Wednesday March 2nd will be my first year anniversary back with HealthInsight, this time amid the REC initiative. The developments keep coming fast and furious, with accelerating pace. There will continue to be no shortage of things to ponder and post on (e.g., how about this? "The Connected Patient: Charting the Vital Signs of Remote Health Monitoring" [PDF] i.e., anytime/anywhere telemetry -- or, as the more paranoid might say, "ObamaCare medical surveillance").
Last week I was pleased to be asked to give a presentation to a class of med students at Touro University. My PPT deck is here. My opening slides below...
LOL. I took a big canvas shopping bag full of "props" with me for some ancillary IT-related Show & Tell. Told the kids I felt like Carrot Top as I rifled through it. Below, a couple of my props, my way expensive 1986 IBM-XT Seagate 20 megabyte hard drive (yeah, I took the drive cover off, it's just a museum piece now), along with my company Blackberry, and (bottom right) a freebie 2 gigabyte USB flash drive I acquired at some EHR event last year (100 times the capacity of my old disk drive, cheap enough to give away nowadays).
My Medical Director Dr. Bill Berliner had come along to give some follow-on remarks (I jokingly introduced him as "my Iraqi Minder"). He picked up my old hard drive prop and told the students about the time when he was a med student, and got to tour the UNIVAC computer site -- which occupied an entire building.
More to come, including the possible ACO/PCMH/"payment bundling" implications of the dust-up now making the rounds about the "RUC."
Jeez... Click the graphic above for the source (PDF, American College of Radiation Oncology).
Also, recent wisecracks about the Meaningful Use program becoming merely "Clicking For Cash" (it gives me no pleasure to have to admit that the phrase has a good bit of resonance).
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MONDAY MORNING UPDATE
From BNet "Jobs Are Plentiful in Healthcare — the Only Question is For How Long"
Department of redundant occupations department
Now let’s suppose, for a minute, that accountable care organizations emerge and begin to take financial responsibility for care in Michigan and other parts of the country. If these ACOs pay hospitals and doctors from an annual budget, they’ll need experienced accountants and people who know how to run information systems. But billers and coders will be unnecessary. In other words, an army of healthcare workers — perhaps more numerous than clinicians — could become redundant.
On the other hand, other categories would grow in importance. ACOs would need far more care managers and patient educators than we have today. And health IT would continue to add positions as it became woven into the fabric of health care. It’s already doing so. As Secretary of Health and Human Services Kathleen Sebelius pointed out in a keynote speech at a recent Orlando conference, “Health IT is one of our most promising new frontiers.”
She’s right, and more investors are committing to health IT as providers gear up to show “meaningful use” and garner up to $27 billion in government incentives. While it’s unclear how many new are jobs being created, HHS is providing money to community colleges to train up to 10,000 new IT technicians per year...
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ERRATA
INTERESTING INTERACTIVE WEBSITE
Adroitly using health data...
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FINALLY,
AN EHR MEANINGFUL USE
USER MANUAL
[Neither an express nor implied endorsement of this product, btw]
Monday evening, Feb 28th. We were just given access to an eCW ONC-certified version (9.0) remote desktop "sandbox" via which to kick the product's tires and learn our way around in order to better serve our REC providers, accompanied by a thorough 241 page PDF file instruction manual replete with workflow steps and screen shots. This will really help us to assist our REC clients on this particular EHR platform.
But...
When I first logged in and searched out one of the simpler MU compliance criteria ("Record Smoking Status," regarding which I've posted before), The NIST-specified six mutually exclusive response options were not there (in the default Social History template). Instead were simply "current smoker," "former smoker," and "never smoker."
Well, here's why (pg 45 of the manual):
Configuring Tobacco Use Structured Data Items
The appropriate Structured Data items must be properly mapped in order to record a patient’s tobacco use from the Progress Notes.
Note: In order to map tobacco use Structured Data items, they must first be created in the local system. For more information, refer to the section titled Creating Smoking Status Structured Data Items on page 169.
IMPORTANT! These Structured Data items are automatically mapped for new installations of eClinicalWorks. Only existing clients that are being upgraded need to configure Structured Data items...
OK. In other words, unless you're an eCW client buying 9.0 new (either converting from paper or from a different system), there's some onsite MU conversion setup data mapping to do by the client in advance of your attestation period (while the database upgrade aspect of this makes perfect sense, eCW doesn't do this for you). I'm still going through the manual to determine what other setup scut work lurks with respect to other MU criteria (one cautionary thing I've noted is that they list five different navigation paths for doing CPOE).
