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Saturday, October 3, 2015

"Free Beer Tomorrow" - "Transforming the Healthcare System"

Speaking of "tomorrow," as I write this today, October 3rd,

Still time to register, here.

We'll be witness to all manner of impressive nascent (and some of it more than simply "nascent") "transformational" stuff (most of it tech-oriented given the Health 2.0 focus).

I thought about this old bit of snark after hearing The Donald Trump® proffer, for the umpteenth time that "in a few weeks we'll be releasing a detailed plan. It'll be terrific. You'll love it."

I am also reminded of my entry into the healthcare space in 1993, when, after my wife was promoted and transferred to Nevada to oversee QA on the Nevada Test Site environmental cleanup program, I took a job as a Medicare hospitalization outcomes analyst (pdf) and LAN manager in Las Vegas, with a HCFA (now CMS) contractor organization known at the time as "Nevada Peer Review" ("NPRO").

It was an interesting time. I was just glad to have found a decent, skills-relevant job in my new garish, bustling Casinoland home after resigning my prior way-cool Digital Industrial Diagnostics gig (pdf) in Knoxville so Cheryl could pursue her opportunity.

I started out as a t-shirt and jeans back-office SAS/Stata-coding data grinder focused on Nevada's acute case hospital caseloads, mining the recurrent releases of claims data for any potential pattern-nuggets bearing improvement possibilities amid the ICD-9s and DRGs, correlated with whatever else we knew about the patients and facilities.

NPRO had lost their Medicare contract prior to my tenure and had been acquired by neighboring Utah's "UPRO," which picked up the Nevada HCFA work. The bi-state culture clash could not have been more striking. While we shared a long high desert border and had similar population sizes, across a raft of personal and public health measures, where Utah consistently ranked #1, Nevada invariably ranked near or at the bottom. UPRO senior management and senior staff were pretty much all openly LDS ("Mormons") and male. NPRO's management were all women, most of them chain-smoking floor-burnout-case, astute older RNs. They told me I'd been hired to mitigate the office estrogen level. I was the only male in NPRO until we interviewed and hired the then newly-minted MHS Kevin Kennedy as a "junior analyst." Kev stayed on across the decades and is now SVP of Corporate Ops (during my 2010-13 REC stint he was nominally my "boss"). My direct boss in 1993-95, "Ruthie," (Dr. Ruth Moore, our "Senior analyst") was a swaggering, hard-drinking, also chain-smoking PhD Medical Anthropologist. Every day, about 4 p.m., the place got quiet; you could hear the door to our ED Jane's office closing, as all the Girls gathered to light 'em up and commence to shoot the shit.

It was like a gas chamber in there. The "health care" business, no less.

Notwithstanding nominal bi-state inter-office decorum, NPRO regarded UPRO as a bunch of prissy, milk-and-cookies, patriarchal, Holier-Than-Thou stuffed-shirt carpetbaggers.

Like I said, it was an interesting time. All I wanted to do was crunch my numbers and write my reports.

In 1994, UPRO management (who did not deserve most of the antipathy aimed at them) sought to mitigate the culture gap. A name-change initiative ensued. Eventually, via consensus bi-state staff assent, we became "HealthInsight." Kumbaya.

The timing was auspicous. HCFA/CMS had declared that "PROs" would henceforth be known as "QIOs" -- "Quality Improvement Organizations" -- with a mandate going forward to progressively, -- wait for it...

"Transform the Healthcare System."

The air was alive with heady, progressive wafts of SPC (my specialty) and Deming TQM/CQI and TPS and Human Factors and Systems Thinking (all music to my ASQ ears). We got sent up to Salt Lake City repeatedly across a six-month period for the acclaimed "Brent James Training" at IHC. It was fabulous. I still have my manual. Dr. James remains a forefront national leader in healthcare. I am blessed to have known him and studied under him.

I left HealthInsight late in 1995 to accelerate graduate school. Then in mid-1996, tragedy struck my elder daughter, and I would get an extended up-close-and-personal view of acute care delivery in southern California from the next-of-kin/caregiver perspective. As that two-year horror drew to a close, my parents began failing, and I found myself on repeated Delta red-eye flights to Melbourne, Florida to help deal with their issues, eventually being named POA on my Mom and Legal Guardian on my dementia-addled Pop, both of whom I eventually relocated to Vegas. My Dad died in 2008, and my Mom several years later in November 2011.

So, what in the healthcare space has been "transformed" across the past 22 years of my connection with the system?

