Welcome to 2012!

Wow… I am officially in awe of all bloggers who can post once a day, once a week or even once a month at this point.  I have clearly fallen off the horse - but am saddling up again for what looks to be an amazing 2012!   Yeah, I've been a bit distracted - helped start up a new HIT company (more to come), am working on a book highlighting the intersection of HIT and Innovation, and am juggling all the regular doctor and CMIO type of things.  BUT - no excuses… I've got to find some time to get my thoughts down!

I actually have a couple of blogs half-written in emails to myself, but I'm going to start with something more current… my take on various stories from one of my favorite blogs - HISTalk.  In their recent blog, they mentioned the following three stories (among others), and I thought each had some major importance so I want to highlight them and give my 2 cents:

First, Meaningful Use (MU) Attestation
CMS has provided the database for the statistics on numbers of physicians who have currently attested for MU.  Modern Healthcare did a nice breakdown in their story on it:

·    For Ambulatory:  Epic was the EHR of choice for 6,045 physicians and other eligible professionals, grabbing a 28% market share of the eligible-professionals segment, a slice larger than that of the next four vendors combined.  Those others in the top five, in rank order, are eClinicalWorks, 1,847 (9%); Allscripts, 1,449 (7%); Athenahealth, 1,158 (5%); and Community Computer Service, 999 (5%).  These top five vendors claimed 54% of the market of early adopters and meaningful users.  The top 10 vendors also claimed 71% of the incentive payments thus far.  But it's still a wide-open market.  The database lists 217 EHR vendors as having products that had been used successfully by at least one eligible professional to either achieve meaningful use or receive incentive payments under Medicaid.  Of those 217 developers, 131, or 60%, had 10 or fewer installations.

·    For Acute Care (Hospitals):  Epic also led among hospitals that received federal incentive payments for using a complete EHR, but the privately held company was not nearly so dominant in this indicator of the hospital IT market as it was in the EP segment.  According to federal data, there were 627 hospitals that have been paid using complete EHRs developed by 22 different companies or organizations.  Of them, 165 were Epic customers, 26% of that niche.  Ranked second was Computer Programs and Systems, commonly known as CPSI, used by 140 hospitals (22%), followed by Cerner Corp., 71 (11%); Healthland, 54 (9%); and Meditech, 47 (7%).

Mr.HISTalk said the following:  Here’s a point/counterpoint issue to mull over.  Inga and I disagree on the value of CMS’s attestation statistics.  Inga thinks the percentage of each vendor’s customers that have attested is a good benchmark, so she did lots of spreadsheet work to compare vendors and to assume that varying percentages among them must be reflective of product capabilities and ease of use in meeting Meaningful Use requirements.  I said the information is useless for that purpose since it’s more reflective of unmeasured customer demographics and buying criteria than anything else and that it would be wrong (not to mention statistically indefensible) to use the CMS figures to infer that vendors with a higher percentage of successfully attested users have a better product for earning Meaningful Use money.  Feel free to take sides.  One thing’s for sure: vendors who massage the data into slick marketing collateral won’t be footnoting their handouts with statistical disclaimers.

Here was my response:  I'm siding with Inga on this Point/Counterpoint… although the numbers are not perfect - they should provide value in two ways:

1. Totals. A general idea about the total number of real EMR users.  I’m sick of the vendors each claiming to have 50-100K users.  Sorry - there are only about 600K total active doctors… and only 25% using EMRs – so you are all splitting about 150,000 docs at best right now.  Although this initial data is a good start, I think very soon we will get a much better idea of how many docs are attesting with each vendor (since many are waiting until end of 2011) and then at least the general proportions will be easier to assess… will it be EPIC with 30%, and the next tier of 5-6 vendors at 5-10%, and then 210 more with under 1% each… or will we see a surprise pop up somewhere?!??!

2. Successes.  Fair enough – it is possible some EMR vendors will have a higher percent of attestations because they are better at implementation, etc… but hey - that’s OK, I think that is a key indicator too… and am fine if that “biases” the numbers.  But they are still valuable.

