Well... it's been a busy summer, and I have a lot of blogs in me, but have been diverted by two major issues going on which will eventually lead to some good blogs in the future:
The Book: I'm writing/editing a book on the intersection of HIT and Innovation. It's been a great experience as we are putting together a series of essays from a variety of innovative physicians and healthcare experts on how they have used HIT in an innovative fashion. These will range from using their EMRs in new and different ways, to a wide range of telehealth activities, to creating an online survey system which allows patients to become increasingly involved with an organizations strategic direction.
The Upgrade: Our Cerner EMR was finally due for an upgrade... and after months of many people working together to make it happen, we had a very successful go live last week. There are still a lot of busy days and late nights as we are in the fine-tuning stage, but it sets us up for MU and more abilities to start managing quality and providing even higher quality care... so yeah, I'm sort of excited about it! Of course, now that I've delved into the world of EMR Usability, my eyes have been opened to usability heuristics issues like Consistency, Recognition rather than Recall, and the importance of expert Accelerators to promote more efficient use. And so whenever I look at the new screens, I start thinking "how could this be better" and in talking to other "usability junkies" - it turns out this is a curse we now carry as we look at anything on the web or in the "real world" - why can't things be more usable!?
I've also gotten more involved with the government in the past year as the push to promote EMRs spreads, and they are looking for input from folks who have been involved in getting EMR systems up and running. I had a particularly good time attending and presenting at the NIST EMR Usability Workshop in June. I plan to dedicate a whole blog to my thoughts on this - but in the meantime you can read some of my ideas at the Healthfinch blog.
The U.S. Agency for Healthcare Research and Quality (AHRQ) created the Health Care Innovations Exchange to speed the implementation of new and better ways of delivering health care. The Innovations Exchange supports the Agency's mission to improve the quality of health care and reduce disparities. The AHRQ Health Care Innovations Exchange offers busy health professionals and researchers a variety of opportunities to share, learn about, and ultimately adopt evidence-based innovations and tools suitable for a range of health care settings and populations. More info at: http://www.innovations.ahrq.gov/about.aspx
In July of 2011, the AHRQ Innovation Exchange published a profile of ExpectED, one of the first projects from the innovation program I run - the Szollosi Healthcare Innovation Program (SHIP). The profile was entitled "Referring Physicians Send Electronic Handoff Note with Pertinent Patient Information to Emergency Department, Improving Physician Efficiency and Quality of Care" and the summary was:
Community-based physicians referring patients to Northwestern Memorial Hospital for emergency care send an electronic handoff note to emergency department personnel to notify them that a patient will be arriving and to provide clinical details pertinent to his or her condition. The note, which includes the patient's name, date of birth, the referring physician's name, a clinical summary, and other information, is entered into the system's electronic medical record, where emergency department clinicians can easily access and review it at the point of care. Anecdotal feedback from physicians suggests that the program has improved physician efficiency and satisfaction, care coordination, and the quality and timeliness of care.
They did a great job in this write-up, I love how they break each innovation down into:
What They Did
Did It Work? (we can learn from failures too!)
How They Did It
Adoption Considerations
Take a minute to peruse the Innovations Exchange - it will expand your mind and make you feel good about the potential for innovations in healthcare care!
I was in DC last week and spent some time with AHRQ's Healthcare Horizon Scanning System folks. Their job is to identify, monitor, and track new and emerging health care technologies and interventions that could signal important changes to patient care, health outcomes, and the United States health care system - ranging from drugs and medical devices to new services and innovative care processes. The HHSS is a resource for the Effective Health Care (EHC) Program as it makes decisions about allocating resources for patient-centered outcomes research. It will also be a tool for the public to identify and find information on new health care technologies and interventions. Any investigator or funder of research will be able to use the HHSS to select potential topics for research.
While this is a relatively new group at AHRQ, it turns out this type of formal "Horizon Scanning" process is common in Europe, although more centered on meds, devices and procedures. For example, there is the UK's National Horizon Scanning Centre as well as the larger International Information Network on New and Emerging Health Technologies (EuroScan), a collaborative network of member agencies for the exchange of information on important emerging new drugs, devices, procedures, programmes, and settings in health care.
One thing that struck me was the clear distinction between Products and Technologies (e.g. pharmaceuticals, medical devices, procedures) vs. Information Technology (e.g. EMRs and "health apps") vs. Care Innovations. For products, it appears that the methodology is relatively consistent (e.g. you can easily find early items via phase 2 trials, prioritize based on significance and effectiveness, and do comparative evaluations against similar products -- and then market forces help with diffusion since some companies can make so much money on successes).
