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Tuesday, May 28, 2013

If I knew then what I know now... pondering the Naked Emperor

Recall, from our prior post,

"Let's Admit the Emperor Has No Clothes- It's Time to Redesign EHRs to Improve Patient Care"

Aside from the fact that time travel and its 20/20 hindsight cognitive fruits are only possible in Hollywood, it's not clear from the Healthcare Innovation Council REBOOT response precisely who is this "Emperor." HHS Secretary Sebelius? CMS Administrator Tavenner?

Yeah, I know, it's likely not aimed specifically at anyone in particular, it's probably just a "witty and original" totemic pejorative metaphorical allusion expressing frustration with bureaucracy. Quite fashionable these days, to be sure.

Anyone who has followed this blog knows by now that I am no reflexive HHS/CMS/ONC cheerleader (far from it), but this unevenly composed letter is so chock full of empty, repetitive echo chamber chants, blinding glimpses of the motherhood-and-apple-pie obvious, a buffet serving of red herrings, and outright misstatements of fact as to compel me into a bit of prefatory snark and Photoshop mockery.

Serious item-by-item critical pushback to ensue shortly. Stay tuned.

"We believe that the root cause reasons why EHRs aren't delivering on their promises include:
  • [1] EHR design issues: EHRs, to date, have been fundamentally designed to create electronic versions of paper medical records. EHRs focus on data collection mostly for regulatory compliance and financial reporting, not to assist physicians, nurses and other clinicians in providing higher quality more efficient patient care. As a result, the EHRs are not designed to reflect or facilitate the way in which providers deliver patient care, and thus disrupt, rather than enhance, patient care; and
  • [2] EHR implementation issues: EHR implementations are often led as IT "projects" by teams that do not obtain robust, meaningful, future-focused input / involvement from nurses, physicians, pharmacy and other clinicians who provide patient care. The end result typically is that EHR implementations don't make life better for EITHER the clinician or the patient. Sadly, more often than not physicians, nurses and other clinicians find EHRs make it more, rather than less, difficult to provide better patient care."
Bullet 1: While still true to a degree with respect to Big Iron "legacy systems" (such as -- hel-LO? -- the ones they cited as data sources from their interviews) that is a dated argument. It becomes less true, more dated with each passing month. Newer EHR developers are working furiously to come up with workflow-compatible applications.

Bullet 2: Any organization large enough to have an "IT department" has to deal with this internal political problem whatever the hardware and software systems being deployed. This, too, is old news. See my July 2010 post wherein I cite the Haugen-Woodside book "Beyond Implementation: A Prescription for Lasting EHR Adoption."

"The following themes emerged from those discussions, which question the ability of the current breed of EHRs to improve patient care and question the implementation methodology used by many providers that doesn’t have sufficient focus on improving patient care:
  • [3] Improving patient care should have been the primary focus for EHR planning/implementation, as directed by Congress in the ARRA. Instead, CMS’ and healthcare providers’ focus has been to "just get EHRs up and running" in a way that meets CMS’ “meaningful use” requirements so that they can get “meaningful use” dollars, without regard to how that affects patient care. CMS should change its “meaningful use” requirements to require measureable improvements in patient care in the short-term.
  • [4] The primary caregivers, nurses, were often not involved in EHR planning or had limited involvement with boundaries and limitations when nurses identified specific patient care needs.
  • [5] EHR planning was primarily from the IT perspective, not from the clinical care perspective.
  • [6] The EHR was not designed to provide a longitudinal view of the patient’s story over a period of time, with trending capabilities for improved decision making.
  • [7] The EHR is cumbersome and requires too many clicks to obtain needed patient information.
  • [8] The EHR does not facilitate patient knowledge, education or input.
  •  [9] Quality of documentation has decreased, not increased, after EHR implementation.
  • [10] The EHR is primarily an electronic documentation tool that unfortunately also isn’t, but could be, a "brain partner" decision support tool that aids clinicians in providing and improving patient care.
  • [11] EHRs should be interoperable so that EHR patient records are accessible to all care givers (subject to appropriate security and privacy), which was another direction to CMS by Congress in the ARRA.
  • [12] The efficiency and effectiveness of care delivery business processes need to be reviewed and  re-engineered prior to, not after, commencement of the EMR implementation."
Bullet 3. First, you should noted the repeated confusion of the roles of ONC and CMS in this letter. to wit:

‘‘(b) PURPOSE.—The National Coordinator shall perform the duties under subsection (c) in a manner consistent with the development of a nationwide health information technology infrastructure that allows for the electronic use and exchange of information and that—
‘‘(1) ensures that each patient’s health information is secure and protected, in accordance with applicable law;

‘‘(2) improves health care quality, reduces medical errors, reduces health disparities, and advances the delivery of patient- centered medical care;

‘‘(3) reduces health care costs resulting from inefficiency, medical errors, inappropriate care, duplicative care, and incomplete information;

‘‘(4) provides appropriate information to help guide medical decisions at the time and place of care;

‘‘(5) ensures the inclusion of meaningful public input in such development of such infrastructure;

‘‘(6) improves the coordination of care and information among hospitals, laboratories, physician offices, and other entities through an effective infrastructure for the secure and authorized exchange of health care information;

‘‘(7) improves public health activities and facilitates the early identification and rapid response to public health threats and emergencies, including bioterror events and infectious disease outbreaks;

‘‘(8) facilitates health and clinical research and health care quality;

‘‘(9) promotes early detection, prevention, and management of chronic diseases;

‘‘(10) promotes a more effective marketplace, greater competition, greater systems analysis, increased consumer choice, and improved outcomes in health care services; and

‘‘(11) improves efforts to reduce health disparities. [ARRA pg 116]
While both ONC and CMS are agencies under the HHS umbrella, CMS's role is more purely administrative -- i.e., managing the disbursement of the Medicare and Medicaid Incentive funds. It is ONC that is charged with setting and guiding HIT policy priorities under ARRA. The phrase "National Coordinator" is found 70 times across 26 pages of the law, and the combined "Medicare" "Meaningful Use" is found 19 times across 8 pages.

Having noted that, it is a fair point to observe that the Meaningful Use program did indeed glom onto a "Body Count" focus to a great degree (I have to confess to our having recruited some duds early on at my REC). Nonetheless, to a significant extent this signup focus was strategic and in keeping with ARRA intent (aiming for tipping point "Network Effect"). Recall this emblematic "Bend The Cost Curve Graphic"?

It is premature to expect much in the way of "improved clinical outcomes" yet, in light of the magnitude of the huge scope of such a transformative project. Even for complex patients seeing their doctors, say, 4 times a year, any emergent outcomes trends for better or worse are unlike to be evident at this point. This expectation was baked into the HITECH planning assumptions. Criticizing the lack of "improved outcomes" in 2013 is either disingenuous or naive.

Bullet 4: I assume the interview data on this lament came from inpatient settings. It is probably true. Bullet 5: Redundant. See my response to #2. Bullet 6: At least in outpatient settings, longitudinal flowsheets are by now EHR staples, so this is to a great degree a misstatement of fact. Even Vista does flowsheets.

Bullet 7: "The EHR is cumbersome and requires too many clicks" Which "EHR"? There are as of today (May 28th) 1,947 ONC "complete" certified EHR systems. Did HIC collect data on this complaint? Say, how many workflow clicks for each num/denom MU measure, stratifed by EHR product?

I rather doubt it.

Bullet 8: Building in patient education / input functionality is in fact part of the ONC plan. Stage 1 functionality necessarily focused on data capture health care clinicians and staff.

Bullet 9: That allegation is so vague as to be worthless. And, is likely not true.

Bullet 10: The "brain partner" thing. Premature to expect at this point, I would think. Not that's it's not a desirable function. See my various postings (Down in the Weeds') on Messrs Weeds' "Medicine in Denial."

Bullet 11: The "Interoperability" misnomer. Yes, I agree, and have posted so repeatedly. But, here we bump up against the inevitable for-profit market conundrum: Margin = Opacity.

Bullet 12: It's not (workflow/BPM) a before or after thing. To the extent that it's "before," we really just mean that it has to be part of the HIT project planning. We've known this for a long time (e.g., DOQ-IT, 2005 - 2008).