Second, Most Online Diabetes Management Tools are Ineffective

CMIO Magazine did a nice summary of the JAMIA study.  It turns out that over 75% of the time - the tools were NOT clinically useful or usable (or said another way- they were only useful and usable 25% of the time).  But perhaps more importantly was the second finding which is that patients just don't use these tools consistently.  Hey - that should be a surprise!  Yet it may shock or offend some in the "consumer empowerment" community who keep saying patients want more tools to use online.  While I think a subset do want these, it is just not the majority.  Unfortunately, the reality is that any tool or business model that relies on behavior change is a really tough sell.  Patients have shown for a very long time how resistant they are to change, and just having a website or app telling them what to do is not going to make that magically happen.  I do look forward to the next slew of websites claiming to have that "secret sauce" that will make patients change (e.g. games, rewards, social interactions), but think that the vast majority of folks who try to crack that code don't fully understand human behavior, especially as it relates to health.  It is much more complex than buying stuff online, banking and Facebook... but I do think we are getting better - and a well researched article like this will help us continue to move in the right direction.

   

Finally, "Smart Contact Lenses Keep Eye On Your Health"… Sensors are here baby! 

This news story asks "What if the lenses could look inside of you to diagnose, monitor and even treat disease? Sound far-fetched?  Well, it may not be too far away… The new generation of contact lenses is being called “smart lenses”, and they are packed with circuits, sensors and wireless technology – all designed to "keep an eye on your health".   It is indicative of a big and growing trend towards ubiquitous biomedical devices, especially involving sensors, which we will be hearing more and more about in the months and years to come.   Of course, it pairs well with the other big trend around big data - because this many sensors are going to need some major analytics to make them useful. 

Bottom line - there is so much amazing change and innovation going on in healthcare, cannot imagine a better industry to be in for the next few decades!!!

A Busy HIT & Innovation Summer - Book, Upgrades, Usability and ExpectED Highlight

Well... it's been a busy summer, and I have a lot of blogs in me, but have been diverted by two major issues going on which will eventually lead to some good blogs in the future:

• The Book: I'm writing/editing a book on the intersection of HIT and Innovation.  It's been a great experience as we are putting together a series of essays from a variety of innovative physicians and healthcare experts on how they have used HIT in an innovative fashion.  These will range from using their EMRs in new and different ways, to a wide range of telehealth activities, to creating an online survey system which allows patients to become increasingly involved with an organizations strategic direction. 
• The Upgrade: Our Cerner EMR was finally due for an upgrade... and after months of many people working together to make it happen, we had a very successful go live last week.  There are still a lot of busy days and late nights as we are in the fine-tuning stage, but it sets us up for MU and more abilities to start managing quality and providing even higher quality care... so yeah, I'm sort of excited about it!  Of course, now that I've delved into the world of EMR Usability, my eyes have been opened to usability heuristics issues like Consistency, Recognition rather than Recall, and the importance of expert Accelerators to promote more efficient use.  And so whenever I look at the new screens, I start thinking "how could this be better" and in talking to other "usability junkies" - it turns out this is a curse we now carry as we look at anything on the web or in the "real world" - why can't things be more usable!?

I've also gotten more involved with the government in the past year as the push to promote EMRs spreads, and they are looking for input from folks who have been involved in getting EMR systems up and running.  I had a particularly good time attending and presenting at the NIST EMR Usability Workshop in June.  I plan to dedicate a whole blog to my thoughts on this - but in the meantime you can read some of my ideas at the Healthfinch blog. 

Finally, I wanted to make sure everyone knows about the AHRQ Healthcare Care Innovations Exchange. 

The U.S. Agency for Healthcare Research and Quality (AHRQ) created the Health Care Innovations Exchange to speed the implementation of new and better ways of delivering health care.  The Innovations Exchange supports the Agency's mission to improve the quality of health care and reduce disparities.  The AHRQ Health Care Innovations Exchange offers busy health professionals and researchers a variety of opportunities to share, learn about, and ultimately adopt evidence-based innovations and tools suitable for a range of health care settings and populations.  More info at: http://www.innovations.ahrq.gov/about.aspx

In July of 2011, the AHRQ Innovation Exchange published a profile of ExpectED, one of the first projects from the innovation program I run - the Szollosi Healthcare Innovation Program (SHIP).  The profile was entitled "Referring Physicians Send Electronic Handoff Note with Pertinent Patient Information to Emergency Department, Improving Physician Efficiency and Quality of Care" and the summary was:

Community-based physicians referring patients to Northwestern Memorial Hospital for emergency care send an electronic handoff note to emergency department personnel to notify them that a patient will be arriving and to provide clinical details pertinent to his or her condition.  The note, which includes the patient's name, date of birth, the referring physician's name, a clinical summary, and other information, is entered into the system's electronic medical record, where emergency department clinicians can easily access and review it at the point of care.  Anecdotal feedback from physicians suggests that the program has improved physician efficiency and satisfaction, care coordination, and the quality and timeliness of care.