But the same process cannot be applied to Care Innovations or HIT. So what is the best way to "find, filter, evaluate and diffuse" these items? Here are some ideas:
• Scanning: The AHRQ Innovations Exchange is an amazing collection of healthcare service and IT innovations and is a great starting point for those who are looking for new ideas to stimulate them! Other obvious resources are a wide a variety of conferences and newsletters. Some conferences I like for cutting edge ideas are Health 2.0, HIMSS (yes, it's big and corporate - but there are always things bubbling there) and World Congress Innovation Summit. I also have stumbled onto a few non-healthcare conferences dealing with User Interface/Human Centered design which are amazing. For blogs, some favorites are HISTalk, Ted Eytan, Jay Parkinson, and Halamka's. For newsletters, I follow CHCF, ModernHealthcare, HIT Strategist, iHealthbeat, H&HN, HDM, CMIO and FierceEMR.
• Filtering/Evaluation: This will involve watching how pilot project fare, creating models to help extrapolate to different environments (e.g. based on size, payment methods…), and ideally help support funding to try additional pilots in different environments to understand if reproducible and scalable.
• Diffusing: Major education, funding for early beacon programs, possible policy change around reimbursement and other (e.g. allowing more tele-care). A recent CHCF paper on Spreading Innovations is particularly relevant.
So thank you AHRQ for being on the lookout for Care and HIT Innovations and trying to figure out how to spread those that are doing well!
The HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) has been around since 1996 - and it's amazing how many healthcare people still over-interpret the privacy and security regulations (and mis-spell it as HIPPA!). Here is the actual law and check out HIPAA.org, a nice website which brings together many sources of info.
With respect to HIT, it focuses on Privacy and Security - and basically puts common sense into law: * Privacy: This addresses policies - and says you can't just give personal health information (PHI) to anybody you want, such as Pharma or the local drugstore (before HIPAA, docs could actually do that legally). But importantly - it does exclude "TPO" (Treatment, Payment and Operations). In other words, there are no restrictions to healthcare organizations sharing PHI with one another as long as it involves treating a patient (or dealing with payment or other operations)! * Security: This addresses technology - and says you should have good technology in place to make sure your IT systems are not open to the free world. Simple enough.
So it is fascinating how many healthcare organization still use HIPAA as an excuse for not sharing information. I can't tell you how many fights I've been in with medical record departments who say that they can't fax me a report because they don't have a "HIPAA waiver" signed by the patient - even if I ordered the test!!! Agghhh! Usually the problem is that the bigger organization scared lower level staff with too many HIPAA emails... but the result is the same - making it harder to get the data which is needed. And while I think this scenario has improved a bit, it is still happening every day.
So I saw this Healthcare IT News article last month entitled "Five social media tips for docs worried about HIPAA" - and thought it was good to share, as it is nicely worded, and I think extends beyond social media in its relevance (my comments will be italicized):
SEATTLE – While many doctors shy away from use of the Internet because of concern over HIPAA penalties, one company is advising the physician community to not become victim to HIPAA hand-wringing and fall out of sync with their colleagues who have learned how to responsibly utilize today's most valuable online visibility tools.
Avvo, the world's largest online directory for doctors and lawyers that provides free rankings for 90 percent of the working physicians in the U.S., offers five tips for physicians who are hesitant, because of perceived HIPAA restrictions, to embrace online and social media marketing.
The company, which was founded to service the legal sector, is no stranger to the impact of regulatory issues on the healthcare industry. Avvo is now striving to help doctors, who may be missing valuable networking opportunities because of unnecessary HIPAA fears, to adopt widely accepted, HIPAA-compliant practices for tapping the Web's significant marketing and reputation building channels.
"HIPAA is a well-intentioned, but poorly implemented law that is unnecessarily scaring doctors and keeping them in an unrealistic 'technology lockdown'," explained Avvo founder and CEO Mark Britton. "Avvo sits at the vortex between law and healthcare – and we believe passionately that physicians are needlessly hand-tied by HIPAA legalities. We want every working doctor out there to know that there are many appropriate and safe channels through which they can build their profile and reputation on the Web."
Avvo, which offers free phone consultations to physicians who have questions about how to safely market their reputation on the Web, equips doctors with the following five tips for managing their career online:
1. DO: Use email, SMS and social media messaging. These are acceptable tools for making outreach to patients, the media, medical industry influencers, and other doctors. The HIPAA regulations actually encourage the use of alternative communication methods, particularly as patients express their preference for a particular mode of communication. (HIPAA does not ban email, in fact it encourages it... but it does say that patients have the right to tell their doctors if they don't want to be contacted by email, or phone, etc...)
2. DO: Feel free to share information with other providers. Many health professionals set up unnecessary procedures that make it harder to share patient information with other providers. If you need input from another provider, you don't have to worry about HIPAA compliance. In fact, HIPAA guidelines specifically permit the sharing of information with other providers (freely and without patient consent) for the purposes of patient treatment. (Correct - let's use common sense for the sake of the patient!)
