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Thursday, July 31, 2014

A quick comparative tour of some national healthcare systems outside the U.S.






My order above differs a bit from the sequence in which they were originally posted. Mine run from closest to home to furthest away.
Interesting: Scotland is soon to vote on whether to secede from the United Kingdom or stay in with England and Ireland. Wonder what would be the healthcare system upshot of the Scots leaving the UK?
And, then, back to the USA:


Dr. Carroll's "Healthcare Triage" is pretty nice. He covers a breadth of clinical issues (including stats methodology), and the structural delivery and payment systems which impact care for better or worse.

The Incidental Economist is one of my priority daily blog stops.


ICD-10 compliance Final Rule issued (pdf).
AGENCY: Office of the Secretary, HHS.

ACTION: Final rule.

SUMMARY: This final rule implements section 212 of the Protecting Access to Medicare Act of 2014 by changing the compliance date for the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) for diagnosis coding, including the Official ICD-10-CM Guidelines for Coding and Reporting, and the International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) for inpatient hospital procedure coding, including the Official ICD-10-PCS Guidelines for Coding and Reporting, from October 1, 2014 to October 1, 2015. It also requires the continued use of the International Classification of Diseases, 9th Revision, Clinical Modification, Volumes 1 and 2 (diagnoses), and 3 (procedures) (ICD-9-CM), including the Official ICD-9-CM Guidelines for Coding and Reporting, through September 30, 2015.

More to come...

Sunday, July 27, 2014


Will we have an ICD-10 code for that?
"The quality of healthcare has decreased with the implementation of EHRs and core measure/meaningful use requirements."
From MedPage Today.
Questioning Medicine: EHRs and Attention Deficit
Published: Jul 27, 2014

EHR-Acquired Attention Deficit Healthcare Disorder

"How are you today sir?" I ask a patient.

"Pretty good, I've been doing what you asked me to do. But I have this problem ... ," the patient replies.

And there I am. One moment, focusing on the patient, and then another hunting for the right series of key strokes to bring up a normal, 10-point review of systems.

The patient trails off into nonpoetic prose, and I am focused on the meaningful use requirements for this visit. One question into the exam, and I have failed my patient. Patient-centric care is a thing of the past.

A mentor of mine once said "Nobody truly can multitask in healthcare. You simply shift focus and attention rapidly from one thing to another." Our attention is being manipulated and stolen by the machine that is modern medicine.

The quality of healthcare has decreased with the implementation of EHRs and core measure/meaningful use requirements.

As we focus on EHR compliance, we miss the very core of what makes a consummate physician in any field. Time. We are blinded by the need to meet coding criteria, fulfill an antiquated guideline, or be compliant with the corporate demands of documentation.

These obstacles have stolen the 15 to 20 minutes a doctor would spend asking "The Question" and listening with ears aged with wisdom. Our time is torn from the patient by these healthcare distractions...
Meaningful Use is gettin' little love these days.
"As we focus on EHR compliance, we miss the very core of what makes a consummate physician in any field. Time. We are blinded by the need to meet coding criteria, fulfill an antiquated guideline, or be compliant with the corporate demands of documentation."
Notwithstanding that, until I retired last year, I worked with the Nevada REC doing Meaningful Use implementations, my iconoclastic views are well-known, and I repeat what I've said before more than once: serious and rational  Health IT critics need to be taken seriously. I would count these physicians among them.
"Medicine is becoming increasingly more regimented and standardized, and I fear the "art of medicine" has been reduced to attempts at navigating the new EHR faster than ever and not the skill sets that made primary care the most respected field in medicine."
But, every time I hear or read that "art of medicine" beg-off, my hand slides inexorably over my wallet.

When I am ailing, I want dx's and tx's that are scientific. apropos, see my December 2013 post "Philosophia sana in ars medica sana," specifically my cites of Mario Bunge's book "Medical Philosophy."

It bears repeating that the etymological roots of "philosophy" are "philo" (love of, devotion to) "sophia" (knowledge, truth). Properly, "science," not long-winded, obtuse, fifty-dollar-word speculations about arcane, unprovable matters.

The "Art of Medicine" goes to the creative use of intuition and heuristics, and making (frequently iterative and/or recursive) "leaps of faith" guided by them. Given the loose, multivariate coupling of cause and effect in biological dynamics, it often "works," saving time over algorithmic "cookbook medicine."

The engineer designing a suspension bridge is accorded no such luxury.

The real beef here, IMO, is not health IT per se or the Meaningful Use requirements, but with the rushed workflows demanded by the payment paradigm, the "Tyranny of the 99213."

What if we could have a Mayo model, writ large? Insulate clinicians from the "productivity treadmill"? Naive?

See my prior post "There is no more wasteful entity in medicine than a rushed doctor."

A personal observation in support of these critics. I "retired" last year from my REC/HIE, sold the house in Vegas, and relocated to the Bay Area, where my wife works. I am now in the Muir healthcare system, with a new Primary, a pleasant, bright young doc with whom I've hit it off pretty well.

I've seen him twice now, and seen a Muir system specialist to whom he's referred me (also twice). 

Muir is on Epic. The day of my first visit (to their new facility in Walnut Creek), they were on Shakedown Cruise in a beautiful new facility on Treat Blvd, and I had to have my visit with an Epic IT guy in the exam room (there were bugs). 

The M.A. had trouble logging on. In and out, in and out...

She then put me through what I knew to be a Meaningful Use-driven workup: FH, SH, PMH, vitals, active dx's active meds, CC (despite my having uploaded to the portal the most recent progress note export dump my former Primary had given me from his EHR).

She took my BP using a stethoscope -- through my shirt sleeve, using my right arm. "Jeez...seriously? How about a digital cuff, on my bare left arm, hooked up directly into the EHR?"

