tag:blogger.com,1999:blog-43832096581833397572024-03-12T23:56:53.828-07:00KHIT Health Information Technology blogTimely news and topical multimedia discussion focused on Health Information Technology and its role in improving health care. This blog will be the successor to The REC Blog.BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.comBlogger161125tag:blogger.com,1999:blog-4383209658183339757.post-88990183700879516272014-06-18T11:44:00.003-07:002014-06-18T11:44:27.527-07:00This is the end of KHIT Blog mirroringThere's really no point in mirroring the KHIT Blog (formerly "The REC Blog") updates further, so, henceforth, simply go to (and bookmark)<br />
<br />
<div style="text-align: center;">
<span style="font-size: x-large;"><span style="font-family: Georgia,"Times New Roman",serif;"><b><a href="http://blog.khit.org/" target="_blank">Blog.KHIT.org</a> </b></span></span></div>
<br />
for the latest posts. Thanks for following this work.<br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><i><b>- BobbyG</b></i></span></span><br />
<br />BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com1tag:blogger.com,1999:blog-4383209658183339757.post-55363342385337301522014-06-14T17:22:00.001-07:002014-06-18T12:05:54.719-07:00On healthcare system improvement: are the Feds proposing the building of a two-legged stool?<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhiTEsaByp3FRLiDQHCEHgH1kaAC-vdtJhgY28d4hkvnmJyeuHoIt8p62GPMb9pgKA7ZlzKlhUTidWZw9TeNGh5qMiE8h9UZ1c114PO8fwy2aYCPPIHZMFkbWc0ph3Ubq5T1luaV4OflLgP/s1600/2_legged_stool.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhiTEsaByp3FRLiDQHCEHgH1kaAC-vdtJhgY28d4hkvnmJyeuHoIt8p62GPMb9pgKA7ZlzKlhUTidWZw9TeNGh5qMiE8h9UZ1c114PO8fwy2aYCPPIHZMFkbWc0ph3Ubq5T1luaV4OflLgP/s1600/2_legged_stool.jpg" /></a></div>
<br />
Recall <a href="http://regionalextensioncenter.blogspot.com/2014/06/the-onc-ten-year-plan-comrades.html" target="_blank">my June 9th post</a> regarding ONC's "ten-year plan" for HIT Interop.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhdCuOVX9dSIWoPj_hHDvG1OMkd9__S36-GwVEq4kj263z1MRFl5rMG1y81RIbvtfWkPCMiJxfXmnR1kMLeAtfmsatkXWenNYGVoHzo1avz382GLtLg0DFV5iXO2YBQBq8LxDnJ7ayUwyR1/s1600/ONC10yrInteropBanner.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhdCuOVX9dSIWoPj_hHDvG1OMkd9__S36-GwVEq4kj263z1MRFl5rMG1y81RIbvtfWkPCMiJxfXmnR1kMLeAtfmsatkXWenNYGVoHzo1avz382GLtLg0DFV5iXO2YBQBq8LxDnJ7ayUwyR1/s1600/ONC10yrInteropBanner.png" /></a></div>
<br />
Well, we should also consider <a href="http://www.whitehouse.gov/sites/default/files/microsites/ostp/PCAST/pcast_systems_engineering_in_healthcare_-_may_2014.pdf" target="_blank">the latest PCAST Report</a> (pdf).<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj4TTNM1qt6TiYJAjuTG9DipffAsjhzLaf7ysPoy4h9ES3Lbf0rMvE8Y8eNRnbZuzONZKXiS2uHBivl5OLy00yBRcqH-NP2v0krWfFLN9S7yAz7iRd9gnKfvY36Egyd1v1f7Eb1DxLIaUr-/s1600/PCAST2014.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj4TTNM1qt6TiYJAjuTG9DipffAsjhzLaf7ysPoy4h9ES3Lbf0rMvE8Y8eNRnbZuzONZKXiS2uHBivl5OLy00yBRcqH-NP2v0krWfFLN9S7yAz7iRd9gnKfvY36Egyd1v1f7Eb1DxLIaUr-/s1600/PCAST2014.png" /></a></div>
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;"><span style="font-size: large;"><b>Executive Summary </b></span></span><br />In recent years there has been success in expanding access to the health-care system, with millions gaining coverage in the past year due to the Affordable Care Act. With greater access, emphasis now turns to guaranteeing that care is both affordable and high-quality. Rising health-care costs are an important determinant of the Nation’s fiscal future, and they also affect the budgets for States, businesses, and families across the country. Health-care costs now approach a fifth of the economy, and careful reviews suggest that a significant portion of those costs does not lead to better health or better care. <br /><br />Other industries have used a range of systems-engineering approaches to reduce waste and increase reliability, and health care could benefit from adopting some of these approaches. As in those other industries, systems engineering has often produced dramatically positive results in the small number of health-care organizations that have implemented such concepts. These efforts have transformed health care at a small scale, such as improving the efficiency of a hospital pharmacy, and at much larger scales, such as coordinating operations across an entire hospital system or across a community. Systems tools and methods, moreover, can be used to ensure that care is reliably safe, to eliminate inefficient processes that do not improve care quality or people’s health, and to ensure that health care is centered on patients and their families. Notwithstanding the instances in which these methods and techniques have been applied successfully, they remain underutilized throughout the broader system. <br /><br />The primary barrier to greater use of systems methods and tools is the predominant fee-for-service payment system, which is a major disincentive to more efficient care. That system rewards procedures, not personalized care. To support needed change, the Nation needs to move more quickly to payment models that pay for value rather than volume. These new payment models depend on metrics to identify high-value care, which means that strong quality measures are needed, especially about health outcomes. With payment incentives aligned and quality information available, health care can take advantage of an array of approaches using systems engineering to redesign processes of care around the patient and bring community resources, as well as medical resources, together in support of that goal. <br /><br />Additional barriers limit the spread and dissemination of systems methods and tools, such as insufficient data infrastructure and limited technical capabilities. These barriers are especially acute for practices with only one or a few physicians (small practices) or for community-wide efforts. To address these barriers, PCAST proposes the following overarching approaches where the Administration could make a difference: </span></span><br />