3. DO: Feel free to answer general patient questions - there is no HIPAA bar to providing this information. Whether it's participating in Avvo's free online Q&A or other forums on- or off-line, answering general health-related queries in a public forum will not present a HIPAA-related problem for doctors. These tools offer a powerful means for patients to take the first steps to getting the care they need.
4. DO: Keep family members in the loop. It is unwarranted to let HIPAA be an excuse for not keeping family members engaged and involved, where relevant, to provide support that is in the best interest of the patient. There is wide latitude under HIPAA to inform a patient's family members about his or her status – and this extends to liaising with family members electronically as well. (I've been guilty of this as well... and now go back to good old common sense if I am unsure. I will also make sure to check with certain patients as to their wishes on this - particularly new adults or the elderly.)
5. DO: Exercise common sense and reasonable practices in all instances to ensure the privacy and security of your communications with patients. This general rule of thumb applies whether the communication is by email, SMS, fax or instant message.
While Britton agrees that HIPAA has created a general "culture of paranoia" among medical practitioners and has in many ways served to logjam the essential progress of technology's role within the healthcare industry, he adds that it is just "unreasonable" for doctors not to embrace the social media revolution because of over-exaggerated fears of privacy and security violations. That level of restrictive behavior, he cautions, is "wholly impractical in today's business climate" and he advises doctors to go ahead and embrace digital tools while still preserving the health and integrity of the patient-physician relationship.
I have not written much on social media in healthcare, which might range from a practice with a facebook site for marketing, to a surgeon tweeting that the gallbladder is out so the family can relax a bit sooner, to a Groupon for reduced botox, or to a system which texts patients to motivate them to eat better or take their meds on time. But instead of commenting myself, this blog entry will mainly be a list of relevant links, including a list of great bloggers and interesting news stories.
Healthcare Social Media Bloggers
* 33 charts focuses on social media in health and is written by Bryan Vartabedian, MD.
* http://www.tedeytan.com/ is written by Ted Eytan, MD - an extraordinary thinker and blogger who often writes about the impact of social media and web 2.0 in healthcare.
The Buzz: Rise of the "Extender Companies"
It was the biggest HIMSS ever (over 31,000 attendees) and yet it was the smaller companies that were the ones to watch. In the past, HIMSS was mostly about the HUGE booths and parties thrown by the top vendors. But this year the buzz was shifting away from the big vendors and towards the rise of the "Extender Companies", who are creating products and services which build around the larger ecosystem created by the established HIT infrastructures in place (and yes, "ecosystem" is already threatening to become the most overused buzzword of 2011).
This should not be a shock, the newer, smaller companies can be quick and innovative while the major HIT vendors (running the gamut from the giants like GE, Siemens and McKesson, to the big boys like Cerner and EPIC, to the now well established middle-tier companies like Allscripts, NextGen and eClinicalWorks) all are BIG BOATS that can't maneuver quickly and are pretty much focused on MU for the next few years anyway. But that's OK - this is a good thing, and parallels the situation seen in other IT industries… the "base level" is being set (just like Microsoft and Apple did with operating systems) and it's time for the next generation of HIT companies to start creating the products that actually move the pointer from "up and running" to actually "usable and useful". The good ones will thrive (and likely be acquired), the bad ones will fade away quickly - and there are books to be written and movies to be filmed about it all in the years to come.
Examples of companies to be on the lookout for (in no particular order or ranking):
• Quipp from Medicomp: a new way to document
• Salar: also new modules replace the note
• Phreesia: office "check in" tools
• Epilogue systems: automated creation of help tools, simulation environments, and testing for EMRs
• Aventura: technology to make computer logins quick and easy
• Precyse: coding support
• dbMotion: system integrator
• Elsevier: content, content, content
• MeDecision: data aggregation and analytics
• Halfpenny Technologies: data integration tools and services
• Merge: kiosks, patient portals
• IMO: standardized vocabulary (so your docs never need to learn ICD 10!)
• CareFx: web-based data aggregator (bought by Harris Corporation)
• AnvitaHealth: data analytics and content tool
• Eprocrates: various content tools
• Sensible Vision: fast access and continuous security authentication via facial recognition
• Logical Images: database of images for every disease
• Phytel: identify patients who need care gaps resolved
• Symphony Care: ACO software
The HIT X.0 Conference: Innovation and Future Thinking
HIMSS knows that it cannot just serve the needs of large hospitals installing monolithic HIT systems, and so I give them a lot of credit for creating the HIT X.0 sub-conference. The idea was to create a series of sessions that spoke more to innovative ideas in HIT and a look at the future. I was fortunate to moderate several sessions including the following:
HIT Geeks Got Talent
This was a take on "America's Got Talent" or "American Idol", in which six "contestants" got to show their "newest product" to a panel of judges who got to provide feedback to each of them. Based on judge and audience feedback, the top four advanced to the final round the next day. General criteria to use for assessment include: Usable, Unique, and Useful
In other words (1) Is it usable (easy to use), (2) Is it Unique, and (3) Is it useful (how does it provide value).
