Search the KHIT Blog

Friday, August 29, 2014

Health IT today. Where do we stand?

Relative market shares, in the context of Meaningful Use attestation through Q1 2014.

Recent article by Becker's Hospital CIO:
50 Things to Know About Epic, Cerner, MEDITECH, McKesson, athenahealth and Other Major EHR Vendors
Written by Helen Gregg, July 14, 2014

"To improve the quality of our healthcare while lowering its cost, we will make the immediate investments necessary to ensure that, within five years, all of America's medical records are computerized." — President-elect Barack Obama, Jan. 8, 2009

Five years later, billions have been poured into the transition to electronic health records. As of May, CMS has paid out a total of $14.6 billion in incentive payments to hospitals and health systems for the adoption and use of EHRs. These incentive payments, coupled with the looming threat of financial penalties for non-adopters and a need to better coordinate care have driven providers to rapidly adopt EHRs over the past few years. The EHR market is expected to reach $9.3 billion annually by the end of 2015.

As the EHR market has matured, a once-crowded field of vendors has narrowed significantly. At the end of 2013, 10 EHR vendors accounted for about 90 percent of the hospital EHR market, based on meaningful use attestation data from CMS: Epic, MEDITECH, CPSI, Cerner, McKesson, Healthland, Siemens, Healthcare Management Systems, Allscripts and NextGen Healthcare.

According to a KLAS report, just three of these vendors expanded their market share in 2013 — Epic, Cerner and MEDITECH — which together account for more than half of the acute-care EHR market.

Several of the big players in the EHR market are led by big personalities, from Judy Faulkner, who founded Epic (and wrote the software's original code) in 1979, kept the company private and is now worth an estimated $3 billion; to Cerner's Neil Patterson, known for his passionate, involved leadership style; to athenahealth's outspoken Jonathan Bush, an advocate for disruptive technologies in the healthcare industry.

Recently, the EHR market has seen an infusion of providers seeking replacements for their current systems. Surveys suggest between 12 and 30 percent of providers are dissatisfied with their EHR. Girish Navani, CEO and co-founder of eClinicalWorks, said in 2013 more than half of his company's new clients came from another vendor.

The 50 points below offer additional facts and insights into the EHR market and some of the most prominent companies. (EHR vendors below are arranged alphabetically.)...
Read on. Very interesting.
Is the Electronic Health Record Defunct?
Jerome Carter, MD
What do you think?
Medscape Medical News
EHR Replacement Trends Reveal Winners and Losers
Robert Lowes, August 28, 2014

Twenty-seven percent of medical practices are looking to replace their current electronic health record (EHR) system, according to a new survey suggesting that some well-known programs are fading in the marketplace.

In addition, another 12% of practices polled by KLAS, a healthcare information technology research firm, said they would like to replace their EHR but can't because of financial or organizational constraints.

These findings speak to more than the animus that many physicians feel toward digital charts, which are criticized for being too click-intensive and time-consuming. Forty-four percent of the 406 practices in the KLAS survey are owned by or tightly affiliated with a hospital. Such groups have little or no choice but to give up their EHR system, even if they like it, for the one deployed by the "Big House" to achieve standardization and integration, said study author Jared Dowland...

Nice piece just up on THCB:

Is It Possible That All Healthcare Needs to Know We All Learned In Kindergarten?
Fun post. Wish it were all that simple.
  • Share everything – In healthcare, this means share ALL the data, all the information, all the acquired wisdom. Interoperable systems are essential.
Yeah. Goes to my ongoing "interoperababble" rant.

CMS Officially Pushes Meaningful Use Stage 3 To 2017, Offers Flexibility In 2014
It’s happened again. Late on a Friday afternoon — right before a long weekend, no less — a federal agency has dropped a rulemaking on an unsuspecting public.

Today, at 4:15 pm EDT, the Centers for Medicare and Medicaid Services finalized its modifications to Stage 2 of the electronic health records incentive program known as Meaningful Use.

From a cursory first read, it looks like, as previously proposed, Stage 3 is officially delayed until 2017 and providers will be able to use technology certified to 2011 standards to meet Stage 2 requirements this year only. Starting next year, only EHRs certified to 2014 standards will be acceptable...
Stage 3 at 2017? We may have a GOP President by then, and MU could get scuttled.


$24.666 billion paid out. Not a lot of movement in the reimbursement total relative to the last monthly report. To be expected, given the time of year.


apropos of Labor Day, I guess. Next post.


More to come...

Tuesday, August 26, 2014

On "Big Data," research ethics, (and just "too much data")

"No human being on this planet can keep up with the literature."

Tangentially apropos,
It is in vain to expect any great progress in the sciences by the superinducing or engrafting new matters upon old. An instauration must be made from the very foundations, if we do not wish to revolve forever in a circle, making only some slight and contemptible progress.

-Francis Bacon
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...

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.

