Mulligan: 7.5 months into my REC adventure

I was re-hired on March 2nd by HealthInsight for the REC initiative. Been a most intense, interesting, and at times sleep-deprivingly frustrating experience. I have a number of developments and concerns on which to report. I started this post on September 3rd, but my heavy work and travel schedule and a bout of illness have necessitated a Mulligan. So, here we go again.

As with most of my blogging, this will necessarily be incremental as time permits, as this is a personal, assiduously off-the-clock independent project (albeit rather unloved by one of my Sups nonetheless) in support of the REC effort.

Among other things, I will reflect on my experience at the recent Salt Lake City REC Regional ONC Conference, the subsequent inaugural (sparsely attended) "Digital Medical Office of the Future Conference" in Las Vegas, the interesting October 12th Nevada Health Care Forum 2010, as well policy developments in the wake of the release of the 864 page Stage One Meaningful Use Final Rule and the subsequent announcements of both the release of NIST test specifications for ARRA Certification of EHR systems and the first two Certification Registrars -- CCHIT and The Drummond Group (I believe there is now a 3rd Registrar in place as well).

First...


You ought read this timely, excellent piece ever so closely, yellow highlighter and red pen at the ready (click the title image above for a PDF copy). A couple of takeaways: While everyone is focally anguishing over the intensified HIPAA privacy and security implications of HIT going forward, this legal writer (a medical liability attorney) points out that

• routine use of HIT (inclusive of both EHR and HIE) will likely become an integral part of accepted legal "standards of care," e.g., "it seems logical that a liability inquiry will turn to how information technology has been used by clinicians and whether that use itself comports with the standard of care for maintaining and using medical records."
• relatedly, issues of data accuracy, security (specifically with respect to inadvertent or intentional data corruption), and retention for "E-Discovery" are likely to find their way into court (including issues relating to the net probative value of the soon-to-be-mandatory always-on "audit logs" in certified EHR systems).
  

Calls continue for FDA regulation of EHRs as de facto "medical devices," and there are now legislative stirrings for mandating EHR use a condition of medical licensure.

"...from the health care law and medical liability perspective, EHRs mark a fundamental shift in how we use and collect electronic medical evidence, as well as what we must think about when anticipating health care litigation."

A lot to consider here. Download it and read it carefully.
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BTW, I'd like to give an unsolicited shout-out to fellow (literally neighboring) HIT blogger John Lynn. I check his blogs every day (among the numerous others within which I routinely lurk), and comment there regularly in the spirit of engaging constructive dialogue. Click the images below for direct links (they're also in my "Links" column on the right).


Also: The NIST EHR Certification test SOPs:

There are 46 SOPs, addressing the full range of Meaningful Use criteria across outpatient and inpatient settings, e.g.,

§170.302 (g) Smoking status. Enable a user to electronically record, modify, and retrieve the smoking status of a patient. Smoking status types must include: current every day smoker; current some day smoker; former smoker; never smoker; smoker, current status unknown; unknown if ever smoked.

The standard here is silent on exactly how the options are to be presented to the EHR user. Mutually exclusive "radio buttons"? A drop-down menu choice list? (It is also silent on the underlying data structure -- which I would assume to be mostly SQL RDBMS tables. The entries could be stored literally as text strings [all lower case, as per the std?], or they could be recorded in binary 0/1 integer fields mapped to the "human-readable structured data" responses a user sees on the screen or in a printed report?)

One could also interpret this standard to mean that some pre- ONC certification EHRs already comply, with no upgrade revision necessary for this particularly criterion. See, for example, a screen shot I clipped of the current release of e-MDs:

One could, I suppose, manually (or via a macro) enter "current every day smoker" or one of the MU-requisite forced-choice alternatives into this catch-all "Tobacco/Alcohol/Supplements" free-text box.

Cleanly and efficiently tabulating/reporting the data back out, however, would likely be a mess. Let us count the ways user could (and would) misspell these.

One more example:

§170.302 (h) Incorporate laboratory test results.

1) Receive results. Electronically receive clinical laboratory test results in a structured format and display such results in human readable format.

2) Display test report information. Electronically display all the information for a test report specified at 42 CFR 493.1291(c)(1) through (7).

3) Incorporate results. Electronically attribute, associate, or link a laboratory test result to a laboratory order or patient record.

A question arose recently regarding lab findings that typically come back in as simply "positive" or "negative" (or "POS"/"NEG") or, equivalently, "present" or "not found/not present" etc text. Again, the standard is silent, in that the specified "test data sets" all simply provide numeric lab values for the variety of assay parameters the EHR must be able to replicate for certification.

The phrase "human-readable structured data," it should be apparent, goes beyond numeric values, and the standard does not address this.

[BTW: It should be noted that not all of the MU criteria involve capturing numerator data in the EHRs for subsequent reporting. e.g., §170.302(a) Drug-drug, drug-allergy interaction checks, §170.302(o) Access Control, §170.302(p) Emergency Access, §170.302(q) Automatic Log-off, §170.302(r) Audit Log, etc. Just to observe that, for the criteria that do involve numerator/denominator data, effective analysis and reporting assume uniform data input, as no one in clinical settings is likely going to have time or inclination to to any post-hoc "data cleaning."]

