The AMA on Usability - "the design and implementation of EHRs do not align with the cognitive and/or workflow requirements and preferences of physicians within and across specialties and settings."

Good paper.

The AMA recognizes that not all EHR usability issues are directly related to software design. Software design varies greatly among vendors and specific organizations that often customize EHR functions. For example, some EHR usability issues are a result of sub-optimal implementation, required by the practice itself or part of an organizational policy (e.g., risk management, institutional liability concerns or inadequate training of users). Other issues may be related to regulatory requirements (e.g., state and federal regulations such as an overly prescriptive MU). EHR usability issues may also be due to suboptimal practice workflow processes that have been incorporated into EHRs. Workflow analysis, collaborative end-to-end workflow design and associated training are very expensive and are often neglected in projects with limited budgets and strict timeframes to meet MU requirements (i.e., deadlines to receive subsidies and/or to avoid penalties)...

Eight EHR Usability Priorities

Enhance Physicians’ Ability to Provide High-Quality Patient Care. Effective communication and engagement between patients and physicians should be of central importance in EHR design. The EHR should fit seamlessly into the practice and not distract physicians from patients.

Support Team-Based Care. EHR design and configuration must: (1) facilitate clinical staff to perform work as necessary and to the extent their licensure and privileges permit and (2) allow physicians to dynamically allocate and delegate work to appropriate members of the care team as permitted by institutional policies

Promote Care Coordination. EHRs should have enhanced ability to automatically track referrals and consultations as well as ensure that the referring physician is able to follow the patient’s progress/ activity throughout the continuum of care.

Offer Product Modularity and Configurability. Modularity of technology will result in EHRs that offer flexibility to meet individual practice requirements. Application program interfaces (APIs) can be an important contributor to this modularity

Reduce Cognitive Workload. EHRs should support medical-decision making by providing concise, context sensitive and real-time data uncluttered by extraneous information. EHRs should manage information flow and adjust for context, environment and user preferences.

Promote Data Liquidity. EHRs should facilitate connected health care—interoperability across different venues such as hospitals, ambulatory care settings, laboratories, pharmacies and post-acute and long-term care settings. This means not only being able to export data but also to properly incorporate external data from other systems into the longitudinal patient record. Data sharing and open architecture must address EHR data “lock in.”

Facilitate Digital and Mobile Patient Engagement. Whether for health and wellness and/or the management of chronic illnesses, interoperability between a patient’s mobile technology and the EHR will be an asset.

Expedite User Input into Product Design and Post-Implementation Feedback. An essential step to user-centered design is incorporating end-user feedback into the design and improvement of a product. EHR technology should facilitate this feedback. 

As one would expect, Jerome Carter, MD is all over this on his excellent EHR Science blog.

AMA Conclusion: The Road Forward

According to the AMA Rand study, the single largest driver of professional satisfaction is the physician’s perceived ability to deliver high quality care to patients. The AMA believes that if the above priorities were implemented in the EHR design, it would (1) enable physicians to deliver such care, (2) improve physician experience with the technology, (3) increase physician productivity and (4) reduce administrative costs. Aside from these eight EHR usability priorities, the AMA believes that additional research is needed to determine how EHR use promotes or inhibits high quality care. It is essential to better understand the cognitive needs of physicians and how EHR products can meet them, identify evidence that outlines the benefit tools that support decision-making and explore how EHRs influence the patient encounter. All are opportunities for research that would benefit the advancement of EHR technology. Finding evidence of what works and what doesn’t work will be critical to improving EHRs.

That's all fine and necessary, and I guess this being the AMA, the physician-centric focus is inevitable. But, there are larger necessary policy (Fee For Service?) and organizational paradigm changes ("Talking Stick?") going far beyond technology that, if left largely unaddressed will likely significantly hinder or negate any UX/workflow advances.

Consider that a typical complete ONC certified ambulatory EHR system may house between 3,000 to 4,000 RDBMS variables under the GUI hood, and a typical "moderately complex patient" encounter (e.g., a 99213) may require finding/accessing, viewing, updating/editing, and evaluating/synthesizing many hundreds of them (or more; e.g., longitudinal "flow sheet" trend data and/or specialist findings) as part of the SOAPE process, all in a severely constrained period of time.

Do a workflow/click-thru time consumption thought experiment. See also my blog post update of August 8th, 2010.

Dr. Carter on the AMA paper:

...Building systems with features in line with the AMA framework requires knowledge about clinical work and models of how information is used by clinicians, neither of which  currently exists.  The same is pretty much true of clinical systems architectures.   Yes, EHR systems exist, but no one knows the ideal architecture or component design strategy to achieve robust, secure, interoperable, collaborative systems.  In other words, there is no blueprint, and there is no source to consult that explains how to create such blueprints.  To anyone who thinks that tweaking current systems is the way to go, I say: Remember what happened with MU Stage 2 certification.

Alteration of current products is not likely to result in systems that reflect the AMA’s framework.  The time, money, and effort required to convert current EHR systems into clinical care systems that support clinical work is likely greater than most companies would care to expend (see Is the Electronic Health Record Defunct?).  Therefore, I expect the next generation of systems will come from new companies and not current market leaders (see Disruption in the EHR Market: Will Anyone See It Coming? ).