The best part of this was easily hearing the judges frank and incredibly insightful comments to each of the contestants - basically they each got invaluable consulting and coaching from some of the top minds in the business. Additionally, anyone in the audience who might be thinking about starting a new company or launching a new product benefitted from hearing these folks think out loud.
* Erica Drazen, FHIMSS: Partner in Emerging Technologies, CSC Healthcare Group
* Dave Garets, FHIMSS: Executive Director, Advisory Board Company
* Jonathan Teich, MD, PhD, FHIMSS, FACMI: Chief Medical Information Officer, Elsevier
And now, here are the list of the six contestants (in alphabetical order), what they presented, and what happened to each of them:
* Anagraph (http://www.anagraphmedical.com/): A mobile application to support provider communication. The judges and I thought it was a cool concept, but the audiences didn't quite get it, and they were knocked out in the first round. * Datatech Solutions (http://www.dtsdss.com/): A data analytics solution from a programmer in Canada. It allowed for a very cheap, very graphical view of complex data sets. Jeremy (the programmer and head of the company) was easily the worse presenter - a true data geek who had trouble explaining his solution in the few minutes he had. However, the judges "got" what he was doing and rewarded him the top prize "The HIT Geek Champion". * Epilogue (http://www.epiloguesystems.com/): This tool automates the process of creating EMR help documentation, as well as allows for creation of a "simulation" environment and a testing application to help confirm user proficiency in the EMR system. The judges were worried that Help documentation wasn't "sexy" enough, but the audience understood the need for this type of application and pushed them into the final round. * Napochi (http://www.napochi.us/): They created a very graphical "Wound Module" that could be used with their EMR or others. The judges felt it was an interesting niche, but they did not make it to the final round. * PatientKeeper (www.patientkeeper.com/products/clinical_applications/cpoe.html): They unveiled their latest product - a mobile CPOE application. While the judges liked the concept, they worried this product might run into trouble truly integrating with the native CPOE products, and questioned whether all the clinical decision support could be handled as well on a small screen. In the end, they were first runner-up in the contest. * YourNurseIsOn (http://www.yournurseison.com/): A SAAS communication staffing tool which allows hospitals to more easily staff nurses and other positions. The judges liked the concept, but wondered if a small company could challenge a big dog like Chronos. The rumor is that this company got so many requests for work after the contest that they felt they could easily out-innovate anyone else.
Iron Programmers
I started off this session with an overview of the importance of agile programming and why hospitals and vendors need to start thinking outside the big EMR box and recognize there is also room for agile development to create quick wins to solve problems as well as "lead the way" to better thinking about how to evolve their EMRs in the future. The full slides are below.
The basic definition is that agile programming involves two core elements:
• Rapid cycles of iteration
• User-Centered Design (Strong customer focus and interaction)
Why is this concept important? Ask yourself these four questions:
• Do your clinicians feel your current HIT system provides the most efficient and highest quality way to practice?
• Do your clinicians ever look at your EMR system and say, “How come it can’t do that?”
• Do you ever feel like you can’t do anything outside the scope of your current EMR system because it would “distract” from your core competencies?
• Do you feel like you can’t do anything “extra” because it costs too much in time, resources and money?
I then reviewed the idea of a paradigm shift away from incremental improvements to an EMR (e.g. annual upgrades) towards the concept of "Focused Innovation" (e.g. create a specific solution for a specific problem and then use it alongside or within your EMR). The results are:
• Solve an immediate need
• Provide an easy and cheap way to "pilot" or test out a new concept or workflow
• Be more creative in your approaches to problem solving
• Create the building blocks or direction to help guide development of more robust solutions within your EMR system
Then I presented an example of this type of "agile project", which was supported by the Szollosi Healthcare Innovation Program (http://www.theshiphome.org/). The concept was how could we help our physicians more easily communicate with our emergency department (ED). The result was ExpectED (http://www.theshiphome.org/ExpectEd.html) - a web-based system which allowed physicians to fill out an "Expect Note" to send into the ED. It was launched independently in 2008, and by 2010 we had incorporated it into our EMR. A more complete explanation will soon be available on the AHRQ Innovations Exchange (http://www.innovations.ahrq.gov/).
Next, we highlighted this concept further by using the "Iron Chef" format of challenging two teams to use agile programming to create a product in two weeks - thus was born "Iron Programmers"! Each team was comprised of a front-end user interface expert and a back-end database programmer. About 2 weeks before HIMSS, they were given instructions to build a system which allowed for physicians to more easily communicate with the ED about incoming patients. This was not a competition as each team was asked to focus on different aspects of programming - Team one was focusing more on web based solutions, Team two on mobile based solutions.
