Post-HIMSS15 Interoperababble Update: Margalit Gur-Arie hits one out of the park.

I coined the irascible, skeptical term "Interoperababble." I see nothing to date seriously challenging or refuting my views. I even offered one of my HL7® critics a Final Cut cross-post here after he took vague issue in an irritable email regarding my takes on FHIR® and HL7® itself.

Silencio, thus far.

Margalit Gur-Arie writes one of the finest healthcare technology blogs out there. Her latest post is a tour de force.

"How did health care become a fully owned subsidiary of the computer industry?"

Cross-posted below under Creative Commons attribution. She really nails it.

Value-based Interoperability: Less is more

Interoperability in health care is all the rage now. After publishing a ten year interoperability plan, which according to the Federal Trade Commission (FTC) is well position to protect us from wanton market competition and heretic innovations, the Office of the National Coordinator for Health Information Technology (ONC) published the obligatory J'accuse report on information blocking, chockfull of vague anecdotal innuendos and not much else. Nowadays, every health care conversation with every expert, every representative, every lobbyist and every stakeholder, is bound to turn to the lamentable lack of interoperability, which is single handedly responsible for killing people, escalating costs of care, physician burnout, poverty, inequality, disparities, and whatever else seems inadequate in our Babylonian health care system. 

When you ask the people genuinely upset at this utter lack of interoperability, what exactly they feel is lacking, the answer is invariably that EHRs should be able to talk to each other, and there is no excuse in this 21st iCentury for such massive failure in communications. The whole thing needs to be rebooted, it seems. After pouring tens of billions of dollars into building the infrastructure for interoperability, we are discovering to our dismay that those pesky EHRs are basically antisocial and are totally incapable or unwilling to engage in interoperability. The suggested solutions range from beating the EHRs into submission to just throwing the whole lackluster lot out and starting fresh to the tune of hundreds of billions of dollars more. When it comes to sacred interoperability, money is not an object. It’s about saving lives.

As the HIMSS15 extravaganza is getting under way, and every EHR vendor flush with cash from the Meaningful Use bonanza is preparing to take its unusable product to the next level, machine interoperability is shaping up to be the belle of the ball. A simple minded person may be tempted to wonder why people who, for decades, manufactured and sold EHRs that don’t talk to each other, are all of a sudden possessed by interoperability fever. The answer is deceptively simple. After exhausting the artificially created market for EHRs, these powerful captains of industry figured out that extracting rents for machine interoperability is the next big thing.

The initial pocket change comes from selling machine interoperability to their current bewildered (or stupefied) clients, and to less fortunate EHR vendors. But the eventual windfall will not come from the health care delivery system or the hapless patients caught in its web. How much do you think access to a national and hopefully global network of just-in-time medical and personal data is worth to, say, a pharmaceutical company giant? How about life insurance, auto insurance, mortgage, agribusiness, cosmetics, homeland security, retail, transportation? Google built an empire by piecing together disjointed bits of personal data flowing through its electronic spider webs. What do you think can be built by combining everything Google knows with everything your doctor knows and everything you know about yourself?

Machine interoperability is not about patient care in the here and now. Interoperability is not about ensuring that all clinicians have the information they need to treat their patients, or that patients have all the information they need to properly care for themselves. Interoperability is about enriching a set of interoperability infrastructure and service providers and about electronic surveillance of both doctors and their patients. Machine interoperability is about control, power and boatloads of hard cash.

For example, if you are hospitalized, it makes sense that your primary care doctor should know that you are (not in the past tense), and when you are discharged, he or she should be appraised of what transpired during your hospital stay. In the old days, before the advent of hospitalists, this could be assumed. Today, thanks to more efficient division of labor, not so much. If the government was genuinely concerned about smooth transitions of care, it would mandate that upon discharge, hospitals must provide all pertinent information to the primary care doctor, and the patient, by any means necessary. If this meant that a piece of paper is stapled to the patient’s robe, and that the hospital employs an army of delivery drones for the purpose, so be it. Eventually, hospitals, which are big businesses, would come up with the most cost effective and efficient way to be compliant with the law.

That’s not how things currently work or how they are envisioned to work. Discharge summaries have a mandated format of structured data elements, complete with metadata, based on government approved standards that change with frightening regularity. Furthermore, to satisfy regulations, the summaries must be generated and transmitted electronically from one “certified” EHR to another, allowing for a host of intermediaries to access and collect said data or at the very least its metadata. Consulting with the PCP by phone for an hour doesn’t count. Sending the information from a non-certified software package doesn’t count. Printing and sending over information by special courier doesn’t even begin to count. Attempting to build a device that streams the information as it happens directly into the PCP medical record will get you excommunicated or burned at the stake.

If you refer a patient to cardiology service, and in a misguided senior moment decide to pick up the phone and talk to the cardiologist at length about this patient, it doesn’t count. If the cardiologist pens a concise and beautiful letter to you after she sees your patient, thanking you for the referral and summarizing her impressions and plan of care in proper English, it doesn’t count. The only thing that counts is a lengthy clinical summary containing all the sanctioned data elements sent from you to the cardiologist, copied in its entirety and returned from the cardiologist to you, hopefully with some indication about what happened during the consult. Having your EHRs talk to each other this way is considered interoperability. Whether you actually read the interoperated information is irrelevant. As long as the contents are captured by the network for other uses, it’s all good.

But wait, there is more. If you practice, say, in St. Louis, Missouri and work for a huge health system or somehow managed to string together a machine interoperable network with the twenty or so specialists you use on a regular basis and the four hospitals where you have admitting privileges, that’s not good enough. Nothing is good enough unless any research lab in Hopewell, New Jersey or Bangalore, India can discover you on the (inter)national interoperability network and request data about a patient you may have treated five years ago, and nothing will be good enough unless any app store developer in Cupertino, California can discover your patient and subsequently obtain her medical data once she downloads a free diet app from iTunes.

Are you “just” a patient eager to be “engaged” in your own care? Picking a doctor who will spend two hours with you listening carefully and explaining things you don’t understand, and who will give you his cellphone number in case you have more questions, doesn’t count. Getting a team of physicians together on a conference call to brainstorm about your mom’s options, doesn’t count. Building a long term relationship with your pediatrician and having her come see your sick kid at home because your car is in the shop and your toddler can’t keep any food down, and now the baby won’t stop crying, doesn’t even register on the interoperability radar. Nothing counts unless you log into a website or an app, accept the cookies, the tracking beacons, the small print, and then click on some buttons to verify that you are a “Never smoker”, or to peruse machine generated visit notes that even your doctors don’t read anymore.

Perhaps machine interoperability on a national scale is a wonderful thing, but so is having arugula in every fridge. There is absolutely no evidence that either one will improve health and/or reduce the price of care. Every dollar spent on national machine interoperability is a dollar that was previously used, or could be used, to provide medical care. Where did we find the moral fortitude to demand that people experience adverse outcomes at least three times before letting them have a slightly more expensive pill, while spending billions of dollars to incentivize the purchase of unproven and often failing technologies? If we are supposed to be parsimonious in our use of health care resources, if we are supposed to choose wisely in all other areas, where is the comparative effectiveness research showing that expensive machine interoperability on a grandiose global scale provides more value than cheaper and simpler localized or human mediated communications?

