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MEDecision ranks 33rd as best place to work in PA http://bit.ly/7wUof4 EHR HIT Healthcare
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The Challenge of Meaningful Use to Joe Sixpack MD: Guest Blog By R. Vaughn, MD
As we continue to see EHR hailed as the mechanism by which American health care will be transformed from an inefficient, anachronistic cottage industry into a sophisticated, statistically relevant expression of cutting edge, evidence based perfection we must resolve the cognitive dissonance that follows from comparing the Brent James disciples' argument that the EHRs should facilitate and amplify the innate desire of clinicians to do good to the actual EHR adoption and failure rate.
If EHRs offer a new paradigm of improved clinical outcomes via more efficient case finding for focused efforts, reminders for complete care and evidenced based care at the point of care then why is the failure rate so high? Chronic clinician EHR critics frequently site the lack of usability, the dearth of clinician input into design, bizarre business rules that drive inefficient EHR functionality and the tension between IT leaders and clinical informaticists that leads to marginalization of the clinicians due to lack of respect and/or lack of project management experience. It is hard to argue with the 2006 Annals HIT review that warned us that the benefits of EHR have been extrapolated from only a few long term self-developed clinical information systems from a remarkably short list of organizations that developed those systems over many years and thousands of Plan-Do-Check-Act iterations and that only with appropriate cynicism should we assume that commercial EHRs are capable of delivering similar results. However it is entirely appropriate to recognize that at least a few of these market offerings are quite robust - certainly good enough to allow population management, case finding and reasonable decision support at the point of decision making. Why then the continuous criticism, the 'down sizing' of some aspects of Meaningful Use to something more akin to 'not quite significant use'? I believe the principle reason is that we have yet to transform most of the health care system from paying for quantity of care to quality of care. If we accept that transformation of the health care system means we will more reasonably utilize resources based on best evidence and best practice then most would agree that primary care has a very important role to play in terms of appropriately matching the consumption of resources to the needs of the patient both individually for acute care and on a population basis for primary and secondary prevention. Yet most primary care physicians continue to practice in small groups organized around maximizing revenue (visits) with a focus on managing acute problems (or acute manifestations of chronic problems). We are all aware of the low utilization of preventative and evidenced-based care in both the clinic and in the hospital at discharge despite the tremendous benefits that would accrue to the country from preventing complications that lead to ER visits, admissions to the hospital, lengthened LOS, not to mention conversion to long term care, disability and death. The current payment system is perfectly designed to deliver the care we find so inadequate today - care that is fragmented, incomplete and at times inappropriate. Is it so surprising then, that physicians view EHRs as impediments to efficiency, when that efficiency is based on providing the minimum required care in the shortest time possible? Is it so surprising that the current care environment which encourages and rewards egregiously irrelevant documentation (re the failed E/M pay for bullets scheme) is equally inefficient when interpreted into EHR functionality? I believe that in 10 years we will look back upon this very fact as one of the great tragedies of the HITECH stimulus dollars; we will have successfully stimulated the purchase and implementation of EHRs but those EHRs will be crippled by designs that forced the worst of the existing incentives into their fundamental architecture. In conclusion:- Currently available EHR systems are available and have been deployed that offer a level of sophistication that can help motivated clinicians achieve remarkably improved results. Kaiser, Cleveland Clinic, Mayo, Geisinger, Group Health and others have demonstrated the value of integrated information systems using existing technology.
- The current failure rate of EHRs cannot be attributed to poor or inadequate design alone
- The failure rate is directly related to the current set of incentives, tradition and lack of transformation change management that prevents clinicians, particularly those in low valued roles like primary care, from being able to afford the costs of redesigning the way they deliver care to focus on patient outcomes.
If we 'design with the end in mind' what would the American health care system look like? Would it change the way we pay for care? Have we had that debate? What successful Accountable Care Organizations exist that provide for significant participation of independent small groups? Should everyone be in a Mayo clinic?
1.Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care. http://www.annals.org/content/144/10/742.full
The Godfather
My son, N, put a contract on one of his classmates.
He always complained that this girl in his class was mean to him, grabbed his shirt and tackled him on the playground. He was fed up and wanted to lay hands on her. I told him that it was unacceptable for him to hit a girl. No son of mine would end up like Chris Brown.
N, realizing he couldn't fight back on his own, enlisted the help of his friend Adrian. Apparently, Adrian's dad hadn't talked to him about not hitting girls. N devised an elaborate scheme where Adrian would hit the girl so N could keep his hands clean.
N's plan unraveled when his sister, Nee, snitched on him.
I'm glad Nee intervened. I wasn't ready to have a 6-year-old godfather in my house.
