Sunday, November 21, 2010

Clinical workflow that is just not sustainable

I am officially a huge fan of "futurist" Jeff Goldsmith (President of Health Futures). In my last post (I can't believe it was over a month ago), I quoted his thoughts about how "core measure mania" and the lack of innovation in HIT are resulting in a failure to address horrible EMR interfaces which make it harder for physicians to improve quality and efficiency.

In a recent interview in California Healthline, he elaborated further by explaining, "It isn't merely the tools that are the problem, but the fact that we have this micro accountability problem with the payment system and increasingly with the quality measurement process. We're absolutely inundating caregivers on the front lines with a level of detail that's required for them to document in their clinical workflow that is just not sustainable…. we're diverting a huge chunk of the clinical work force's available time to feeding the machine."

Bang - he nailed it right on the head.  Said another way, one of our fundamental problems is that we are using EMRs to force doctors to document for billing purposes - which takes a lot of time and energy.   And our EMR vendors keep giving us slightly refined versions of the same process, essentially saying "this upgrade will make it a little easier to do this really hard and unsatisfying task".   Instead, we need systems that focus on helping physicians (and other clinicians) actually take care of their patients, and make documentation the "byproduct" of that care.   I know, it sounds like common sense... but it just is not happening to any significant degree (don't worry - I, and hopefully others, are working on it).

Other great quotes from this interview:

I would have given meaningful users of clinical IT who actually followed the embedded care guidelines ... a malpractice shelter. That would have been the approach I would have taken is to carve out some kind of exception and reduce their malpractice expense.
Cool - I like this idea.  Instead of the government "piecemeal" giveaway of $40 billion dollars, why not use that force and energy to actually change the system... with the knowledge that short term incentives rarely provide long-term gains... it is much better to change the system at a large sense. 

I think at this point the meaningful changes are going to come from the margins not from the core vendors.
As with every industry with a lot of "big companies" who have trouble innovating due to their size, watch for the rise of smaller companies who will be creating products and services that will work both with and without the existing HIT infrastructure in place.  

Other interesting announcements of particular relevance:

* CMS launches their Innovation Center, with a goal to create better experiences of care and better health outcomes for all Americans and at lower costs through improvements.   It appears their method will be to "identify and test care models that provide beneficiaries with a seamless care experience, better health and lower costs” (per physician Richard Gilfillan, the acting director for the new center, in their news release).
* ONCHIT launches SMArt (Substitutable Medical Apps, reusable technologies) - an iPhone like platform which will allow developers to create apps using consistent standards.   And yes, this is VERY exciting stuff - something I've been talking and lecturing about for the past few years... can't wait to see how this unfolds!
* Video montage of HIT Usability Problems - from Canada's Healthcare Human Factors Group

Sunday, October 10, 2010

Health 2.0 Conference and Innovation

I was just at the Fall Health 2.0 conference last week in San Francisco - it was the biggest (over 1000 people) and the most well-run Health 2.0 conference to date (kudos to Matthew and Indu).   The conference was enjoyable as usual - good networking and stimulating thinking galore.   There were some definitely interesting companies and ideas (more on those in another quote) - but still so many companies that don't yet understand the difference between creating software which allows users to do a task online that they don't really want to do vs. creating solutions which automatically does things you don't want to do.  In other words, we don't need an app that allows users to enter in their daily weight or glucose or med compliance, we need real life solutions which can "sense" each of those things as they happen and then send those to a "cloud" for analysis.   The good news is that we are seeing more of these "connected" devices, such as the Withings Scale, the Gluconix wireless meter, the MIT Mirror that can check your pulse and the Vitality GlowCaps which helps remind you to take your meds... and I hope to see more solutions taking advantage of them in the future.

Tonight, I want to comment on the keynote presentations - some of the best I've EVER seen...I think due to the fact that the two presenters were not just smart, but they were really prepared for their audience. This article from Healthcare IT news was an excellent write-up.  I have added a few of my own comments:

Health 2.0 keynoters differ on health IT innovation
Two keynote speakers at the fourth annual Health 2.0 Conference yesterday – a futurist and the "godfather” of Web 2.0 – disagreed over whether innovation was happening in the healthcare industry.  While Jeff Goldsmith, author, futurist and president of Health Futures, said the industry is experiencing an innovation “drought”, O’Reilly Media founder Tim O’Reilley said innovation is coming from outside of the formal healthcare industry.

Goldsmith attributed the dearth of creativity on “management menopause" – wrong-business-model, risk-averse management that used to be run by scientists and engineers but is now overseen by lawyers and marketing people – and slow decision making. “This doesn’t get you to innovation,” he said. He questioned whether public companies can successfully create new knowledge, saying it was easier for large firms to buy than to grow new intellectual property. The drought is most prominent in the medical imaging, medical device and enterprise clinical IT markets.
(LB:, this is so dead-on accurate!)

“Health IT has degraded clinical care,” he said.  "The industry is suffering from core measure mania, and the solution is to tame the 'documentation monster',” he said.  "Interfaces today are too hard to use and can’t be connected," Goldsmith said. "The health IT community must help people find the information they need effortlessly, accommodate the diversity of people and their lifestyles, and equip families with tools to manage their healthcare. The goal is to get to human connection,” he said.
(LB: Yes, yes, yes...see some of my recent past blogs on Usability.)

At the same time, said O'Reilly, medicine needs to be turned into a science. The data exists, but it just needs to be used effectively to understand the customer.  Analysis is not sufficient, he said. Healthcare needs an information nervous system that reacts in real time. “The power of the real-time enterprise is absolutely critical."

Sensors, data monitoring, collective intelligence and predictive analysis are everywhere. “Healthcare must be a part of that,” O’Reilley said. “We focus our energy on the wrong things,” he added. “We need to work on stuff that matters. We need to work on the hard problems.”
(LB: He gave an example of a recent announcement about work on a potato chip bag that makes less noise - which got a good laugh from the audience, as we know that more money will likely be spent on that than on improving EMR interfaces in the coming year.)

"We know the right treatment in 98 percent of medicine," said O'Reilly. "The two percent is art and we need systems to do the right thing. That’s the end state of IT." 
(LB: in other words, we need to figure out systems that make us consistent with the 98% of medicine we already know and support our data needs for the 2% of medicine that requires more critical thinking - see my past blog of Process over Product Innovation.)

Other resources
* Review of the Healthcamp during HC Innovation Week in SF - including a video from Todd Park about the government's release of health data via the Community health data initiative.  Check out more about this topic at:

Sunday, September 26, 2010

The Real EMR Incentive: We want LONG-TERM EFFICIENCY, not short-term funding!!!

This is a mantra I have long been espousing, and it was nice to see a recent report from the CapSite research firm backing up this assertion.  More specifically, this study of more than 2000 medical groups across the US found that "the most important reason driving Ambulatory EHR purchases was the goal of physicians making their practice more efficient and not the ARRA / HITECH Act Stimulus funding".

Said another way, to get real adoption - we need to figure out how to promote USABILITY not just Certification.  And let's continue to move from the inefficient paper-based paradigm (EMR 1.0) to the much more appropriate web-based or iPhone paradigm (EMR 2.0).   My last post, which talked about "The Future of EMRs", provides more details on this idea.  And I am looking forward to learning more on this topic when I go to SanFran this week for the "Annual Meeting of the Human Factors and Ergonomics Society" - where I will be listening to the top experts across all fields, as well as speak on a panel of EMR aficionados discussing the importance of improving usability of these tools.

