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Monday, February 29, 2016

#HIMSS16 Day 1

Got my badge, tried to login to the conference website to review my calendar.

"The website that you're trying to reach
is having technical difficulties and
is currently unavailable.
We are aware of the issue and are working hard to fix it.

Thank you for your patience."

Lordy. We're the IT people...

OK. one core thing I will be looking for this week, apropos of my recent review of Dr. Nortin Hadler's book, are affirmative responses to this Hadler cite:

"If there is a role for computers in decision making, it is to facilitate dialogue between patient and physician, not to supplant the input from either or to cut health-care costs."

Now, obviously, the physician and her patient are not the only "stakeholders" in the health care space, but if all of our cherubic talk of "patient-centered care" is more than just Suit talk, then I'm looking for affirmative evidence of the foregoing. The salient question: "how does what you do/sell 'facilitate physician-patient dialogue'?"

Good a time as any for a bit more Hadler by the Bedside. Keyword search "EHR."
At the beginning of this chapter, I pointed out that the transformation of “medicine” into a “health-care industry” required first creating a different setting for caring. That is fait accompli. Next, it had to intrude into the examining room itself. The coup de grâce is the commandeering of the doctor-patient relationship itself, the topic of the next chapter. The health-care industry took ownership of the examining room by computerizing the clinical interview. This required convincing the country and the federal government that an Electronic Medical Record (EMR) was much more than a confusing, expensive way to garner fees for services. Furthermore, EMR was to be replaced by another acronym, EHR, to denote that matters of “health” were to be recorded, not just “medical” matters... [pg 120]

The Affordable Care Act does not assault the Babel of invoicing. To the contrary. The solution currently being offered is buried in the Electronic Health Record, which is already mandatory for larger institutions and will be universal before long if the federal government has its way. These are computer programs that require providers to enter actions and codes leading to large data sets with the “granularity” that is considered the secret to efficient invoicing. The ICD-10 appeals to this mindset, but even with the ICD-9, a patient encounter or admission can send myriad data points into the maw of invoicing. I’m not surprised that it has proved difficult to demonstrate that the implementation of the EHR leads to a reduction in costs or any other impressive utility,  even in outpatient settings. But the EHR has its stakeholders; some are wonks with their policy prowess at risk, and others are stockholders with deep pockets. All are crying “wait and see,” even the current crop of RAND Corporation thought leaders... [pg 125]

Perhaps the most evil example of propaganda masquerading as clinical pedagogy is the insidious introduction of contentious clinical guidance into the Electronic Health Record. Not only are various guidelines and reviews linked to the EHR, but adherence to them also can be monitored digitally— with the assumption that adherence is a measure of “quality of care.” [pg 137]
Plenty more where those came from. Buy the book (I am not pimping it; I get nothing for these cites).


I really admire Dr. Carter's work.
Diagnostic Error, Results Management, and Software Design
by Jerome Carter on February 29, 2016
As I have spent more time thinking about clinical software design, my ruminations have become more problem-focused. I have begun to look at specific care delivery problems and how changes in software designs might help or hinder clinical work. Lately, the problem of diagnostic error as it relates to results management has captured my attention. Having dealt with results management headaches in practice, this is an issue that resonates with me.

When approaching a software design challenge, I like to start with high-level concepts before jumping into detailed design issues. Here, the question is: What is the optimal way to manage test results? When designing software for clinical work, it is helpful to pose two questions. The first question: What is it about managing results that is common (or should be) across all clinicians within a specific domain? The second question: What necessarily varies among clinicians within a domain? Creating software that helps and doesn’t hinder requires answers to all three questions...
EHR systems are data-centric, and as such, they can be great for event-based support of clinical work, but if process support is needed, they have serious shortcomings. Current EHR systems lack workflow capability, so do not expect sophisticated process support to appear anytime soon.

Improving diagnostic decision support for test results requires moving beyond alerts. It requires process-centric software designs that make use of tools that fit into the workflows of busy clinicians. Results management is a process, not an event…

Had not heard of them.
"The Association of University Programs in Health Administration (AUPHA) is a global network of colleges, universities, faculty, individuals and organizations dedicated to the improvement of health and healthcare delivery through excellence in healthcare management and policy education. Its mission is to foster excellence and drive innovation in health management and policy education, and promote the value of university-based management education for leadership roles in the health sector. It is the only non-profit entity of its kind that works to improve the delivery of health services – and thus the health of citizens – throughout the world by educating professional managers. AUPHA's membership includes the premier baccalaureate, master's and doctoral degree programs in health administration education in the United States, Canada, and around the world. Its faculty and individual members represent more than 400 colleges and universities...

The association continues to provide forums for discussion where leaders from the field can gather to share information on educational methods and research. The association continues to serve as an effective advocate for the health administration education community before various legislative and executive bodies. Most importantly, AUPHA continues to focus on providing its members with the tools, research, venues, support, and forums that enable each program, as well as healthcare administration education as a whole, to evolve and thrive in a constantly changing industry."
I was expecting to hear (perhaps overlapping) broad stuff about developing and nurturing effective curricula -- pedagogy. e.g., say,

I was pretty disappointed. They lost me with the first two presentations: "Characterizing Pioneer Hospital ACOs" and "The HIPAA Privacy Rule: Regulatory Success and Legacy Technology." The 3rd, "Learning Health IT Management Using Data Visualization," though, was a bit more on point.

I didn't stay for the ensuing session following the break, "eHealth Use by Mature Adults -- Does One Size Fit All."
"foster excellence and drive innovation in health management and policy education"?

They were touting a new book. Looks interesting.

Available in Kindle edition for about $16.


Drought? What drought? LOL.


More to come...

Saturday, February 27, 2016

#HIMSS16, up next

On my way shortly over to my old stomping grounds Las Vegas and the HIMSS 2016 Conference. Should be an interesting week. I'll be particularly interested in topics such as
  • Data exchange / "Interoperability";
  • Health IT Usability ("UX" and UCD");
    Security and Privacy;
  • Markets / Venture Capital in HIT;
  • Workflow;
  • "Omics" / "Precision Medicine";
  • Policy trends;
  • Clinician burnout;
  • "Leadership"
to cite just a few.

Speaking of "leadership," just read this in my New Yorker:

Shut Up and Sit Down
Why the leadership industry rules.


...For a long time, leadership experts remained nostalgic for old-type leaders. In the nineteenth century, books such as Thomas Carlyle’s “On Heroes, Hero-Worship, and the Heroic in History” attempted to isolate, through historical surveys, the character traits of “great men”; well into the twentieth century, many scholars elaborated on a “trait model” of leadership. They proposed that leaders possessed certain personality traits—courage, decisiveness, intelligence, attractiveness, and so on—that made them intrinsically followable, bureaucracy be damned. A great deal of time was spent thinking about how leadership qualities might be detected, so that leaders could be identified in advance of their elevation.

The trait model endures. Many leadership gurus talk about Jack Welch and Steve Jobs as people with the right stuff to lead. But plenty of people with the right stuff fail as leaders. In a 2002 book called “Searching for a Corporate Savior: The Irrational Quest for Charismatic C.E.O.s,” Rakesh Khurana, a professor at Harvard Business School, took stock of corporate America’s investment in the trait model of leadership. Khurana found that many companies passed over good internal candidates for C.E.O. in favor of “messiah” figures with exceptional charisma...

