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.
Stories of Interest
* Could Facebook be your Platform for Care Coordination? (e-Care Mgt Blog, May, 2011)
* Social media could 'accelerate clinical discovery' (Article about PatientsLikeMe.com, April, 2011)
* Five social media tips for docs worried about HIPAA (April, 2011): Great advice about how to understand that HIPAA actually promotes email and other electronic forms of communication - and is often misunderstood due to paranoid legal beagles!
* What do Physicians Really Think about Social Media?: A series of blogs by Dr. Ted Eytan based on interviews with doctors from Sermo as well as some Academic sites (Spring, 2011).
* Social media tools may reduce attrition in online health programs... and prove an effective way to boost participation in online health programs, according to researchers at the University of Michigan Medical School (Dec, 2010)
* AMA Guide to Social Media (Nov, 2010): The American Medical Association has adopted a new policy that gives guidance to physicians using social media.
* Tips on mitigating risk of social networking in healthcare organizations (Nov, 2010): like it sounds!
* 6 reasons to manage and archive your social media (May, 2011)
* Facebook friends with your doctor: good medicine or ethically 'icky'? (Aug, 2012) - Advice is to educate in general (eg professional FB or twitter page for education), not create a personal social interaction.
Thursday, April 14, 2011
Saturday, March 05, 2011
HIMSS 2011 Wrap-up: Big and Small
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.
If you want some more info, well known HIT writer Neil Versel did a nice writeup at: http://mobihealthnews.com/10287/agile-health-app-developers-bring-the-heat-in-iron-programmer-challenge/
And finally, my slides for the Iron Programmer session:
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.
If you want some more info, well known HIT writer Neil Versel did a nice writeup at: http://mobihealthnews.com/10287/agile-health-app-developers-bring-the-heat-in-iron-programmer-challenge/
And finally, my slides for the Iron Programmer session:
View more presentations from Lyle Berkowitz, MD.
Friday, February 18, 2011
HIMSS Mania 2011
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.
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.
Thursday, February 10, 2011
EMR's and Typewriters: They both have potential
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).
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).
Monday, January 31, 2011
What Motivates us? Autonomy, Mastery and Purpose.
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!
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!
Saturday, January 22, 2011
DC Hearings for Meaningful Use
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.
I blogged about my experience at the HISTalk Blog, so full details are here:
http://histalk2.com/2011/01/18/the-mu-hearings-drlyle-goes-to-washington-11811/
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.
Relevant Links
- Full details and testimonies from the hearings
- Review of the different types of ONC Certifications
I blogged about my experience at the HISTalk Blog, so full details are here:
http://histalk2.com/2011/01/18/the-mu-hearings-drlyle-goes-to-washington-11811/
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.
Relevant Links
- Full details and testimonies from the hearings
- Review of the different types of ONC Certifications
Sunday, January 02, 2011
Health Innovation in 2011
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:
1. We need to base our reimbursement system on Value (Outcomes/Cost) not Volume. In 2009, Porter described this in more depth in his NEJM article "A Strategy for Health Care Reform — Toward a Value-Based System".
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 of Recovery). 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!!!
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:
1. We need to base our reimbursement system on Value (Outcomes/Cost) not Volume. In 2009, Porter described this in more depth in his NEJM article "A Strategy for Health Care Reform — Toward a Value-Based System".
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 of Recovery). 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!!!
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
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: Ummm...wow, 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: http://www.hhs.gov/open.
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: Ummm...wow, 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: http://www.hhs.gov/open.
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.
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 NewTaste.com. 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 (http://www.theshiphome.org/) 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.
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 NewTaste.com. 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 (http://www.theshiphome.org/) 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.
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?
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?
Resources
• 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
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?
Resources
• 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 CMIO.net.
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:
Simplicity
Everything from lack of visual clutter and concise information display to inclusion of only functionality that is needed to effectively accomplish tasks.
Naturalness
This refers to how automatically “familiar” and easy to use the application feels to the user.
Consistency
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.
Readability
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 (www.TheSHIPHome.org), 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.
* NEW ADDITIONS *
* 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: http://drlyle.blogspot.com/2010/09/mayo-clinic-center-for-innovation-2010.html
* 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: http://healthit.ahrq.gov/workflowfinalreport
* 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
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 CMIO.net.
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:
Simplicity
Everything from lack of visual clutter and concise information display to inclusion of only functionality that is needed to effectively accomplish tasks.
Naturalness
This refers to how automatically “familiar” and easy to use the application feels to the user.
Consistency
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.
Readability
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 (www.TheSHIPHome.org), 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.
* NEW ADDITIONS *
* 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: http://drlyle.blogspot.com/2010/09/mayo-clinic-center-for-innovation-2010.html
* 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: http://healthit.ahrq.gov/workflowfinalreport
* 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
• http://healthcareforamericanow.org/
-- The best site I have found to simply explain, "What does the new health reform law mean for YOU?"
• http://www.healthcare.gov/
-- 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 (www.NMPG.com) 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)
Key Web sites
• http://healthcareforamericanow.org/
-- The best site I have found to simply explain, "What does the new health reform law mean for YOU?"
• http://www.healthcare.gov/
-- 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 (www.NMPG.com) 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.
HealthSystemCIO.com (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.
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.
HealthSystemCIO.com (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.
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