Latest HIT news, on the fly...


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)

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).

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…

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:
Want to hire a coding superstar? Call the agent.


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."

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:


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 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].

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.


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.

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."



More to come...

Thursday, November 13, 2014

The AMA on Usability - "the design and implementation of EHRs do not align with the cognitive and/or workflow requirements and preferences of physicians within and across specialties and settings."

Good paper.
The AMA recognizes that not all EHR usability issues are directly related to software design. Software design varies greatly among vendors and specific organizations that often customize EHR functions. For example, some EHR usability issues are a result of sub-optimal implementation, required by the practice itself or part of an organizational policy (e.g., risk management, institutional liability concerns or inadequate training of users). Other issues may be related to regulatory requirements (e.g., state and federal regulations such as an overly prescriptive MU). EHR usability issues may also be due to suboptimal practice workflow processes that have been incorporated into EHRs. Workflow analysis, collaborative end-to-end workflow design and associated training are very expensive and are often neglected in projects with limited budgets and strict timeframes to meet MU requirements (i.e., deadlines to receive subsidies and/or to avoid penalties)...
Eight EHR Usability Priorities
Enhance Physicians’ Ability to Provide High-Quality Patient Care. Effective communication and engagement between patients and physicians should be of central importance in EHR design. The EHR should fit seamlessly into the practice and not distract physicians from patients.
Support Team-Based Care. EHR design and configuration must: (1) facilitate clinical staff to perform work as necessary and to the extent their licensure and privileges permit and (2) allow physicians to dynamically allocate and delegate work to appropriate members of the care team as permitted by institutional policies
Promote Care Coordination. EHRs should have enhanced ability to automatically track referrals and consultations as well as ensure that the referring physician is able to follow the patient’s progress/ activity throughout the continuum of care.
Offer Product Modularity and Configurability. Modularity of technology will result in EHRs that offer flexibility to meet individual practice requirements. Application program interfaces (APIs) can be an important contributor to this modularity
Reduce Cognitive Workload. EHRs should support medical-decision making by providing concise, context sensitive and real-time data uncluttered by extraneous information. EHRs should manage information flow and adjust for context, environment and user preferences.
Promote Data Liquidity. EHRs should facilitate connected health care—interoperability across different venues such as hospitals, ambulatory care settings, laboratories, pharmacies and post-acute and long-term care settings. This means not only being able to export data but also to properly incorporate external data from other systems into the longitudinal patient record. Data sharing and open architecture must address EHR data “lock in.”
Facilitate Digital and Mobile Patient Engagement. Whether for health and wellness and/or the management of chronic illnesses, interoperability between a patient’s mobile technology and the EHR will be an asset.
Expedite User Input into Product Design and Post-Implementation Feedback. An essential step to user-centered design is incorporating end-user feedback into the design and improvement of a product. EHR technology should facilitate this feedback. 
As one would expect, Jerome Carter, MD is all over this on his excellent EHR Science blog.
AMA Conclusion: The Road Forward

According to the AMA Rand study, the single largest driver of professional satisfaction is the physician’s perceived ability to deliver high quality care to patients. The AMA believes that if the above priorities were implemented in the EHR design, it would (1) enable physicians to deliver such care, (2) improve physician experience with the technology, (3) increase physician productivity and (4) reduce administrative costs. Aside from these eight EHR usability priorities, the AMA believes that additional research is needed to determine how EHR use promotes or inhibits high quality care. It is essential to better understand the cognitive needs of physicians and how EHR products can meet them, identify evidence that outlines the benefit tools that support decision-making and explore how EHRs influence the patient encounter. All are opportunities for research that would benefit the advancement of EHR technology. Finding evidence of what works and what doesn’t work will be critical to improving EHRs.
That's all fine and necessary, and I guess this being the AMA, the physician-centric focus is inevitable. But, there are larger necessary policy (Fee For Service?) and organizational paradigm changes ("Talking Stick?") going far beyond technology that, if left largely unaddressed will likely significantly hinder or negate any UX/workflow advances.

Consider that a typical complete ONC certified ambulatory EHR system may house between 3,000 to 4,000 RDBMS variables under the GUI hood, and a typical "moderately complex patient" encounter (e.g., a 99213) may require finding/accessing, viewing, updating/editing, and evaluating/synthesizing many hundreds of them (or more; e.g., longitudinal "flow sheet" trend data and/or specialist findings) as part of the SOAPE process, all in a severely constrained period of time.