• Add one doctor visit for every Medicare beneficiary for the next 8 years
• Give primary care a 20% raise for the next 4 years
• Double the number of residencies for the next 3 years
• Educate 60,000 new primary care doctors from scratch
• Buy an iPhone glucose monitor for every diabetic patient and an iPhone BP monitor for every hypertensive patient (no, I'm not a "technophobe")
• Put a brand new playground, a gym teacher and a home economics teacher in every elementary school in the U.S.
• End homelessness in America

These are some of the things we could do with the billions of dollars spent on machine interoperability. Which has more value for our collective health? How did health care become a fully owned subsidiary of the computer industry? Who authorized this unholy acquisition and how much were those brokers paid? Have we forfeited our right to choose, or even know, how endless fortunes are steadily interoperating out of our treasury and into the hands of global technology firms? Publishing fuzzy ten year plans on obscure websites, so the Technorati can tweak them, doesn’t count. Publishing thousands of pages of regulations in the federal register, so interest groups can preview the fruits of their labor, doesn’t count either. Raiding public coffers to please friends and family and to curry political favors is hardly a disruptive innovation, so let’s just call it what it is.

Killer post, Margalit.
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UPDATE

Another important issue. From The Atlantic.

The Problem With Satisfied Patients
A misguided attempt to improve healthcare has led some hospitals to focus on making people happy, rather than making them well.
ALEXANDRA ROBBINS APR 17 2015

When healthcare is at its best, hospitals are four-star hotels, and nurses, personal butlers at the ready—at least, that’s how many hospitals seem to interpret a government mandate.

When Department of Health and Human Services administrators decided to base 30 percent of hospitals’ Medicare reimbursement on patient satisfaction survey scores, they likely figured that transparency and accountability would improve healthcare. The Centers for Medicare and Medicaid Services (CMS) officials wrote, rather reasonably, “Delivery of high-quality, patient-centered care requires us to carefully consider the patient’s experience in the hospital inpatient setting.” They probably had no idea that their methods could end up indirectly harming patients.

Beginning in October 2012, the Affordable Care Act implemented a policy withholding 1 percent of total Medicare reimbursements—approximately $850 million—from hospitals (that percentage will double in 2017). Each year, only hospitals with high patient-satisfaction scores and a measure of certain basic care standards will earn that money back, and the top performers will receive bonus money from the pool.

Patient-satisfaction surveys have their place. But the potential cost of the subjective scores are leading hospitals to steer focus away from patient health, messing with the highest stakes possible: people’s lives...

[A] national study revealed that patients who reported being most satisfied with their doctors actually had higher healthcare and prescription costs and were more likely to be hospitalized than patients who were not as satisfied. Worse, the most satisfied patients were significantly more likely to die in the next four years.

Joshua Fenton, a University of California, Davis, professor who conducted the study, said these results could reflect that doctors who are reimbursed according to patient satisfaction scores may be less inclined to talk patients out of treatments they request or to raise concerns about smoking, substance abuse, or mental-health issues. By attempting to satisfy patients, healthcare providers unintentionally might not be looking out for their best interests. New York Times columnist Theresa Brown observed, “Focusing on what patients want—a certain test, a specific drug—may mean they get less of what they actually need. In other words, evaluating hospital care in terms of its ability to offer positive experiences could easily put pressure on the system to do things it can’t, at the expense of what it should.”

As a Missouri clinical instructor told me, “Patients can be very satisfied and dead an hour later. Sometimes hearing bad news is not going to result in a satisfied patient, yet the patient could be a well-informed, prepared patient.”...

And because almost every question on the survey involves nurses, some hospitals are forcing them to undergo unnecessary nonmedical training and spend extra time on superfluous steps. Perhaps hospitals’ most egregious way of skewing care to the survey is the widespread practice of scripting nurses’ patient interactions. Some administrators are ordering nurses to use particular phrases and to gush effusively to patients about both their hospital and their fellow nurses, and then evaluating them on how well they comply. An entire industry has sprouted, encouraging hospitals to waste precious dollars on expensive consultants claiming to provide scripts or other resources that boost satisfaction scores. Some institutions have even hired actors to rehearse the scripts with nurses.

In Massachusetts, a medical/surgical nurse told The Boston Globe that the scripting made her feel like a “Stepford nurse,” and wondered whether patients would notice that their nurses used identical phrasing. She’s right to be concerned. Great nurses are warm, funny, personal, or genuine—and requiring memorized scripts places a needless obstacle in their path. 

The concept of “patient experience” has mischaracterized patients as customers and nurses as automatons. Some hospital job postings advertise that they are looking for nurses with “good customer-service skills” as their first qualification. University of Toledo Medical Center evaluates staff members on “customer satisfaction.”...

More disturbing, several health systems are now using patient satisfaction scores (likely from hospitals’ individual surveys) as a factor in calculating nurses’ and doctors’ pay or annual bonuses. These health systems are ignoring the possibility that health providers, like hospitals, could have fantastic patient satisfaction scores yet higher numbers of dead patients, or the opposite...

Many hospitals seem to be highly focused on pixie-dusted sleight of hand because they believe they can trick patients into thinking they got better care. The emphasis on these trappings can ultimately cost hospitals money and patients their health, because the smoke and mirrors serve to distract from the real problem, which CMS does not address: Patient surveys won’t drastically and directly improve healthcare.

But research has shown that hiring more nurses, and treating them well, can accomplish just that. It turns out that nurses are the key to patient satisfaction after all—but not in the way that hospitals have interpreted.

A Health Affairs study comparing patient-satisfaction scores with HCAHPS surveys of almost 100,000 nurses showed that a better nurse work environment was associated with higher scores on every patient-satisfaction survey question. And University of Pennsylvania professor Linda Aiken found that higher staffing of registered nurses has been linked to fewer patient deaths and improved quality of health. Failure-to-rescue rates drop. Patients are less likely to die or to get readmitted to the hospital. Their hospital stay is shorter and their likelihood of being the victim of a fatigue-related error is lower. When hospitals improve nurse working conditions, rather than tricking patients into believing they’re getting better care, the quality of care really does get better.

Instead, hospitals are responding to the current surveys and weighting system by focusing on smiles over substance, hiring actors instead of nurses, and catering to patients’ wishes rather than their needs. Then again, perhaps it’s no wonder that companies are airbrushing healthcare with a “Disney-like experience,” a glossy veneer. One of the leading consulting companies now advising hospitals on “building a culture of healthcare excellence” is, oddly enough, the Walt Disney Company.
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"When hospitals improve nurse working conditions, rather than tricking patients into believing they’re getting better care, the quality of care really does get better."

Just Culture? Talking Stick, anyone?

The foregoing Atlantic article goes to this fascinating new book, which I am now about 60% of the way through reading.

Highly recommended. I will have a lot to cite and say once I finish both it and Matt McCarthy's new book "The Real Doctor Will See You Shortly," which I cited in my prior post "Hippocratic Oaf."

CODA

Pretty good summary of HIMSS15 from a THCB attendee.

And, from the ONC Department of Blinding Glimpses of The Obvious, ONC informatics official says EHR usability promotes safety.
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"Hippocratic Oaf"

I can come up with pretty good, snarky ("clickbait"?) blog post headlines, but this one can't be improved upon.