In fairness, notwithstanding the potential hassle factor here, overall this really is a valuable MU user guide -- the sort of thing that every ONC-certified vendor needs to supply to their clients (if you've read all of my posts you may recall that I noted previously that I would have made such a condition of certification).
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POLICY STUFF: THE SCARY ACO
(from "THE HMO IN YOUR FUTURE")
'ACOs have been called “HMOs on steroids.” They will have capitated payments and, like the traditional HMO, the ACO will get to keep any money it doesn’t spend. But the organization will also incorporate all the latest fads in health policy: electronic medical records (EMRs), pay-for-performance (P4P) incentives, quality report cards, etc.'
HIT is a "fad"?
'Evidence-based policy would admit ignorance about what works and why, and would let a thousand flowers bloom. It would pay more for low-cost, high-quality care, regardless of how it is achieved.'
OK, I see, we don't know what constitutes clinical quality ("what works" -- not that I wholly disagree, but that's the point of pushing out HIT/HIE), but, like obscenity, we'll somehow know it when we see it. But, only, if it comes out of the for-profit sector -- which, of course, will magnanimously and freely promulgate its findings, notwithstanding the otherwise differential "business intelligence" value of the data.
MARCH 2nd UPDATE APROPOS OF ACOs and HIE
From FierceHealthIT:
Insurance companies' leap into HIE field will change health IT
...David Classen, MD, senior partner at consulting firm CSC, says that health plans are "looking at their future business model under healthcare reform." They view health information exchange (HIE) as an implementation tool for the value-based reimbursement methods that are coming, he says. Accountable care organizations (ACOs) also will be a big issue, and Classen expects hospitals to partner with health plans to create ACOs. Health plans have core competencies that most providers lack but will need for ACOs, such as the ability to analyze data and manage care, he notes.
Steve Tolle, senior vice president of provider markets for Ingenix, states that United's desire to partner with ACOs and to help providers form these organizations are among the reasons for Ingenix's acquisition of Axolotl. The company's purchases of other firms like Lighthouse MD (now CareTracker), Picis and A-Life similarly reflect its desire "to get close to the doctor and hospital workflow."
Tolle points out that Ingenix can bring "payer analytics" to bear on ACOs, helping them with care coordination and management. Axolotl will supply clinical data that can be analyzed and used in decision support. He adds that doctors need not fear that their patient data will be made available to United. Ingenix serves many payers and understands how to maintain data security, he says...
Think about all that.
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MEANINGFUL USE, HIT/HIE, AND "PRIVACY"
"Patient privacy safeguards are woefully missing from initial draft criteria for Stages 2 and 3 of meaningful use, according to Deborah Peel, M.D., founder of the Patient Privacy Rights organization."
Interesting. I've been following "privacy" issues since before graduate school. See here, and here, as well. Ironic, in a way, given that I'm rather public; I've had the same web address and associated core email address since I was in grad school (1993-98), and given that I have both MySpace and Facebook pages. And, moreover, since I willingly revealed some very personal information in my painful web essay "1 in 3."
What are the legitimate concerns?
Some ought be obvious. A for-profit health insurance company still wants to find every possible legally defensible reason for disqualifying you from coverage (even after they've started taking your money). A prospective employer wants to likewise learn of your possible "dirt" (even if it cannot be substantiated). In a world still of ~five applicants for every available position in the U.S., odds of your possibly becoming "false positive" collateral damage, well, that's your problem, given the reality of your having no substantive recourse should they get it wrong (or even your unlikely awareness of the fact that they got it wrong). More mundanely, marketers of every stripe are looking to more effectively sell you stuff. Are you an indentfiable prospective statins, cholesterol, diabetic, PAD, "erectile dysfunction" (or other "worried well") customer, etc?
More on all of this shortly. For now, Google "Moral Hazard" and "Adverse Selection." You can also Google "Deborah C. Peel" and "Latanya Sweeney," the latter of whom is widely notable for her claim (published, no less, in "Scientific American" some years ago) that all she needs is your gender, date of birth, and ZIP code to have a better than 80% chance of identifying you.