By the mid-twentieth century, alternatives to the trait model of leadership emerged. Experts have studied leadership psychologically, sociologically, and even “existentially-experientially.” Many have settled on a “process-based” approach. They’ve come to see leadership as something that unfolds in stages. A problem emerges, a leader is selected, a goal is developed, a team is assembled, the goal is reëvaluated, and so on. From this perspective, the working life of an organization begins to look like an unending sequence of leadership events. A leader’s job is to shepherd the team through the leadership process.

Process models favor the bureaucratic over the charismatic, and have a number of advantages over trait models. For one thing, they suggest that leadership is learnable: you just observe the process. For another, they’re capable of differentiating between the designated leader—often a broad-shouldered white guy with a power tie and a corner office—and the actual, “emergent” leaders around whom, at particular moments, events coalesce. (Research shows that workplaces often function because of unrecognized emergent leaders, many of them women.) Most fundamentally, process models acknowledge that “being a leader” isn’t an identity but, rather, a set of actions. It’s not someone you are. It’s something you do...
Nice that he cites Stanford's Dr. Jeffrey Pfeffer, whom I cited at some length in a prior post, "What exactly is "Leadership," anyway?"
Reading “Indispensable” and other works from the field of leadership studies, you can get the impression that leaders, like authors, have been deconstructed. Leaders used to be titanic and individual; now they’re faceless guiders of processes. Once, only the people in charge could lead; now anyone can lead “emergently.” The focus has shifted from the small number of people who have been designated as leaders to the background systems that produce and select leaders in the first place.

Leaders, moreover, used to command; now they suggest. Conceptually, at least, leadership and power have been decoupled. In 1927, Personnel Journal cited an expert who defined leadership as “the ability to impress the will of the leader on those led and induce obedience, respect, loyalty, and cooperation.” But after the Second World War the concept of leadership softened. Leaders, it was said, weren’t dictators or tyrants; instead of ordering us around, they influenced, motivated, and inspired us. A distinction began to emerge between leadership, which was said to be inspirational, and management, which was seen as more punitive. (As the business books have it, “Managers require, leaders inspire.”) The distinction persists today. On diagrams of the leadership process, “punishing disobedient subordinates” rarely appears.

This development has helped make the leadership industry possible, by making the idea of leadership more appealing. The notion that you don’t have to be officially powerful to lead has allowed more people to think of themselves as leaders. Leaders, it’s said, “elevate,” “empower,” and “inspire” those around them to do “extraordinary” things. But not everyone is happy with this cheerful vision. In “Leadership BS,” a book published last year, Jeffrey Pfeffer, a professor at Stanford’s Graduate School of Business, identifies five virtues that are almost universally praised by popular leadership writers—modesty, authenticity, truthfulness, trustworthiness, and selflessness—and argues that most real-world leaders ignore these virtues. (If anything, they tend to be narcissistic, back-stabbing, self-promoting shape-shifters.) To Pfeffer, the leadership industry is Orwellian. Its cumulative effect is to obscure the degree to which companies are poorly and selfishly run for the benefit of the powerful people in charge. That’s why bosses spend billions on leadership seminars: they make corporate life look like “The West Wing,” even though, in reality, it’s more like “House of Cards..."
apropos of our current mauldlin Presidential primary election campaign season,

People who fetishize leadership sometimes find themselves longing for crisis. They yearn for emergency, dreaming of a doomsday to be narrowly averted. Last month, Donald Trump’s campaign released its first official TV advertisement. The ad features a procession of alarming images—the San Bernardino shooters, a crowd at passport control, the flag of Syria’s Al Nusra Front—designed to communicate the idea of a country under siege. But the ad does more than stoke fear; it also excites, because it suggests that we’ve arrived at a moment welcoming to the emergence of a strong and electrifying leader. (Trump, a voice-over explains, will “quickly cut the head off ISIS—and take their oil.”) By making America’s moment of crisis seem as big (or “huge”) as possible, Trump makes himself seem more consequential, too.

Many of today’s challenges are too complex to yield to the exercise of leadership alone. Even so, we are inclined to see the problems of the present in terms of crises and leaders. “Crises of leadership are the order of the day at the beginning of the twenty-first century,” Elizabeth Samet writes, in the introduction to “Leadership: Essential Writings by Our Greatest Thinkers” (Norton). “If we live in a world of crisis,” she continues, “we also live in a world that romanticizes crisis—that finds in it fodder for an addiction to the twenty-four-hour news cycle, multiple information streams, and constant stimulation.” Samet believes that our growing addiction to the narrative of crisis has gone hand in hand with an increasing veneration of leadership—a veneration that leaves us vulnerable to “the false prophets, the smooth operators, the gangsters, and the demagogues” who say they can save us. She quotes John Adams, who suggested, in a letter to a friend, that there was something both undemocratic and unwise in the lionization of leadership. The country won’t improve, Adams wrote, until the people begin to “consider themselves as the fountain of power.” He went on, “They must be taught to reverence themselves, instead of adoring their servants, their generals, admirals, bishops, and statesmen.” It can be dangerous to decide that you need to be led...
Good article, read all of it.
...sociologist Max Weber distinguished between the “charismatic” leadership of traditional societies and the “bureaucratic” leadership on offer in the industrialized world. In the past, Weber wrote, the world revolved around “old-type” rulers, who could be “moved by personal sympathy and favor, by grace and gratitude.” Modern rulers, by contrast, are supposed to be emotionally detached; they work within a network of laws and systems designed to eliminate nonrational considerations like love and hatred. Weber was getting at a core problem for modern leaders. How can the performance of bureaucratic tasks (such as the design of a health-care overhaul) be infused with charismatic warmth?

Also, reflecting on Tomasello, where does the adaptive utility of prosocial, empathic behavior fit in to the "leadership" concept?

Hope to see you at #HIMSS16.

Are we "Transforming Health through IT"? Or do things largely remain "Free Beer Tomorrow?"

I guess "Incremental, Albeit Lucrative Improvements in Our Vexingly Fragmented Shard-Ridden Health Care System" wouldn't cut it as a tagline.

More to come...

Monday, February 22, 2016

Fixing U.S. health care by "monetizing altruism"?

A week from today I'll be in Vegas to cover HIMSS 2016. Rather doubt that I'm going to encounter any discussions on "monetizing altruism."

A lot to discuss and consider in this post. I just finished Dr. Nortin Hadler's latest book.

"Figuring out a way to monetize altruism"

Chapter Nine: Medical Professionalism in the Twenty-First Century 
It is one thing to champion a trustworthy patient-physician relationship that promotes informed medical decision making and proclaim the physician to be the wise facilitator in such a relationship. But it is quite another thing to extricate such a relationship from the current dialectic, which is heavily funded to promote a systems approach to patient care. I find it impossible to remain passive in the face of this dialectic. There is an old proverb in medical circles that internists know everything but do nothing, and surgeons know nothing yet do everything. I am an internist. But I am a loose-cannon internist. 

