Just DO it.

Yes, there's a lot about the U.S. healthcare "system" comprising legitimate targets for criticism, complaining, and outrage. We all know that. Crappy, workflow-inimical, silo'd Health IT, intractable reimbursement system misalignments, maddening "government mandates," looming provider shortages, and on and on and on...

I started blogging about the issues back in 2009. See, e.g., my post The U.S. health care policy morass. 

But, given that we go to Rumsfeldian healthcare delivery "war" every day with the healthcare system we have, and not the one we'd like to have, it helps to give close study to the folks out there who are leading the way --  doing rather than bitching.

I just finished this book.

This is the 3rd book release I've studied from the ThedaCare Center for Healthcare Value, following these prior two:

The reference to "heroes" goes to the notion of the valiant, adroit "firefighters" who repeatedly have to drop in to save the day in the dysfunctional healthcare delivery system. I call them "Quadrant One" people, those called upon to deal with the seemingly never-ending, chaotic "Important and Urgent."

The layout of "Beyond Heroes."

Over the next eight chapters, we will examine each of the elements of our business performance system in detail, since all have been critical in helping us to create a business performance system that is transforming ThedaCare.

Here, I would like to draw a big picture, describing how each element links to the others to create a system, not just a pile of discrete tasks. Think of this as the engineering drawings, showing the bare structure of ThedaCare’s business performance system and how the elements become interlocking gears.

1. Status Reports. At ThedaCare, we call this a stat sheet meeting, and it is the most transformative element in our system. Short for “status of the business,” this conversation, usually between a manager and a supervisor or clinical lead, begins with a series of standardized questions on a single sheet of paper intended to provoke a dialogue about improvement opportunities and roadblocks. This daily, focused discussion about the business, taking place hundreds of times each day with different players all over our hospitals, is the cornerstone of our business performance system. This is about preparedness, about planning our days instead of firefighting our way through them.

2. Team Huddle. Every day, every leader gathers his or her team members into a huddle to widen the conversation about opportunities for improvement, roadblocks, and ongoing projects. This is where we teach and practice standardized problem solving using A3s and the plan-do-study-act cycle and then employ these tools to work through issues and improvements.

3. Managing to the Established Standard. This is the discipline of auditing standard work for both clinical and leadership processes in order to keep it from changing or falling to the wayside. By auditing or observing standard work, we also work to spread best practices. It is difficult to maintain any standardized process, clinical or administrative, so auditing must be hardwired into the business performance system and every manager’s day. This is where we emphasize that standard work is not a weapon or critique but is the best currently known way to do the work. Standard work is the best practice, and auditing or observing the work is a method for teaching and coaching.

4. Problem Solving. We used the A3 or PDSA (plan-do-study-act) as our guide to problem solving with the scientific method. But these tools are as much about mentoring the team on ways to solve problems as they are about finding the best countermeasures for a specific problem.

5. Transparency. A visual workplace— where area defects are as visible as team accomplishments— is difficult to establish, but it is the way we keep everyone focused on reality while looking for new opportunity.

6. Advisory Teams. For every manager we created a board-of-directors-style team of advisors to help fill in gaps in the manager’s areas of expertise and provide fresh perspectives. Advisors might be from finance, human resources, or pharmacy and are responsible for the overall performance of drivers in that area. At ThedaCare, drivers refer to the targets or goals on an area’s scorecard that lead much of the work of improvement teams. Every unit, clinic, or area has drivers that are tied to the organization’s main goals. In general, each advisor on the team “owns” one of the area’s drivers and is responsible for understanding problems that affect performance toward the goal. Advisors may come from inside or outside the manager’s area.

7. Scorecard. Every manager had a monthly scorecard developed and maintained by the advisory team to help keep track of progress against drivers. The scorecard’s vital few metrics help us focus deeply to solve problems and improve performance.

8. Leadership Standard Work. This is the most effective weapon available against heroics. When a supervisor, manager, or executive adopts standard work, she promises to be reliable and accountable to her team. Standard work tells the team where a manager will be and when, what questions she will ask and when she will be available to work through issues. According to Toyota, work is standardized when the precise elements of the job are done the same way every time and at a repeatable cycle time. Our stat sheet conversations and huddles are not as precisely timed or repeatable as a mechanized process, so maybe it is more correct to say that our standard work is more like a fixed schedule of activities. We are, however, still evolving, and our goal is a repeatable, reliable system of managing for improvement.

Here is how it all fits together. We use stat sheets to see the business, plan our day, and see the trends developing. We widen the conversation with the team huddle, where we look for trends in performance and use standards to find the gaps between our goals and our performance. This leads directly to problem solving and using the scientific method to close the gaps. Information gathered in huddles and problem solving is then published to the area improvement center— whether that is in an outpatient clinic, an inpatient unit, or a finance office— allowing for transparency so that everyone can monitor progress. The advisory team gathers around the area improvement centers to monitor progress and advise the leader, who monitors the team’s performance through the monthly scorecard. Standard work at all levels ensures that everyone stays on track and that we have a measurable norm for leadership performance.

Reduced to seven words, these elements add up to developing people, solving problems, and improving performance...

Barnas, Kim (2014-05-09). Beyond Heroes: A Lean Management System for Healthcare (Kindle Locations 523-568). ThedaCare Center for Healthcare Value. Kindle Edition.

They're doing ACO. They use Epic. They consistently hit high on HEDIS. They have to comply with all of the regulations and clinical reporting measures that bedevil everyone else.

They're obviously doing something right. This book and the other two antecedent works I cited will give you a good idea of precisely what. Imagine going to work every day within an organization where an ongoing priority for everyone is scientifically improving the work processes.

Imagine.

Highly recommended, if a bit pricey (that ticked me off somewhat). I bought the $35 hardcover straight away ("First Mover Disadvantage"), but it's now available on Amazon in $9.99 Kindle edition. Yeah, I bought that as well.

Concluding observations from "Beyond Heroes."

The future at our door
...Just a few decades ago, hospitals were the centers of catastrophe. We saw victims of sudden illness and accidents. We generally offered short courses of treatment that the patient either survived or did not. For lesser maladies people saw a family doctor and, even there, care was usually targeted at a particular complaint with a limited time horizon.

Now, we have entered into long-term relationships with our patients. Longevity is increasing. Diabetes, obesity, asthma, arthritis, and mental disorders such as depression and bipolar disease now call for regular, ongoing treatments that can last a lifetime. Many cancers are becoming chronic conditions, joining HIV/ AIDS as a disease we can live with for decades.