Do a workflow/click-thru time consumption thought experiment. See also my blog post update of August 8th, 2010.

Dr. Carter on the AMA paper:
...Building systems with features in line with the AMA framework requires knowledge about clinical work and models of how information is used by clinicians, neither of which  currently exists.  The same is pretty much true of clinical systems architectures.   Yes, EHR systems exist, but no one knows the ideal architecture or component design strategy to achieve robust, secure, interoperable, collaborative systems.  In other words, there is no blueprint, and there is no source to consult that explains how to create such blueprints.  To anyone who thinks that tweaking current systems is the way to go, I say: Remember what happened with MU Stage 2 certification.

Alteration of current products is not likely to result in systems that reflect the AMA’s framework.  The time, money, and effort required to convert current EHR systems into clinical care systems that support clinical work is likely greater than most companies would care to expend (see Is the Electronic Health Record Defunct?).  Therefore, I expect the next generation of systems will come from new companies and not current market leaders (see Disruption in the EHR Market: Will Anyone See It Coming? ).

Building usable, interoperable systems that intimately support clinical work will require creativity, research, patience and, I imagine, some amount of luck (or serendipity if you prefer). In other words, the road from here to there is not on a map.   There are a lot of challenges, so let’s acknowledge this and get going.  Those blueprints will not design themselves.
apropos of all of the foregoing, is the data acquisition/assimilation burden likely to grow?
IOM Panel Identifies 12 Social, Behavioral Measures for EHRs
Thursday, November 13, 2014

On Thursday, the Institute of Medicine released a report detailing 12 social and behavioral factors it feels should be included in electronic health records, FierceEMR reports...

Those measures are:
  • Alcohol use;
  • Depression;
  • Educational attainment;
  • Financial resource strain;
  • Intimate partner violence for women of reproductive age;
  • Median household income;
  • Physical activity;
  • Race/Ethnicity;
  • Residential address;
  • Stress;
  • Social isolation; and
  • Tobacco use.
In the report, the committee noted that adding these domains to EHRs could put more pressure on providers. However, the authors also noted that patients could report the data via their personal health records or a computer, which would not greatly disrupt providers' workflow.

In addition, IOM said the health benefits of including these domains outweigh the administrative burden (Gold, Politico Pro, 11/13)...
Certain to be controversial, for a variety of reasons. And, what about the burgeoning accretion of "omics" data?

For one thing, I would not be so sanguine about "minimal workflow disruption."

Hmmm... tangentially, how about this?
EHRs are increasingly common and contain detailed data about patients’ encounters with the health system — data that have tremendous value for health care improvement efforts. These same data also provide opportunities for marketing. Using EHR data, it’s possible to determine the clinical and demographic characteristics of patients within a given practice and the circumstances under which physicians choose particular treatments, even when information is anonymized at the patient level. Although most large EHR vendors do not sell data to third parties, some have made information sales part of their business model. For example, Practice Fusion offers its EHR software to physicians free of charge but generates revenue by selling access to anonymized clinical data derived from more than 80 million patient records.

EHRs can also be used for direct marketing to physicians at the point of care, through features such as banner ads, industry-sponsored clinical resources, and tools for requesting samples, article reprints, and other items — a role previously filled by sales representatives. Unlike traditional forms of advertising, digital technologies (e.g., MD On-Line) enable tailoring of advertisements to individual physicians on the basis of data from clinical encounters. Some marketing platforms (e.g., Physicians Interactive) integrate advertising at the point of prescribing with “eCoupons” that are generated in real time and transmitted directly to pharmacies when physicians select promoted medications.
From NEJM, by way of The Incidental Economist.


From Kaiser-Permanente Physician Leader:

A culture of doctors over-treating as a defense mechanism against medical liability should be replaced by a culture of patient-centered care.