Bullet points 13 through 19 comprise a (cherry-picked?) summary of studies critical of the effort. I observed in my prior post: 
In meta-analytic fashion, they cite seven studies [bullet points 13 - 19] critical of Health IT deployment, but only allude to aggregate concerns contained in these reports. Seven critical reports across four years? Is that unusual for any large government initiative of comparable complexity and magnitide?
Bullet point 20 simply involves some speculative hand-wringing regarding the recent ONC de-certification of two EHR products and its potential for disruption in the industry should more vendors get decertified. That concern is to an extent reasonable (though I bet HHS is gonna march lockstep carefully past that minefield). My views on the shallowness of the ONC CHPL certification methodology are well known by now to regular blog readers.

The final bullet points
"Strong nurse, physician and clinician EHR involvement will help achieve the following patient care improvement objectives:
  • [20] Improved focus on EHR design and implementation that starts by mirroring the way care is actually delivered by nurses, doctors and other clinicians. This basic design then would move to new, information enhanced processes that not only help clinicians do their jobs easier, but measurably improve patient care safety and quality.
  • [21] Discovery and integration of ways to enable a richer, more engaged and meaningful patient/caregiver relationship versus one that requires increased clinician time for record keeping instead of patient care.
  • [22] Redesigned EHR processes that ensure nothing falls through the cracks in care transitions (e.g., medication reconciliation,) which are a major source of patient safety issues.
  • [23] Rethinking, redesigning and re-engineering nurse, physician and clinician workflows to take full advantage of the capabilities of the new (and evolving) EHR tools to result in improved healthcare processes and care experiences."
In reading through this entire piece, I couldn't help but notice one or another permutation of the phrase "nurses, doctors and other clinicians" occurring repeatedly -- 15 times to be exact (in an 8 page proffer). "Clinician(s)" specifically 22 times.

Roger that. 10-4. We got ya. These are hardly original thoughts. Repeating them multiple times doesn't serve to strengthen the argument.

Bullets 20 and 23: Well, in #20 we're gonna re-design HIT to align to the way clinicians actually work (see #1 also), but in #23 we'll be modifying ("redesigning and re-engineering") clinical workflows to align them with HIT capabilities. Okee-Dokee.

Truth is, it has to be a PDSA improvement mix of tactics. We've known that for quite some time. See, e.g.,  the substantial workflow document repository. It goes back at least 20 years.Truth is, "the way clinicians actually work" is not cast in granite; it has to change with the technological times. Health care is not unique in this regard.


Bullets 21 and 22: Well, NO ONE is arguing against any of that. The HIT literature of the past decade is full of such recommendations.

  • Who, precisely is is to be in placed charge of "re-designing EHRs" to produce the functionalities recommended by the HIC? The authors don't say. SOMEONE, SOME ENTITY will have to be in charge. And, while the tone here could not be more transparently anti-government, the private market imperative is fraught with its own adversities. Again, opacity (coupled with barriers to entry) = margin. That is simply an upshot of Efficient Markets 101. Transparency is the inverse linear correlate of Margin. And, it's worth noting in this regard, that Transparency would not beget us 1,945 ONC "Meaningful Use Certified" proprietary EHR systems (and 2 Open Source products, Vista, and Open EMR).
  • Yeah, "frictionless, intuitive, Steve Jobs-ian" usability would be swell. Plug 'n Play. No Training Required. Total Ease of Use for the Busy Clinician. What's not to love?

    But it's a weak analogy. Jobs gave us great entertainment-oriented consumer products (and no one is a bigger "Mac Snob" than me), and, while there is in fact a smidgeon of emerging convergence, the kids now getting $3-5 million in Series A VC IPO money in the Bay Area for their cute small-footprint tablet and smartphone apps are not going to do squat about the industrial-strength IT architectural needs of clinical ambulatory and (especially) in-patient HIT. I've been hanging around the Health 2.0 crowd for nearly a year. I'm mostly seeing a euphoric DotCom Bubble v2.0.