So, OK, whatever. This was a "Moderately Complex Patient Initial Visit" meet 'n greet. It went well, except that I could feel the doc's productivity treadmill time pressure intruding toward the end.

I later looked up my referral in the Muir patient portal. Didn't see it.

I called the specialist's office.

They're on NextGen. They're a recent Muir acquisition (something I didn't know at the outset), and they remain on a different EHR. Zero "interop" here. The specialist doesn't have a patient portal.

I was handed a clipboard when I first showed up. The usual Overprocessing.

I had to get a lab draw. Went to a "MuirLab" close to my house. Notwithstanding it had the same name on the strip mall front, Muir had sold it off (I forget the new vendor). They take your insurance information and require that you give them a credit card number for anything that doesn't get covered. Revenue Cycle, baby.

I got my bill from the Primary visit alone. $416.00. Given that we're on a high-deductible / HSA plan, my cut was $303.77.

Bending The Cost Curve, all right. Significantly upward in my case. With all of the historical data silo impediments still rather firmly in place.

There are three principal players here in the East Bay Area, judging by their respective soothing billboards that litter the Contra Costa County landscape: Kaiser, Sutter, and Muir.

Dunno, man. You can't just change medical providers and systems like changing your shoes. I have to admit to some frustration.


Budding legislation in the Senate Appropriations Committee:
The Committee makes available $61,474,000 to ONC. The Committee provides funding for ONC entirely through budget authority, rather than through both budget authority and transfers available under section 241 of the PHS Act. ONC is responsible for promoting the use of electronic health records in clinical practice, coordinating Federal health information systems, and collaborating with the private sector to develop standards for a nationwide interoperable health information technology infrastructure.

Information Blocking.—The Committee urges ONC to use its certification program judiciously in order to ensure certified electronic health record technology [CEHRT] provides value to eligible hospitals, eligible providers and taxpayers. The Committee believes ONC should use its authority to certify only those products that clearly meet current meaningful use program standards and that do not block health information exchange. ONC should take steps to decertify products that proactively block the sharing of information because those practices frustrate congressional intent, devalue taxpayer investments in CEHRT, and make CEHRT less valuable and more burdensome for eligible hospitals and eligible providers to use. The Committee requests a detailed report from ONC regarding the extent of the information blocking problem, including an estimate on the number of vendors or eligible hospitals or providers who block information. This detailed report should also include a comprehensive strategy on how to address the information blocking issue.

Interoperability.—The Committee directs the Health IT Policy Committee to submit a report to the Senate Committees on Appropriations and Health, Education Labor, and Pensions no later than 12 months after enactment of this act regarding the challenges and barriers to interoperability. The report should cover the technical, operational and financial barriers to interoperability, the role of certification in advancing or hindering interoperability across various providers, as well as any other barriers identified by the Policy Committee [pp 170-171].
Only a committee draft at this point, but, bears watching. Jonathan Bush and Judy Faulkner will no doubt put their people on it to dilute down or eliminate substantive interop language.

More news just in...
Ending debate on EMR effectiveness?
New data is [sic] coming to the fore on EHRs

July 28, 2014

For at least the last decade, the health IT field has seen a scholarly back-and-forth on the effectiveness of electronic medical records. As soon as one study is published that finds technology has little impact on patient outcomes, another emerges that seems to show just the opposite.

These studies are frequently limited by the size of the data set or scope of the analysis. Take, for example, a June 2014 JAMA article that found meaningful users of electronic health records failed to deliver improved care for five chronic diseases. According to one news report, the new study cast “doubt on whether the tens of billions of dollars invested to encourage EHR adoption among healthcare providers is really enhancing patient outcomes.”

The analysis, it turns out, included just three months of data from 818 physicians (about .1 percent of the 834,769 active physicians practicing in the United States) across seven clinical quality measures. By the way, all those physicians were employed by a single hospital or its affiliated practices.

And the variable being studied? It distinguished physicians who qualified for MU1 against those who did not. Considering the low bar set by MU1, the distinction might not signify all that much.

So what if, instead, you had a data set that drew from ALL the hospitals in the United States. And what if that data ranked healthcare IT adoption not on MU1, but on a multi-tiered scale, from no technology use to completely paperless systems? And what if the outcomes studies included 19 patient cohorts in five service lines, from heart failure and pneumonia to sepsis and stroke, with findings adjusted for risk and other differences in patient health status?

That study might be a little more authoritative when it comes to evaluating "whether the tens of billions of dollars invested to encourage EHR adoption among healthcare providers is really enhancing patient outcomes."

And the good news is, that study now exists and it has found that EMRs do have a measurable, positive impact on care as measured by clinical outcomes of risk-adjusted mortality rates..

​Serious patient safety questions raised in Maryland, D.C. hospitals. So what’s the fix?
Tina Reed, BizBeat, Washington Business Journal

Despite billions in spending in the last decade to improve health care quality, patients aren't much safer today from preventable medical errors and complications, a D.C. patient safety expert said.

The reason for the problem? The very thing that the feds long hoped would help fix patient safety in the first place: incentives for health care providers to adopt electronic medical records, a process called "meaningful use'' standards.

So says Dr. David Classen, chief medical information officer of D.C.-based patient safety company Pascal Metrics. In the rush to bring the health care world into the technology age, from mobile apps to digital patient records, providers are losing their focus on patient safety, he said.

“Meaningful use has completely driven what the focus of the industry is,” Classen said. "And you get what you pay for."

The new federal standards for electronic records have spawned a huge industry in the health IT sector, Classen said. But companies in that space are centered on cost savings and faster communications — not necessarily safety.