Building usable, interoperable systems that intimately support clinical work will require creativity, research, patience and, I imagine, some amount of luck (or serendipity if you prefer). In other words, the road from here to there is not on a map.   There are a lot of challenges, so let’s acknowledge this and get going.  Those blueprints will not design themselves.

apropos of all of the foregoing, is the data acquisition/assimilation burden likely to grow?

IOM Panel Identifies 12 Social, Behavioral Measures for EHRs
Thursday, November 13, 2014

On Thursday, the Institute of Medicine released a report detailing 12 social and behavioral factors it feels should be included in electronic health records, FierceEMR reports...

Those measures are:

• Alcohol use;
• Depression;
• Educational attainment;
• Financial resource strain;
• Intimate partner violence for women of reproductive age;
• Median household income;
• Physical activity;
• Race/Ethnicity;
• Residential address;
• Stress;
• Social isolation; and
• Tobacco use.

In the report, the committee noted that adding these domains to EHRs could put more pressure on providers. However, the authors also noted that patients could report the data via their personal health records or a computer, which would not greatly disrupt providers' workflow.

In addition, IOM said the health benefits of including these domains outweigh the administrative burden (Gold, Politico Pro, 11/13)...

Certain to be controversial, for a variety of reasons. And, what about the burgeoning accretion of "omics" data?

For one thing, I would not be so sanguine about "minimal workflow disruption."

Hmmm... tangentially, how about this?

EHRs are increasingly common and contain detailed data about patients’ encounters with the health system — data that have tremendous value for health care improvement efforts. These same data also provide opportunities for marketing. Using EHR data, it’s possible to determine the clinical and demographic characteristics of patients within a given practice and the circumstances under which physicians choose particular treatments, even when information is anonymized at the patient level. Although most large EHR vendors do not sell data to third parties, some have made information sales part of their business model. For example, Practice Fusion offers its EHR software to physicians free of charge but generates revenue by selling access to anonymized clinical data derived from more than 80 million patient records.

EHRs can also be used for direct marketing to physicians at the point of care, through features such as banner ads, industry-sponsored clinical resources, and tools for requesting samples, article reprints, and other items — a role previously filled by sales representatives. Unlike traditional forms of advertising, digital technologies (e.g., MD On-Line) enable tailoring of advertisements to individual physicians on the basis of data from clinical encounters. Some marketing platforms (e.g., Physicians Interactive) integrate advertising at the point of prescribing with “eCoupons” that are generated in real time and transmitted directly to pharmacies when physicians select promoted medications.

From NEJM, by way of The Incidental Economist.

UPDATE

From Kaiser-Permanente Physician Leader:

A culture of doctors over-treating as a defense mechanism against medical liability should be replaced by a culture of patient-centered care.

The Dallas/Fort Worth Healthcare Daily ran a fascinating excerpt from the Steve Jacob’s book So Long, Marcus Welby, M.D.* The excerpt contained some very interesting assertions and statistics. For example: 

• Consultant PwC, relying on that Congressional Budget Office (CBO) report, estimated that malpractice insurance and defensive medicine accounted for 10 percent of total health-care costs. A 2010 Health Affairs article more conservatively pegged those costs at 2.4 percent of healthcare spending. 
• In a 2010 survey, U.S. orthopedic surgeons bluntly admitted that about 30 percent of tests and referrals were medically unnecessary and done to reduce physician vulnerability to lawsuits. 
• A 2011 analysis by the American Medical Association found that the average amount to defend a lawsuit in 2010 was $47,158, compared with $28,981 in 2001. The average cost to pay a medical liability claim—whether it was a settlement, jury award or some other disposition—was $331,947, compared with $297,682 in 2001. 
• Doctors spend significant time fighting lawsuits, regardless of outcome. The average litigated claim lingered for 25 months. Doctors spent 20 months defending cases that were ultimately dismissed, while claims going to trial took 39 months. Doctors who were victorious in court spent an average of 44 months in litigation. 
• A study in The New England Journal of Medicine estimated that by age 65 about 75 percent of physicians in low-risk specialties have been the target of at least one lawsuit, compared with about 99 percent of those in high-risk specialties. 
• According to Brian Atchinson, president of the Physician Insurers Association of America (PIAA), 70 percent of legal claims do not result in payments to patients, and physician defendants prevail 80 percent of time in claims resolved by verdict.

My comment:

Very interesting. will have to cite this on my blog. One area I feel gets insufficient attention is that of what I call “workplace psychosocial toxicity,” e.g., “bully culture” (or just the more prevalent FUD environments). I argue that all of the Health IT and process QI (my specialty) in the world may be negated by chronically toxic workplaces where one speaks truth to power at one’s peril. It’s a sad irony that many healthcare workplaces are anything BUT “Just Cultures.” I have examined this issue at great length, breadth, and depth. The chronically psych-toxic workplace issue is ultimately a patient safety issue.