A simple example will illustrate medicine’s missing foundation. Consider a person with chest pain. Careful review of the literature shows that a practitioner investigating this symptom needs to take into account approximately 100 diagnostic possibilities, involving most medical specialties. Each diagnostic possibility is definable as a combination of simple,inexpensive findings from the history, physical and basic laboratory tests. Checking all of the findings for all of the diagnostic possibilities results in approximately 440 findings on each patient. Each positive finding suggests one or more of the diagnostic possibilities. Each patient’s particular combination of positive findings can be matched against all of the combinations of findings representing the diagnostic possibilities for chest pain. The output of this matching process is an individualized set of diagnostic possibilities, plus the patient’s positive and negative findings for each. These findings constitute initial evidence for and against each possibility. The total set of possibilities (i.e. those for which at least one positive finding is made) represents the diagnoses worth considering for that patient. External tools generate this output by simple matching, without dependence on the fallible minds of costly physicians. The tools distill this output from the accumulated experience of countless patients and practitioners—experience that would be otherwise lost.
This meticulous matching process is feasible only with software tools. The minds of physicians do not have command of all the medical knowledge involved. Nor do physicians have the time to carry out the intricate matching of hundreds of findings on the patient with all the medical knowledge relevant to interpreting those findings. External tools are thus essential. But the tools are trustworthy only when their design and use conform to rigorous standards of care for managing clinical information...
Medical practice is thus trapped in a subjective realm. Unlike scientific practitioners, medical practitioners do not operate in an objective realm, where the contents of thought and knowledge exist independently of the individual mind, a realm where knowledge can be reliably transmitted and applied, where new knowledge can be rapidly translated into practice, where all knowledge can be tested against patient realities. Isolated from this objective realm, the mind becomes a negative force, a cause of confusion and disorder. Physicians are not equipped to fulfill their immense responsibility safely and effectively. Other practitioners are not equipped to share that responsibility with physicians. Patients are not equipped to work effectively with multiple practitioners, nor to assume the ultimate burden of decision making over their own bodies and minds. Third parties are not equipped to create order out of this chaos. Practitioners and patients are not accountable for their own behaviors, while third parties are left free to manipulate disorder for their own advantage.
In short, essential standards of care, information tools and feedback mechanisms are missing from the marketplace. These missing elements are in large part already developed. Yet, the underlying medical culture does not even recognize their absence. This does not prevent some practitioners from becoming virtuoso performers in narrow specialties or skills. But their virtuosity is personal, not systemic, and limited, not comprehensive. Missing is a total system for enforcing high quality care by all practitioners for all patients...
That's from the opening pages of the Weeds' seminal book on medicine and health IT, "Medicine in Denial." I could not recommend it more highly, though I know full well that some physicians will bristle at its core argument. to wit, one of my THCB comment responses.

Not yet available in Kindle/eBook format.


Another interesting related observation:
"Just when we are starting to have some impact, for example, ideologically motivated pseudoskeptics try to steal the mantle of skepticism to deny established science. Social media has also been a double-edged sword. It has greatly expanded our reach, but unfamiliarity with the medium and a lack of filters has also exposed some poorly considered and unflattering opinions among some science promoters.

A lot of ideological opinion is getting mixed in with the science, and this can be divisive and distracting..."
From The Neurologica Blog, Scientific Literacy.

Given Time, 'Big Data' Promises to Transform Patient Care

August 27, 2014 11:28 am Michael Laff – With limited time and a heavy patient load, physicians face a daunting task trying to identify a patient's multiple needs during a single office visit.

Now, growing implementation of electronic health records (EHRs) and other health information technology, combined with rapidly evolving clinical analytics techniques, promises to make this task easier. By collecting and analyzing data that present a more comprehensive, detailed medical picture of entire patient populations, physician practices can monitor their patient panels more efficiently -- often without scheduling additional office visits.

"Big data" in health care refers to a wide-ranging combination of clinical, genetic and genomic, outcomes, claims, social and other data that is collected from multiple sources. Bringing diverse sets of data together will allow physicians to use predictive analytics and identify patients who are, for example, most likely to be "high-cost" -- that is, frequent utilizers of costly health care services.

AAFP News recently reached out to David Bates, M.D., to discuss how physicians can use big data to anticipate patient needs. A general internist, Bates is a professor and chief of the Division of General Medicine at Brigham and Women's Hospital in Boston, as well as a professor in the Department of Health Policy and Management at Harvard Medical School. He has written widely on the use of technology in health care, most recently as co-author of an article on big data( published last month in Health Affairs...
One hopes. But, problems and barriers will dog the utility of "Big Data."

From Science Based Medicine:
Bad Science Journals
Posted by Steven Novella on August 27, 2014

It’s an excellent business model. The only real infrastructure you need is a website, and you can have a custom site made for 5-10 thousand. Then you just have the monthly bandwidth charges. The rest is just e-marketing, which can be done for free, or the cost of some e-mails lists. After that, the money just comes rolling in.

The best part is that other people do all the actual work. All you have to do is charge them for publishing on your open-access online journal.

What you are selling is essentially scientific/academic fraud.

Unfortunately, this is a good business model, even though it is a terrible scientific model, and so it has proliferated. We may be living in the heyday of dubious open-access scientific journals...
Great post. Read all of it.

Pulse Systems Publishes Free eBook About Meaningful Use
eBook Teaches Eligible Professionals How to Attest for Meaningful Use and Earn Financial Incentives From CMS
Free with cursory registration. Not bad. Nice graphic renderings, good content. 130 pages.


HSPC Incorporates, Gears Up to Tackle Interoperability Problem

The Healthcare Services Platform Consortium, a group of providers, IT vendors, system integrators and venture-led firms dedicated to solving the industry-wide interoperability problem, has filed for incorporation in the State of Delaware as a first step to gaining legitimacy as an organization...

There are three levels of health IT interoperability: foundational, structural, and semantic. Of the three, semantic interoperability--which relies on a Services Oriented Architecture (SOA)—provides the highest level of interoperability, namely the ability of two or more systems or elements to exchange information and to use the information that has been exchanged taking advantage of both the structuring of the data exchange and the codification of the data including vocabulary so that the receiving IT systems can interpret the data.

This level of interoperability supports the electronic exchange of patient summary information among caregivers and other authorized parties via potentially disparate EHR systems and other systems to improve quality, safety, efficiency, and efficacy of healthcare delivery. According to HSPC, this services orientation will allow the healthcare industry to “transcend conventional clinical-data operations to enable software application developers to respond to events across disparate information systems, seamlessly aggregate data from both new and legacy systems, deliver advanced clinical decision support with data analytics, and support business process interoperability.”...
How about a dad-gumbed Data Dictionary Standard? Instead of / in addition to 36 pages of nicely rendered Interoperababble (pdf).

More to come...

Monday, August 25, 2014

Gorilla in our midst

Props to HealthDataManagement:
Health Gorilla Goes Mobile, Gets Big Funding Boost
Greg Goth, Aug 25th, 2014

Healthcare information marketplace vendor Health Gorilla has released a mobile app for iOS devices.

The Sunnyvale, Calif.-based company says its Health Gorilla Mobile enables physician users to securely and compliantly forward diagnostic test results, radiology images, admission and discharge summaries, and other clinical documents to patients and care coordinators through secure messaging.