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HIT "USABILITY" UPDATES IN THE WAKE OF HIMSS11
First, from an interview with ONC's Farzad Mostashari, MD, deputy national coordinator for health IT:
Q: How can ONC and the Centers for Medicare & Medicaid Services (CMS) enforce usability of EHRs? It shouldn't be so complicated that it takes extensive training and refreshers every six months to make EHRs work.
A: I don’t think we should set standards for what a user interface looks like. You don’t want government telling you what it should be. We need more transparency, with agreed-upon metrics for measuring usability first. That’s what we’re doing this year. By next year's HIMSS, there will be--as a result of an open process with industry participation and comments--some initial guidelines and metrics around aspects of usability and measurability. We need to get the current systems to have incentive for usability and transparency. We’ve gone too far not to have some guidelines.
Nothing exactly radical there. I've commented on "usability" issues before (see, e.g., my January 2nd, 2011 post). It 's a net good thing that they're finally paying some attention.
Then there was this, reported by John Moore over at The Health Care Blog:
Some Miscellaneous HIMSS Snippets:
Much to the chagrin of virtually every EHR vendor at HIMSS (still far too many and I just can’t even begin to figure out how they all stay in business) Chuck Friedman of ONC announced in his presentation on Sunday that they are looking into usability testing of EHRs as part of certification process [PDF]. Spoke to someone from NIST who told me this is a very serious consideration and they are putting in place the necessary pieces to make it happen.
OK. But, look at this slide of Dr. Friedman's...
Your tax dollars at work.
WHAT? I'm sorry, all attempts at (duly "branded") Powerpoint cutesy-ness aside, that is just flat wrong. ("Rigorability"? LOL.)
Another beauty from his presentation: "End users of health IT will ideally form a seamless cognitive and psychomotor bond with the technology."
Yeah, "we are all The Matrix."
Or, how about "fighter jet and pilot become One"?
In fairness, I wasn't there, and there's no YouTube of his presentation, so maybe it was pretty good overall. Still, why not just stick to the basics? If it ain't broke, don't fix it.
Look, "Usability" simply refers to three overlapping (for better or worse) and mutually reinforcing core elements.
- Effectiveness: the extent to which an application achieves its intended purpose, i.e., by capturing (and providing the capability for reporting back out) the requisite breadth of data;
- Efficiency: the end-user operational task times-to-completion and associated error rates;
- User experience/satisfaction: the more "subjective" / cognitive component. The extent to which using the app gives you a migraine or elevated BP.
Don't take my Great Unwashed word for it. See NISTIR 7714, issued just back in November (start with page 10).
See also "4.4. What Usability is Not" (pg 13 et seq).
"If usability is defined as above, it can be instructive to distance usability from some common misunderstandings.
- Usability is not User Acceptance Testing (UAT). UAT involves taking use cases or procedures for how the system was designed to perform. and ensuring that someone who follows the procedure gets the intended result. That is, UAT examines whether the system is capable of performing all specified functions but not necessarily how well the system supports users in performing those functions..."
"UAT" rather precisely describes the ONC-ATCB HIT certification process, no? Read through the NIST Cert stds.
On the topic, check this out.
How We're Botching Our Attempts to Redesign the Healthcare System
- Roderick McMullen
Fixing our floundering healthcare system may be the single most complex design challenge ever. Bad design forced Dr. Bruce Mason (not his real name - BG), the clinical director of a large outpatient department at one of the preeminent teaching hospitals in the country, to force out one of the best doctors in his department. The doctor who was let go, Dr. Davis, didn’t violate the doctor’s code of ethics. He wasn’t old enough to retire. He hadn’t been sued for malpractice. In fact, he was a renowned practitioner.
Ultimately, Dr. Davis failed because he was unable to produce the required levels of documentation in the hospital’s version of an Electronic Health Record (EHR)...
Interesting.
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LOOKING BACK ON "USABILITY":
THE LATE JEF RASKIN (father of AZA)
The "father of the Macintosh interface"...
A summary of design rules
Jef Raskin
The first principle.
When using a product to help you do a task, the product should only help and never distract you from the task.
Definition
A gesture is an action that you finish without conscious thought once you have started it. Example: For a beginning typist, typing the letter "t" is a gesture. For a more experienced typist, typing the word "the" is a gesture.
Commentary
Designing a human-machine interface demands that both the human and the machine be understood as well as possible. A understanding of the relevant portions of cognitive psychology, ergonomics, and cognetics is essential. That is not all that is needed, but it is a prerequisite.