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AUGUST ONC REGIONAL CONFERENCE IN SALT LAKE CITY

The final of five 2010 ONC regional meetings. I was struck by the large number of very young (to me) ONC staffers, an ebullient, brash cadre of ambitious MBAs and MPHs mostly, full of evangelistic energy and smarts (but most of them relatively short on direct operational HIT experience). I wanted to card some of these people during the evening open bar reception.

It was very well attended, and very busy; a packed agenda, the most contentious of which was the "Meaningful Use Deep Dive" session. A harbinger of the frequently inscrutable, vexing interpretations of the Meaningful Use criteria that continue to this day. At our REC we continue to hold bi-monthly Meaningful Use Study Group teleconference sessions to help us clarify issues as they emerge during interaction with our providers.

One fun activity during the Plenary Session: "Meaningful Use Jeopardy," LOL.

Your tax dollars at work. They did a good job with this, I have to say. The questions spanned the gamut, and were often very tough. My HealthInsight REC tied for first place.

One of the principal ONC operatives present was Thomas Tsang, M.D., M.P.H., Medical Director, Meaningful Use. I approached him during an intermission to ask why the RECs had not been made mandatory as part of the legislation (regarding which he'd been involved in drafting), lamenting that we were burning up a lot of FTE "marketing" our federally subsidized services, in lieu of focusing on actual technical assistance activities -- that it opened the administration up to the criticism of just wildly throwing money at the problem at cross-purposes.

He ever so politely blew me off, responding that "you are federal grantees, you are not part of the federal government."

Right. Well, my very same not-for-profit federal contractor company is also the NV-UT Medicare QIO, and our QA/beneficiary protection "statutory side," while equally "not [directly] part of the federal government" is nonetheless mandatory for providers who serve Medicare beneficiaries. You provide medical services to Medicare benes, you will submit to QIO statutory review purview, period.

I dropped the line of inquiry. He obviously didn't want to hear it, and it was moot by now in any event.

THE WORKFLOW SESSION

The MassPro QIO people led this session. It was very good, though much of the material struck me as "warmed-over DOQ-IT" (the now discontinued CMS HIT initiative within I which I worked during 2005-2007). My concern here is that both the ends and the scale of the Meaningful Use program require a significant re-thinking of the "adoption support" workflow M.O.

Notwithstanding, one has to give MassPro credit for sharing their considerable experience and expertise.
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The HITRC

When I began this blog series, I noted that the Health IT Research Center, "whose purpose is to gather relevant information on effective practices from a wide variety of sources across the country and help the Regional Extension Centers (RECs) collaborate with one another and with relevant stakeholders to identify and share best practices in EHR adoption, effective use, and provider support" was not slated to be in place until FY 2012. Happily, though, I can report that this online resource is in fact now up and running, with REC staff nationwide contributing and sharing tools and ideas.

Not without bursts of silliness here and there, though. Some REC folks have had the earnest idea of doing "SWOT analysis" on the Meaningful Use criteria themselves. This is what ensues, I suppose, when MBAs go unsupervised. SWOT analysis is a tactical tool for assessing the competitive characteristics of organizations.

How about mere "pros and cons," folks? To me, this is somewhat methodologically akin to calculating Likert Scale data out to four decimal places (and then maybe even doing regression analyses on them, just because Excel makes it so easy).

Another bit of puzzlement. Someone enthusiastically posted to the HITRC regarding the nascent "ONC branding logo." I quickly grabbed the image and merged it with our corporate logo for a quick bit of Photoshop "co-branding" imagery (at the request of my Sup)...

Only to be subsequently informed that the ONC logo was not yet available for REC use, as it was still "undergoing the trademarking process."

A taxpayer-funded graphic. "Trademarked"?

Legalistic "ownership" and "use in commerce" hair-splitting aside, why not just slap the common law "TM" on it and put it to use? Awaiting granting of a "registered" ® symbol seems pointless, given the typical long timeline (not to mention the expense) of that process. A good number of RECs may well have folded their tents by "® Day."

Whatever. Your tax dollars at work.
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SEPTEMBER:
THE INAUGURAL "DIGITAL MEDICAL OFFICE THE THE FUTURE" CONFERENCE.

Well, can you say "underwhelming"?

They gave us 40 comps. Telling, right there, I suppose. Obviously, they hoped we'd spread them around to our REC client and prospect providers. A tough sell here in southern Nevada, asking marginally viable docs to give up a couple of days of billable visits to come and hear yet more rah-rah about the virtues of HIT.

When I arrived and looked in the attendee packet, there was a total of 88 people on the attendee list -- seven of which were us (from HealthInsight). The total actual body count was more like 60 or so. As I ambled about the expansive lower-level conference center of Green Vally Ranch, the quietude evoked scenes from "The Shining."

It was during this conference that I got my first taste of the overt vested-commercial-interest REC-bashing that has ensued. A presenter, who was also a presentation track chair (a private EHR consultant whom I will not name), launched into his session with an inappropriate slide deriding the "Socialist" federal HIT program, whereafter he went on to mischaracterize the RECs as all "choosing the EHRS" for their REC provider clients and all "driving doctors toward SaaS model platforms" (web-based EHRs). His presentation also inappropriately gave ample play to his own EHR evaluation website and newsletter and books.