<ol>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Accelerate alignment of payment systems with desired outcomes, </span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Increase access to relevant health data and analytics, </span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Provide technical assistance in systems-engineering approaches, </span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Involve communities in improving health-care delivery, </span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Share lessons learned from successful improvement efforts, and </span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Train health professionals in new skills and approaches. </span></span></li>
</ol>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Through implementation of these strategies, systems tools and methods can play a major role in improving the value of the health-care system and improving the health of all Americans. <br /><br />...In addition to ensuring that care remains affordable, there is a need to center health care on patients, families, and population health. That objective requires action on multiple fronts, as stated well by the Institute of Medicine: care should be safe, timely, effective, efficient, feasible and patient centered. There are opportunities to improve in each of these areas. For example, recent reviews suggest that over one-quarter of Medicare patients experienced some type of harm during a hospital stay, and other research finds that between one-fifth to one-third of all hospitalized patients experienced a medical error. Almost half of these errors were likely preventable. Other studies suggest that patients are not routinely involved in decisions about their treatments or managing their conditions. And anecdotal evidence and studies highlight the impact inefficiencies have on patients—long waits for appointments, information not transmitted between clinicians, and patients with complex diseases feeling lost trying to get the care they need. <br /><br />These shortfalls are occurring even as most clinicians work tirelessly for their patients. Their work is frustrated by processes that contain unnecessary burdens and inefficiencies, with some studies suggesting that almost one-third of front-line health-care workers’ time is wasted. The current stresses on clinicians mean that improvement initiatives cannot simply add to a clinician’s workload or rely on the clinicians finding time to participate in additional initiatives. Rather, successful and sustainable improvement must involve reconfiguring the workflow and overall environment in which these professionals practice, which can help to reduce the burden of work while improving the performance of the system. <br /><br />Making such changes in an integrated manner is the essence of systems engineering. Recent policies, deriving from the Affordable Care Act and the American Recovery and Reinvestment Act, have laid the groundwork for wider use of systems engineering through new care models that promote integrated care and rapid adoption of electronic health records. The National Quality Strategy identifies areas for improvement in health-care quality and outcomes that systems-engineering initiatives need to address. The current policy environment and advances in technical capabilities combine to make this the right time to focus on expanding systems methods and tools throughout health care. </span></span></blockquote>
What's not to love with respect to <i>any</i> of this? All good and necessary stuff. <i><b>"Systems Engineering"</b></i>? You can just <i>hear</i> the clucking sounds of approval among my gearhead colleagues at <a href="http://www.asq.org/" target="_blank"><b>ASQ</b></a>.<br />
<br />
Continuing... <br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;"><span style="color: #073763;"><span style="font-size: large;"><b>Factors Limiting Dissemination and Spread of Systems-Engineering Principles </b></span></span><br />Barriers to greater use of systems methods and tools include the lack of quality and performance measures and the misaligned incentive structure of the predominant fee-for-service payment system, which encourages a fragmented delivery system. To support needed change, the Nation needs to move more quickly to payment models that pay for value. These approaches depend on metrics to identify high-value care, which means that strong quality measures are needed, especially about health outcomes. With payment incentives aligned and quality information available, health care can take advantage of an array of approaches using systems engineering to redesign the process of care around the patient and bring community resources, as well as medical resources, together in support of that goal. <br /><br /><span style="color: #073763;"><i><b>Another challenge is an organization’s leadership and culture, which determine people’s commitment to improvement efforts.</b></i></span> <span style="color: black;">[emphasis mine -BG]</span> For example, one systems-engineering initiative achieved some success by using checklists to reduce infections among severely ill patients, but significant improvement did not occur until there was a culture where everyone felt they were able to speak up about potential safety concerns.19 Other barriers include technical challenges, workforce capabilities, and limited knowledge about what works.</span></span></blockquote>