Features of the platform include its HIPAA-compliant and ONC modular certified Meaningful Use Stage 2 status, immediacy of receiving and forwarding results to patients and other clinicians, the elimination of paper processes, and a no-charge business model for doctors and their teams...
They just got $1.2 million in VC funding from venture capital firm True Ventures. I wish them well.


From No sugarcoating this.
1. Americans consume, on average, 765 grams of sugar every five days. To put that in perspective, in 1822 we consumed on average 45 grams every five days. That is equal to one can of soda. Now we consume 17 times that, or the equivalent of 17 cans of soda.

2. Americans consume 130 pounds of sugar every year. Our 1822 predecessors ate under 10 pounds of sugar a year. 130 pounds a year means about three pounds a week. That equals about 3,550 pounds in an average lifetime—approaching two tons of sugar.

3. More on that last one: 130 pounds of sugar equals about 1,767,900 Skittles. Or just fill an industrial a dumpster with Skittles.

4. The American Heart Association recommends we consume less than 10 teaspoons of sugar a day. The average adult American misses that mark by a lot. Like about 12 teaspoons. The average American gobbles down on average 22 teaspoons a day. And the average child? 32 teaspoons. Pretty sure none of us needs that much to make the medicine go down. Mary Poppins, it seems, was an enabler.

5. Our sugar consumption is both in plain sight and hidden, ingested from the most unlikely places. Sugar in cookies seems obvious. Sugar in potato chips not so much. And ketchup and TV dinners and soup and crackers and just about every other processed food out there. Who are the biggest baddies? Soft drinks lead the list at 33% of our sugar consumption (drink water instead of coke and you’ve already made a huge dent). Candy and other obvious sweets, 16%. Baked goods like cookies and cakes, 13%. Fruit drinks 10%. Sweetened yogurt, ice cream and milk almost 9%.

6. One can of Coke, 12 ounces, contains 10 teaspoons of sugary goodness. That’s more sugar than two Frosted Pop Tarts with a Twinkie thrown in.

7. The average American consumes 53 gallons of soda a year. Let’s do the math. 128 ounces in a gallon times 53. That’s 6,784 ounces. Or just to simplify it, that’s 565 cans of soda a year.

8. If you took away all the sugar in an average American diet, you would subtract 500 calories a day. Of course, since we are not taking it away, that means sugar adds 500 calories a day to our diet (and waistlines). That is like eating 10 strips of bacon a day. Even bacon-loving Americans might stop short of that.

9. So, given all the bad stuff: Diseases, bad teeth, expanding waistlines. Zero nutrition. Why do we keep consuming sugar? Well, there is that DNA connection. Sugar is how we are wired for energy, but evolution never took processed sugar into account. Sweets eaters survived because they ate more energy-efficient fruit and veggie sugar that metabolizes slowly and doesn’t kill us.

Sugar is as addictive as cocaine. Brain scans after sugar consumption, are very similar to when we do blow. Dopamine floods the brain and, boy, do we feel good...
I use maybe a quarter teaspoon of sugar in my coffee. Don't drink soft drinks, maybe break down and have a coke a year. Hardly use any salt in my cooking either. Inveterate label reader too -- "High fructose corn syrup" is a no-buy.

Then there's Gluten.

I only drink gluten-free water.

In other news...

"According to the CDC, on any given day, about one in twenty-five hospital patients have at least one HAI"
Data mining keeps HAIs from spreading
Infection surveillance technology proving to be a critical tool
..."One of the great things having a software as a service model is that we have the ability to do population-wide analysis, not only at the hospital-level but across health systems, CDC regions, and nationally," said Glover. Moreover, he said, "standardized data enables us to know that we're viewing the data in the same manner at a hospital in Birmingham Ala. as we're viewing the data at a hospital in Seattle."

MedMined employs the use of advanced analytics to help pinpoint patient population groups that need additional focus or that further evaluation of care. This is accomplished through a patented nosocomial infection marker. That patented algorithm, said Glover, identifies patients who have likely acquired an HAI.

"We utilize algorithms to look at the patient's current condition as we receive them; it's not making the final clinical determination," he said. "The algorithm reviews all of the patients and acts as a filter to narrow the scope of what needs to be evaluated by the clinicians."

Glover said it becomes very challenging for infection preventionists to be able to do whole-house surveillance on all infection types, not just does that are required to be reported to the government.

"Our system uses data mining technology to mine through all the hospital data and identify trends that could be outbreaks or clusters that have occurred that the hospital may not have previously identified. We really look at this technology as identifying the smoke before the fire."...
BobbyG THCB rant

Re: The Data Response Curve (In Honor of the Dose Response Curve) 


I live about 40 miles from the epicenter. Didn't feel a thing.

We were just up there last week, took our daughter to Brix for a glorious Sunday birthday brunch. Drove right through the area that was to become the epicenter.

Lots of injuries, some of them critical. No deaths thus far.

More to come...

Saturday, August 23, 2014

"The only person who enjoys change is a baby with a wet diaper." - Brent James, MD, M.Stat

Indeed. Props to The Incidental Economist. You may have seen it depicted this way (below):

Panic typically ensues at ~2.5, often followed by abandonment of the improvement effort, leaving things worse off.


More to come...

Thursday, August 21, 2014

The Yeshi Dhonden dx, and other business

I first acquired and read this amazing book 40 years ago. It remains among my prized literary possessions.

Blessedly, it is now out in Kindle, with an update preface. A favorite excerpt I have quoted elsewhere:
On the bulletin board in the front hall of the hospital where I work, there appeared an announcement. “Yeshi Dhonden,” it read, “will make rounds at six o’clock on the morning of June 10.” The particulars were then given, followed by a notation: “Yeshi Dhonden is Personal Physician to the Dalai Lama.” I am not so leathery a skeptic that I would knowingly ignore an emissary from the gods. Not only might such sangfroid be inimical to one’s earthly wellbeing, it could take care of eternity as well. Thus, on the morning of June 10, I join the clutch of whitecoats waiting in the small conference room adjacent to the ward selected for the rounds. The air in the room is heavy with ill-concealed dubiety and suspicion of bamboozlement. At precisely six o’clock, he materializes, a short, golden, barrelly man dressed in a sleeveless robe of saffron and maroon. His scalp is shaven, and the only visible hair is a scanty black line above each hooded eye.