So what can we (especially the government) do if this concept is true (the key to adoption is Efficiency)?  Maybe we should reconsider how we spend the $30+ billion in HITECH funds?   Perhaps instead of giving "relatively" small grants to a lot of doctors, we use the money to help the whole industry create more Efficient and Usable products?   Myself, and others, have brought up this concept before (see "How should we use $36 billion to promote EMRs").   But it becomes more relevant when one of their own ask the question, which just happened:

As reported in this article, at a recent DC conference, former Secretary of the Treasury Paul O'Neill (who has authored academic papers on patient safety with current Medicare chief Dr. Donald Berwick and Lucian Leape) posed a technical question to keynote speaker Dr. David Blumenthal, the National Coordinator for Health Information Technology: "Why is it that we're reluctant to declare that we are going to design the best prototype that we can with an idea that we will have [iterative versions] as we learn more and we identify more needs?  Why is it that we can't call to question and get on with what's a clear and apparent need for a national standard that's a work in progress?  It's not that it has to be perfect from day one, but your office basically says, 'We're going to do this now?'," O'Neill said before a packed house of doctors and administrators of corporatized health systems. 

Dr. Blumenthal's answer did not clear things up as he talked about analogies to the interstate highway and the Internet - which actually seemed to hurt his own conclusion.  In other words, if you look at those government investments - you see that they created the infrastructure upon which others could build.  They did not involve the government giving money to end-users (e.g. local truckers) to buy and install concrete paths themselves, nor did the government give money to Internet end-users to buy and install web-servers themselves.  And yet, here we are - giving money to end-users (physicians) to buy and install a variety of proprietary systems that don't talk to one another without heavy lifting since each vendor creates their own versions of the concrete road - with proprietary data models and back-end functionality.

If the government believes in these past analogies - then they need to reconsider how they distribute their EMR monies...perhaps building a single standardized EMR platform (like they do with highways or Internet protocols) upon which the vendors can add their "value" and healthcare providers and patients can benefit from consistency and competition around the key issue at hand - Efficiency.

Monday, September 20, 2010

Mayo Clinic Center for Innovation: 2010 Transform Symposium

I finally visited the Mayo Clinic this past week!  I was there for the Mayo Clinic's Center for Innovation Annual Conference - The 2010 Transform Symposium, where the theme was "Thinking Differently about Healthcare".
I got a tour of the Clinic, as well as their Innovation Center… so you can imagine, I was like a kid in a candy store!  The Mayo Clinic has a culture of innovation that starts with "Drs. Will and Charlie" (the Mayo Brothers) as well as their father (William W. - who mortgaged his house to get a crazy device called a microscope so he could study disease better).   And while this is part of their culture, they also recently recognized the importance of having a full Center dedicated to expanding on this arena - thus launching their Center for Innovation in 2008, which now includes around 50 people - a very impressive size.

There were some great people and speakers at the conference. I was inspired in various ways - including the need to eat better (more whole grains, less processed foods and fats), the need to walk more (NEAT = Non-Exercise Activity Thermogenesis), the need to relax in whatever manner works for you, and the importance of living and working in a space that is designed well.  I realize those don't sound like they actually met the theme of the conference (since we've been preaching those themes for a long time) but it was how these people said it and what they are doing differently that made an impact.

The first speaker (Dr. Coombs, president of the Mass Medical Society) pointed out the importance of both empowering patients to ask questions AND giving them resources to find answers.  Jaime Heywood (PatientsLikeMe) always gives a great talk about the power of patient data.  Mrs. Q (who blogs at "Fed up with School Lunch") made me very happy my kids are in a school that treats lunch with respect.  Dr. Dean Ornish opened my eyes once again to the importance of Lifestyle and a focus on "health care, not sick care" (FYI - he also told us Medicare is now paying for wellness programs - wow!).  And the conference walked the walk by having a fantastic chef make healthy and delicious meals and snacks for us the whole time - check out his recipes at  Various Design experts gave examples of the importance of their work. And anything by Sekou Andrews (a "spoken-word artist") was amazing.

I was fortunate to have a little time on stage as well to present some of the work we've been doing with the Szollosi Healthcare Innovation Program ( around "Thinking Differently about EMRs" (Electronic Medical Records).  The summary is that today's systems (EMR 1.0) are failed paradigms which try to simulate paper rather than try to take advantage of what computers can do well - information visualization, predictive analysis, etc.  Part of this is due to doctors and IT people who don't understand the difference between tasks/workflow and "thoughtflow".  Another part is due to the vendors who don't utilize true information designers in creating their systems, and the last part is due to the evolution of monolithic 3-tiered siloed systems which don't allow for easy innovation (see the NRC Report for more details).  I then displayed a few screen shots of the potential for future systems (EMR 2.0) - to hopefully stimulate the audience into realizing we can do better.  This was similar to a talk I gave in 2009 at HIMSS - here is a blog with the slides.

Finally, kudos to the Mayo Center for Innovation (and particularly Dr. David Rosenman, the conference coordinator) for an excellent meeting.   For more thoughts on the conference - check out the Mayo Center for Innovation's Blog.

Friday, August 20, 2010

SHIP in the Harvard Business Review article on Healthcare Innovation

Healthcare remains one of the largest parts of the US economy, accounting for $2.5 trillion dollars, or about 17% of the GDP in 2009, which is estimated to rise to 25% of the GDP by 2025 (unless major changes are made).

So it is no surprise that mainstream business magazines will be writing more about healthcare innovation in the years to come. This month's issue of the Harvard Business Review (September, 2010) has an article entitled “Kaiser Permanente’s Innovation on the Front Lines”.

The first part of the article talks about how Kaiser funds an internal "Innovation Consultancy" group (led by good friend Chris McCarthy) whose focus is to develop "service line innovations" to improve the quality and efficiency of care, as discussed below:

The Innovation Consultancy takes on carefully chosen projects throughout Kaiser Permanente, which is based in Oakland, California, and serves the health needs of more than 8.6 million members in nine states and the District of Columbia. That’s a huge laboratory for tackling opportunities to improve health care practice. McCarthy and his colleagues pursue an expansive, service-focused version of innovation, not the conventional one that by definition excludes everything but new technologies or tangible products. Surprisingly little attention has yet been paid to this version. But, as Kaiser is discovering, the bucks are relatively few and the bang can be disproportionately big. Compared with costly, long-horizon, research-driven innovation, service-focused innovation can be done both rapidly and economically.

The second part of the article talks about how Kaiser’s Innovation Group helps lead the Innovation Learning Network (ILN) – a consortium of non-profit organizations who have banded together to learn about and share healthcare innovations. The innovation program I direct (the Szollosi Healthcare Innovation Program , aka SHIP) has been an active member of the ILN and was featured in this article. The author highlights our “Inflection Navigator” project as an example of the importance of open collaboration between institutions to create these “service line innovations” which focus on both increasing quality while also improving the patient experience. Here is what he wrote:

Care Coordinators
Lyle Berkowitz is a Chicago primary-care physician who also runs the Szollosi Healthcare Innovation Program, a charitable foundation that belongs to the Innovation Learning Network. Berkowitz has worked with the ILN on a process to help patients who’ve received a frightening diagnosis more easily negotiate the ensuing flurry of necessary activity: follow-up tests, visits to specialists, decision making about treatment and care. The process is called Inflection Navigator, because a diagnosis of cancer or serious cardiac disease, for example, presents the patient with a profound inflection point.

At such times many patients feel too overwhelmed to ask important questions or undertake important tasks. Inflection Navigator assigns to each patient a care coordinator, who explains, assists, sets up appointments, anticipates questions, and provides answers. The care coordinator sequences activities to minimize the inconvenience to patients and maximize the value of the time they spend with doctors. For example, a patient’s visit to a specialist might be scheduled only after the necessary tests have been done and the results can guide a recommendation. “It decreases the burden on both the patient and the doctor,” Berkowitz says.

It also bends the cost curve down. Care coordinators don’t have to be highly trained and heavily compensated. They depend on a database of medical protocols reflecting best practices for diagnostic procedures and the latest treatments for various diseases. This frees physicians to spend more time where their expertise makes the greatest difference. The process bends the learning curve, too. If, say, the standard treatment for atrial fibrillation changes, “the cool thing is I don’t have to go and try to educate all my doctors,” Berkowitz says. “Because it can take years to do that. All I have to do is change the protocol that’s already built into the system.” The physician makes the diagnosis and then hands the patient off to the care coordinator.