I had to bite my tongue.
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REC BASHING

It picked up steam here, in an online article entitled "Five Reasons We Think RECs are RECkless," written by one Houston Neal, a person with no apparent experience in HIT (I emailed him to ask. He deflected with a vague non-answer, while at the same time having the amazing chutzpah to ask me if I'd have his derogatory article linked on our HealthInsight website).

His summary allegation:

In our opinion, there are five fundamental flaws with RECs:

1. Doctor’s [sic] aren’t moving as fast as the money is flowing
2. The market already delivers on what RECs promise
3. “Preferred vendor lists” limit choice and free markets
4. RECs won’t get doctors to “meaningful use” fast enough
5. The REC model leads to under-staffed, ephemeral entities

Anyone who has troubled themselves to fully read my REC blog to date has to admit -- if honest -- that I am no Pollyana REC cheerleader, but, this this stuff is loaded down with dilettante and ulterior motive Straw Men. I cannot speak for every REC, but I bristle at the broad-brush assertion that we are all under- and otherwise inadequately staffed, that we don't deliver any value not already available via the commercial consultant market (that is patently absurd), and that we are all "limiting choice" via "preferred vendor lists" (HealthInsight is assiduously vendor neutral). Moreover, that the docs may not be moving as fast as the money and the MU deadlines is certainly not of our doing. We have play the hand we were dealt.

Finally, with respect to the "RECs can't compete with the private market for HIT talent" assertion, let me just observe that when I went through the HealthInsight re-hiring process, I was one of several hundred candidates.

Unhappily, this article got rather wide and mostly uncritical play (e.g., at The Health Care Blog and on one of my friend John Lynn's blogs). Like we need more sand in the gears (and, again, not to assert that we are above criticism).
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OCTOBER:
THE NEVADA HEALTH CARE FORUM

Policy. Gets my juices flowing (my grad degree is in "Ethics and Policy Studies"). While I was not re-hired by HealthInsight for my policy chops (I'm a technical assistance project coordinator), it's nonetheless in my blood, and I was gratified to attend this event, which was all about a breadth of policy issues as they bear on the fiscally ailing state of Nevada. Our CEO Marc Bennett served on a discussion panel, and, to me, he was the most astute person on the podium that day (and I am not sucking up, either, we have very little contact, notwithstanding that I have known him since 1993).

One upshot of my attending was my being invited to present on Nov 18th statewide via live audience and teleconference to the Nevada Chapter of the Health Care Financial Management Association on the subject of health policy reform, about which I've written rather extensively, e.g.,

• The U.S. health care policy morass
• Doing some basic health care reform math
• BREAKING: Foreign born Radical Communist Obama wants to kill Grandma and Grandpa
• Public Optional
• Irrespective of national health care policy reform legislation, the medical sector is going full-steam-ahead HITECH
  
  

Should be fun. One question I will pose goes to the implications of this image from the recently-released 2010 NCQA HEDIS-based report.

Zero apparent linear "Pearson-R" relationship between cost and quality of outcomes (albeit via their summary "quality vs. cost" proxy scales). The foregoing plot addresses cardiovascular disease, but the scattergrams in the report illustrating other major chronic conditions (hypertension, diabetes, COPD) evince the very same random buckshot patterns. My red rectangle upper left quadrant annotation above is meant to focus on the question this begs of me: are we, consequently, paying too much? What is it about the "above average quality/below average cost" segment that we might discern were we able to "peel the onion back" in search of relevant causal correlates? Is use of HIT a factor? And/or other organizational factors? ( The NCQA report is silent on such implications).

We have seen a similar kind of thing before, e.g.,

Evidence a decade ago of a weak inverse relationship (just a tad this side of purely random, unlike the NCQA/HEDIS data) between per capita Medicare expenditures and "quality ranking." Again, of interest to me analytically would be the lower cost/higher quality outcomes cohort.

I am again reminded of the words of Dr. Atul Gawande last year in "The Cost Conundrum" -

"Dramatic improvements and savings will take at least a decade. But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world...

...In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue."

Indeed.

More to come...

NEW POST UPSTAIRS
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Game ON - Meaningful Use Final Rule issued

On July 13th HHS issued the Final Rule document (PDF) comprising the eligibility and "Meaningful Use" (MU) compliance specifications of the HITECH Act. The 864 page volume makes note of and addresses all of the major comments and concerns submitted by the more than 2,000 reviewers during the public comment and review period following Federal Register publication of the IFR (PDF, "Interim Final Rule," a.k.a. "Notice of Proposed Rulemaking").While some loose ends remain -- with respect to [1] the still pending issuance of a Final Rule on new HIPAA privacy/security requirements, and [2] temporary designation of EHR certification Registrars -- the path forward has now clarified to a significant and operable degree.

While CMS did not relent on the proposed compliance timelines (Year I/Stage I 90-day attestation period still commences on Jan 1st, 2011 at the earliest for eligible Medicare and Medicaid outpatient providers), they did significantly ratchet back both the number of and percentage thresholds pertaining to MU performance criteria (some of which are now "Menu Set" optional).