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;">The siloed nature of the health system, in which clinical care is separated in an uncoordinated fashion across multiple specialties and settings, presents another challenge that can limit the use of systems approaches. Clinicians often focus only on the activities in their particular silo, as opposed to considering the broader concerns of the patient. Moving away from the current siloed state requires systematic knowledge of the many processes and providers involved in a given patient’s care, as well as a cultural shift toward team-based care where all work together to address a patient’s needs... </span></span></blockquote>
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;"><span style="color: #073763;"><span style="font-size: large;"><b>Goal 6: Train Health Professionals in New Skills and Approaches</b></span></span><br />Given changes in the way health care is delivered and an improved understanding of the many factors affecting a patient’s health, health professionals of the future will need new skills to succeed. They will need effective communication and collaboration skills to work in teams, a commitment to lifelong learning to manage the flow of new evidence, and an appreciation and understanding of routine improvement methods. Expertise in systems engineering is especially critical as such tools can rarely be applied in a cookbook fashion, but rather need to be tailored to local circumstances to have the greatest chance of success.</span></span> </blockquote>
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;">Because systems science and systems engineering are central to improving health outcomes and health care’s performance, system sciences and systems engineering need to be much more firmly and formally embedded in the training of all health-care professionals. It is crucial that both the knowledge of systems science and the skills of implementing the principles in health care are emphasized. To this end, education must involve opportunities for interprofessional problem-solving and for building capacity for collaboration that facilitates practice change.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;"><br />At present, clinical education and training falls short of this vision. Most clinicians were not trained in using systems-engineering approaches, and many clinicians may not even recognize that systems methods and tools could be helpful for improving care. Yet there are reasons for optimism. Several universities are leading the way by incorporating systems engineering directly into the curriculum for health professionals of all kinds (see Box 9 for an example of integrating systems engineering in nursing education). In addition to training clinicians about systems engineering tools, there is an opportunity to teach engineers about applying their tools in a health care environment. Some institutions have started internship opportunities for undergraduate and graduate students to work in hospitals and health systems, and others have begun joint classes where engineers and clinicians learn together about applying engineering concepts to care. More broadly, organizations such as the Accreditation Council on Graduate Medical Education (ACGME) have already taken steps under their New Accreditation System and the Clinical Learning Environment Review to spotlight the need for trainees to develop competence in systems-based patient safety and quality improvement related tools. The Association of American Medical Colleges (AAMC) is addressing the need to develop skills related to systems engineering in medical schools; the American Association of Colleges of Nursing (AACN) includes organizational and systems leadership as an essential element of nursing education, particularly at the graduate levels; the American Medical Association (AMA) has launched an Accelerating Change in Medical Education Initiative to expand training in systems based practice and practice based improvement; and multiple clinical certifying boards have included practice-improvement modules in their maintenance-of-certification process. These are all positive developments and lay the groundwork for further improvement...</span></span></blockquote>
<span style="font-family: inherit;">Again, all good and necessary stuff. Systems Engineering? <i>Check</i>. "Interoperable" Health IT? <i>Check</i>. OK, what might be missing here?</span><br />
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Hint (from above):</span><br />
<blockquote class="tr_bq">
<span style="font-family: inherit;"></span><span style="color: #990000;"><span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;"><i><b>"Another challenge is an organization’s leadership and culture, which determine people’s commitment to improvement efforts."</b></i></span></span></span></blockquote>
What is "culture" in the organizational context? How much does it matter?<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEji6CPZwShoXQL6Qkk_pKAVfRMRc_cZlwDLfLhYclunMsoCk2293PzLTkAKyxCp9SPEZA8_azzbZmR_srRU_oFM2dBf-ObcmEJTP_idMhSGP9EgQ5SP7vl8IDK8MO9laohh-08TzMbjbCVM/s1600/bacteria-in-a-petri-dish-compressed.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEji6CPZwShoXQL6Qkk_pKAVfRMRc_cZlwDLfLhYclunMsoCk2293PzLTkAKyxCp9SPEZA8_azzbZmR_srRU_oFM2dBf-ObcmEJTP_idMhSGP9EgQ5SP7vl8IDK8MO9laohh-08TzMbjbCVM/s1600/bacteria-in-a-petri-dish-compressed.jpg" height="240" width="320" /></a></div>