Democratizing Health Care
Lyle Berkowitz mans one corner of a small booth on the modest show floor of a conference and expo in Boston. The event is a joint production of the Innovation Learning Network and the Center for Integration of Medicine & Innovative Technology, a nonprofit consortium of Boston-area teaching hospitals and engineering schools. The proceedings might best be described as a festival for health care geeks. Berkowitz is busy explaining Inflection Navigator to interested attendees. The emphasis here is on sharing, not selling. No booth bunnies, blaring music, flashing lights, or branded tchotchkes, just conversation—enough conversation that superior listening skills are needed to hear above the din. The exhibitors have zeal in common. They want to make health care better, smarter, cheaper, and more accessible.

Chris McCarthy hovers and circulates. It’s the last day of the event, and he has the semirelaxed look of someone who has either dodged or dealt with whatever might have gone wrong and is finally surrendering to satisfaction. Sharing real-world evidence of what works—ideas, practices, protocols—exhilarates people like McCarthy and Berkowitz. To them, there’s nothing odd about 16 independent organizations coming together to improve more quickly than they could if they were left to themselves. It simply makes sense to spread improvement as broadly as possible. This is not the vision of health care that emerged in the grinding yet cartoonish debate leading up to the passage of what is now called Obamacare. It was easy then to imagine that the whole system was willfully committed to cruelty, greed, vanity, and ineptitude. Beyond the fray, however, creativity flourishes. McCarthy and others, by democratizing the methods of innovation, are democratizing health care, giving patients and non-physician caregivers a louder voice in designing the future.

Tuesday, August 10, 2010

Minute Clinics - Destruction or Inspiration

A poster at The Health Care blog recently pointed out that Minute Clinics (and similar) are seeing increasing number of visits while Americans are going to their doctor less... and wondered if this was the dawning of a new age (and sun-setting of an old one).

Here was the comment I posted:

What is old is new again... "quick care clinics" have come and gone many times over the past few decades - are they really the be-all and end-all answer this time? I think they have a role, but certainly don't solve everything - and their major benefit may be in making doctors think more innovatively about how they deliver their care for low complexity cases.

More specifically - let's start with the clinical perspective: there will be anecdotal stories of great convenience, but also those of horribly missed diagnoses. From an efficiency perspective, there will be wonderful stories of quicker access vs. going to the standard practice... but two things are critical to understand:
1. There are not enough NPs and quick care clinics to truly handle all the demand out there.
2. Practices aren't going to stay standard forever. Many are now doing virtual visits via phone or the web - and hey, that's even easier and more convenient than having to find a clinic with an NP and register there. So boom... the efficiency rod strikes right back at them.

Of course, the truth is that there is PLENTY of DEMAND right now, and not nearly enough supply, so everyone will be busy for awhile. But this is an important time for care providers to start rethinking how they deliver care, especially to the "easy, highly structured" cases (e.g. URIs, UTIs, as well as stable Htn, DM...) and hopefully we will start seeing more innovation in this model - thus freeing up doctors to have more time for the more complicated cases as well!

I wrote a more thorough review of all this back in 2007 when the same questions were coming up... check it out:
A Time of Change: New technology-enhanced care models may change everything. Will you be able to adapt?

Monday, August 02, 2010

DrLyle's Take on the Meaningful Use Rules

I wrote up some notes about MU last week and the folks at HISTalk published it - here is the link to that posting (as well as some interesting comments from others):
DrLyle's Take on the Meaningful Use Rules 7/30/10

And here is the text from that post, with links to resources on the bottom:

In mid-July, the government released the final rules on MU and EHR certification. I was actually at the perfect place for this — the annual meeting of AMDIS (Association of Medical Directors of Information Systems). So we had 200 CMIO-type docs and a panel of speakers ready to talk about this topic. HIT geek heaven!

From my bias of focusing on ambulatory EMRs, here is what I learned at this meeting from listening and talking to some very smart people on the topic and reflecting on everything the past few weeks:

Big picture stuff
MU Rules are reasonable. The government listened to the end users and decreased the expectations on the "Core Rules" (decreased the percentage of eRx required), while putting other rules in an optional "Menu" (i.e. choose five of 10). But be aware, anything optional you don’t do in Phase 1 will be required in Phase 2 in 2013 (i.e. you’ll need to do 10/10 from the Menu)… and they will likely think of more things to add by then.

MU Rules are still not a slam dunk. Even for mature users, there will be work that needs to be done. It is hard to believe that a non-mature user, or users without a lot of resources, will be able to easily accommodate everything.

The government seems to think this will really work well and we will see over 50% adoption by 2015. I would love that, but am less optimistic. Best quote I have heard is that MU incentives are like giving someone money to have a baby. You will have a baby if you want a baby. The money is a nice extra, but not the main driver. Change is hard, so I am hoping that while we keep asking vendors and users to add functionality, we consider how we can improve usability at the same time.

I do hope the government is at least working on a secret Plan B in case 2015 comes and we are only at a fraction of where we need to be (e.g. maybe they give money to innovation think tanks to figure out better EMR user interfaces). If you want to read more about the rationale behind having a Plan B, check out the great Kuraitis/Kibbe blog on this topic.

Per John Glaser, we need to think about MU not as a simple, one-time incentive, but rather as a stepping stone to bigger reimbursement reform. In other words, it helps groups create the HIT foundation for alternative care models and payment reform of the future (e.g. Medical Homes, ACOs). In that future, an EMR is no longer a competitive differentiator, but rather how we use our EMRs will be the differentiator (e.g. care efficiency and improvement, use of clinical decision support, secondary use of data, and patient engagement).

Some details that popped out at me
1. The denominator is now "unique patients" rather than patient visits. So if a patient is seen three times in a year, you just have to fulfill the rule at least once for that patient.
2. Scoring will be done on an individual physician basis, not on a group-wide analysis.
3. To correctly measure many of these details (e.g. give clinical summary to 50% of those who ask) we would need to figure out a way to keep track of who "asks". That seems like a strange request for structured data and certainly should not be what a doctor is spending his time doing. So either we need to make it an easy administrative chore or consider doing it for 100% of people automatically.
4. For patient reminders (for patients over 65), physicians can decide content and format. For example, we can decide to just do colonoscopy reminders and only do it via mailers to patients — it does not have to be electronic. The point is to just prove we can identify patients by age and communicate with them in some way.
5. Patient education. We need to figure out a way to document when we provide these handouts. Some EMR systems may have that built in, but even then, just for the handouts they have. What if I go online and print something else out? Or give them a special handout I have created? We may need to create a special patient education section to document this, but it is again more busy work for physicians (which I am not a fan of!).
6. EMR vendors are on the hook. They are required to ensure some level of MU reporting from their EMRs to get certification. The result will likely be that they will be spending a lot of extra time and money preparing their EMRs and then trying to get everyone to take those upgrades. They will then likely just certify the most recent version of their system.
7. EMR users need to upgrade, due to above point. It is unclear how all current EMR users are going to be able to quickly upgrade their systems in the coming 6-12 months. That takes a lot of planning, time, resources, and money. I wonder if users of "older versions" will band together to try and get their older versions certified, or if the vendor will help at all?

• The NEJM summary from Dr. Blumenthal
• A summary from Computer Science Corporation (CSC)
•  Full text of the MU rule from HISTalk
MU PPT Slides from CMS
* The HHS FAQ about MU

Sunday, July 11, 2010

Usability and EMRs: An Update

I've talked since the start of this blog about the importance of improving "Usability" for Electronic Medical Records (EMRs), and this post is an update which provides a single collection of relevant information:

First, a report raises growing concerns that electronic health record products are being developed without specific best practices and design standards related to EHR product use in a healthcare setting. To overcome this difficulty, many vendors support an independent body guiding development of voluntary usability standards for EHRs, the study found.

Second, here are two stories on the recent debate about how Usability should be part of EHR Certification - one is from Healthcare IT News, the other from

Third, a Comparison of Questionnaires for Assessing Website Usability - while this is not healthcare specific, it provides some insight into Usability testing.