“We know hospitals and vendors respond to these meaningful use incentives,” he said. "The solution is to rethink meaningful use."...
Contention will no doubt continue. Given the ongoing DC gridlock, I don't expect much progress, congressional hearings notwithstanding.

More to come...

Thursday, July 24, 2014

Interoperababble update update

Lack of EHR interoperability 'fraud' against taxpayers
July 22, 2014 | By Marla Durben Hirsch

Electronic health record vendors--particularly Epic--may not deserve Meaningful Use incentive money because their systems hinder data sharing, according to physician-turned-lawmaker Rep. Phil Gingrey (R-Ga.). 

In a July 17 hearing of the House Energy and Commerce Committee's subcommittee on Communications and Technology and Health, Gingrey questioned whether the nation is currently on a path of interoperability or whether changes to the law need to be made. He expressed concern that according to a recent RAND report, more than half of the $24 billion spent by the Meaningful Use program has gone to Epic, a vendor operating a "closed platform."

Pointing out that the committee has jurisdiction over the Office of the National Coordinator for Health IT and the HITECH Act--which created the Meaningful Use program--Gingrey said that if the RAND report is true, "we have been subsidizing systems that block information instead of allowing for information transfers, which was never the intent of the [HITECH] statute...
"It may be time for this committee to take a closer look at the practices of vendor companies in this space given the possibility that fraud may be perpetrated against the American taxpayer," he added...
I'm not a big fan of this hyperpartisan reactionary Gingrey fellow (who recently -- falsely -- claimed that central American child refugees were bringing Ebola into the U.S.), but even a broken clock is right twice a day.

Epic has certainly Made Bank on MU. In large measure that owes to Efficient Markets Hypothesis 101: Opacity (plus barriers to entry, I would add) = Margin. The most transparent markets are by definition the least profitable, according to standard economic theory (rational actors all pursuing self-interest, each possessing "perfect information," "market clearing price," and all that).

I refer you yet again to my Interop rant. See also my related antecedent "Interoperababble update" post.

Health IT Now recommends HHS, Congress take steps against non-interoperable systems
June 18, 2014 | By Marla Durben Hirsch

Health IT Now, buoyed by RAND's recent report on electronic health records, has called on the U.S. Department of Health and Human Services and Congress to "decertify systems that require additional modules, expenses, and customization to share data," and to investigate business practices that prohibit or restrict data sharing in federal incentive programs...
I won't be holding my breath.

Who are these people?

I've been one of their twitter followers. They have not reciprocated thus far.

This CEO is out for blood
by  Roger Parloff, Fortune

Elizabeth Holmes founded her revolutionary blood diagnostics company, Theranos, when she was 19. It’s now worth more than $9 billion, and poised to change health care...

Theranos today is a potentially highly disruptive upstart in America’s $73 billion diagnostic-lab industry, which performs nearly 10 billion tests a year and is estimated to provide the basis for about 70% of doctors’ medical decisions. Medicare and Medicaid each pay roughly $10 billion annually on reimbursements for these tests...
I read this yesterday in my wife's hardcopy. Pretty interesting. Brilliant young woman. This lab-on-a-chip market is a rather crowded space, though (but, they're likely to push back "that's not our business line"). See my posts from the Health 2.0 Conference in Santa Clara last fall.

One more reason to short Quest and Labcorp.

More to come...

Tuesday, July 22, 2014

Mission Statement

Mission Statement

[Verse 1:]
We must all efficiently
Operationalize our strategies
Invest in world-class technology
And leverage our core competencies
In order to holistically administrate
Exceptional synergy
We'll set a brand trajectory
Using management's philosophy
Advance our market share vis-à-vis
Our proven methodology
With strong commitment to quality
Effectively enhancing corporate synergy
Transitioning our company
By awareness of functionality
Promoting viability
Providing our supply chain with diversity (versity, ooooh)
We will distill our identity
Through client-centric solutions
And synergy (Oooooh oooh oooh)

At the end of the day (At the end of the day)
We must monetize our assets
The fundamentals of change
Can you visualize a value-added experience?
That will grow the business infrastructure and
Monetize our assets
Monetize our assets
Monetize our assets

[Verse 2:]
Bringing to the table
Our capitalized reputation
Proactively overseeing
Day-to-day operations
Services and deliverables
With cross-platform innovation
Networking, soon will bring, seamless integration
Robust and scalable, bleeding-edge and next-generation
Best of breed
We'll succeed
In achieving globalization

And gaining traction with our resources in the marketplace
It's mission-critical to stay incentivized
Against this purple-poster-flexible-solutions for our customer base
If you can't think outside the box
You'll be downsized
It's a paradigm shift! (Hey, Hey! Look out!)
Well, it's a paradigm shift, now!
(Here we go! Here we go! Here we come! Here we come! Ha!)

Weird Al Yankovic, from his new CD "Mandatory Fun."

Perhaps the best song of all is the Crosby, Stills & Nash-inspired “Mission Statement,” made for everyone who has found herself sinking in the mire of meaningless gibberish that flows through the modern corporate office. In the video, which features that annoyingly overused trope of a hand scribbling illustrations, the despair of office alienation is juxtaposed with the relentlessly upbeat buzzwords and conventions taught in MBA schools. What’s particularly resonant about this song is how Al skewers the corporate capitalism which promised us all the wonders of efficiency, harmony and prosperity, only to deliver us to Dilbert’s cubicle of despair.

In “Mission Statement,” the dreams of love and peace echoed in ’60s folk tunes have congealed into a nightmare in which we can’t escape capitalism’s relentless propaganda. Instead, we’re brought to a kind of posthuman wretchedness in which we are forced to speak in the tongues of the market’s abstract gods.

Monday, July 21, 2014

"There is no more wasteful entity in medicine than a rushed doctor."