<br />
<b><i>"The way we do things around here"</i></b>? That's a popular, succinct summary, one I first heard proffered by Dr. Brent James <a href="http://www.bgladd.com/IHC_CQI_certificate.jpg" target="_blank">20 years ago</a> during our HealthInsight IHC healthcare QI training in Salt Lake City.<br />
<br />
Dr. James also noted that "healthcare is both high-tech <u>and</u> high-<i>touch</i>," going on to state that patients are much less likely to litigate in the wake of an adverse outcome stemming from medical error if they feel they've been accorded the caring, "high-touch" component of treatment.<br />
<br />
To the extent we fail to successfully address the myriad issues of "culture" dysfunctionality all too prevalent in healthcare, we will be stuck with a wobbly two-legged stool, irrespective of its technological, scientific, and "systems re-engineering" brilliance. See, e.g., some salient elements proffered my prior post "<i><a href="http://regionalextensioncenter.blogspot.com/2014/05/dx-machina.html#SoftSkills" target="_blank"><b>dx Machina</b></a>."</i><br />
<br />
Healthcare is necessarily a high-stress, endlessly high-cognitive-burden enterprise. There's no getting away from that fact. Moreover, it is likely to become ever more stressful, given the expected new demands on the system as money gets tighter, clinical science advances, populations age, and the PPACA brings new patients into the fold, and in light of the orders-of-magnitude increases in data availability wrought by Health IT (<i>someone</i> has to find time to turn data into clinically beneficial insights).<br />
<br />
Healthcare -- at least on the clinical and administrative sides -- is also a milieu wherein there are relatively few entry level positions. "Human resources" (I <i>hate</i> that phrase), consequently, are <i>literally</i> precious. Misuse and turnover of talent comprise a significant, frequently crippling waste.<br />
<br />
Recall Dr. Toussaint's "eight wastes" within the Lean model.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjdDvvzh9bMHyuLNr92baYE5p-XooYG2VJq3mOnC7-NP-mnwzpVwVxE1S_YSwsLgGC8MWYBEhFec87ruBJHXabvM3KjpNWnbbUA8NEcafO6vVTDILKOVQn0C-3m4NBLM2tDFBZiWUBGkccV/s1600/8wastes.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjdDvvzh9bMHyuLNr92baYE5p-XooYG2VJq3mOnC7-NP-mnwzpVwVxE1S_YSwsLgGC8MWYBEhFec87ruBJHXabvM3KjpNWnbbUA8NEcafO6vVTDILKOVQn0C-3m4NBLM2tDFBZiWUBGkccV/s1600/8wastes.jpg" height="393" width="400" /></a></div>
<br />
He added "unused talent" to Lean's traditional "seven wastes."<br />
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0c343d;"><span style="font-size: large;"><b>The 8 Wastes of Lean Healthcare </b></span></span></span></span><br />
<ol>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>Defect</b>: making errors, correcting errors, inspecting work already done for error</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>Waiting</b>: for test results to be delivered, for a bed, for an appointment, for release paperwork </span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>Motion</b>: searching for supplies, fetching drugs from another room, looking for proper forms</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>Transportation</b>: taking patients through miles of corridors, from one test to the next unnecessarily, transferring patients to new rooms or units, carrying trays of tools between rooms</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>Overproduction</b>: excessive diagnostic testing, unnecessary treatment</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>Over processing</b>: a patient being asked the same question three times, unnecessary forms; nurses writing everything in a chart instead of noting exceptions</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>Inventory</b> (too much or too little): overstocked drugs expiring on the shelf, under stocked surgical supplies delaying procedures</span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #134f5c;"><b>Talent</b>: failing to listen to employee ideas for improvement, failure to train emergency technicians and doctors in new diagnostic techniques</span></span></li>
</ol>
<span style="font-family: inherit;">Toussaint, John (2012-05-28). <a href="http://www.amazon.com/Potent-Medicine-Collaborative-Cure-Healthcare-ebook/dp/B00873GUMY/ref=sr_1_1?ie=UTF8&qid=1402791648&sr=8-1&keywords=Potent+Medicine%3A+The+Collaborative+Cure+for+Healthcare" target="_blank"><u>Potent Medicine: The Collaborative Cure for Healthcare</u></a> (Kindle Locations 909-918). ThedaCare Center for Healthcare Value. Kindle Edition. </span></blockquote>
My only lament here is that #8 does not get sufficient attention with respect to the broad, deep, and critical nuance it implies in terms of what I call the relative "psychosocial health" of healthcare organizations. You cannot effect and sustain high-performance teamwork in the healthcare delivery space where the culture is burdened by dysfunction ranging from the "bully culture" on down to the "merely" autocratic and/or "FUD" environment (<u><b>F</b></u>ear, <u><b>U</b></u>ncertainty, and <u><b>D</b></u>oubt").<br />
<br />
<i>apropos -</i><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #351c75;"><span style="color: #20124d;"><span style="font-size: x-large;"><b>The Bullying Culture of Medical School</b></span><br />By PAULINE W. CHEN, M.D.<br />NY Times, August 9, 2012 12:00 pm</span> </span></span></blockquote>
