The KHIT Blog: "Fix the EHR!"

Monday, April 9, 2018

"Fix the EHR!"

From THCB:

By ROBERT WACHTER and JEFF GOLDSMITH

After a blizzard of hype surrounding the electronic health record (EHR), health professionals are now in full backlash mode against this complex new tool. They are rightly seen as a major cause of professional burnout among physicians and nurses: Clinicians are spending almost half their professional time typing, clicking, and checking boxes on electronic records. They can and must be made into useful, easy-to-use tools that liberate, rather than oppress, clinicians.

Performing several tasks, badly. The EHR is a lot more than merely an electronic version of the patient’s chart. It has also become the control panel for managing the clinical encounter through clinician order entry. Moreover, through billing and regulatory compliance, it has also become a focal point of quality-improvement efforts. While some of these efforts actually have improved quality and patient safety, many others served merely to “buff up the note” to make the clinician look good on “process” measures, and simply maximize billing…

Above, my Photoshop reaction.

I've cited Dr. Wachter multiple times on this blog.

My solution? My next iteration of my Clinic Monkey EHR will be "Blockchain Monkey EHR!"

But, according to "Healthcare Kate," "EHR's are a dying technology."

"Relational Leadership™" to the rescue?

Stay tuned. Just getting underway. A lot going on at my house these days. None of it fun.

ERRATUM

I'm demonstrably no newcomer to crackin' on EHR technology policy.

See "ICD-10: W6142XA, Struck by turkey, initial encounter."

UPDATE

After reading this week's accruing comments under the THCB "Fix the EHR" post, I feel like it's pointless to yet again point out the direct experience-based assertions I've posted many times. It's not the technology per se, it's the prevailing "productivity treadmill" economic paradigm (including the "shards" of a fragmented system) which leaves clinicians insufficient time to document their work in a timely, necessary, and accurate fashion. Nibbling around the edges, tossing out frustrating, admittedly dubious value "process indicators" (they are not "clinical quality measures") won't move the needle visibly (not that we shouldn't pare them back).

I'd ask these aggrieved blog commenter policy geniuses: "which of the (hundreds to thousands) pt encounter SOAP note elements would you discard?"

Paper is not "better." Paper kills. As does the prevailing socioeconomic / political system as it impacts health care.

Yes, my own broad, multi-EHR in-the-trenches HIT experience is getting a bit dated. But, my world is now "All Epic, All The Time" as my daughter's caregiver and as a patient myself. I continue to be a keen observer of the workflows I see during our clinical interactions.

Yes, clinicians suffer from 'burnout," worn down by impossible demands. But cutting the guts out of EHRs or tweaking the UX at the margins, well, not gonna get us anywhere.

RELATED NEWS...

eClinicalWorks CEO Girish Navani: Our next EHR will be like a Bloomberg Terminal
The electronic health record vendor is working on a version that would run on monitors such as Microsoft Surface and feature four distinct panels to help doctors make decisions.

LAS VEGAS – While eClinicalWorks is demonstrating its latest cloud-based EHR and new offerings for inpatient settings at HIMSS18, CEO Girish Navani gave a glimpse of the forthcoming iteration — and the goal is to resemble a Bloomberg Terminal.

The hosted service would make a bold step forward for the EHR vendor that last year settled a $155 million case with the U.S. Department of Justice in a False Claims Act suit.

Much in the way the Bloomberg device delivers information to help bond traders make decisions in near real-time, the next version of eClinicalWorks will provide doctors with four key technologies each on its own screen.

Navani described the setup as such: A physician walks into her office with a big monitor that has a population health panel containing information about the patients the doctor will see that day, a telemedicine tool for virtually connecting with patients, a voice-based virtual assistant for interacting with the software and a machine learning-based panel making evidence-based clinical suggestions…

OK, then. More data onscreen, fewer mouse clicks? What about quickly actionable data "visibility?"
_____________

More to come...

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Brave New Health

Commonwell Health Alliance

Another important read (pdf)

I love this kind of stuff. It sustains and humbles me. "As politicians, advertisers, salesmen, and propagandists for various political, economic, moral, religious, psychic, environmental, dietary, and artistic doctrinaire positions know only too well, fallible human minds are easily tricked, by clever verbiage... Common language—or at least, the English language—has an almost universal tendency to disguise epistemological statements by putting them into a grammatical form which suggests to the unwary an ontological statement. A major source of error in current probability theory arises from an unthinking failure to perceive this."

Quotes

"An economist is a person who sees something that works in practice and tries to figure out whether it will work in theory."

- J.D. Kleinke, medical economist
___

"The only person who enjoys change is a baby with a wet diaper."

"Every misspent dollar in our health care system is part of somebody's paycheck.

- Brent James, M.D., M.Stat

“We could do healthcare, at markedly higher quality, for everyone in this country, without rationing or denying anybody the care that they need, without having the government dictate how doctors practice or whether hospitals could expand, at half the cost we do it now.”

- Health Care Futurist Joe Flower

Most of the sciences, unlike parts of medical science, are not concerned with the impossible. There is not complementary and alternative physics, or chemistry, or biochemistry, or engineering. These disciplines compare their ideas against reality, and, if the ideas are found wanting, abandoned."