He bows in greeting while his young interpreter makes the introduction. Yeshi Dhonden, we are told, will examine a patient selected by a member of the staff. The diagnosis is as unknown to Yeshi Dhonden as it is to us. The examination of the patient will take place in our presence, after which we will reconvene in the conference room where Yeshi Dhonden will discuss the case. We are further informed that for the past two hours Yeshi Dhonden has purified himself by bathing, fasting, and prayer. I, having breakfasted well, performed only the most desultory of ablutions, and given no thought at all to my soul, glance furtively at my fellows. Suddenly, we seem a soiled, uncouth lot.

The patient had been awakened early and told that she was to be examined by a foreign doctor, and had been asked to produce a fresh specimen of urine, so when we enter her room, the woman shows no surprise. She has long ago taken on that mixture of compliance and resignation that is the facies of chronic illness. This was to be but another in an endless series of tests and examinations. Yeshi Dhonden steps to the bedside while the rest stand apart, watching. For a long time he gazes at the woman, favoring no part of her body with his eyes, but seeming to fix his glance at a place just above her supine form. I, too, study her. No physical sign nor obvious symptom gives a clue to the nature of her disease.

At last he takes her hand, raising it in both of his own. Now he bends over the bed in a kind of crouching stance, his head drawn down into the collar of his robe. His eyes are closed as he feels for her pulse. In a moment he has found the spot, and for the next half hour he remains thus, suspended above the patient like some exotic golden bird with folded wings, holding the pulse of the woman beneath his fingers, cradling her hand in his. All the power of the man seems to have been drawn down into this one purpose. It is palpation of the pulse raised to the state of ritual. From the foot of the bed, where I stand, it is as though he and the patient have entered a special place of isolation, of apartness, about which a vacancy hovers, and across which no violation is possible. After a moment the woman rests back upon her pillow. From time to time, she raises her head to look at the strange figure above her, then sinks back once more. I cannot see their hands joined in a correspondence that is exclusive, intimate, his fingertips receiving the voice of her sick body through the rhythm and throb she offers at her wrist. All at once I am envious— not of him, not of Yeshi Dhonden for his gift of beauty and holiness, but of her. I want to be held like that, touched so, received. And I know that I, who have palpated a hundred thousand pulses, have not felt a single one.

At last Yeshi Dhonden straightens, gently places the woman’s hand upon the bed, and steps back. The interpreter produces a small wooden bowl and two sticks. Yeshi Dhonden pours a portion of the urine specimen into the bowl, and proceeds to whip the liquid with the two sticks. This he does for several minutes until a foam is raised. Then, bowing above the bowl, he inhales the odor three times. He sets down the bowl and turns to leave. All this while, he has not uttered a single word. As he nears the door, the woman raises her head and calls out to him in a voice at once urgent and serene. “Thank you, doctor,” she says, and touches with her other hand the place he had held on her wrist, as though to recapture something that had visited there. Yeshi Dhonden turns back for a moment to gaze at her, then steps into the corridor. Rounds are at an end.

We are seated once more in the conference room. Yeshi Dhonden speaks now for the first time, in soft Tibetan sounds that I have never heard before. He has barely begun when the young interpreter begins to translate, the two voices continuing in tandem— a bilingual fugue, the one chasing the other. It is like the chanting of monks. He speaks of winds coursing through the body of the woman, currents that break against barriers, eddying. These vortices are in her blood, he says. The last spendings of an imperfect heart. Between the chambers of her heart, long, long before she was born, a wind had come and blown open a deep gate that must never be opened. Through it charge the full waters of her river, as the mountain stream cascades in the springtime, battering, knocking loose the land, and flooding her breath. Thus he speaks, and is silent.

“May we now have the diagnosis?” a professor asks.

The host of these rounds, the man who knows, answers.

“Congenital heart disease,” he says. “Interventricular septal defect, with resultant heart failure.”

A gateway in the heart, I think. That must not be opened. Through it charge the full waters that flood her breath. So! Here then is the doctor listening to the sounds of the body to which the rest of us are deaf. He is more than doctor. He is priest.

I know ... I know ... the doctor to the gods is pure knowledge, pure healing. The doctor to man stumbles, must often wound; his patient must die, as must he.

Now and then it happens, as I make my own rounds, that I hear the sounds of his voice, like an ancient Buddhist prayer, its meaning long since forgotten, only the music remaining.

Then a jubilation possesses me, and I feel myself touched by something divine.

Selzer, Richard (1996-04-15). Mortal Lessons: Notes on the Art of Surgery (Harvest Book) (Kindle Locations 302-320). Houghton Mifflin Harcourt. Kindle Edition. 
(BTW: That's not the cover; I did that in Photoshop from one of the illustrations in the book)

I have all of his books in hardback. What a writer. Rare erudition and passion.

Fast forward 40 years.

When I look at my career at midlife, I realize that in many ways I have become the kind of doctor I never thought I’d be: impatient, occasionally indifferent, at times dismissive or paternalistic. Many of my colleagues are similarly struggling with the loss of their professional ideals. Of course, the relinquishment of one’s ideals is standard fare in the midlife phase. In this period, fundamental questions about life often arise: What is its purpose? What is my ultimate aim? Depression and nostalgia can take hold as middle-aged adults struggle with responsibility, regret, and the nagging awareness that their lives are half over.

I used to think that my life would settle down when I got to this stage, but I was wrong. The insecurity and ambivalence of my youth have persisted, though in different forms. In my twenties, hamstrung by my passions, I yearned for consistency in my core beliefs. I obsessed about what I was going to do with my life. Those ruminations now seem like luxuries. The challenges I face now— supporting my family, navigating the precarious domains of job, marriage, and fatherhood while trying to maintain personal and professional integrity— seem so much bigger (if no less insoluble). As a young adult I believed that the world was accommodating, that it would indulge my ambitions. In middle age, reality overwhelms that faith. You see the constraints and corruption. Your desires give way to pragmatism. The conviction that anything is possible is essentially gone.