This means that much of healthcare will focus on helping patients to help themselves in managing and improving their lives. Out of absolute necessity, we will finally begin to focus— as an industry— on wellness instead of illness. We will pay more attention to the life needs of the patients, to keeping people independent and able to care for themselves well into old age. This will require new tools and more time and patience. We will spend more time counseling people on how, for instance, specific diets and exercise affect their chronic disease, and our information will be based on solid scientific evidence rather than fads. We will talk more about staying out of the exhausting cycle of hospitalization and recovery and less about what new, short-term treatments we can offer.

We will focus on patient wellness because it is the right thing to do and because we will be paid that way. In the near future, healthcare organizations will most likely receive a pool of funds to look after the healthcare needs of a population of patients, as I noted in the previous chapter. A number of experiments have been running around the United States and the value-based, or population-based, payment concept has emerged as the most likely method for controlling costs while improving patient outcomes and experiences.

Using this system, independent healthcare providers will be profitable only if they offer good care with a minimum of defects and waste. If patients in an organization’s population pool suffer from runaway obesity, asthma attacks that require hospitalization, and births complicated by a lack of prenatal care, that will cost the organization. A lot. That means we will see a major push by the healthcare industry to offer better preventive care.

Physicians and administrators will have a vested interest in knowing which tests and procedures are the most effective for patients, as opposed to the most billable. So how does this relate to the business performance system? Healthcare organizations that practice continuous improvement will have the advantage in this system because they are already accustomed to increasing profit margins by eliminating waste and creating more efficient processes. If medical group A investigates its treatment path for stroke victims and creates better outcomes by reducing the time it takes to administer clot-busting drugs, for instance, it will spend fewer resources on patient recovery time than group B and therefore earn a better profit margin and reputation. (This will also save the family and community from the costs and heartbreak associated with long-term care of a person who can no longer function at full capacity.) Saving money by offering better treatment also means a medical group could afford to attract the best providers and reinvest in its facilities and people...

One nice thing about the book is the way these Lean deployment principles, management strategies, and process improvement tactics are illustrated via the stories of individuals at work, doing their jobs and working to improve their jobs as a matter of course. It's a good, conversational read.

SPEAKING OF EPIC AND DOING THINGS RIGHT

Recall my February 6th, 2014 review of this book? See Meaningful Use 2013 review, ONC Working Group Stage 3 draft report, and discussion of KP's book "Connected for Health"

Another bunch out there successfully doing.

AND, THEN THERE ARE THOSE NOT DOING THINGS RIGHT

The VA Scandal: Implications for Health Reform and a Call for Clinical Research into the Reported Death Rate

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More to come...

Has regulatory compliance become an end in itself?

From InformationWeek.com

Healthcare IT Priorities: No Breathing Room
Regulatory requirements have gone from high priority to the only priority for healthcare IT.

Healthcare has always been a highly regulated industry, but in the last few years requirements for implementing and documenting digital healthcare systems have been piling up so fast that IT organizations have little time for anything else -- including making sure the systems they already have in place are being used effectively. The InformationWeek Healthcare IT Priorities Survey of 322 technology pros at healthcare providers shows "meeting regulatory requirements" is the No. 1 initiative on participants' minds. Most of the other items at the top of the list, such as implementing or upgrading electronic health records (EHR) systems, are also largely driven by federal government requirements.

 "The priorities we're trying to deal with right now are those being mandated," says Randy McCleese, CIO of St. Claire Regional Medical Center. "We can't do anything else. We have put everything else on the back burner except for those things that absolutely have to be done."

Against the crushing wave of requirements, what's most neglected by IT organizations is optimizing how healthcare providers use all the technology they've bought of late -- "and we've been provided with a lot of functionality in the last three to four years," says McCleese, who's also chairman of CHIME, the College of Healthcare Information Management Executives. "We've put all this technology in place quickly to meet the requirements, but we have not had a chance to make sure it's working effectively."...

 Register to get the free pdf paper. Nicely done. Sample size is a bit small, though.

The grousing about MU continues apace of at THCB: "The Case for Dropping MU Stages 2 and 3." From the comments:

I was one of the leaders in the EMR arena for many years, and was initially really excited about meaningful use. Yes. I admit that with some embarrassment now. I even was part of a CDC public health grand rounds regarding meaningful use and why it would be a good thing. Over time, however, I saw what you see now: meaningful use is not a definition of using the EMR productively; it is simply another bureaucratic layer doctors must get through before they can focus on patient care.

I do agree with items on your list, but the real benefit of the EMR is not one of documentation, it is about work-flow. Computers are good at remembering things we don’t remember, and are good at organizing information more efficiently. I would add several things that would make EMR systems more meaningfully useful:

1. Task managment. Why don’t any products focus on team management of tasks, as it is clearly one of the bigger barriers to good care. I believe that a system that focused on this would gain adoption without incentive, as it would actually make doctors’ jobs easier.

2. Information prioritization. It’s not what is put into the system that is important, it is what you can get out of it. Most EMR systems are a jumble of useless information that hides the useful information.

3. Better communication tools. We are using iChat in our office (locally hosted) and have found it to be incredibly useful to answer questions while the patients are on the phone. We can handle problems with fewer steps. There are many tools out there to make this kind of thing work. Patients could, for example, record MP3 files on their portable devices and have that upload to an EMR for handling by the office staff (in lieu of the overworked phone system).

4. Risk assessment and reduction – this is the overall goal of care: to make patients healthy and prevent problems from happening. The problem is that risk assessment tools are scarce in most EMR systems.

Our success at EMR implementation was due to our focus on it as a tool to improve patient care by transforming our workflows. As the burdens of meaninful use came on, however, the ability to do that was hampered enough that I not ony abandoned Meaninful Use, but I left the system altogether. My home-grown EMR is far more useful than anything I could find on the market.
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MU is meaningfully useless for patient care,. No, it is worse than that. It is an additional impediment to patient care.

Medical care is about ambiguity and shades of gray. EHR systems depreciate the nuances of care, and meaningful ruse destroys care processes by focusing on the irrelevant.
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It can be an odd combination of naive and doggedly determined, both of which might apply to this situation.