Ripples from the HealthCare Reform D.C. Silo – Why Transparency Matters
A lot has been said about the impact of technology on HealthCare and how 50,000 HealthCare IT jobs will be created as part of the healthcare reform debate.
Let me share an example of the reality of what is occurring due to the utter lack of transparency coming from D.C. around HealthCare reform.
Healthcare organizations are planning to run lean in 2010. While the quality and quantity of care will continue to be emphasized and of paramount importance, the much touted impact on HealthCare IT is a different story.
Capital expenditures are being scaled back to the absolute critical projects – and even there hard choices are being made. Maybe you can wait another year for new hardware or the next version of software.
New HIT jobs are being scaled back or eliminated directly; the money, rightfully so, goes towards clinical service and quality first. Maybe you can just buy a third party product, if you can get a pricebreak.
Healthcare Organizations just don’t know and simply cannot divine from the offal of entrails they are being thrown from D.C. as to what the impact to their bottom lines are going to be – and keep in mind, most of them struggle to stay in the black, and what profit is made is typically reinvested, not sent to line any pockets. Further many of these organizations genuinely emphasize quality care of their customers (aka patients!).
Gone is the talk of decoupling insurance, patient choice, portability standards and tort reform, replaced instead with an obfuscated miasma from the swamp that is already having a negative impact on that which can bring about efficiencies – information technology.
If healthcare organizations, even healthy ones, are scaling back on IT now, what, one wonders will occur when it finally becomes a reality?
HL7 & the ODS
In the process of designing and prototyping our Operational Data Store (ODS) for our Enterprise Products, we’ve noticed a couple of things that we expected but (vainly) hoped weren’t there.
First, a good number of our HL7 messages don’t follow documented standards closely. Most importantly, there are Z-segments (custom messages) in all sorts of places in a message instead of where they should be. This means our integration implementation has to be smarter and more defensive in handling these messages, such that the message transactions continue to flow when an unexpected or unanticipated message is consumed.
Second, we are replicating a lot of data with our HL7 messages. Say you change a zip code on a registration screen. You get the entire screen of data, not just the change, replete with whatever customized Z-segments. This means we’ll have some extra heavy lifting to do when consuming messages.
The key points here are two fold.
First, this is no one person’s fault – no one did a bad job – people work to their level of awareness. What it does indicate is that HIT hasn’t evolved. We’re still making the same mistakes we’ve been making for the last few decades, and that is inexcusable.
Second, this only reinforces why HL7 and standard don’t ever belong in the same sentence. It doesn’t matter than one vendor’s HL7 specifications may adhere to the standard, such as it is, the problem is that the HL7 message is too easily hijacked. Z segments should be the exception, not the rule and they certainly shouldn’t cause a problem when it comes to consuming the message nor require defensive coding to accommodate it.
The only way this is going to be solved is if an alliance of HIT-centric entities, not vendors, not the government, work together to force industry adoption of standards and practices that are common place across most enterprises else. In short, HIT needs to evolve out of its current calcification by having the people that feel the pain the most do something about it
For our project needs, we knew these would be problems, we planned and allocated for them. For anyone else embarking on similar ODS or Data Warehousing projects in HIT – caveat emptor, a standard isn’t always a standard in HIT.
On the Advent of Inadvertent Mediocrity
Fair warning, this is more of an internalized discussion written down, appropriate caveats on misinterpretations apply.
While I feel that American Exceptionalism is being apathetically eroded into guilt-ridden mediocrity, this post is going to focus on the beginnings of a sort of depressing epiphany that I’ve stubbornly fought against for the better part of my nearly 2 decade career in computing, far preferring a bloody head over what I, personally, deem an ethical compromise of commitment.