The Dallas/Fort Worth Healthcare Daily ran a fascinating excerpt from the Steve Jacob’s book So Long, Marcus Welby, M.D.* The excerpt contained some very interesting assertions and statistics. For example: 
  • Consultant PwC, relying on that Congressional Budget Office (CBO) report, estimated that malpractice insurance and defensive medicine accounted for 10 percent of total health-care costs. A 2010 Health Affairs article more conservatively pegged those costs at 2.4 percent of healthcare spending. 
  • In a 2010 survey, U.S. orthopedic surgeons bluntly admitted that about 30 percent of tests and referrals were medically unnecessary and done to reduce physician vulnerability to lawsuits. 
  • A 2011 analysis by the American Medical Association found that the average amount to defend a lawsuit in 2010 was $47,158, compared with $28,981 in 2001. The average cost to pay a medical liability claim—whether it was a settlement, jury award or some other disposition—was $331,947, compared with $297,682 in 2001. 
  • Doctors spend significant time fighting lawsuits, regardless of outcome. The average litigated claim lingered for 25 months. Doctors spent 20 months defending cases that were ultimately dismissed, while claims going to trial took 39 months. Doctors who were victorious in court spent an average of 44 months in litigation. 
  • A study in The New England Journal of Medicine estimated that by age 65 about 75 percent of physicians in low-risk specialties have been the target of at least one lawsuit, compared with about 99 percent of those in high-risk specialties. 
  • According to Brian Atchinson, president of the Physician Insurers Association of America (PIAA), 70 percent of legal claims do not result in payments to patients, and physician defendants prevail 80 percent of time in claims resolved by verdict.
My comment:
Very interesting. will have to cite this on my blog. One area I feel gets insufficient attention is that of what I call “workplace psychosocial toxicity,” e.g., “bully culture” (or just the more prevalent FUD environments). I argue that all of the Health IT and process QI (my specialty) in the world may be negated by chronically toxic workplaces where one speaks truth to power at one’s peril. It’s a sad irony that many healthcare workplaces are anything BUT “Just Cultures.” I have examined this issue at great length, breadth, and depth. The chronically psych-toxic workplace issue is ultimately a patient safety issue.


We have superb doctors in the United States. These exceptionally well-trained men and women understand that they are crucial patient advocates. Physicians must accept the responsibility of guiding our nation to a better health care delivery system, but the pathway forward, amid jarring changes in our health care system, is not always clear.
The doctor crisis is the convergence of a complex amalgam of forces preventing primary care and specialty physicians from doing what they most want to do: put their patients first at every step in the care process every time. Barriers include overzealous regulation, bureaucracy, the liability burden, reduced reimbursements, and more. As a result, many physicians hold deeply negative views of the medical profession.
Solving the physician crisis is a prerequisite to creating a health care system that is patient-centered, safe, equitable, accessible, and affordable. And we believe that freeing doctors to concentrate on providing excellent care is, by definition, patient-centered.
Cochran, Jack; Kenney, Charles C. (2014-05-06). The Doctor Crisis: How Physicians Can, and Must, Lead the Way to Better Health Care. PublicAffairs. Kindle Edition.
We'll see. Looks like an interesting read.


OK, this is funny. Props to


 in light of #GruberGhazi...


More to come...

Wednesday, November 12, 2014

With friends like these...

"This bill [The Affordable Care Act] was written in a tortured way to make sure CBO did not score the mandate as taxes. If [Congressional Budget Office] scored the mandate as taxes, the bill dies. Okay, so it’s written to do that. In terms of risk-rated subsidies, if you had a law which said that healthy people are going to pay in -– you made explicit that healthy people pay in and sick people get money — it would not have passed… Lack of transparency is a huge political advantage. And basically, call it the stupidity of the American voter, or whatever, but basically that was really, really critical for the thing to pass. And it’s the second-best argument. Look, I wish Mark was right that we could make it all transparent, but I’d rather have this law than not."
- Jonathan Gruber
Totally coincidental that this little stab in the back surfaced right in the wake of SCOTUS taking up King v Burwell? Arrogant weaselwonk is dancin' between the media raindrops today.

"[D]on’t assume that people who disagree with you are stupid, misinformed, greedy, or evil. They may just have different preferences about health insurance, taxes, income redistribution, or the role of government in health care. If preferences differ, telling people they can’t understand the complexities won’t help matters. Such condescension just makes aggrieved citizens angrier."

- David Hyman
Props to Nicholas Bagley, "Transparency and Grubergate 2.0"

More to come...