Hippocratic Oaf: My First Day as a Doctor
I was technically a real physician the moment I walked through the hospital doors, but I quickly realized that medical school had left me woefully unprepared.
MATT MCCARTHY

...In medical school, I had moved through  rotations in surgery, neurology, psychiatry, radiology, internal medicine, pediatrics, and finally, obstetrics, where a young Jamaican woman let me deliver her child on my first day. She insisted on giving birth on her hands and knees, her back arched like that of a cat as the baby slowly emerged. An amused midwife later said that I had looked like a nervous quarterback, receiving a snap in slow motion.

As graduation approached, choosing a specialty had proved to be difficult. Ultimately I had settled on internal medicine because it was the broadest field, the one that might allow me to feel like a jack-of-all-trades. But tonight was my debut in the big show, a 30-hour shift taking care of critically ill patients and responding effectively to anyone who might roll through the door...

Until a few days ago, I had never set foot in a cardiac-care unit. Nothing about the setup looked terribly familiar. I continued to study the room, trying to decode the symphony of incessant beeps and alarms and wondering what each of them meant. It felt like I was sitting in the middle of a giant equation with infinite variables...

Baio wiped off the bagel crumbs on his scrubs and leaned in close to me. “We have to work as a team. Everything is teamwork. So I need to know what you’re able to do. The more you can do, the more time I have to think about the patients. So rather than listing the shit you can’t do, tell me what you can do.”

My mind went blank. Or more accurately, I searched it and found it was blank. “Well …” I glanced at the sedated patient before us. He was on a ventilator and had a half-dozen tubes in his neck, arms, and groin, almost all of which pulsed with medications I’d never heard of. As a medical student, I had been exposed to all sorts of patients. But all of those encounters had involved walking, talking, reasonably well-functioning individuals. Lying there, inert and blanched of all color, the patient before me seemed well beyond the reach of my limited powers. If he needed his appendix out or his face stitched together, I was his man. But intensive cardiac care? The learning curve in medicine was so unforgivably steep.

Finally Baio broke the silence. “All right,” he said, “I’ll start. Can you draw blood?”

“No.”

“Can you put in an IV?”

“No.”

“Can you put in a nasogastric tube?”

“I can try.”

“Ha. That’s a no. Ever done a paracentesis?”

“I’d love to learn.”

He smiled. “Did you actually go to medical school?” Even I had to wonder. If Baio had been asking me to recite pages from a journal article on kidney chemistry or coagulation cascades, I could’ve put on quite a show. But I hadn’t learned much of the practical business of keeping people alive. In fact, I had been allowed to skip the CCU month of my med-school training at Massachusetts General Hospital so I could learn tropical medicine in Indonesia. Who had talked me into that?

“I graduated from Harvard earlier this month.”

“Oh, I know you went to Haaahvaahd,” Baio said with exaggerated fake reverence. “But do you know how to order medications?”

A bright spot. “Some!” I practically beamed.

“Do you know how to write a note?”

“Yes.” The moment I said it I realized just how paltry a contribution it would seem to him. Baio must have seen my face drop.

“That will actually be a big help,” he said. “Examine every patient and write a note on them for the chart. That will save me time. You need to be concise yet precise.”

I grabbed my small notebook and scribbled examine everyone/write notes...

Matt McCarthy, MD, is the author of this new self-effacing book, which has been on my get-and-read list since I first learned it was coming out. Just downloaded the Kindle edition.

Sometimes I read linearly, cover-to-cover. Sometimes I read a ways in, and then cut to the concluding chapter(s) prior to going back and finishing all of them. Sometimes I scan the table of contents, looking for specific topics.

In this case, I first used the keyword search function: "health IT"? "health information technology"? "EHR?" "EMR"? "digital"? "interoperability"?

Nothing. Nada. Nyet. Zip. Zilch. "0 matches found"

OK... "chart"?

"23 matches found"

Paydirt.

I logged in to the computer and found my patient panel. I was scheduled to see patients in thirty-minute increments from 1: 00 P.M. until 4: 30 P.M. Opening the medical record of my first patient, I felt a small thrill as I prepared to jot down notes about him, a fifty-three-year-old man who had been coming to the clinic for several years. I opened the last note from the previous primary care provider. But as I read, my eyes almost instantly went crossed.

The note began: Problem List

1. HTN
2. CKD
3. CAD
4. TIA
5. COPD
6. GERD
7. PVD
8. Migraines
9. ED 1
0. DM2
11. BPH
12. Active tobacco use
13. Depression
14. HLD
15. OSA on BiPAP
16. Afib on Coumadin
17. Glaucoma?
18. HCM: needs c-scope

What kind of patient had eighteen different problems to deal with? It seemed like I’d need a team of specialists in the room with me just to provide primary care. Sifting through the befuddling acronyms, I felt my stomach turn. I recognized some of the letter combinations, but every unknown acronym felt like a small knife in my side. Were they using a different set of abbreviations at Columbia? I suddenly missed the immediacy of surgery, of just fixing something right then and there, showing Axel, and moving on. I reread the note from the beginning and began Googling the various combinations of letters that weren’t immediately recognizable.

My palms broke into a light sweat as I typed. What if this patient had other problems— problems that weren’t on this list? Patients were more likely to focus on things they could feel, like a sore knee, than on things they couldn’t, like diabetes or high blood pressure. How could I possibly address old issues and new ones in one short clinic visit? While the computer performed the search, my thoughts drifted back to Carl Gladstone, as they had every time I found myself with a moment of free time. Was he going to be okay?

I had to say something.

After twenty distracted minutes I was only a third of the way through the patient’s medical record, but sitting behind the large desk I did feel somewhat like a real doctor, at least more than I did in the cardiac care unit. Feeling a moment of modest inspiration, I hopped up from my swivel chair and decided to test out the blood pressure cuff. In medical school I’d always found the contraption cumbersome and knew from experience that fumbling with it would be a dead giveaway that I was new in town. Once satisfied that I could hold the stethoscope in place with one hand while pumping up the cuff with the other, I returned to the medical record. After fifteen more minutes of referencing and cross-referencing, I had to shut my eyes.

Was it really possible to memorize and retain all of this knowledge? And more important— was it necessary? Or did real physicians retain a core of crucial information and simply look the rest up on the fly? Baio seemed like he’d seen it all before, drawing on experience to guide his decision making. As I dug deeper into the chart and all hope of diagnostic parsimony appeared lost, there was a knock at the door.

I sprang up from my chair and opened the door.

“Dr. McCarthy,” the receptionist said, “your one P.M. is here.”

“Okay,” I said. “Great.”

“Do you want to see him?” she asked.

As I glanced at my notebook, I momentarily wondered whether any answer besides yes would be acceptable. In truth, I thought I’d need another hour before feeling prepared to see the patient.

“Well,” I said, folding my arms, “I suppose I should—”

“It’s one forty-seven P.M.,” she said. “He was almost an hour late and your one-thirty P.M. just arrived.”

“He seems kinda sick,” I said.

 “Maybe we could do a shorter visit or—”

“I’ll send him in,” she said and closed the door.

A moment later, a stocky bearded man in a faded barn jacket entered the room and extended a callused hand.

“Sam,” he said firmly.

“Matt. Mr. McC—— Dr. McCarthy. Please have a seat.”

I waved my hand across my desk like I’d just performed a magic trick. “You actually gave me some time to familiarize myself with your chart.”