Other Links of Interest
• The HIMSS WhitePaper on EMR Usability
-- This paper is a very well done introduction and review of this topic, so definitely a good place to start. Or if you want the very short version, here is an HISTalk Reader post (kudos to Odell Tuttle) which summarizes the 11 HIMSS EHR Usability Principles as follows:
Everything from lack of visual clutter and concise information display to inclusion of only functionality that is needed to effectively accomplish tasks.
This refers to how automatically “familiar” and easy to use the application feels to the user.
External consistency primarily has to do with how much an application’s structure, interactions, and behaviors match a user’s experience with other software applications. An internally consistent application uses concepts, behavior, appearance, and layout consistently throughout.
Minimizing Cognitive Load
Clinicians in particular are almost always performing under significant time pressure and in environments bursting with multiple demands for their attention. Presenting all the information needed for the task at hand reduces cognitive load.
Efficient Interactions
One of the most direct ways to facilitate efficient user interactions is to minimize the number of steps it takes to complete tasks and to provide shortcuts for use by frequent and/or experienced users.
Forgiveness and Feedback
Forgiveness means that a design allows the user to discover it through exploration without fear of disastrous results. Good feedback to the user supports this goal by informing them about the effects of the actions they are about to take.
Effective Use of Language
All language used in an EMR should be concise and unambiguous.
Effective Information Presentation – Appropriate Density
While density of information on a screen is not commonly measured (though it can be), it is a very important concept to be cognizant of when designing EMR screens.
Meaningful Use of Color
Color is one of several attributes of visual communication. First and foremost, color should be used to convey meaning to the user.
Screen readability also is a key factor in objectives of efficiency and safety. Clinical users must be able to scan information quickly with high comprehension.
Preservation of Context
This is a very important aspect of designing a “transparent” application. In practical terms, this means keeping screen changes and visual interruptions to a minimum during completion of a particular task.

• Some excellent posts from John Halamka on this subject:
-- EHR Usability
-- Top 10 Barriers to EHR Implementation

Improving Usability of Health IT for Physicians
-- A great article in Healthcare Informatics which starts by pointing out that most health professionals do not use available health IT systems because they actually increase their work effort and can too frequently hurt quality, whereas the objective should be to help physicians decrease their work effort while increasing their quality consistently. They offer thoughts on a "physician-specific point-of-care system that continuously adapts to practice patterns that could result in dramatic improvements to the quality and efficiency of healthcare delivery".

• Some past posts from me on this subject which I love so much!
-- The Dark Side of EHRs: Explores the issue of unintended consequences, often due to poor usability.
-- Good software includes superb usability: Discussion about how EMR vendors need to improve how they create their products.
-- Improving EMRs: Usability, Usability, Usability: My first ever blog post, the name speaks for itself.

And in case anyone is interested in "building a better mousetrap" - the charitable endeavor I manage, the Szollosi Healthcare Innovation Program (, is sponsoring one of the inaugural challenges in The Health 2.0 Developer Challenge. Our specific challenge is to rethink how we document in EMRs by using publicly available blog or wiki software to create a longitudinal medical record that represents a patient's multi-day hospital stay, or a multi-year relationship with a physician in the outpatient setting.

* July, 2010: Usability in Health IT: Technical Strategy, Research, and Implementation (National Institute of Standards and Technology Conference) - this actually has about 20 different presentations on this topic.
* Sept, 2010: I presented at the Mayo Center's Innovation Conference about the need to rethink how we use computers in healthcare and shift from EMR 1.0 to EMR 2.0.   Full blog is online at:
* Nov, 2010:  Incorporating Health IT into Workflow Redesign, prepared by the University of Wisconsin-Madison’s Center for Quality and Productivity Improvement (CQPI):  or PDF of full summary:
* Nov, 2010: From NIST (and Usability expert Bob Schumacher), as report entitled "Customized Common Industry Format Template for Electronic Health Record Usability Testing"  (PDF)
* Dec, 2010: The Usability Toolkit is a collection of forms, checklists and other useful documents for conducting usability tests and user interviews.
* Feb, 2011: Promoting Usability in Health Organizations: Initial Steps and Progress Toward a Healthcare Usability Maturity Model (HIMSS White Paper)
* March, 2012: NIST releases EHR usability guidance.  The three-step protocol includes: Analyzing the EHR system's functionality; Conducting an expert review of the EHR system; and Performing validation testing of the user interface.  According to NIST, the protocol assesses whether the EHR system can: Contain, collect and display the correct information; Ensure that users understand the information; and Allow users to easily locate needed information.
* August, 2012: A Long Way to Go for EMR Usability: Updates, Trends and Recommendations

Our Healthcare System: Update

A variety of websites and stories which I found to be important or at least thought-provoking:

Key Web sites
-- The best site I have found to simply explain, "What does the new health reform law mean for YOU?"
-- The federal government's site that includes specific advice on how to find health insurance and how that is impacted by the new health reform law.

Healthcare IT stories
Use of HIT Improves the Quality of Care
-- A Kaiser Permanente Study Finds Quality of Care Scores Increase as Patients and Physicians Communicate via Secure E-mail.

Improving Usability of Health IT for Physicians
-- A great article in Healthcare Informatics which starts by pointing out that most health professionals do not use available health IT systems because they actually increase their work effort and can too frequently hurt quality, whereas the objective should be to help physicians decrease their work effort while increasing their quality consistently. They offer thoughts on a "physician-specific point-of-care system that continuously adapts to practice patterns that could result in dramatic improvements to the quality and efficiency of healthcare delivery".

General Healthcare Stories
Process improvement to improve compliance with specialty visits
-- Turns out that when a PCP refers a patient to a specialist, they only make the appointment 70% of the time, and of those - only 70% show up - thus less than 50% of people go to the specialists when they are referred! This article talks about how a process improvement improved those metrics. Our medical group ( does something similar to help with this process and we believe it provides a higher quality and more efficient process for sure!

Better ways to manage the flood of test results
-- New recommendations target how physicians and hospitals can best communicate test results and prevent harm to patients.

Aftercare Tips for Patients Checking Out of the Hospital
-- NY Times article on how good discharge planning can keep patients from needing to be re-admitted after leaving a hospital, and could save Medicare billions.

How the Performance of the U.S. Health Care System Compares Internationally (2010 Update)
-- Yet another report, placing the US healthcare system last among industrialized nations. US spends $7,300 per person per year on healthcare and gets the worst results. UK spends $3,000, New Zealand $2,500; Canada $3,900; Australia $3,400.

Health overhaul may mean longer ER waits, crowding
-- Due to a shortage of primary care physicians (PCPs), Emergency Rooms may grow even more crowded with longer wait times under the nation's new health law since there will be many more patients with insurance, but no increase in PCPs.

The Variability of Patient Care - by John Glaser
-- One of the smartest guys in healthcare explains the theory from one of my favorite books (Designing Care by Richard Bohmer),which I talked about in a previous post about Checklists and process improvement. The key point being that there are two classes of care in a hospital and in a physician's practice, and the importance of understanding that these two very diverse scenarios need to be recognized when designing process/workflows for care (especially including use of EHRs). Glaser explains further;
---- Sequential care is a form of production: It involves performing well-understood tasks in a well-understood sequence (e.g. routine heart surgery). Sequential care's mental image is that of a production line. With sequential care it is possible to engineer a preferred sequence of steps and have the EHR guide the care team in performing these steps. And it should be quite possible to measure the outcomes of these steps. (This is similar to Clay Christensen's Value Added Process)
---- Iterative care is a form of discovery: It addresses complex diagnoses and conditions for which the diagnosis and treatment are a repeating series of hypothesis-test/treat-revise hypothesis steps. Iterative care is different. The mental image should not be the factory floor but a group of scientists in the laboratory. In this scenario we must encourage collaboration, enable an unpredictable set of actions to be taken, and provide easy access to information and other experts that might help the team form and test hypotheses. Measuring the outcome of discovery is very difficult. (This is similar to Clay Christensen's Solution Shops)

Sunday, June 27, 2010

Allscripts and Eclipsys Merger - A Review

Earlier this month, outpatient focused vendor Allscripts announced a major move - merging with (or more officially buying) hospital focused vendor Eclipsys… and thank goodness, because I always had trouble spelling Eclipsys! We seem to get 1-2 of these major acquisitions a year, and I would predict we'll continue to see about that rate until there are only 3-4 major healthcare IT vendors standing. And don't be surprised if one or two of those are not the classic ones, but rather larger IT companies who finally want to get into this market (e.g. IBM, Microsoft).