I agree that politicians being what they are, they are unlikely to pull the plug on MU because that means an admission of fault and a loss of money to the constituents that are benefitting from MU. But… I’m naive enough to believe that, with enough groundswell, we could do something, even if not outright cancellation, that would improve the Frankenstein that we created, especially if we redirected the money to better HIT uses and sustained the appeal to constituency.

I’ve always dreamt of an EMR that was designed from the beginning to support clinician efficiency; quality of care; and cost of care. And then rolled all of that together into something that looked like a project management tool, like Base Camp, that recognized healthcare as a long term project involving several project teammates that need to interact and communicate. Dropping a bill would become a natural functional outcome, but wouldn’t be the primary motive of the design.

It’s amazing to me that those of us who procure EMRs don’t insist on a downloadable, transferable patient record. How did the music industry manage to pull off the MP3 standard without a government mandate? Maybe there’s a lesson in there for us, somewhere.

Critics have been griping about these issues since I started in the DOQ-IT program back in 2005. I've been addressing them since I started this blog four years ago.
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More to come...

I'd planned to put up a thoughtful, meaningful post today, but...

Nah. Today is the day that our nation's capitol was be be occupied by a reported 10 to 30 million "patriots" intent on "forcibly removing" the President and a long list of congressional leaders from office, at the behest of some group calling itself "Operation American Spring" (they eventually dialed back the "forcible" part that was central to the initial proffer).

Well, what would be the point, in light of the incipient overthrow of the government? So, I turned to Photoshop for a bit of OTC medications fun.

Turnout was disappointing, by all accounts, but, hey, all several hundred or so actual attendees got a free tube. ;)

The twitter hashtag #AmericanSpringExcuses is pretty funny.
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More to come. Back on topic shortly...

We're about to be Bushwhacked

Read an interesting post by athenahealth CEO Jonathan Bush on THCB this morning. Led me to this:

Interesting. I bet it's one long (ghostwritten?) riff on this well-known theme of his (from his THCB post):

...To create a modern, caring and efficient health care economy, we have to create more spaces where entrepreneurs can compete in the marketplace—and not in the corridors of Capitol Hill.

Unlike many entrepreneurs, I had reason to feel comfortable in Washington. Even though I couldn’t call my presidential cousin for help, I had my political name, fancy venture firms behind me, and my equally fancy business degree from Harvard. That gave me the confidence—or hubris—to assume I could get in there and make a difference. I was an outsider with insider status. I’d guess that 90% of businesses that get blown up by government mis-steps, or even prevented from being born, are run by outsiders with outsider status. That is why it’s so hard for an activist government to be effective. It works with known players—while the future should be in the hands of unknown players working to make the household names obsolete.

The government, by regulating industry, actually ends up protecting the incumbents. Here’s how. Let’s say the news comes out that insurance companies are taking advantage of customers in an especially awful way. Because this a service that society views as vital, the government comes in and says, “Whoa, what’s going on in here?” Now the best thing to do at this point would be to make it as easy as possible for new entrants to come into the system and disrupt these guys—clean their clock, kill them, or at the very least force them to change. But instead the government looks to control them. They do this by writing up cumbersome regulations. These discourage newcomers from the market. Many of the best would-be competitors don’t employ a single lobbyist or lawyer. They take one look at a market regulated up the wazoo, and conclude, wisely, that they’re not built to play that game. They’re better off building a new video game or a dating app. So instead of making the bad incumbents vulnerable, the government leaves them fat, lame and stupid—but with formidable lobbying power. Since these companies employ a lot of people, they become untouchable...

From CNBC:

[David] Einhorn, co-founder of Greenlight Capital, called Athenahealth a "bubble" stock that could fall 80 percent or more from its peak share price of more than $204 in March. He also said the company's potential products are being overvalued.

Einhorn has been advising investors to short ATHN.

UPDATE: I emailed athenahealth asking for a comp review copy. They blew me off. No reply. The gall of some pissant small-fry curmudgeon independent blogger.

Just checked; the price of the Kindle edition has already dropped $3, from $14.99 to $11.99. I don't think I'm gonna buy it, even though it's probably pretty well done. Competing priorities for my dollars.

Once we get past the 5-Star effusive "Friends and Family" hagiographic Amazon shill "reviews," we'll see what people actually think.

FROM THE AMAZON "LOOK INSIDE" SAMPLE

I used Dragon to transcribe this little excerpt.

In the lumbering healthcare industry that we have come to know in the last half-century, information is a scarce resource. Patients rarely have access to the records. No one can hazard a guess as to what an operation, a medicine, or even a Band-Aid might cost. Keeping this information button and up benefits the incumbents, who thrive within what we might call and ignorance economy. Some, as we’ll see, are still attempting to control their local markets by limiting access to data. It sooner or later, data promises to turn this status quo on its head, ushering in a slew of new digital startups and — most important — delivering vital and timely information to the patients, or customers.

And what will they do with this information? It can be summed up in a single word: shopping. This has to do with making choices. We weigh countless options in the rest of our lives, but not nearly enough of them in healthcare. Shopping, whether it’s driven by an individual, a retail buyer, or a wholesaler, creates the market, and the market responds with choices and innovation. What’s more, in markets driven by shopping, losers figure out how and where to change their fortunes, or they disappear.

We need shopping, I believe, not only to fix healthcare, but also — and I know this may sound strange — to express our own humanity. Think about it. We shop for clothes to express our tastes and personality. We do the same for music and food. Some of us trick out our cars, put them on mega wheels, or hang big, fuzzy dice from the mirror. We express we are with these choices. And yet for the care of our bodies, for some of the most important decisions we make in life, we rely on a handful of menu options and lists drawn up by bureaucrats. What I want is for people to have a dizzying array of options in healthcare, so they can care for themselves and their  loved ones in a way that suits them best, that makes them happy and proud. Some of the choices will be simple, of course, others delightfully convoluted. But in my vision, each of us will fashion the health care we want and deserve. We'll express ourselves.

Go shopping? Where have we heard that before? Right, health care purchases are no different from buying clothing or CDs or cars. We don't want actual health care, we want "choice," via which to make fashion statements?

From the Amazon blurb on another of my favorite books, The Paradox of Choice: Why More Is Less:

Whether we're buying a pair of jeans, ordering a cup of coffee, selecting a long-distance carrier, applying to college, choosing a doctor, or setting up a 401(k), everyday decisions -- both big and small -- have become increasingly complex due to the overwhelming abundance of choice with which we are presented.