The fact that Sam was even upright and walking into my office under his own power came as a small surprise . After reading the long list of conditions in his chart, I was expecting a borderline invalid, but Sam looked rather well. He was husky, with shaggy gray hair that drooped into his eyes, and if Heather saw him on the street she might whisper to me that he looked like a sheepdog. “Terribly sorry I’m late,” he said. “Didn’t know you guys still used charts.”

His smile revealed crowded, champagne-colored teeth. “It’s mostly computerized,” I conceded, “but yes, some records are still on paper.”

McCarthy, Matt (2015-04-07). The Real Doctor Will See You Shortly: A Physician's First Year (pp. 56-59). Crown/Archetype. Kindle Edition. 

After slogging through all of the passages containing the word "chart," I found nothing else discussing the use of health IT.

How about searching the word "computer"? "18 matches found." But, not all that revealing.

Ashley had greeted me that morning by saying, “Don’t do anything without running it by me first. Are we clear?” Before I could respond, she’d launched into the array of tasks that needed to be completed before rounds— rattling off assignments like wheeling a patient to dialysis and transporting a vial of blood to the chemistry laboratory— faster than I could write, and then withdrew the work delegated to me just as quickly, explaining that it was quicker if she just did everything herself. This was becoming a regular routine, and it made me feel expendable and potentially dangerous. It was clear she considered me a liability, someone who still couldn’t enter computer orders related to HIV care or write notes as proficiently as she could. Our brief exchanges were reminiscent of a naughty child and a frustrated babysitter. Her friends called her Ash, but she’d instructed me to call her Ashley. The intentional distance she put between us made me anxious. Even though we were hardly a personality match, I wanted to click with her. I wanted to click with everyone...

I no longer trusted myself to remember anything unless it was written down. There were literally hundreds of small tasks and new factoids that popped into my brain over the course of the day, and I found it impossible to keep track of them all without committing them to paper. And prioritizing it all required yet another set of skills. “Yes, ma’am,” I said awkwardly. My daily scut list looked like a madman’s diary, every inch covered in scrawl. I often thought of Axel, imploring me not to write on my hands. “

And if I can give you one piece of advice, it’s this: be efficient.” 

“I’ll do my best.” 

“But efficiency necessitates competency,” she said. “There’s too much to know. Information is generated so quickly. And at your stage you’re still trying to learn the basics.” Again, Ashley was right. Scores of scientific journals were constantly churning out new and at times contradictory medical information. We would never have time to read it all and were in need of a competent curator. In many ways, Baio had filled that role for me in the CCU . But I needed to do it myself now... [ibid, pp. 112-114].

Notwithstanding the paucity of health IT references, this looks like a worthy read. It's amiably well-written and painfully candid through the six chapters I've thus far read.

All part of my endless contextual learning quest, always trying to better grasp the clinicians' point of view as it pertains to clinical pedagogy, physician workflow, and the ever-increasing, inexorable use of digital health IT as part of workflow.

Just some of the clinician-focused books I've cited in this blog:

apropos of "pedagogy,"

Forget SXSW - Austin's Most Radical New Idea May Be In Medical Education
David Shaywitz

Austin, the birthplace of Whole Foods, Dell Computer, Heritage Boot (just bought my first pair), and SXSW (never been) is in the process of launching something even more radical: a fundamentally new way to think about medical education and the role of an academic medical center.

At the core of this effort is a new medical school to be built in Austin, funded in part by revenue from an increase in local property tax (Proposition 1, approved in 2012) and in part by a gift announced in 2013 from the Michael Dell and Susan DellFoundation, after whom the school will be named.  The first class is slated to begin in 2016.

The big idea – at least from the perspective of the founding team – is this: traditional academic medical centers are (as they see it) essentially clinical care factories that throw off a lot of revenue, a small fraction of which is used to support (on average) 50% of the research and 90% of the educational activities associated with medical schools.

Like many health policy experts, they look at the healthcare system, and see a huge amount of “waste” (“waste” was perhaps the most common word I heard in my conversations) – unnecessary or inefficient care, and the costs associated with this waste.  Or rather, in the case of most hospitals, the enhanced revenue associated with this waste.

How can you expect a medical school to train physicians to think innovatively about reducing waste, or pursue serious research on waste reduction, the new Dell Medical team asks, when the results of this waste are responsible for such a large share of medical school revenue?  One leader at Dell Medical described this as “the ultimate conflict of interest.”

As if this wasn’t enough, I also detected an undercurrent of concern from Dell Medical leaders that much of the research agenda at traditional academic medical centers tends to be driven by reductionist basic scientists, keen to defend and if possible, augment their territory.  Their approach, Dell Medical executives seemed to suggest, are often not informed by the sorts of broader questions you would ask if you were truly focused on improving the health of the population in front of you.  The implication is that the direction and emphasis of traditional academic medical research is driven more by the political power wielded by scientists rather than by any concerted effort to discern and respond to the actual health needs of a community, which may require less focus on molecular description, and on more on prevention and care delivery...

Interesting. Go onto this by way of my daily stop at The Incidental Economist.

ERRATUM

I could not attend HIMSS15 in Chicago. Health issues. Nice recap by Katie Bo Williams here.

What you missed at HIMSS15: The biggest announcements, afterparties and IT buzz

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More to come...

"Obama Administration Report Slams Digital Health Records"

Gotta love the framing, "Obama Administration." This is pure ONC, responding to recent congressional rumblings, and looking to stay visible and relevant now that they're essentially out of HITECH money. As reported in The Wall Street Journal,

Report criticizes vendors for making it costly to share patient information

The Obama administration took vendors of electronic health records to task for making it costly and cumbersome to share patient information and frustrating a $30 billion push to use digital records to improve quality and cut costs.

The report, by the Office of the National Coordinator for Health Information Technology, listed a litany of complaints it has received about vendors allegedly charging hefty fees to set up connections and share patient records; requiring customers to use proprietary platforms; and making it prohibitively expensive to switch systems.

The report also cited complaints that some hospital systems make it difficult to transfer patient records to rival systems or physicians as a way to control referrals and enhance their market dominance.

The agency didn’t cite any companies by name, however, and said it couldn’t determine the extent of information-blocking—in part because contracts often forbid customers from discussing prices and other terms.

“This is our first deep dive, where we have taken the opportunity to describe the situation and identify practices that interfere with the flow of health information,” said ONC chief Karen DeSalvo. “We believe it will take an array of solutions and we look forward to working with Congress on this.”...

Absent naming names and citing specific instances, I'm not sure what the impact of this 39 page ONC report (pdf) will be.

Information Blocking and its Potential Impacts

In contrast to these well-known interoperability challenges, the extent to which information blocking is impeding the effective sharing of electronic health information is less clear. While ONC and others are studying the problem, formal research is limited and anecdotal evidence is often difficult to interpret and still more difficult to generalize.

The term “information blocking” presents significant definitional challenges. There are many types of electronic health information and just as many factors that can inhibit its effective exchange and use. Many actions that prevent information from being exchanged may be inadvertent, resulting primarily from economic, technological, and practical challenges that have long prevented widespread and effective information sharing. Further, even conscious decisions that prevent information exchange may be motivated by and advance important interests, such as protecting patient safety, that further the potential to improve health and health care. These interests must be carefully balanced with the potential benefits from sharing of electronic health information. Finally, it is important to acknowledge that certain constraints on the exchange of electronic health information are appropriate and necessary to comply with state and federal privacy laws; this is not considered information blocking. [pg 7]

"[C]onscious decisions that prevent information exchange may be motivated by and advance important interests, such as protecting patient safety..."