Until now.Based on personal observation and comparison of peer experiences, exceptionalism is neither encouraged nor rewarded in corporate computing. I’m sure the odd corporate computing environment exists out there where this may not be the case, but a very odd duck it will be.HealthCare IT, regardless of talks of reform and funding, sadly suffers from the same issue that cancerously gnaws at the heart of ingenuity and innovation in corporate computing, but writ larger.Unfortunately, HealthCare IT seems to have further devolved into purchasing disparate solutions and cramming them into weak integration platforms, repeated ad infinitum with insufficient focus on first, defining the problem, then designing the solution, before creating or purchasing or integrating anything. The tumor has spread to the extent that few things seem possible without the intervention or resources of a third party vendor, from defining the need to delivering the solution to supporting and training.We’ve achieved 100% de facto outsourcing! The counterpoint of course is that you have a body of knowledge workers who have been robbed of the opportunity to gain the knowledge they need to replace that vendor mentality.Healthcare organizations: the consultants you want are the ones who will not sell you a single license or product until they have helped you define the problem and design the solution; expect to pay for their time.Fundamentally, this is no one person’s fault, per se, nor should this be seen as an assignment of blame, but rather a general reflection that, for all the books, talks, discussions, groups, whitepapers and consultants, corporate computing will remain mired in a necrotic momentum that seeks to continue to survive instead of thrive and grow, learning the same wrong lessons from each ancestral generation and imparting it on to each successive descendant generations in situ. What mold-breaking successes that do come, stagnate and seem to not develop into behavior that can be consistently repeated.In considering root causes, there is one key, very lacking, cornerstone. Accountability - the accountability that speaks to a pride in ownership and a desire to excel, to step up instead of cleave to the accepted status quo, in particular by those very same computing professionals. This isn’t just a management problem, this isn’t just a business problem.There are many understandable, wholly justifiable reasons, mostly rooted in fear and lack of support, as to why this doesn’t occur. While the parable of the tortoise and the hare teaches that slow and steady get’s you there, I have to wonder if what’s missed is that the hare likely only lost the race once, then learned a valuable lesson and modified its behavior. That tortoise is welcome to that singular gold medal, hanging lonesome on its mantle, it’s only true testament that it lead to another’s success, another who wears shades from the overpowering brilliance of its accolades.Now replace speed with accountability in the above story. Dig deeper and realize the other lesson here is that a lesson was learned and applied.The lesson learned for me has been that it’s not for me to expect nor to demand, except in myself and those I lead, mentor or raise, a level of accountability that I hold myself to.For me the this leads to my epiphany. I have defined myself by my work for the better part of two decades, the cornerstone of which is accountability – from which I am convinced all other things such as delivery, flows. I can no longer afford to do so, largely for my own sanity but also because of the perception this sets. While I take at least half of the responsibility in setting that perception, it appears that the balance of the half remains looking for a home. Sound familiar? Yes, there’s accountability (or lack thereof) again.So, where the balance of my career in corporate computing is involved, it would appear that a reset of expectations is called for and the balance to be sought is contentment, not satisfaction nor happiness.The sub-conclusion here is that as risky as entrepreneurial endeavors’ are it would appear that my happy professional place is there, which leads me to considered thought on my future professional growing exercises. I’m still ruminating on that; been there, got the t-shirt(s), if I’m unwilling to return to that fertile ground …Certainly, I will not allow qualities to neither suffer nor erode, instead, they will enjoy a tighter scope!There is comfort in this, in a way; it’s the self-inflicted globe off Atlas’ shoulders. There’s certain liberation in looking forward to not being defined by work and expelling those same energies into other avenues too long neglected.While this still has legs to run around and finish baking, I can honestly say that I am breathing easier now than I have in years.I will, however, shed a tear, but not for myself, but rather for the endurance of mediocrity where it already existed rather than the desperately needed elevation of excellence.The loss here, is not mine.
Michel Cleis - La Mezcla (Original Mix)
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Inspired by Toto La Momposina
Take a Walk on the Wild Side
Do da do da do da do da da do...
I love Halloween specials.
I just watched I Love You, Man. It was hilarious.
I liked when he asked a group of guys to go out for beer, and they were like "oh, we can't, we're celebrating ..." and they didn't even invite him.
That happens to me a lot. It made me feel good that I'm not the only one it happens to.
I love how handwriting has so much character.
Some old lady -old, but not like old enough that she would be unable to drive- almost hit me with her car today. She had a red light. I had the "walk" light. She starts beeping. I thought, maybe her breaks aren't working, so I stopped. She passes me and looks at me and points to the light and then taps her head symbolizing that I'm an idiot. But the damn light was red. She was making a right on red, but she still was supposed to stop. Weird.
When it's Saturday night and I have nothing to do; I'm sad.
The problem I have with guys saying "girls lie when they say they want, a nice guy because they don't want me," is that most people -in my experience- who say this are ass holes.
Hellogoodbye.
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HealthIT.hhs.gov: Consumer Preferences Requirements Document HIT (http://ping.fm/QDXAN)
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Slam the Doctors.... Lose the Doctors
For a number of years, physicians, as the most visible symbol of health care delivery, have been criticized, chastised, and blamed for everything -- as the primary source of exploding health costs, practicing poor quality care, to being computer troglodytes for failing to accept money-losing electronic health records designed to document their every act.
Another great post by Dr. Reece. He has a keen insight into the tremendous difficulties and potential ramifications the new administration faces with its health care reform efforts.
Every action has an equal and opposite reaction.
What will the reaction be if the physicians of this country are forced to bear the brunt of the burden imposed by some of the reform/HITECH/HIT agenda items ???