There is a desperate need to position the patient’s narrative as raison d’être and a desperate need to provide wise ears to hear it. The only way that will happen is to create an atmosphere that demands it, an administrative structure that supports it, and a reimbursement scheme based on fees for serving. Getting there is an uphill battle, somewhat Sisyphean given the powerful push-back from stakeholders in the status quo, but it is not insurmountable. The top of the hill is the moral high ground. Medical professionalism must plant its flag there because there is no other way to serve patients well in the twenty-first century. 

Finding a way to plant that flag has been a twenty-five-year odyssey for me, but it has not been a steady upward climb. In fact, it was a gentle saunter for many years because there was neither urgency nor an obvious path of least resistance. Besides, these were years when I was focused on my career as an educator and clinical investigator while American medicine was reveling in its transformation into a behemoth. It was difficult to step aside long enough to effectively question the enthusiasm surrounding me. It became less difficult when I realized that the aspects of my career and my competence that I valued the most were losing value in the new version of American medicine. I felt little pain since other aspects of my career were thriving, but colleagues who were focusing exclusively on the bedside found themselves progressively disenfranchised. So about fifteen years ago, I started to climb with more determination. It was clear that the developing version of American medicine was no champion of my notion of excellence at the bedside. It was clear that prior versions of American medicine had too many flaws to bemoan their passing. And it was clear that American realpolitik would not countenance a national health-insurance scheme, not even the copying of elements of such schemes that were successful elsewhere. The hope was in finding a way to overlay the American approach with a layer of rationality and reestablish the patient-physician relationship at the center of American medicine. That would require figuring out a way to monetize altruism.

Hadler M.D., Nortin M. (2016-01-11). By the Bedside of the Patient: Lessons for the Twenty-First-Century Physician (pp. 159-160). The University of North Carolina Press. Kindle Edition.
I could not recommend it more highly. "Altruism," 'eh? A rather out-of-fashion concept these days during this time of our acrimonious neo-Randian/Tea Party/Trumpist "Selfishness Uber Alles" political idiocracy atmosphere. More on this in a bit, perhaps. For now, you might want to See my citation of Tomasello's fine book "A Natural History of Human Morality" (scroll down). The actual science is telling us that there's adaptive/evolutionary utility in prosocial, empathic, and altruistic conduct.

I took a rather odd path in reading Dr. Hadler's book.

I began at the introduction, then did a bit of keyword/phrase searching, highlighting and bookmarking the findings. From there I read "backwards," commencing with the final "Guideposts for Future Physicians" chapter, and thereafter reading chapters 9, 8, 7, 6, 5, 4, and 3 in that reverse order before finishing up with chapters 1 and 2 in sequence.

Yeah, odd. It's a time-saving tactic of mine (ended up not helping much this time, though). At a pace of about 80 books a year plus all of my periodicals and the endless wash of online stuff (like blogs such as THCB, Science Based Medicine, The Incidental Economist, etc, and now STATnews), many times I delve into a book and shortly think "yeah, OK, I get it, where's this going? Cut to the chase..." whereupon I'll read concluding material to determine whether I need burrow back into detail in the middle (aided by ad hoc topical keyword-searching).

I came by this book by way of a comment Dr. Hadler left under a THCB post entitled "Why We Have so Little Useful Research on ACOs."
"Excellent article and discussion.

In the current issue of the Annals of Internal Medicine ( doi:10.7326/M14-2633) Kern et al have published the results of the 5-year Hudson Valley cohort study comparing the “Patient-centered medical home” approach to practice with practices that utilized just the EHR or retained their paper charts.The study was supported by the Commonwealth Fund and the NYS Department of Health. It recruited 438 primary care physicians in 226 practices, with 136 480 patients across 5 health plans.

There was no clinically meaningful difference in health care quality or utilization between the 3 practice types.

No one should be surprised. Everyone should be disappointed. Some might be upset that prescience drives policy more than science. I am of all these persuasions:"
" clinically meaningful difference in health care quality or utilization..."

That stung. Was my time with the QIO during DOQ-IT and the REC amid the subsequent Meaningful Use initiative simply part of an enormous, expensive waste of time and money (or worse)? Is my interest in and advocacy of digital health InfoTech of nil value? Is my long experience with process QI irrelevant -- even that which took place in the health care setting? Dr. Hadler takes dour, iconoclastic pains to dump all over Health IT and what he calls "quality zealots" and the view of health care as a "system"/"industry."

I'm no unreflective "quality zealot," but I find efforts such as "Lean Health Care" rational and worthy. That it does in fact comprise a huge and growing "industry" is simply a fact. Pining for a more bucolic clinical time of yore is not likely to change that reality one iota.

Back to the present. Dr. Hadler:
"If there is a role for computers in decision making, it is to facilitate dialogue between patient and physician, not to supplant the input from either or to cut health-care costs." [op cit, pg 138]
Well, I've agreed with that sentiment all along. Moreover, the increasing "fragmentation" ("shards") we see in the health care space is not the fault of information technology. See, e.g., my cites of the work of Einer Elhauge ("Allocating Health Care Morally") here and here.

Dr. Hadler on the "ACO" thing:
Gatekeepers Since the attempt to target hospital systems for the sake of affordability has been largely co-opted by the costliness of the approach and the ability of hospital systems to game the system, policy experts have been tweaking the latest versions of the multispecialty clinic, even though the lucrative specialties have fled and the more viable of these clinics have been purchased by various health-care systems. The policy approach is based on a simple tenet: if disease can be managed efficiently in the outpatient clinics, the need for recourse in hospitals would be abrogated and their costliness circumvented. This is the reasoning that is driving some of the reforms in Graduate Medical Education we discussed previously. In an amusing gambit, the policy experts decided there must be another designation for these clinics to distinguish their novelty and desirability: 

Patient-Centered is one shibboleth, as if this is a radical innovation. Clinics have always been patient-centered. As with hospitals, the issue is whether the patients are advantaged by being the center of attention.

Medical Homes are another shibboleth, also touted as a radically new idea. However, it is really the However, it is really the idea embodied by the American “family practice” or, recently, the British “general practice,” where a “team” is the primary caregiver from cradle to grave. Usually, a physician is designated the responsible cognitive leader working with the administrator responsible for infrastructure. As has been true for some time, the roles played by the members of the team are in flux. Some “medical homes” assign an “intake” nurse responsible for asking the patient what’s wrong and directing him or her to what is presumed to be the person with the solution. Some larger “medical homes” have pharmacists, even pharmacists with a doctorate in pharmacy, monitoring prescriptions. Some make use of nurse practitioners more than medical doctors as resources. And some designate a single practitioner to the care of each patient with rules for cross-coverage. 

Accountable Care Organizations (ACO) are the most ludicrous of the neologisms because all they denote is another attempt at the promulgation of a Health Maintenance Organization (HMO). An ACO is a patient-centered medical home that is capitated, meaning it is given a fixed sum of money based on the number of enrolled patients and charged with living within these means. The better the ACO lives within its means, the less the allocated sum of money is expended, leaving behind a “profit.” In America, it is a viable model as long as the patients are not too sick and the means substantial. It is the business model for the Kaiser-Permanente organization. The Medicare administration is fostering ACOs around the country with the expectation that primary-care physicians can burden the “chief executive” function regarding expenditures and reimbursement while maintaining quality of care. Many in the policy world are applauding. 4 Of course, all are aware of the potential for perverse incentives in a capitated delivery model. Will care be withheld, or more expensive care withheld, to pad the pot at the end of the budgetary cycle? To do so overtly would be unethical, if not illegal, as the U.S. Veteran’s Administration is demonstrating. However, how can we develop some assurance that such false efficiency is not a subliminal action? 