As Americans, we assume that more choice means better options and greater satisfaction. But beware of excessive choice: choice overload can make you question the decisions you make before you even make them, it can set you up for unrealistically high expectations, and it can make you blame yourself for any and all failures. In the long run, this can lead to decision-making paralysis, anxiety, and perpetual stress. And, in a culture that tells us that there is no excuse for falling short of perfection when your options are limitless, too much choice can lead to clinical depression.

In The Paradox of Choice, Barry Schwartz explains at what point choice -- the hallmark of individual freedom and self-determination that we so cherish -- becomes detrimental to our psychological and emotional well-being. In accessible, engaging, and anecdotal prose, Schwartz shows how the dramatic explosion in choice -- from the mundane to the profound challenges of balancing career, family, and individual needs -- has paradoxically become a problem instead of a solution. Schwartz also shows how our obsession with choice encourages us to seek that which makes us feel worse.

By synthesizing current research in the social sciences, Schwartz makes the counter intuitive case that eliminating choices can greatly reduce the stress, anxiety, and busyness of our lives. He offers eleven practical steps on how to limit choices to a manageable number, have the discipline to focus on those that are important and ignore the rest, and ultimately derive greater satisfaction from the choices you have to make.

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BTW: Got my hardcopy of the ThedaCare Center book "Beyond Heroes" yesterday. Started on it in earnest last night.

Just downloaded this as well:

The Scientific American eBooks are excellent, and inexpensive. I have a bunch of them.

Stay tuned...
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AND THE HITS JUST KEEP ON COMIN'

How Meaningful Is Meaningful Use?

The government's Meaningful Use program mandating electronic health records is out of touch with reality. EHRs bog down process and can even worsen care. Despite the existence of a government program called Meaningful Use, as a doctor I have yet to see a meaningful, positive impact on care from electronic health record (EHR) systems.

Regulators pushing for better and more cost effective medicine have decided that electronic technology, which has revolutionized many industries, is the solution needed to revolutionize medicine. We have been told that EHRs will make us better doctors, and they will make patients more responsible and engaged in their care. They go so far as to claim that EHRs will save doctors and hospitals time, that they will provide better coordination of care and save lives. While I can envision a world where this could be true, those of us living in the real world struggle with the disconnect between what is touted and what we experience every day.

It is true that some studies have shown specific benefits on selectedmeasures when EHRs are used. Unfortunately, this is not true in all studies. Some studies have failed to show improvement of any kind when an EHR system is implemented. Some show an increase in adverse outcomes, including death. The EHR is not a proven technology. It is an experiment, and hospitals and clinics are beta testing new ways of doing things every day. The en masse adoption of EHRs into hospitals is akin to forcing car makers to make all vehicles from a new plastic that theoretically could make them safer without having shown that it really works.

High expectations for a new technology are typical, but pushing adoption of a technology that hasn't proven itself yet is inappropriate and flawed. Many haven't seen improvement in care coordination, efficiency, or patient engagement. In fact, some think things are worse with EHR. Patients now have to compete with computers to get their provider's full attention. Good documentation can take more time to input, and coordination of care still requires highly motivated teams. It is not clear if the EHR is more effective that a cohesive team with a spreadsheet. Additionally, health information exchanges are years away from truly interconnecting institutions and are not adding proven benefit to many.

Part of the problem is the menagerie of disconnected proprietary systems, all trying to solve problems in their own way. They don't speak to each other. Many are plagued with poor design and poor usability. These problems can be solved, but they should have been solved before we bought the software, not after.

In an effort to push EHR adoption and use, the Center for Medicare and Medicaid Services (CMS) has created the Meaningful Use (MU) incentive program, which defines what people should be doing with their EHR and pays them for doing it. The CMS has also instituted penalties for those who would remain on the sidelines. MU Stage 2 is ongoing, with the goals of increasing use of health information exchanges and patient engagement by enabling patients to access and transmit their own data. It also requires more intense use of EHR by physicians who must order tests, e-prescribe more consistently, look at labs in an electronic format, and keep everything safe from hackers.

On the surface, these seem laudable. Yet the technology remains cumbersome and disconnected, making many of these tasks difficult at best. Some tasks require someone else to act -- the patient or the health IT vendor. Even with a certified product, meeting MU Stage 2 requires overcoming some major hurdles. It is not clear that any of these things are improving care or saving time, money, and lives, as claimed by the CMS...

I am all for advancement, but trying to push a technology that is not mature nor the best one to solve the problems at hand is ill-conceived and foolish. Many of the current EHR systems are simply inadequate. Continuing to put energy into making these systems do tasks they can't isn't helping anyone. We are wasting time and resources trying to fit a round peg in a square hole. MU is pushing adoption of technology, but it is not improving the technology. It is simply making people use systems they wouldn't use without incentives.

Our institution is striving to meet MU Stage 2. I am not sure if we will be able to. Our push to meet the required metric for patient engagement is not going well. Perhaps we are doing it wrong, or we have a lot of apathetic patients. Additionally, getting staff to go out of their way to use a very time-consuming CPOE process is more than challenging. Using CPOE makes it harder to look back and see what the current orders are. In order to care for patients, we have to keep separate notes outside of the EHR, creating more than twice the work as doing it on paper. Consultants can't figure out what is going on without talking to the other providers in person. This adds to the challenge of providing good care. If an EHR fails to achieve its No. 1 objective -- being a well-organized repository of information that is pertinent to a patient -- it is of little value, even if it can meet MU.

EHRs need to be measured by usability and functionality, not whether they can achieve Meaningful Use metrics. Right now, we need to be focused on usability. Certifications mean nothing when a product doubles or triples the workload. Our EHR is a roadblock to providing well coordinated, evidence-based, efficient, and compassionate care. MU might have merit, but it is taking the focus off the bigger issue of usability.

We shouldn't be pushing for universal measures until they can be met -- and until we have evidence that they are truly beneficial.
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David M. Denton is a board-certified pediatrician and member of the American Academy of Pediatrics. He is a partner of the Pocatello Children's Clinic in Pocatello, Idaho, and is affiliated with Portneuf Medical Center where he currently serves as the medical staff

Link to full article here.

AMA Wants Major Overhaul of Meaningful Use

Warning that many physicians will not be able to advance to Stage 3 of the electronic health records meaningful use program, the American Medical Association is suggesting radical changes to all three stages.