From the New York Times:
Busy Doctors, Wasteful Spending

OF all the ways to limit health care costs, perhaps none is as popular as cutting payments to doctors. In recent years payment cuts have resulted in a sharp downturn in revenue for many hospitals and private practices. What this has meant for most physicians is that in order to maintain their income, they’ve had to see more patients. When you reduce the volume of air per breath, the only way to maintain ventilation is to breathe faster...
Indeed. "Productivity treadmill" and all that. He cites the Mayo and Cleveland Clinic models, in which physicians are ostensibly insulated from the Suits and all their MBA Worry Beads.

Read all of it. What do you think?

apropos, from Health Affairs (subscription firewalled):
‘Nothing Is Broken’: For An Injured Doctor, Quality-Focused Care Misses The Mark
Charlotte Yeh

It was just after 6 o’clock in the evening on Wednesday, December 7, 2011—Pearl Harbor Day—when I left my organization’s Washington, D.C., office to meet a colleague for dinner. It was dark and rainy, and I had one more intersection to cross to get to the restaurant. I was about a third of the way across the intersection when I heard a loud “thump” and felt a sharp pain squarely in my backside. A dialogue unfolded in my head: “Wow! I wonder what that was…. I think it was me. No, I don’t think it was me. Wait…I think I just got hit by a car! But there’s no way!” Before I could even make sense of the situation, I had flown through the air and landed on the street...

As a medical professional who became an accident victim and then a trauma patient, I was a participant-observer in emergency care, with a big-picture window into how well our health care system does or doesn’t work...

In my case, I was struck by the uneven nature of my care, marked by an overreliance on testing and a narrow focus on limited quality metrics such as pain management or catheter care processes. Looking back, I believe that this approach fostered an inattention to my overall well-being. Instead of feeling like a connected patient at the center of care, I felt processed and disengaged. This is disconcerting, especially at a time when patient-centered care—that is, care delivered with me, not to me or for me—is becoming the new normal.

The Oath of Hippocrates, the medical profession’s ethical creed, reads: “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.” This vow compels physicians to heed both the “science” and the “art” of medicine. The science often lies in defining the treatment regimens. The art lies in understanding what matters personally to the patient.

Even in an ideal world, this would be a high bar to clear. Despite some national consensus on quality metrics, we have continued struggling to measure “the good of the patient.” Still, quality metrics cannot alone advance the good of the patient. Focusing on clinical measures in particular is not enough as long as other measures that focus on patient-desired outcomes are ignored. If we don’t understand what patients’ expectations are, we can’t engage patients effectively in their care.

Through my experience as a patient, I observed a bias in what the metrics track: toward the clinical and away from the personal. To help restore this balance and reassert the “art” of care, I see three areas that the medical community should address...

The unintended consequence of our current approach is that the clinical measure can become more important than the patient. I am afraid that as a result, we may be training a new generation of practitioners to equate high-quality care with conducting a test. Instead of having the test be used to discover new information about the patient, it is being used to define if one even is a patient.

Personalizing care
After I’d spent four days in the hospital, it dawned on me that not once had anybody come by to ask how I was doing, what I needed, what I wanted, or whether I had any concerns. I then understood something that my own patients had been telling me all the time: They don’t feel engaged in their own care. There is nothing personal about it...

Patient-reported outcomes currently in development, such as asking for the patient perspective (“what do you want,” “what are your fears,” “what matters to you”) and equalizing the patient-provider dialogue, create shared partnership in the outcomes and might have made a difference in my care. Going forward, quality metrics should give more weight to patient-reported outcomes, if we want to truly assess care more effectively. As my experience suggests, we’re not quite there yet.

The 'North Star' of Care
If I resolved anything on my care journey, it is that the “North Star” guiding all care must be providers using “any means possible,” to know the patient, hear the patient, and respond to what matters to the patient. It should make no difference where you practice; any provider can do this. Emergency departments can’t hide behind the excuses of “we’re too busy” or “it’s too chaotic” to avoid connecting with every patient.

It is time to frame a new paradigm of care, a consumer-driven approach that concentrates attention on the art of medicine. This might begin with a reinvigorated focus on patient-centered care and mastering the skills of listening, empathy, and patient partnership...
Yes, but the "productivity treadmill" could not be more antithetical  to "listening, empathy, and patient partnership."

Dr, Yeh's article is a lengthy and thoughtful piece, poignantly so. I have cited only some small excerpts. Highly recommended.

I groused a bit about our obsession with "quality metrics" back in April.

Process measures like Meaningful Use, CQMs, PQRS, etc, as I've noted before, are tangential proxies for effectiveness in health care. It's assumed that if you are doing and reporting on X, Y, Z, A, B, C, D, E, and F, improved outcomes will eventually follow.

How about if we lay on a concerted effort to measure actual outcomes directly?
Yeah, like maybe to include actually listening to the patient at greater length and depth?

More to come...

Saturday, July 19, 2014

Medical Error, Interop, and the Patient Safety-Health IT nexus

"Preventable medical errors persist as the No. 3 killer in the U.S. – third only to heart disease and cancer – claiming the lives of some 400,000 people each year."
Wow. Where does Health IT fit into that?