Team One was Jon Baran and Ash Gupta from Healthfinch (http://www.healthfinch.com/) - a new company creating workflow tools which make life easier for physicians and their staff (BTW - I like this concept so much I'm working with these guys to build out these types of tools). They showed a web-based version of their "ExpectER" program, including the ability to access on a smart phone, and ways to send messages via text or automated voice technologies.
Team Two included Hunter Whitney (www.hunterwhitney.com/) and Doug Naegele (www.infieldhealth.com/). They showed a pure mobile-based app, as well as a web-based "control system" to help edit the questions asked in the mobile version.
It was a very impressive showing of programming prowess as all of these were working versions of software. To make it even more fun, we had each team give the audience a choice of options for an additional function to be added to their systems. Then each team had to program live on stage to show their completed results… they each finished strong and wowed the audience.
The big HIMSS conference is here once again (for those not in the field - that is the Healthcare Information Management Systems Society... the conference is 5 days, about 30,000 people).
I'm looking forward to hearing keynote talks from former Secretary of Labor Robert Reich and Actor/Parkinson's Advocate Michael J. Fox, as well as CMS chief Don Berwick. And I'm wondering if David Blumenthal will give his usual rah-rah talk to the audience he has been giving (as head of ONCHIT), or if he will plan to unleash how he might really feel as he is "retiring" this spring.
I'm also looking forward to catching up with a lot of friends and colleagues, as well as meeting new folks, hearing new ideas and seeing new products - it's a big event and a long haul, but I always walk away with some new ideas and inspiration at this event (as well as achy feet).
I've been helping out with a "sub-conference" at HIMSS called HIT X.0. It is basically a track of "special" educational sessions which highlight innovation and future thinking, with a fun twist. It will be held in a single auditorium that seats up to 900 people and I'm moderating/presenting at four of these sessions - so if you are at HIMSS, hope you can make these!
FYI, if you registered for the HIT X.0 "sub-conference" separately - you will be guaranteed seats (they limited registrations to around 900)... BUT, if you didn't register for it - you can just show up a bit early and about 5-10 minutes before the event starts they will open the doors to everyone (since you have to assume that all 900 won't be showing up for every session).
Here is what will be keeping me busy for part of each day:
HIT Geeks Got Talent? Round 1 Monday, February 21, 12:15 PM - 1:15 PM Description: HIT Geeks Got Talent?" HIT X.0 is a multi-media educational series that takes attendees on a trip to the not-too-distant future of healthcare technology. Building on the blockbuster reality show "America's Got Talent", these sessions will host a talent-search-like format featuring eight contestants demonstrating their latest technologies developed for the healthcare IT space. The three judges will be: * Erica Drazen, FHIMSS, Partner, CSC Healthcare Group * Dave Garets, FHIMSS, Executive Director, Advisory Board Company * Jonathan Teich, MD, PhD, FHIMSS, FACMI; Chief Medical Information Officer, Elsevier
AND the Audience gets to help choose the four finalists
HIT Geeks Got Talent? Final Round Tuesday, February 22, 2:15 PM - 3:15 PM
The four finalists vie for a shot at top HIT Geek!
Same judges, same audience participation!
Iron Programmer Challenge: Agile Programming for Web and Mobile Wednesday, February 23, 2:15 PM - 3:15 PM Description: Iron Chef meets HIT! We give two teams the same "ingredients" (specifications for a new tool) and they use "agile software development" (quick, iterative) to create a web or mobile solution. Objectives:
* Learn about the benefits of agile programming methodologies and how it can be used to create solutions which can work in parallel or be interfaced with your EMRs and other IT systems.
* Think about how own organization can use agile programming techniques to build small focused tools which result in "quick wins" for your users.
* See and hear how two teams of agile programmers addressed this challenge and created brand new tools. These tools will be demonstrated at the session.
Check out Healthfinch ("We create easy-to-use medical apps for clinicians.") and their blog to get an idea of what one team is working on for this challenge!
Expensive, Exasperating and Exhausting - EHR the Extormity Way Thursday, February 24, 11:15 AM - 12:15 PM Description: Fictional Extormity CEO Brantley Whittington explains how his company combines the principles of extortion and conformity to extract revenues from hospitals and physicians who pay dearly for its proprietary EHR solutions. Objectives:
* Describe the need for physicians and healthcare executives to suspend disbelief and allocate significant budgets to the purchase and maintenance of an inflexible client-server EHR from Extormity.
* Learn to self-attest to meaningful use in a convincing manner, confidently proclaiming that with the aid of Extormity, you have met all the requirements and there is absolutely no need for an audit.