This particular merger is a reasonably logical acquisition since they were both likely losing out on deals where the buyer wanted an integrated inpatient and outpatient system from the same vendor. Of course, it will take awhile (at least 1-2 years) to really allow them to offer a well interfaced product (and don't be fooled - it will never be a truly integrated one, see below for more). In the meantime, the following business logic makes sense:
• Current organizations who work with both companies will immediately benefit as they should be able to assume that the products will start integrating and that the vendor should now pay for that (that's certainly what I'd ask of them).
• Current organizations who use Eclipsys and want to buy an outpatient EMR for their affiliated physicians will make Allscripts their "vendor to beat".
• Current organizations who use Allscripts and are looking to replace their inpatient systems will make Eclipsys their "vendor to beat".
• Organizations who are ready to "start from scratch" right now should at least be willing to hear what Glen Tullman has to say, and maybe he'll convince a few to be "early partners" in this great experiment…

Here is what various pundits are saying about this merger:
The official Press Release on June 9, 2010
Allscripts and Eclipsys announced a definitive agreement to merge in an all-stock transaction valued at approximately $1.3 billion...The combined company's client base will include over 180,000 U.S. physicians, 1,500 hospitals, and nearly 10,000 nursing homes, hospices, home care and other post-acute organizations. In addition, Allscripts will buy back the majority of their shares from Misys (who will go from a 54% to a 10% owner).

Glen Tullman will remain CEO of the company. Eclipsys President and CEO Philip Pead will be chairman of the company and will focus on strategic relationships, product and process integration and international business. The companies project $25 million in cost savings in 2011 and more in subsequent years. The transaction is expected to close in four to six months.

Healthcare IT News Story (June 9, 2010): Allscripts, Eclipsys to merge in $1.3 billion deal
- A simplified version of the press release.

Information Week (June 9, 2010): Allscripts Eclipsys Merger Saps Resources
This author points out how "the costs of integrating the ambulatory and acute expertise of Allscripts and Eclipsys may outweigh the synergies of combining the two companies".

Health Data Management (June 10, 2010): The Early Take on Allscripts-Eclipsys
Allscripts' pending acquisition of Eclipsys makes sense but has perils, according to several consultants specializing in helping providers select information systems.

Modern Healthcare (June 14, 2010): Allscripts' Eclipsys deal: the financial details
Allscripts-Misys Healthcare Solutions, Chicago, a developer of electronic health records systems for ambulatory-care physicians, will borrow most of the $577 million or more needed to extricate itself from the majority control of British IT developer Misys and then swap $1.3 billion in stock to buy all of Atlanta-based hospital and physician electronic health-record system developer Eclipsys....

Modern Healthcare (June 15, 2010): Allscripts deal: Success is in the execution
“If they perform really well, this strengthens them, because this is what the market wants, inpatient and ambulatory,” said Adam Gale, president of healthcare information technology market watcher KLAS Enterprises, based in Orem, Utah. “But can they deliver it? That's a whole other question. I guarantee you that is heavy on their minds.”

HISTalk Blog (June 15, 2010): Interview with Glen Tullman and Phil Pead
Glen Tullman is CEO of Allscripts. Phil Pead is president and CEO of Eclipsys. (June 16, 2010): Will Allscripts and Eclipsys truly integrate?
"True & total integration is almost impossible in the maddeningly complex world of HIT today…When a company like AllScripts buys a suite of products from another firm like Eclipsys, all they can truly integrate are the brochures, Powerpoints, proposals and contracts. The rest is interfaces, like every HIS vendor (and hospital) has plenty of already."

HIStalkPractice (June 21, 2010)
HIT Vendor Executives on Reactions to the Allscripts/Eclipsys Acquisition.

Wednesday, June 16, 2010

10 Point Program to Improve EHR software

The HISTalk Blog lets users write in with ideas, rants, and raves now and then - and a recent post by an anonymous writer was so good - I am reposting it here. He wrote up a ten point program to improve EHRs... it was great. I think the first four points are key for actual development, the others are important for deployment. Read on:

10 Point Program to Improve EHR software
1.Less configurable. The Demotivators® said it best “When people are free to do as they please, they usually imitate each other”. Every hospital or physician practice is unique — they uniquely solve the exact same problems everyone else is facing.
2.Better designed. End-user input and UI design should be part of the specs, not the pilot.
3.Customer-prioritized enhancements. Fifty percent vendor-driven (sales and demo feedback, regulatory requirements, infrastructure, etc.), 50% prioritized by customers. Yearly process, projects grouped to be equal number of hours, one vote per licensed bed, top x projects will be roadmapped to fill 50% time.
4.Consensus-driven standard content and configuration. Vendor designed, large group customer editing — majority rules, everyone uses.
5.Remote hosted. 99.999% uptime, capacity and response time are key requirements.
6.Rapid install. If you’ve followed 1-5, training the end-users should be the most time-intensive phase of the implementation.
7.Qualified buyers. We’ll sell to you if you agree to: follow our standard workflows, use our standard build and participate (end-user input, content design, and prioritization). Must agree to mandate adoption! Better to support 50 involved, committed customers than 100 unhappy, non-standard, partially-implemented, low-adoption targets.
8.Equitable pricing. Low upfront, subscription-based. Every customer pays the same, scaled by size or volume.
9.Play nice with other vendors. Integration > Interfacing > Interoperating.
10.Record portability. Remove vendor lock-in. The intersection of the NHIN and CCDs with the market transitioning to replacement will make this a necessity. You know it will be mandated eventually.

The only thing I'd add is the concept of "Open those platforms" - meaning the vendors should release APIs that allow 3rd parties to innovate on the user interfaces and functionality that can interact with the data model without changing it (as per some past posts).

Wednesday, May 26, 2010

Physician Ratings vs. Healthcare Narratives

An interesting study came out last week which aligns with some of my thinking and thoughts on individual physician ratings:
• The overall activity of ratings is pretty low (e.g. there are not many ratings being posted by patients). I think a major part of that is because consumers are not really confident in how to rate doctors since (1) there is a fair amount of subjectivity which makes it hard to put into a "standardized rating" and (2) they don't do it often. In other words, consumers might feel they can be experts on restaurants and movies since they have a lot of experience at those venues AND there are often obvious metrics. Meanwhile, most people just see a doctor 2-3 times in a year (and then it's just for 15 minutes), they usually just see 1-2 doctors (so not a lot of comparisons), AND the experience each time might be different depending on a variety of factors (e.g. how sick they are, the type of syndrome they have, how they respond to the therapy, etc.). In other words, most patient's actual experience with the doctors is often short and incomplete (at least with respect to fully rating them).
• Most of the ratings are positive… which makes sense since that is often human nature. But at least this dispels the myth that only "haters" would post! However, it should be pointed out that it often only takes 1 bad review to sour most people, unless there are over 5-10 good ones also present. A small amount of reviews can be easily biased by one bad one.

The LA times even did an article about this study: Physician rating websites mainly sing doctors' praises, study finds. It is a good story, although I think they used this study to too quickly dismiss these sites. Rather, I would use this study to explain that:
1. Physician rating sites are still in their early phases and the jury is still out on how important they will be.
2. For a true objective rating of doctors, we ideally need much greater numbers of consumers doing these ratings, and ideally in a more consistent manner (e.g. randomly poll patients, otherwise you will mostly get the most extreme examples on either end to post a review).
3. There needs to be a way for physicians to respond, particularly to negative posts (although without violating patient confidentiality). For example, I am impressed that now does allow for that function.

