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Friday, May 30, 2014

dx Machina

I spend a lot of time studying the cognitive processes of "experts," most notably those in the professions of medicine and law (the only two disciplines traditionally accorded the characterization; nowadays we've defined the appellation down to the point where your garbage truck driver is touted as an "Environmental Management Professional").

So, I read everything I can concerning "how doctors think," "how to think like a lawyer," etc. I've been studying legal reasoning since my senior undergrad year at UTK in 1985, when I took "Senior Seminar in the Psychology of Law," a course taught by a psych prof who also had a Juris Doc, a degree he acquired while researching the salient elements of eyewitness testimony (bottom line, it's egregiously unreliable; nonetheless, if you are charged with but innocent of some crime but have an eyewitness against you at trial, you are probably so screwed).

I just finished this book the other day:

Ran across a couple of interesting tidbits. e.g.,

Recently a new tool for improving predictions about case outcomes is making waves: computers. “Lex Machina” is Latin for “Law Machine.” It’s also the name of a tech startup that emerged in 2009 from a Stanford Law School project to help “companies anticipate, manage, and win patent and other intellectual property [IP] law suits.” The idea to create a sophisticated database with reliable information about IP suits came to Stanford law professor Mark Lemley after he grew tired of hearing unsubstantiated assertions about patent litigation. “People would make all kinds of claims in policy debates that were presumably testable but were radically different from each other, you know with one saying patent suits are 50 percent of all lawsuits and another saying, no, it’s 1 percent.” A team of lawyers and engineers put in over 100,000 hours categorizing, tagging, and coding information to produce a database of 150,000 IP cases, 134,000 attorney records, and information about 1,400 judges, 63,0000 law firms, and 64,000 parties from the last decade. Every day the database grows. Lex Machina’s crawler, using natural language processing and machine learning tools, continues to extract new data from all ninety-four federal district court sites, the Patent and Trademark Office site, and other sites with IP litigation data.

According to an executive of a venture capital fund that poured more than $ 2 million in funding into the project, Lex Machina offers clients “previously impossible insights” that “inform winning IP business and legal strategies.” Sasha Rao, a partner in the Palo Alto firm of Ropes & Gray, says Lex Machina’s rich and easily searchable data “fundamentally improves an IP litigator’s chances of winning” by facilitating everything from “initial investigations through trials and appeals.” Vicki Veenker, an attorney with Sherman & Sterling, praised the data that “reveal a judge’s entire case decision history” in IP cases, information she finds “invaluable for choosing venue, drafting motions, preparing oral arguments and advising on settlement.”

For every company executive contemplating initiating IP litigation, the question they want answered is “What are our chances of winning and how much will it cost?” According to the Federal Judicial Center, the average cost of taking a patent case to trial is about $ 5 million per patent, so companies have strong incentives to carefully assess the odds of success. Joshua Walker, co-founder of Lex Machina, is confident that the technology his company provides will “revolutionize how corporate finance looks at litigation. We’ve done a number of use cases where we’ve said, ‘Here are the settlement patterns and win rates for these companies’.”

Predictive computer databases are likely to make their mark first in legal fields that, like IP, are complex and involve high stakes. (Don’t expect public defenders or legal aid lawyers to be using tools like this anytime soon.) The trend, however, is unmistakable. Company executives hoping to hold down litigation costs will have more access than ever before to data that will empower them to participate with their legal counsel in strategizing. Lawyers whose predictions about litigation outcomes reflect overconfidence or other biases can expect to be exposed by the data and abandoned by increasingly sophisticated clients. The lesson for attorneys is clear: make better predictions or lose clients.

Linder, Douglas O.; Levit, Nancy (2014-04-06). The Good Lawyer: Seeking Quality in the Practice of Law (Kindle Locations 2805-2847). Oxford University Press, USA. Kindle Edition.
Yeah. apropos of medicine and health IT, think messrs Weed. Recall my 2012 post "Down in the Weeds'"
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 $21⁄2 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...

"dx Machina"

Everyone wrestling with the myriad contentious issues that continue to bedevil Health IT should read this important book, IMO. I also commend to everyone the works of Dr. Jerome Taylor on his blog "EHR Science," specifically his two posts entitled "Is the Electronic Health Record defunct?"
When building software, requirements are everything. And although good requirements do not necessarily lead to good software, poor requirements never do.   So how does this apply to electronic health records? Electronic health records are defined primarily as repositories or archives of patient data. However, in the era of meaningful use, patient-centered medical homes, and accountable care organizations, patient data repositories are not sufficient to meet the complex care support needs of clinical professionals. The requirements that gave birth to modern EHR systems are for building electronic patient data stores, not complex clinical care support systems–we are using the wrong requirements...
Excellent stuff, if a bit abstract and theoretical at times. Important, all of it.

Beyond data systems and data availability, equally important are the "soft" cognitive elements of expert judgment. Another interesting excerpt from The Good Lawyer.

We’ve seen that empathy allows lawyers to better understand their clients’ problems, reduces miscommunication, and provides the basis for telling the stories of clients in more effective and compelling ways. Lawyers short on empathy might well ask whether they can increase their empathy, or whether their bad “empathy genes” or deficient family bonding have set their empathy quotient in stone. The honest answer is that the jury is still out on that question. Role-playing techniques, such as the psychodrama used at the Trial Lawyers College, might well increase empathy over the longer term, but there have been few, if any, controlled studies to justify drawing that conclusion with confidence. Sure, many graduates of TLC might say they now have more empathy, but do they really?

Research provides stronger evidence that emotion recognition, one of the two main components of empathy, can be improved than exists for the other component, empathetic response. It seems that it is easier to teach people to pick up on the emotions another is experiencing than it is to teach them to respond to that person with an appropriate emotion of their own. Better emotion recognition will reduce miscommunications between a lawyer and client, but without appropriate emotional responses, your client might still think you an insensitive jerk. Even though no training program can guarantee that it will turn a low empathizer into a high empathizer, there are simple steps to make the most of the empathy we do have

How to Make the Most of Your Empathy: A Checklist

  1. Give your client your full attention. Do not multitask when meeting with clients. Take steps to avoid interruptions and external distractions, such as noise.
  2. Listen actively. Avoid thinking about what you will say next when your client is talking. Understanding should precede being understood.
  3. Pay close attention to clients’ clues (body language, tone of voice) so as to appropriately respond to their concerns.
  4. Reflect your understanding of your client’s emotional state. Acknowledge how your client’s legal problem makes him feel.
  5. Think of your client as a person, not just as a source of income, and be curious about your client’s entire story.
  6. Think of yourself as a coach as well as a provider of legal services. Recognize that part of your job is to move clients toward more positive emotions.
  7. Avoid legal jargon, lectures, and long-winded answers. Pause between paragraphs to give clients time to process your explanations and their own emotions.
  8. Ask clients open-ended questions. Ask for explanations and examples. Don’t just ask leading questions.
  9. If possible, meet clients in their environment rather than in a sterile law office.
  10. Role-play and engage in simulation scenarios with colleagues to improve your empathetic response.
  11. Communicate regularly with clients. Respond to their emotions and their expressed regrets. Ask them frequently if you are accurately perceiving their concerns and desires.
  12. Use resources such as personality inventories to become more aware of your own strengths and weaknesses as a communicator.
Change "lawyer" to "doctor," and "clients" to "patients." While #9 is impractical in all but the rarest of circumstances and #10 is not really relevant to the practice of medicine, the other ten might well be applicable -- if you feel that empathy is an important clinical skill component. I do.

apropos, I point you back to the writings of Dr. Danielle Ofri:

...Smack square in this debate over whether empathy is innate or learned is the consistent and depressing observation that medical students seem to lose prodigious amounts of empathy as they progress along the medical training route. Something in our medical training system serves to stamp out whatever empathy students bring with them on day one.