* Practice endorsing your stimulus checks over to Extormity, as this EHR solution will require every penny of the ARRA funds you receive.
* Prepare for breach notification, as the security protocols embedded in the Extormity EHR will no doubt result in a leak of PHI.
* Learn about Extormity's shackled PHR solution that takes the tethered patient portal model to a new level, turning patients into indentured servants.
A couple of weeks ago an article came out in the Archives of Internal Medicine which essentially said that "Ambulatory EMR's don't improve quality", based on a meta-analysis (review of multiple research published in the past few years). Wow - that's like saying 'typewriters don't help create better stories' just a few years after typewriters were invented because there wasn't a lot of evidence proving that they did. Clearly I'm not a fan of this article. Let me break it down as follows:
First, I personally think it is crazy to expect research on individual EMR implementations to mean anything right now - the systems are all immature and evolving quickly, the implementations are all different, and individual usage is all over the place. Any research that is done at one location at one time is pretty much limited to that place and time. It is not like a drug study, where the drug is made and used the same way every time and thus research will be consistent. It will be a long time before research on any single EMR provides any value except to show what the POTENTIAL is for EMRs - and since it is a tool, we already know that there is good potential if done well, and poor potential if done poorly. So what would be much more interesting and relevant would be if we could start by assuming EMRs have the potential to help (since we know some research studies show they can), and focused research dollars on figuring out WHY an EMR did or did not improve quality at a specific time and place - I bet we would really learn from that!
Second, the follow-up discussion in the Archives by Clem McDonald (a true father of medical informatics) highlighted multiple studies that did show benefits and had a good breakdown of why this meta-analysis was not very valid. It is certainly worth a read, especially if you are getting asked by your friends at cocktail parties about "that report on CNN which said EMRs don't improve quality"… Now you can have some snippy comebacks like:
• "Sure, if you like meta-analyses which only include medication quality indicators, but I prefer my meta-analyses the way I get my annual physical exams - with vaccines and screening labs."
or • "Those chumps only looked at single visit outcomes, not multi-visit ones- can you believe that?!? And umm, pass the wine please."
Or one more provided by my friend and colleague Dr. Bill Galanter: • "You mean the one that shows that the American healthcare system doesn't deliver reliable, quality care no matter what kind of tools you give them? Since in addition to the physicians, insurance reimbursement, short visits, ill-advised mandatory government regulation, uninsured patients, pharmaceutical advertising, a terrible diet, overly expensive drugs and EMR's, co-pays, donut holes (will come back if republicans get their way) and a trillion other factors are also to blame..."
Or you can quote Dr. McDonald specifically, who wrote: First, and most important, the current article tells us nothing about which CDS guidelines were implemented in the systems that they studied. Practices and EHRs vary considerably in the number and type of CDS rules that they implement, and we do not know whether the CDS rules implemented by the practices that participated in the surveys addressed any of the 20 quality indicators evaluated by Romano and Stafford. Second, the current study and Garg and coauthors' review considered very different categories of guidelines. Most of the guidelines (60%) in Romano and Stafford's study concern medication use; none of them deals with immunizations or screening tests, which were the dominant subjects in the studies reviewed by Garg et al. Furthermore, in our experience, care providers are less willing to accept and act on automated reminders about initiating long-term drug therapy than about ordering a single test or an immunization. The third difference is that the current study examined the outcome of a single visit, while most of the trials reviewed by Garg and colleagues observed the cumulative effect of the CDS system on a patient over many visits. Finally, the data available from NAMCS/NHAMCS may be limited compared with what is contained in most of the EHRs used for Garg and coauthors' trials. For example, the NAMCS/NHAMCS instruments have room to record only 8 medications, even though at least 17% of individuals older than 65 years take 10 or more medications.
Finally, this whole issue reminds me of what Don Berwick has been preaching for many years… that the way academic researchers study the effect of a new medication or procedure is great for those scenarios, but is not so good in studying the process of quality improvement, which usually relies on a combination of factors, including IT, cultural shifts and process changes. In this 2008 JAMA article called "The Science of Improvement" he explains how to improve the measurement of quality improvement programs:
Four changes in the current approach to evidence in health care would help accelerate the improvement of systems of care and practice. First, embrace a wider range of scientific methodologies. To improve care, evaluation should retain and share information on both mechanisms (ie, the ways in which specific social programs actually produce social changes) and contexts (ie, local conditions that could have influenced the outcomes of interest). Evaluators and medical journals will have to recognize that, by itself, the usual OXO experimental paradigm is not up to this task [observe a system (O), introduce a perturbation (X) to some participants but not others, and then observe again (O).]. It is possible to rely on other methods without sacrificing rigor. Many assessment techniques developed in engineering and used in quality improvement—statistical process control, time series analysis, simulations, and factorial experiments—have more power to inform about mechanisms and contexts than do RCTs, as do ethnography, anthropology, and other qualitative methods. For these specific applications, these methods are not compromises in learning how to improve; they are superior.