For one thing, you can't deny the impact of EHRs, even if they contribute only incrementally to "transformation" over the longer haul. When Sissy was sick, "Medical Records" was typically a "department," with manila folder charts stored en masse in the basement somewhere, with all of the workflow (and patient care) obstruction such entailed. The penetration of digitized medical records is increasingly broad and will continue. Whether that is uniformly seen as beneficially "transformative" is another matter, one hotly contended. to wit:
Ask any group of clinicians about how they like their EHRs and one will find seemingly conflicting replies. On one hand, most will complain about mouse clicks, screens, data sharing, and implementation headaches. If asked whether they would go back to paper, the answer is usually, “No.” Clinicians see the value in electronic systems; they simply want systems that make their lives better. There is a market for clinical care systems that make clinical work more productive, that are easier to extend, and that address emerging needs such as population health and care coordination. Practices are willing to switch to demonstrably better products.
From Dr. Jerome Carter's EHR Science.

We clearly have a long way to go.  Fragmentation of care remains the norm. Incumbent deployed EHRs commanding the bulk of market share remain basically layered arrays of templated and tabbed landscape format I/O forms riding atop rigid RDBMS repositories, with widely varying workflow-supporting "usability." As a prostate cancer patient now, I see this on a daily basis (as I also saw as a Meaningful Use REC guy; not a lot has changed materially, IMO).

Again. Dr. Carter:
Building clinical care systems that intimately support clinical work has to begin with the acknowledgement that clinicians perform many tasks within the context of a patient encounter, and those tasks very in type, number, and sequence. Everyone knows this. So, one might ask, if this is common knowledge, why are there so many problems with EHR usability? The answer is very simple. EHR systems are designed to be one-size-fits-all.

One-size-fits-all (OSFA) is such a fundamental precept of EHR design that no one even questions it. Instead, there is a pursuit of every possible means of fixing EHR systems, while allowing them to remain OSFA. Why? Because it is a design assumption carried over from past software design/development limitations. Achieving the highest possible level of usability requires dumping deeply-ingrained OSFA thinking.

How did OSFA become so entrenched in EHR designs? Here are the main reasons.

Poor choice of design metaphor
Paper charts are the inspiration for current EHR systems. Charts are OSFA. No clinician was allowed to customize the chart to fit his/her personal work habits or information needs. Every hospital or practice has strict rules about chart organization and use. There are legal rules that dictate how charts must be stored and what they must contain. There is an entire profession dedicated to charts. Charts are designed to be standardized information repositories; they are not designed to aid in care delivery. Paper charts are a means to an end, and I have never heard anyone gush over how wonderful a paper chart was or how it made their lives so much better. However, since paper charts are (were) a fact of life, one simply adapted to them, like it or not...
 A chronic worry of mine is that all this API pecking-around-at-the-surface data exchange work (the "interoperability" misnomer) may serve to significantly glom things up further, at least in the short to medium term -- not to even mention implications of the looming "transformational" cascades of "Omics" data.  e.g., see my prior post "Personalized Medicine" and "Omics" -- HIT and QA considerations."

I would love to be wrong.

I hope to get my fill of good "Healthcare Futurism" stuff this week at Health 2.0 as our new FY2016 commences with ICD-10 now in tow and absent a DC wingnut shutdown.

I'll buy my own beers.

P.S. You simply must check out Inspired EHRs: Designing for Clinicians.
7. What is Human Factors Engineering?

Human Factors Engineering seeks to improve human performance by designing systems that are compatible with our perceptual, cognitive, and physical abilities. Imagine an EHR that requires a physician to cancel a prescribing task, then navigate through several screens, remember a value, and navigate back to complete the prescription. This EHR taxes the well-known limits of human memory. Over-taxing users’ memory causes them to make errors, especially if they’re interrupted while using the system – a common occurrence in healthcare.

In contrast, an EHR that allows a physician to see at a glance how well a patient is controlling his diabetes and hypertension gives the physician the situational awareness (and time) he needs to begin to address his patient’s current concerns. The physician can focus attention on understanding the story of the human sitting across the room, instead of on remembering and finding the necessary information to make decisions.

The Fundamental Theorem of Biomedical Informatics states “that a person working in partnership with an information resource is ‘better’ than that same person unassisted.” Human Factors Engineering involves building this partnership, designing hardware and software that make it as easy as possible for users to do tasks safely and efficiently. An EHR based on sound human factors engineering principles can help clinicians focus on the difficult task of caring for patients, rather than on figuring out how to use or work around the EHR. We must understand the ways people see, read, think and decide so that we can use this information to build systems that enhance people's job performance...
I will give deep study to every word of this noble effort.


This was very nice. Thank you, sir

More to come...

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