The research appears to conclude that it is the third year of the traditional medical curriculum that does the most damage. This is a dispiriting finding, as the third year of medical school is the one in which medical students take their first steps into actual patient care. For most students, the third year of medical school is eagerly awaited. After two long years sitting in classrooms, you get to actually do what it is that doctors do— be in hospitals, take care of patients. One would think that these first steps into real patient care would bring forth all the idealism that drove students to medical school in the first place— idealism that is sorely tested in the first two years of memorizing reams of arcane facts.

But the reverse seems to occur. After their seminal clinical experiences involving real contact with real patients, medical students emerge with their empathy battered. Their ideals of medicine as a profession are pummeled by their initiation into the real world of clinical medicine. And it is in this demoralized state that we send them into residency to accrue what are arguably the most influential and formative experiences of becoming practicing physicians.

Why do medical students lose empathy during the clinical years of medical school? There are likely many reasons. Some are related to the disorientation and fatigue experienced by students as they are thrown into the fire of hospital life— so different from the orderly, clean, controlled classroom life in which they have existed for two years. That student world is cemented along predetermined schedules, explicit curricula, definitive tests. Even if the knowledge requirements are overwhelming— as they are— medical students at least know what to expect, down to nearly every second of their waking hours.
Wednesday, 8: 30 a.m.– 10: 00 a.m., Pathology class; Topic: Peptic Ulcer Disease, room 203, Professor O’Brien, pages 237– 54 in Robbins’ Pathologic Basis of Disease, Exam on December 15.
This elaborately structured world of lectures, labs, classrooms, tests, and professors is a heliotropic universe with the medical students squarely at the fiery center. Everything exists for their sake. Their medical education is the raison d’être of the entire enterprise.

When the students enter the wards, however, the tables are not just turned, they are upended entirely. Temperamentally, the world of the hospital is a different planet from the medical-school lecture hall. To the greenhorn, it is sheer anarchy. Some of this is the nature of medicine: human beings and their illnesses do not trouble themselves with schedules, flow charts, or textbooks.
Chemotherapy infusion protocols conflict with CT scanner availability, but bronchoscopy can only be done after the CT scan, however the pulmonologist was called away to an emergency so the bronchoscopy needs to be rescheduled. Mrs. Baradi spiked a fever so chemo needs to be canceled and the patient in the next bed over just developed an unusual rash so needs to be moved to an isolation room, but the ER is backed up with admissions so five new patients are coming to the ward at the same time and no isolation beds are available. Mr. Langley’s family is here and needs to speak to his doctor, but 15-West is short-staffed today so two nurses will have to be “floated” over there, and if the ambulette forms aren’t filled out immediately then Ms. Gemberson’s discharge will be delayed another day. There’s a code on 17-North— drop everything!
Hospital life— with its byzantine array of moving parts layered atop the unpredictable rhythms of illness— is a permanent state of flux. Seasoned doctors and nurses are accustomed to working with a certain amount of ongoing bedlam. But new medical students, used to the orderly scheduling of academic life, are overwhelmed. They are easy to spot on the wards, not just because of their short white coats but because of the befogged expressions on their faces as clinical medicine swirls around them. They stand awkwardly on the edges of the ward as people, stretchers, emergencies, hospital lingo, and rapidly changing clinical priorities zing past them at bewildering speeds.

To add to their discomfort, the students are astute enough to know that they don’t actually have any real purpose on the wards, no definitive job description like the doctors, nurses, pharmacists, phlebotomists, respiratory therapists, X-ray technicians, clerks, orderlies, dietitians, housekeepers, and electricians. Medical students are there only to learn. The inherently self-centered nature of their existence in a setting that is not specifically designed for their education— as the classroom part of medical school had been— creates an intensely uncomfortable state of being.

They did choose a career in medicine to help others, didn’t they? Most medical students desperately want to help out on the wards— to ease some of their guilt, to “pay back” the interns and residents who are teaching them, to do some good for the patients in need they see all around them. But it’s hard to know where to start when your skills are minimal and everything is moving at breakneck speed with a paradoxically anarchic efficiency that you are sure to jam up. Indeed, the help that medical students earnestly offer often slows things down, a point that is painfully obvious to all parties involved.

Although medical students eventually acclimatize somewhat to the clinical tumult, most retain that awkward sense of feeling useless, of being a constant fifth wheel. This difficulty in finding purpose, in finding a justified place in the beehive, can cause many students to unconsciously curtail their desire for engagement and hence their empathy.

A second and perhaps even more significant factor in loss of empathy is what has been termed the hidden curriculum of medical school. The formal curriculum— what is taught in the lecture halls, what is embodied in the school’s mission statement, what is intoned by the deans and senior faculty who usher the students into the sacred world of medicine— can be trounced in a thrice by the hidden or informal curriculum that the students are submerged in once they enter the clinical fray.

The students’ true teachers are no longer the august, gray-haired professors who practiced medicine in “the days of the giants” but harried interns and residents in grubby white coats stained with the badges of medicine in the trenches. These younger doctors are the immediate interface with clinical medicine for the students. The students trail their interns and residents every waking minute and absorb from them how medicine is done— how it is spoken, thought, written, performed, attired, and equipped.

Residents and interns are the grunts of the medical profession, tasked, simply, with getting everything done. The practical side of the clinical buck stops with them (even if the ultimate clinical and legal responsibility rests with the attendings), and the house staff do whatever it takes to get everything done. With their scut lists in hand, their coat pockets doubling as supply cabinets, they are the embodiment of the pragmatic. While many still retain their interest in the theories and mechanisms of disease, the overriding modus operandi is utilitarian, because unlike the electricians, housekeepers, therapists, technicians, orderlies, dietitians, even the nurses and senior doctors, their job description has no bounds.

If an X-ray needs to be done and transport is not available, it is the intern who wheels the patient down to radiology. If a form needs to get to the social worker’s office immediately because a discharge is riding on it but the fax machine is broken, there is the intern galloping down the stairs, paper in hand. Although house staff are not enamored of the clerical, administrative, transportation, and nonmedical miscellany that falls into their laps, they would rather do it themselves than suffer the time delays inherent in waiting for the regular channels to creak forward.

They don’t want time delays for their patients because they do genuinely want the best, timeliest care for them. But they don’t want time delays for themselves either, because time delays translate to more work. And more work translates to less sleep. (One doctor recalled a board game he and his colleagues used to play during residency. It was called the Intern Game. Instead of money, the units of the game were hours of sleep, and this is what you would “spend” for any activity or item in the game.)

There is a baseness to this, but it’s the natural outcome of putting smart, competitive, perfectionist people in a high-stress system with myriads of ever-changing tasks for which they feel professional responsibility, coupled with sleep deprivation and the granite-hard fact of only twenty-four hours in the day . . . even in a sleepless one.

This whatever-it-takes-to-get-it-done attitude breeds an efficiency that often dispenses with niceties.