Rule 1. An interface should be habituatingCommentary
If the interface can be operated habitually then, after you have used it for a while, its use becomes automatic and you can release all your attention to the task you are trying to achieve. Any interface will have elements that are habituating, but the principle here is to make the entire interface habituating.
Rule 1a. To make an interface habituating, it must be modeless
Commentary
Modes exist where the same gesture yields different results depending on system state at a time when your attention is not on system state. In the presence of modes, you will sometimes make mode errors, where you make a gesture intending to have one result but get a different and unexpected result, distracting you from your task.Rule 1b. To make an interface habituating, it must be monotonous. Commentary
"Monotony" here is a technical term meaning that you do not have to choose among multiple gestures to achieve a particular sub-task. Crudely, there should be only one way to achieve a single-gesture subtask.
The second principle: An interface should be reliable
Commentary
Aside from not crashing, the system should never lose any work you have done or any information you have received or retrieved, even if you make a mistake or are forgetful. This is often not thought of as a property of an interface, but one can build a reliable interface on top of an unreliable system (of the order of unreliability of todays operating systems).
Rule 2:
The system should neither lose your work nor through inaction allow your work to be lost.
The third principle
An interface should be efficient and as simple as possible.
Commentary
Time is an irreplaceable asset. An interface should not take more of your time than is necessary, either in use or in learning.
Rule 3
Good engineering practices should be applied to interface design. Quantitative measures should be used, and an interface should be close to its theoretical minimum in terms of the time it takes to do an operation.
Commentary
The GOMS model and information theoretic measures of efficiency (to name two particular techniques among many) must be mastered and used by interface designers. Another set of techniques and measures can be used to help judge learnability.
The fourth principle
The suitability of an interface can only be determined by testing.
Commentary
All of the theory in the world, and the wisest guru, cannot always predict how an interface will work in practice. One must test, objectively observe, and modify the interface if testing shows that users have difficulties. It is never the user's fault, but also remember that people find it difficult to change, so difficulties based on previous habits may not be dispositive.
The fifth principle An interface should be pleasant in tone and visually attractive.
Commentary
How messages are phrased is important, how the interface looks is also important. But these are of secondary importance in terms of task completion. When use of the interface has become habitual, these elements go unnoticed. All of the principles, if followed, create learnable interfaces.
Summary
An interface should be effective, habituating, reliable, efficient, and tested. To the extent that doing so does not conflict with these essentials, an interface should also be attractive.
See also
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Usability. Not exactly a new topic. But, it'll be interesting to see how ONC will manage to develop and administer appropriate EHR "usability" certification standards this year and incorporate them into the already hugely contentious proposed Stage 2 Meaningful use criteria (and concomitant HIT vendor "UAT" re-certification).
It's worth keeping in mind that the maximum MU reimbursement incentives are skewed in favor of the earliest participants, and decline year after year (e.g., below, example on the Medicare provider side), so, at the same piling on more complex and operationally onerous requirements will indeed comprise a challenge to the long-term viability of the program (and this assumes Congress won't be able to rescind the MU money now on the table).
March 3rd a.m. news update:
Meaningful use updates available by e-mail
Physicians and health care organizations can sign up with CMS for news about the payment process and tips on wading through the incentive program.
By PAMELA LEWIS DOLAN, amednews staff. Posted March 3, 2011.
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OFF ON A BIT OF A TANGENT, JUST 'CAUSE
Ah, the jousting within science, e.g., the "Frequentist" vs the "Bayesian" (count me in the latter camp, net).
As I've noted, one of my favorite daily hangs is sciencebasedmedcine.org. Apropos of "Evidence-Based Medicine" (EBM), I love this March 4th post:
Of SBM and EBM Redux. Part IV, Continued: More Cochrane and a little Bayes...
Bayes Revisited
A few years ago I posted three essays about Bayesian inference... The salient points are these:
- Bayes’s Theorem is the solution to the problem of inductive inference, which is how medical research (and most science) proceeds: we want to know the probability of our hypothesis being true given the data generated by the experiment in question.
- Frequentist inference, which is typically used for medical research, applies to deductive reasoning: it tells us the probability of a set of data given the truth of a hypothesis. To use it to judge the probability of the truth of that hypothesis given a set of data is illogical: the fallacy of the transposed conditional.
- Frequentist inference, furthermore, is based on assumptions that defy reality: that there have been an infinite number of identically designed, randomized experiments (or other sort of random sampling), without error or bias.