I've been reviewing the recent RAND study (pdf).
Promoting Patient Safety Through Effective Health Information Technology Risk Management
Health information technology (IT) safety has several dimensions: using health IT to make care safer, ensuring that health IT is itself safe, and ensuring that health IT is used safely. The potential for health IT to improve the safety of health care delivery has been appreciated for decades, but the role of health IT in introducing safety risks has been recognized only more recently. As the use of health IT has grown, users have begun also to observe its fallibility. Hardware and software can malfunction. Data can be lost or corrupted during transmission. Deploying complex technologies in a complex organizational environment can introduce new hazards and safety risks. Identifying and mitigating health IT safety risks is a relatively new undertaking for most health care organizations. The introduction of health IT safety improvement initiatives could be expected to face many of the challenges that accompany introduction of any change to clinical practice. Introduction of new tools and practices can require substantial organizational effort...
None of these concerns are actually "news." And, the most strident critics of Health IT continue to angrily assert that EHRs are dangerous, unregulated "medical devices." I joust with them regularly on the major HIT blogs. Not that I summarily dismiss their concerns. Having commenced my white collar career writing apps code in a forensic-level radiation lab in Oak Ridge in the 80's, I know a thing or two about software QA and "usability" (dated as my keyboard-level experience may now undeniably be). Skeptics are a necessary and good thing, insofar as they don't wander off into "Perfectionism Fallacy" territory (sometimes called the "Nirvana Fallacy"). While there is indeed much merit in the HIT criticisms, I find a good bit of the anti-HIT carping as unscientific as the charges of lack of rigor they lob (usually from behind their untraceable troll screen names) at the industry and the regulators.

You gotta Walk your Talk, boys.

The RAND methodology:
To learn about the sites’ experience with the process improvement strategy, including the resources and safety event reporting, an evaluation team from the RAND Corporation conducted in-person and telephone interviews with representatives of six of the hospitals and ambulatory practices. The evaluation team used a semi-structured interview protocol to elicit information about the sites’ experiences with identifying risks and implementing new health IT safety practices, as well as their experiences with the AHRQ Common Formats. The evaluation data were analyzed thematically and described in case study reports. A comparative analysis was performed to identify differences and similarities in sites’ implementation experiences; to develop a series of lessons learned; and to offer recommendations that may be useful to hospitals and ambulatory practices seeking to manage safety risks posed by health IT, policy makers, electronic health record (EHR) developers, and other stakeholders.
More excerpts:
Health IT Safety Risk Identification and Mitigation
Identifying and mitigating health IT safety risks is a relatively new undertaking for most health care organizations. The introduction of health IT safety improvement initiatives could be expected to face many of the challenges that accompany introduction of any change to clinical practice. Introduction of new tools and practices can require substantial organizational effort.11, 12 Health IT improvement poses unique challenges. Line authority over health IT–related risks within health care provider organizations is not well articulated or standardized. The multiple distinct lines of management authority over health IT, quality, and safety within organizations may create a hurdle to the systematic and coordinated identification and management of IT risk. For example, in hospitals and larger medical groups, operation of EHRs is typically managed by an IT department, efforts to improve safety may be carried out by a quality management group with a medical director and a patient safety officer, risk management is the purview of risk and liability managers, and regulatory compliance and reporting may be embedded in a compliance department. In ambulatory settings, one individual may be responsible for several of these tasks. Hospitals and ambulatory practices may be able to collaborate with health IT developers to reduce health IT–related safety risks, but it is unclear how developers and their customers should work together to identify and mitigate such risks...
Fostering Collaboration Among Departments and Disciplines
Health IT safety is a cross-cutting area that creates an opportunity for risk management staff, safety staff, and IT staff to collaborate. Each disciplinary perspective contributes distinct knowledge to the detection, analysis, and mitigation of health IT safety risks. Several enablers of collaboration could support future initiatives: (1) disseminating best practices (case study examples of organizations that have successfully tackled a particular problem) and project templates (step-by-step project guides for specific problems or checklists); (2) providing staff from distinct disciplines with training in core terminology and methods related to safe use of health IT; and (3) developing a cadre of experts who can provide consultation through regional extension centers (RECs), PSOs, or other organizations and can facilitate training programs. The SAFER Guides provide a valuable tool for multidisciplinary, multifunctional teams to optimize the safety and safe use of health IT, EHRs in particular...
Content I was most interested in finding is referenced in Table 2.1
  • Internal organizational features -- Policies, procedures, work environment, and culture.
Cutting to the chase,
Beyond expertise and infrastructure for quality improvement, staff at several sites emphasized the need for a “culture of safety” within the organization. A culture of safety (or “just culture”) implies that an organization treats error as an opportunity for improvement rather than cause for individual blame. Indicators of a culture of safety include a system for encouraging and rewarding staff for identifying risks and reporting adverse events and a non-punitive approach to addressing medical error...
OK, so far, so good. Recall my "Talking Stick" post. to wit:
My recent posts have ruminated on what I see as the underappreciated necessity for focusing on the "psychosocial health" of the healthcare workforce as much as focusing on policy reform (e.g., P4P, ACOs, PCMH), and process QI tactics (e.g., Lean/PDSA, 6 Sigma, Agile), including the clinical QI Health IT-borne "predictive analytics" fruits of ""Evidence Based Medicine" (EBM) and "Comparative Effectiveness Research" (CER). Evidence of psychosocially dysfunctional healthcare organizational cultures is not difficult to find (a bit of a sad irony, actually). From the patient safety-inimical "Bully Culture" down to the "merely" enervating emotionally toxic, I place it squarely within Dr. Toussaint's "8th Waste" (misused talent).
Summing things up:
The challenges and lessons identified in this pilot project point to several opportunities to increase the safe use of health IT systems. We draw several conclusions about the current state of health IT safety risks:
  1. With few exceptions, awareness of the safety risks introduced by health IT is limited. Many organizations sense that health IT is difficult to implement successfully, and some have experienced significant patient safety events, but organizations vary in their appreciation of the connection between those difficulties and events and their health IT installation. At the current time, engagement of front line clinicians in detecting and mitigating health IT–related safety risks appears to be limited.
  2. The traditional departmental “silos” between risk management, IT, and quality and safety management may impede the ability of organizations to recognize and respond to health IT safety risks. This is especially the case in hospitals. For some hospitals, this project represented the first time that staff from these different departments had worked in collaboration with one another.
  3. External facilitation appears to be important to hospitals and practices, but the model for providing consultation and technical assistance requires further elaboration. This model has to account for wide variation in the capabilities of most hospitals and ambulatory practices to take on health IT risk mitigation projects.
  4. Most ambulatory practices lack the risk management, IT, and quality and safety expertise that is available in hospitals. Ambulatory practices have limited staff capacity to address health IT safety, given the more pressing challenges of maintaining a financially viable ambulatory practice in a rapidly changing health care market.
  5. There is an urgent need for tools and metrics to enable project teams in hospitals and ambulatory practices to detect, mitigate, and monitor health IT safety risks. Tools available to project teams during this project were not adequate to fully support the needs of the organizations participating in this pilot project.
  6. The current structure of the EHR marketplace, and the low awareness of the risks introduced by health IT systems, lead to weak incentives for EHR developers and providers to invest in the type of joint effort required to reduce health IT safety risks. Because of that market failure, certification and standards will continue to be an important mechanism for ensuring that EHR products are designed to minimize the introduction of new safety risks.
The RAND report concludes:
The investment that is converting the U.S. health data infrastructure into a 21st century enterprise has the potential to improve care for patients in countless ways. However, “digitizing” the health system also has the potential for harm. In this project, we worked with 11 hospitals and ambulatory practices to evaluate a process improvement strategy and tools developed to help health care organizations diagnose, monitor, and mitigate health IT–related safety risks. While many of the health care organizations (especially the hospitals) had expertise in process improvement, we found a general lack of awareness of health IT–related safety risks (especially in ambulatory practices) and concluded that better tools are needed to help these organizations use health IT to improve care and to optimize the safety and safe use of EHRs. The SAFER Guides provide an excellent beginning, but until health care organizations have a better understanding of the safety risks posed by EHR use, tools like the SAFER Guides may not be used to their full potential. There may also be a need for additional tools and metrics (and further usability study of existing tools and metrics) to better support the needs of health care organizations. ONC could additionally support efforts in this area by strengthening incentives for EHR developers to make safer health IT products and to participate with providers in risk mitigation.
Yeah. One persistent limitation I find in all of these reform proposals is that we continue to have a near-exclusive "transactional / instrumental" view of people in the healthcare workforce. Maybe that works fine for Amazon or WalMart (see Simon Head's "Mindless"), but I would like to see more explicit "Just Culture" emphasis on what I have come to call the "psychosocial health" of care delivery organizations. Maybe I'm being naive, running the risk of becoming the butt of Dilbert Zone jokes.