Direct link to the write-up is at: http://www.innovations.ahrq.gov/content.aspx?id=3107

They did a great job in this write-up, I love how they break each innovation down into: 

• What They Did 
• Did It Work?  (we can learn from failures too!)
• How They Did It
• Adoption Considerations

Take a minute to peruse the Innovations Exchange - it will expand your mind and make you feel good about the potential for innovations in healthcare care!  

The Importance of Looking into the Future: Horizon Scanning at AHRQ

I was in DC last week and spent some time with AHRQ's Healthcare Horizon Scanning System folks.  Their job is to identify, monitor, and track new and emerging health care technologies and interventions that could signal important changes to patient care, health outcomes, and the United States health care system - ranging from drugs and medical devices to new services and innovative care processes. The HHSS is a resource for the Effective Health Care (EHC) Program as it makes decisions about allocating resources for patient-centered outcomes research. It will also be a tool for the public to identify and find information on new health care technologies and interventions. Any investigator or funder of research will be able to use the HHSS to select potential topics for research.



While this is a relatively new group at AHRQ, it turns out this type of formal "Horizon Scanning" process is common in Europe, although more centered on meds, devices and procedures.  For example, there is the UK's National Horizon Scanning Centre as well as the larger International Information Network on New and Emerging Health Technologies (EuroScan), a collaborative network of member agencies for the exchange of information on important emerging new drugs, devices, procedures, programmes, and settings in health care.


One thing that struck me was the clear distinction between Products and Technologies (e.g. pharmaceuticals, medical devices, procedures) vs. Information Technology (e.g. EMRs and "health apps") vs. Care Innovations. For products, it appears that the methodology is relatively consistent (e.g. you can easily find early items via phase 2 trials, prioritize based on significance and effectiveness, and do comparative evaluations against similar products -- and then market forces help with diffusion since some companies can make so much money on successes).



But the same process cannot be applied to Care Innovations or HIT. So what is the best way to "find, filter, evaluate and diffuse" these items?  Here are some ideas:



• Scanning: The AHRQ Innovations Exchange is an amazing collection of healthcare service and IT innovations and is a great starting point for those who are looking for new ideas to stimulate them!  Other obvious resources are a wide a variety of conferences and newsletters.  Some conferences I like for cutting edge ideas are Health 2.0, HIMSS (yes, it's big and corporate - but there are always things bubbling there) and World Congress Innovation Summit.  I also have stumbled onto a few non-healthcare conferences dealing with User Interface/Human Centered design which are amazing.  For blogs, some favorites are  HISTalk, Ted Eytan, Jay Parkinson, and Halamka's.  For newsletters, I follow CHCF, ModernHealthcare, HIT Strategist, iHealthbeat, H&HN, HDM, CMIO and FierceEMR. 



• Filtering/Evaluation: This will involve watching how pilot project fare, creating models to help extrapolate to different environments (e.g. based on size, payment methods…), and ideally help support funding to try additional pilots in different environments to understand if reproducible and scalable.



• Diffusing: Major education, funding for early beacon programs, possible policy change around reimbursement and other (e.g. allowing more tele-care).   A recent CHCF paper on Spreading Innovations is particularly relevant.



So thank you AHRQ for being on the lookout for Care and HIT Innovations and trying to figure out how to spread those that are doing well!

  

Taming HIPAA Insanity

The HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) has been around since 1996 - and it's amazing how many healthcare people still over-interpret the privacy and security regulations (and mis-spell it as HIPPA!).  Here is the actual law and check out HIPAA.org, a nice website which brings together many sources of info.  

With respect to HIT, it focuses on Privacy and Security - and basically puts common sense into law:
* Privacy: This addresses policies - and says you can't just give personal health information (PHI) to anybody you want, such as Pharma or the local drugstore (before HIPAA, docs could actually do that legally).   But importantly - it does exclude "TPO" (Treatment, Payment and Operations).   In other words, there are no restrictions to healthcare organizations sharing PHI with one another as long as it involves treating a patient (or dealing with payment or other operations)! 
* Security: This addresses technology - and says you should have good technology in place to make sure your IT systems are not open to the free world.   Simple enough.