Ofri, Danielle (2013-06-04). What Doctors Feel: How Emotions Affect the Practice of Medicine, Beacon Press. Kindle Edition.
Indeed. See also my December 4th, 2013 post "Philosophia sana in ars medica sana."

Perhaps if physicians were paid more like lawyers, some of these problematic cognitive burden issues would be attenuated.

Good luck with that proposition, I know.


Interesting article by Phillip Carter.

President Barack Obama had no choice but to accept Veteran Affairs Secretary Eric Shinseki’s resignation. The VA inspector general’s interim report issued this week contained too many damning findings of “systemic” problems that grew under Shinseki’s watch. Key among these was the finding that the actual VA primary care wait times in Phoenix averaged 115 days—more than four times the VA’s previously reported average of 24 days. That discrepancy revealed a gap between reality and official reporting, and suggested questions about the VA’s integrity ran all the way up to the secretary’s office.

More broadly, the growing VA scandal cast doubt on the ability of the government to deliver health care, a major Obama administration priority. If the White House could not deliver on this promise to veterans, a key constituency for whom the president and vice president have frequently described health care as part of a “sacred trust,” then how could the administration be trusted to provide care for all Americans? Coming after the legal and practical challenges to the Affordable Care Act, the White House could not afford another health care failure. And so Shinseki had to go.

Unfortunately, his departure will do little to fix the broader problems in the massive VA health care system—and may even set the quasi-leaderless agency back as it waits for a new secretary to be appointed and confirmed.
The VA is the second-largest cabinet agency, and the nation’s largest health care and benefits provider, with an overall fiscal 2015 budget of $165 billion (greater than the State Department, USAID, and entire intelligence community combined), including $60 billion for health care. The VA employs more than 320,000 personnel to run 151 major medical centers, 820 outpatient clinics, 300 storefront “Vet Centers,” more than 50 regional benefits offices, and scores of other facilities. This massive system provides health care to roughly 9 million enrolled veterans, including 6 million who seek care on a regular basis...
Read the entire piece. Phillip Carter is an Iraq veteran who now directs the veterans research program at the Center for a New American Security.

More to come...

Wednesday, May 28, 2014

Joe Flower on the Health tech revolution

Cross-posted, with permission. Joe is an important healthcare thinker.

Will Tech Revolutionize Health Care This Time?
by JOE FLOWER on MAY 27, 2014

First published in Hospitals and Health Networks Daily, the online publication of the American Hospital Association, on May 27, 2014.

After decades of bravely keeping them at bay, health care is beginning to be overwhelmed by “fast, cheap, and out of control” new technologies, from BYOD (“bring your own device”) tablets in the operating room, to apps and dongles that turn your smart phone into a Star Trek Tricorder, to 3-D printed skulls. (No, not a souvenir of the Grateful Dead, a Harley decoration or a pastry for the Mexican Dia de Los Muertos, but an actual skullcap to repair someone’s head. Take measurements from a scan, set to work in a cad-cam program, press Cmd-P and boom! There you have it: new ear-to-ear skull top, ready for implant.)

Each new category, we are told, will Revolutionize Health Care, making it orders of magnitude better and far less expensive. Yet the experience of the last three decades is that each new technology only adds complexity and expense.

So what will it be? Will some of these new technologies actually transform health care? Which ones? How can we know?

There is an answer, but it does not lie in the technologies. It lies in the economics. It lies in the reason we have so much waste in health care. We have so much waste because we get paid for it.

Yes, it’s that simple. In an insurance-supported fee-for-service system, we don’t get paid to solve problems. We get paid to do stuff that might solve a problem. The more stuff we do, and the more complex the stuff we do, the more impressive the machines we use, the more we get paid.

A Tale of a Wasteful Technology
A few presidencies back, I was at a medical conference at a resort on a hilltop near San Diego. I was invited into a trailer to see a demo of a marvellous new technology — computer-aided mammography. I had never even taken a close look at a mammogram, so I was immediately impressed with how difficult it is to pick possible tumours out of the cloudy images. The computer could show you the possibilities, easy as pie, drawing little circles around each suspicious nodule.

But, I asked, will people trust a computer to do such an important job?

Oh, the computer is just helping, I was told. All the scans will be seen by a human radiologist. The computer just makes sure the radiologist does not miss any possibilities.

I thought, Hmmm, if you have a radiologist looking at every scan anyway, why bother with the computer program? Are skilled radiologists in the habit of missing a lot of possible tumors? From the sound of it, I thought what we would get is a lot of false positives, unnecessary call-backs and biopsies, and a lot of unnecessarily worried women. After all, if the computer says something might be a tumor, now the radiologist is put in the position of proving that it isn’t.

I didn’t see any reason that this technology would catch on. I didn’t see it because the reason was not in the technology, it was in the economics.

Years later, as we are trending toward standardizing on this technology across the industry, the results of various studies have shown exactly what I suspected they would: lots of false positives, call-backs and biopsies, and not one tumor that would not have been found without the computer. Not one. At an added cost trending toward half a billion dollars per year.

It caught on because it sounds good, sounds real high-tech, gives you bragging rights (“Come to MagnaGargantua Memorial, the Hospital of the Jetsons!”) — and because you can charge for the extra expense and complexity. There are codes for it. The unnecessary call-backs and biopsies are unfortunate, but they are also a revenue stream — which the customer is not paying for anyway. It’s nothing personal, it’s just business. Of course, by the time the results are in saying that they do no good at all, you’ve got all this sunk cost you have to amortize over the increased payments you can get. No way you’re going to put all that fancy equipment in the dumpster just because it fails to do what you bought it for.

Is this normal? Or an aberration? Neither. It certainly does not stand for all technological advances in health care. Many advances are not only highly effective, they are highly cost effective. Laparoscopic surgery is a great example — smaller wounds, quicker surgeries, lower infection rates, what’s not to like? But a shockingly large number of technological advances follow this pattern: unproven expensive technologies that seem like they might be helpful, or are helpful for special rare cases, adopted broadly across health care in a big-money trance dance with Death Star tech.

Cui Bono?
But that is in health-care-as-it-has-been, not in health-care-as-it-will be. How we think about the impact of new technologies is bound up with the changing economics of health care.

Under a fee-for-service system the questions about a new technology are, Is it plausible that it might be helpful? What are the startup costs in capital and in learning curve? And: Can we bill for it? Can we recoup the costs in added revenue?

In any payment regime that varies at all from strict fee for service (bundled payments, any kind of risk situation), whether we can bill for it becomes irrelevant. The focus will be much more on efficiency and effectiveness: Does it really work? Does it solve a problem? Whose problem?

Many times, extra complexity and waste are added to the system for the convenience and profit of practitioners, not for the good of patients. For example, why do gastroenterologists like to have anaesthesiologists assisting at colonoscopies, when the drugs used (Versed and fentanyl) do not provoke general anaesthesia and can be administered by any doctor? The reason is simple: It turns a 30-minute procedure into a 20-minute procedure. The gastroenterologist can do three per hour instead of two per hour. In the volume-based health care economy, they make more money. The use of the anaesthesiologist adds an average of $400 per procedure to the cost without adding any benefit, lowering the value to the patient. Altogether this one practice adds an estimated $1.1 billion of waste to the health care economy every year.