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #351c75;">Powerfully built and with the face of a boxer, he cast a bone-chilling shadow<br />wherever he went in the hospital.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #351c75;"><br />At least that is what my medical school classmates and I thought whenever<br />we passed by a certain resident, or doctor-in-training, just a few years older than<br />we were.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #351c75;"><br /></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #351c75;">With the wisdom of hindsight, I now see that the young man was a brilliant<br />and promising young doctor who took his patients’ conditions to heart but who<br />also possessed a temper so explosive that medical students dreaded working with<br />him. He had called various classmates “stupid” and “useless” and could erupt<br />with little warning in the middle of hospital halls. Like frightened little mice, we<br />endured the treatment as an inevitable part of medical training, fearful that<br />doing otherwise could result in a career-destroying evaluation or grade.<br />But one day, one of our classmates, having already been on the receiving end<br />of several of this doctor’s tirades, shouted back. She questioned one of his<br />conclusions in front of the rest of the medical team, insisted on getting an<br />explanation, then screamed back when he started yelling at her.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #351c75;"><br /></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #351c75;">The entire episode unnerved us all; and over the next few weeks, we<br />marveled at her courage and fretted over her potentially ruined career prospects.<br />But there was one aspect of the event that disturbed us even more. One classmate who had witnessed the “screaming match” described how our fellow<br />medical student had raised her voice and positioned her body as she threatened<br />the doctor. “It was weird,” he recounted. “It was like watching her turn into him.”<br /> </span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #351c75;">For 30 years, medical educators have known that becoming a doctor<br />requires more than an endless array of standardized exams, long hours on the<br />wards and years spent in training. For many medical students, verbal and<br />physical harassment and intimidation are part of the exhausting process, too.<br /> </span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #351c75;">It was a pediatrician, a pioneer in work with abused children, who first<br />noted the problem. And early studies found that abuse of medical students was<br />most pronounced in the third year of medical school, when students began<br />working one on one or in small teams with senior physicians and residents in the<br />hospital. The first surveys found that as many as 85 percent of students felt they<br />had been abused during their third year. They described mistreatment that<br />ranged from being yelled at and told they were “worthless” or “the stupidest<br />medical student,” to being threatened with bad grades or a ruined career and<br />even getting hit, pushed or made the target of a thrown medical tool...</span></span></blockquote>
While this example is by no means exemplary of <i>all</i> of
healthcare, nonetheless the prevalence of psychosocially toxic
healthcare workplaces is widespread enough to deserve much more of our
attention (dictatorialism and <i>"shame and blame"</i> still rule in far
too many circumstances). At its worst, it poses patient safety issues.
Unduly stressed workers make more mistakes. At its most banal, it
inexorably wastes talent -- Lean Waste #8. Workers will not be inclined
to speak candidly and offer ideas for improvement in an environment
where one speaks truth to power at one's peril, nor will they be
motivated to become fully engaged members of the "high-performance
team-based care" that simply <i>must</i> become the norm in the new healthcare space.<br />
<br />
In
the face of a dysfunctional healthcare work culture, the best talent
will take their skills elsewhere at the first opportunity. A
psychosocially healthy workplace, then, is a significant profitability
and sustainability differentiator.<br />
<br />
Let me repeat that.<br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;"><span style="font-size: large;"><i><b>A psychosocially healthy workplace is a significant profitability and sustainability differentiator. </b></i></span></span></span></blockquote>
The stool needs three legs. Perhaps the best that government can do
is provide the technical assistance recommendations and resources and
policy guidance legs, but the stool needs three legs. Period.<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>LEADERSHIP, "JUST CULTURE," AND ENGAGEMENT</b></span><br />
<br />
From my never-ending, endlessly growing reading list of late.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSJrF8nfcwG9v3tyONl5LmhFZuS6sJnukTuPVu2w9xsveJtwVNzLKVjrsTUE9F6BnQfv3Yo8HF51HsznYmClBJBKja1eoEBmJvWGHz0caNMjoxyGQZvNEFGp5jld9vQJ9fWAz9MHjqf8Wz/s1600/CultureLeadership.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSJrF8nfcwG9v3tyONl5LmhFZuS6sJnukTuPVu2w9xsveJtwVNzLKVjrsTUE9F6BnQfv3Yo8HF51HsznYmClBJBKja1eoEBmJvWGHz0caNMjoxyGQZvNEFGp5jld9vQJ9fWAz9MHjqf8Wz/s1600/CultureLeadership.png" height="206" width="400" /></a></div>
<br />
Maccoby's books caught my eye while I was attending <a href="http://regionalextensioncenter.blogspot.com/2013/12/more-ihi25forum.html" target="_blank">the IHI 25 Forum back in December</a>.