It occurs to me that my profession is in a sort of midlife crisis of its own. In the last four decades, doctors have lost the special status they used to enjoy. In the mid-twentieth century, at least, physicians were the pillars of any community. They made more money and earned more respect than just about any other type of professional. If you were smart and sincere and ambitious, the top of your class, there was nothing nobler or more rewarding that you could aspire to become. Doctors possessed special knowledge. They owned second homes. They were called upon in times of crisis. They were well-off, caring, and smart, the best kind of people you could know.

Today medicine is just another profession, and doctors have become like everybody else: insecure, discontented, and anxious about the future. In surveys, a majority of doctors express diminished enthusiasm for medicine and say they would discourage a friend or family member from entering the profession. In a 2008 survey of twelve thousand physicians, only 6 percent described their morale as positive. Eighty-four percent said their incomes were constant or decreasing. The majority said they did not have enough time to spend with patients because of paperwork, and nearly half said they planned to reduce the number of patients they would see in the next three years or stop practicing altogether. American doctors are suffering from a collective malaise. We strove, made sacrifices, and for what? For many, the job has become only that— a job.

Consider what a couple of doctors had to say on Sermo, the online community of more than 125,000 physicians:
I wouldn’t do it again, and it has nothing to do with the money. I get too little respect from patients, physician colleagues, and administrators, despite good clinical judgment, hard work, and compassion for my patients. Working up patients in the ER these days involves shotgunning multiple unnecessary tests (everybody gets a CT!) despite the fact that we know they don’t need them, and being aware of the wastefulness of it all really sucks the love out of what you do. I feel like a pawn in a money-making game for hospital administrators. There are so many other ways I could have made my living and been more fulfilled. The sad part is we chose medicine because we thought it was worthwhile and noble, but from what I have seen in my short career, it is a charade.
Another wrote:
I loved what I did, running an ICU. But I was on call 11 of every 14 days for more than 25 years. Over a third of my work weeks were 100 hours. I quit when I was 56 because my wife developed a terminal illness and I wanted to return all the lost hours I had promised her “when we retire.” In my last year of practice I asked the billing department to collect all the actual money we had collected on one particularly long and difficult weekend on call  … After overhead, I was actually paid $ 11.74/ hour. Who would do that again? Fool that I am, I probably would, but my wife and I brought up our sons from an early age to be totally against the idea of medical school. They were clearly bright enough, with full academic scholarships. And while they respect physicians, they are not doctors. And I am glad they are not.
The discontent is alarming, but how did we get to this point? This book, chronicling my experiences in my first few years as a new doctor, is my attempt to answer this question.

Jauhar, Sandeep (2014-08-19). Doctored: The Disillusionment of an American Physician (pp. 6-7). Farrar, Straus and Giroux. Kindle Edition.
A bit more:
Because insurers had been slashing reimbursement rates, that summer my LIJ colleagues and I were told we had to increase our “relative value unit” collections, or RVUs (the currency of medical payment). With all the cuts in reimbursements over the prior few years, academic medical departments across the country had suffered sharp downturns in revenue. Some physicians had responded by upcoding— claiming greater complexity in patient encounters than was in fact the case— and fraud investigations at some centers were under way. Obviously I wasn’t going to upcode, so what the department’s directive meant for me on a practical level was that I had to see more patients. I reduced the time in my schedule earmarked for new patients from sixty minutes to forty and for established patients from thirty minutes to twenty. With administrative tasks, conferences, teaching, chart reviews, and letters and phone calls to physicians, hospitals, and pharmacies increasingly gobbling up my day, I began to rush through visits, hurrying patients along in subtle and not so subtle ways. I stopped making small talk. I interrupted histories after a few seconds to get patients on point. I even urged my patients to breathe a little faster when I was listening to their lungs. “Doctor, I just want to know…” “One second, ma’am, please, one second…” (pp. 224-225).
Related readings of mine:

Another awesome book, reported on here.

Yet another:

Reported on here.

Periodical literature has been rife with recursive reports of the dismay in recent years.
The Root of Physician Burnout

Incentivizing with money is a self-fulfilling prophecy of cynicism. We must promote compassion, courage, and wisdom among our physicians before we "make a sordid business of this high and sacred calling."

A colleague of mine in primary care medicine has decided to leave the practice of medicine. She is very well trained, has impeccable professional credentials, and works in a thriving practice. Over the past several years, however, she has noticed an unrelenting decline in the sense of fulfillment she derives from her work. She feels increasingly frustrated with what she calls the "bureaucratization" of medicine, and resents spending "more time filling out forms than caring for patients." My colleague is suffering from what is commonly described as burnout...

The Epidemic of Disillusioned Doctors
We all know medicine has become a frustrating profession. But surveys show that a younger generation of doctors are more resilient to burnout

By Danielle Ofri, MD

Last week I was ready to quit medicine. I was seeing a new patient with diabetes, heart disease, anemia, hypertension, osteopenia, hypothyroidism, reflux, depression and pain in every part of her body. From a bag she produced 18 pill bottles — from about as many doctors — and piled them onto my desk. She pulled out a form from her job that needed to be filled out, plus a prior-approval form that her insurance company required, as well as a stack of photocopied records from the other doctors. She didn’t speak English, so we waded through her complicated medical history via a telephone interpreter. I don’t like to write while I am talking with a patient, but I couldn’t afford to fall behind in my documentation, so I typed madly into the 50 required fields of our electronic medical record while the patient recounted her complex medical history.

In the middle of this, the computer seized up, then turned a shade of gray that in an ICU would elicit the code team. I didn’t want to lose the interpreter on the phone, so I fiddled with the control-alt-delete buttons while I continued the interview, moving on to the refresh buttons, the escape buttons, finally squatting awkwardly under the desk to yank the on-off switch of the computer.

Forty-five minutes into our 15-minute visit, with an interpreter telephone in one ear translating back and forth into Bengali, my office phone in the other ear, on hold to tech support, my desk swimming with insurance forms, pill bottles, MRI reports, and mammogram referrals, the computer flashing ominous error messages, plus six more patients waiting outside, eight phone messages from yesterday still to return, I thought: “That’s it, I quit!”...
I got off into thinking about this in particular after reading this on THCB:
An Open Letter to Primary Care Physicians

Dear Doctor,
The future is in your hands.