See a nice New England Journal of Medicine summary here.

July 30th HHS MU Final Rule rationale summary:

• Flexibility: We were convinced by commenters that the all-or-nothing approach was not a practical solution for getting the majority of providers on the escalator to meaningful use of EHRs. Building flexibility into the program makes allowances for providers facing a wide variety of external challenges to achieve Stage 1 meaningful use. As a former Surgeon General said about medication adherence, “Medications don’t work in patients who don’t take them.” Likewise, EHRs have no benefits if providers don’t implement them.
• Simplicity: We increased feasibility of calculating HIT functionality measures by substantially reducing the reporting burden for providers. This was primarily achieved by eliminating manual chart review requirements and using electronic calculation of denominators for the HIT functionality measure denominators.
• Consistency: Wherever we could, we tried to align the program requirements—hospitals and professionals, Medicare and Medicaid. Registration for the Medicare incentive programs will begin in January 2011, and State Medicaid agencies will launch any time, beginning in January 2011. With the possible exception of a very limited set of public health functionalities, the Medicare and Medicaid will have the same meaningful use objectives and measures.
• Quality & Patient-Centeredness: We always evaluated the three principles above with an eye toward the fundamentals of meaningful use: making care delivery more patient-centered and improving the quality, safety and efficiency of health care. We never lost sight of the laser focus that the meaningful use principle provided: It’s not about the technology; it’s about transforming health care delivery for the benefit of patients and everybody else involved in their care.

Game on.
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A POST I ADDED TO THE NEW
CSC MEANINGFUL USE COMMUNITY SITE

Jul 23, 2010 2:31 PM

Meaningful use is in fact quite doable -- at least in the outpatient setting

One clinic I visited yesterday in northern Nevada -- Silver Sage -- will be an exemplar for me (I'm a REC adoption support workflow specialist). They look to be a shoo-in for Meaningful Use compliance. They use e-MDs, and they are really using it. eRx? Check. CPOE? Check. 2-way lab interface feeding back structured data? Check. Reminders? Check. Patient cohort lists by various problem areas? Check. Active meds list (incl drug-drug, drug-allergies, formularies)? Check. Patient portal? Check... etc, etc, etc.

With the Final Rule relaxation of the MU criteria and what I saw in operation yesterday, I'm now of the "stop-whining-and-just-DO-it" mindset. Use your Regional Extension Center services, too. We're not in it for the money, we're in it to improve healthcare, period.

Yes, you will need a viable, highly "usable" system, and will need to use it in a way that goes beyond just an electronic filing cabinet (e.g., scanning everything in sight into TIFF files, etc). Yes, you will need to re-do workflow in order to eliminate process waste and align information flow. Of course. Just do it. You'll improve both patient outcomes and your bottom line, attacked adroitly...

...While I have many concerns with the way this whole HITECH Act thing has been rolled out (and with U.S. health care policy more broadly), it's time for everyone to pull together and make this work.

BobbyG

I would note with caution that I interacted with another comparable small primary care clinic about a month ago here in Las Vegas, one using the same EHR system (e-MDs). While they seem to be a smoothly functioning, successful operation, absent extensive workflow policy changes, their pervasive overuse of document scanning is going to be a huge barrier to MU attestation. Notwithstanding that a .tiff file image attached to an EHR "chart" may be quicker to pull up, review, and "sign off" than its paper counterpart, it adds no "structured data" (queryable alphanumeric database entries) to the system, nullifying the tracking, trending, and data sharing/reporting capability of the EHR -- functions that will be central to "meaningful use."
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A COUPLE OF ADDITIONAL EXCELLENT READS


The cut-to-the-chase core take-away from this very worthy book is pretty straightforward:

1. The truly difficult work begins after EHR go-live implementation. This is NOT about "IT" per se;
2. You simply must have HIT physician champions;
3. And, you must devote extended post go-live resources to function-based training, delivered via simulators and Adult Learner modeled content -- i.e., constrained, didactic, classroom-based (and "train-the-trainer") methods simply do not suffice.

Anything less is a recipe for failure (regarding which they enumerate some painfully honest examples from within their own organization). PDF sample here.

This is simply the finest book I have yet to run across on the topic of healthcare QI (one going beyond the topic of mere HIT deployment). Had I the money personally, I'd buy a copy for everyone in my company, and every member of my family and all of my friends. It is replete with examples of care delivery across a gamut of outpatient to inpatient settings from the patients' points-of-view, perspectives that put you right in the midst of the chronic chaos that too frequently charaacterizes our wasteful, error-hobbled healthcare processes.

The publisher graciously provides some extended excerpt PDF samples:

• Foreword;
• Introduction;
• Chapter 2: "Focus on the patient";
• Author Q&A

"...Governments can tweak payment systems and probably get some temporary fiscal relief. But until we focus reform efforts on where most of the money goes, which is healthcare delivery, we will remain stuck in a revolving door of near disaster and narrow escapes.To get to the point where all people have access to high-quality healthcare, affordably, we must focus our attention on how the healthcare delivery system determines costs and quality. Then we need to change that delivery model entirely.