I would make it and the other two depicted above required reading for
every healthcare executive, manager, and physician. David Marx is the
founder of the "Just Culture" methodology. It is <i>not</i> some
touchy-feely Kumbaya thing. Marx is both an engineer and a lawyer,
nationally respected in both aviation safety and patient safety. Bowles
and Cooper are well-known authorities on organizational engagement.<br />
<br />
<i>to wit,</i> from "<u><b>The High Engagement Work Culture</b></u>"<br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;">When we look at the cultures within our organizations, we cannot help but wonder how they affect day-to-day work life for hundreds of millions of people who work in them. To give just one example, if the “individual is hero,” how does that affect people who might be very good at their jobs but very poor at being “heroes”? <br /><br />To examine these issues we have to look at what culture is within an organization, how it comes about and how it ultimately will determine whether or not our workers engage. This is a topic that is enjoying an explosion of attention around the world, from government reports on the subject, to fast-growing online communities, and for very good reason: <br /><br />Work environments can be much improved, workers’ lives can be healthier and happier, our productivity can be raised and our standard of living protected … at the very least … if we become far more conscious at managing the culture, or “the way we do things” at work. Specifically, if we make that culture much more “engagement-friendly.”<br /><br /><span style="font-size: large;"><span style="color: #073763;"><b>Industry sector and culture </b></span></span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;">An organization culture that might be successful in one industry could be a disaster in another. We would expect a hard-charging and risk-taking culture to be prevalent in the financial services industry (but with some changes to which we have already alluded) but such a culture would be bad news for the operators of nuclear power plants or hospitals. In the hospital, strict adherence to rules and procedures (such as infection control, triage, etc.) are key; not that the culture of medicine is one of no risk, but it is a carefully controlled risk. So we see the need to match the culture to the business one is in, leaving room for the unique features that leadership always brings to the table. This is why Dell is not Apple and Virgin Atlantic is not British Airways. </span></span></blockquote>
<blockquote class="tr_bq">
<span style="font-size: large;"><span style="color: #073763;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>Leadership</b></span></span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">An organization’s culture rests on the shoulders of its top leaders, whether or not they created it in the first place. <br /><br />If an organization wants to change its culture, it usually must change its leader( s). Time and again, we have seen new leaders come into organizations and completely turn around their cultures and their organization’s performance. We have also seen new start-ups forge what are clearly high engagement cultures from scratch, because of their leaders’ vision, force of personality and the most important (and most misused) factor of all: values.<br /><br /><span style="font-size: large;"><span style="color: #073763;"><b>Values</b></span></span></span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">With leadership and management levels, we looked at the structure of the organization and its relationship to organizational culture. But no culture comes into existence via structure alone: instead values breathe life into the structure and shape how things will be done. Values are one of the most important factors in any organizational culture and those values start at the top. Every organization has values whether they are written down or not. Some values are distributed widely and not just within the organization: for example, on every Starbucks Coffee Company cup and sleeve there are statements about the company’s commitment to “doing business in ways that are good to each other, coffee farmers and the planet.” Other organizations may have values that are unwritten and even unspoken but drive the internal culture nonetheless. The fact that some organizations have values that are regularly expressed verbally, written down and distributed widely such as on materials used by customers or in annual reports, does not always mean much: those values may not be lived at all. Not uncommon is the company that states a particular value, but when we have surveyed those people, we find just the opposite. Such things can make one cynical, and can also be the subject of wickedly accurate cartoons such as that by Garry Trudeau’s Doonesbury, which is well worth a click-through due to its timely connection to the financial services Crash! 4 Values, then, are easier said than done.<span style="font-size: large;"><br /><br /><span style="color: #073763;"><b>People</b></span></span></span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">As a living and breathing thing, culture therefore both affects and depends on whom you bring into it. Far better to take the time and pick someone who will fully support your culture from day one, rather than compromising and think that that person will “come around” with time. Smart organizations know this and go far beyond talent and skills in their recruitment activities. Picking the right people to work for you, and picking or promoting the right ones as managers, coaches, supervisors, mentors, whatever you call them, is a crucial cultural effort that will pay big dividends going forward. It will be an incredibly important determinant of whether your organization’s culture can be successful. When the factors driving culture in the organization reach the workforce, the stage is set for whether those people will engage or not, which is something we will expand on extensively further. This in turn will serve to enhance— or detract from— the performance of your organization.<br /><br /><span style="font-size: large;"><span style="color: #073763;"><b>Conclusions</b></span></span></span></span><span style="font-size: large;"><span style="color: #073763;"> </span></span><br />
