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Monday, March 28, 2016

"Meaningful Use"? Remember that? Anyone still care?

As we finish up Q1-2016, two of the latest available MU tabulations:

Click to enlarge if you wish.

564,621 active clinician registrations, nearly $32 billion in MU incentive payouts through January 2016. It was interesting back in January during the San Francisco  JP Morgan Conference and Health 2.0 WinterTech week that the announcement came of the 2016 demise of the Meaningful Use program -- an announcement that subsequently got awkwardly sort of walked back by ONC brass.

I launched this blog on May 10th, 2010 as an online diary of my then-new work with the Nevada-Utah Regional Extension Center (REC) after my episodic employer HealthInsight won the bi-state REC contract.

The MU initiative has been a raucously contentious one across its history. RECs were derisively referred to as "wrecks" (athenaHealth CEO Jonathan Bush once jibed that RECs should "get a quick bullet; no one will even notice." He was openly pleased to take the MU money, though). The incentive funds were seen as corporate welfare for HIT incumbents (like, well, athenaHealth). The MU compliance workflow demands were (and remain) widely hated.

I even bit the hand that fed me.

My specific core REC role was that of "workflow specialist" whose goal was to mitigate or eliminate additional labor expense associated with MU compliance in the participating ambulatory primary care clinics on my caseload. Adding just a minute or two of charting time per patient complying with MU would essentially negate any incentive money gain.

Our REC was "vendor agnostic" and served MU clients on about 40 EHRs. My personal caseload ran to about 8 of those: eClinicalWorks, e-MDs, Amazing Charts, athenaHealth, Practice Fusion, Allscripts, SOAPware, and Greenway (and a couple of one-offs whose names I now forget). The MU documentation workflow paths varied considerably from vendor to vendor. I argued -- to no avail -- that all MU documentation paths should be "one-click" via either internal Certified EHR functionality or some sort of "macro" keystroke utility.

Any noble intentions we had about "improving care" through more adept use of health IT abetted by process QI-enhanced workflows quickly fell victim to chasing REC contract payment "milestones" (1/3rd at sign-up, 1/3 at Certified EHR implementation, and 1/3rd at MU attestation). ONC needed to show nominal ARRA/HITECH "progress" on the Hill. The "body count" imperative quickly became the overarching goal.

Then, with RECs only really having hit their aggregate stride for about two years (of the 4-year initial contract term), ONC shut the whole thing down. Farzard and his successor Karen DeSalvo voiced the obligatory REC-supportive statements (see here as well), but it was clear that they had no stomach for fighting for more REC funding.

What a waste. I even offered to come to DC on my own dime and testify in support of continuing REC funding, but it was clear that nothing was going to happen.

Google "Meaningful Use" today (including the quotation marks), you'll get nearly 2 million hits (with, interestingly, athenaHeath right at the top above the fold one page one). The program has been repeatedly reported on and analyzed from every possible viewpoint. It has been under the congressional microscope. See, e.g., my "Reboot" stuff here and here.

So, total ONC/CMS outlay to date, what? MU average attestation payments to date per EP & EH?
  • Medicare EPs: $27,081
  • Medicaid EPs: $27,198
  • Eligible Hospitals: $3,875,004
Maybe $35 billion or so total HITECH cost, inclusive of RECs and CMS admin expenses? Has it all been worth it, net? What do you think? (The critics remain legion and loud) By now we're pretty much in the provider "penalty phase," with the bulk of the MU incentive money out the door.

A broader question, one posed by Margalit Gur-Arie: "Are structured data now the enemy of health care quality?" See also its antecedent post "On Health Care Technology: EHR Call-Outs."


I read and report on a ton of books here, -- beyond the purely tech stuff, anything related to process improvement, "leadership," organizational culture, clinical cognition, and pedagogy, etc.

I won't have to buy this book.

Great New Yorker review. Pretty funny. Fairly long read. Excerpted below. Well worth your time.
The Life Biz
How to succeed at work and at home.

