The KHIT Blog: "Fix the EHR?" Of course, but how about fixing the clinical process workflows?

Monday, April 23, 2018

"Fix the EHR?" Of course, but how about fixing the clinical process workflows?

Per my prior post "Fix the EHR!"

As reported in Healthcare IT News:

Can Lean methodology help improve EHR documentation?
Mayo Clinic researchers write in an AHIMA report that the process technique could improve electronic health record efficiency and overall satisfaction by users.

Clinical documentation improvement has been a major focus of many health systems' value-based care initiatives. But getting to more efficient and more accurate charting, especially for providers using older electronic health record systems, is a tall task with no dependable template for success.

But in AHIMA's Perspectives in Health Information Management, four experts from the Mayo Clinic College of Medicine showed how their department – the college's Department of Physical Medicine and Rehabilitation – used Lean processes for a redesign of an inefficient, first-generation EHR documentation system.

The project was a success, at least with respect to a boost in productivity and staff morale…

From the AHIMA paper:

Abstract
Providing efficient, accurate, and timely patient health information is the overriding aim of an electronic health record (EHR) documentation system. As new technologies evolve and regulatory requirements continue to change, administrators who find limitations in earlier iterations of EHR systems may need to rethink existing systems and processes. Seeking to optimize quality of patient care, the leadership of the Department of Physical Medicine and Rehabilitation at an academic medical center initiated a quality improvement project utilizing Lean methodology to guide redesign of an inefficient, first-generation EHR documentation system. Baseline data were collected using therapist/EHR interaction time studies, therapist productivity measurements, and stakeholders’ surveys. Existing documentation templates, available technology, and regulatory requirements were evaluated. Outcomes included mean reductions in time spent using the EHR from 2.8 hours per day to 1.9 hours per day per therapist, increases in patient care time from 53 percent to 71 percent, and overall improvements in internal and external stakeholders’ satisfaction from 17 percent to 97.4 percent and 43 percent to 80.3 percent, respectively. The implementation of Lean methodology applied to EHR documentation template inefficiencies proved to be an effective way of reducing time spent in the EHR by therapists, improving therapist productivity, and increasing satisfaction of internal and external stakeholders.

Introduction
Providing well-organized, accurate, and timely patient health information is an important aim of an electronic health record (EHR) documentation system. By the end of 2014, three-fourths of the acute care hospitals in the United States had transitioned away from exclusively paper-based health records to some form of electronic system that provided the ability to capture clinician notes in addition to other basic EHR functionality. A major concern among clinicians is that EHR adoption can interfere with practice productivity. Studies have shown that clinicians spend extra time entering data in the EHR, and it can negatively affect the time spent on patient care. As the numbers of EHR users have grown, some early adopters of EHR products have recognized the inherent process and design limitations and are reevaluating, redesigning, and even replacing earlier versions of health record automation.

Lean methodologies, which have been used for several decades in the industrial sector, are increasingly being applied to healthcare to drive quality improvement in order to reduce or eliminate errors, delays, and redundancy. The leadership of the Department of Physical Medicine and Rehabilitation of an academic medical center identified ongoing EHR limitations following the adoption of a first-generation documentation system designed for inpatient and outpatient physical therapists and occupational therapists (PTs and OTs). Lean methodology was applied utilizing the Define, Measure, Analyze, Improve and Control (DMAIC) framework to modify and enhance the existing patient care documentation system…

Good stuff. PDF copy of the paper here.

See some of my prior riffs on "workflow" here. See also my "Health Care Productivity Treadmill" post. And, my old REC deck on workflow (pdf).

Also, apropos of "Lean" methodology, see some of my coverage of the annual Lean Health Care Summits. See here as well.

Another thought: how about data-mining the EHR security logs for what they might reveal about workflow?

Also of interest:

"Q&A with Stanford Dean Dr. Lloyd Minor on harnessing technology for future physicians"

"...we will be sponsoring a national conference here on June 4 with leaders from the industry, from the EHR sector, as well as from the policy world, to focus on how we could improve the EHR so that it becomes an opportunity to improve the efficiency of practice, rather than a burden."

He addressed clinician burnout during the interview. "Relational Leadership™" anyone?

HIT UPDATE

A THCB post by Don Rucker, MD, current ONC Coordinator:

APIs: A Path to Putting Patients at the Center

Some of the natives ain't buyin' it. A commenter:

meltoots
Blah blah blah…the one thing you failed to mention is that Apple and Google both do API’s WITHOUT the US government’s heavy hand. They compete for developers. Have you EVER tried to ask Cerner or Epic for access to their API’s, its a total mess, a huge special effort, and just does NOT happen at all for anyone not willing to pay to play. They do NOT want you to use them.