- Bayes’s Theorem formally incorporates, in its “prior probability” term, information other than the results of the experiment. This is the sticking point for many in the EBM crowd: they consider prior probability estimates, which are at least partially subjective, to be arbitrary, capricious, untrustworthy, and—paradoxically, because it is science that is ignored in the breach—unscientific.
- Nevertheless, prior probability matters whether we like it or not, and whether we can estimate it with any certainty or not. If the prior probability is high, even modest experimental evidence supporting a new hypothesis deserves to be taken seriously; if it is low, the experimental evidence must be correspondingly robust to warrant taking the hypothesis seriously. If the prior probability is infinitesimal, the experimental evidence must approach infinity to warrant taking the hypothesis seriously.
- Frequentist methods lack a formal measure of prior probability, which contributes to the seductive but erroneous belief that “conclusions can be produced…without consideration of information from outside the experiment.”
- The Bayes Factor is a term in the theorem that is based entirely on data, and is thus an objective measure of experimental evidence. Bayes factors, in the words of Dr. Goodman, "show that P values greatly overstate the evidence against the null hypothesis."
Awesome. I've cited Bayes before, e.g.,
As I wrote, "Relax, it's only algebra."
- Let p(t|+) = the probability of being a true positive ("t") given a positive test finding (+);
- Let p(+|t) = the probability of testing positive (+) given that you are in fact a "t";
- Let p(t) = the "prevalence" of true positives, e.g., the proportion of true positives in the aggregate population;
- Let p(+|f) = the probability of testing positive (+) given that you are in fact NOT a "t" (i.e., the false positive rate);
- Let p(f) = 1 - p(t), the proportion of true negatives in the population.
A concrete example:
It goes to both the empirically established "accuracy" of a test (how reliably it can return the value of a known reference standard) and the "prevalence" (proportion) of true positives in a population. Not widely enough understood. In practical terms, should you test "positive" for some rare condition, you might want to question the extent of the "known accuracy" of the assay (and how much it varies in production from lab to lab) before getting all bent out of shape (ruminate on #5 above). There's a danger, particularly in light of the new national push for HIT-enabled CER, for those (both researchers and patients) who take lab results at face value.
"[P]rior probability matters whether we like it or not, and whether we can estimate it with any certainty or not."
Indeed.
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AND THE HITS JUST KEEP ON COMING...
Click above for the full article.
Hans Rosling's 200 Countries,
200 Years, 4 Minutes - The Joy of Stats - BBC Four
From poor and sick to healthy and wealthy.
Pretty cool. Go to Gapminder.org for more.
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APROPOS OF WHERE THIS POST STARTED,
COOL BOOK
Props to my email correspondent pal health care Futurist Joe Flower for turning me on to this awesome, radically simple yet profound book.
[ click the book cover image for the author's website ]
While I wish I'd read it prior to giving my Touro University presentation, I'm gratified to know that I'd intuitively gotten some of the Jobsian presentation principles right, -- i.e., [Numero Uno] attempt to answer the audiences' question "why should I care about any of this?" right at the outset (i.e., "what's in this for me?"). Then build your case via a "story," using core "story" principles: Conflict, Villain(s), Hero, and Resolution.
Yeah. A widely known trial lawyer maxim is 'he/she with the best story wins."Keep it simple. Headline that could fit in a Twitter post. The Power of Three. Zen. Less Is More. No bullet lists. Use images. Use props. Eye contact. Body language. Vocal inflection variations. Never Let Them See You Sweat (i.e., woodshed your material so much that it's virtually autopilot for you, so the likelihood of sweating it out is next-to-nil). Be self-deprecating. Have fun.
Highly recommended read. Everyone in my REC (and ONC) ought to read this book. There are also a number of nice summary / reinforcing YouTube clips online, e.g..
BTW, Joe also recommended to me "Presentation Zen," which I already had in my book stash.
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CMS will begin taking MU attestations for year one incentive fund remittances on April 18th. I would expect that they will make a big PR play on it to help entice the laggard into participation.
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LOL. Click the image to enlarge. When I go into the mostly small primary care ambulatory clinics I serve and bring up "workflow," I usually get the MEGO blank stares. This is from a booklet I'm assembling for my REC to try to cut to the chase and sell the concept to those lacking any clue or interest (i.e., most of them). Irrespective of the nominal swimlanes and/or nested complexity of any process, this is really the core logic.