I don't think so. I repeat once more:
A psychosocially healthy workplace is a significant profitability and sustainability differentiator.
Again, some of my recent recommended reading list on the subject:

To which I will add one more.

This book is an utter delight. An important read. I read it quite some time back, and am going back through it closely with the highlighter for further triangulation.
To err is human. Yet most of us go through life tacitly assuming (and sometimes noisily insisting) that we are right about nearly everything, from the origins of the universe to how to load the dishwasher. If being wrong is so natural, why are we all so bad at imagining that our beliefs could be mistaken – and why do we typically react to our errors with surprise, denial, defensiveness and shame?

In Being Wrong, journalist Kathryn Schulz explores why we find it so gratifying to be right and so maddening to be mistaken, and how this attitude toward error corrodes our relationships—whether between family members, colleagues, neighbors, or nations. Along the way, she takes us on a fascinating tour of human fallibility, from wrongful convictions to no-fault divorce, medical mistakes to misadventures at sea, failed prophecies to false memories, “I told you so!” to “Mistakes were made.” Drawing on thinkers as varied as Augustine, Darwin, Freud, Gertrude Stein, Alan Greenspan, and Groucho Marx, she proposes a new way of looking at wrongness. In this view, error is both a given and a gift – one that can transform our worldviews, our relationships, and, most profoundly, ourselves.

In the end, Being Wrong is not just an account of human error but a tribute to human creativity – to the ways we generate and revise our beliefs about ourselves and the world. At a moment when economic, political, and religious dogmatism increasingly divide us, Schulz explores the seduction of certainty and the crisis occasioned by error with uncommon humor and eloquence. A brilliant debut from a new voice in nonfiction, this book calls on us to ask one of life’s most challenging questions: what if I’m wrong?
"Human factors," "culture of safety," "UX," etc, yeah, all fine and necessary. But, a more nuanced view of the breadth of the nature of error -- "being wrong" -- is warranted, in my view.


From a Journal of Quality and Safety in Healthcare paper cited in the RAND study:
Safety culture assessment: a tool for improving patient safety
in healthcare organizations

V F Nieva, J Sorra

...Professional and organizational cultures in health care must undergo a transformation in the interests of promoting safer patient care. Health care must come to see itself as a high hazard industry which is inherently risky. It must abandon the philosophy of requiring perfect, error free performance from individuals and focus, instead, on designing systems for safety. Healthcare systems must move away from the current ‘‘blame and shame’’ culture that prevents acknowledgement of error and therefore obstructs any possibility of learning from error. Safety improvement requires that healthcare systems have ready access to information that supports learning from experience in order to promote systems that both prevent errors and mitigate the impact of errors that occur. In contrast to a ‘‘pathological culture’’ where failure is punished or concealed and people refuse to acknowledge that problems exist, a positive safety culture recognizes the inevitability of error and proactively seeks to identify latent threats...