So it is fascinating how many healthcare organization still use HIPAA as an excuse for not sharing information.  I can't tell you how many fights I've been in with medical record departments who say that they can't fax me a report because they don't have a "HIPAA waiver" signed by the patient - even if I ordered the test!!!   Agghhh!  Usually the problem is that the bigger organization scared lower level staff with too many HIPAA emails... but the result is the same - making it harder to get the data which is needed.   And while I think this scenario has improved a bit, it is still happening every day.

So I saw this Healthcare IT News article last month entitled "Five social media tips for docs worried about HIPAA" - and thought it was good to share, as it is nicely worded, and I think extends beyond social media in its relevance (my comments will be italicized):


SEATTLE – While many doctors shy away from use of the Internet because of concern over HIPAA penalties, one company is advising the physician community to not become victim to HIPAA hand-wringing and fall out of sync with their colleagues who have learned how to responsibly utilize today's most valuable online visibility tools.


Avvo, the world's largest online directory for doctors and lawyers that provides free rankings for 90 percent of the working physicians in the U.S., offers five tips for physicians who are hesitant, because of perceived HIPAA restrictions, to embrace online and social media marketing.

The company, which was founded to service the legal sector, is no stranger to the impact of regulatory issues on the healthcare industry. Avvo is now striving to help doctors, who may be missing valuable networking opportunities because of unnecessary HIPAA fears, to adopt widely accepted, HIPAA-compliant practices for tapping the Web's significant marketing and reputation building channels.

"HIPAA is a well-intentioned, but poorly implemented law that is unnecessarily scaring doctors and keeping them in an unrealistic 'technology lockdown'," explained Avvo founder and CEO Mark Britton. "Avvo sits at the vortex between law and healthcare – and we believe passionately that physicians are needlessly hand-tied by HIPAA legalities. We want every working doctor out there to know that there are many appropriate and safe channels through which they can build their profile and reputation on the Web."

Avvo, which offers free phone consultations to physicians who have questions about how to safely market their reputation on the Web, equips doctors with the following five tips for managing their career online:

1. DO: Use email, SMS and social media messaging. These are acceptable tools for making outreach to patients, the media, medical industry influencers, and other doctors. The HIPAA regulations actually encourage the use of alternative communication methods, particularly as patients express their preference for a particular mode of communication.
(HIPAA does not ban email, in fact it encourages it... but it does say that patients have the right to tell their doctors if they don't want to be contacted by email, or phone, etc...)

2. DO: Feel free to share information with other providers. Many health professionals set up unnecessary procedures that make it harder to share patient information with other providers. If you need input from another provider, you don't have to worry about HIPAA compliance. In fact, HIPAA guidelines specifically permit the sharing of information with other providers (freely and without patient consent) for the purposes of patient treatment.
(Correct - let's use common sense for the sake of the patient!)

3. DO: Feel free to answer general patient questions - there is no HIPAA bar to providing this information. Whether it's participating in Avvo's free online Q&A or other forums on- or off-line, answering general health-related queries in a public forum will not present a HIPAA-related problem for doctors. These tools offer a powerful means for patients to take the first steps to getting the care they need.

4. DO: Keep family members in the loop. It is unwarranted to let HIPAA be an excuse for not keeping family members engaged and involved, where relevant, to provide support that is in the best interest of the patient. There is wide latitude under HIPAA to inform a patient's family members about his or her status – and this extends to liaising with family members electronically as well.
(I've been guilty of this as well... and now go back to good old common sense if I am unsure.  I will also make sure to check with certain patients as to their wishes on this - particularly new adults or the elderly.)

5. DO: Exercise common sense and reasonable practices in all instances to ensure the privacy and security of your communications with patients. This general rule of thumb applies whether the communication is by email, SMS, fax or instant message.

While Britton agrees that HIPAA has created a general "culture of paranoia" among medical practitioners and has in many ways served to logjam the essential progress of technology's role within the healthcare industry, he adds that it is just "unreasonable" for doctors not to embrace the social media revolution because of over-exaggerated fears of privacy and security violations. That level of restrictive behavior, he cautions, is "wholly impractical in today's business climate" and he advises doctors to go ahead and embrace digital tools while still preserving the health and integrity of the patient-physician relationship.

Social Media and Healthcare

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.

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:

View more presentations from Lyle Berkowitz, MD.

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.

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).

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!

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

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!!!

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

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.

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.

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.