Absent significant changes, more physicians--already struggling with the first two stages--will drop out of the program or be unable to move to Stage 3, the association contends in a letter to Centers for Medicare and Medicaid Services Administrator Marilyn Tavenner and National Coordinator for Health IT Karen DeSalvo, M.D...

AMA sharply criticized a HIT Policy Committee certification workgroup last week for being "unwilling to make a recommendation on making the overall program more manageable for physicians." Mari Savickis, AMA's assistant director for federal affairs, told the workgroup about 40 percent of eligible professionals have never participated in the meaningful use program and, of the 60 percent that have, 20 percent have dropped out. "The way to keep physicians from dropping out today or keeping them from making a decision to not participate is to make the program criteria more flexible," said Savickis.

Fear and loathing in meaningful use
'I cannot stress this enough: It is fear that drives this process – fear of audit, fear of penalty.'

When it comes to the topic of meaningful use, Colin Banas, MD, is driven by fear. And he's far from being the only one.

The chief medical information officer at the Virginia Commonwealth University Medical Center's concern is the potential to fail meaningful use requirements because VCU sometimes tailors a vendor's certified product in order to make it more usable.

Whereas such customization is a common practice in the world of enterprise software, in the realm of electronic health records it has become the veritable equivalent of stepping into a rather cloudy area wherein it is very hard to discern whether they’ve gone so far that an auditor might say VCU did not achieve meaningful use.

What's more, Banas said that it would be impossible to estimate the resources VCU has used to readjust clinical workflows and codes to follow the letter of the law, when it was already clearly following the intent of the measure.

"I cannot stress this enough: It is fear that drives this process – fear of audit, fear of penalty," Banas said, "and fear of vendor abandonment should a client choose to forge a different path."...

Man! Where's the love?

Read the full AMA letter here (pdf).

BUT WAIT! THERE'S MORE!

John Halamka: 80% of providers won't meet MU Stage 2 deadline
May 15, 2014 | By Susan D. Hall

Reiterating his belief that the federal mandates for the healthcare industry are "too much, too soon," Beth Israel Deaconess Medical Center CIO John Halamka predicted that 80 percent of hospitals will fail to successfully attest to Meaningful Use Stage 2 within the allotted time.

He told those attending the iHT2 Health IT Summit in Boston this week that he expects many provider organizations to opt out of the program, according to Healthcare Informatics...

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More to come...

The future of Meaningful Use?

Thrill is gone as meaningful use strains
'I’m telling you, it’s really, really hard out here.'
Dana Manos, WASHINGTON | May 9, 2014

It seems just about everybody has a gripe or two concerning the meaningful use program: software vendors that make electronic health records systems, hospital CIOs, the very people charting the related committees and, of course, physicians.

Whether that means it’s time to trim the EHR program’s sails, turn the boat around, or abandon ship entirely is becoming a matter of increasingly winded debate...

Is meaningful use driving eligible providers off course?
Kyle Murphy, PhD,  May 12, 2014

The concept of meaningful use has many supporters. Its execution, however, has its fair share of detractors. Even the most ardent proponents of meaningful use recognize the deficiencies present in the certified EHR technology required by the EHR Incentive Programs...

Meaningful use involves a big amount of money: billions in incentives to eligible providers, more so to the EHR vendors whose systems they had adopted. As the industry shifts toward a value-based approach to care delivery, patients will more and more assume the role of consumers which in turn will require providers to be more discriminating in how they treat their customers.

“If reimbursement is going down, we have to always vet our decisions about how they provide value and we can recover that cost. There’s a very serious value proposition we’re having to make, and that’s good. It should be that way — we should be good stewards anyway,” says Reid.

Meaningful use is only in its second phase, but early results from Stage 2 are underwhelming. Could it be the case for providers that the meaningful use journey is already.

4 hospitals, 50 EPs have attested to Stage 2 Meaningful Use
Jennifer Bresnick, May 7, 2014

Only four eligible hospitals (EHs) and fifty eligible providers (EPs) have attested to Stage 2 of Meaningful Use so far, said Beth Myers on behalf of CMS during the latest Health IT Policy Committee meeting this week.  While Myers stressed that the “slim amount of data” is too little to form an opinion about the success of Stage 2 so far, she was optimistic about the outlook for the second stage of the EHR Incentive Programs despite ONC Acting Director, Office of Economic Analysis, Evaluation, and Modeling, Jennifer King, noting that small rural and critical access hospitals (CAHs) are significantly lagging behind their peers in adopting EHR technologies ready for the new challenges ahead...

I have never really liked the phrase "Meaningful Use." Too easy to mock. Meaningful to whom? The clinicians who have to use the technology, or the payers and policy wonks?

We need Effective Use of health IT by those who must use it. That assertion implies a ton, obviously, and it goes way beyond capturing a relative handful of measures in "structured data" formats.

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Oh, yeah, btw...

EHR Hardship Exception Deadline Is July 1
By Christine Kern

CMS provides update on EHR Hardship exceptions for eligible professionals who haven’t applied yet.

Those eligible professionals within the Medicare EHR Incentive Program who did not successfully meet meaningful use in 2013 may still submit a hardship exception application for payment year 2015, according to the Centers for Medicare and Medicaid Services.

As HealthData Management reports, the CMS deadline for eligible professionals to apply for 2013 reporting year-2015 payment adjustment year hardship exceptions is July 1. To date, 600 eligible professionals have applied for hardship exceptions, according to a CMS official who made a presentation during the Health IT Policy Committee's May 6 meeting.

Elisabeth Myers, policy and outreach lead for the CMS Office of E-Health Standards and Services, told the committee that "We have received a number of hardship exemption applications. I know that that's been a big question of how those are going."

Acceptable conditions for applying for the hardship exemptions include EHR vendor issues, lack of infrastructure and unforeseen/uncontrollable circumstances, "lack of control over the availability of Certified EHR Technology" and "lack of Face-to-Face Interaction." Hardship exceptions are valid for one payment year only; new applications must be submitted each year to continue a hardship exception claim for the following payment year...

See the relevant CMS site here.
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UPDATE

From NBC News. Who owns your health data?

 

I posted on health data ownership back in 2011. Here as well.

apropos...

Hospitals overcharge med records by $7M
Lawsuit alleges three New York hospitals and business associate overcharging up to $0.50 per page
Erin McCann, May 5, 2014

A triad of big name hospitals have come under fire recently for allegedly overcharging patients for copies of their medical records.