In fact, hospitals, physicians, and nurses—all of healthcare—must change. First, we must emphasize the science of medicine over the art. This means turning to evidence-based medicine, which is already underway in some sectors. But we are also talking about evidence- based delivery, work that has barely begun..."

"...By starting with the value being delivered to patients and thinking carefully about the delivery process for creating this value, we have proved that it is possible to enhance patient experiences while dramatically improving medical outcomes and lowering costs. Finally, we have distilled our experiments into an action plan that the senior management team of any healthcare organization can follow to achieve similar results..."

"...We do not mean to suggest, however, that the external environment of healthcare—payment systems, insurance coverage, and regulations—does not need to be overhauled. It is a badly broken system requiring major surgery. But we are convinced that the healthcare debate needs to start from a deep understanding of how healthcare value is actually delivered.

This is an understanding we all need—policy makers and patients, as well as medical professionals.We all have a role to play in reforming healthcare. Caregivers need to rethink their priorities and remake their working environments. Lawmakers need to rewrite the rules to ensure that value is rewarded instead of waste. And patients must understand how healthcare works in order to demand truly effective change..." [from the Introduction, pp. 2 - 4]

Highly, highly recommended -- for the healthcare professional and layperson alike. You should also spend some time at the ThedaCare Center for Healthcare Value website. A rich environment of resources.
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SUNDAY REFLECTION

Well, having waxed rather rhapsodic regarding the inspiring "On The Mend" book, upon reflection a couple of caveats come to mind that bear both on U. S. health care policy broadly and the REC initiative specifically.

• After reading and even more enthusiastically re-reading the book and related materials (e.g., interviews with Dr. Toussaint), one is struck by his optimism that the way out of the healthcare debacle will necessarily be led by a commitment to significantly leaning up healthcare delivery processes across all settings (concomitant with increasingly widespread deployment of evidence-based medicine) -- i.e., that there is so much low-hanging process reform/QI fruit to be picked, we had better start picking ASAP. To a great extent I agree with this (otherwise I would not be giving the foregoing so much attention). I am reminded of an environmental analogy: "Don't drill in the Gulf or the ANWR or mine the Colorado shale, drill under the vehicle hoods and mine inside the factories and office buildings." (from an earlier, unrelated blog post of mine). Just wring out the waste. There is so much to be wrung.
  
  But, the question remains (an irascible question I routinely field from physicians), to wit: 'To whom do these putative benefits accrue, in the main? I'm to fork out up-front to "meaningfully" adopt EHR and Lean/QI my clinic into a nimble, Lean, Clinical NBA Playoff Team -- for the principal benefit of EHR software vendors, IT hardware vendors, for-profit payors and the government: All the while ramping up my daily "treadmill medicine" so that I can see more patients in less time with marginally better claims coding and more laudatory "patient satisfaction" surveys?'
  
  I'm just sayin'... this is a essentially good bit of what I hear. Yes, some of it is the predictable "yes, but" beg-off naysaying by those with no interest in changing the way they have long practiced medicine. But, even Dr. Toussaint warns against summarily blowing off the critics.
• Given the REC contractual imperative (driving enrolled providers to the Meaningful Use incentive monies -- in which we have a vested and compressed ONC timeline "milestone payment" interest), will there even be the FTE time on both our part and the part of clinic staffs to effectively engage in this sort of work? This goes to the dubiety expressed my some of my Adoption Support team members. The early imperative is seen as simply putting in place procedures (e.g., "std work," "SOP work instructions") through which to drive providers to consistently documenting those aspects of care delivery mapping to the MU criteria -- "hitting the money fields," in a manner that doesn't add significant FTE burden that cuts into the incentive money.[1]

1. e.g., assume that routinely documenting all MU measures only adds an average 30 seconds per chart. Further assume a provider seeing 100 patients a week. Annualize that: 5,000 charts in 50 weeks. Nearly 42 hours of FTE labor just for MU documentation. Assume a staff-blended G&A/indirect-cost-multiplied labor cost of $40/hr. Close to $1,700 extra labor cost. Add to that the HHS estimated FTE hrs for attestation compilation -- ~13 hrs "worst case" by by their (overoptimistic?) reckoning (pp. 656 et seq in the Final Rule). You get the idea. Dump it all in Excel, play with the variables. What's if it's materially more time? Consider that there are 15 required "Core" MU data documentation elements and 5 of 10 from the "Menu Set," for a total of twenty. Thirty seconds per chart would mean you're spending only an average of 1.5 seconds per item. Think about that the next time you navigate your way through any piece of software via mouse clicks, menu pulls, Enter key strikes, and data entry. The FTE burden might in fact be much higher than that which I first posited -- e.g., what if it's a mere 10 seconds per measure? That would annualize to ~167 hrs, or nearly $6,700 additional FTE cost under the assumptions proffered above (I will soon be stopwatching this as I work with my providers' efforts to document MU data).
   
   More about this issue shortly.

From one of my recent PPT presentation decks.


"Lean is Mean" refers to the (unmerited) rep that Lean has gotten in some quarters that "oh, here come the hard-eyed 'efficiency experts' with their clipboards and stopwatches, out to take away my job if I'm not 'efficient' enough."

