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Monday, September 26, 2011

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

 YEAH. to wit
The Challenge of ICD10 Adoption
by John Halamka

On October 1, 2013, the entire US healthcare system will shift from ICD9 to ICD10. It will be one of the largest, most expensive and riskiest transitions that healthcare CIOs will experience in their careers, affecting every clinical and financial system...

...Most small to medium healthcare organizations are desperate. They are consumed with meaningful use, 5010, e-prescribing, healthcare reform, and compliance. They have no bandwidth or resources to execute a massive ICD10 project over the next 2 years...

And don't forget PQRS, HIE, and various QIO 10th Scope HIT related initiatives. At times it all seems pretty crazy. One astute commenter in the foregoing Halamka post:
ICD-10 is one piece of a much larger picture. What is the common denominator of: meaningful use, value based purchasing, the March ACO regs, Medicare’s hospital and physician quality reporting initiatives? They all impose “nice to have” documentation requirements which subtract clinician time from direct patient care in the name of “transparency” and “accountability”.

Health care providers added one million jobs since 2007, despite declining utilization in virtually every category of service (hospital admissions, physician visits, etc.). A lot of those jobs were to cope with the escalating complexity of reporting requirements in the payment transaction.

Halamka is exactly right: we need to be simplifying and consolidating payment transactions, and reducing the documentation burden on caregivers. And it isn’t for provider convenience (or enabling them to hide quality defects) , but for the impact on cost and the patient’s experience of care. The micromanagement of medical practice has reached crisis stage.


September 27, 2011, 7:40 AM

Lessons From Britain’s Health Information Technology Fiasco
Government press releases tend to be bland, earnest blather. But not one posted on the British Department of Health’s Web site last Thursday. Its headline: “Dismantling the NHS National Programme for IT.”

To translate the acronyms a bit, the NHS is Britain’s state-run National Health Service and the program in question was the ambitious drive to computerize England’s health records and let doctors, clinics and hospitals share patient information electronically. The project, begun in 2002, was budgeted at £12 billion (about $19 billion) and the government hailed it as “the world’s biggest civil information technology program.”

The British digital health project has been a slow-motion train wreck for some time with last week’s announcement mainly confirmation — and a pledge to change course. (The announcement was also a political gesture, as the Conservative government of David Cameron tries to get as much distance as it can from an unpopular initiative, begun by Tony Blair’s Labor government.)

Yet the United States is about to begin its own government-funded drive to accelerate the adoption of electronic health records, with Washington set to hand out more than $20 billion in incentive payments over the next five years. So what are the lessons to be learned from the English experience? ...

OK, first lesson? Guess.


I was on a HITRC Practice Workflow and Re-design CoP call and web presentation yesterday (9/27) during which we had a presentation by WIREC, the Washington-Idaho REC, a QualisHealth QIO REC contract initiative (like our own).

They are all over it (and, they are not the only ones). I cannot say enough good about these people. One slide that I screen-captured:

Bring it. Lean.

I started this blog on May 10th 2010 touting Lean for health care.


Yeah, I know...


First, from The Health Care Blog:

Adverse Events is an interesting place.
As is

More shortly...

Monday, September 12, 2011

National Health IT Week, Sept 12 - 16

Comprehensive health care reform is not possible without system-wide adoption of health information technology, which improves the quality of healthcare delivery, increases patient safety, decreases medical errors, and strengthens the interaction between patients and healthcare providers.

With Meaningful Use now providing the way forward, eligible providers across the country increasingly understand the benefits for themselves and their patients, and are adopting Meaningful Use compliant electronic health records...


'[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...

…Most clinical decision-making is gray, not black and white. What I would like to see is a comprehensive study is how computers affect issues in the gray world - how computers impact or improve the totality of decision-making on sociological and psychological problems, which may be more subjective rather than objective.'

- Richard Reece, MD
Interesting. I've written about these clinical decisionmaking issues before. Difficult stuff.