<span style="color: #0b5394;">Work culture and worker engagement are a core part of the makeup of those places where we spend so much of our lives, and ultimately determine much of how we feel at work and whether we and our organizations are successful. Inevitably national cultures have an impact, as we have seen, but this is less and less as globalization creates the situation where our organizations straddle the boundaries between countries. India-born managers show up in the UK as they do in the US, and bring their fresh ideas and experiences with them. Young US and British workers go to Bangalore for a unique experience and the invaluable learning that occurs when one leaves one’s own culture. Chinese companies and their managers are showing up around the world, like their Japanese counterparts did decades ago, as China extends its influence. We all learn from each other, and find out that no one national culture has all the answers when it comes to organizational culture and engagement. </span></blockquote>
<blockquote>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">What we do know is that all work cultures are not created equal: we see the Apples, Googles, Virgins, Tata Motors and others, and know that they have something special, which goes beyond engineering or finance or strategy. They have a culture that produces and sustains that great engineering and marketing and customer service and makes their people excited to work there and to contribute. <br /><br />Worker engagement is no simple topic, involving as it does the rich mosaic of contributing factors we have examined. Some of these can be controlled (whom we hire or promote, the culture we create inside our organizations), others we can only work with, react to and mitigate (the economy, national cultures, etc.). But even in reactive mode such as during the 2008 Crash we have choices, some of which will themselves be creators of favorable environments for engagement, and some will not. As we have seen, most countries not in the emerging areas of Asia have their work cut out for them, in regard to worker engagement. Levels of engagement are not especially high across large areas of the developed world, and many have slipped as the effects of the Crash played out; we have also seen why this is so important, in terms of lost productivity and competitiveness. This is hardly the time to be slipping, as competition heats up to unprecedented levels. <br /><br />While we have covered the drivers of work culture and engagement in some detail as we moved from national to organization to individual levels, we have only hinted at one of the most significant ones, playing its role relentlessly and often outside of many peoples’ conscious awareness. It occupies a unique space in that it can clearly be said to have played a role in both the Crash, and in ongoing low worker engagement around the world. It is the ego.<br /><br /><span style="font-family: inherit;"><span style="color: black;">Bowles, David; Cooper, Professor Cary (2012-05-31). <a href="http://www.amazon.com/The-High-Engagement-Work-Culture-ebook/dp/B00885UG5I/ref=tmm_kin_title_0?ie=UTF8&qid=1402790063&sr=8-1-fkmr1" target="_blank"><u>The High Engagement Work Culture: Balancing Me and We</u></a> (pp. 20, 24, 25, 29-30, 5454). Palgrave Macmillan - A. Kindle Edition. </span></span></span></span></blockquote>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZya0Ol67dQJQKoxaSU-2V0_-Ufpku4Qncxm_942PD-AbiWTc9lO3DdX7_yT-3_PbL-w1bJXi5s1hyphenhyphen614IRYpMtXVPLOqyYowB47X0huvVF7G3jWJQN4yCFwWORTiY8sxY1zb1vfVm07qJ/s1600/Engagement.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZya0Ol67dQJQKoxaSU-2V0_-Ufpku4Qncxm_942PD-AbiWTc9lO3DdX7_yT-3_PbL-w1bJXi5s1hyphenhyphen614IRYpMtXVPLOqyYowB47X0huvVF7G3jWJQN4yCFwWORTiY8sxY1zb1vfVm07qJ/s1600/Engagement.jpg" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<b>David Marx:</b><br />
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Whack-a-Mole is also a metaphor for modern life. It’s a game we play with each other—particularly here in the U.S. It’s how we respond to predictable human fallibility. It’s how we set expectations of each other, how we respond when our fellow human being makes a mistake. Whack-a-Mole...</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">The mole in these examples is the adverse event, those outcomes in life that just don’t seem to be what we wanted. They’re created most often by the mistakes we make, missing that stop sign seemingly hidden behind an old elm tree, addressing that sensitive e-mail to the wrong person, forgetting that the gas nozzle is still connected to the car when we pull away from the gas pump. In the aftermath of these mistakes, both catastrophic and relatively benign, we take the easy route: How bad was the harm? Who touched it last? Who is to blame? Who is to pay? As adults, we push our need for “justice” to the point that every adverse outcome in life must have an accompanying blameworthy human behind it. It’s the game of Whack-a-Mole. </span></span><br />