Pay-for-Performance is proposed as a solution to maintaining the quality of care in ACOs (and elsewhere). Obviously, in an ACO, there is an incentive to offer care so efficiently that there are residual funds to disburse to the members of the staff at the end of the budgetary cycle. It is not clear how many and how often ACOs are even able to stay within their budgets, let alone have a surplus. It isn’t even clear how to distribute any surplus fairly among physicians, physician assistants, nurse practitioners, and others. 5 Should it be based on performance, or should some component or all be distributed regardless of performance in deference to a “team” spirit? If it’s by performance, what weight should be given to experience, clinical purview, and patient mix (relative degree of clinical challenge)? And what do we mean by “performance”? 

This last question is at the very heart of health care. What do we mean by “performance,” and can we measure it in order to value it? [ibid, pp. 152-154]
So, ACO's are really just HMOs v2.0?

I am reminded of a book published 20 years ago that I've long had in my stash.

From the opening chapter:
Introductory remarks
Medicine took an earlier flight

Henry Greenberg

This volume emerged out of the primary concerns of the hard physical and biological sciences. Proponents and organizing committee of the conference on which this volume is based reflects this. In the individual chapters concentrate on the threats to these disciplines. Although a majority of the authors come from a background in the social sciences, the issues under scrutiny relate to scientific reasoning, logical deduction, and professional expertise.

Let me take a brief look at a soft science that engages all levels of society — namely, medicine. Last year I organized the conference, sponsored by this Academy, that sought to enlarge the view of health care reform so that potential long-term results could be included in the debate. Its title was Beyond the Crisis: preserving the capacity for excellence in healthcare and medical science. In my talk I focused on threats to excellence in medicine. Toward that end, I explored the Genesis of the term healthcare provider, a description with which we are all familiar and one which infuriates positions. I tried to show that the apparent democratizing of the team, the cultural leveling of the peak usually inhabited by the physician, was a genuine threat to the professional uniqueness of the physician. The social construction of reality has come to medicine. Borrowing from Larry Churchill, I showed that without his or her own professional ethic, a physician who is dependent only upon the usual guiding ethics — law, custom, and common sense — would not be able to defend the best interests of his patient when law, common practice, and conventional wisdom defined a patient's interest in terms that best serves society and not the individual. The loss of the professional ethic will curtail the physician's ability to defend his patient's best interests.

Since then — and those of us in the East are behind — a new threat has emerged. The for-profit health maintenance organization (HMO) has arrived in Gotham. Everyone — hospitals, doctors, medical schools — is fighting to join. Packaging themselves in new organizations, bundling their services in financially pleasing ways, and then devaluing the services so as to be the lowest bidder, they are part of the great game to survive; at least we all think so. And the HMOs, with their $10 million CEOs, paying out $.68 on the dollar for care, understand and like what they see. With little extra effort they will reduce the physician to an employee. Again, the unique professional ethic will be stripped away, and the doctor will measure his life in degrees of compliance with cost driven algorithms and will hone his skills to reduce an office visit to seven minutes.

One HMO circulated a memorandum stating that it wanted all its specialists to have at least 20 office hours a week. Since a physician could arrange to see a patient within a day should the need arise, why are his 10 hours a week in adequate? I think I know the answer. He must have a financial base outside the office. If he does, he may not be as subservient to the HMO requirements as he should be. But if he is dependent upon his office practice, the HMO will gain the control it wants. The physician can be kept in place.

Medicine, then, is being put at grave risk by many strong forces. The social construction of its reality is only one of these forces. This ongoing assault has, however, weakened medicine. The professions inability or unwillingness to confront, let alone recognize, this attack has sapped it of much of its bigger. The other criticisms have a core validity. Because of accentuate it attention to these — arrogance, greed, and excessive paternalism — medicine feels constrained to defend itself and is paralyzed when it comes to speaking clearly about its strengths. The rare but highlighted focus on fraud and the less rare examples of marginally scrupulous positions feeding at the "pass-through" trough of Medicare and other insurance plans are commonplace headlines. However, the near comprehensive inability to distinguish the profession from the practitioner has inhibited the defense of professionalism. And yet when the profession is dead, it will be missed, warts and all.

There is a parallel development in the research science environment. If the incursion of attempted invalidation of scientific reasoning gains a foothold and then saps significant energy for its reputation, the body politic of science will be weakened. If the defense is incomplete or intellectually ineffective, the situation will be frighteningly similar to medicine's. Such a failure to defend science from its irrational critics can set the stage for a lethal blow when the real budgetary attacks arrive, and they are nearly upon us. Some would say they are here, but I am not so optimistic. If science cannot claim a preeminence for its intellectual virtues or in excellence for its methodologies and sense of design, then it will have great difficulty laying claim to rational share of the nation's resources for its perpetuation. This volume has an important role to play.
I dug this book out after reading an irritating THCB post entitled "Why I Don't Believe in Science" by one Michel Accad, MD. I noted in the comments that I had "reported" him to Science Based Medicine. He subsequently tried to weasel out and deflect from his phrasing choice, that it had been merely allusive and "in quotes" (which THCB had removed). In a word, "clickbait."


Speaking of old books on my library shelves.

Ever wonder about Princess Di's recent affair with Elvis Presley? You can read all about it on the front page of the supermarket tabloid. Elsewhere on the page appear stories of bizarre accidents and fantastic misadventures. An impact with a car's steering wheel causes lung cancer. Breast cancer is triggered by a fall from a streetcar, a slip in a grocery store, an exploding hot-water heater, a blow from an umbrella handle, and a bump from a can of orange juice. Cancer is aggravated, if not actually caused, by lifting a forty-pound box of cheese. Everybody knows, of course, that such stories are fiction. Falls and bumps don't cause cancer.

Other stories tell how a spermicide used with most barrier contraceptives causes birth defects. We know it doesn't. The whooping cough vaccine causes permanent brain damage and death. That's not true either. The swine flu vaccine caused "serum sickness." It didn't. A certain model of luxury car accelerates at random, even as frantic drivers stand on the brakes. Not so. Incompetence by obstetricians is a leading cause of cerebral palsy. It isn't. The morning-sickness drug Bendectin caused an epidemic of birth defects. It didn't. Trace environmental pollutants cause "chemically induced AIDS." They don't.

How can anybody be absolutely, positively certain about these didn'ts, doesn'ts, and don'ts? No one can. But the science that refutes these claims is about as solid as science ever is.

And yet all of these bizarre and fantastic stories-- Elvis and Di excepted--are drawn not from the tabloids but from legal reports. They are announced not in smudgy, badly typed cult newsletters but in calf-bound case reports; endorsed not by starry-robed astrologers but by black-robed judges; subscribed to not only by quacks one step ahead of the authorities but by the authorities themselves. They can be found on the dusty shelves of any major law library. The cancer-by-streetcar cases are decades old, but the others are recent.