The phrase "patient safety" appears ten times in the ONC report. Now, I'm not the sharpest tool in the drawer, but I'm a careful, plodding, thorough reader, and I could find nothing citing where a "patient safety" rationale was proffered (by an EHR vendor or anyone else) as a justification for impeding the otherwise appropriate and necessary flow of ePHI. All we get is ONC's gauzy, oblique, groveling statement that PHI data siloing may "advance important interests, such as protecting patient safety."

Who writes this crap?

A quick dip into Bob Wachter's excellent new book here.

What I’ve come to understand is that computers and medicine are awkward companions. Not to diminish the miracles that are Amazon.com, Google Maps, or the cockpit of an Airbus, but computerizing the healthcare system turns out to be a problem of a wholly different magnitude. The simple narrative of our age— that computers improve the performance of every industry they touch— turns out to have been magical thinking when it comes to healthcare. In our sliver of the world, we’re learning, computers make some things better, some things worse, and they change everything.

Harvard psychiatrist and leadership guru Ronald Heifetz has described two types of problems: technical and adaptive. Technical problems can be solved with new tools, new practices, and conventional leadership. Baking a cake is a technical problem: follow the recipe and the results are likely to be fine. Heifetz contrasts technical problems with adaptive ones: problems that require people themselves to change . In adaptive problems, he he explains, the people are both the problem and the solution. Leadership, he once said, requires mobilizing and engaging people around a problem “rather than trying to anesthetize them so you can go off and solve it on your own.”

The wiring of healthcare has proven to be the Mother of All Adaptive Problems. Yet we’ve mistakenly treated it as a technical problem: simply buy the computer system, went the conventional wisdom, take off the shrink-wrap, and flip the switch. We were so oblivious to the need for adaptive change that when we were faced with failed installations , mangled work flows, and computer-generated mistakes, we usually misdiagnosed the problem; sometimes we even blamed the victims, both clinicians and patients. Of course, our prescription was wrong— that’s what always happens when you start with the wrong diagnosis.

Making this work matters . Talk of interoperability, federal incentives, bar coding, and machine learning can make it seem as if healthcare information technology is about, well, the technology. Of course it is. But from here on out, it is also about the way your baby is delivered; the way your cancer is treated; the way you are diagnosed with lupus or reassured that you aren’t having a heart attack; the way, when it comes down to whether you will live or die, you decide (and tell the medical system ) that you do or you don’t want to be resuscitated. It is also about the way your insurance rates are calculated and the way you figure out whether your doctor is any good—and whether you need to see a doctor at all. Starting now and lasting until forever, your health and healthcare will be determined, to a remarkable and somewhat disquieting degree, by how well the technology works…

We can— in fact, we must— wire the world of medicine, but we need to do it with our eyes open, building on our successes, learning from our mistakes , and mitigating the harms that are emerging.

To do so effectively, we need to recognize that computers in healthcare don’t simply replace my doctor’s scrawl with Helvetica 12. Instead , they transform the work, the people who do it, and their relationships with one another and with patients. Sorting out all these issues will take deep thought and hard work on the part of clinicians, healthcare leaders, policy makers, technology vendors, and patients. Sure, we should have thought of this sooner. But it’s not too late to get it right.

Wachter, Robert (2015-04-01). The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age . McGraw-Hill Education. Kindle Edition, Locations 160-161.

Yeah, it's not a "tech problem," it's an "adaptive problem," one fundamentally -- as it concerns this issue -- a policy/legal problem.

My recommendation, Congress? Make willful ePHI blocking a crime. Later for all this endless, polite episodic white paper consideration of (and deference to) "all stakeholder interests and viewpoints."

Tangentially apropos, more Dr. Watcher:

Since we’re talking about government programs, you can be certain that while many people criticize Meaningful Use and HIPAA for being too much and too rigid, others criticize the ONC for being too lax in certain areas. The two biggies are usability (the ease of use and learnability of the IT system) and interoperability (common standards that allow different EHR systems to connect with each other).

Blumenthal agrees that today’s electronic health records could be far more usable, but when he tried to convert that concern into policy during his tenure as ONC director, he came to believe that judging usability was like Justice Potter Stewart’s “I know it when I see it” take on pornography. “We could not get any experts to say they could measure usability in a reproducible, valid way,” said Blumenthal, “a way we could stand behind from a legal standpoint.” While this issue continues to be debated, Halamka and others believe that the market is now mature enough for usability to take care of itself . With today’s high rate of EHR adoption, Halamka argues, the vendors will compete on usability, and the best products will win. As proof, he is piloting a cloud-based system built by athenahealth in Beth Israel’s extensive ambulatory clinics, a system known for its emphasis on usability (I’ll have more to say about this company later).

On this one, I side with those who believe that government should keep its nose out. Imagine if the government tried to design the look and feel of your smartphone or your computer’s desktop— well, enough said. I do, however, support a proposal to create a federal health IT safety center that can collect and analyze reports of dangerous IT interfaces (like the mg versus mg/ kg Septra confusion that nearly killed Pablo Garcia) and take appropriate action. And federal support for a nonpartisan organization that grades the usability of different systems based on standard criteria— that might work. But as for the government dictating standards for fonts, colors, and clicks, well, thanks, but no thanks.

Interoperability is a different matter. Interoperability is just the kind of thing government intervention was designed for, since it is a powerful public good that the private market will not automatically create. Why is it so important? Think about your cell phone: your iPhone can call your friend’s Samsung without a hiccup, even if your service is with AT& T and your friend’s is with Verizon. The same is true with your Web browser: whether you like Safari, Chrome, or Firefox for its look or features, all of them can get you onto the Internet just fine.

In the EHR world, just think how great it would be to have an interoperable system. We’d no longer need a paper airplane to get crucial patient information from one hospital to another. The costs of switching from a crummy EHR to a better one would plummet, since the patient data stored in the old system would be easily transferrable to the new one. A world of innovators (the folks who are currently writing apps for your iPhone and Android) would be freed up to create programs to help diabetic patients or families of patients with ALS manage their care— and these would sync seamlessly with existing EHRs.

On interoperability, Blumenthal defends the ONC’s early prioritization of adoption over interoperability. “I had the basic feeling that you had to ‘operate’ before you could ‘interoperate.’ And you couldn’t create a business case for interoperability,” at least at first. Today, while the market for interoperability has gotten a bit stronger, he and I both doubt that the same business case that will drive usability will also drive interoperability. This one needs an assist from Uncle Sam.

While it would be great to have total interoperability tomorrow, it will take some time, even if the ONC puts its shoulder behind it, as it now seems to be doing with its October 2014 proposal for standardized APIs. Not only are there political obstacles to overcome (put in place mostly by vendors and healthcare systems that remain reluctant to share, as you’ll see in the next chapter), but the kinds of people involved in the nitty-gritty work of interoperability do not make for a speedy process. Said Halamka, “You know, there are forest people and there are tree people. Standards folks are, by necessity, bark people. They’ll spend a day debating the relative merits of an ampersand or a semicolon.” [ibid, Locations 3613-3614]

Expect yet more of what I've named "Interoperababble"? Ahhh... but, maybe now the current darling HL7® FHIR® APIs will bail us out forthwith.