UPDATE NOTE: Diane Brown, MD reminds me that for safety it is best to have a pair of eyes dedicated to monitoring the anesthesia. But it need not be an anesthesiologist. It can be a nurse trained to the task, a regular member of the endoscopy team.
So in thinking about whether these new technologies will propagate across health care, we can ask how exactly they will fit into the ecology of health care, who will benefit from their use, and how that benefit will tie in to the micro economy of health care in that system, with those practitioners and those patients.

Change Is Systemic
A cardiologist in an examining room whips out his iPhone and snaps it into what looks like a special cover. He hands it to the patient, shows the patient where to place his fingers on the back of the cover, and in seconds the patient’s EKG appears on the screen. Dr. Eric Topol, speaking at last summer’s Health Forum Summit, performs a sonogram on himself on stage using a cheap handheld device. These things are easy to imagine in isolation, as something a single doctor or nurse might do with an individual patient.

In reality, in most of health care, the things we need to do to incorporate such technologies are systemic. To be secure, reliable, HIPAA-compliant and connected to the EMR, they can’t be used randomly by the clinicians who happen to like them. They must be tied into and supported by the IT infrastructure.

Similarly, in moving from “volume” to “value” we are talking about changes that don’t happen at the level of a single doctor or single patient. In most cases we cannot treat the patients for whom we are at risk differently from those we are treating on a fee-for-service basis. When you are paid differently, you are producing a new product. When you are producing a new product, you are a beginner. The shift from “volume” to “value” demands and dictates broad systemic changes in revenue streams, which dictate changes in business models, compensation regimes and governance structures. Getting good at these new businesses means changing practice patterns, collaboration models and cultures.

Hospitals, integrated health systems and medical groups face a stark choice: They can either abandon the growing part of the market that demands a “value” business arrangement and stick to the shrinking island represented by old-fashioned “volume” arrangements. Or they can transform their entire business.

The use and propagation of these new low-cost technologies are entirely wrapped up in that decision. In old-fashioned fee-for-service systems, they will be used only where their use can be billed for, or where they lower the internal costs of something that can be billed for. They will not be used to replace existing services that can be billed at higher rates.

“That’s a Lot of Money”
Dr. Topol in his talks likes to make the point that there are over 20 million echocardiograms done in the United States every year at an average billing of $800. As he puts it, “Twenty million times $800 — that’s a lot of money. And probably 70 to 80 percent of them will not need to be done, because they can be done as a regular part of the patient encounter.”

Precisely: That is a lot of money. In fact, it’s a big revenue stream. It’s difficult to imagine that fee-for-service systems for which various types of imaging, scanning and tests represent large revenue streams are going to be early adopters of such technologies that diminish the revenue streams to revenue trickles. When you are paid for waste, being inefficient is a business strategy.

In the “value” ecology of the Next Health Care, the questions are much more straightforward: Does it work? Does the technology make diagnosis and treatment faster, more effective, more efficient? Does it make it vastly cheaper?

Imagine replacement bones (and matrices for regrowing bones) 3-D printed to order. Imagine replacement knee joints, now sold at an average price of €7000 in Europe and $21,000 in the United States, 3-D printed to order. (Imagine how ferociously the legacy makers of implants will resist this change, and how disruptive it will be to that part of the industry.)

Imagine the relationship between the doctor, the nurse and the patient with multiple chronic conditions, now a matter of a visit every now and then, turned into a constant conversation through mobile monitoring.

Imagine a patient at risk for heart attack receiving a special message accompanied by a special ring tone on his cell phone — a message initiated by nano sensors in his bloodstream — warning him of an impending heart attack, giving him time to get to medical care.

Imagine all of this embedded in a system that is redesigned around multiple, distributed, inexpensive sensors, apps and communication devices all supporting strong, trusted relationships between clinicians and patients.

Imagine all this technological change supported with vigor and ferocity because the medical organizations are no longer paid for the volume they manage to push through the doors, but for the extraordinary value they bring to the populations they serve.

That’s the connect-the-dots picture of a radically changed, mobile, tech-enabled, seamless health care that is not only seriously better but far cheaper than what we have today.


Joe Flower is the author of Healthcare Beyond Reform: Doing it Right for Half the Cost, a widely acclaimed manifesto on where healthcare is and has to be heading, based on his in-depth survey of healthcare trends and innovation. He is also the author of hundreds of healthcare articles. For over 20 years he was a contributing editor and regular columnist at the Healthcare Forum Journal. When the Healthcare Forum became the Health Forum of the American Hospital Association, he went on to a regular column in the AHA’s Hospitals and Health Networks Daily. He is member of the AHA’s Health Forum’s speaking faculty, and serves on the board of the Center for Health Design.


Rest in peace, Maya Angelou.


More to come...

Sunday, May 25, 2014

A Memorial Day weekend reflection -- apropos of the VA scandal

My late Dad and all four of his brothers were in WWII for the duration. Only Pop and my uncle Warren survived the war years. Three uncles I never got to meet and know.

One of my Mom's brothers was in the D-Day invasion, coming ashore on one of those LSTs so horrifically depicted in Spielberg's "Saving Private Ryan." I did not find the movie's cinema veritae entertaining. It was, "oh, shit; this is just what they described to me over the years."

I visited the D-Day Omaha Beach cemetery in 2004

Pop left a leg behind on Sicily after his munitions glider crashed during a night landing. He was pinned in the wreckage overnight, both legs crushed up under him and badly broken. They had to amputate the right one just above the knee. He subsequently spent a year in recovery and rehab stateside, in Atlanta. He married my mother after that, walking haltingly with the gimpy gait that came with the relatively crude artificial leg of the time.

Had they had the battlefield triage MASH technology and tx's/px's of Vietnam during WWII, my Dad would probably not have lost his leg. Conversely, had they only had such technology during George W. Bush's Afghanistan and Iraq wars of the 2000's, we'd have had far fewer survivors -- the physically and psychically mangled survivors that will now require ruinously expensive lifetime care in many, many cases.
Early this month at the National 9/11 Museum opening ceremony, participants recounted the litany of loss that day when nearly 3,000 innocent civilians were murdered. In all the reporting on the opening, there was much discussion about the challenge the curators faced in how to present the Sept. 11 narrative.

Thirteen years later it’s still hard to wrap one’s head around the magnitude of the loss experienced that day. One day, loved ones were here — the next they were not.

Still harder to comprehend: the staggering global bleed-out since the U.S. decided to wage a global war on terrorism in response. More than 6,700 American soldiers have lost their lives and more than 57,000 have been wounded. By some expert estimates, as many as 200,000 of the soldiers that served in Iraq and Afghanistan are living with some form of traumatic brain injury.

And that’s just “our” people. [from]
My sister's late husband, my beloved brother-in-law Tony Poggi, succumbed prematurely -- tragically -- to the after-effects of his Agent Orange exposure during his "tour" in Vietnam.

Tony refused to sign up for his VA benefits, on principle. Did it cost him his life?

My Dad was a "WWII 100% Service-Connected Disability" bene. He took every penny they gave him. A lot of pennies, as it were. He always got good service and good care, to the extent I can determine. The VA even paid for his dementia-addled nursing home care from 2001 to his death in 2008. During my time looking after him after he'd gone senile, I was always able to get him prioritized, even before I became his legal guardian. One VA administrator told me "don't worry, WWII disabled veterans are a specialty of mine." Fair or not, there is a service pecking order within the sprawling VA bureaucracy.