When they learn of these legal frolics, most members of the mainstream scientific community are astounded, incredulous, and exasperated in about equal measure. Some now speak with open derision about tortogens, litogens, scientific bamboozlement, and the carcinogenic properties of insurance; others wonder why courts invite the inmates to run the asylum. The derision is understandable. Maverick scientists shunned by their reputable colleagues have been embraced by lawyers. Eccentric theories that no respectable government agency would ever fund are rewarded munificently by the courts. Batteries of meaningless, high-tech tests that would amount to medical malpractice or insurance fraud if administered in a clinic for treatment are administered in court with complete impunity by fringe experts hired for litigation. The pursuit of truth, the whole truth, and nothing but the truth has given way to reams of meaningless data, fearful speculation, and fantastic conjecture. Courts re- sound with elaborate, systematized, jargon-filled, serious- sounding deceptions that fully deserve the contemptuous label used by trial lawyers themselves: junk science.

Junk science is the mirror image of real science, with much of the same form but none of the same substance. There is the astronomer, on the one hand, and the astrologist, on the other. The chemist is paired with the alchemist, the pharmacologist with the homeopathist. Take the serious sciences of allergy and immunology, brush away the detail and rigor, and you have the junk science of clinical ecology. The orthopedic surgeon is shad-owed by the osteopath, the physical therapist by the chiropractor, the mathematician by the numerologist and the cabalist. Cautious and respectable surgeons are matched by some who cut and paste with gay abandon. Further out on the surgical fringe are outright charlatans, well documented in the credulous pulp press, who claim to operate with rusty knives but no anesthesia, who prey on cancer patients so desperate they will believe a palmed chicken liver is really a human tumor. Junk science cuts across chemistry and pharmacology, medicine and engineering. It is a hodgepodge of biased data, spurious inference, and logical legerdemain, patched together by researchers whose enthusiasm for discovery and diagnosis far outstrips their skill. It is a catalog of every conceivable kind of error: data dredging, wishful thinking, truculent dogmatism, and, now and again, outright fraud.

On the legal side, junk science is matched by what might be called liability science, a speculative theory that expects lawyers, judges, and juries to search for causes at the far fringes of science and beyond. The legal establishment has adjusted rules of evidence accordingly, so that almost any self-styled scientist, no matter how strange or iconoclastic his views, will be welcome to testify in court. The same scientific questions are litigated again and again, in one courtroom after the next, so that error is almost inevitable.

Junk science is impelled through our courts by a mix of opportunity and incentive. "Let-it-all-in" legal theory creates the opportunity. The incentive is money: the prospect that the Midas-like touch of a credulous jury will now and again trans- form scientific dust into gold. Ironically, the law's tolerance for pseudoscientific speculation has been rationalized in the name of science itself. The open-minded traditions of science demand that every claim be taken seriously, or at least that's what many judges have reasoned. A still riper irony is that in aspiring to correct scientific and medical error everywhere else, courts have become steadily more willing to tolerate quackery on the witness stand.
I first read this back during my 1980's time as a programmer and QC analyst in a forensic-level radioanalytic lab in Oak Ridge (e.g., evidentiary assays for dose and exposure litigation and regulatory enforcement). While I am not into "scientism" -- the notion that only reductive western science is epistemologically sound (I came away from my late daughter's illness unsure of what to believe anymore) --, the burden of proof is on the naysayers. I'm glad that Dr. Accad is not my physician.

While Dr. Hadler's new book is rife with appeals to the importance of "science," it does so in leavened fashion:
Humanism for the Patient with Symptoms That Defy Diagnosis 
Of the many shortcomings of a reductionistic approach to the care of the patient, few cause more consternation for the patient and for the physician than when no convincing cause for the patient’s symptoms can be discerned. Physicians have long been inclined to take the path of least resistance when faced with this conundrum, applying labels to this lack of explanation that range from the theoretical to the fatuous. Anything other than such obfuscating labels might be seen as an admission of the limitations of the physician’s competency or a confession about the inadequacy of the state of clinical science. In any case, these labels provide a way to dismiss the patient’s concerns without angering him or her or making the physician seem less all-knowing. Peabody, the humanist, was keenly sympathetic to the plight of the patient whose symptoms defied diagnostic acumen. He decried dismissing these patients with, “There really is nothing the matter with you. . . . I’ll give you a tonic to take when you go home.” Patients with symptoms of unknown origin were a challenge in Peabody’s time, just as they are today: “Numerically, then, these patients constitute a large group, and their fees go a long way toward spreading butter on the physician’s bread.” Peabody argued that dismissing them drives them to try “chiropractic or perhaps . . . Christian Science.” Besides, while not being a reassuring diagnosis, “nothing the matter” is also not a tenable concept because, “except for a few low grade morons and some poor wretches who want to get in out of the cold, there are not many people who become hospital patients unless there is something the matter with them. And, by the same token, I doubt whether there are many people except for those stupid creatures who would rather go to the physician than go to the theater, who spend their money on visiting private physicians unless there is something the matter with them.”...
Osler, Peabody, and Putnam are exemplars. They were leading advocates of a scientific basis for modern medicine a century ago. But they knew that science offered only a partial solution for the miseries that drove people to become patients. These legendary clinicians and teachers realized that the experience of illness is always contextual. Hopes and dreams are as susceptible to dissolution and damage as any organ system, or more so; in fact, they can suffer the harmful effects of illness even when organ systems are spared. Society may need practitioners who are skilled in techniques and others who are wedded to advancing technologies, but patients need physicians who are committed to their humanity. [Hadler, op cit, pp 13-15]
"Art of Medicine" stuff, anyone? Again, apropos of HIT,
"If there is a role for computers in decision making, it is to facilitate dialogue between patient and physician, not to supplant the input from either or to cut health-care costs."
Yes, but where do "Artificial Intelligence and Intelligence Augmentation" fit here?

It's useful also in this context to take seriously Margalit's lament "Are structured data the enemy of health care quality?"

Bit of a break here. More to say on these issues, but I'm gonna throw it out there at this point.


"the malignant granularity of EPIC, the antithesis of dispassionate information technology." [op cit, pg 177]

Any attempt to digitize the clinical record that denigrates the humanity of the clinical narrative is iatrogenic. The main reason for the clinical record is to remind you or a colleague, in the middle of the night or in six months, what you were thinking about and concerned about for the sake of your patient. Any other role for the digitized record is ancillary at best. [pp 177-178]
So, has Health IT become a massive case of "Tail Wags Dog"? Have the needs of the patient and the empathic humanist physician been relegated to the back of the bus?

Questions I will be asking at HIMSS16 next week amid all the well-funded, glitzy hoopla.

By the Bedside of the Patient: Lessons for the Twenty-First-Century Physician is a veritable gold mine of quotes (his takedowns of NQF and IHI alone are worth the ticket price). His recounting of his training and life as an eminent physician is priceless.

I've cited Dr. Hadler's prior book "Citizen Patient" before. See, e.g., "ICD-10: W6142XA, Struck by turkey, initial encounter."