Back in March, New York-based Mount Sinai Hospital, Montefiore Medical Group, Beth Israel Medical Center and release of information service company HealthPort Technologies were slapped with a class action lawsuit for reportedly violating New York State's public health law regarding medical record request fees.

The group of plaintiffs representing some 100 members alleged the three hospitals and HealthPort Technologies, the company responsible for handling the record requests, overcharged patients and clients by up to $0.50 per page. New York Public Health Law stipulates fees for medical records are not to exceed $0.75 per page and that fees are not to exceed the actual costs incurred by the provider.

[See also: Charging for data: What is too much?]

According to the lawsuit, clients were charged around $0.75 per page when the incurred costs only calculated to $0.25 per page...

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More to come...

The Blog turns 4

With the REC initiative winding down -- heading quietly off the national health IT stage in "no-cost extension" mode, and given that I have retired from the program, it is time to finally execute a name change. I will continue to use the old URL while I lock down the explicit URL custom domain, but the re-direction URL "Blog.KHIT.org" will get you here. I've been mirroring these posts at KHITblog.blogspot.com, but that seems like a duplicative waste of effort and bandwidth, so I may soon quit doing that. Too much hassle to migrate everything in my right-hand Links column.

I originally registered both "RegionalExtensionCenter.blogspot.com" and "RegionalExtensionCenters.blogspot.com" (I use the free Blogger.com), with the latter simply "squatted" to prevent someone else from getting it and causing confusion with my active REC blog work. My masthead title was "The HHS Regional Extension Center Blog," but I always noted that it was not a HHS project, but was a in fact private, independent undertaking. This is what the marketing peeps call "positioning." Today, the simple phrase "REC blog" entered into a Google search (even absent the quotes) returns this blog as the first search result. Didn't pay a penny for that. Meta-tags, baby (among other SEO things).

I launched this effort four years ago today. My initial post was entitled Opportunity for collaboration? ASQ and the RECs. I have to admit to disappointment that I never got any traction with the collaboration. I am a senior member of ASQ and continue to believe it could bring a lot to the healthcare and health IT tables. ASQ Healthcare Division Chair Dr. Joe Fortuna agreed, and invited me into the Division Leadership Council, and we made repeated proposals for pro bono collaboration with ONC.

ONC, though, exuded a "not-invented-here,-not-interested-here" indifference, and the various relevant ASQ Divisions seemed equally uninterested. In fact, the only feedback I got early on after pitching the idea around the Society was a that of being admonished by some dope in the Software Quality Division for "using the ASQ logo without permission"  on my blog.

Seriously, bro'? That the best you can do?

We see how far that got him.

I attended seven major healthcare and Health IT conferences and events in 2013 for the blog (HIMSS13, Health 2.0 Refactored, California State HIT Day, Lean Healthcare Summit, Health 2.0 2013 Annual, NYeC 2013, and the IHI 25th Forum). I was apparently the only ASQ member at any of them. Sigh...

The other weird thing that went down at the launch of this blog was the upshot of my mistake in having had the impolitic temerity of directly contacting my CEO, Marc Bennett with the good news of Dr. Fortuna's interest in helping the REC initiative. I got immediately and publicly upbraided within HealthInsight by our then-REC Executive Director for "exceeding your scope." The soap opera Uproar was pretty lame.

I thought I was gonna get fired after only two months into the job. It was stressful. It sucked. I was blindsided. My relationship with Marc went back to the early '90's, when the Utah Peer Review and Nevada Peer Review were merged to form the bi-state HealthInsight. Marc was on the Communications team and I was an analyst. Way antedated the tenure of this particular ED. I was unaware that I was now not to directly approach His Most Serene High CEO-ness.

Cooler heads prevailed, though, and she never brought it up again. The Big Emergency Inquisition Meeting never happened. 314 posts later I am still blogging, still supporting the now-mostly moribund REC program, and still trying to add content and perspectives of value to the healthcare and Health It spaces. My interests, as regular readers of this blog know full well, go way beyond just IT to process improvement and rational healthcare and Health IT policy.

I don't get paid for any of this. I do it because it's important. I'm "retired" now, and have been joyfully catching up with life with my awesome wife after five years of difficult work separation (and dealing with some of the inevitable chronic health issues that come with my age). I'm behind on some of my prospective KHIT work, but I will catch up. I have two books to finish writing, and more reading to do than I can possible ever keep up with.  Some KHIT stuff remains under wraps 'til I get them done.

Spending some quality time with my guitars, too. And, last night I exercised my live performance photographer chops by attending a benefit performance in Mill Valley at the Throckmorton Theater for the "3 Still Standing" documentary project. I'll be dumping, triaging, and posting my shots from last night to my Facebook page and another of my blogs as soon as I finish here.

Lots of important stuff to continue to write about. And, if you would like to write for/cross-post with the KHIT blog, just let me know. My traffic numbers are pretty decent; you'll get good exposure.

Thank you for your continued interest.

- BobbyG

UPDATE:

Some of my shots from last night, uploaded to my Facebook site.

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More to come...

ICD-9: E922.9, E955.4, E956, E970, Health IT, public health, and the Second Amendment

Imagine coming across an EHR Social History sub-template like this:

Preposterous. First of all, notwithstanding the potential public health data mining utility of such information, it's illegal for a clinician to ask a patient about firearms possession and usage. The gun lobby made sure to have such a proscription inserted in the PPACA. to wit:

PPACA, consolidated:

SEC. 2717 [42 U.S.C. 300gg–17] ENSURING THE QUALITY OF CARE.

(b) WELLNESS AND PREVENTION PROGRAMS -- For purposes of subsection (a)(1)(D), wellness and health promotion activities may include personalized wellness and prevention services, which are coordinated, maintained or delivered by a health care provider, a wellness and prevention plan manager, or a health, wellness or prevention services organization that conducts health risk assessments or offers ongoing face-to-face, telephonic or web-based intervention efforts for each of the program’s participants, and which may include the following wellness and prevention efforts:

(1) Smoking cessation.
(2) Weight management.
(3) Stress management.
(4) Physical fitness.
(5) Nutrition.
(6) Heart disease prevention.
(7) Healthy lifestyle support.
(8) Diabetes prevention.