For example, adverse event reporting systems will not overcome chronic under-reporting problems within a punitive culture where acknowledgement of error is not acceptable. Analytical methods such as root cause analysis (RCA) and failure mode effects analyses (FMEA) will not succeed in uncovering latent sources of error if staff, bound by an implicit ‘‘code of silence’’ and a fear of challenging the institutional hierarchy, are uncomfortable with exposing weaknesses in processes for which they are responsible. Even benefits from new technologies designed to improve safety, such as computerized physician order entry, may not be realized if they are not accompanied by cultural and process changes...

OK, that was published in 2003! Are we just gonna study things to death forever, publishing an endless stream of papers for wonk audiences, redundantly advocating for that which has already been advocated multiple times? I know: maybe AHRQ can let an RFP for an $800,000 two-year research grant via which to study the RAND study (like they've done with topics such as workflow).


It's been a tough week for focusing attention on the issues pertinent to this blog. First, the renewed acute violence in Gaza, and then the astonishing atrocity of the shooting down of Malaysian Airlines flight 17 over the Ukraine. Very depressing.

More to come...

Wednesday, July 16, 2014

Pedant's delight

My crusty views on sloppy use of language are well known. It is at once a cause of and a reflection of sloppy thinking, for which we have no time.

This is great fun.

BTW: "Data ARE..." Grrrr.r...

Weird Al is the undisputed King of the send-up. I dabble in it, in my Other Life. See, e.g., here, and here (my latest, music video in progress). I just bought his new CD "Mandatory Fun." His spoof of "Royals" is very funny: "Foil" (mp3).


Layoff notice, Microsoft style.

More to come...

Saturday, July 12, 2014

"No clinical metric conforms to a six sigma standard"

Nortin Hadler, MD, posting on THCB:
"If patients were widgets, if care givers were production workers, and if caring conformed to “six sigma” principals [sic], even slight deviations from standards of care would be as easy to recognize, those responsible could be singled out for improvement, and remedies would be obvious. This is the mantra of the quality agenda that drives health policy. In a corollary exercise in linguistic determinism, health economists and hospital administrators are wont to speak of patients as “units of care”, physicians as “providers”, and clinical demand as “throughput.”  But manufacturing cell phones or producing fast food has little in common with managing the care of patients in all their variability and with all their unpredictability. No clinical metric conforms to a six sigma standard; we in medicine are barely comfortable defining “normal” with a 95% confidence interval and we are fully aware that “outliers” can be clinically normal and those in the normal range can be abnormal. Forcing the clinic into the six sigma paradigm is worse than an exercise in futility; it is an exercise in iatrogenicity."
When Dr Hadler speaks, we do well to listen. His criticism of Health IT goes beyond the usual UX carping:
"It was the end of a long day in clinic a couple of weeks ago. I found myself sitting next to a colleague, a young, talented and well-read academic orthopedic surgeon. Each of us was staring at a computer screen displaying our “Physician’s Dashboard”, the gateway to the granularity-generating Electronic Medical Record (EMR) purveyed by EPIC. EPIC is a privately-held, exceedingly profitable company that dominates the multi-billion dollar EMR marketplace. Both of us are novitiates with the interface; UNC Hospitals only recently “went live” with EPIC at great cost in terms of personnel time and in terms of hundreds of millions of dollars. I was grumbling as I fought with the program to create a clinically useful medical record for the sake of the patients I had been seeing that day. My surgical colleague urged me to create templates and “smart sets”; he found EPIC easily manageable thanks to these short-cuts to record keeping which took advantage of any and all aspects of patient care that were stereotypical.

First, I took him to task on behalf of my patients. I explained that for a rheumatologist like me, and all others who are labeled “cognitive” specialists, the care of the patient revolves around the “granularity” of the narrative. I needed to listen actively to my patient to understand the particular idioms that populate any narrative of distress. And I need to communicate the approach the patient and I would take to sorting out the illness and formulating management to all involved in this patient’s care. It is an exercise that takes advantage of individual differences and idiosyncrasies rather than pummeling narratives into common denominators. I never assume the average, nor do I ever presume the outcome. Templates and “smart sets” are anathema."
Read the entire post, including the comments. Lots to think about. For openers, it has me reaching back down in the Weeds'

Essential to health care reform are two elements:  standards of care for managing clinical information (analogous to accounting standards for managing financial information), and electronic tools designed to implement those standards. Both  elements are external to the physician’s mind. Although in large part already developed, these elements are virtually absent from health care. Without these elements, the physician continues to be relied upon as a repository of knowledge and a vehicle for information processing. The resulting disorder blocks health information technology from realizing its enormous potential, and deprives health care reform of an essential foundation. In contrast, standards and tools designed to integrate detailed patient data with comprehensive medical knowledge make it possible to define the data and knowledge taken into account for decision making. Similarly, standards for organizing patient data over time in medical records make it possible to trace connections among the data collected, the patient’s problems, the practitioner’s assessments, the actions taken, the patient’s progress, the patient’s behaviors and ultimate outcomes.

Two basic standards of care, and corresponding tools, bring order and transparency to medical decision making:
  • First, from the outset of care, relevant patient data must be chosen, and its implications determined, based on the best available medical knowledge, independent of the limited personal knowledge of the practitioners involved. Patient data must be systematically linked to medical knowledge in a combinatorial manner, before the exercise of clinical judgment, using information tools to elicit all possibilities relevant to the problem situation, while defining and documenting the information taken into account. Practitioners’ clinical judgments may add to, but must not subtract from, high standards of accuracy, completeness and objectivity for that information.
  • Second, in complex cases, particularly in cases of chronic disease, the organization of data in medical records must be optimized for managing multiple problems over time. This means that each medical record must begin with a complete list of carefully defined patient problems, and that other clinical information in the record must be linked to the problem or problems to which it relates. Without that structure for the medical record, decisions are made out of context, follow-up and coordination of care are haphazard, and records are not usable for rigorous clinical research.
With these two basic standards of care, and the information tools needed to implement them, practitioners and patients can manage the flood of detailed information required for sound decision making over time. With this detailed information, made usable for research in structured electronic medical records, medical care can become increasingly refined and individualized. In contrast, so-called “evidence-based medicine” is derived from large population studies that fail to account for the medical uniqueness of each patient.