One counter I now always use to address that concern when doing workflow assessment interviews takes the form of this question: "Tell me about things around here that just never seem to get done, that you'd get to if only you could?" That invariably begets rolling eyes and painful laughs, followed by a litany of examples regarding things for which they chronically lack the time to address and complete. Which, of course, opens the door for my selling Lean tactics via which to garner such time -- and then some.

We wait for defects to be corrected. We wait while tasks involving excess motion and transportation get completed. We wait while multiple forms get filled in -- all asking for much of the same information (overprocessing). We wait while piled-up chart review goes unfinished 'til after-hours (overproduction and inventory). Finally, we wait owing to unrealized/underutilized talent and skills.

Rid ourselves of eradicable waiting, and maybe the wish list of necessary but chronically unfinished business might go away.

Perhaps we might even end up with a circumstance wherein documenting MU adds zero net new FTE burden.
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A SHORT RUMINATION ON THE BANALITY OF WASTE

Below, from one of my recent Powerpoint presentation decks, a typical outpatient visit example with which we are all surely more or less familiar.
 The Lean model posits three core types of process components; [1] those adding value, [2] those adding no direct value but still necessary for the operation, and [3] those that should/could be eliminated, as they simply represent "waste." The encounter depicted about consumes 50 minutes door-to-door, of which only 13 minutes (26%) can truly be said to be "value-adding" from both the POV of the patient and the physician. Why? Well, this is truly why the patient came in -- to obtain the expert advice from and treatment by the physician (patient's value) -- and because from the perspective of the practice, only the patient-physician interaction generates a billable event (physician's business value); everything else is "overhead" or "waste."

Twelve minutes of the foregoing scenario (24%) fall into the category of "necessary but non value-adding," (requisite overhead tasks in support of the physician) and fully 50% of the time spent (25 minutes), from the patient's POV, anyway, is waste.

Now, while we all might justifiably get a bit irritated when others waste our time (which has quantifiable value to us, even if we've never calculated it), patients are by now long wearily accustomed to the ostensible inevitability of waiting. As I observed while recounting my experience during my late daughter's cancer struggle in L.A.,

"Our summer of 1996 was one of frequent trips across town to an endless and tedious series of outpatient appointments, the worst of which were the visits to Oncology, a dingy and comfortless clinical purgatory adjacent the main hospital. I learned to take a book and a cushion. A noon appointment actually meant a hurried consultation with the oncologist -- who had to quickly review the chart outside the cubicle to remember just who the patient was -- by 4:30 or 5 at best..."

In the main, the Principle of Charity leads me to conclude that no one managing healthcare processes intends to waste our time. It just happens. Too many uncontrollable daily variables. Events in healthcare cannot be tightly coupled for smooth flow in a way they can on the factory floor. Healthcare processes have evolved in a manner such that they are what they are, and are the best we can manage. These are all smart people, doing the best they can within their budgetary and larger organizational constraints. Quit complaining.

So goes the apologetic refrain. Is it true?

No, it is not. Not one whit. I would exhort you to read Dr. Toussaint et al's "On The Mend" (for starters) to review the fairly extensive, dispositive empirical Lean operational counter evidence.

BTW- The "scenario" illustrated above? From my pocket notes jotted down during my last semi-annual follow-up visit with my Primary back in June. During the Q&A following a recent presentation I made to the "EHR Nevada" consortium during which I'd used the foregoing slide, a questioner correctly observed that, while this was from my POV, perhaps the provider and his staff were fully engaged doing value-adding and necessary support tasks. Stipulated. But it still begs a question: Are they overbooking? We expect to wait at the likes of the TSA security queue, Liffy Lube and The Olive Garden, etc. Capacity is fixed, while demand -- albeit not totally random -- is unpredictable, and frequently overwhelming. But, we make appointments to see the doctor, and if 50% of my time is viewed as expendable (notwithstanding its quantifiable value to me), something cannot but be significantly amiss within the clinic's workflow. Either they don't know how to schedule effectively, or they don't care (or give it any substantive thought, best of intentions aside). Perhaps they could "Lean Up," to the benefit and satisfaction of everyone involved.___

HELLO? DOES YOUR PRODUCT SUPPORT MACROS?

Early on, I'd recommended that, as part of our Adoption Support strategy, we build for each of our REC clients a set of Meaningful Use "SOPs" (Standard Operating Procedures) -- specifically inclusive of the "Work Instructions" that typically comprise the "Methods Section" enumeration of repetitive tasks within a process as governed by the SOP. Nowadays, in Lean lingo, such things are known as "Standard Work." Same principle. Essentially,

1. the textual step-by-step start-to-finish instruction set, accompanied by
2. Successive EHR screen shot captures illustrating the visuals the user would encounter during the course of traversing the EHR to the "money fields" where MU data were to be reposed.

Straightforward in principle, but, given the numerous EHRs we would likely encounter in our enrollee clinics, still a good bit of work, owing to the myriad differing data target paths surely to be EHR-specific. We might easily end up authoring and distributing hundreds of customized SOPs for the 20 MU criteria across dozens of EHR platforms.

I had a thought: "wait -- macros..."