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JUST BOUGHT THIS BOOK

AUTHORS' NOTE 
We have superb doctors in the United States. These exceptionally well-trained men and women understand that they are crucial patient advocates. Physicians must accept the responsibility of guiding our nation to a better health care delivery system, but the pathway forward, amid jarring changes in our health care system, is not always clear.

The doctor crisis is the convergence of a complex amalgam of forces preventing primary care and specialty physicians from doing what they most want to do: put their patients first at every step in the care process every time. Barriers include overzealous regulation, bureaucracy, the liability burden, reduced reimbursements, and more. As a result, many physicians hold deeply negative views of the medical profession.

Solving the physician crisis is a prerequisite to creating a health care system that is patient-centered, safe, equitable, accessible, and affordable. And we believe that freeing doctors to concentrate on providing excellent care is, by definition, patient-centered.

Cochran, Jack; Kenney, Charles C. (2014-05-06). The Doctor Crisis: How Physicians Can, and Must, Lead the Way to Better Health Care. PublicAffairs. Kindle Edition.

We'll see. Looks like an interesting read.
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ERRATUM

OK, this is funny. Props to Salon.com.

THIS IS FUNNY AS WELL

 in light of #GruberGhazi...

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More to come...

With friends like these...

"This bill [The Affordable Care Act] was written in a tortured way to make sure CBO did not score the mandate as taxes. If [Congressional Budget Office] scored the mandate as taxes, the bill dies. Okay, so it’s written to do that. In terms of risk-rated subsidies, if you had a law which said that healthy people are going to pay in -– you made explicit that healthy people pay in and sick people get money — it would not have passed… Lack of transparency is a huge political advantage. And basically, call it the stupidity of the American voter, or whatever, but basically that was really, really critical for the thing to pass. And it’s the second-best argument. Look, I wish Mark was right that we could make it all transparent, but I’d rather have this law than not."
 
- Jonathan Gruber

Totally coincidental that this little stab in the back surfaced right in the wake of SCOTUS taking up King v Burwell? Arrogant weaselwonk is dancin' between the media raindrops today.

UPDATE

"[D]on’t assume that people who disagree with you are stupid, misinformed, greedy, or evil. They may just have different preferences about health insurance, taxes, income redistribution, or the role of government in health care. If preferences differ, telling people they can’t understand the complexities won’t help matters. Such condescension just makes aggrieved citizens angrier."

- David Hyman

Props to Nicholas Bagley, "Transparency and Grubergate 2.0"
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More to come...

Meaningful Use and total GOP control of Congress. What's next?

What will happen to the Meaningful Use program now? Is it simply, in relative terms, too piss-ant to even bother with, given other much larger, more pressing, politically radioactive items such as immigration, Keystone XL, "Free Trade," the reinvogorated ObamaCare takedown challenge, ISIL, Iran, climate change (and the hated EPA)?

2014 MU Attestations and incentive payments through Q3 are pretty puny. 2014 may shake out with perhaps 15-20% of the action of 2013 and 2012 respectively, even assuming a Q4 uptick.

Click the image to enlarge.

Better than 90% of MU money has been distributed. ONC is out of leadership (all the brave talk notwithstanding), out of dough, and still slavishly devoted to their espoused "non-regulatory, market-based incentives approach" to Interoperababble.

Republican Congress could spur meaningful use slowdown
CIOs think needed changes to meaningful use may happen with a Republican Congress, but health IT advocates fear trouble with ONC in disarray.

The midterm election near sweep that gave Republicans control of both houses of Congress could help move a CIO-inspired meaningful use reform bill, as it elevates a leader of the Senate GOP "Reboot" group critical of meaningful use.

Meaningful use was already under the gun before the elections, and the election results will likely intensify that trend, according to health IT legislative specialists.

The Democratic administration's program was facing a growing backlash among CIOs and leaders in most sectors of health IT, who had coalesced in fall 2014 to demand that CMS and ONC back off from what many doctors and hospital executives saw as too demanding a pace...

Meanwhile, turnover and instability at ONC, as well as diminishing funding in the past two years of the Obama administration, have further weakened the agency, according to health IT advocates.

"The cost of the interregnum at ONC is that they have been unable to decide where to focus their energies and that's unfortunate," said David Harlow, a Boston lawyer and health IT blogger who served on ONC's Health IT Standards Committee...

Yeah.

Why Is Healthcare IT Under Fire?
The Office of the National Coordinator for Health IT has lost several key figures in recent months. An economic report suggests that meaningful use may have been a waste of money. Why is healthcare IT under such duress?

It's been a rough year for the Office of the National Coordinator for Health IT – and it's unclear when things will get better...

More...

Washington Debrief: How the Republican Election Victories Impact Health IT Reform
As 2014 MU Attestations Lag, Healthcare IT Leaders Worry about 2015

Key Takeaway: Centers for Medicare and Medicaid Services (CMS) data released during the November Health IT Policy Committee indicate that 2014 attestations are lagging, compared with 2013. Approximately 1,900 hospitals have attested to either Stage 1 or Stage 2 of Meaningful Use (MU) in 2014, compared with nearly 3,400 in 2013.

