with physicians. Just as the doctors in Colorado needed preservation and enhancement of careers to trigger a surge in the quality of patient care, so too do we need a comparable deal now for the nation. This work to preserve and enhance physician careers is so critical that, as Bodenheimer says, “the Triple Aim should be a quadruple aim, with clinician and staff satisfaction a necessity to achieve the other three aims.”
Physician compacts are deals that health care organizations make with their doctors. More and more organizations throughout the country are turning to compacts to make as explicit as possible what the organization can expect from doctors and what doctors can expect from the organization... [The Doctor Crisis, pp. 118-120, 178]
This book hits all of the by now familiar best practices process QI notes (including adroit use of Health IT for data-driven analytics across the board), but goes well beyond that into detail regarding explicit "compact"/"code of conduct" workforce culture policy--policy that is essentially "Just Culture" material. e.g.,
Colorado Permanente Medical Group [CPMG] physicians demonstrate commitment to our patients, practices, and one another by providing high-quality, responsible medical care in a professional manner. 

In meeting this commitment, CPMG physicians will: 
1. Interact with other physicians , practitioners, and staff in their department, CPMG Leadership , and contacts in the community in a collegial, supportive, and professional manner.
  • Give feedback to colleagues in a professional manner.
  • Give corrective feedback to staff in a respectful manner away from patients and other staff. Take concerns about a colleague which cannot be resolved directly to the department chief. 
  • Express dissenting views in a respectful manner. 
  • Accept responsibility and seek solutions to problems.
  • Give candid and timely feedback on peer/ staff evaluations. 
2. Provide excellent service to patients and internal customers:
  • Communicate patient care plans, consultations, and treatments back to referring providers. 
  • Maintain strict patient confidentiality.
  • Treat members as valued customers.
  • Maintain appropriate provider-patient boundaries.
  • Be punctual in all medical care settings (medical center, hospital, etc.).
  • Maintain high-quality provider-patient relationships by any member satisfaction measurement (Art of Medicine, Patient Satisfaction, etc.).
  • Attempt to resolve patient concerns.
  • Assume responsibility in general for decreasing his or her patient waiting time for appointments when the wait is unacceptably prolonged.
  • Respond appropriately to hospitals, page operators, and others.
  • Be flexible in accommodating changes in patient demand to best meet the needs of the patient and the medical group.
  • Balance multiple and at times unexpected or conflicting demands of patients.
  • Clearly explain the plan for care to the patient to better ensure patient compliance and satisfaction.
  • Demonstrate courtesy, respect, and a caring attitude to patients in order to enhance the provider-member relationship. 
  • Control emotional reactions toward patients and others.
3. Support the Principles of Medical Practice (Policy No. 5.03, Appendix A) and be careful stewards of our members’ resources. 
4. Participate as members of the health care team:
  • Meet work unit requirements and equitably share in the workload to ensure the department's needs are met.
  • Participate in Quality Assurance activities and follow accepted clinical guidelines.
  • Attend and participate in departmental meetings and team improvement activities.
  • Schedule time-off requests in a fair and collaborative manner subject to department needs.
  • Avoid maligning or undermining colleagues to patients or other physicians and staff, either verbally or in writing
  • The supervision of and collaboration with midlevel practitioners is strongly encouraged.
5. Contribute to the success of the Medical Group: 
  • Be an advocate of Kaiser Permanente and its principles.
  • Follow the policies and directives of the Board of Directors and administration.
  • Support and participate in the development and implementation of strategic change initiatives. 
[This Code of Conduct was not intended as an exhaustive statement about professional conduct and did not limit the discretion of Medical Group management in addressing concerns regarding conduct.] (ibid, pp. 194-196)
"Just Culture." See in particular Marx's "Whack-a-Mole: The Price We Pay For Expecting Perfection."

While some physicians make no bones about their irascible disdain for anything that impinges on their "autonomy" (particularly when it comes from non-clinician superiors), the authors note that
Throughout their careers, physicians have been continuously tested and measured. After all, every physician went through a challenging undergraduate course of study in the sciences just to be able to make it to medical school. As medical school students, they work to absorb immense amounts of clinical learning . Then comes the rigor of residency. Every step of the way for those ten or more years of education and training, these young men and women are measured on performance. They understand what it means , and in the vast majority of cases they welcome it. For most, it affirms their commitment to excel. [ibid, pg. 88]
Yes, assuming a Just Culture, I would add. The physician must internalize the necessity and desirability of becoming Healer-Leader-Partner within his/her own workplace culture if the goal of truly effective patient-centered care is to be realized.
Physician, Heal Thy System.
CODA

Dr. Toussaint on "Leadership."

Gemba is another useful word from the Japanese. Literally translated as “workplace,” gemba refers to the place where real value is created in an organization. Senior leadership of most companies spend shockingly little time there. If the CEO does appear in the intensive care unit or a busy emergency room, it’s usually a backslapping tour, meant to underline his authority and spread the idea that he both cares about and keeps a close eye on operations. At Toyota, on the other hand, going to the gemba meant assisting operations: looking for problems or improvement opportunities and finding out what workers need to stay on target. It means getting to know, first hand, the issues facing front-line workers and helping to work out solutions. It means learning, not teaching and telling.
Toussaint, John; Gerard, Roger (2010-06-06). On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry (Kindle Locations 1315-1320). Lean Enterprise Institute, Inc.. Kindle Edition.
"It means learning, not teaching and telling."
Indeed. apropos, brings to mind another of my endless reads.


Below, from one of my irreverent REC slide decks:


"Lean Champions." Uh, that would be "leadership."

ONE LAST THING...

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More to come...