So lets back up…we have tried the Certified EHR and it left us here…dejected, burned out MDs that are using 1990’s technology that does NOTHING to improve the Triple Aim, and obviously failed the Quad Aim.

Its time that ONC and CMS just stop all the certified madness, the hyper-regulatory action and just get out of the way of real competition. The artificial market made by HITECH has nearly destroyed the practice of medicine and further actions by the tone deaf ONC leaders and HIT leaders that can’t seem to understand that why their heavy regulatory action has not brought about positive change… you just need to go away…

So thanks ONC, CMS, but get out of the exam room, get out of the way of MDs and patients. We know what we need, stop trying to regulate and think for us. Let REAL innovation happen, we do NOT need to be babysat for our products. Stop CertEHR, Stop MIPS MACRA and counting attesting for quality points.

Do you understand you have failed Mr Rucker? Stop all the puffery language and “Value Based” talk and how you are gonna help clarify “special effort”. Just stop and let innovation come back in. You have set us back AT LEAST a decade of real progress.

Okeee dokeee, then. Tell us what you really think.
__

ERRATUM

Got a new Twitter Follow. Reciprocated.

What?
NatureVolve was created to act as a platform for scientific researchers to communicate their research to broader audiences, and for creative thinkers to share their ideas.

This is through an online digital magazine, and an online blog. In the future, we have plans for the magazine to be released to the UK in print.

Why?
We believe that combining scientific thought with artistic expression can generate effective engagement with public audiences. We also believe there is a growing need for science and art to rekindle the harmonious relationship that was once seen during the early age of the Enlightenment. We would like to show that artists and scientists can support each other, and engage with the world while working in unison.

By sharing understandable scientific stories with the general public, and inspiring art, we hope that wider audiences can enjoy finding new ways of appreciating the natural world…

Hmmm... "Art of Medicine" stuff?
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CODA: HOSPICE UPDATE

My terminally ailing Danielle, when she was 5. Below, with comedian Margaret Cho in 2014 at San Francisco Comedy Day in the Park.

Below, April 13th, probably the last photo I will post of Danielle. An increasingly rare "good" day.

We are now 6 weeks into home hospice care. She is fading away. Mostly sleeping in the hospital bed, unable to stand. Increasingly emaciated. Increasingly incoherent. Mostly one-word responses to questions. A distant stare when awake. Her son is here. He got FMLA dispensation from his employer.

Words fail to describe the sadness and stress. See my post "A tale of two sisters."
_____________

More to come...

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Brave New Health

Commonwell Health Alliance

Another important read (pdf)

I love this kind of stuff. It sustains and humbles me. "As politicians, advertisers, salesmen, and propagandists for various political, economic, moral, religious, psychic, environmental, dietary, and artistic doctrinaire positions know only too well, fallible human minds are easily tricked, by clever verbiage... Common language—or at least, the English language—has an almost universal tendency to disguise epistemological statements by putting them into a grammatical form which suggests to the unwary an ontological statement. A major source of error in current probability theory arises from an unthinking failure to perceive this."

Quotes

"An economist is a person who sees something that works in practice and tries to figure out whether it will work in theory."

- J.D. Kleinke, medical economist
___

"The only person who enjoys change is a baby with a wet diaper."

"Every misspent dollar in our health care system is part of somebody's paycheck.

- Brent James, M.D., M.Stat

“We could do healthcare, at markedly higher quality, for everyone in this country, without rationing or denying anybody the care that they need, without having the government dictate how doctors practice or whether hospitals could expand, at half the cost we do it now.”

- Health Care Futurist Joe Flower

Most of the sciences, unlike parts of medical science, are not concerned with the impossible. There is not complementary and alternative physics, or chemistry, or biochemistry, or engineering. These disciplines compare their ideas against reality, and, if the ideas are found wanting, abandoned."

- Mark A. Crislip, MD

"Q: How much alcohol is too much?
A: More than your doctor drinks."

- a physician I once heard speak during a CME presentation

“Just because science doesn’t know everything, doesn’t mean you get to fill in the gaps with whatever fairy tale most appeals to you.”

- Dara O’Briain

'[I]t is one small step from using the computer for "helping" doctors to monitoring them, judging them, dictating to them what to do, and withdrawing payment for computer non-compliance. The use of computer data is a multi-edged sword. It can be used for the "good," facilitating diagnosis and treatment and making it more accurate and up-to-date, and for “evil,” invading privacy, inviting security breechs, and making decisions based on the opinions of remote authorities rather than those present at the patient-doctor encounter.'