Why it Matters: Participation rates released last week validate industry concerns that changes to MU, meant to provide flexibility in 2014, will be greatly muted by providers’ inability to meet more difficult program requirements for a full year in 2015.

CMS figures indicate that approximately 2,560 hospitals were scheduled to meet Stage 2 Meaningful Use in 2014. However, new flexibility from a final rule released on September 4 gave hospitals the ability to repeat Stage 1 if they could not meet Stage 2 requirements, and they could attest to having troubles with 2014 Edition CEHRT implementation. Despite lowered expectations of Stage 2 hospital participation, CMS data released last week show that 840 hospitals have met the Stage 2 bar, over a 90-day reporting period, in 2014; this amounts to less than one-third of hospitals scheduled to meet Stage 2 in 2014, and health IT leaders worry this data paints an ominous picture of the program’s near-term future.

In 2015, nearly 4,000 hospitals are scheduled to meet Stage 2 Meaningful Use requirements for a 365-day reporting period. CHIME and other health IT leaders say this will put senseless stress on program participants and will impede program success, because many hospitals will be unable to achieve the next phase of MU...

Just search "Meaningful Use" at Google News. Plenty of speculative chatter.

Here's a doozy via Politico, one having nothing to do with the midterms:

EHR RECORD CERTIFICATION PROCESS DRAWS CONCERN: An alarmingly high percentage of electronic health records were certified by ONC without ever being tested on physicians or other clinical staff, which may partly explain why doctors and nurses find the software so clunky, hard to use and occasionally dangerous, according to a research team from MedStar’s National Center for Human Factors in Healthcare. They examined the products of 62 ONC-certified EHR vendors and found that 25 percent had not been tested on physicians; 10 percent were not tested on clinical staff of any kind. Sometimes as few as two people were involved in the end user testing of the products — and sometimes those two were employees of the EHR vendor. The unpublished study was discussed at a federal IT policy committee meeting Friday that centered on whether ONC’s EHR certification process should be made more rigorous.

Well, it goes to the fact that certification has solely to do with whether you can enter and retrieve the requisite MU data, no matter how clunky the process. We at Clinic Monkey have known that all along.

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YA GOTTA LOVE THIS

So, HHS allowed the $673 million Regional Extension Center initiative expire after just four years (only 3 of which -- max -- were truly operational). Now, they're gonna spend $840 million on this:

Transforming Clinical Practices Initiative

The Transforming Clinical Practice Initiative is designed to help clinicians achieve large-scale health transformation. The initiative is designed to support 150,000 clinician practices over the next four years in sharing, adapting and further developing their comprehensive quality improvement strategies. The initiative is one part of a strategy advanced by the Affordable Care Act to strengthen the quality of patient care and spend health care dollars more wisely...

That's an average of $1,400/year per provider, $117/month.

Meanwhile, we'll take money away from the docs over "here."

NEW POST BY DR. CARTER

The AMA’s Usability Initiative Is a Good Start, so What Comes Next?

Jerome Carter's EHR Science blog is a must-read for anyone who cares about improving Health IT.
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MU AUDITS: CLAWING BACK SOME OF THE MONEY

Click to enlarge.

MORE ON KING v BURWELL

 

As I pointed out in my prior post, it's really a simple matter in terms of the plain English of PPACA Section 1321.

From SCOTUSblog:

Symposium: The grant in King – Obamacare subsidies as textualism’s big test
Abbe R. Gluck is a Professor of Law at Yale Law School.

Obamacare’s opponents have depicted the challenges in King v. Burwell, Halbig v. Burwell, and the other subsidies cases as the choice between clear statutory text and vague notions of statutory purpose.   This is a smart strategy, because it creates the illusion of an easy choice for the Court’s textualists, and even for most of the other Justices...

Justice Scalia’s own statutory interpretation treatise argues (at pages 63 and 168) that “there can be no justification for needlessly rendering provisions in conflict if they can be interpreted harmoniously,” and that statutory provisions should not be interpreted to render them ineffective or superfluous.

Textualists also advocate structural, contextual interpretation. As Justice Scalia’s treatise puts it (at 168): “[N]o interpretive fault is more common than the failure to follow the whole-text canon, which calls on the judicial interpreter to consider the entire text, in view of its structure and of the physical and logical relation of its many parts.” The subtitles of the ACA immediately surrounding the provision in question are a set of interlinking pieces: they add new requirements on insurers to make insurance accessible; impose the infamous individual mandate on the public to populate the insurance pools; and create the federal and state exchanges and authorize the subsidies (which the exchanges deliver) to make insurance purchase accessible and affordable enough for the individuals now required to purchase it. In their 2012 joint dissent in NFIB v. Sebelius, Justices Scalia, Kennedy, Thomas, and Alito read these parts as making no logical sense without one another and also read the statute to include subsidies on federal exchanges:

“Congress provided a backup scheme; if a State declines to participate in the operation of an exchange, the Federal Government will step in and operate an exchange in that State.”

and then:

“That system of incentives collapses if the federal subsidies are invalidated. Without the federal subsidies, individuals would lose the main incentive to purchase insurance inside the exchanges, and some insurers may be unwilling to offer insurance inside of exchanges. With fewer buyers and even fewer sellers, the exchanges would not operate as Congress intended and may not operate at all.”...

