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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...

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