You have the opportunity to make primary care better.

More efficient.

More accessible.
And more affordable.

We know you and other primary care doctors have more responsibilities than ever. But you also have great influence, along with the ability and opportunity to change this country’s health care system for the better.

Primary care is essential to the quality of health care, and we need you now more than ever.

Maneuvering the Minefield

According to research firm Harris Interactive, “the practice of medicine is … a minefield. … Physicians today are very defensive – they feel under assault on all fronts.’’* Harris questions, “how much fight the docs have left in them. Some are still fired up … while others have already been beaten down.’’

Those who feel frustration, anger and burnout say they are squeezed by administrators, regulators, insurance companies and more. They worry about the possibility of a lawsuit that could destroy your career.

The question is: What can be done about it? Some of you may choose to remain in the status quo. Some of you have chosen to retire early or otherwise leave the field of medicine entirely. Yet some of you have said enough is enough and found specific solutions that mark a pathway forward. You sought – and found – specific solutions that mark a pathway forward.

If you’ve rejected the status quo and joined your fellows in search of innovations from other practices that you have applied at home, congratulations. You’re a physician leader who’s doing great things for your patients, your colleagues and yourself. You are undoubtedly more satisfied in your work than before, and you are quite likely providing better care.

To those of you who aren’t sure of how to proceed, there is a way out. But you have to act...
A lot to think about. The authors continue:
If you have the courage to stand up and lead, you will quickly find that identifying great practices from which to learn isn’t that difficult. Don Berwick, MD, former head of the Centers for Medicare and Medicaid Services (CMS) for the United States, puts it this way: “It’s not hard to describe the health care system we want; it’s not even hard to find it. … Among the gems and the jewels throughout our country… lie answers; not theoretical ones, real ones where we can go and visit these organizations and see how good they are.”

So, when we add these elements together, the pathway forward emerges:

  1. Step forward as a leader
  2. Identify problem areas within your practice
  3. Find practices that have done a nice job of solving those problems
  4. Learn from others
  5. Apply what seems like the best fit to your practice
Ah, that "Leadership" thingy I've been working on.

Which leads me to another book I have underway.

This book is about a naturally occurring pattern, a way of thinking, acting and communicating that gives some leaders the ability to inspire those around them. Although these “natural-born leaders” may have come into the world with a predisposition to inspire, the ability is not reserved for them exclusively. We can all learn this pattern. With a little discipline, any leader or organization can inspire others, both inside and outside their organization, to help advance their ideas and their vision. We can all learn to lead...

Sinek, Simon (2009-09-23). Start with Why: How Great Leaders Inspire Everyone to Take Action (p. 1). Penguin Group US. Kindle Edition. 
Got hip to him from that TED talk in my prior post. Again, "Talking Stick culture," anyone?

See also my citation of the book "When Doctors Don't Listen" in my post "Philosophia sana in ars medica sana." (scroll down)

Saturday morning, Jerry woke up with tightness in his chest. It hurt when he sat up and he figured he must have pulled something while he was moving. But his uncle or grandfather (maybe both?) had heart problems, and Jerry’s wife persuaded him to go to the ER to get it checked out.

A generation ago, a doctor might have heard Jerry’s story and told him that he had a muscle strain. He would have left and felt better. Not so on this particular day. The nurse who greeted Jerry noted his “chief complaint” of chest pain and called over a tech, who took off Jerry’s shirt and attached him to a monitor that beeped and displayed waves and numbers that made no sense to him, but Jerry trusted the folks around him to make sense of it all. He was given some aspirin to chew and another tiny pill under his tongue that tingled a bit and gave him a headache. He was brought to a treatment room where another nurse came in and asked a series of questions about his “chest pain” before proceeding to take several vials of blood and shuttling him off to the next destination, the radiology suite for X-rays. When he finally got back, a doctor stopped in and went over yet another checklist of questions, these seeming even less relevant to why he was there. (“ Why did it matter whether I had blood in my stool or slept on two pillows at night?”) But while long, convoluted, and confusing for Jerry, the whole process nevertheless appeared routine and procedural for the ensemble of medical professionals coming and going...

Wen, Leana; Kosowsky, Joshua (2013-01-15). When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Tests (p. 2). St. Martin's Press. Kindle Edition.
Issues at every turn. I'm sure physicians feel shot at from every direction every day.


...A third player is increasingly encroaching on the doctor-patient relationship, and more and more doctors are beginning to suspect that it may be the vector of much of contemporary healthcare’s pathology. Who is the third party? Its precise identity is often difficult to pin down, but its seat in the doctor’s office and at the patient’s bedside is often occupied by a hospital, a health insurer, or a government agency.
This third party usually does not see individual patients. Instead it sees aggregates, such as rates of mortality, disease incidence, and the utilization rates of particular tests, procedures, and pharmaceuticals. It tends to be particularly interested in parameters such as efficiency, safety, cost, and revenue.  Because it is largely blind to individuals, however, its risk of developing certain disorders is dramatically increased...
From THCB. Nice. Will there be an ICD-10 code for that dx?

But, wait! There's more...
Another such disorder is hypermechanosis. Many third parties envy the kinds of productivity and quality gains that have been achieved in other industries through the application of various forms of statistical process control. For example, six sigma focuses on reducing variation, usually treated as error. If only we could run medical practices the same way Toyota manufactures automobiles, Southwest flies airplanes, and Disney treats its theme park visitors, proponents argue, we could revolutionize healthcare...
Yeah, hahahaha.... Good for laughs among the Perpetually Pissed At Their Loss of Clinical and Business Autonomy, but, more than just a bit of Straw Man there.

More to come...

Wednesday, August 20, 2014

@BobbyGvegas says...

