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Friday, February 3, 2012

Back down in the Weeds'

"...In the current non-system, physicians bear impossible burdens of performance, other practitioners are barred from sharing those burdens, patients do not participate effectively in their own care, the U.S. spends $2.5 trillion annually without clinical accounting standards, third parties manipulate the situation for their own advantage, and none of the stakeholders are accountable for their own behaviors..."


Props to The Health Care Blog, specifically Nimble Medicine by Dave Chase...

Indeed. The latter graphic above goes to a a point I wrestle with all of the time. I hear related pushback routinely out in the field, sometimes angrily so.

Apopros of the broader point, consider:

...[F]alse conclusions ... are now not only causing major economic waste, but also creating unnecessary dangers to public health and safety. Society has only finite resources to deal with such problems, so any effort expended on imaginary dangers means that real dangers are going unattended. Even worse, the error is incorrectible by the currently most used data analysis procedures; a false premise built into a model which is never questioned, cannot be removed by any amount of new data. Use of models which correctly represent the prior information that scientists have about the mechanism at work can prevent such folly in the future.

But such considerations are not the only reasons why prior information is essential in inference; the progress of science itself is at stake. To see this, note a corollary to the last paragraph; that new data that we insist on analyzing in terms of old ideas (that is, old models which are not questioned) cannot lead us out of the old ideas. However many data we record and analyze, we may just keep repeating the same old errors, and missing the same crucially important things that the experiment was competent to find. That is what ignoring prior information can do to us; no amount of analyzing coin tossing data by a stochastic model could have led us to discovery of Newtonian mechanics, which alone determines those data.

But old data, when seen in the light of new ideas, can give us an entirely new insight into a phenomenon; we have an impressive recent example of this in the Bayesian spectrum analysis of nuclear magnetic resonance data, which enables us to make accurate quantitative determinations of phenomena which were not accessible to observation at all with the previously used data analysis by Fourier transforms. When a data set is mutilated (or, to use the common euphemism, ‘filtered’) by processing according to false assumptions, important information in it may be destroyed irreversibly...
["Probability Theory:The Logic of Science," pg xvi, pdf]
I ran across the foregoing link while reading "What is Science?" over at (SBM), one of my regular online stops. Now, SBM is largely focused on relentless pseudoscience debunkery on the clinical side of things, but after reading the the Dave Chase post, the Weeds' book, and the works of people like the amazingly astute Health Care Futurist Joe Flower and medical economist J.D. Kleinke, I am reminded of yet another pertinent resource, comprised of the works of Messrs Toussaint and Gerard, in On The Mend, a book I cited early on in the life of this blog. e.g.,
Every time you walk into a hospital or clinic in the United States, you take your life in your hands. Whatever your condition, you will probably be cared for by people who are overworked and hobbled by wasteful systems.With 15 million incidents of medical harm in the United States every year, such as drug errors, wrong-site surgeries and infection, there is a good chance you will be hurt in this interaction. Medical professionals like us are horrified every time we cause harm, but even the best intentions do not change facts.

Meanwhile, government policy makers argue about the healthcare crisis and focus almost exclusively on money—who pays, how much, and from what budget. From the sidelines, we have been repeatedly struck by how little the players seem to know about how healthcare is actually provided. It is as if they are talking about a black box they have never cracked open to investigate, so they can only talk about the environment surrounding the box—about changing payment systems to providers, insurance coverage for patients and reporting requirements for healthcare organizations. These prescriptions are based on one abstract theory or another with no real insight into why healthcare costs so much. With few exceptions, the debaters assume that healthcare costs are fixed, that America’s proud history of medical care and innovation comes with a staggering bill.

We know different.

Governments can tweak payment systems and probably get some temporary fiscal relief. But until we focus reform efforts on where most of the money goes, which is healthcare delivery, we will remain stuck in a revolving door of near disaster and narrow escapes.To get to the point where all people have access to high-quality healthcare, affordably, we must focus our attention on how the healthcare delivery system determines costs and quality. Then we need to change that delivery model entirely.

In fact, hospitals, physicians, and nurses—all of healthcare—must change. First, we must emphasize the science of medicine over the art. This means turning to evidence-based medicine, which is already underway in some sectors. But we are also talking about evidence-based delivery, work that has barely begun...

...Throughout this book, we are speaking directly to the people involved with delivering healthcare.We do not mean to suggest, however, that the external environment of healthcare—payment systems, insurance coverage, and regulations—does not need to be overhauled. It is a badly broken system requiring major surgery. But we are convinced that the healthcare debate needs to start from a deep understanding of how healthcare value is actually delivered.

This is an understanding we all need—policy makers and patients, as well as medical professionals.We all have a role to play in reforming healthcare. Caregivers need to rethink their priorities and remake their working environments. Lawmakers need to rewrite the rules to ensure that value is rewarded instead of waste. And patients must understand how healthcare works in order to demand truly effective change.

Only when we all have clear insight into the work going on inside the black box can useful reforms be crafted. [Toussaint and Gerard, "On The Mend," pp. 1-4]

"First, we must emphasize the science of medicine over the art. This means turning to evidence-based medicine, which is already underway in some sectors. But we are also talking about evidence-based delivery, work that has barely begun."
I could not agree more. Without significant and continuing improvement on the care delivery process side of things (everything associated with workflow, both physical and informational), clinical improvements will be immeasurably more difficult to achieve.