I come away from this effort with profound new respect for the man, gotta say.

Just buy the new book, OK? (BTW, Amazon has lowered the price by ten bucks.  It's now $16.49 instead of the $26.60 I'd griped about. Gratifyingly, they gave me a differential refund.)

I could enthusiastically keep going, but I'll be pushing the "fair use" boundary.


More briefly on the ramble of one hapless patient caught in the maw...

Well, now that we've switched from our BCBS HSA coverage to full Medicare, we expect and hope there will be less of the frustrating no-value-add sand in the gears I began recounting here. But, some vestigial bozo-ness has recently come in the mail.

First, I just got a bill from my urologist's office for $40.11 net charges from "Date of Service 08/18/2015."

At first, I thought "WTF?" "CPT 76924, Sono Guide Needle Biopsy"? My prostate biopsy px was done on March 30th, 2015. August 18th? What? I had no "biopsy" in August.

It was my (woefully unpleasant) Calypso implant px for my ensuing IMRT tx. I guess they have no code for that. Great revenue cycle you have, folks, August to February. No wonder y'all are all going broke.

Then there was this little doozy, from BCBS.

OK. I was not involved in any "accident resulting in injury" on April 2nd, 2015 (Date of Service regarding this notice). That was the day I was admitted to Muir Hospital suffering from sepsis in the wake of my March 30th prostate biopsy (ugh).

The fully processed and settled claims for which are right there in your own dad-gumbed records.

Irritated, I started to fill out the form (concerned that they might be retroactively trying to claw back money from me), but stopped and called first, wading through all of the "Your Call is Important to Us" auto-attendant phone tree waste of time.

Finally got through. After I explained the details, I got "just ignore that letter; it was automatically kicked out by our system by the encounter coding. I have informed our Subrogation Unit of the error."

Shards of coding. Hmmm... Maybe I'll fill out the form anyway and send it back, late, replete with some "pithy" commentary. Just to reciprocate on the jerking around.


New post up at THCB, "Will Feeding Watson $3 Billion Worth Of Healthcare Payment Data Improve Its Decisions?"
"Physicians often don’t know what the heck is going on but are forced to enter specific diagnoses in the EHRs, which can’t handle probabilities or ambiguity."
Yeah. What was I just saying? My iatrogenic prostate biopsy sepsis morphs to "injury resulting from accident" and my Calypso implant px becomes "sono guide needle biopsy."

All they care about is getting paid.

I loved this:
Our question is whether healthcare payer data are so inaccurate and, worse, biased, that they are more likely to mislead than guide? Will the supercomputer’s semiconductors digestion of junk and contradictory information produce digital flatulence or digital decisiveness?
"Digital flatulence," LOL. Whole 'nuther nuance to the phrase "digital exhaust"?

I'll say it again; medical coding = "lossy compression."


Stay tuned...

Wednesday, February 17, 2016

Syntactic and Semantic Interoperababble 2016

I recently read a THCB interview post by Leonard Kish on that hardy perennial misnomer "interoperability."
Interoperability Form and Function: Interview with Doug Fridsma

Leonard Kish talks to Douglas Fridsma, President and CEO at American Medical Informatics Association, about his work in the Office of the National Coordinator for Health Information Technology, or ONC, and the barriers to implementing MIPS in the most useful and transparent way. In order to communicate the data, of course, we’ll need informatics; but how will that work? And which comes first, policy or technology?...

DF: I’ve tried to maintain for the last six years a consistent definition of what interoperability is. The first thing I can describe is what interoperability is not. It is not a state of utopia in which there is this information liquidity. You will hear this all the time: we want ubiquitous information, and free-flow, data liquidity and all those things.

But interoperability is not that state of the world. Interoperability is defined operationally. I use one of the definitions by the IEEE folks. The best version is that interoperability has two parts: the first part of the ability of two or more systems to exchange information and the second one – the one we usually overlook – is the ability of the systems to use the information that has been exchanged. It’s about exchange and use.
I posted a comment.
I see “interoperababble” is alive and well, inclusive of leaving out a key phrase in the IEEE definition of interoperability: “…without special effort on the part of the customer.” No amount of calling n-dimensionally interfaced “data exchange” “interoperability” will make it so...
Let me return briefly to my original 2014 rant on "interoperability."

“We should not prescribe specific functionality for the EHR other than interoperability and security.”
 - John Halamka

Updated, annotated: on the (misnomer) “interoperability” side, from my recurring blog 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).
Actually, all digital data are simply collections of “representations” of values coded in the binary ASCII (or the legacy EBCDIC) collating sequence (“under the hood” of all this stuff at the bit/byte level). Yeah, I’m givin’ away my age.
You can’t tell me that a world that can live with, e.g., 10,000 ICD-9 codes (going up soon by a factor of 5 or so with the 2015 migration to ICD-10) would melt into a distraught puddle on the floor at the prospect of a requisite standard data dictionary comprised of perhaps a similar number of metadata-standardized, “strongly typed” data elements spanning the gamut of administrative and clinical data definitions cutting across ambulatory and inpatient settings and the numerous medical specialties. We’re probably already a good bit of the way there given the certain overlap across systems, just not in any organized fashion.

Think about it.

Why don’t we do this? Well, no vendors want to have to “re-map” their myriad proprietary RDBMS schema to link back to a single data hub dictionary standard. And, apparently the IT industry doesn’t come equipped with any lessons-learned rear view mirrors.

That’s pretty understandable, I have to admit. In the parlance, it goes to opaque data silos, profitable “vendor lock,” etc. But, such is fundamentally anathema to efficient and accurate reciprocal data interchange (the “interoperability” misnomer) that patients ultimately need and deserve.

Yet, the alternatives to a data dictionary standard are our old-news, status quo, frustratingly entrenched, Clunkiness-on-Steroids, Nibble-Endlessly-Around-the-Edges Outside-In workarounds — albeit quixotic efforts that keep armies of Health IT geeks employed starting and putting out the fires they themselves started.

Resources better devoted to actual clinical care.

Visualize going to Lowe’s or Home Depot to have to choose among 800+ ONC Stage 2 CHPL Certified sizes and shapes of 120VAC 15 amp grounded 3-prong wall outlets.

Imagine ASCII v3.14.2.a.7. Which, uhh…, no longer supports ASCII v2.05.1 or earlier…

Ya with me here, Vern?

NIST/ANSI/ISO Health IT ICDDS – Interoperability Core Data Dictionary Standard.
In response to the repeated allusions to data as "the lifeblood of medicine," I've subsequently begun to characterize "standard data" (via a metadata data dictionary standard) as the "Type-O Blood" of health care.

Leonard alludes to the "vendor lock" issue:
LK: It seems like the lack of interoperability is in some ways used as a strategic advantage.  So how do we get from this insular or institution-based perspective of interoperability to a global perspective? Does it have to be a legislative solution? And how do we communicate and bridge to the consumer (which may actually be key to decentralized thinking)?

DF: There are three fundamental things we need to turn the ship in a better direction. The first step is I think we need to focus on those fundamental building blocks; for how we represent meaning, how we structure information, how we transport it, and how we secure it.  Those four things are really just an API.