UPDATE; Apropos of the foregoing comes this (PDF) from Health Affairs:
Today’s ‘Meaningful Use’ Standard For Medication Orders By Hospitals May Save Few Lives; Later Stages May Do More

ABSTRACT The federal government is currently offering bonus payments through Medicare and Medicaid to hospitals, physicians, and other eligible health professionals who meet new standards for “meaningful use” of health information technology. Whether these incentives will improve care, reduce errors, and improve patient safety as intended remains uncertain. We sought to partially fill this knowledge gap by evaluating the relationship between the use of electronic medication order entry and hospital mortality. Our results suggest that the initial meaningful-use threshold for hospitals—which requires using electronic orders for at least 30 percent of eligible patients—is probably too low to have a significant impact on deaths from heart failure and heart attack among hospitalized Medicare beneficiaries. However, the proposed threshold for the next stage of the program—using the orders for at least 60 percent of patients, a rate some stakeholders have said is too high—is more consistently associated with lower mortality. Our results suggest that the higher standard that will probably follow in the second stage of meaningful-use regulations would be more likely than the first-stage standard to produce the improved patient outcomes at the heart of the federal health information technology initiative.


"The technologies collectively known as health information technology (health IT) share a common attribute: they enable the secure collection and exchange of vast amounts of health data about individuals. The collection and movement of this data will power the health care of the future. Health IT has the potential to empower individuals and increase transparency; enhance the ability to study care delivery and payment systems; and ultimately achieve improvements in care, efficiency, and population health.

However, these technologies – including electronic health records (EHRs), personal health records (PHRs), telehealth devices, remote monitoring technologies, and mobile health applications – are remarkably underutilized today. In 2010, only 25 percent of physician offices and 15 percent of acute care hospitals took advantage of EHRs. Even fewer used remote monitoring and telehealth technologies. While many consumers access their banking information online daily, only 7 percent have used the web to access their personal health information..."

We shall see shortly the extent to which Congress will permit these initiatives to continue.





1. Presidential Support: President Barack Obama proclaims September 11-17 National Health IT Week. Techies everywhere rejoiced that an entire week will be devoted to health IT. An excerpt from the proclamation reads, “Health information technology connects doctors and patients to more complete and accurate health records. Tools like electronic health records and electronic prescriptions help patients and providers make safer, smarter decisions about health care.” Support from the White House is paramount to the continued success of health IT initiatives in the future. It’s refreshing to have Presidential-level support for that work.

2. The Super Committee: Technically speaking, it’s the Joint Select Committee of Deficit Reduction, and there was a lot of talk about the Committee and its work. The bi-partisan assembly composed of six members of the House and six from the Senate is charged with finding more than $1 trillion in savings over the next 10 years. That means the couch cushions will be over turned and every drop of savings matters. Even something as detailed and technical as health IT will be considered for cost savings and efficiencies. So, it’s crucial that the health IT community maintain an active dialogue with the Super Committee members about the integrity and importance of HITECH funding.

3. Minority Health: Numerous workgroups held Congressional briefings on the state of their affairs. One of those groups launched earlier this year is the HIMSS Latino community. Together with the HHS Office of Minority Health, they are addressing significant issues facing minority populations and how health IT can ease some challenges they face. In their Congressional briefing, the group shared a community-wide concern for healthcare provider shortages and ways to close the disparity gap in minority populations. They also discussed the increasing importance of patient involvement in the healthcare process and how health IT initiatives like patient messaging can improve the delivery of care.


...While there has been no overt effort to repeal the HITECH Act, which authorized up to $27 billion in incentives for Meaningful Use of EHRs, anything is considered possible as Congress moves to reduce the size of the federal budget deficit. So HIMSS' appeal is more than just pro forma.

"National efforts to transform healthcare delivery systems and to bend the cost curve, including implementation of improved quality measures and reporting systems, are entirely dependent on the widest possible adoption of EHRs and [health information exchange]," HIMSS says in its recommendation to Congress. "Meaningful Use of EHRs supports quality reporting that helps providers analyze and continually improve the quality of care they provide."

Moreover, HIMSS adds, many small practices and smaller community hospitals would not have the resources to implement EHRs without government financial support...

From the Sept 16th article HIMSS urges Congress: Create a national patient identifier

Yeah, the HIT field ought to be a bit anxious.


From the blog of the CEO of the American Society for Quality:
The Fight for Baldrige–What’s Next?
Posted on September 16, 2011 by borawski

Well, it’s come to this.

On Wednesday, the Senate Appropriations Subcommittee on Commerce, Justice and Science voted to zero out for the Baldrige Program for fiscal year 2012. Yes, I’m disappointed. It’s likely though that Congress will not pass a budget and resort to a continuing resolution. It’s already on the floor and could extent funding for Baldrige.