The VA is in the throes of scandal these days. Touted for their EHR (VistA) and touted for their heretofore high patient satisfaction scores (see below), they now find themselves under serious partisan political assault -- over their apparent gaming of the scheduling backlog system.
Independent 2013 Survey Shows Veterans Highly Satisfied with VA Care
Higher rating than Private-Sector Hospitals on Average

WASHINGTON — The American Customer Satisfaction Index (ACSI), an independent customer service survey, ranks the Department of Veterans Affairs (VA) customer satisfaction among Veteran patients among the best in the nation and equal to or better than ratings for private sector hospitals.   The 2013 ACSI report assessed satisfaction among Veterans who have recently been patients of VA’s Veterans Health Administration (VHA) inpatient and outpatient services.   ACSI is the nation’s only cross-industry measure of customer satisfaction, providing benchmarking between the public and private sectors.
In 2013, the overall ACSI satisfaction index for VA was 84 for inpatient care and 82 for outpatient care, which compares favorably with the U.S. hospital industry (scores of 80 and 83, respectively).   Since 2004, the ACSI survey has consistently shown that Veterans give VA hospitals and clinics a higher customer satisfaction score, on average, than patients give private sector hospitals. These overall scores are based on specific feedback on customer expectations, perceived value and quality, responsiveness to customer complaints, and customer loyalty.  One signature finding for 2013 is the continuing high degree of loyalty to VA among Veterans, with a score of 93 percent favorable.  This score has remained high (above 90 percent) for the past ten years...
Politicians on all sides of the aisles routinely laud "our sacred obligation" to our veterans. They do not, however, routinely Walk their Talk. Flying off secretly to photo-op with the troops in Afghanistan on Memorial Day weekend doesn't constitute meeting the Sacred Obligation.

Jon Stewart unequivocally calls bullshit.

Veterans with service-connected conditions and injuries should have carte blanche, IMO. They should be able to present their VA cards at any clinical site and get treatment. The closed system "government-run healthcare" comprising the VA is part of the problem.

More to come...

Wednesday, May 21, 2014

Just DO it.

Yes, there's a lot about the U.S. healthcare "system" comprising legitimate targets for criticism, complaining, and outrage. We all know that. Crappy, workflow-inimical, silo'd Health IT, intractable reimbursement system misalignments, maddening "government mandates," looming provider shortages, and on and on and on...

I started blogging about the issues back in 2009. See, e.g., my post The U.S. health care policy morass

But, given that we go to Rumsfeldian healthcare delivery "war" every day with the healthcare system we have, and not the one we'd like to have, it helps to give close study to the folks out there who are leading the way --  doing rather than bitching.

I just finished this book.

This is the 3rd book release I've studied from the ThedaCare Center for Healthcare Value, following these prior two:

The reference to "heroes" goes to the notion of the valiant, adroit "firefighters" who repeatedly have to drop in to save the day in the dysfunctional healthcare delivery system. I call them "Quadrant One" people, those called upon to deal with the seemingly never-ending, chaotic "Important and Urgent."

The layout of "Beyond Heroes."
Over the next eight chapters, we will examine each of the elements of our business performance system in detail, since all have been critical in helping us to create a business performance system that is transforming ThedaCare.

Here, I would like to draw a big picture, describing how each element links to the others to create a system, not just a pile of discrete tasks. Think of this as the engineering drawings, showing the bare structure of ThedaCare’s business performance system and how the elements become interlocking gears.
1. Status Reports. At ThedaCare, we call this a stat sheet meeting, and it is the most transformative element in our system. Short for “status of the business,” this conversation, usually between a manager and a supervisor or clinical lead, begins with a series of standardized questions on a single sheet of paper intended to provoke a dialogue about improvement opportunities and roadblocks. This daily, focused discussion about the business, taking place hundreds of times each day with different players all over our hospitals, is the cornerstone of our business performance system. This is about preparedness, about planning our days instead of firefighting our way through them.

2. Team Huddle. Every day, every leader gathers his or her team members into a huddle to widen the conversation about opportunities for improvement, roadblocks, and ongoing projects. This is where we teach and practice standardized problem solving using A3s and the plan-do-study-act cycle and then employ these tools to work through issues and improvements.

3. Managing to the Established Standard. This is the discipline of auditing standard work for both clinical and leadership processes in order to keep it from changing or falling to the wayside. By auditing or observing standard work, we also work to spread best practices. It is difficult to maintain any standardized process, clinical or administrative, so auditing must be hardwired into the business performance system and every manager’s day. This is where we emphasize that standard work is not a weapon or critique but is the best currently known way to do the work. Standard work is the best practice, and auditing or observing the work is a method for teaching and coaching.

4. Problem Solving. We used the A3 or PDSA (plan-do-study-act) as our guide to problem solving with the scientific method. But these tools are as much about mentoring the team on ways to solve problems as they are about finding the best countermeasures for a specific problem.

5. Transparency. A visual workplace— where area defects are as visible as team accomplishments— is difficult to establish, but it is the way we keep everyone focused on reality while looking for new opportunity.

6. Advisory Teams. For every manager we created a board-of-directors-style team of advisors to help fill in gaps in the manager’s areas of expertise and provide fresh perspectives. Advisors might be from finance, human resources, or pharmacy and are responsible for the overall performance of drivers in that area. At ThedaCare, drivers refer to the targets or goals on an area’s scorecard that lead much of the work of improvement teams. Every unit, clinic, or area has drivers that are tied to the organization’s main goals. In general, each advisor on the team “owns” one of the area’s drivers and is responsible for understanding problems that affect performance toward the goal. Advisors may come from inside or outside the manager’s area.

7. Scorecard. Every manager had a monthly scorecard developed and maintained by the advisory team to help keep track of progress against drivers. The scorecard’s vital few metrics help us focus deeply to solve problems and improve performance.

8. Leadership Standard Work. This is the most effective weapon available against heroics. When a supervisor, manager, or executive adopts standard work, she promises to be reliable and accountable to her team. Standard work tells the team where a manager will be and when, what questions she will ask and when she will be available to work through issues. According to Toyota, work is standardized when the precise elements of the job are done the same way every time and at a repeatable cycle time. Our stat sheet conversations and huddles are not as precisely timed or repeatable as a mechanized process, so maybe it is more correct to say that our standard work is more like a fixed schedule of activities. We are, however, still evolving, and our goal is a repeatable, reliable system of managing for improvement.
Here is how it all fits together. We use stat sheets to see the business, plan our day, and see the trends developing. We widen the conversation with the team huddle, where we look for trends in performance and use standards to find the gaps between our goals and our performance. This leads directly to problem solving and using the scientific method to close the gaps. Information gathered in huddles and problem solving is then published to the area improvement center— whether that is in an outpatient clinic, an inpatient unit, or a finance office— allowing for transparency so that everyone can monitor progress. The advisory team gathers around the area improvement centers to monitor progress and advise the leader, who monitors the team’s performance through the monthly scorecard. Standard work at all levels ensures that everyone stays on track and that we have a measurable norm for leadership performance.
Reduced to seven words, these elements add up to developing people, solving problems, and improving performance...
Barnas, Kim (2014-05-09). Beyond Heroes: A Lean Management System for Healthcare (Kindle Locations 523-568). ThedaCare Center for Healthcare Value. Kindle Edition.
They're doing ACO. They use Epic. They consistently hit high on HEDIS. They have to comply with all of the regulations and clinical reporting measures that bedevil everyone else.