- Mark A. Crislip, MD

"Q: How much alcohol is too much?
A: More than your doctor drinks."

- a physician I once heard speak during a CME presentation

“Just because science doesn’t know everything, doesn’t mean you get to fill in the gaps with whatever fairy tale most appeals to you.”

- Dara O’Briain

'[I]t is one small step from using the computer for "helping" doctors to monitoring them, judging them, dictating to them what to do, and withdrawing payment for computer non-compliance. The use of computer data is a multi-edged sword. It can be used for the "good," facilitating diagnosis and treatment and making it more accurate and up-to-date, and for “evil,” invading privacy, inviting security breechs, and making decisions based on the opinions of remote authorities rather than those present at the patient-doctor encounter.'

- Richard Reece, MD

“[T]here ARE statistics which are non-political. Just because The Washington Post/Fox News reports the temperature is 75 degrees doesn’t mean it’s really snowing and sunscreen is a liberal/conservative plot. Even if you earn a living being ideological.”

- Michael L. Millenson

"It is a generally a fairly convincing argument that people shouldn’t have to be subsidized to undertake a change which is in their best interest.

The reconciliation seems to be that EHR is not supposed to make a doctor’s practice more efficient and higher quality. It is supposed to make the system of care more efficient and higher quality, which is not the same thing. Those of you who took calc recall that maximizing the total of variables is not achieved by maximizing any one variable and this is a perfect example of that.

Those of you have served in combat certainly noticed that too — if everyone works as a team the unit takes fewer casualties. If you try to save your own hide, you might, but at the expense of more casualties overall."

- Al Lewis

"There are two ideas to keep in mind about Bayesian reasoning and how we tend to mess it up. The first is that base rates matter, even in the presence of evidence about the case at hand. This is often not intuitively obvious. The second is that intuitive impressions of the diagnosticity of evidence are often exaggerated."

- Daniel Kahneman, "Thinking, Fast and Slow"

"Physicians apply advanced scientific knowledge, but they must do so without the favorable conditions that experimental scientists create for themselves. Multitasking is forced on physicians, often in chaotic environments and under severe time and resource constraints."

- Lawrence and Lincoln Weed, "Medicine in Denial"

"It’s time to stop the whining about Obama care and acknowledge we already have universal health care. We just pay for it in the stupidest way possible that ensures problems are that much more disastrous and complicated when they’re finally treated."

- Mark Hoofnagle, MD, PhD

"Every act of conscious learning requires the willingness to suffer an injury to one's self-esteem. That is why young children, before they are aware of their own self-importance, learn so easily."

- Thomas Szasz, MD
___

"Of course, one reason that process metrics* are so popular is that processes are much easier to define and measure than outcomes."

- The Skeptical Scalpel
___

"There is an “illusion of validity” for any random data point, a seductive sense that is colored by what we hope will be true. Mountains of pharmaceutical claims are often made from mere molehills of data."

- Danielle Ofri, MD
___

"Joy empowers people. It is a source of energy that enables people to hope and plan and change their lives for the better. Spend some time around someone who is relentlessly negative and how do you feel–drained, right? More and more research shows that joy is not something that just happens to you, like a bolt of lightening out of the blue. Joy is, instead, a habit to cultivate. Negative thinking and despair are the crabgrass of our souls–weeds that take root and spread, sometimes to all areas of life. Joy, in contrast, is a soul’s rose–hardy when cared for, able to put down roots over time and withstand disease and extremes. Like a rose, however, your joy can become blighted from neglect or harsh conditions. We all need to tend to our joy–to prune away the badness, and to know that, even though it may look like a prickly bare root, if you invest time in a joyous outlook, gorgeous things will bloom, even in the harshest conditions."

- Dr. Jan Gurley
___

"'Solutions' exist only in mathematics."

- Karen Martin
___

"The issue of how to regulate clinical software is, in the long run, indistinguishable from the issue of how to regulate medicine. The only difference is that medicine is practiced in the open, without secrecy, subject to peer review, and under a merit-based state license."

- Adrian Gropper, MD
___

"Economist, rope, tree: some assembly required."

- Source unknown

DISCLAIMER:

I write this blog wholly on my own time and my own dime. The views proffered are expressly my own as a concerned and active citizen/taxpayer (in addition to being the result of my substantive experience in the various IT fields), and in no way reflect any policy views of my former employer, notwithstanding that some of the thinking has indeed obviously been spurred by the implications of the work with which I have been doing for them.

FAIR USE POLICY
I cite a ton of news and web sources spanning the breadth of relevant technical and policy domains, sometimes at substantial length. I believe I remain well within the bounds of "Fair Use," as [1] I am not doing any of this for profit, [2] I always provide attribution and links -- which, [3] far from negatively impacting any copyright holders' commercial interests, might actually increase traffic to and interest in their offerings.

Nonetheless, should I post anything of yours regarding which you have any objection, just let me know and I will remove it forthwith.

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Monday, April 9, 2018

"Fix the EHR!"

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