I started calling various EHR vendors to ask whether their product supported macros. The few that would speak with me said "no," with the exception of Athena. One of their reps told me that, while they do not support macros globally, they would be providing equivalent MU "Hot Keys" in their upcoming MU Certified release.

Ding, ding, ding, we have a winner.

WHAT IS A "MACRO"?

Anyone familiar with standard Windows business software apps ought know this.
 As an independent macro utility vendor describes it:

Creating a Macro
A macro is a series of written instructions or recorded keystrokes and mouse actions. With a single keystroke, play back these actions at a much faster speed than can be performed manually. Eliminate wasted time and the risk of error that typically occur when performing repetitive tasks.

The program contains hundreds of commands to automate practically any function on the computer. These include keystrokes, mouse movements and clicks, launch programs, send email, window reposition and resize, variables, if then else logic, input boxes, questions, menus, ASCII delimited and text file processing, network connections, file manipulation, math calculations, waits, pauses, repeat loops and much more...

Playing back a Macro
Macro Express and Macro Express Pro provide a number of methods for executing macros. These include the use of Hot Keys, Shortkeys, Scheduled Macros, Window Activation, Mouse Clicks, Popup/Floating Menus and others.

1. A Hot Key is a set of keys pressed to initiate a macro. This includes pressing CTRL+ALT+R, F3, Shift+F12 or over 700 other combinations...

You get the idea. Earlier versions of Windows came bundled with a macro utility named RECORDER.EXE While it has been abandoned, independent macro apps abound these days, typically priced well below $100. Encapsulating MU "Standard Work" processes within macro utility scripts might well serve to eliminate 90% or more of the work required to "hit the money fields" for MU documentation.

I will be looking into the feasibility of this. It may well be that other major EHR vendors are going to be compelled to follow Athena's lead, but for those that do not, macro utilities (adequately QA tested, of course) might well serve the purpose.
___

UPDATE: EXAMPLE OF OBSCURE TIME WASTE?

I have spent a lot of time in hospitals, rehab units, clinics, and long-term care facilities as next-of-kin / POA / Legal Guardian since the mid-1990's. Some years back, during one of my mother's increasingly frequent hospital episodes down in Florida, I came to observe staff using the EMR terminals positioned in the various halls and nursing stations. Typically a doctor, nurse, or other authorized user would walk up, log in, use the system, and then log out when finished and walk away.

I took back-of-the-envelope note of the usage frequency and time involved. Didn't seem like much of a big deal.

 
Put it all in a simple spreadsheet, though, and a different picture emerges [**]. Above, assume 50 authorized users (physicians, RNs, LPNs, PAs, MAs, Case Managers, IT staff, etc.). Further assume an average login frequency of only once every 10 minutes each (6 logins per hour) and only 10 seconds consumed in logging in and out (I subsequently stopwatched this myself at home on my computer, logging and and off variosu accounts).

Now, in this scenario, further assume 365 day operation (and just one shift -- more on that in a minute), and a blended labor cost of $40/hr ("G&A-multipled" refers to a conventional labor cost measure comprised of base pay rate, all employer-provided benefits and employer tax contributions, and proportionally pro-rated per capita indirect overhead cost burden -- which varies by relative position in the org chart).

Nearly $100,000 a year consumed in this seemingly "necessary but non value-adding" process? What about, then, the 2nd and 3rd shifts (in a hospital setting). Assume they together only add a third more to the cost, owing to their perhaps lighter staffing and lower activity levels.

Wow.

[**] NOTE: You really don't even need a spreadsheet to do this math. Just plug the following into Google, "((6*10*50*8*365)/3600)*40=" i.e., "6 logins/hr x 10 sec ea. x 50 users x 8 hrs/day x 365 days/yr, all of it divided by 3600 seconds/hr, and then multiply the result by $40/hr."

Now, my first thought was that you could deploy login swipe cards affixed to staff lanyards (like we now see used by wait staff in every major restaurant chain). Perhaps hold down a combination of user-specific "hot keys" (for card loss/theft security), swipe, and you're in. Probably 90% of login time abated. Even netting out for the cost of the technology, you'd likely be reducing the cost by three quarters.

OR -- you could now provide every authorized staff user with an iPad (50 of them would set you back about $25k) and have ~3/4 of the money left over. [1]

[1] Speculate here as well how much "transportation waste" time would also be saved, i.e., repeatedly scurrying to the nearest available terminal (while I did not measure that, we indeed could do so as part of a Lean study; it's likely, on average, equal to or in excess of the login/out time burden). 'eh?

Think about it.
___

SUNDAY AUG 8th UPDATES

Not coming from a clinical background, I've recently spent some time trying to get more fully up to speed regarding the details of the "mid-office piece" of the outpatient visit (which HIT is supposed to better facilitate). More remarkable to me than ever what the provider is expected to traverse in a severely compressed window of billable time (e.g, the conventional 15-30 minute primary care patient encounter).

Consider the basic categories of the myriad data elements that feed into the "SOAP Note," the "Subjective --> Objective --> Assessment --> Plan" clinical decisionmaking process.