They're obviously doing something right. This book and the other two antecedent works I cited will give you a good idea of precisely what. Imagine going to work every day within an organization where an ongoing priority for everyone is scientifically improving the work processes.


Highly recommended, if a bit pricey (that ticked me off somewhat). I bought the $35 hardcover straight away ("First Mover Disadvantage"), but it's now available on Amazon in $9.99 Kindle edition. Yeah, I bought that as well.

Concluding observations from "Beyond Heroes."
The future at our door
...Just a few decades ago, hospitals were the centers of catastrophe. We saw victims of sudden illness and accidents. We generally offered short courses of treatment that the patient either survived or did not. For lesser maladies people saw a family doctor and, even there, care was usually targeted at a particular complaint with a limited time horizon.

Now, we have entered into long-term relationships with our patients. Longevity is increasing. Diabetes, obesity, asthma, arthritis, and mental disorders such as depression and bipolar disease now call for regular, ongoing treatments that can last a lifetime. Many cancers are becoming chronic conditions, joining HIV/ AIDS as a disease we can live with for decades.

This means that much of healthcare will focus on helping patients to help themselves in managing and improving their lives. Out of absolute necessity, we will finally begin to focus— as an industry— on wellness instead of illness. We will pay more attention to the life needs of the patients, to keeping people independent and able to care for themselves well into old age. This will require new tools and more time and patience. We will spend more time counseling people on how, for instance, specific diets and exercise affect their chronic disease, and our information will be based on solid scientific evidence rather than fads. We will talk more about staying out of the exhausting cycle of hospitalization and recovery and less about what new, short-term treatments we can offer.

We will focus on patient wellness because it is the right thing to do and because we will be paid that way. In the near future, healthcare organizations will most likely receive a pool of funds to look after the healthcare needs of a population of patients, as I noted in the previous chapter. A number of experiments have been running around the United States and the value-based, or population-based, payment concept has emerged as the most likely method for controlling costs while improving patient outcomes and experiences.

Using this system, independent healthcare providers will be profitable only if they offer good care with a minimum of defects and waste. If patients in an organization’s population pool suffer from runaway obesity, asthma attacks that require hospitalization, and births complicated by a lack of prenatal care, that will cost the organization. A lot. That means we will see a major push by the healthcare industry to offer better preventive care.

Physicians and administrators will have a vested interest in knowing which tests and procedures are the most effective for patients, as opposed to the most billable. So how does this relate to the business performance system? Healthcare organizations that practice continuous improvement will have the advantage in this system because they are already accustomed to increasing profit margins by eliminating waste and creating more efficient processes. If medical group A investigates its treatment path for stroke victims and creates better outcomes by reducing the time it takes to administer clot-busting drugs, for instance, it will spend fewer resources on patient recovery time than group B and therefore earn a better profit margin and reputation. (This will also save the family and community from the costs and heartbreak associated with long-term care of a person who can no longer function at full capacity.) Saving money by offering better treatment also means a medical group could afford to attract the best providers and reinvest in its facilities and people...
One nice thing about the book is the way these Lean deployment principles, management strategies, and process improvement tactics are illustrated via the stories of individuals at work, doing their jobs and working to improve their jobs as a matter of course. It's a good, conversational read.


Recall my February 6th, 2014 review of this book? See Meaningful Use 2013 review, ONC Working Group Stage 3 draft report, and discussion of KP's book "Connected for Health"

Another bunch out there successfully doing.

The VA Scandal: Implications for Health Reform and a Call for Clinical Research into the Reported Death Rate

More to come...

Monday, May 19, 2014

Has regulatory compliance become an end in itself?

Healthcare IT Priorities: No Breathing Room
Regulatory requirements have gone from high priority to the only priority for healthcare IT.
Healthcare has always been a highly regulated industry, but in the last few years requirements for implementing and documenting digital healthcare systems have been piling up so fast that IT organizations have little time for anything else -- including making sure the systems they already have in place are being used effectively. The InformationWeek Healthcare IT Priorities Survey of 322 technology pros at healthcare providers shows "meeting regulatory requirements" is the No. 1 initiative on participants' minds. Most of the other items at the top of the list, such as implementing or upgrading electronic health records (EHR) systems, are also largely driven by federal government requirements.

 "The priorities we're trying to deal with right now are those being mandated," says Randy McCleese, CIO of St. Claire Regional Medical Center. "We can't do anything else. We have put everything else on the back burner except for those things that absolutely have to be done."

Against the crushing wave of requirements, what's most neglected by IT organizations is optimizing how healthcare providers use all the technology they've bought of late -- "and we've been provided with a lot of functionality in the last three to four years," says McCleese, who's also chairman of CHIME, the College of Healthcare Information Management Executives. "We've put all this technology in place quickly to meet the requirements, but we have not had a chance to make sure it's working effectively."...
 Register to get the free pdf paper. Nicely done. Sample size is a bit small, though.

The grousing about MU continues apace of at THCB: "The Case for Dropping MU Stages 2 and 3." From the comments:
I was one of the leaders in the EMR arena for many years, and was initially really excited about meaningful use. Yes. I admit that with some embarrassment now. I even was part of a CDC public health grand rounds regarding meaningful use and why it would be a good thing. Over time, however, I saw what you see now: meaningful use is not a definition of using the EMR productively; it is simply another bureaucratic layer doctors must get through before they can focus on patient care.

I do agree with items on your list, but the real benefit of the EMR is not one of documentation, it is about work-flow. Computers are good at remembering things we don’t remember, and are good at organizing information more efficiently. I would add several things that would make EMR systems more meaningfully useful:

1. Task managment. Why don’t any products focus on team management of tasks, as it is clearly one of the bigger barriers to good care. I believe that a system that focused on this would gain adoption without incentive, as it would actually make doctors’ jobs easier.

2. Information prioritization. It’s not what is put into the system that is important, it is what you can get out of it. Most EMR systems are a jumble of useless information that hides the useful information.

3. Better communication tools. We are using iChat in our office (locally hosted) and have found it to be incredibly useful to answer questions while the patients are on the phone. We can handle problems with fewer steps. There are many tools out there to make this kind of thing work. Patients could, for example, record MP3 files on their portable devices and have that upload to an EMR for handling by the office staff (in lieu of the overworked phone system).

4. Risk assessment and reduction – this is the overall goal of care: to make patients healthy and prevent problems from happening. The problem is that risk assessment tools are scarce in most EMR systems.

Our success at EMR implementation was due to our focus on it as a tool to improve patient care by transforming our workflows. As the burdens of meaninful use came on, however, the ability to do that was hampered enough that I not ony abandoned Meaninful Use, but I left the system altogether. My home-grown EMR is far more useful than anything I could find on the market.


MU is meaningfully useless for patient care,. No, it is worse than that. It is an additional impediment to patient care.

Medical care is about ambiguity and shades of gray. EHR systems depreciate the nuances of care, and meaningful ruse destroys care processes by focusing on the irrelevant.

It can be an odd combination of naive and doggedly determined, both of which might apply to this situation.

I agree that politicians being what they are, they are unlikely to pull the plug on MU because that means an admission of fault and a loss of money to the constituents that are benefitting from MU. But… I’m naive enough to believe that, with enough groundswell, we could do something, even if not outright cancellation, that would improve the Frankenstein that we created, especially if we redirected the money to better HIT uses and sustained the appeal to constituency.