Color me skeptical, ongoing.

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ONC post at THCB

Link here. Some of the comments are scathing. First, the reliably confused conflationist National Privacy Scold Deb Peel, who thinks Epic's EHR killed Dallas ebola patient Duncan:

Deborah C. Peel, MD says:

ONC is finally discovering the lack of interoperability??? It’s been blatantly obvious for years.

The lack of interoperability started in 2002 when HHS cut patients out of data exchange by eliminating the patient’s right to give consent before PHI could be disclosed. Now it’s clear patients are the only ‘stakeholders’ motivated to disclose health data for treatment purposes.

HHS put data holders in control of data exchange, ie of ‘interoperability’. Guess what? The data holders began to treat the nation’s health data as a corporate asset and to use it for their benefits, not ours.

Patient Privacy Rights has pointed out the lack of ‘interoperability’ and the easy, cheap solution for years: restore patient control over data exchange. 

Here’s a blog from 2007: http://patientprivacyrights.org/2007/07/privacy-is-key-to-interoperability/

And another blog from 2012: http://patientprivacyrights.org/2012/05/report-hies-failing-at-true-interoperability/

HHS abdicated its duty to ensure patients’ rights were built into HIT systems. Why? HHS is protecting corporations, not people. The lack of ‘interoperability’ is a massive technology design flaw engineered by industry & HHS.

Hippocrates swore to keep patients’ sensitive information private. His oath not to disclose patient information without permission is the foundation of trust in physicians. It’s embedded in American law and Medical Ethics so sick people can trust the people who treat them.

See: http://www.patientprivacyrights.org

1. 
   

   Emma Thomas, RN says:

   
   

   
   Pathetic. You should be ashamed. How many $ millions did this report cost? You reinvented the wheel.
   
   You conveniently failed to address the risks and adverse events from these devices themselves.
   
   So what? You interconnect a bunch of medical devices that have side effects of injury and death at an incidence that is unknown because there is not any mandatory reporting. Great!
   
   You are worried about interoperability yet you fail to address the crashes and EHR unavailability and aftermath, as recent;y experienced at all MedStar clinics in your neighborhood and state.
   
   Why is there not mandatory reporting of any and all EHR crashes and the deaths that arise from the mayhem and delays in care that are part and parcel of these crashes?
   

   
   
2. Emma Thomas, RN says:

   
   Addendum:
   
   ONC does not care:
   
   The systems are not fit for purpose. The adverse events, errors, and near misses go unreported. 
   
   This week, the doctor had CPOEed and [sic] order for BID potassium with a perameter [sic] to hold it if the serum k+ was > 4.6 mg%. the order on my palate was obfuscated by innumerable lines of instructions such that I missed the perameter [sic] and gave the potassium supplement when the serum potassium was 4.7, and the next day, 4.9.
   The doctor missed it because the MAR is terribly inaccessible and user unfriendly when accessed.
   
   The next day, the serum potassium level was at life threatening levels and I was beating on myself. 
   
   Yet, I have no one to report this to, because, no one really cares.

 Emma Thomas, I'm glad you're not my nurse. Learn to spell if you want to be taken seriously -- and, more importantly, do accurate charting.
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UPDATE

Interesting comment over at THCB's new post "Why the Market Can’t Solve the EHR Interoperability Problem."

...I disagree strongly with Dr. Yarhagi’s faith in the market to ensure that healthcare information technology (HIT) vendors will be obliged to “develop sustainable revenue stream through reasonable exchange fees negotiated with the medical providers.”  That is, he asserts that if there were a real market without federal subsidies and requirements that all healthcare providers buy the HIT,  then providers and the HIT vendors would agree on reasonable fees for exchanging patient records.

But why would the vendors do this?  Hospitals and doctors are generally locked into their HIT systems for years. A very big hospital EHR can cost $400 million plus 4 times that for implementation (e.g., training, software upgrades, etc.) over several years. Installing an EHR in a small clinic or doctor’s office is of course far less money, but nevertheless costs a few hundred thousand dollars.  The healthcare providers have no bargaining power. Why would the vendors even bother to negotiate over fees for sharing patient data?

The more salient question is: why should any HIT vendor be permitted to charge a penny to help share data that is needed to make medical care safer, more efficient, more informed, better?  A key feature of HIT is that it allows exchanging information on patients.  The government is giving $30 billion to subsidize purchase and use of these technologies; hospitals and other providers are spending trillions of dollars buying and installing them. It is unconscionable that a vendor would even think about charging clinicians to share data on patients’ health—data that clinicians themselves entered in the first place! The government need not threaten vendors who don’t allow sharing of data. There should be no choice. Data exchange must be required through regulation.  We don’t negotiate with car drivers about stopping at red lights, and we don’t compromise on truck weight limits on certain bridges. Some rules are simply necessary for public safety.

Vendors are allowed to keep patients’ data, but they should not be allowed to hold those data hostage until the creators and users of those data pay up.  Anyway, officially, the data are owned by the patients. The last thing patients want is to be treated by doctors who are blind to their medical needs.

See my February 17th post "On ONC's "non-regulatory, market-driven" Health IT fetish, and other related business."

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More to come...

 

Health IT and patient safety: a JCAHO Sentinel Alert

From The Joint Commission comes this.

Safe use of health information technology
March 31, 2015

Health information technology (health IT) is rapidly evolving and its use is growing, presenting new challenges to health care organizations. This alert builds upon Sentinel Event Alert #42 on safely implementing health information and converging technologies (published in 2008) to take a broader look at health IT, particularly the socio-technical factors having an impact on its safe use. This alert’s suggested actions center on safety culture, process improvement and leadership.

Incorrect or miscommunicated information entered into health IT systems may result in adverse events. In some cases, interfaces built into the technology contribute to the events. The following examples obtained from ECRI Institute1 show a few ways adverse events may occur through the use of electronic health records (EHRs) and related technologies:

• A chest X-ray was ordered for the wrong patient when the wrong patient room number was accidentally clicked. The orderer noticed the error right away and promptly discontinued the order, but not in time for the X-ray technician to see that the order was withdrawn. The technician performed the test on the wrong patient.
• A drug was ordered as an intramuscular injection when it was supposed to be administered intravenously. The physician did not choose the appropriate delivery route from the drop-down menu.
• A nurse noted that a patient had a new order for acetaminophen. After speaking with the pharmacist, the nurse determined that the order was placed for the wrong patient. The pharmacist had two patient records open, was interrupted, and subsequently entered the order for the wrong patient.

These examples show the risks inherent in health IT, and studies have documented mixed results in EHRs’ ability to detect and prevent errors. On the positive side, however, well-designed and appropriately used EHRs coupled with strong clinical processes can improve and monitor health care quality and safety through their ability to access important medical history data, provide clinical decision support tools, and facilitate communication among providers and between providers and patients. EHRs have demonstrated the ability to reduce adverse events, particularly EHRs with clinical data repository, clinical decision support, computerized provider order entry (CPOE) and provider documentation functionalities.

"Social factors?" Hmmm... "Talking Stick," anyone?