- Richard Reece, MD

“[T]here ARE statistics which are non-political. Just because The Washington Post/Fox News reports the temperature is 75 degrees doesn’t mean it’s really snowing and sunscreen is a liberal/conservative plot. Even if you earn a living being ideological.”

- Michael L. Millenson

"It is a generally a fairly convincing argument that people shouldn’t have to be subsidized to undertake a change which is in their best interest.

The reconciliation seems to be that EHR is not supposed to make a doctor’s practice more efficient and higher quality. It is supposed to make the system of care more efficient and higher quality, which is not the same thing. Those of you who took calc recall that maximizing the total of variables is not achieved by maximizing any one variable and this is a perfect example of that.

Those of you have served in combat certainly noticed that too — if everyone works as a team the unit takes fewer casualties. If you try to save your own hide, you might, but at the expense of more casualties overall."

- Al Lewis

"There are two ideas to keep in mind about Bayesian reasoning and how we tend to mess it up. The first is that base rates matter, even in the presence of evidence about the case at hand. This is often not intuitively obvious. The second is that intuitive impressions of the diagnosticity of evidence are often exaggerated."

- Daniel Kahneman, "Thinking, Fast and Slow"

"Physicians apply advanced scientific knowledge, but they must do so without the favorable conditions that experimental scientists create for themselves. Multitasking is forced on physicians, often in chaotic environments and under severe time and resource constraints."

- Lawrence and Lincoln Weed, "Medicine in Denial"

"It’s time to stop the whining about Obama care and acknowledge we already have universal health care. We just pay for it in the stupidest way possible that ensures problems are that much more disastrous and complicated when they’re finally treated."

- Mark Hoofnagle, MD, PhD

"Every act of conscious learning requires the willingness to suffer an injury to one's self-esteem. That is why young children, before they are aware of their own self-importance, learn so easily."

- Thomas Szasz, MD
___

"Of course, one reason that process metrics* are so popular is that processes are much easier to define and measure than outcomes."

- The Skeptical Scalpel
___

"There is an “illusion of validity” for any random data point, a seductive sense that is colored by what we hope will be true. Mountains of pharmaceutical claims are often made from mere molehills of data."

- Danielle Ofri, MD
___

"Joy empowers people. It is a source of energy that enables people to hope and plan and change their lives for the better. Spend some time around someone who is relentlessly negative and how do you feel–drained, right? More and more research shows that joy is not something that just happens to you, like a bolt of lightening out of the blue. Joy is, instead, a habit to cultivate. Negative thinking and despair are the crabgrass of our souls–weeds that take root and spread, sometimes to all areas of life. Joy, in contrast, is a soul’s rose–hardy when cared for, able to put down roots over time and withstand disease and extremes. Like a rose, however, your joy can become blighted from neglect or harsh conditions. We all need to tend to our joy–to prune away the badness, and to know that, even though it may look like a prickly bare root, if you invest time in a joyous outlook, gorgeous things will bloom, even in the harshest conditions."

- Dr. Jan Gurley
___

"'Solutions' exist only in mathematics."

- Karen Martin
___

"The issue of how to regulate clinical software is, in the long run, indistinguishable from the issue of how to regulate medicine. The only difference is that medicine is practiced in the open, without secrecy, subject to peer review, and under a merit-based state license."

- Adrian Gropper, MD
___

"Economist, rope, tree: some assembly required."

- Source unknown

DISCLAIMER:

I write this blog wholly on my own time and my own dime. The views proffered are expressly my own as a concerned and active citizen/taxpayer (in addition to being the result of my substantive experience in the various IT fields), and in no way reflect any policy views of my former employer, notwithstanding that some of the thinking has indeed obviously been spurred by the implications of the work with which I have been doing for them.

FAIR USE POLICY
I cite a ton of news and web sources spanning the breadth of relevant technical and policy domains, sometimes at substantial length. I believe I remain well within the bounds of "Fair Use," as [1] I am not doing any of this for profit, [2] I always provide attribution and links -- which, [3] far from negatively impacting any copyright holders' commercial interests, might actually increase traffic to and interest in their offerings.

Nonetheless, should I post anything of yours regarding which you have any objection, just let me know and I will remove it forthwith.

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Monday, April 23, 2018

"Fix the EHR?" Of course, but how about fixing the clinical process workflows?

"Q&A with Stanford Dean Dr. Lloyd Minor on harnessing technology for future physicians"

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