Second, reconsider thresholds for action on evidence. Embedded in traditional rules of inference (like the canonical threshold P<.05) is a strong aversion to rejecting the null hypothesis when it is true. That is prudent when the risks of change are high and when the status quo warrants some confidence. However, the Institute of Medicine report Crossing the Quality Chasm calls into question the wisdom of favoring the status quo.
Auerbach et al warned against “proceeding largely on the basis of urgency rather than evidence” in trying to improve quality of care. This is a false choice. It is both possible and wise to remain alert and vigilant for problems while testing promising changes very rapidly and with a sense of urgency. A central idea in improvement is to make changes incrementally, learning from experience while doing so: plan-do-study-act.
Third, rethink views about trust and bias. Bias can be a serious threat to valid inference; however, too vigorous an attack on bias can have unanticipated perverse effects. First, methods that seek to eliminate bias can sacrifice local wisdom since many OXO designs intentionally remove knowledge of context and mechanisms. That is wasteful. Almost always, the individuals who are making changes in care systems know more about mechanisms and context than third-party evaluators can learn with randomized trials. Second, injudicious assaults on bias can discourage the required change agents. Insensitive suspicion about biases, no matter how well-intended, can feel like attacks on sincerity, honesty, or intelligence. A better plan is to equip the workforce to study the effects of their efforts, actively and objectively, as part of daily work.
Fourth, be careful about mood, affect, and civility in evaluations. Academicians and frontline caregivers best serve patients and communities when they engage with each other on mutually respectful terms. Practitioners show respect for academic work when they put formal scientific findings into practice rapidly and appropriately. Academicians show respect for clinical work when they want to find out what practitioners know.
Additional Studies/Articles on this subject
* Health Affairs article (March, 2011) from Dr. Blumenthal: Meta-Analysis of recent studies shows more positive effect of EHRs on quality (less on provider satisfaction).
My friend Shelly posted a great video the other day entitled "Drive: The surprising truth about what motivates us", (video is below). It's a fun, quick breakdown of Daniel Pink's book of the same name, which illustrates the hidden truths behind what really motivates us at home and in the workplace. He starts out by laying this on us: "Our motivations are unbelievably interesting and the science is a little freaky! We are not as predictable as we think."
What really motivates us? Once basic money is off the table (i.e. get enough to buy the basics), there are really three main things that drive us:
1. Autonomy: We like to be self-directed. Pink says employers should realize their employees probably want to do something interesting, they just need to get out of their way.
2. Mastery: It is fun and satisfying to get really good at something (i.e. learning the guitar, working on open source software).
3. Purpose: We want to feel we are doing something important with our lives. Additionally, when the profit motive is not aligned with the purpose motive, bad things happen - a common problem in healthcare!
I think these apply very well to a physician's life, and explain why we will push ourselves very hard - we enjoy our autonomy, we enjoy mastering our skills, and our high level purpose is fulfilling. However, what we don't like is when others try and tell us what to do (i.e. insurance company, poorly designed clinical decision support), when we are told to master something we don't particularly enjoy (i.e. not all doctors love EMRs - especially when they are really hard to master), and when we start feeling like our purpose is to make someone else money instead of focusing on patients.
As for patients, I think this theory helps explain why we fail so often at helping them make significant lifestyle changes. They need to feel they are doing it themselves (autonomy), they need to find something they enjoy mastering (a lot of people don't like exercise), and they need to see a tighter link between their actions and their ultimate "purpose" (which is likely to be healthy).
So as we talk about further implementing EMRs, expanding insurance access, reforming reimbursement schemas, and changing the very nature of patient care... let's remember both patients and physicians are still human, and will be driven by these age old motivations. In other words, when making a change... think deeply about how you can best align autonomy, mastery and purpose - and you will clearly improve your chances of success!
I went to DC earlier this month to speak at a governmental "hearing" about Meaningful Use. Since the Feds are about to spend up to $40 billion on creating incentives for EMRs - I give them credit for wanting to make sure they hear as early as possible if there might be problems with their program.
For those who just are looking for a quick summary, here you go:
ONCHIT's Implementation Committee wanted to hear from Eligible Providers (EPs) and Hospitals about their early experience in preparing to meet MU requirements for this year.