• Family History (FH);
• Social History (SH);
• Past Medical History (PMH);
• Active Meds List;
• Known Allergies;
• History of Present Illness (HPI)
• Chief Complaint (CC);
• Vital Signs,

All of which provide contextual grist for the ensuing facets of the "ROS" exam (Review of Systems):

• General Impressions;
• Skin;
• HEENT (Head, Eyes, Ears, Neck, and Throat);
• Respiratory;
• Cardiovascular;
• Muscular-Skeletal;
• Gastrointestinal;
• Urinary;
• Genital;
• Breasts (females);
• Vascular;
• Hematological;
• Endocrine;
• Neurological;
• Psych.

To the foregoing, add lab results (incl chem and imaging), minimally perhaps routine things such as

• CBC;
• Metabolic Panel;
• Urinalysis;
• Lipid Panel;
• PSA (males);
• PAPs, Mammos (females);
• Other "PACs" imaging, as ordered.

By my quick count, the foregoing typically comprise close to 300 data variable elements. When I reviewed my last lab report alone, I found 57 parameters, each comprised of 4 data fields: analytical parameter name, lab result value, reporting units, and normality range.

ROS is comprised of about 120 elements (117 male, 122 female), some of which are recorded quantitatively, others via qualitative impressions requiring narrative documentation (however cryptic). Documentation of FH, SH, PMH, HPI, CC, Meds, and Allergies may well require another 45 or so data elements (again, some of which are quantitative, others being either "yes/no" binary or qualitative/subjective).

I don't know how they do it...

Actually, I do (to a point). It's typically a frenetic, tactically heuristic differential-diagnosis sprint to the "Assessment" and "Plan" components of SOAP, requiring an expert drive-by review of case-specific (and billing requisite) salient elements contained in the voluminous clinical data alluded to above.

Not a lot of time for thoroughly deliberative, drill-down investigative contemplation. To the extent that HIT adds to the documentation burden and takes time away from diagnoses and care plans, clinicians will resist, its other potential recordkeeping, data-mining, and continuity-of-care benefits notwithstanding. This concern is surely at the heart of much of the provider resistance RECs continue to see in their recruitment efforts to date (the continuing lack of EHR Certification clarity being another major barrier, along with EHR cost concerns).

All the more reason to systematically "go Lean," I would argue. To wit...
 
From the AthenaHealth blog (they're an EHR vendor). While I'm in no way shilling for these people (I've never met any of them nor seen their product in operation), I found this interesting:

At athenahealth we recently ran a patient flow study in the office setting. We wanted to find out how clients using athenaClinicals, our electronic health record service, could maintain or even boost their productivity. With the collaboration of my colleague Aixa Almonte and others here, we set out to learn just how.Lean methodologies were originally invented by automakers to boost efficiency and quality on the production line but have been adopted and utilized by the healthcare industry in recent years. The basic idea behind lean methodologies is to understand the steps in a process and remove or re-engineer waste while preserving and optimizing the steps that add real value...

Click the link in their name for the complete blog post. They go on to report on how they have basically started analytically mining their clients' EHR "audit logs" (the "metadata") in order to shed useful light on workflow effectiveness. Precisely that regarding which I'd ruminated back down in my first REC blog post. Athena claims that, in addition to inclusion of time-saving MU "hotkeys" (de facto "macros"), they will be providing their EHR clients with a "Meaningful Use Dashboard" which which to monitor provider progress toward Stage One MU compliance and attestation for the incentive reimbursements. Obviously, the audit log database is what undergirds that.

Very good.
___

VOICE RECOGNITION

I use the Mac version of Dragon Naturally Speaking at home (MacSpeech Dictate), and I absolutely love it; it's about four times as fast as the fastest typing, with fewer net errors. So, I found the following YouTube clip of the eClinicalWorks EHR interfaced with Dragon rather interesting:



Until I can find out more about the cred of the person who posted this, I would have to say a few grains of salt may be warranted. If it's legit, it's very nice to see.
___

AUG 9th MONDAY EVENING UPDATE:
MORE ADVENTURES IN "NON VALUE-ADDING-BUT-NECESSARY LAND"

I ran across a post today on EHRbloggers.com, by Robert Rowley, MD, Practice Fusion's Chief Medical Officer "What do PCPs do all day long?" that jogged my memory back to a NEJM article I'd read a while ago wherein were enumerated some findings from a year-long study in an internal med outpatient clinic. Some significant daily non- patient visit tasks were found to be as follows:

• 23.7 telephone calls, most of which the doctor handled directly
• 16.8 emails, mostly for interpreting test results
• 12.1 prescription refills, not including those resulting from one of today’s patient visits
• 19.5 lab reports to review, act on if abnormal, and file in the chart
• 11.1 imaging reports to review, act on if abnormal, and file in the chart.
• 13.9 consult reports to review, interpret, file and act upon depending on the report.

Add 'em up and you get a sort of blended average 97.1 ancillary tasks per day. OK, assume an average of just 20 seconds disposing of each item every day, times five days per week (roughly 2.5 hrs /wk) times 48 weeks per year. Then multiply that by a plausible G&A multiplied physician gross FTE rate of $150/hour.

$19,420 a year in unrecoupable but necessary labor cost.

More thoughts on this shortly...