I’ve always dreamt of an EMR that was designed from the beginning to support clinician efficiency; quality of care; and cost of care. And then rolled all of that together into something that looked like a project management tool, like Base Camp, that recognized healthcare as a long term project involving several project teammates that need to interact and communicate. Dropping a bill would become a natural functional outcome, but wouldn’t be the primary motive of the design.

It’s amazing to me that those of us who procure EMRs don’t insist on a downloadable, transferable patient record. How did the music industry manage to pull off the MP3 standard without a government mandate? Maybe there’s a lesson in there for us, somewhere.
Critics have been griping about these issues since I started in the DOQ-IT program back in 2005. I've been addressing them since I started this blog four years ago.

More to come...

Friday, May 16, 2014

I'd planned to put up a thoughtful, meaningful post today, but...

Nah. Today is the day that our nation's capitol was be be occupied by a reported 10 to 30 million "patriots" intent on "forcibly removing" the President and a long list of congressional leaders from office, at the behest of some group calling itself "Operation American Spring" (they eventually dialed back the "forcible" part that was central to the initial proffer).

Well, what would be the point, in light of the incipient overthrow of the government? So, I turned to Photoshop for a bit of OTC medications fun.

Turnout was disappointing, by all accounts, but, hey, all several hundred or so actual attendees got a free tube. ;)

The twitter hashtag #AmericanSpringExcuses is pretty funny.

More to come. Back on topic shortly...

Wednesday, May 14, 2014

We're about to be Bushwhacked

Read an interesting post by athenahealth CEO Jonathan Bush on THCB this morning. Led me to this:

Interesting. I bet it's one long (ghostwritten?) riff on this well-known theme of his (from his THCB post):
...To create a modern, caring and efficient health care economy, we have to create more spaces where entrepreneurs can compete in the marketplace—and not in the corridors of Capitol Hill.

Unlike many entrepreneurs, I had reason to feel comfortable in Washington. Even though I couldn’t call my presidential cousin for help, I had my political name, fancy venture firms behind me, and my equally fancy business degree from Harvard. That gave me the confidence—or hubris—to assume I could get in there and make a difference. I was an outsider with insider status. I’d guess that 90% of businesses that get blown up by government mis-steps, or even prevented from being born, are run by outsiders with outsider status. That is why it’s so hard for an activist government to be effective. It works with known players—while the future should be in the hands of unknown players working to make the household names obsolete.

The government, by regulating industry, actually ends up protecting the incumbents. Here’s how. Let’s say the news comes out that insurance companies are taking advantage of customers in an especially awful way. Because this a service that society views as vital, the government comes in and says, “Whoa, what’s going on in here?” Now the best thing to do at this point would be to make it as easy as possible for new entrants to come into the system and disrupt these guys—clean their clock, kill them, or at the very least force them to change. But instead the government looks to control them. They do this by writing up cumbersome regulations. These discourage newcomers from the market. Many of the best would-be competitors don’t employ a single lobbyist or lawyer. They take one look at a market regulated up the wazoo, and conclude, wisely, that they’re not built to play that game. They’re better off building a new video game or a dating app. So instead of making the bad incumbents vulnerable, the government leaves them fat, lame and stupid—but with formidable lobbying power. Since these companies employ a lot of people, they become untouchable...
From CNBC:
[David] Einhorn, co-founder of Greenlight Capital, called Athenahealth a "bubble" stock that could fall 80 percent or more from its peak share price of more than $204 in March. He also said the company's potential products are being overvalued.

Einhorn has been advising investors to short ATHN.

UPDATE: I emailed athenahealth asking for a comp review copy. They blew me off. No reply. The gall of some pissant small-fry curmudgeon independent blogger.

Just checked; the price of the Kindle edition has already dropped $3, from $14.99 to $11.99. I don't think I'm gonna buy it, even though it's probably pretty well done. Competing priorities for my dollars.

Once we get past the 5-Star effusive "Friends and Family" hagiographic Amazon shill "reviews," we'll see what people actually think.


I used Dragon to transcribe this little excerpt.
In the lumbering healthcare industry that we have come to know in the last half-century, information is a scarce resource. Patients rarely have access to the records. No one can hazard a guess as to what an operation, a medicine, or even a Band-Aid might cost. Keeping this information button and up benefits the incumbents, who thrive within what we might call and ignorance economy. Some, as we’ll see, are still attempting to control their local markets by limiting access to data. It sooner or later, data promises to turn this status quo on its head, ushering in a slew of new digital startups and — most important — delivering vital and timely information to the patients, or customers.

And what will they do with this information? It can be summed up in a single word: shopping. This has to do with making choices. We weigh countless options in the rest of our lives, but not nearly enough of them in healthcare. Shopping, whether it’s driven by an individual, a retail buyer, or a wholesaler, creates the market, and the market responds with choices and innovation. What’s more, in markets driven by shopping, losers figure out how and where to change their fortunes, or they disappear.

We need shopping, I believe, not only to fix healthcare, but also — and I know this may sound strange — to express our own humanity. Think about it. We shop for clothes to express our tastes and personality. We do the same for music and food. Some of us trick out our cars, put them on mega wheels, or hang big, fuzzy dice from the mirror. We express we are with these choices. And yet for the care of our bodies, for some of the most important decisions we make in life, we rely on a handful of menu options and lists drawn up by bureaucrats. What I want is for people to have a dizzying array of options in healthcare, so they can care for themselves and their  loved ones in a way that suits them best, that makes them happy and proud. Some of the choices will be simple, of course, others delightfully convoluted. But in my vision, each of us will fashion the health care we want and deserve. We'll express ourselves.
Go shopping? Where have we heard that before? Right, health care purchases are no different from buying clothing or CDs or cars. We don't want actual health care, we want "choice," via which to make fashion statements?

From the Amazon blurb on another of my favorite books, The Paradox of Choice: Why More Is Less:
Whether we're buying a pair of jeans, ordering a cup of coffee, selecting a long-distance carrier, applying to college, choosing a doctor, or setting up a 401(k), everyday decisions -- both big and small -- have become increasingly complex due to the overwhelming abundance of choice with which we are presented.

As Americans, we assume that more choice means better options and greater satisfaction. But beware of excessive choice: choice overload can make you question the decisions you make before you even make them, it can set you up for unrealistically high expectations, and it can make you blame yourself for any and all failures. In the long run, this can lead to decision-making paralysis, anxiety, and perpetual stress. And, in a culture that tells us that there is no excuse for falling short of perfection when your options are limitless, too much choice can lead to clinical depression.

In The Paradox of Choice, Barry Schwartz explains at what point choice -- the hallmark of individual freedom and self-determination that we so cherish -- becomes detrimental to our psychological and emotional well-being. In accessible, engaging, and anecdotal prose, Schwartz shows how the dramatic explosion in choice -- from the mundane to the profound challenges of balancing career, family, and individual needs -- has paradoxically become a problem instead of a solution. Schwartz also shows how our obsession with choice encourages us to seek that which makes us feel worse.

By synthesizing current research in the social sciences, Schwartz makes the counter intuitive case that eliminating choices can greatly reduce the stress, anxiety, and busyness of our lives. He offers eleven practical steps on how to limit choices to a manageable number, have the discipline to focus on those that are important and ignore the rest, and ultimately derive greater satisfaction from the choices you have to make.