But unless we think about what those fundamental building blocks are, even if we develop APIs, we’re still going to be in the situation with the switchboard and the cords. The building blocks are the first goal, and one of the pieces that’s missing is “how do we represent granular data” because most of our exchange right now is document centric.

We need to move from document-centric to data-centric exchange. We need to have a way to represent data at a granular level because that’s how we’re going to be able to calculate quality measures, that’s how we’re going to do decision support, and a lot of the other sophisticated computable things that we need to do...
"We need to move from document-centric to data-centric exchange. We need to have a way to represent data at a granular level..."

Well, yes. Maybe we're making progress here ("document-centric" obviously refers to things like "CCD" and "CDA"). Maybe. But, it's critical to keep in mind that -- particularly in patient care -- context matters. More on that point momentarily. First, you might want to Google "semantic interoperability."

"Syntactic and Semantic Interoperability"
Semantics concerns the study of meanings. Semantic interoperability is the ability of computer systems to exchange data with unambiguous, shared meaning. Semantic interoperability is a requirement to enable machine computable logic, inferencing, knowledge discovery, and data federation between information systems.

Semantic interoperability is therefore concerned not just with the packaging of data (syntax), but the simultaneous transmission of the meaning with the data (semantics). This is accomplished by adding data about the data (metadata), linking each data element to a controlled, shared vocabulary. The meaning of the data is transmitted with the data itself, in one self-describing "information package" that is independent of any information system. It is this shared vocabulary, and its associated links to an ontology, which provides the foundation and capability of machine interpretation, inferencing, and logic.

Syntactic interoperability is a prerequisite for semantic interoperability. Syntactic interoperability refers to the packaging and transmission mechanisms for data. In healthcare, HL7 has been in use for over thirty years (which predates the internet and web technology), and uses the unix pipe (|) as a data delimiter. The current internet standard for document markup is XML, which uses "< >" as a data delimiter. The data delimiters convey no meaning to the data other than to structure the data. Without a data dictionary to translate the contents of the delimiters, the data remains meaningless. While there are many attempts at creating data dictionaries and information models to associate with these data packaging mechanisms, none have been practical to implement. This has only perpetuated the ongoing "babelization" of data and inability to exchange of data with meaning...

Semantic as a function of syntactic interoperability
Syntactic interoperability, provided by for instance XML or the SQL standards, is a pre-requisite to semantic. It involves a common data format and common protocol to structure any data so that the manner of processing the information will be interpretable from the structure. It also allows detection of syntactic errors, thus allowing receiving systems to request resending of any message that appears to be garbled or incomplete. No semantic communication is possible if the syntax is garbled or unable to represent the data. However, information represented in one syntax may in some cases be accurately translated into a different syntax. Where accurate translation of syntaxes is possible, systems using different syntaxes may also interoperate accurately. In some cases the ability to accurately translate information among systems using different syntaxes may be limited to one direction, when the formalisms used have different levels of expressivity (ability to express information). The idea of semantic proximity to specify degree of semantic similarity to achieve interoperability of objects (in the context of database systems) was first discussed in a paper titled ″So Far (Schematically) yet So Near (Semantically)″ published in 1993...
"the ongoing "babelization" of data and inability to exchange of data with meaning"

Love it. Nice to see others make the analogy.

Consider any one datum contained in an EHR, whether residing in Demographics, Family History, Social History, Vitals, Active Problems, Active Meds, Past Medical History, Chief Complaint, History of Present Illness, Review of Systems, Labs (including Imaging), Specialist notes, etc.

An accurate and effective clinical "SOAP" process (Subjective, Objective, Assessment, and Plan) typically derives from the multidimensional contextual synthesis comprised of dozen to hundreds of data points (many of them trended over time via multiple patient encounters -- the "flow sheet" thing). Any individual datum in isolation provides little to nil actionable clinical information.

"Type-O" data cannot but grease those skids.

More on "SOAP." Doug Fridsma:
LK: Teaching the actual care delivery, which health IT is a part, hasn’t until recently been a part of medical curriculum, and still only at a few medical schools so far. Now that we’re focusing economic attention on value and outcomes, you see a little more of it.

: I think we have to change the way to document care delivery. We use something called the SOAP Note (Subjective, Objective, Assessment, Plan) as an outline of how medical information is captured by physicians and others. The problem is that none of those talk about outcomes...
My THCB comment:
...with respect to “SOAP.” it would properly be “SOAPe” (kudos to my former Sup Keith Parker at my QIO/REC/HIE for the observation), wherein the “e” refers to “evaluation” — i.e., “outcome” eval of the assessment and plan. In PDSA terms, the “e” would be the “S,” the “Study” component of science-based QI.
Yeah. Back to the broader point, I am also reminded of one of my earlier posts, "Personalized Medicine" - will Health IT be up to the task?

Scrolling down,

"The next step will be to add your genomic, proteomic, microbiomic, and all the other data to your EMR"

Yeah, but, beyond workforce capacity and dx acumen, what about the chronic, persistent data silo/opacity issue? A recent THCB post asks
What’s the Definition of Interoperability?
Seriously? We already have it. The IEEE definition. As I commented at THCB:
We already HAVE a concise definition of “interoperability," via the IEEE, “interoperability: Ability of a system or a product to work with other systems or products without special effort on the part of the customer. Interoperability is made possible by the implementation of standards.”

This other stuff is merely about “data exchange.” What is happening is that we’re “defining interoperability down,” removing the “without special effort” part. Were there a Data Dictionary Standard, then we could talk about interoperability. Data are called “the lifeblood of health care.” Fine. Think Type-O, the universal blood type, by way of precise analogy.

Maybe the API will comprise data exchange salvation. Maybe.
Responding to the interviewee in the THCB post, I quoted him and offered a response.
“One of the key ways we build good support systems is by having good data. It’s a “garbage in – garbage out” problem. One can’t make good decisions without good data. One of the problems is that a lot of the time data exists but it isn’t in the computer or isn’t in MY computer. Maybe someone has had a test somewhere else and I might not have any info, or if I’m lucky I might have a scanned PDF of the results. But it’s rarer still that I’ll have good, structured data that I’ve been able to pull in from outside sources without a lot of transcription or effort. So I became very interested in this problem of interoperability and have been doing a range of different kinds of work. Some of it actually focuses on how you do decision support, in the cloud or across systems. So the question becomes: how can you build a decision support system that spans several electronic health records and integrated data from multiple sources to make more accurate suggestions for patient care?”