A comment I just made over at THCB.
There are 3 fundamental aspects of workflow in the digital era: physical tasks, IT (EHR) tasks, and cognitive tasks. Every certified EHR has to have an audit trail to comply with HIPAA, given that every time ePHI is created, viewed, updated, transmitted, or deleted the transaction must be “date-time/who/what/about whom” captured in the audit trail log.
The ePHI audit log, to me, is a workflow record component. It can’t tell me WHY front desk Susie or Dr. Simmons took so long to get from one transaction element to the next — i.e., physical movements or cognitive efforts — but it can tell me a lot, adroitly analyzed.
I worked for number of years as a credit risk and portfolio management analyst in a credit card bank. We had an in-house collections department that took up an entire football field sized building, housing about 1,000 call center employees. I had free run of the internal network and data warehouse. One day I just happened upon the call center database and the source code modules (written by an IT employee in FoxPro, which I already knew at an expert level). I could open up the collections call log and watch calls get completed in real time. We were doing maybe a million outbound calls a month (a small Visa/MC bank).

(My fav in the Comments field was “CH used fowl language,” LOL)

It was, in essence, an ongoing workflow record of collections activity.
I pulled these data over into SAS and ground them up. I could track and analyze all activity sorted by any criteria I wished, all the way down to the individual collector level. I could see what you did all day, and what we got (or didn’t) for your trouble.

I was [able to] rather quickly show upper management “Seriously? You dudes are spending $1,000 to collect $50, every day, every hour” etc. The misalignment was stunning. I started issuing a snarky monthly summary called “The Don Quixote Report” with a monthly “winner.” …Yeah, we called this hapless deadbeat 143 times this month trying to get 15 bucks out of him…

Well, it didn’t take long to squelch all that. We saved the bank 6 million dollars in Collections Department Ops costs that year via call center reforms. Didn’t exactly endear me to the VP of Collections, whose bonus was tied to his budget.

Gimme a SAS or Stata install and SQL access to the HIT audit logs, and I will tell you some pretty interesting (Wafts-of-Taylorism 2.0) workflow stories.

More to come...

Monday, August 18, 2014

Crappy Health IT reporting

Let a thousand non sequiturs bloom.
Survey: EHR use cuts into resident education, productivity
By: DOUG BRUNK, Family Practice News Digital Network

SAN DIEGO – Family medicine residents reported that documentation time increased by about 16 minutes per patient encounter following implementation of an electronic health record system at two academic medical institutions in Southern California.

"We have learned about how electronic health records are going to improve our patient care and our efficiency in the clinic but not a lot of studies have explored how the implementation of an electronic health record at academic centers is going to impact resident education," Dr. Maisara Rahman said in an interview during a poster session at the annual meeting of the American Academy of Family Physicians.

Dr. Rahman and her associates surveyed 122 family medicine residents, attending physicians, and other clinical staff from Riverside County Regional Medical Center (RCRMC) and Pomona Valley Hospital Medical Center (PVHMC) to assess their perceptions about the adequacy of EHR training, the amount of time spent on documentation, and the effects of EHRs on patient care and resident education. Of the 122 people surveyed, 99 responded, for a response rate of 83%.

Dr. Rahman, in the department of family medicine at Loma Linda University and an attending physician in the department of family medicine at RCRMC, reported that there was an overall decrease in resident productivity at both academic institutions following implementation of the EHR: a 30% decrease at RCRMC and a 20% decrease at PVHMC. Overall, respondents indicated that EHR documentation took about 16 minutes longer to complete compared with documentation by paper chart (an average of 37 vs. 21 minutes, respectively.)...
"Residents"? To the extent that this implies that health IT will negatively impact post- academic training clinical care, where most of the ambulatory primary care EHR documentation is done for the doctor by subordinate staff, it tells us nothing. Moreover, we would expect that those still in training will be episodically encountering halting upward steps on the leaning curve upslope. HIT competency is not "See One, Do One, Teach One." HIT training -- hel-LO? -- is a necessary part of medical training.

Little To Show For $26 Billion Health IT Investment
By Christine Kern

The advancement of HIT-related initiatives has been slow despite “considerable investments.”

The electronic sharing of information (health information exchange) plays a critical role in improving the cost, quality, and patient experience of healthcare. However, there is very little electronic information sharing among clinicians, hospitals, and other providers despite more than $24 billion in incentive payments to hospitals and eligible professionals who "meaningfully use" electronic health records, and another $2 billion spent on interoperability standards and EHR certification over the past five years...
I'd like to know whether this author wrote the headline for this article. I also have to wonder about her chops for opining about the state of Health IT.
Christine Kern is a contributing writer for Jameson Publishing, featured in Health IT Outcomes, Integrated Solutions For Retailers, and Business Solutions magazines. She has a PhD in European history from Penn State University, is widely travelled, spent over 15 years in the college classroom teaching European and World history, and is a published author of both academic and creative works.
Her article is simply an uncritical report on the recent Health Affairs Policy Brief on interoperability. Fine. But, I have to quibble with the simplistic headline. While I am by no means an unreflective cheerleader for Health IT -- as my regular readers have long known -- it is way too early to summarily declare that there it "little to show" for the national effort.

My Clinic Monkey spoof site
How "little," relatively speaking? Where would we likely be today absent the effort? (See JD Kleinke).

Then there's good reporting:

Delegating tasks to practice staff enhances team-based care

Physician practice owners carry much more responsibility than they did in previous years. In fact, an avalanche of administrative requirements required to succeed, even survive, in healthcare is placing an even greater toll on morale. According to a Medical Economics web poll in December 2013, 41.9% of physicians say that administrative hassles threaten their relationships with patients. And while the challenges have been well documented, the solutions require a new approach to delegation and teamwork, experts say.

 “The notion of what it means to lead has shifted. We are moving to a team-based model of care—and it’s not just doctors,” says Andrew Morris-Singer, MD, president and founder of Primary Care Progress, a nonprofit organization that develops leadership practices amongst an interprofessional group of medical professionals. “There are different levels of credentials, expertise and diversity in the doctor’s practice right now. And we never taught physicians how to be on a team and lead a team that’s not all physicians.”

Morris-Singer adds that physicians no longer can have the mentality that they have all of the answers—and this is a good thing. Because of the increased complexity of patient care, especially surrounding chronic disease, it will be important for physicians to build a staff that can manage all areas of a patient’s needs.

The need for appropriate delegation can save a team time. According to a Health Affairs study primary care physicians could save 30 minutes per day by delegating routine functions to staff members. While it’s not a lot of time, it is a start.