The good news is that this bill has indeed "stimulated" many organizations to move forward with various upgrades and focus on how to produce quality reports from the data in their EMRs. But mostly we heard about the challenges: • This is hard. It’s not impossible, but it’s a higher bar than many had anticipated because the requirements are not simple, nor are they fully explained. • Time crunch. There is a very tight time frame between the release of the requirements, embedding them into EMRs, the "rollout" of the new EMRs, and the updating of workflows and reports to ensure users are actually meeting the MU requirements. • Resource crunch. This is often a zero-sum game with resources. • We need more flexibility. Not every practice is the same, and requiring 100% mandate of every requirement is not reasonable. • Functionality is not the same as usability. An EMR vendor can get MU certification for their functionality whether their usability is great, good, or poor. Fortunately, the government is starting to look into usability requirements for the certification process, so let’s hope they follow through on that sentiment. • Standards. "We’d rather have one bad standard we can work with than three good ones without a clear winner." On the other hand, we should make it clear we do NOT want the government to make standards about actual functionality – we can and should be creative in that domain. • The cost of implementing MU may often be more than the actual monies themselves, when you factor in costs for various software upgrades, consultants, and change management. • Certification requirements don’t always exactly match MU process requirements. Someone has to keep a better eye on this. • Communication with CMS and ONCHIT has not been easy.
• The result of most of the above is that the biggest and the best are struggling with MU… so you have to wonder, how much harder will it be for others?
It has been interesting that this is in stark contrast with recent ONCHIT announcements about a recent survey showing that the majority of doctors plan to apply for MU. However, let's be serious - most docs don't even know what MU means, and less than 25% even use a "basic" EMR (and under 10% use an "advanced" EMR). So if a doctor gets asked, "Do you plan to apply for free money from the government for using EMRs in the coming years?"... it should not be a shock that most will say, "Sure, I'll give it a try."
I know ONCHIT is trying to keep an optimistic view here, but I wished they spent some time at these hearings listening to real world users and less time crowing about a survey asking a hypothetical question. In fact, no one from ONCHIT actually came to these hearings - even though they paid for people from all across the country to fly in (to be fair and balanced, someone from ONCHIT did listen on the phone during the morning session, and the Committee did summarize and report to ONCHIT later on).
I think we all agree that ONCHIT's goals are noble, but if they don't get feet first into the reality of the situation, they will have a hard time getting there - these hearings were a good step in the right direction, and I hope they continue to keep their ears on the ground and make adjustments as appropriate.
This is going to be a big year - healthcare needs more change and innovation than ever! So one of my resolutions is to do more regular blogging. I will likely move to shorter blogs about news stories of interest, with a plan to distill them down to points which will be relevant to those interested in promoting innovative thinking and action in healthcare.
I'm going to start with two new stories that are more related than one might think - one on healthcare value, the other on snow removal.
How Measuring Outcomes Drives Innovation
I just read Michael Porter's latest NEJM essay entitled, "What is Value in Healthcare?". The key points are:
2. Measuring real outcomes is critical (what really happens to the person, not simply their lab values or process followed). For example, for a diabetic - real outcomes are whether someone loses their sight, needs to go on dialysis or has a heart attack (not what their HbA1C value is and how often it is checked). He defines these in an "Outcome Measures Hierarchy" that involves three tiers: Tier 1 (Degree of Recovery), Tier 2 (Time to Recovery) and Tier 3 (Sustainability ofRecovery). This spectrum is what we really care about and encompasses both short and long-term outcomes, as well as "cycle time" (how quickly one gets to recovery).
3. The main purpose of measuring actual outcomes is to enable "innovations in care". He describes how measuring, reporting and comparing these actual outcomes are what allows us to think and act in innovative ways.
Dr. Thomas Lee follows up on Porter's essay with his own complementary one: "Putting the Value Framework to Work". He says, "When measurement is oriented toward what happened to patients instead of what services were performed, interesting challenges and opportunities arise." For example, he notes that their typical PCP reports included data on number of office visits and RVUs, but not on the number of ER visits and hospital re-admissions, nor on the cycle times for how quickly discharged patients are seen in follow up clinic. Dr. Lee also notes that "just the collection of such data requires organizational change and the weakening of walls between our silos", (which I assume he means is a good thing!). He notes that his system (Partners) is currently working on creating "value dashboards" for issues such as stroke, diabetes and colon cancer. They will identify "pause points" in patients care and define what should be routine at those points via checklists. That is basically what we have been developing with our Process Checklist System (we call them "Pathways") - for things like new diagnoses of Hematuria, Afib and Cancer - so I am a big can of that concept!
Paying plows by inch, not hour, can save a city’s snow budget (link to story)
The second story which caught my attention was an NPR interview I heard with the Mayor of small town in Massachusetts... and how they saved time and money by creating a value based system for snow removal. Apparently, the typical reimbursement mechanism for snow removal has been to pay for the amount of time to remove snow ("hourly rate"). Thus the incentive for truckers has been to go slow so they can charge more. The Mayor of Quincy changed the incentive to paying by the inch. The result is that they saved money AND the snow was removed more quickly! Yep - just common sense, and something that I'd like to see more of in the healthcare system as well!!!