Just getting started here. Much to triangulate. But first, a bit of "Usability" comic relief. I saw this TV ad this morning on CNN:

"There's even one that Glows In The Dark, so you can work late at night without disturbing others!"
OK, where's my Metamucil? Where the hell are my glasses? And, GET OFF MY LAWN!!!

Click the graphic. These would be perfect for Medicare patient waiting room kiosks, no?


 More to come...



A culture of denial subverts the health care system from its foundation. The foundation—the basis for deciding what care each patient individually needs—is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new, secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical information.

Electronic information tools are now widely discussed, but the tools depend on standards of care that are still widely ignored. The necessary standards for managing clinical information are analogous to accounting standards for managing financial information. If businesses were permitted to operate without accounting standards, the entire economy would be crippled. That is the condition in which the $2 1⁄2 trillion U.S. health care system finds itself—crippled by lack of standards of care for managing clinical information. The system persists in a state of denial about the disorder that our own minds create, and that the missing standards of care would expose.

This pervasive disorder begins at the system’s foundation. Contrary to what the public is asked to believe, physicians are not educated to connect patient data with medical knowledge safely and effectively. Rather than building that secure foundation for decisions, physicians are educated to do the opposite—to rely on personal knowledge and judgment—in denial of the need for external standards and tools. Medical decision making thus lacks the order, transparency and power that enforcing external standards and tools would bring about. [pp 1-2]

I know that a lot of interests don't want to hear it, but the Weeds' are right.

I'm gonna end up citing the entire book. Just buy a copy, OK? Click the "Medicine in Denial" link on the right (again, I'm not shilling it; l I get nothing -- beyond the satisfaction of having alluded to something IMO substantive).


Is the Center For Innovation Innovating Too Fast?

...Advocates of market-based solutions to cost and quality problems argue that innovation springs from competitive forces...
My response? "Perhaps to a good degree. But, markets properly exist to serve the net advancement of humanity in the aggregate, not the other way around..."

Too fast? Too slow? You just can't win. I'm a month shy of two years into the REC initiative, and the sideline critics are coming out blazing from every IP address, angrily dissing us and the feds we because haven't yet magically created frictionless HIT/HIE and improved outcomes and reduced costs by75%.

Yeah, I know, I have skin in this game, our company having just submitted for a CMMI grant (see my prior post on January 8th, "Shovel Ready"). Nonetheless, no one can ever accuse me of being an uncritical cheerleader of all of this stuff.

Neither have I any use for "Perfectionism Fallacy" carping.


So, HIMSS 2012 is here in Vegas this year. I really wanted to go, but I think only a small contingent of HealthInsight management folks above me (three from UT, IIRC) were approved for paid registration.

So, on a bit of a lark, I applied for a comp Media Pass, thinking 'yeah, your piddly little nights/weekends non-commercial blog. Right, dream on, Mr. HIT Journalist...'

They approved me in all of about a minute.

 I'm fairly decent with a camera. So. I will have mine in tow, and will dutifully report on what I find, both pictorially and via write-up. I will be a REC champion during the proceedings.


The goal of EMRs is to wrestle control of healthcare away from the doctor-patient relationship into the hands of third parties who can then implement their policies by simply removing a button or an option in the EMR. If you can’t select a particular treatment option, for all intents and purposes the option doesn’t exist or the red tape to choose it is so painful that there is little incentive to “fight the system.”

Really? Entire article here. The comments are particularly interesting. See also the source post I ran across amid my daily HIT topic Google searches that led me to it.

OK, related to the foregoing, how about this concern?
Healthcare IT Expert Exposes Hidden Risks of Lawsuits Due to Electronic Health Record

"...EHRs unquestionably have the potential to improve patient safety and the quality of care delivered, but what few people realize is that using an EHR exposes physicians to an Orwellian level of analysis of every single act while doing their job," said [Dr Sam] Bierstock, who has advocated and pioneered the use and benefits of EHRs for more than 30 years." EHRs, however, can also be audited to examine how long it took them to act after an abnormal lab result came in, if the doctor checked on on-line references before making a clinical decision, what was said in every email and how long the doctor took to respond, and even how long the doctor looked at a screen or scrolled down to read an entire document. Physicians are exposing themselves to an unacceptable level of scrutiny and analysis of their use of computers that may serve to encourage malpractice suits. Meaningful tort reform is essential to getting the maximal benefit from these wonderful systems..."

"...Quite simply, physicians may be in a situation that leaves them vulnerable to litigation and threatens loss of their professional standing and personal assets – all because an external evaluator may not think the physician lived up to arguable standards in the digital age," said Bierstock. "Overall, EHRs are the litigator's proverbial golden goose. They are to malpractice attorneys what the electron microscope is to microbiology..."

The EHR/HIE audit logs as grist for a new generation of adversarial "Utilization Review," 'eh?

I've posted on some of the potential liability issues pertaining to HIT before. See First, do no "Hold Harmless."

JOE FLOWER, "Healthcare Beyond Reform"

Can't wait to buy and read the book. All of his writings are excellent. I quote him frequently. I call him "Sensei."

A couple of observations on on this trailer: Joe looks great, the lighting is great, but, whoa, back the audio down, it's clipping (I'd have put a compressor/limiter on the mic channel during the takes), and put some segues in to attenuate those jerky jump-cuts (e.g., maybe a quick thematic cross-dissolve "lens shutter" image, replete with concomitant "shutter-snap" sfx). The jumps (most w/changing L/R framing on Joe and often rushed end/begin edits) make it distractingly obvious that he's reading a prompter, and that these pieces were stitched together.

Whatever. I'm maybe the only one who will notice these things.

More to come...

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