As I observed back in June 0f 2014,

My recent posts have ruminated on what I see as the underappreciated necessity for focusing on the "psychosocial health" of the healthcare workforce as much as focusing on policy reform (e.g., P4P, ACOs, PCMH), and process QI tactics (e.g., Lean/PDSA, 6 Sigma, Agile), including the clinical QI Health IT-borne "predictive analytics" fruits of ""Evidence Based Medicine" (EBM) and "Comparative Effectiveness Research" (CER). Evidence of psychosocially dysfunctional healthcare organizational cultures is not difficult to find (a bit of a sad irony, actually). From the patient safety-inimical "Bully Culture" down to the "merely" enervating emotionally toxic, I place it squarely within Dr. Toussaint's "8th Waste" (misused talent)...

See also my July 19th 2014 post "Medical Error, Interop, and the Patient Safety-Health IT nexus."

So, is this new Joint Commission Sentinel Event Alert 54 (pdf) giving us anything relating to improving the interpersonal psychosocial aspects of healthcare organizational culture, as a component of improving patient safety in general, and improving the effectiveness of health IT use specifically?

I'm not seeing much, beyond the usual vague (albeit necessary) exhortations.

Safety Culture
Create and maintain an organizational-wide culture of safety, high reliability and effective change management…

Process Improvement
Develop a proactive, methodical approach to health IT process improvement that includes assessing patient safety risks…

Leadership
Within a culture of safety and process improvement described earlier in this alert, enlist multidisciplinary representation and support in providing leadership and oversight to health IT planning, implementation and evaluation...

Read the entire Alert, decide for yourselves.

What of the above-cited antecedent JCAHO Sentinel Event Alert #42? (pdf)

Issue 42, December 11, 2008
Safely implementing health information and converging technologies

As health information technology (HIT) and “converging technologies”—the interrelationship between medical devices and HIT— are increasingly adopted by health care organizations, users must be mindful of the safety risks and preventable adverse events that these implementations can create or perpetuate. Technology-related adverse events can be associated with all components of a comprehensive technology system and may involve errors of either commission or omission. These unintended adverse events typically stem from human-machine interfaces or organization/system design. The overall safety and effectiveness of technology in health care ultimately depend on its human users, ideally working in close concert with properly designed and installed electronic systems. Any form of technology may adversely affect the quality and safety of care if it is designed or implemented improperly or is misinterpreted. Not only must the technology or device be designed to be safe, it must also be operated safely within a safe workflow process…

Contributing factors
Inadequate technology planning can result in poor product selection, a solution that does not adapt well to the local clinical environment, or insufficient testing or training. Inadequacies include failing to include front-line clinicians in the planning process, to consider best practices, to consider the costs and resources needed for ongoing maintenance, or to consult product safety reviews or alerts or the previous experience of others. Implementing new clinical information systems can expose latent problems or flawed processes with existing manual systems; these problems should be identified and resolved before implementing the new system. An over-reliance on vendor advice, without the oversight of an objective third party (whether internal or external), also can lead to problems. “There’s often an expectation that technology will reduce the need for resources, but that’s not always true,” says Bona Benjamin, BS Pharm, director of Medication-Use Quality Improvement, American Society of Health-System Pharmacists. Instead, technologies often shift staffing allocations, so there is not typically a decrease in staff.

Technology-related adverse events also happen when health care providers and leaders do not carefully consider the impact technology can have on care processes, workflow and safety. “You have to understand what the worker is going through – whether that worker is a nurse, a doctor, a pharmacist or whoever is using the technology. The science of the interplay between technology and humans or ‘human factors’ is important and often gets short shrift,” says Ronald A. Paulus, M.D., chief technology and innovation officer, Geisinger Health System.

If not carefully planned and integrated into workflow processes, new technology systems can create new work, complicate workflow, or slow the speed at which clinicians carry out clinical documentation and ordering processes. Learning to use new technologies takes time and attention, sometimes placing strain on demanding schedules. Th resulting change to clinical practices and workflows can trigger uncertainty, resentment or other emotions that can affect the worker’s ability to carry out complex physical and cognitive tasks. For example, through the use of clinical, role-based authorizations, CPOE systems also exert control over who may do what and when. While these constraints may lead to much needed role standardizations that reduce unnecessary clinical practice overlaps, they may also redistribute work in unexpected ways, causing confusion or frustration. Physicians may resent the need to enter orders into a computer. Nurses may insist that the physician enter orders into the CPOE system before an order will be carried out, or nurses may take over the task on behalf of the physician, increasing the potential for communication-related errors. Physicians have reported a sense of loss of professional autonomy when CPOE systems prevent them from ordering the types of tests or medications they prefer, or force them to comply with clinical guidelines they may not embrace, or limit their narrative flexibility through structured rather than free-text clinical documentation. Furthermore, clinicians may suffer “alert fatigue” from poorly implemented CPOE systems that generate excessive numbers of drug safety alerts. This may cause clinicians to ignore even important alerts and to override them, potentially impairing patient safety…

apropos of that last paragraph, this THCB post (to which I referred in my prior post) comes to mind.

An Epic Struggle for the Soul of Medicine

By MARTIN SAMUELS, MD

This week I attended an all day “training” session in a new medical record system.  I thought it was interesting that the experience was called “training”...

The experience transported me back to the Northwood Elementary School when my parents decided to enroll me in clarinet lessons. They rented a metal clarinet. The teacher, Mrs. Strickland, traveled among the elementary schools in the district, spending a half day in each, introducing kids to music. The emotional memory remains vivid.  I just couldn’t make a sound with the thing; not even a squeak!  I also didn’t know where to put my hands and, of course, could not read the music.  It was a horrifying experience. Now, at the age of 69 I was back in the same situation; infantilized in a windowless room with 16 computers, behind each of which was a doctor who should have been seeing patients. There were only two differences between then and now. One, I now have many more things that I should be doing than I did then.Two, at least the end product of what I was doing then was inherently meritorious; namely making music. Now I was playing a video game, and what was even more horrifying was that some of the people around me were actually enjoying it.

I know all the rationales for an electronic medical record, such as bringing our supposedly chaotic medical system into line, reducing medication errors and improving communication; all meritorious goals. There is nothing inherently good or evil about an electronic record. After all it is just a computer program; basically a machine.  The fact is that a machine has no soul. It has no feelings and no commitment to the practice of medicine. To allow the machine to dictate the rules reminds one of HAL from Stanley Kubrick’s film, 2001: The Space Odyssey. “Just what do you think you’re doing, Dave.”

The electronic medical record does not adhere to any natural laws, such as the laws of biology. The rules are arbitrary. They are created by people. Playing with the machine is nothing more than a video game.  In fact, at the end of my day in “training” I was told to go home a use the “playground”; a simulated electronic medical record that would help me to become more facile at following the unnatural rules of what is really a billing machine. But this is not play for me. It is tedium which distracts me from the job for which I am educated; namely reducing suffering in human beings. I only have a finite number of days when I can utilize my skills. One day in the windowless room is one fewer that I have left. If we are not very careful, we might even convince society that the electronic medical record, and what it represents, is an end in itself; more important than taking care of the sick, training our successors and finding cures for human disease. Or, is it already too late? Has the door already closed behind us?…

You don't have to look far at all to come upon cascades of HIT scorn. Dr. Samuels never utters the name "Epic," but, IMO it's a pretty safe bet as to which EHR platform he's referring.