Should SCOTUS strike down the federal HIX clause, it will truly be nothing more than egregiously partisan "legislating from the bench."
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More to come...

Clinical workflow: "YAWL," y'all?

OK, "y'all" (I'm a "Damn Yankee"), trying to shake off my post-midterms malaise.

Recent Health IT articles document continuing CIO displeasure with EHR "usability," with some expressing the view that it will likely continue to worsen. The recent Dallas ER Ebola dustup has quickly become totemic regarding poor usability and siloed workflows.

Some of my graphic riffs on workflow.

Dr. Carter has a good new post up over at EHR Science:

EHR Systems and Patient Safety: The Interplay of Workflow and Information Needs
by JEROME CARTER on NOVEMBER 3, 2014

...User interactions with software systems are workflows.  I doubt anyone would disagree with this.  However, what seems to be lacking in the general perception of workflow is that any workflow consists of not only a series of tasks, but also the information created and consumed by those tasks as well as the people and software systems that execute them.    Simply put, information needs are workflow needs, and the two cannot be separated...

Using workflow patterns, one can precisely capture the task to be completed, who will do it, and what information will be required. It is time to move away from workflows as simply something one captures in a swim lane or flow chart and accept that they are mathematical entities that can be captured and rendered unambiguously using workflow patterns. Workflow patterns can be rendered visually using tools such as YAWL, therefore they can be used for interactions with clinicians as well as developers...

"YAWL"? (Yet Another Workflow Language)

Open source, a freebie, with a 307 page manual (pdf).

Nowadays, organisations are challenged to continuously improve their efficiency and to respond quickly to changes in their environment, such as new business opportunities, competition threats, and evolving customer expectations. It is not surprising then that organisations are paying more attention to capturing, analysing and improving their work practices in a systematic manner. The methods, techniques and tools to do this are collectively known as Business Process Management (BPM).

For IT departments, BPM provides an opportunity to align IT systems with business requirements, and to re- organise existing application infrastructure to better support the day-to-day operations of the organisation. BPM initiatives often translate into requirements for IT systems. Here is where workflow technology comes into play. Business process models produced by business experts are taken as a starting point by software architects to produce a blueprint for a software application that co-ordinates, monitors and controls some or all of the tasks that make up these business processes. Such software applications are called workflows...

Many years ago, workflow was a bit of a dark art, practised by deep-pocketed companies that were able to afford expensive workflow management systems and highly specialised consultants. Today, workflow technology is widely available and its benefits and pitfalls are more widely understood. A word of warning though: while workflow doesn’t have to belong to arcane masters of lore, it’s also not something to trivialise. If a workflow application is not aligned with the business it’s been deployed in, it can be worse than a manual, paper-based bureaucracy. It is therefore important that both business and IT stakeholders follow a sound BPM methodology before attempting to deploy a workflow application..

Key observation here:

"If a workflow application is not aligned with the business it’s been deployed in, it can be worse than a manual, paper-based bureaucracy."

More from the YAWL manual.

3.3 Building a Simple Workflow Example
Designing a workflow typically begins with a process modelling exercise. A process modelling expert sits down with a domain expert, and picks their brains on “how things are done”. The knowledge gained on the sequencing and nature of the work done is then transformed into an executable workflow...

Given the irreducible hypercomplexity of clinical workflow, I have to have some concerns as to whether this app can scale up and model medical processes in a manner accessible to anyone outside of IT geekdom. Recall, a typical complete, certified ambulatory EHR contains close to 4,000 variables within its RDBMS schema, and a typical 99213 visit will likely have to hit on (view and/or update) hundreds of them (via multiple staffers) within in the time constraints of a 30-40 minute office visit.

Below, a "healthcare" example (pg 274):

Yeah, that's really clear. I'm havin' a swell UX.

See my post back in March, Chuck Webster's "Pragmatic Interoperability," continued...

My Garageband visual analogy.

Make it 3-d? How about one more visual analogy?

Where the inner insulation coverings stand for "data/communications siloing"?

Workflow apps that continue to focus on logic paths (e.g., "conditionals" branches and loops) will continue to miss the critical time element. And, it doesn't help that the visual illustrations are typically contorted to fill the dimensional constraints of the 8.5 x 11 page (whether portrait or landscape).

To that end, one egregiously overlooked asset is sitting right there under the EHR hood in the now-requisite "audit log." to wit:

An EHR audit log is essentially an information workflow record that should be mined to analyze routine tasks times-to-completion and variability. Analysis can also reveal the "pain points," i.e., iterative, recurrent "flow" barriers. You then couple these data with data taken regarding concomitant physical tasks to flesh out a more useful picture for systematic improvement activities.