By having a comprehensive standard data dictionary. Absent that, you have to have “n” variables x n(n-1) translative “interfaces” (if you’re after computable “structured data” rather than document-centric reports).
It's an excellent post, albeit replete with the usual obtuse "interoperababble" we have all come to know and love. On the upshot of Meaningful Use:
[Adam Wright] We were going to create these strong incentives for people to adopt EHR’s, knowing that EHR’s were not yet perfectly interoperable or even always perfectly usable and didn’t have all the functionality that we wanted. And now we’re trying to go back and patch that. The thing is we now have had a lot of opportunity to learn how, with these EHR’s that were developed with large hospitals or academic systems in mind, how do they really work in critical access hospital or in a single doctor practice. So we’ve learned, and I think the key is going to be to translate what we’ve learned into concrete improvements. But I think that’s been hard. I talk to some of my friends who are vendors and they’ve said “A lot of people are giving us feedback and we’re working on it as fast as we can but at the same time we’re getting a lot of pressure from Meaningful Use. So we can’t even use our best developers to build the stuff our customers are asking for asking for.” So I think some way of fixing how we do innovation in health IT is going to be important and I don’t know how exactly how we’ll do it, given how many competing priorities there are.
Indeed. Nicely stated. More Adam Wright:
I absolutely think that seeing a complete picture of a patient’s information is key for safety and I do think that lack of interoperability is 100% a safety issue. It’s something that we need to work on. But we need to get beyond the “unconscious patient in Wyoming.” I think that there’s so many more complex, subtle and insidious issues. The thing is that it’s often hard to measure. It’s hard to say “this is the one piece of information that changed my mind”. But I do think complete information like that is going to be very important. I’ll also offer you a flip side that I don’t really have an answer for yet: How much information am I responsible for viewing about a patient? Somehow I now have every piece of information about a patient from the moment of birth to the present. That might be more information than I can review before my brief visit with a patient. Part of the solution to that is going to be in technology or tools that will help me summarize the information, spot key information, spot trends etc. I think it’s going to be really exciting when we have that problem and have to build those tools. I look forward to the day when we have so much information that we really need sophisticated tools to organize and sort through it. Right now we’re a long way from that. But I think you’re 100% right that it’s a safety issue.
Interesting. Some of that maps right back to the "omics" concerns set forth above.

At the conclusion of the THCB post:
LK: So the last question is something Dan Monro brought up. Dan did a three-part series on interoperability on the site I write for called HL7 Essentially if you don’t have a patient identifier, then interoperability is a waste of time. He alluded to the idea of patient identifiers being something like a social security number in that they’re kind of old-school. There’s better ways to do it with cryptography and being able to ID people biometrically. So what can you tell us about patient identifiers? 

AW: I think it’s awfully important. It’s certainly the case that when I have a database and you have a database and we want to link them together, it matters that we have a key so that we can tell who is the same person. The approach right now with using a social security number has problems. Not everyone always has a SSN, not everyone remembers them, there are errors, they lack any way to validate them, etc. Using something like your Blue Cross member number is no good either because you can get another job. So I think the solutions we have now are rotten. We need some way to identify patients across systems. The most commonly proposed, and probably simplest or most parsimonious solution, is a national patient identifier. A numerator who sits in the government and assigns everyone a number shortly after birth and that’s their number. That is just not going to fly palatably. I just can’t see us creating the political will and I also am not sure that it is that desirable. Travelers could come to the country and not have numbers or Americans can go elsewhere and how will this all work? It seems problematic. But I think there are smart ways we could use technology to approximate that. For a long time we had probabilistic record linking approaches where we look at your name, date of birth, address, age, sex, etc. and try to figure out what is the probability that these two people are the same, and we’ve had some pretty good results. The Indianapolis Network for Patient Care has had some pretty good results there, using probabilistic linking rather than an identifier. The reality is that if we can put the patient at the center of this and creates a credential and authentication that they control, I think that would be a lot more palatable than if we put some sort of central government number assigned to people...
Well, yeah, a "national patient identifier" seems to be a non-starter, and multi-field proxy keys seem to be the only practical work-arounds. Adam sums up:
I think there’s probably a lot we can learn from internet authentication about how to create reliable patient identifiers with creating better identifiers, more security around them. The patient could see more of their information and how it was shared. I just think that there are better solutions than a single government based national patient identifier. And even if it’s the best solution, I just don’t think it’s politically possible. So I think we ought to be focusing our efforts on something else.
For more on this line of thought, and the "EXTREME" interop model, see "Defining Our Terms: Does Anyone Know What an "Open EHR" Really Is?"

See also my 2015 post "Interoperability? We don't need no steenkin' definition." And, my 2014 "Interoperability solution? HL7® FHIR® -- We ® Family."

I will be keenly interested in and attentive to interop/data exchange topics at the looming HIMSS16 conference in Vegas. Maybe the notion of "standard data" is on old-hat concept, maybe APIs will suffice.


I'm not the only one with concerns. My pal Jerome Carter, MD at EHR Science:
Is it time for a standard patient data set?
Determining the computational aspects of patient data requires research. At present, this is being done mostly at individual companies. As a result, every EHR system has its own database design with proprietary names, formats, properties, and groupings for data elements.   The same freedom exists for representing higher concepts such as the problem list, medication list, or family history.  Currently, it is difficult for clinical software designers to build on the work of others because so little is discussed publicly concerning clinical system design and construction.  What if clinical software designers setting out to build a clinical system did not have to reinvent the patient-data-model wheel?

Wouldn’t life be easier for everyone if a standard data set specification existed that provided a data model that included the metadata, context, and provenance information suggested by JASON?   The patient data set specification could be managed at a central location (e.g., the National Library of Medicine), and protocols would be in place for adding, naming, and revising data elements and their extended properties.  The latest version of the data set definition and a working implementation example would be available for download.

Such an approach might actually stimulate innovation because modeling for patient data is a huge headache for anyone designing clinical software.  I know this from personal experience… When designing the EHR at UAB, I spent over eight months tweaking the data model. I would have welcomed a “drop in” patient data specification—especially one that had been vetted by a community of researchers and software companies...
Finally It's worth noting again the contrarian views on "structured data" and "interoperability" ("tail wags dog?") voiced by the ever-pithy Margalit Gur-Arie. See "On Health Care Technology: EHR Call-Outs" and "Are structured data the enemy of health care quality?"


Big data: Death by mozzarella cheese

...Some have suggested that big data will rapidly improve healthcare delivery. […] The strongest proponents of such big data applications believe that with enough information, causal relationships reveal themselves without an RCT.

Are they right? For clinical applications, this is a vital question. For instance, for every 5 million packages of x-ray contrast media distributed to healthcare facilities, about 6 individuals die from adverse effects. With big data, we learn that such deaths are highly correlated with electrical engineering doctorates awarded, precipitation in Nebraska, and per capita mozzarella cheese consumption (correlations 0.75, 0.85, and 0.74, respectively)...

A Hospital Paralyzed by Hackers
A cyberattack in Los Angeles has left doctors locked out of patient records for more than a week. Unless the medical facility pays a ransom, it’s unclear that they'll get that information back.

A hospital in Los Angeles has been operating without access to email or electronic health records for more than a week, after hackers took over its computer systems and demanded millions of dollars in ransom to return it.

The hackers that broke into the Hollywood Presbyterian Medical Center’s servers are asking for $3.6 million in Bitcoin, a local Fox News affiliate reported. Hospital staff are working with investigators from the Los Angeles Police Department and the FBI to find the intruders’ identities.

Meanwhile, without access to the hospital’s computer systems, doctors and nurses are communicating by fax or in person, according to an NBC affiliate. Medical records that show patients’ treatment history are inaccessible, and the results of X-rays, CT scans, and other medical tests can’t easily be shared. New records and patient-registration information are being recorded on paper, and some patients have been transferred to other hospitals...

More to come...