BTW: Got my hardcopy of the ThedaCare Center book "Beyond Heroes" yesterday. Started on it in earnest last night.

Just downloaded this as well:

The Scientific American eBooks are excellent, and inexpensive. I have a bunch of them.

Stay tuned...


How Meaningful Is Meaningful Use?
The government's Meaningful Use program mandating electronic health records is out of touch with reality. EHRs bog down process and can even worsen care. Despite the existence of a government program called Meaningful Use, as a doctor I have yet to see a meaningful, positive impact on care from electronic health record (EHR) systems.

Regulators pushing for better and more cost effective medicine have decided that electronic technology, which has revolutionized many industries, is the solution needed to revolutionize medicine. We have been told that EHRs will make us better doctors, and they will make patients more responsible and engaged in their care. They go so far as to claim that EHRs will save doctors and hospitals time, that they will provide better coordination of care and save lives. While I can envision a world where this could be true, those of us living in the real world struggle with the disconnect between what is touted and what we experience every day.

It is true that some studies have shown specific benefits on selectedmeasures when EHRs are used. Unfortunately, this is not true in all studies. Some studies have failed to show improvement of any kind when an EHR system is implemented. Some show an increase in adverse outcomes, including death. The EHR is not a proven technology. It is an experiment, and hospitals and clinics are beta testing new ways of doing things every day. The en masse adoption of EHRs into hospitals is akin to forcing car makers to make all vehicles from a new plastic that theoretically could make them safer without having shown that it really works.

High expectations for a new technology are typical, but pushing adoption of a technology that hasn't proven itself yet is inappropriate and flawed. Many haven't seen improvement in care coordination, efficiency, or patient engagement. In fact, some think things are worse with EHR. Patients now have to compete with computers to get their provider's full attention. Good documentation can take more time to input, and coordination of care still requires highly motivated teams. It is not clear if the EHR is more effective that a cohesive team with a spreadsheet. Additionally, health information exchanges are years away from truly interconnecting institutions and are not adding proven benefit to many.

Part of the problem is the menagerie of disconnected proprietary systems, all trying to solve problems in their own way. They don't speak to each other. Many are plagued with poor design and poor usability. These problems can be solved, but they should have been solved before we bought the software, not after.

In an effort to push EHR adoption and use, the Center for Medicare and Medicaid Services (CMS) has created the Meaningful Use (MU) incentive program, which defines what people should be doing with their EHR and pays them for doing it. The CMS has also instituted penalties for those who would remain on the sidelines. MU Stage 2 is ongoing, with the goals of increasing use of health information exchanges and patient engagement by enabling patients to access and transmit their own data. It also requires more intense use of EHR by physicians who must order tests, e-prescribe more consistently, look at labs in an electronic format, and keep everything safe from hackers.

On the surface, these seem laudable. Yet the technology remains cumbersome and disconnected, making many of these tasks difficult at best. Some tasks require someone else to act -- the patient or the health IT vendor. Even with a certified product, meeting MU Stage 2 requires overcoming some major hurdles. It is not clear that any of these things are improving care or saving time, money, and lives, as claimed by the CMS...
I am all for advancement, but trying to push a technology that is not mature nor the best one to solve the problems at hand is ill-conceived and foolish. Many of the current EHR systems are simply inadequate. Continuing to put energy into making these systems do tasks they can't isn't helping anyone. We are wasting time and resources trying to fit a round peg in a square hole. MU is pushing adoption of technology, but it is not improving the technology. It is simply making people use systems they wouldn't use without incentives.

Our institution is striving to meet MU Stage 2. I am not sure if we will be able to. Our push to meet the required metric for patient engagement is not going well. Perhaps we are doing it wrong, or we have a lot of apathetic patients. Additionally, getting staff to go out of their way to use a very time-consuming CPOE process is more than challenging. Using CPOE makes it harder to look back and see what the current orders are. In order to care for patients, we have to keep separate notes outside of the EHR, creating more than twice the work as doing it on paper. Consultants can't figure out what is going on without talking to the other providers in person. This adds to the challenge of providing good care. If an EHR fails to achieve its No. 1 objective -- being a well-organized repository of information that is pertinent to a patient -- it is of little value, even if it can meet MU.

EHRs need to be measured by usability and functionality, not whether they can achieve Meaningful Use metrics. Right now, we need to be focused on usability. Certifications mean nothing when a product doubles or triples the workload. Our EHR is a roadblock to providing well coordinated, evidence-based, efficient, and compassionate care. MU might have merit, but it is taking the focus off the bigger issue of usability.

We shouldn't be pushing for universal measures until they can be met -- and until we have evidence that they are truly beneficial.


David M. Denton is a board-certified pediatrician and member of the American Academy of Pediatrics. He is a partner of the Pocatello Children's Clinic in Pocatello, Idaho, and is affiliated with Portneuf Medical Center where he currently serves as the medical staff
Link to full article here.
AMA Wants Major Overhaul of Meaningful Use

Warning that many physicians will not be able to advance to Stage 3 of the electronic health records meaningful use program, the American Medical Association is suggesting radical changes to all three stages.

Absent significant changes, more physicians--already struggling with the first two stages--will drop out of the program or be unable to move to Stage 3, the association contends in a letter to Centers for Medicare and Medicaid Services Administrator Marilyn Tavenner and National Coordinator for Health IT Karen DeSalvo, M.D...
AMA sharply criticized a HIT Policy Committee certification workgroup last week for being "unwilling to make a recommendation on making the overall program more manageable for physicians." Mari Savickis, AMA's assistant director for federal affairs, told the workgroup about 40 percent of eligible professionals have never participated in the meaningful use program and, of the 60 percent that have, 20 percent have dropped out. "The way to keep physicians from dropping out today or keeping them from making a decision to not participate is to make the program criteria more flexible," said Savickis.
Fear and loathing in meaningful use
'I cannot stress this enough: It is fear that drives this process – fear of audit, fear of penalty.'

When it comes to the topic of meaningful use, Colin Banas, MD, is driven by fear. And he's far from being the only one.

The chief medical information officer at the Virginia Commonwealth University Medical Center's concern is the potential to fail meaningful use requirements because VCU sometimes tailors a vendor's certified product in order to make it more usable.

Whereas such customization is a common practice in the world of enterprise software, in the realm of electronic health records it has become the veritable equivalent of stepping into a rather cloudy area wherein it is very hard to discern whether they’ve gone so far that an auditor might say VCU did not achieve meaningful use.

What's more, Banas said that it would be impossible to estimate the resources VCU has used to readjust clinical workflows and codes to follow the letter of the law, when it was already clearly following the intent of the measure.

"I cannot stress this enough: It is fear that drives this process – fear of audit, fear of penalty," Banas said, "and fear of vendor abandonment should a client choose to forge a different path."...
Man! Where's the love?

Read the full AMA letter here (pdf).

John Halamka: 80% of providers won't meet MU Stage 2 deadline
May 15, 2014 | By Susan D. Hall

Reiterating his belief that the federal mandates for the healthcare industry are "too much, too soon," Beth Israel Deaconess Medical Center CIO John Halamka predicted that 80 percent of hospitals will fail to successfully attest to Meaningful Use Stage 2 within the allotted time.

He told those attending the iHT2 Health IT Summit in Boston this week that he expects many provider organizations to opt out of the program, according to Healthcare Informatics...

More to come...