With that said, I think there is also a very important role for more "narrative" reviews of healthcare as well. However, that is likely to be best done at the systemic level (e.g. total healthcare experience across an enterprise), rather than geared towards a single physician. For example, I recently heard about a website called Patient Opinion . This is a non-profit organization in the United Kingdom founded by Paul Hodgkin, a GP who wanted to make the wisdom and insights of patients, available to the NHS (National Health Service). He states "the old ways of doing this – inviting a patient to sit on a working party or carrying out a survey – did not work very well", so he devised Patient Opinion as a way for thousands of patients to both share their own experience and gain support from others. The results are story after story about the good and bad in the system. And hospitals and other entities actually read and respond to these stories. They have found that these stories have more power and information than any objective rating scale could ever provide - and that they are often able to fix systemic problems based upon these narratives. Wow - that's a very powerful thought...

Thursday, May 13, 2010

Storytelling and Innovation

I am fortunate to be part of the Innovation Learning Network (ILN) which "brings together the most innovative healthcare organizations in the country to share the joys and pains of innovation. Its purpose is to foster discussion on the methods of Design Thinking and application of innovation / diffusion, ignite the transfer of ideas, and provide opportunities for inter-organizational collaboration." Some other members include Kaiser, Partners Healthcare, the VA system, UPMC and the Ascension Health System.

We meet twice a year for "in person" meetings where we learn formal innovation techniques, brainstorm on how they can be applied at our institutions, and share stories of successes (and failures - since the nature of innovation requires some failures!). Our most recent meeting was last week and was in Chicago - it was primarily hosted by a fantastic innovation and design consultancy called gravitytank (and the Szollosi Healthcare Innovation Program helped to co-host since it was in our home town!). As usual, my friend and fellow blogger Dr. Ted Eytan has already written this up a bit - check his ILN report out and you might also be able to see a picture of me about to be adorned with a leopard robe...

The theme for this meeting was "Storytelling" - particularly around how can stories help one develop or spread innovative ideas. I took away a couple of major learning's:

Stories are a very powerful communication tool - humans are innately and culturally programmed to hear and understand stories. It is much easier and better to explain a problem or solution in the context of a story than as a bunch of numbers and statistics. What would you rather hear as a prelude to a decision to open up a new medical office in a certain area of town: "Bob and Jane were 25 years old when they met at Margie's Candy store, fell in love, bought a house in the new section of Lakeview, and then had a son named Bobby Jr. and later a daughter named Scarlett", or "The average age of marriage in Lakeview is 27 and the majority of couples have two children". Think about how much of the story of Bob and Jane you already filled in with your own mental images (the look and smell of the candy store, the kids playing in the house…) and how much you are already interested in their lives vs. how little you care about the stats.

There is an art and a science to creating stories. First, define your Hero, the Villain, the Weapon (the tool which the hero uses to defeat the villain), and the Treasure that is received. Consider adding in a Mentor, a Companion (an important partner), some sidekicks (humorous extra characters). Next, set up your plot to mirror some of the typical archetype stories that people are used to hearing… almost all stories have a Hero overcoming a Villain to get to the treasure, but more specific stories each have their own subtleties, such as "Rags to Riches" (think Aladdin), "Overcoming the Monster" (think Jaws) and "A Quest" (think Indiana Jones). Finally, always make sure to humanize any data and keep things interesting by doing things like proposing puzzles, using props and interacting with your audience.

Storyboarding is an excellent tool for brainstorming. Draw picture panels of the current state, put them up for everyone to see, and then step back and think about how else it could be done. Draw new panels and put them up, mix and match.. and create a whole new story. We broke into groups and looked at the problem of getting thru the airport - some groups looked at this from the eyes of a single mother with two children, others from the eyes of a busy consultant, others from the eyes of an aging couple. Within 30 minutes, the amount of great ideas was staggering - from "Family tickets" (one ticket for the adult and kids) to "amusement-like rides" through security, to pat downs with cooking-like gloves which smelled of warm cookies (hey - no holds barred on innovating!).

There are a ton of books on how to more effectively use stories; one of my favorites is Squirrel, Inc. Others include Made to Stick and The Seven Basic Plots: Why We Tell Stories.

Wednesday, April 21, 2010

The Dark Side of EHRs

Sir Cyril Chantler noted, "medicine used to be simple, ineffective and relatively safe; now it is complex, effective and potentially dangerous." His quote was from a Lancet article in 1999 - much before EMRs were being used regularly. I wonder what he would say now!

I blogged back in February about the FDA's consideration of regulating EMRs... and a series of recent stories have come out reminding us of the unintended consequences of using information technology in healthcare… the truth being that problems occur due to a combination of issues, including;
Implementation problems, such as forcing through awkward workflows.
Technical problems, such as failed integration, slow speeds, system outages and true errors in the system design (e.g. 1 + 1 = 3).
Usability problems, such as difficult to read screens, which can affect speed and judgment. Something I've been commenting on a lot in the past year, as in blogs of April, 2009 and August, 2009.

Here are two interesting stories from the Huffington Post Investigative Fund (a new nonpartisan nonprofit dedicated to in-depth reporting):
As Doctors Shift to Electronic Health Systems, Signs of Harm Emerge : A device that is central in the shift toward electronic medical records systems has been linked to instances of death or injury, according to an Investigative Fund review of Food and Drug Administration data.

Amid Digital Records Surge, a Lack of Policing by the FDA: As federal officials encourage the rapid expansion of electronic medical records to help doctors improve care and cut costs, they lack a reliable and systematic method for tracking the safety of these products, agency data and audits show.

Finally, my friend Dale Sanders, a well-known healthcare CIO, wrote an excellent blog bringing the personal touch and common sense thoughts to this topic of Patient Safety and EHRs.
I love this quote: Remember when safety belts in automobiles first became popular? They were simple lap belts, no shoulder strap. Did they aid passenger safety? Yes, in some ways… but they also introduced the danger of a whole new range of injuries, such as lumbar separation and paralysis, which hadn’t previously existed. It wasn’t until we added shoulder straps and the three point anchor to seat belts in cars that the evidence of benefit to passenger safety became clear and without question. We need pause now and add shoulder straps to EHRs.

If you are interested in searching the FDA's database for HIT problems, or submit one of your own, you can do so at MAUDE (Manufacturer and User Facility Device Experience)

With all that said, this should not stop the forward march of EMRs and HIT from helping us improve the quality and efficiency of healthcare... but it should certainly remind us that we are FAR from our ultimate destination and we all (vendors and users) have to figure out how to build, implement and use these systems better and better...

Other stories and articles
NY Times article (April, 2010) on how EMRs in the exam room can provide so much info that it pushes a doctor into “cognitive overload”

The Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry (JAMIA, 2007)

Overdependence on Technology: An Unintended Adverse Consequence of Computerized Provider Order Entry (AMIA Conference, 2007)

The unintended consequences of computerized provider order entry: Findings from a mixed methods exploration (Intl J of Med Informatics, 2009)

Rush to Electronic Health Records Could Increase Liability Risk
(Insurance Journal, June, 2010) which references this paper:
E-Health Hazards: Provider Liability and Electronic Health Record Systems

Nov, 2011: has been created in collaboration with medical professional insurance carriers and adverse event reporting and government experts to improve EHR and patient safety and help to reduce professional liability. EHR event reports will be provided to participating EHR vendors and kept confidential by PDR Secure™.  Information from the PDR Secure PSO may be used by medical professional insurance carriers and the FDA to better understand EHR events and to develop education materials that will increase patient safety and benefit physicians and other clinicians in their use of EHR technology.