Smarter Faster Better: The Secrets of Being Productive in Life and Business” (Random House) is Charles Duhigg’s follow-up to his best-selling “The Power of Habit: Why We Do What We Do in Life and Business,” which was published in 2012. The new book, like its predecessor, has a format that’s familiar in contemporary nonfiction: exemplary tales interpolated with a little social and cognitive science. The purpose of the tales is to create entertaining human-interest narratives; the purpose of the science is to help the author pick out a replicable feature of those narratives for readers to emulate.

What enabled the pilot to land the badly damaged plane? How did the academic dropout with anxiety disorder become a champion poker player? What made “West Side Story” and Disney’s “Frozen” into mega-hits? All that was necessary, it turns out, was one key tweak to normal mental functioning or group dynamics. “Mental models” helped the pilot land the plane. “Bayesian thinking” transformed the basket case into a winner at cards. An “innovation broker” brought “West Side Story” together, and “Frozen” became the highest-grossing animation film of all time because of a principle known as “intermediate disturbance.”

Other tweaks on offer in “Smarter Faster Better” include “creating disfluency,” “a bias toward action,” “SMART goals” versus “stretch goals,” and the concept of “psychological safety.” There are a few mind-sets to avoid as well (side effects may include crashed aircraft and the Yom Kippur War): “cognitive tunneling,” “reactive thinking,” and an exaggerated disposition for “cognitive closure.” Basically, the good stuff boils down to organizational buzzwords like “lean,” “nimble,” “flexible,” “innovative,” and “disruptive.” Negative stuff has to do with mindless routines, mechanical thinking, and the need for certainty.

There is not much to disagree with here, and that is one of the intriguing things about the genre this book belongs to. Not dozens or hundreds but thousands of titles like “Smarter Faster Better” are published every year, and they account for a disproportionate percentage of total book sales. Yet they mainly reiterate common sense.

Does anybody think it’s unwise to be lean, nimble, and innovative? Who needs a book to know that rote behavior and fear of uncertainty are not going to take us very far? It’s not startling to learn that organizations that nurture a “culture of commitment” are more productive than organizations that don’t, or that setting ambitious objectives can jump-start innovation. “People who know how to self-motivate, according to studies, earn more money than their peers, report higher levels of happiness, and say they are more satisfied with their families, jobs, and lives.” I can believe that. “Determined and focused people . . . often have higher paying jobs.” I won’t argue. “An instinct for decisiveness is great—until it’s not.” An impregnable assertion.

Probably the most famous book of this type is Dale Carnegie’s “How to Win Friends and Influence People,” which was published in 1936 and has never gone out of print. It is reported to have sold more than thirty million copies. I can tell you the lesson of that book in one sentence: If you are nice to people, they will like you. You just saved yourself sixteen dollars. (Not to spoil the reading experience, but the lesson of Duhigg’s previous book, “The Power of Habit,” is: Replace bad habits with good ones.)...

These all sound like ways to help you feel better about yourself, and maybe even be a better person. But the books are not beauty products for the personality, and that is not the reason people buy them. Most functioning people are probably O.K. with the personalities and temperaments that the Good Lord or natural selection has given them. They’ve learned work-arounds for their grumpiness and fretfulness. What they’re worried about is how others see them and, specifically, how employers see them. The clue to the real purpose of these books is the section of the bookstore you find them in. They’re not in the psychology section, and they’re not in with the diet and exercise books. They’re with the business books.

This is because books like “How to Win Friends” and “Smarter Faster Better” are essentially applied management theory. They try to sum up current thinking in the business world about “human resources” and transmute it into a manual for self-improvement. People don’t read these books to find out how to be better human beings. People read them to figure out how to become the kind of human being the workplace is looking for....

The key ingredient, the replicable feature of all success stories that explains why some people do better than other people, is not arbitrarily chosen. It reflects the nature of the economic times. When Smiles published his book, in the laissez-faire era of industrial capitalism, the novel feature of contemporary life for the sort of person who bought books like “Self-Help” was economic and social fluidity. Upward mobility was newly possible for many people, but so was downward mobility. Many of the novels of Smiles’s contemporary Charles Dickens are illustrations of the latter. Smiles made the case for diligence and dedication as the ticket upward...