Back to JCAHO. What did these good folks proffer a good six years ago, back in 2008?

Joint Commission suggested actions

Below are suggested actions to help prevent patient harm related to the implementation and use of HIT and converging technologies.

• Examine workflow processes and procedures for risks and inefficiencies and resolve these issues prior to any technology implementation. Involving representatives of all disciplines—whether they be clinical, clerical or technical—will help in the examination and resolution of these issues.
• Actively involve clinicians and staff who will ultimately use or be affected by the technology, along with IT staff with strong clinical experience, in the planning, selection, design, reassessment and ongoing quality improvement of technology solutions, including the system selection process. Involve a pharmacist in the planning and implementation of any technology that involves medication.
• Assess your organization’s technology needs beforehand (e.g., supporting infrastructure; communication of admissions, discharges, transfers, etc.). Investigate how best to meet those needs by requiring IT staff to interact with users outside their own facility to learn about real world capabilities of potential systems, including those of various vendors; conduct field trips; and look at integrated systems (to minimize reliance on interfaces between various vendor systems).
• During the introduction of new technology, continuously monitor for problems and address any issues as quickly as possible, particularly problems obscured by workarounds or incomplete error reporting.
• During the early post-live phase, consider implementing an emergent issues desk staffed with project experts and champions to help rapidly resolve critical problems. Use interdisciplinary brainstorming methods for improving system quality and giving feedback to vendors.
• Establish a training program for all types of clinicians and operations staff who will be using the technology and provide frequent refresher courses. Training should be appropriately designed for the local staff. Focus training on how the technology will benefit patients and staff, i.e. less inefficiency, fewer delays and less repeated work. Do not allow long delays between orientation and system implementation.
• Develop and communicate policies delineating staff authorized and responsible for technology implementation, use, oversight, and safety review.
• Prior to taking a technology live, ensure that all standardized order sets and guidelines are developed, tested on paper,and approved by the Pharmacy and Therapeutics Committee (or institutional equivalent).
• Develop a graduated system of safety alerts in the new technology that helps clinicians determine urgency and relevancy. Carefully review skipped or rejected alerts as important insight into clinical practice. Decide which alerts need to be hard stops when using the technology and provide appropriate supporting documentation.
• Develop a system that mitigates potential harmful CPOE drug orders by requiring departmental or pharmacy review and sign off on orders that are created outside the usual parameters. Use the Pharmacy and Therapeutics Committee (or institutional equivalent) for oversight and approval of all electronic order sets and clinical decision support alerts.
• Assure proper nomenclature and printed label design, eliminate dangerous abbreviations and dose designations, and ensure MAR acceptance by nurses.
• To improve safety, provide an environment that protects staff involved in data entry from undue distractions when using the technology.
• After implementation, continually reassess and enhance safety effectiveness and error-detection capability, including the use of error tracking tools and the evaluation of near-miss events. Maximize the potential of the technology in order to maximize the safety benefits.
• After implementation, continually monitor and report errors and near misses or close calls caused by technology through manual or automated surveillance techniques.
• Pursue system errors and multiple causations through the root cause analysis process or other forms of failure-mode analysis. Consider reporting significant issues to well recognized external reporting systems.
• Re-evaluate the applicability of security and confidentiality protocols as more medical devices interface with the IT network. Reassess HIPAA compliance on a periodic basis to ensure that the addition of medical devices to your IT network and the growing responsibilities of the IT department haven’t introduced new security and compliance risks.

Again, all important and necessary. But, all process and technology oriented (and, stuff we were all talking about back during the MU-antecedent "DOQIT" era) -- two legs of a stable 3-legged stool. All assuming the continuation of a transactional / instrumental view of those toiling within healthcare organizations.

From the perspective of my hospital gurney last week:

Q: "So, what do you think of Epic?”
A:  "It's a great tool -- for tracking our every move."

Ouch. Yeah, I know this quite well from another context. As I posted last August,

There are 3 fundamental aspects of workflow in the digital era: physical tasks, IT (EHR) tasks, and cognitive tasks. Every certified EHR has to have an audit trail to comply with HIPAA, given that every time ePHI is created, viewed, updated, transmitted, or deleted the transaction must be “date-time/who/what/about whom” captured in the audit trail log.

The ePHI audit log, to me, is a workflow record component. It can’t tell me WHY front desk Susie or Dr. Simmons took so long to get from one transaction element to the next — i.e., physical movements or cognitive efforts — but it can tell me a lot, adroitly analyzed.

I worked for number of years as a credit risk and portfolio management analyst in a credit card bank. We had an in-house collections department that took up an entire football field sized building, housing about 1,000 call center employees. I had free run of the internal network and data warehouse. One day I just happened upon the call center database and the source code modules (written by an IT employee in FoxPro, which I already knew at an expert level). I could open up the collections call log and watch calls get completed in real time. We were doing maybe a million outbound calls a month (a small Visa/MC bank).

(My fav in the Comments field was “CH used fowl language,” LOL)

It was, in essence, an ongoing workflow record of collections activity.

I pulled these data over into SAS and ground them up. I could track and analyze all activity sorted by any criteria I wished, all the way down to the individual collector level. I could see what you did all day, and what we got (or didn’t) for your trouble.

I was [able to] rather quickly show upper management “Seriously? You dudes are spending $1,000 to collect $50, every day, every hour” etc. The misalignment was stunning. I started issuing a snarky monthly summary called “The Don Quixote Report” with a monthly “winner.” …Yeah, we called this hapless deadbeat 143 times this month trying to get 15 bucks out of him…

Well, it didn’t take long to squelch all that. We saved the bank 6 million dollars in Collections Department Ops costs that year via call center reforms. Didn’t exactly endear me to the VP of Collections, whose bonus was tied to his budget.

Gimme a SAS or Stata install and SQL access to the HIT audit logs, and I will tell you some pretty interesting (Wafts-of-Taylorism 2.0) workflow stories.

In this regard, see my cite of Simon Head's book "Mindless."
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UPDATE

I'm deep into Dr. Bob Wachter's fine new book.

While I will have plenty to say about it, Matthew Holt of Health 2.0 has a review of it up on THCB. Worth your time.

The Digital Doctor -- The Review

...There are by and large three camps of opinions about what’s happened [within Health IT]. One is that the EMR is a pox visited on physicians that costs a fortune, has worsened quality, heightened medical errors, blown up successful processes, and ruined the lives of doctors–unless they were given scribes. The second is that because of the “rush to judgement” caused by the HITECH Act and Meaningful Use, we put in EMRs that were based on 1990s client-server technology but they were the only ones mature enough for the job. Most of this camp thinks that they were way better than paper, will slowly improve, and that doctors and patients will find that these technologies will soon integrate with easy to use iPhone-like apps as their APIs open up–and that if we hadn’t mandated EMRs when the great recession gave us the chance, nothing would have happened. The third camp agrees that EMRs are better than paper but felt that the way HITECH was rolled out kept a bunch of dinosaurs in business, and is preventing the health IT equivalent of Salesforce displacing Siebel (or Slack displacing email).

I'm finding the book an excellent read thus far. Reading it carefully in linear fashion.
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More to come...