Tuesday, April 13, 2010

Stats and Stories

With the recent passage of the Healthcare Reform bill (meaning more patients will be looking for PCPs), along with HITECH getting closer to reality... we will be seeing more and more stories such as these:

Physician Shortage
WSJ Article (April, 2010)
The new federal health-care law has raised the stakes for hospitals and schools already scrambling to train more doctors. Experts warn there won't be enough doctors to treat the millions of people newly insured under the law. At current graduation and training rates, the nation could face a shortage of as many as 150,000 doctors in the next 15 years, according to the Association of American Medical Colleges. That shortfall is predicted despite a push by teaching hospitals and medical schools to boost the number of U.S. doctors, which now totals about 954,000. The greatest demand will be for primary-care physicians. These general practitioners, internists, family physicians and pediatricians will have a larger role under the new law, coordinating care for each patient. The U.S. has 352,908 primary-care doctors now, and the college association estimates that 45,000 more will be needed by 2020. But the number of medical-school students entering family medicine fell more than a quarter between 2002 and 2007. A shortage of primary-care and other physicians could mean more-limited access to health care and longer wait times for patients....

No surprise, a big part of this is due to:
Gap between PCPs and specialist compensation
MGMA Study (April, 2010)
Annual compensation for primary care and specialty care groups in academic practice slowed between 2008 and 2009, increasing only 2.93 percent for primary care physicians and 2.43 percent for specialists, according to the MGMA Academic Practice Compensation and Production Survey for Faculty and Management: 2010 Report Based on 2009 Data. Primary care physicians reported compensation of $158,218, while specialty care physicians reported compensation of $238,587, a difference of $80,369. From 1999 to 2009, compensation in academic practices continued to trail that in private practices.

Problems with the US Healthcare System, and Kaiser as a shining beacon.
This short story in the Economist (April, 2010) aptly (and somewhat pessimistically describes) how; for the most part, the American health system is dominated by cream-skimming health insurers and the myriad “fee for service” providers they do business with, which drive up costs by charging high prices for piece work. Whereas Kaiser is able to balance quality with cost AND patient satisfaction because it "aligns incentives both to promote parsimony and to improve the quality, rather than merely the quantity, of the care it gives." Thanks for Dr. Ted Eyten for finding and posting this in his blog first.

And we have to deal with this...

The Invisible (Uncompensated) Burden of PCPs
A NYT story (April, 2010) highlighted a NEJM article on this topic and points out the need to change how PCPs are paid — particularly as the new health care law promises to add millions more patients to the system.
The NEJM article (April, 2010) details the uncompensated work burden on PCPs, including about 100 extra tasks a day - including telephone calls and emails for various questions and refills, labs and other studies which need interpretation and communication to patients, as wells as forms and other paperwork for things like school paperwork and medication approval.

The Challenge of Multiple Comorbidity for the US Health Care System
Article in JAMA (April, 2010)
The aging of the US population, combined with improvements in modern medicine, has created a new challenge: approximately 75 million people in the United States have multiple (2 or more) concurrent chronic conditions, defined as "conditions that last a year or more and require ongoing medical attention and/or limit activities of daily living". Is the 21st-century US health care system prepared to deal with the consequences of successfully treating patients who have conditions, often multiple, that they would not have survived in the early 20th century? Current indications suggest that it is not. As the number of chronic conditions affecting an individual increases, so do the following outcomes: unnecessary hospitalizations; adverse drug events; duplicative tests; conflicting medical advice; and, most important, poor functional status and death. Approximately 65% of total health care spending is directed at the approximately 25% of US population who have multiple chronic conditions.

A wider look at health in the US
CDC Report on Health in the United States, 2009
- Use of MRI, CT and PET imaging has soared in the past decade
- Rates of many procedures have increased dramatically: knee replacements (up 70%), Angioplasties with stents (75% of all PTCA in 2006), Fertility treatments (especially in females > 40), Outpatient endoscopies (rose 90%).
- Prescription med use is also up: Diabetes drugs (up 50% in patients over 45), Statin (up 10-fold in past decade), Percent of people on at least 1 drug (increased from 38 to 47%), those taking three or more drugs (increased from 11% to 21%).
- Life expectancy has improved a little. Overall mortality from Cancer, Stroke and Heart disease has declined. Deaths from Respiratory illness and accidents are stable.
- Leading causes of death (by age): 1-44 (accidents), 45-64 (cancer), over 65 (heart disease)
- Chronic conditions: steady at 10% of people reporting chronic conditions limit their activity - most likely arthritis and other musculoskeletal issues. Second leading cause was Mental illness (age 18-44) or heart/circulatory disorders (over 45) - with mental illness a third in that age group.

Meanwhile, with respect to HIT...
Health IT: The Road to 'Meaningful Use'
Health Affairs (April, 2010)
A series of articles that reviews many of the pros/cons of trying to adopt HIT/EMRs to meet our growing needs for quality and care coordination. On one hand, there are definite theoretical advantages to using HIT, and there is a push to do something NOW rather than wait forever for "perfect systems". On the other hand, these systems are still immature and success is often more about workflow re-engineering, executive support, and process and culture change rather than on any specific technology... thus implying that attempting to rapidly adopt IT tools may result in more problems and implementation failures since the other non-IT support needs are so high.

Electronic Medical Records and Communication with Patients and Other Clinicians: Are We Talking Less?
Center for Studying Health System Change (HSC) study (April, 2010)
Commercial electronic medical records (EMRs) both help and hinder physician interpersonal communication—real-time, face-to-face or phone conversations—with patients and other clinicians... EMRs assist real-time communication with patients during office visits, primarily through immediate access to patient information, allowing clinicians to talk with patients rather than search for information from paper records. For some clinicians, however, aspects of EMRs pose a distraction during a visit . Moreover, some indicated that clinicians may rely on EMRs for information gathering and transfer at the expense of real-time communication with patients and other clinicians. Given time pressures already present in many physician practices, EMR and office-workflow modifications could help ensure that EMRs advance care without compromising interpersonal communication. In particular, policies promoting EMR adoption should consider incorporating communication-skills training for medical trainees and clinicians using EMRs.

Re-Inventing Primary Care
From Health Affairs (May, 2010): "The nation’s primary care system is broken, and fixing it is an urgent priority—all the more so because of the enactment of national health reform." The May 2010 issue of Health Affairs examines what it will take to reinvent primary care in the United States. Operational, payment, regulatory, legal, and educational reforms will be necessary to improve care and achieve savings —and to prepare for the influx of millions of Americans who will be insured for the first time as of 2014.

Sunday, March 28, 2010

Why I Blog...

Last month, a friend and fellow blogger asked me why I blog... and I had to stop and think about it for a second, but it became quickly clear to me there are two main reasons:

1. So that I can document my ideas and experiences in a single repository, which I can then refer to later. Sometimes these are thoughts stirred by the current climate or an experience I've had. Other times I am directly "responding" to articles I have read - and thus this blog allows me to save a link to the article and why I thought it was particularly good or at least thought-provoking.

Although I mainly am just creating these blogs as a placeholder for ideas I want to think more about at another time... It turns out that I often use them as a source to explain myself more quickly to others. So if I get an email asking about my thoughts on EMR adoption or usability or the new healthcare plan, I can provide a quick summary and then a link to my blog which has details. In other words, although it takes some time to write the blog, if I can re-use it in these ways, I can actually be more efficient.

2. Writing helps me take some whirling thoughts and put some order into them - forcing some definite structure. In other words, it helps me generate a clear product that both I, and others, can understand and ideally use in some way.

So while I mainly write for myself, if these blogs stimulate thoughts, ideas and motion from others- then all the better. Last month, my little blog actually was recognized in the list of "Top 50 Healthcare IT Blogs", which I really appreciated (of course, maybe there are only fifty of us?). So hope everyone out there is enjoying reading along!

Monday, March 22, 2010

Healthcare Reform (well, at least Insurance Reform)

The Change Doctor Blog has to comment on this important moment in our country's history... On Sunday night, the House passed “The Patient Protection and Affordable Care Act,” a landmark health care reform bill. This legislation, along with a crucial package of specific improvements, aims to lower costs and expand access to millions of Americans. It's been a long road, but the echo of "Yes, We Can!" rings a bit louder this week.