    There are again investors to be fleeced. Google "Built to Flip."

    apropos, from The New Yorker (05/27/13):

    Evgeny Morozov,, in his new book "To Save Everything, Click Here," calls this belief [health care salvation via Health 2.0] "solutionism." Morozov, who is twenty-nine and grew up in a mining town in Belarus, is the fiercest critic of technological optimism in America, tirelessly dismantling the language of its followers. "They want to be 'open,' they want to be 'disruptive,' they want to 'innovate'...You might not be able to pay for health care or your insurance, but if you have an app on your phone that alerts you to the fact that you need to exercise more, or that you aren't eating healthily enough, they think they are solving the problem." [Changing the World, George Packer, pg 50]
    Hear, Hear.
  • "...spend the remainder of the “meaningful use” funds on providing financial incentives for hospitals and other providers that demonstrate “meaningful improvements in patient care” through whatever means they choose, and leave it to the healthcare providers, not our federal government, to choose the most effective means to improve patient care."

    That begs a host of questions, starting with "what will constitute 'meaningful improvements in patient care'?" In science, someone -- in a position of some legitimate authority -- has to determine in advance what will constitute a "significant" improvement above baseline (for each clinical outcome measure of priority concern). These authors are utterly silent on the specifics here. We get instead gauzy Apple Pie sentiments.
I have agree that the "mad race for 'meaningful use' dollars" is real and unhelpful -- though that money chase incentive has peaked on the Medicare side (you'd have needed to attest for year one stage one in 2012 to preserve full 5-year $44k reimbursement potential, and 2013 attesters have additionally gotten hit with a 2% "sequester" cut).

"And thus far the Centers for Medicare & Medicaid Services (CMS) has spent over $12.7 billion of EHR stimulus monies." [page 1]

"These indictments of both our current breed of EHRs and the way in which EHRs are being implemented cry out for change in direction of the “meaningful use carrot” in CMS’ program that has already cost taxpayers $12.8 billion..." [page 3]

Emphasis mine. Was this not subjected to any proofreading prior to submission?
I have no reason to doubt the sincerity of these HIC people with respect to the envisioned widely-shared ends they proffer. But, I have good reason to be skeptical of their argument as it is set forth in their letter. Maybe they do in fact have detailed operational plans for implementing their vision. They failed to cite any here (nor does this response provide any links to such detail).


Who/what is the Healthcare Innovation Council, really? Let's begin with Mr. Kneipper.

He's a lawyer, not a clinician.

He's a Health IT/Ops Mgmt vendor. Co-founder, interim CEO of Anthelio. From the corporate website:
EMR Services

Hospitals and physicians are rapidly implementing electronic medical records (EMRs) in order to obtain the "meaningful use" EMR funding under the American Recovery and Reinvestment Act of 2009. EMRs, if properly implemented and utilized, have the potential to improve the quality, efficiency and safety of healthcare delivery.

Though the number of healthcare providers implementing EMRs continues to rise, they are still struggling with the complexity of implementations. We at Anthelio Healthcare understand that the providers may not realize the full value of their EMR implementations due to numerous challenges such as scarcity of skilled resources, interoperability issues and the lack of end-user adaptation.

Anthelio Healthcare, with its proven implementation methodology and its expertise with the leading EMR applications, is a valuable partner for hospitals to lead and support the EMR implementation. We provide EMR solutions for the leading vendors: McKesson, Epic, Cerner, GE, Meditech and Healthland. Our EMR service offerings focus on assisting healthcare organizations create an operationally optimized EMR environment...
Implementations Services

Anthelio Healthcare provides end-to-end implementation services for all leading EMR applications. Based on our extensive experience with EMR implementations, we have developed a propriety [sic] "HeLIX" methodology for implementation...  

Essentially, they're a VAR for some legacy HIT products.

I found it curious that this Anthelio "Independent Council" has no independent web presence (it resides in a sub-folder on the Anthelio website). Haven't yet looked to see whether they've filed 501(c)(3) or 501(c)(4). Anyone want to guess?

No Trademark declaration (not even "TM" common law).

I could cybersquat all of those domains for about 50 bucks. And then mount one of them, with just some basic homepage content, for about $100 a year.

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