Enforcing the necessary standards and tools depends on changing medicine’s culture of professional autonomy for highly educated physicians. Indeed, the concept of a physician as we know it is not viable. All practitioners must submit to meticulous definition and control of their inputs to care (a principle recognized by the patient safety movement). The primary barrier to this cultural change is graduate medical education and credentialing. These social institutions (1) fail to define, disseminate and enforce high standards of quality for provider inputs to care, (2) inhibit effective design and use of information technology to manage clinical information, and (3) suppress competition among providers who might otherwise exploit information technology to generate remarkable advances in patient care and medical knowledge.
“The consequences of that digitization of information in a reasonably systematic way, guided by meaningful use, will have enormous, difficult to predict, and generally positive effect on the American health system over a generation to come. That’s my view of it. I know that physicians find certain aspects of meaningful use problematic. Some find it too aggressive. Some find it not aggressive enough. But, I still think it was a reasonable way to proceed, and we’ll see the results over decades.”

- David Blumenthal, MD

The Misuse of Meaningful Use, Part II

Originally Certified EMRs and Meaningful Use policies were created so as to provide the financially incentive to encourage primary care physicians to adopt electronic medical record programs and then use these electronic medical record programs according to specified “meaningful use” mandates. It was the hope that the appropriate use of EMRs would improve the quality or reduce the cost of healthcare. Since the program’s introduction, Meaningful Use has been expanded to almost every medical specialty and subspecialty, regardless of the appropriateness/relevance.

There has now been a fair amount of data accumulated regarding the effectiveness of electronic medical record programs. Unfortunately, most of the published data is not high quality and the majority of clinical trials are now being funded by the EMR industry. As we have seen with clinical trial sponsored by the pharmaceutical industry, only an irrational person would accept the results of a vendor sponsored EMR trial on face value...

In recognition of the federal government’s desire to promote electronic medical record programs, and despite the lack of “proof of efficacy,” the Massachusetts insurance industry appears to feel that they too should promote the use of EMRs/ and Meaningful Use. As a result, some of the large Massachusetts insurers are including clauses in their contract which mandate that physicians use certified EMRs according to Meaningful Use standards, and they are applying these mandates both to primary care physicians and specialists.

Given the lack of objective data about the effectiveness of EMRs, this is an outlandish overreach by the Massachusetts insurance companies which will interfere with the patient-physician interaction. As a practicing physician I am appalled to learn that the Massachusetts insurance companies seriously believe that they know how I should structure the use of my time in the exam room...
Read all of it, including the comments. Massachusetts is trying to be the first state to make Meaningful Use Certified EHR use a condition of physician licensure and insurance carrier acceptance. We'll see how that plays out.


The past decade has witnessed an explosion of electronic health data. Diagnostic images, lab results, and biometric information are generated and stored in digital form. Key elements of medical records are abstracted using natural language processing. Medical claims provide a treasure trove of longitudinal data. Those who bring these disparate threads together and apply them to real-life situations have created the next big thing in health care: big data.

Big data has the potential to improve clinical decision making at the point of care. Tapping into vast databases, a physician can access knowledge relevant to the individual patient, yielding better decisions and outcomes. Big data also has the potential to revolutionize research. Massive databases enable observational studies on a scale and at a speed randomized controlled trials cannot approach...
I now subscribe. Stay tuned...





Building Clinical Care Software Systems, Part I: Issues and Challenges

by Jerome Carter on July 14, 2014
Creating software is hard. The entire process, from deciding that a piece of software is needed to implementation, requires analysis and problem-solving–every step. I was reminded of this reality anew when I began the latest round of coding for my seemingly mythical startup. There are so many decisions to make that affect the final product, even though I consider what I am trying to build to be fairly straightforward in design and features. Building a good clinical care software system is many times more difficult.

Given the troubles that are plaguing EHR vendors in meeting MU stage 2 requirements, this seems like a good time to talk about what goes into building a system that supports clinical care...
Well worth your time. Jerome is definitely a SME. Below, I annotated his table of the components of Health IT architecture.

Recall my "standard data dictionary" rant:
One. That’s what the word “Standard” means -- er, should mean. To the extent that you have a plethora of contending “standards” around a single topic, you effectively have none. You have simply a no-value-add “standards promulgation” blindered busywork industry frenetically shoveling sand in the Health IT gears under the illusory guise of doing something goalworthy.

One. Then stand back and watch the private HIT market work its creative, innovative, utilitarian magic in terms of features, functionality, and usability. Let a Thousand RDBMS Schema and Workflow Logic Paths Bloom. Let a Thousand Certified Health IT Systems compete to survive on customer value (including, most importantly, seamless patient data interchange for that most important customer). You need not specify by federal regulation (other than regs pertaining to ePHI security and privacy) any additional substantive “regulation” of the “means” for achieving the ends that we all agree are necessary and desirable. There are, after all, only three fundamental data types at issue: text (structured, e.g., ICD9, those within other normative vocabulary code sets, and unstructured, e.g., open-ended free-form SOAP note narratives), numbers (integer and floating-point decimal), and images. All things above that are mere “representations” of the basic data (e.g., text lengths, datetime formats, Boolean/logical, .pngs, bmps, .tiffs, .jpegs etc)...

More to come.