While it is not ideal, we are at least closer to reaching what I believe is both an ethical and financial imperative in making healthcare insurance affordable to every American. A good summary of this bill is found in this MarketWatch article. Also check out:

But let's not kid ourselves- the race is far from over. We need to realize that this is just "Insurance Reform", meaning that it makes insurance companies act as they should act: like risk pools who do not get to cherry pick who is in their pool (i.e. no more exclusions based on past history). At the same time, it makes the game fair for insurers by pushing everyone to get insurance - thus making sure that young, healthy adults don't get to completely opt out of the system. There are nuances, but that is the core part of what is happening - and it will take a few years to get into full effect.

What this does NOT do is stop the spiraling cost of healthcare related to increasing illnesses, tests and treatments... in a system that predominately rewards Volume over Value. In other words, the second part of this movie is "Reimbursement Reform", in which the government helps shift reimbursement of quality and efficiency over simple volume. For example, in the current volume-based system, a Primary Care Physician (PCP) makes money by seeing as many patients as possible in their office. The result is increased cost for patients and insurers, and a shortage of PCPs to do all this work. In a value-based system, a PCP could oversee a team of nurses who manage a much larger group of patients - taking care of the stable ones via phone and web-based services, and only needing to see the sickest and most complicated patients in the office. The result would solve both the cost and access problems we face!

Fortunately, this issue is not lost completely in this insurance reform bill. Atul Gawande, MD, correctly points out in a December 2009, New Yorker article, that the current bill does provide some ability to "test" new reimbursement ideas. Let's hope that those tests quickly prove some ideas which can then be extrapolated... because otherwise we will look back on a collapsed healthcare system in a few years and point to all these problems we know about, and say we wish we had done reimbursement reform sooner.

Saturday, March 13, 2010

The Dawning of the EMR as a Platform...allowing us to "get the health care that we build"

Joe Flower continues to be one of my favorite healthcare writers. In a recent article in HHN Online, he talks about the heroes in healthcare who are constantly trying to improve the system. I love the quote on which he ends his article:

As Aristotle famously shaped it, "We are what we repeatedly do. Excellence, then, is not an act, but a habit." We will not get the health care that we want. We will not get the health care that we deserve. We will get the health care that we settle for. We will get the health care that we build, where we are, with the tools that we have, with the courage and compassion and collaboration and hard insistence on excellence that lies within us.

At the recent HIMSS conference, I think we began to really see the first signs of an important paradigm shift in the EMR world which will help make this ability to build a better healthcare system more feasible. Specifically, we saw the rise of the "Ecosystem" or "Platform" - terms which will become the buzz word of the coming year as vendors are starting to "open" up their systems (e.g. via APIs, or other technical and business transparency).

Stepping back, the historical scenario for an EMR vendor is to sell you all three tiers (database level, application/functionality level, and user interface level) as a tightly integrated unit. The upside is they should all work well together, the downside is minimal ability to customize one layer without having to get involved with the other layer because they were so tightly linked. For example, if you wanted to display vital signs in a different way in your user interface - you would also have to change the underlying data model and application abilities. We can refer to this as the "Tyranny of the Three-Tier Architecture".

Unfortunately, what we have seen are quite bad user interfaces from the EMR vendors and minimal ability for real life users to improve upon them. The result has been poor adoption of EMR systems, as well as multiple instances of "unintended consequences" from poorly defined user interfaces. Fortunately, the EMR vendors must have realized this was the case (or they are getting spooked by the new crop of HIE vendors and system integrators who are trying to take their data and allow for more customized user interfaces).

So at HIMSS, I found that many EMR vendors are now allowing at least some ability for users or third parties to create new widgets and user interfaces to "put on top of" their EMRs. We are still pretty early in this phase, but eventually- the hope is that this will become analogous to Apple creating the "iPhone Platform": The EMR vendors will ideally compete to create the best platform which will then allow for some true innovation at both the application and presentation layers, or alternatively brand new vendors will come along to create platforms which take what is needed from legacy systems while allowing for others to build on top of them in a unified environment (e.g. GE's new Qualibria). Either way... the ideal result will be an Ecosystem where we can indeed Build the Healthcare System we need and deserve.

Thursday, February 25, 2010

FDA Considers Regulating Safety of Electronic Health Systems - Now that would shake up the industry!

WOW - now this is a true news alert to think about!
FDA Considers Regulating Safety of Electronic Health Systems

Here are some quotes from this article - with my thoughts in parentheses:

But digital medical systems are not risk-free. Over the past two years, the FDA's voluntary notification system logged a total of 260 reports of "malfunctions with the potential for patient harm," including 44 injuries and the six deaths. Among other things the systems have mixed up patients, put test results in the wrong person's file and lost vital medical information.
(Hmmmm... let me add some more: how about crashes, slowness, broken decision support tools, awkward workflows that result in both errors of omission and commission.)

The FDA official outlined three possible approaches for tighter scrutiny. The agency could require makers of the devices to register them with the government and to submit reports on safety issues and correct problems that surface. The FDA could track this information "to help improve the design of future products."
(I wonder if the government would have any better luck than the rest of us in asking our vendors to fix technical and design problems that cause safety issues!)

In a second scenario, the agency could require manufacturers to report safety concerns and set minimum guidelines to assure the quality of products on the market. In a third approach, the systems could be subject to the broader regulatory actions that new medical products must face before they ever reach the market.
(I have a feeling the government has no idea how poorly designed most EMRs are... they would never allow clunky, erratic software to be put into pacemakers, IV pumps, etc...I also wonder if they truly understand the difference between inpatient and outpatient systems.)

The manufacturers of the systems generally have opposed regulation by the FDA, arguing in part that imposing strict controls would slow down the government's campaign to spur widespread adoption of the technology.
(Sure- let's put cars on the road that have hard-to-turn steering wheels, and which only go 10 mph - because we need to stimulate buying of cars!)

Regulation will not necessarily create a "safer" electronic medical record "and might actually limit innovation and responsiveness when it is needed most," Carl Dvorak, executive vice president of Epic Systems Corporation....
(Well, that is true - but I'm still waiting for any significant innovation and responsiveness from the EMR vendors... the systems we use today are honestly just slight variations of the same paper-paradigm based EMR systems originally developed in the 19060's - except those were actually more consistent and reliable to use.)

Yet some inside the industry favor stepped-up scrutiny. One major vendor, Cerner Corporation, which has voluntarily reported safety incidents to the FDA in recent years, signaled its support for a rule that would make those reports mandatory. Cerner has reported potential safety concerns because it is the "right thing to do," a company official said.
(Really, that's great- I've got to find out from Cerner who is collecting those incidents... I wonder if they fully understand the volume they might face if they really wanted to hear it all. Did my sarcasm come through? I can't believe any EMR vendor wants to REALLY hear how screwy their systems can act in ALL its different forms and types of implementations.)

The federal government's Office of the National Coordinator for health information technology also has recognized the need for better surveillance. In January, the office issued a contract to address "undesirable and potentially harmful unintended consequences" of the systems.
(Tricky part here is clarifying the difference between an error, a safety issue, and unintended consequence. There is some overlap but also some parts that are clearly separate issues.)

Though officials in some other countries have tightened oversight of the systems, U.S. manufacturers have managed to stave off formal regulation, telling the FDA in May 2008 that their products should be excluded from review partly as a means to speed up their adoption.

But critics argue that tighter scrutiny is needed to protect the public. "Oversight and quality control may slow things down, but it's absolutely critical," said Hoffman, the law professor. "Patients' lives are at stake."

In all honesty, it's a tough call - one on hand it seems insane that these important systems have no regulation as to how crappy they might be - they directly impact care! On the other hand, over-regulation may increase costs, stifle innovation and create new problems we can't fully predict...and finally, who is the final decision maker on what is truly a safety issue vs. just an unintended consequence?

Addendum (3/13/10)...things could start getting more interesting...
FDA Asks Hospitals to Report Safety Glitches in Digital Health Systems

And another perfect Dilbert reflects the confusion in understanding the difference between a true error and a poorly designed system...