“We aren’t able to know the exact answers anymore in terms of care delivery,” he says, adding that different staff members can assist physicians with getting patients to adhere to prescriptions and other guidelines.

“We have to work in a team with a unique, complementary set of skills. This is not substituting the doctor. There’s no one on the team who knows complex diagnoses and can build a therapeutic alliance better than the physician. But that’s not the only thing a patient needs.”...
Also, re "credibility,"
Why I Am Still Optimistic About the State of HIT
Jerome Carter, MD
MU stage 2 is making everyone miserable.  Patients are decrying lack of access to their records and providers are upset over late updates and poor system usability. Meanwhile, vendors are dealing with testy clients and the MU certification death march.  While this may seem like an odd time to be optimistic about the future of HIT, nevertheless, I am.
The EHR incentive programs have succeeded in driving HIT adoption. In doing so, they have raised expectations of what electronic health record systems should do while bringing to the forefront problems that went largely unnoticed when only early adopters used systems.  We now live in a time when EHR systems are expected to share information, patients expect access to their information, and providers expect that electronic systems, like their smartphones, should make life easier.

Moving from today’s EHR landscape to fully-interoperable clinical care systems that intimately support clinical work requires solving hard problems in workflow support, interface design, informatics standards, and clinical software architecture.  Innovation is ultimately about solving old problems in new ways, and the issues highlighted by the current level of EHR adoption have primed the pump for real innovation.   As the saying goes, “Necessity is the mother of invention,” and in the case of HIT, necessity has a few helpers...
I have reported on Dr. Carter's work before.


Re "analytics," and the "big data" Health IT nexus. HealthCatalyst offers another free eBook (downloadable PDF with registration). I am well into it, and will finish it today. A lot of good stuff, fairly technical.

  • Introduction
  • Chapter 1: What Is a Data Warehouse?
  • Chapter 2: Why an EDW Is a Foundational Platform for Future Analytic Success
  • Chapter 3: Which Approaches Are Commonly Used in Healthcare before
  • Implementing an EDW?
  • Chapter 4: What Works Best For Healthcare? Introducing the Late-Binding Data Warehouse
  • Chapter 5: Alternatives to Late-Binding. The Star Schema Approach in Healthcare
  • Chapter 6: Alternatives to Late-Binding. Can a BI Tool Be an Effective Data Warehouse?
  • Chapter 7: Six Reasons Why Healthcare Data Warehouses Fail
  • Chapter 8: Four Phases of a Successful EDW Implementation
  • Chapter 9: Should We Build or Buy Our Data Warehouse?
  • Chapter 10: How to Evaluate a Healthcare Data Warehouse and Analytics Vendor
  • Chapter 11: Health Catalyst’s Solutions
  • Chapter 12: Success Stories: Reaching Goals Through Healthcare Data Warehousing
  • Appendix:
  • Further reading
  • Contributors
I cited their eBook HEALTHCARE: A BETTER WAY. THE NEW ERA OF OPPORTUNITY in a recent prior post. While these gratis eBooks are in fact "frisbees," -- marketing giveaways via which to promote their company, the information contained therein seems to be totally on the up-and-up and relatively unbiased (and rendered with great aesthetics).

to wit, Brian Ahier on "late binding" -
[The] third wave of analytics will enable large numbers of healthcare organizations to realize some significant returns on their IT investments and thrive in the healthcare marketplace of the future. Developing a consensus model for adoption of analytics capabilities could help healthcare leaders and vendors succeed by providing a common roadmap for the deployment of these capabilities. But much of the success of these analytics platforms will depend on the underlying architecture and I think the "late-binding" data warehouse model holds the most promise.

The term late-binding dates back to at least the 1960s, where it can be found in Communications of the ACM. The term was widely used to describe languages such as LISP, though usually with negative connotations about performance. In the 1980s Smalltalk popularized object-oriented programming (OOP) and with it late binding. Alan Kay in History Of Programming Languages 2 laid out the fundamentals of OOP and late-binding architecture in The Early History of Smalltalk section. In the early to mid-1990s, Microsoft heavily promoted its COM standard as a binary interface between different OOP programming languages. COM programming equally promoted early and late binding, with many languages supporting both at the syntax level.

The late-binding data warehouse model is a just in time method and is more adaptable to new analytics use cases and data content than those that make use of early binding and tightly coupled enterprise data models. Late-binding is a method of assembling data from disparate sources just in time for particular analytic use cases, known as the late-binding model of data warehousing, is starting to gain traction in healthcare as many provider organizations gear up for population health management. The advantage of this approach is that it allows users to combine disparate data very quickly for targeted analyses without locking data warehouses into a predetermined data model...
See also "late binding" in the Wiki for a more geeky discussion.

During my stint in credit risk modeling and portfolio analytics (pdf) a decade go, we established an Oracle platform "EDW" (Enterprise Data Warehouse), so all this stuff rings true to me. I routinely hit against ours using SAS Proc SQL to pull in "late bound" data for exploratory drilling and modeling (after cleaning up the crap they never ceased to let into the EDW).

Dignity Health goes big for data
Bernie Monegain, HealthCare IT News

Dignity Health, one of the largest health systems in the country, with a 20-state network, will build a cloud-based data analytics platform.

The health system tapped Cary, N.C.-based SAS to lead the big data and predictive analytics project.

The platform will be powered by a library of clinical, social and behavioral analytics, according to Dignity Health executives.

The initiative is aimed at helping doctors, nurses and other healthcare providers better understand each patient and tailor care to improve health while reducing costs.

In the short term, Dignity Health and SAS will use the big data analytics platform to reduce readmission rates, determine best practices for addressing congestive heart failure and sepsis, manage pharmacy costs and outcomes and create tools to improve each patient's experience.

"In order to deliver the right care at the right place, cost and time for every patient, we must connect and share data across all our hospitals, health centers and provider network," said Dignity Health CIO Deanna Wise, in announcing the move. "The SAS cloud-based analytics platform will help us better analyze data to optimize and customize our treatment for each patient and improve the care we deliver."...
Pretty interesting. An "EDW," eh? Bears watching.

I wonder whether SAS will be exhibiting at Health 2.0 in Santa Clara next month? I've long been a SAS user and enthusiast.

More to come...