PROTECTION OF SECOND AMENDMENT GUN RIGHTS -- As added by section 10101(e)(2)

(1) WELLNESS AND PRIVENTION PROGRAMS -- A wellness and health promotion activity implemented under subsection (a)(1)(D) may not require the disclosure or collection of any information relating to—

(A) the presence or storage of a lawfully-possessed firearm or ammunition in the residence or on the property of an individual; or
(B) the lawful use, possession, or storage of a firearm or ammunition by an individual.

(2) LIMITATION ON DATA COLLECTION -- None of the authorities provided to the Secretary under the Patient Protection and Affordable Care Act or an amendment made by that Act shall be construed to authorize or may be used for the collection of any information relating to

(A) the lawful ownership or possession of a firearm or ammunition;
(B) the lawful use of a firearm or ammunition; or
(C) the lawful storage of a firearm or ammunition.

(3) LIMITATION ON DATABASES OR DATABANKS -- None of the authorities provided to the Secretary under the Patient Protection and Affordable Care Act or an amendment made by that Act shall be construed to authorize or may be used to maintain records of individual ownership or possession of a firearm or ammunition.

(4) LIMITATION ON DETERMINATION OF PREMIUM RATES OR ELIGIBILITY FOR HEALTH INSURANCE

A premium rate may not be increased, health insurance coverage may not be denied, and a discount, rebate, or reward offered for participation in a wellness program may not be reduced or withheld under any health benefit plan issued pursuant to or in accordance with the Patient Protection and Affordable Care Act or an amendment made by that Act on the basis of, or on reliance upon—

(A) the lawful ownership or possession of a firearm or ammunition; or
(B) the lawful use or storage of a firearm or ammunition.

(5) LIMITATION ON DATA COLLECTIONS REQUIREMENTS FOR INDIVIDUALS -- No individual shall be required to disclose any information under any data collection activity authorized under the Patient Protection and Affordable Care Act or an amendment made by that Act relating to—

(A) the lawful ownership or possession of a firearm or ammunition; or
(B) the lawful use, possession, or storage of a firearm or ammunition.

[Emphases mine}

Moreover, in today's acrimonious 2nd Amendment climate, irrespective of the foregoing PPACA clauses, any EHR vendor providing such a template would likely get death threats. I've gotten them simply for posting this (below) online in weapons rights-related article comments sections and advocating for repeal of the 2nd Amendment, which I view as a dangerous anachronism -- a relic of a distant and very different time, one whose benefits are nil and lethal risks are empirically incontrovertible and legion.

Not kidding. One Keyboard Commando comedian warned me that "you'll change your attitude after we come and kick your front door down" and sent me URL links to jpegs showing automatic weapons and ammo caches. Another wrote "We'll be over to Antioch soon. Until then, sleep tight."

From a Salon.com article this morning:

Imagine you’re sitting in a restaurant and a loud group of armed men come through the door. They are ostentatiously displaying their weapons, making sure that everyone notices them. Would you feel safe or would you feel in danger? Would you feel comfortable confronting them? If you owned the restaurant could you ask them to leave? These are questions that are facing more and more Americans in their everyday lives as “open carry” enthusiasts descend on public places ostensibly for the sole purpose of exercising their constitutional right to do it. It just makes them feel good, apparently.

For instance, in the wake of the new Georgia law that pretty much makes it legal to carry deadly weapons at all times in all places, parents were alarmed when an armed man showed up at the park where their kids were playing little league baseball and waved his gun around shouting, “Look at my gun!” and “There’s nothing you can do about it.” The police were called and when they arrived they found the man had broken no laws and was perfectly within his rights to do what he did. That was small consolation to the parents, however. Common sense tells anyone that a man waving a gun around in public is dangerous so the parents had no choice but to leave the park.  Freedom for the man with the gun trumps freedom for the parents of kids who feel endangered by him.

After the Sandy Hook elementary school massacre, open carry advocates decided it was a good idea to descend upon Starbucks stores around the country, even in  Newtown where a couple dozen armed demonstrators showed up, to make their political point. There were no incidents.  Why would there be? When an armed citizen decides to exercise his right to bear arms, it would be reckless to exercise your right to free speech if you disagreed with them. But it did cause the CEO of Starbucks to ask very politely if these gun proliferation supporters would kindly not use his stores as the site of their future “statements.” He didn’t ban them from the practice, however. His reason? He didn’t want to put his employees in the position of having to confront armed customers to tell them to leave. Sure, Starbucks might have the “right” to ban guns on private property in theory, but in practice no boss can tell his workers that they must try to evict someone who is carrying a deadly weapon...

Anyone recall Nevada's absurd "Second Amendment Remedies" Senate candidate Sharron Angle? And more recently, we have the maudlin spectacle of the scofflaw Bunkerville Nevada rancher Cliven Bundy, the bumbling, inarticulate hero to a throng of fractious, equally delusional self-appointed "militia" irregulars?

"The second amendment in effect prevents the national government from destroying the militias of the states and preserves a personal right that is centuries old. Joel Barlow, the Connecticut wit and writer, in 1792 sagely declared that a tyrant disarms his subjects to "degrade and oppress" them, knowing that to be unarmed "palsies the hand and brutalizes the mind," with the result that people "lose the power of protecting themselves." But arms privately held can be dangerous to society. President George Washington once reminded Congress that "a free people ought not only be armed but disciplined." He meant that the militias of his time had to be under military authority or, in the frequently used phrase, should be "a well-regulated" militia. However, we no longer depend on militias, a fact that in some respects makes the right to keep and bear arms anachronistic. An armed public is not the means of keeping a democratic government responsible and sensitive to the needs of the people. As the Supreme Court said in 1951, in Dennis v. United States: "That it is within the power of Congress to protect the government of the United States from armed rebellion is a proposition which requires little discussion." Whatever hypothetical value there might be, the Court said, in the notion that a "right" against revolution exists against dictatorial government "is without force where the existing structure of the government provides for peaceful and orderly change." The Court added, "We reject any principle of government helplessness in the face of preparations for revolution, which principle, carried to its logical conclusion, must lead to anarchy."

The right to keep and bear arms still enables citizens to protect themselves against law breakers, but it is a feckless means of opposing a legitimate government. The so-called militias of today that consist of small private armies of self-styled superpatriots are entitled to their firearms but deceive themselves in thinking they can withstand the United States Army. The Second Amendment as they interpret it feeds their dangerous illusions. Even so, the origins of the amendment show that the right to keep and bear arms has an illustrious history connected with freedom even if it is a right that must be regulated."