The very word 'workflow' has become a cliche. Rolls readily off the tongue with little thought given to what it entails. A more apt analogy might be a traffic copter shot of the jerky stop-&-go freeway traffic of rush hour. In most clinics, it's nearly ALWAYS rush hour...

A decade ago I was working in credit risk and portfolio management at a relatively small privately-held issuer of VISA/MC subprime credit cards (roughly a million active accounts). I had free run of most of the internal network. I got to looking at our in-house developed collections call center system (~1,000 collectors assiduously working the phones every day), and knew the source language and data tables architecture, so I started importing the data into SAS and mining them (it was basically a Collections "audit log," though I was the first to audit it, on my own initiative).

I was able to rather quickly show management that their staffing deployment and call volumes were egregiously misaligned. We were typically spending $1,000 to collect $50 (or less), hounding delinquent customers with sometimes up to 140 calls per month, at all hours of the day and night (the classic, hated subprime M.O.).

It was a lava flow of waste. I issued a snarky monthly report on these activities, dubbed "The Don Quixote Report."

On the basis of my rather simple call log analytics we were able to save the bank about $5 million a year in Collections Ops cost, dragging the VP of Collections kicking and screaming all the way (his annual bonus was tied in part to his budget, which was the largest in the company -- he did not become My Friend).

"Workflow" tactics deployed in healthcare remain stuck about 10-15 years behind the times, as they don't drill down into time consumed and error rates. Mining the EHR audit logs might be of great utility here -- though the datetime() stamps are gonna need to be more granular than just down to the second. SQL now supports time capture down to the microsecond, though tenths or hundreds might suffice.

Another barrier here in general might be "once you've seen one audit log data dictionary, you've seen one audit log data dictionary." Recall that we have at this point nearly 1,800 "complete Certified EHR systems" [March 2014]. How many differing audit log architectures we have is probably unknown outside of ONC CHPL -- if they even bother to look...

As I wrote back in March:

Lean / Six Sigma Process Improvement initiatives would likely focus principally (though not exclusively) on the "Physical Tasks" leg of clinical ops. Couple that with adroit analyses of HIT audit logs, and we might be able to better leverage significant improvement efforts. Time is, of course, the fundamental, inescapable constraint in any business. Saving time and reducing physical task and HIT inefficiencies and errors would leave more of it for improving the most important facet -- the cognitive.

So goes my theory, anyway.

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IN OTHER NEWS

With the mid-term elections out of the way, SCOTUS has quickly reversed itself and agreed to hear Burwell v. King, the case challenging the legality of the federal health insurance exchange subsidies under the PPACA. The suit is over one sentence in the consolidated 974 page law (pdf; not "2,700," 974).

Section 1311, page 72. "...established by a State." These litigants argue that the feds cannot extend insurance subsidies to lower income households, that such subsidy is solely the province of state-run exchanges. SCOTUS has to determine Congressional "intent," via "Ouija Board Jurisprudence," instead of just, -- well-- asking those who voted in the majority. (Depose them. Call them as witnesses. Under Oath. Ask for documentation. The victors know what they intended, irrespective of any bill drafting oversights.)

I know, I know. You can't do that. "Separation of Powers." Much better to spend millions quibbling over the ostensibly inscrutable contextual meaning of one sentence.

Fine, 1311(d). Aren't y'all just thrilled with yourselves.

However, the rightfully governing clauses follow shortly on its heels, on pages 85-86, in Section 1321.

PART 3—STATE FLEXIBILITY RELATING TO EXCHANGES

SEC. 1321 42 U.S.C. 18041. STATE FLEXIBILITY IN OPERATION AND ENFORCEMENT OF EXCHANGES AND RELATED REQUIREMENTS.
(a) ESTABLISHMENT OF STANDARDS.—

(1) IN GENERAL.—The Secretary shall, as soon as practicable after the date of enactment of this Act, issue regulations setting standards for meeting the requirements under this title, and the amendments made by this title…

(c) FAILURE TO ESTABLISH EXCHANGE OR IMPLEMENT REQUIREMENTS.—
(1) IN GENERAL.—If—
(A) a State is not an electing State under subsection (b); or
(B) the Secretary determines, on or before January 1, 2013, that an electing State—
(i) will not have any required Exchange operational by January 1, 2014; or
(ii) has not taken the actions the Secretary determines necessary to implement—
(I) the other requirements set forth in the standards under subsection (a); or
(II) the requirements set forth in subtitles A and C and the amendments made by such subtitles; the Secretary shall (directly or through agreement with a not- for-profit entity) establish and operate such Exchange within the State and the Secretary shall take such actions as are necessary to implement such other requirements.
(2) ENFORCEMENT AUTHORITY.—The provisions of section 2736(b) of the Public Health Services Act shall apply to the enforcement under paragraph (1) of requirements of subsection (a)(1) (without regard to any limitation on the application of those provisions to group health plans).
(d) NO INTERFERENCE WITH STATE REGULATORY AUTHORITY.—Nothing in this title shall be construed to preempt any State law that does not prevent the application of the provisions of this title...