One striking thing about the exemplary tales in “Self-Help” is the all-consuming nature of the careers they document. There is no separation between work life and private life. Personal prosperity and professional success coincide, and this elision became a staple of the genre. The secrets of success in business are the secrets of success in life. The reason that the nature of the secrets changes is that the nature of work changes. Different modes of work call for different types of people.

Let’s say you were running a steel company a hundred years ago. You would want the workers in your factory to perform physical tasks as efficiently as possible. You’d want them to be able to move large objects around quickly and operate heavy machinery with a minimum of rest or redundant effort. You’d be looking to maximize the ratio of output to time; that would be your measure of productivity. You would therefore want your workers to become habituated, through repetition, to a specified mechanical routine. You would not want them to do a lot of thinking on the job. You would reward the most efficient workers with higher wages.

The buzzword in this manufacturing economy was “efficiency,” and its bible was Frederick Taylor’s “Principles of Scientific Management,” first published in 1911. Taylor didn’t want workers to think about what they were doing; he wanted their actions to be designed scientifically by management to maximize speed. His chief illustration had to do with pig-iron handlers, men who moved large pieces of iron all day. That example might not seem a model for the practice of daily life, but, as Jill Lepore showed in these pages a few years ago, the value of “efficiency” was duly imported into the home in the form of home economics, a scientific approach to baking pies and cleaning dishes. “Efficient” moved over from a term of business to the name for a personality type.

If you owned an advertising agency fifty years ago, on the other hand, you wouldn’t care how much pig iron your workers could carry in an hour. You would want your account executives to have winning personalities, to be able to bond easily with other people, to be likable. You would want them to have manners tailored to attract the patronage and retain the loyalty of your customers. Their task would be to persuade, not to push. You would therefore want them to be able to conceal, maybe even from themselves, the manipulative and possibly mercenary nature of their relationship with clients, and to transform a business transaction into a friendly quid pro quo. You would reward the most successful account executives with lavish expense accounts.

This is, of course, the service-economy world of “How to Win Friends and Influence People.” Among the things that the book promises to do for its readers (in the original edition; these were omitted in later printings) are: “Enable you to win new clients, new customers,” “Increase your earning power,” and “Make you a better salesman, a better executive.” It’s nice to be nice, but it also pays...

Today, if you were starting up a tech company (hey, maybe you are!), you would simply outsource your customer relations. In house, you would want your employees to be innovative and flexible, able to work in teams and adjust to new goals as they arose. You’d want to encourage your employees’ creativity by making them feel valued partners in the enterprise, active agents rather than code-writing drones. You’d be looking to maximize the ratio of brains to adaptability. You’d try to insure your employees’ commitment by making them feel that they were generating their own tasks and measures of performance, by having them “take ownership” of the workplace. You’d want reliable people who can also think “outside the box,” not people who think that successful performance means merely meeting preset goals. You would reward the most loyal employees with stock options...
LOL. Yeah, a few Dilbert Zone Moments.


From STATnews:

Google’s bold bid to transform medicine hits turbulence under a divisive CEO

MOUNTAIN VIEW, Calif. — Google’s brash attempt to revolutionize medicine as it did the Internet is facing turbulence, and many leaders who launched its life sciences startup have quit, STAT has found.

Former employees pointed to one overriding reason for the exodus from Verily Life Sciences: the challenge of working with CEO Andrew Conrad.

Verily, one of Google’s “moonshots,” pursues ambitious, even radical, ideas that could take years to pay off. The emerging Silicon Valley juggernaut has attracted elite scientists, engineers, and data crunchers, and inspired buzz about its futuristic projects — as well as envy among competitors nervously eyeing this upstart with a seemingly unlimited bankroll.

The three-year-old venture has operated largely out of public view and carefully manages its image; employees said talking to a reporter without permission is a firing offense.

But people who know Conrad or have worked with him said in interviews that Google has entrusted its life sciences initiative to a divisive and impulsive leader whose practices are driving off top talent and leaving openings for competitors. They said many employees in key jobs were dispirited, and described a lack of focus and clear priorities that is unusual even in the chaotic culture of startups...
Wow. "Leadership," 'eh?

More to come...

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