Professor Leonard W. Levy. Origins of the Bill of Rights (pp. 148-149). Kindle Edition.

From my blog post Force Majeure?

We routinely capture and risk-analyze all manner of "lifestyle" data: smoking, alcohol, drug use, motorcycle-riding, skydiving, etc. I would add firearms possession and use to the EHR SHx templates.

I won't be holding my breath, though. In fact, I'll likely be threatened yet again for even suggesting it. Meanwhile, ICD-9 dx codes E922.9, E955.4, E956, E970 and their kin will continue to populate U.S. hospital EHRs post hoc at a rate of several hundred per day.

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More to come... #NeverAgain

Meaningful Use: who's making bank here?

The feds just released a huge dataset comprised of Meaningful Use attestations by EHR vendor to date. The dictionary:

552,406 data rows in the main sheet. You can grind these sixteen ways to Sunday for useful substrata. Here's my quick Excel tally of the aggregate ranks to date, all years, all programs (EPs, EHs, Medicare, Medicaid), top 25:

An "EPIC situation," no? While their relative share has decreased as the program has matured, they still rule, far and away.

Note that the top 10 comprise ~2/3rds of the attestation action and the top 25 nearly 80%. Interesting that the freebie Practice Fusion is ranked 9th (beating out even Jonathan Bush's anti-REC athenahealth).

I wonder how much of the $22.9 billion MU money paid out to date [1] passed through to the vendors, and [2] cycled back around in taxes? To the latter question, were it, say, ~20%, you'd have a bit more than $5 billion coming back to the Treasury.

I'd also like to know how much the Meaningful Use program has cost the taxpayers in total, net (incentive payments, RECs, administrative costs at ONC and CMS, etc).

HIMSS ON THE REC FUTURE

Just out (pdf).

In August of 2013, the Office of the National Coordinator for Health Information Technology (ONC) announced the opportunity for a no-cost extension of the remaining funds available through the American Recovery and Reinvestment Act of 2009 (ARRA).

In order to assess how Regional Extension Centers (RECs) are going to prepare for a future in which funding was uncertain, HIMSS developed a study to evaluate organizations’ preparedness to sustain operations in the future. This survey assesses a number of factors including key information technology (IT) priorities, the business issues impacting RECs, and the types of strategic relationships organizations are creating to sustain viability...

By all accounts, the REC program has been extremely successful to date. Over 147,000 providers are currently enrolled with a REC. Of these, more than 124,000 are now live on an EHR and more than 70,000 have demonstrated Meaningful Use. Additionally, 872 Critical Access Hospitals (CRHs)/SRHs have been paid for MU1. Yet, as the ARRA funding winds down, there are questions around the financial sustainability of these organizations.

Findings from the 2014 HIMSS Regional Extension Center Study suggest executives are optimistic about the future of RECs. For example, 85 percent of executives responding to the survey indicated they did not expect to close their doors, despite the fact that 28 percent of the 36 executives responding to the 2014 HIMSS Regional Extension Center Study indicated that their funding ran out prior to the end of February 2014.

Indeed, RECs are moving forward with a number of strategies in which to ensure they can continue to fulfill their mission. Approximately three-quarters (72 percent) had applied for a no-cost extension of their ONC funding. Nearly half are creating strategic partnerships with other organizations in their service area. Finally, approximately half reported that they have received state funding to maintain operations...

...[A] handful of the RECs responding to this study noted that they have already been generating revenue streams to sustain operations going forward. One respondent noted that they are earning money from “provider membership fees, consulting services, selling IT resources and IP to other RECs and government entities”. This is not an easy model to achieve, and not all respondents believed that this model will yield full-blown sustainability. One respondent suggested that “the level of interest remains high among providers to continue with Stage 2 and embark in PCMH (patient centered medical home) recognition; the revenue generation from such activities is insufficient to maintain full-blown REC services”. Another noted that many organizations, including “RECs are not accustomed to looking for sustainability models nor have the infrastructure to operate as a for-profit entity. This has been the biggest concern with being a REC”. Finally, a respondent commented that “their organization will not commit to building a sustainable model”.

I continue to bemoan the short-sightedness of HHS not infusing the RECs with funding sufficient to get them and their clients through Stage 2.

A NEW BOOK ON ORDER

From the Thedacare Center for Healthcare Value.

If the history of revolution around the globe has taught us one thing, it is this: leadership succeeds only when it learns to evolve. No matter how necessary and just the rebellion, when the dust clears, the leaders need to govern, to make systems work in order to keep a country or an organization running. And that requires an ongoing willingness to change and adapt.

For nearly a decade, the lean revolution in healthcare centered on improving quality and reducing costs in advance of the huge systemic changes we all knew were coming.With healthcare bills bankrupting families and threatening to do the same to the United States, major hospitals and health-system leaders began experimenting with various improvement methods. A healthy percentage of those organizations embraced lean thinking and adopted tools and methods from the Toyota Production System...

It turns out that revolutionary change is necessary, but it is not sufficient.

The kinds of change that come from rapid process improvements are essential but are only the first steps of a lean journey.The core work of the transformation is changing the culture—changing how we respond to problems, how we think about patients, how we interact with each other. This is an issue not only in healthcare organizations; we have also seen manufacturing, service companies, retailers, and government agencies all struggle with the same issues.When lean thinking goes only skin deep and management does not change, improvements cannot be sustained, and savings never quite hit the bottom line...

We are finally moving beyond the age of heroes chasing exceptions and are looking forward to innovations in management that will move us even further ahead.The faster we can implement these ideas, the better it will be for all of us—patients, physicians, nurses, managers, and everyone who pays for healthcare.

—John Toussaint, MD Founder and CEO,ThedaCare Center for Healthcare Value, January 2014

Not available in eBook format. Yet.
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OFF-TOPIC ERRATUM ON "MAKING BANK"

I recently finished Nomi Prins excellent, best-selling history of the modern U.S. financial system, "All the Presidents' Bankers."

Read my Amazon review here. Highly recommended. I have some personal history with the often slimy FIRE Sector (Finance, Insurance, and Real Estate).

Playing off the phrase "making bank," I've been bugging Ms. Prins and her agent with this idea.

My quickie Photoshop. A no-brainer, this one. She is utterly gracious to put up with (and respond to) my emails.

I can't help it; I just have ideas all the time. I mostly just give them away, e.g., see this one. And this old one.
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MU INFOGRAPHIC

nuemd.com

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More to come...