1321(1)(c)(1)(ii)(I and II) 

What part of "the Secretary shall (directly or through agreement with a not- for-profit entity) establish and operate such Exchange within the State and the Secretary shall take such actions as are necessary to implement such other requirements" do people fail to comprehend?

This is nothing more than a cowardly, disingenuous tactical attempt to scuttle the PPACA by pricing millions of lower income earners out of the health insurance market in Red states that have refused to set up HIXs.

A week ago, SCOTUS announced they would not hear the case. Now, with the mid-terms out of the way, they're quickly green-lighting it. Hmmm... why would that be?

BTW, if you insist on the long-winded, scholarly version of divining Congressional intent with respect to the PPACA and this latest challenge, see  

BRIEF AMICI CURIAE FOR ECONOMIC SCHOLARS IN SUPPORT OF APPELLEES ON EN BANC REVIEW

Amici curiae are a group of 49 distinguished professors and internationally recognized scholars of economics who have taught and researched the economic forces operating in the health care and health insurance markets. The Economic Scholars include economists who have served in high-ranking positions in the Johnson, Ford, Carter, George H.W. Bush, Clinton, George W. Bush, and Obama administrations; two Nobel Laureates in Economics; two recipients of the John Bates Clark medal, which is awarded biennially to the American economist under 40 who has made the most significant contribution to economic thought and knowledge; one of only two social scientists awarded the Alan T. Waterman Award, usually reserved for physical and chemical scientists; six recipients of the Arrow award for best paper in health economics; and two recipients of the American Society of Health Economists Medal for the best American health economist aged 40 and under. A complete list of the Economic Scholars is provided in the Certificate as to Parties, Rulings, and Related Cases at the front of this brief.

Amici believe that reform of the health care system is essential to constraining the growth of health care spending and to extending health insurance coverage, and that such reforms cannot succeed without premium subsidies for people with low or moderate incomes. 

Amici submit this brief to explain the economic reasons why premium subsidies are essential to achieving the reforms of the health care system that Congress seeks through the Affordable Care Act (“ACA”), and to urge that the ACA cannot conceivably achieve those reforms if it is interpreted in the manner proposed by the Appellants. Congress – correctly – structured the ACA as a series of interlocking reforms, of which premium subsidies are essential components. If those subsidies are unavailable to the many who will buy insurance on the federal Exchange, the other components of the ACA will not work, and the legislation will fail to achieve its goal of expanding coverage...

 "...and the legislation will fail to achieve its goal..."

Precisely what opponents of the PPACA want. By any means necessary.

More (pp 25-27)" 

According to Appellants’ construct, Congress knew that § 1401 of the ACA limited availability of premium subsidies to residents of states that established their own exchanges. As Appellants see it, Congress was willing to exclude from the promise of affordable health insurance any low-or moderate-income family or individual who happened to be unfortunate enough to live in a state that refused to set up its own Exchange. Congress, Appellants assert, intentionally conditioned federal assistance to make health insurance affordable for these families and individuals on each state’s willingness to undertake the thankless job of establishing and operating Exchanges. According to Appellants’ theory, states will eventually buckle under the pressure of their uninsured citizenry and create their own exchanges.

But the tale told by Appellants is entirely at odds with what Congress knew and intended when it enacted the ACA. First, as explained above, Congress fully understood the economic need for the ACA to rest on the three interlocking reforms, of which subsidies were one primary component. Nothing in the record suggests that Congress intended the economically disastrous approach of dramatically limiting subsidies only to participants in state exchanges. Second, the Congressional Budget Office never entertained the possibility that subsidies would not be available across all Exchanges. See supra. Members of Congress consulted regularly with the CBO, yet not one of them indicated that the CBO’s work was at odds with congressional intent. Third, initial versions of the ACA indicate that premium subsidies were understood to be available for enrollees buying insurance on the federal Exchange. Premium tax credits were included in the House bill even though that bill provided for a single Federal exchange rather than state exchanges. Affordable Health Care for America Act, H.R. 3962, 111th Cong. tit. III, § 301 (2009) (establishing single, federal exchange); id. tit. III, § 343 (providing for “affordability premium credit”). In the endgame debate in which the House debated Senate language, it is inconceivable that the House would have accepted a change sure to cripple the federally-run Exchange. Appellants point to nothing in the legislative record to support their economically implausible argument that the purpose of the subsidies changed from the initial House proposal to the final Act. Instead, as Judge Edwards put it, Appellants peddle a “narrative concocted to provide a colorable explanation for the otherwise risible notion that Congress would have wanted insurance markets to collapse in States that elected not to create their own Exchanges.” Halbig, 758 F.3d at 416 (Edwards, J., dissenting).

If anything, the record establishes that Congress created the state Exchanges not because it intended the federally-run Exchanges to be dysfunctional, but simply to provide States the option of creating their own exchanges. The federally-run Exchanges remained available to those States that lacked the resources, expertise, or desire to build their own.

The one plausible reason for SCOTUS even hearing this case?

P.S.

You will see media references to PPACA Section 1401 citing the contentious phrase "established by the state." Yeah, but take note of what it cites (page 110).

Again, 1311 is governed by Section 1321 in the event of state inaction or refusal (see above).