But this really shouldn’t be such uphill work As I said in ASQ’s public statement, Congress should be shining a light on Baldrige recipients and point with pride to their accomplishments as an example of what the best can do. Baldrige recipients are creating jobs, saving lives and enriching students. It’s discouraging that the Subcommittee apparently doesn’t understand how valuable the government’s role has been. In these challenging times, model programs — like Baldrige — should be showcased, not eliminated...

Dicey times ahead. Let's hope initiatives like this (below) don't fall victim to the meat axe.

About the Health Data Initiative

The Health Data Initiative is a major new public-private effort that aims to help Americans understand health and health care performance in their communities -- and to help spark and facilitate action to improve performance.

The fundamental approach being taken by the initiative is to catalyze the advent of a network of community health data suppliers (starting with HHS) and “data appliers” who utilize that data to create applications that (1) raise awareness of community health performance, (2) increase pressure on decision makers to improve performance, and (3) help facilitate and inform action to improve performance.

A lot of good work being done, with great promise. I hope it continues. Let's hope we don't end up with this by the end of the year.

Yeah, I know, I have a vested interest. And, I certainly have my detractors (just about all of them using anonymous or otherwise untraceable screen names). This one is one of the more civil ones.

"Academic dilettante." Gotta love it.

Sunday, September 11, 2011

September 11, 2001

I simply and humbly reflect on our heroic First Responders of that ghastly day a decade ago, and on the subsequent life-and-limb sacrifices of so many thousands of my countrymen and women is its wake.
If blood will flow when flesh and steel are one
Drying in the colour of the evening sun
Tomorrow's rain will wash the stains away
But something in our minds will always stay
Perhaps this final act was meant
To clinch a lifetime's argument
That nothing comes from violence and nothing ever could
For all those born beneath an angry star
Lest we forget how fragile we are

On and on the rain will fall
Like tears from a star like tears from a star
On and on the rain will say
How fragile we are how fragile we are
How fragile we are how fragile we are...

- Sting

Wednesday, September 7, 2011

Another "Use Case"

NORTH KINGSTOWN, RI, Sep 07, 2011 (MARKETWIRE via COMTEX) -- Improved outcomes for patients is believed to be an important benefit of using electronic health records, yet few physicians can cite specific instances where such software has made a life-saving difference. Dr. Shankar Santhanam of Lawrenceville, NJ, is a notable exception. He recently used the Amazing Charts electronic health record (EHR) system to save a patient's life by following the evidence-based, decision-support recommendations offered by the software...
Story link here.

Anecdotal, to be sure. Nonetheless...

And, how about this, from The Health Care Blog?
The Cleveland Experiment


There have been a number of research studies published that question the value of Electronic Health Records (EHRs), particularly as it pertains to improving quality of care and ultimately outcomes. Chilmark has always viewed these reports with a certain amount of skepticism. Simple logic leads us to conclude that a properly installed (including attention to workflow and thorough training) of an enterprise software system such as an EHR will lead to a certain level of standardization in overall process flow, contribute to efficiencies and quality in care delivery and ultimately lead to better outcomes. But to date, there has been a dearth of evidence to support this logic, that is until this week...

Electronic Health Records and Quality of Diabetes Care

NEJM | August 31, 2011 | Topics: Health IT, Quality of Care
Randall D. Cebul, M.D., Thomas E. Love, Ph.D., Anil K. Jain, M.D., and Christopher J. Hebert, M.D.

One commenter was unimpressed:
The study is flawed by selection bias and investigator bias. This report simply reaffirms that wealthy and educated people are more compliant and achieve better outcomes. The pro HIT bias of the NEJM and the ONC is more than evident.


Apropos of that, see
Natural Language Processing Coming to HIM Depts.

Natural Language Processing technology can take transcribed text, structure it into computable data, and apply SNOMED CT and other terminologies or codes for richer data abstraction and analysis.

During an educational session at the American Health Information Management Association annual convention, Oct. 1-6 in Salt Lake City, two NLP experts will walk through the technology and its potential. They'll cover tagging and preparing data for electronic health records meaningful use reporting, identifying caps in ICD-10 coding, and tools needed for data mining, among other issues. "We want the audience to walk away understanding how NLP works," says Dee Lang, vice president of product management and strategy at Precyse Solutions, Wayne, Pa...

...Educational session 7142, "Driving Your Organization to Meaningful Use with Data Analytics," is scheduled on Oct. 3 at 4:45 p.m. More information is available at

See also the Praxis article "Why Templates Don't Work."

More to come...