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Monday, June 18, 2018

EHR Science update

My online pal Dr. Jerome Carter has resurfaced. He's been burrowed away for months working on what he calls "a monograph" (he'd asked me to be one of the pre-pub reviewers).

From his latest blog post:
…Clinical processes have many moving parts, and many of those parts are ad-hoc adaptations (workarounds) invented by process participants. Frequently, there is a significant difference between what should happen (formal process, as written in policy and procedure documentation) and what actually happens—even when no EHR is present. Process variations may be introduced by a number of factors. Variations created by those performing the process may or may not be a good idea. (After all, workarounds are not necessarily bad if the formal process is poorly designed.) Likewise, patients may introduce process variations, and those variations are actually good if they help to ensure each patient gets the care that is best for his/her situation.

The unavoidable reality is that clinical environments are inherently dynamic and messy, and when safety or quality issues arise, the underlying causes are likely to be multi-factorial. No two ICUs work the same, and primary care practices, even those under the auspices of the same organization, may vary.  So what does all of this mean? It means we need a more scientific way of describing, decomposing, and modeling clinical processes so that for any given process we understand what it actually accomplishes, how it affects patients and those who perform it, and what goes wrong.  The first stab at meeting all of these requirements is found in the two chapters currently in progress.

Matters of software usability and safety have also taken on a new light with this evolution in thinking on clinical processes. Software implementation adds new ways of performing tasks, disrupting existing clinical processes. The resulting disruptions are only partially understood because the original processes were probably incompletely understood and documented. Thus, addressing usability and safety issues requires both looking deeply into existing processes and their variations in addition to looking at software-specific issues. Stated another way, workarounds and disruptions that arise after EHR implementation are not likely arising in an otherwise orthodox process environment. The more probable case is that heterodoxy is already present and the EHR simply adds some of its own.
Further, the mistaken belief that orthodoxy ever prevailed likely results in many futile attempts to correct the problems that arise after implementation.

Usability testing, as now performed, does not have a well-defined method for capturing the nuances of clinical processes in a standard way. Further, usability research is itself not standardized across researchers and institutions. Since each care setting is different, usability findings in one setting may not apply well in another, even though they are ostensibly the same…
I really look forward to reading it.

I've posted on "workflow" many times, see, e.g., Clinical workflow: "YAWL," y'all?

Tangentially apropos, I've been poring over a massive book (849 pages) lately as a registered Springer "journalist online reviewer" It's way too expensive for my piss-ant budget.

You gotta be kidding.

(BTW, I got onto this book in the wake of hooking up with "The International Center for Information Ethics.")

I can peruse all of it via the cumbersome template interface, but cannot screen-scrape any excerpts. I can get at some non-firewalled summary info, though. to wit:
This handbook enumerates every aspect of incorporating moral and societal values into technology design, reflects the fact that the latter has moved on from strict functionality to become sensitive to moral and social values such as sustainability and accountability. Aimed at a broad readership that includes ethicists, policy makers and designers themselves, it proffers a detailed survey of how technological, and institutional, design must now reflect awareness of ethical factors such as sustainability, human well-being, privacy, democracy and justice, inclusivity, trust, accountability, and responsibility (both social and environmental). Edited by a trio of highly experienced academic philosophers with a specialized interest in the ethical dimensions of technology and human creativity, this syncretic handbook collates an array of published material and offers a studied, practical introduction to the field. The volume addresses myriad aspects at the intersection of technology design and ethics, enabling designers to adopt a constructive approach in anticipating, preventing, and resolving societal and ethical issues affecting their work. It covers underlying theory; discrete values such as democracy, human well-being, sustainability and justice; and application domains themselves, which include architecture, bio- and nanotechnology, and military hardware. As the first exhaustive survey of a field whose importance is characterized by almost exponential growth, it represents a compelling addition to a formerly atomized literature.

The design of new products, public utilities, and the built environment is traditionally seen as a process in which the moral values of users and society hardly play a role. The traditional view is that design is a technical and value-neutral task of developing artifacts that meet functional requirements formulated by clients and users. These clients and users may have their own moral and societal agendas, yet for engineers, these are just externalities to the design process. An entrenched view on architecture is that “star” architects and designers somehow manage to realize their aesthetic and social goals in their design, thus imposing their values rather than allowing users and society to obtain buildings and artifacts that meet user and societal values.

Below, the table of contents via Mac graphical snips (Shift-Ctrl-Command-4, click-drag).

I am principally interested in implications for improving healthcare tech (e.g., EHR, mHealth UX) and intertwined privacy considerations.

Lots to consider. Stay tuned.


While we were up in Napa for Father's Day Brunch we heard this NPR/KQED segment while driving home.
City Arts and Lectures
The New Science Of Psychedelics With Michael Pollan

When Michael Pollan set out to research how LSD and psilocybin (the active ingredient in magic mushrooms) are being used to provide relief to people suffering from difficult-to-treat conditions such as depression, addiction and anxiety, he did not intend to write what is undoubtedly his most personal book. But upon discovering how these remarkable substances are improving the lives not only of the mentally ill but also of healthy people coming to grips with the challenges of everyday life, he decided to explore the landscape of the mind in the first person as well as the third. Thus began a singular adventure into the experience of various altered states of consciousness, along with a dive deep into both the latest brain science and the thriving underground community of psychedelic therapists. In “How to Change Your Mind: What the New Science of Psychedelics Teaches Us About Consciousness, Dying, Addiction, Depression, and Transcendence,” Pollan sifts the historical record to separate the truth about these mysterious drugs from the myths that have surrounded them since the Sixties, when a handful of psychedelic evangelists catalyzed a powerful backlash against what was then a promising field of research. Pollan’s other books include “Omnivore’s Dilemma,” “The Botany of Desire,” “Food Rules,” and “Cooked.”
They've not yet posted the audio. I will embed it as soon as it becomes available. I'm reading his book.


ICD-10 K40.90. Should be an interesting day.


My laparoscopic hernia job went quickly and without incident. Home by mid-afternoon. Lotta sharp lower right side abdomen pain today (episodic, mostly movement-related). CVS put sand in our gears over filling the Norco scrip post-discharge. A "new policy" requiring not only that you walk the paper Rx to the counter and present photo ID, but they now require a confirmation phone call direct from the ordering surgeon.

10:30 this morning, NADA, zilch, no callback from CVS. Welcome to Opiate Overreaction Land.

UPDATE UPDATE: The Muir post-discharge follow-up nurse called. I recounted the CSV dust-up. She intervened with them, and I got a CVS call straight away saying the scrip had been filled. Duh.


I'm never gonna get caught up on my reading.

"Why is America’s health care system so expensive? Why do hospitalized patients receive bills laden with inflated charges that come out of the blue from out-of-network providers or that demand payment for services that weren’t delivered? Why do we pay $600 for EpiPens that contain a dollar’s worth of medicine? Why is more than $1 trillion—one out of every three dollars that passes through the system—lost to fraud, wasted on services that don’t help patients, or otherwise misspent?

Overcharged answers these questions. It shows that our health care system, which replaces consumer choice with government control and third-party payment, is effectively designed to make health care more expensive. Prices will fall, quality will improve, and medicine will become more patient-friendly only when consumers take charge and exert pressure from below. For this to happen, consumers must control the money. As Overcharged explains, when health care providers are subjected to the same competitive forces that apply to other businesses, they will either deliver better services more cheaply or they will be replaced by someone who will do so."
Saw this cited over at THCB. This book is slated for July 3rd release. I've addressed these macro issues multiple times. See also my prior "Healthcare Shards" post.

I left an initial flip comment response under the THCB post.


More to come...

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