Moreover, at the risk of belaboring what ought be obvious with respect to "legislative construction," the very header at the top of page 110 says

"Subtitle E--Affordable Coverage Choices for All Americans."

Not "Affordable Coverage Choices for Only Those Americans Living in States That Follow PPACA Legislative Intent and Establish Health Insurance Exchanges."

Seriously, people? We really need legions of $500 per hour lawyers spewing forth lengthy "briefs" over something that simply jumps right off the page?

CODA

Indeed. This comes down to Chief Justice Roberts, given that four of SCOTUS have already vote to strike down the PPACA in toto. Should he provide the 5th vote to strike down federal HIX subsidies, given the dispositive countervailing evidence of legislative intent, it will scream partisan political corruption inside SCOTUS loud and clear.

BUT WAIT! THERE'S MORE!

Supreme Court already said DC Court was wrong on Obamacare subsidies

...Sophisticated textual analysis of complex laws like this one requires attention to the statutory text as a whole, in context, and not in isolation. That’s how the Virginia appeals court read the ACA today, and the Supreme Court itself offered the same admonition last month, through an opinion by Justice Antonin Scalia in the EPA case.

In fact, it was Justice Scalia himself, together with Justices Anthony Kennedy, Clarence Thomas, and Samuel Alito, who interpreted the health reform statute precisely this way in the 2012 health reform case—holistically, and assuming the statutory text makes subsidies available on state and federal exchanges alike.

In their joint dissent, they wrote:

“Congress provided a backup scheme; if a State declines to participate in the operation of an exchange, the Federal Government will step in and operate an exchange in that State.”

And then: “In the absence of federal subsidies to purchasers, insur­ance companies will have little incentive to sell insurance on the exchanges. … That system of incentives collapses if the federal subsidies are invalidated.”

The dissenters also assumed: “By 2019, 20 million of the 24 million people who will obtain insurance through an exchange are expected to receive an average federal subsidy of $6,460 per person”—numbers that only make sense if the federal exchanges are included.

So there you have it.

While one never can be certain about what the Supreme Court will do if it takes a case, the four Justices who held that the mandate was unconstitutional in 2012 then understood the Affordable Care Act to provide subsidies for insurance bought through the federal and state exchanges...

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More to come...

Now what?

Below, from my email inbox this morning.

Republicans pretty much ran the table. NBC's Chuck Todd is calling it "a repudiation of President Obama" this morning.

Couple of my tweets.

This loss was a long time coming and belongs on the White House doorstep. President Obama’s leadership can be defined by one word: reaction. He never seemed to be leading Democrats anywhere, but instead was seen to be reacting to events. As we all learned with George W. Bush, "wrong and strong always beats weak and right," though the President hasn’t been right on very many things either, making matters worse.

- Taylor Marsh

Again, to what extent -- if any -- will this political power realignment affect Health IT?
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More to come...

November 4th day of reckoning: what happens to Health IT should the GOP regain full control of the Congress?

Any thoughts? While it's a safe bet that we'll see multiple renewed bills passed in both the House and the Senate to "repeal ObamaCare," Republicans will still not be able to muster veto-proof margins, so that effort will simply continue to be the maudlin circus with which we are by now quite familiar.*

* SCOTUS could still effectively scuttle the PPACA by striking down the federal HIX subsidies in the states that refused to play ball and establish exchanges. There's a case in play right now (King v. Burwell). 11/3 UPDATE: the Supreme Court has declined to hear it -- for now.

We're also perhaps likely to see an Impeachment resolution accepted by the Senate for "trial." But, again, there will not be even close to sufficient votes to convict. Simply more narcissistic dog and pony show on this count. In that vein, there will be new GOP Senate committee chairs exercising subpoena power for all manner of political fishing expeditions. We can also expect a halt to federal judicial nomination confirmation hearings, given that the Republicans will control the Senate proceedings calendar.

Beyond the Clown Car stuff will be all manner of serious, pressing national and global issues to be dealt with, all vying for attention and resources: ISIL, Iranian nukes, Russia, climate change, immigration policy, financial regulation reform, etc, just to cite a few above-the-fold topics.

One consequence is that health IT looks to me like it's entering an even more pronounced  period of "benign neglect" at the federal level. ONC is out of effective leadership (leaders with sufficient visible national Cred to have Juice on the Hill), out of money, and still slavishly committed to their Quixotic "non-regulatory, market-based incentives" approach to interoperability. Stage 2 Meaningful Use is not gettin' any love from providers (increasingly dubious now that Stage 3 will even get out of the gate), and CCHIT has tossed in their CHPL Certification towel (see my prior post).

Moreover, -- beyond the foregoing carnival items -- all eyes will be firmly focused on the 2016 Presidential and downrace efforts (already well underway, to be sure). Hard to see how any new federal health IT initiatives will get much congressional attention or traction (and funding). Maybe market forces will continue to rule, in random walk fashion -- albeit shaped to a degree by statutes and regs already in place, increasingly vestigial as they may be.

Dunno.

IN OTHER NEWS

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More to come...