<br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">It’s a game that costs us dearly. We’re all poised to pounce, caught up in the adult version of Whack-a-Mole, with the media all too willing to help swing the hammer even before the investigation has started. Bad outcome must mean bad actor. Whack that bad actor and the game is won...</span></span><br />
<br />
<br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">The statistics are these. You have a one-in-21 chance of dying from accidental causes in your life. That’s a one in 1,600 chance of accidental death per year. It’s a one in 584,000 chance you will accidentally die today, all things being equal. </span></span><br />
<br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">The greatest threat to your inadvertent demise is a medical mistake—one of our hard working doctors, nurses, or pharmacists making a mistake. Some reports say medical errors lead to 200,000 lives lost per year in the U.S. alone. Consider this: for every one person who dies in war, four will die in automobile accidents. And for every person in the U.S. who dies in an automobile accident, four to five will die from a preventable medical mistake. Nowhere in life’s endeavors does our human fallibility lead to so much harm. </span></span><br />
<br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">On January 25, 2000, Dr. Lucian Leape, a Harvard professor of health, testified before Congress on what he saw as the state of healthcare safety in the U.S. He told Congress that the single greatest impediment to error prevention in the medical industry is that “we punish people for making mistakes.” A co-author of the Institute of Medicine’s (IOM) report, To Err is Human, Leape cited that study’s estimated 44,000 to 98,000 annual deaths that are caused as a result of medical error alone. He said that healthcare providers would often only report what they could not hide. The process is simple: doctors make mistakes, professional boards take licensing action, and newspapers demonize the dedicated professional who made the mistakes. Case closed. Problem solved. Mole whacked—although we haven’t learned anything about what we can do better...</span></span> </blockquote>
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Whack-a-Mole may be addicting for its simplicity, but it’s not a productive way to deal with adverse events. Whether it’s our attitude toward spilt milk at the dinner table or our attitude toward the airline pilot who misses an item on a checklist, we simply cannot believe that an expectation of perfection will get us the results we want. We spend far too much time looking at the severity of the adverse outcome (how bad was it?) and who was the unfortunate soul to be closest to the harm. In turn, we spend far too little time addressing the system design that got us there and the behavioral choices of the humans in those systems that might have ultimately contributed to the adverse outcome. It’s called Whack-a-Mole...</span></span><br />
<br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">...in the hectic, fast-paced world of healthcare, thousands of patients suffer from adverse drug events every day. Some of these events are simply the statistically predictable side effects of the drug/human interaction. Others, however, are the result of error. </span></span><br />
<br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Human error. Your doctor may write down the wrong drug or the wrong dose. She might write the order for the wrong patient. A pharmacist might make the medication mistake and dispense the wrong drug or dose. Nurses can draw up the incorrect dosage into a syringe or deliver the medication to the wrong patient. Or it may be the patient who does not read the medication label, or even after looking at the instructions, makes a simple measurement mistake that leads to the adverse drug event. </span></span><br />
<br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">The healthcare industry refers to those events involving human error as “medication errors.” They occur every day around the world. In some cases, patients and their doctors will never know they’ve experienced a medication error due to the body’s ability to adjust to the unintended drug or dose. In other cases, it may mean an extended hospital stay to correct this new healthcare-caused condition. In the worst cases, the patient dies as a result...</span></span><br />
<br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">What do we do when things go awry? We face a two-fold challenge: 1) hold those who caused the event appropriately accountable, and 2) make fixes to prevent future events. What we will see is that these two goals are often at odds with each other. And when Whack-a-Mole rules the day, the prevention of future events takes a back seat. As Lucian Leape said, the single greatest impediment to safety is that we punish people for making mistakes. In healthcare today, as with any industry, from aviation to children’s day care, potential responses to the individual who makes the mistake run the gamut from termination to license revocation, from criminal indictment to civil lawsuit. </span></span></blockquote>
<blockquote>
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Whack-a-Mole...</span></span><br />
<span style="font-family: inherit;"><br />Marx, David (2012-06-06). <a href="http://www.amazon.com/Whack---Mole-Price-Expecting-Perfection-ebook/dp/B0089PFHT2/ref=sr_1_1?ie=UTF8&qid=1402790098&sr=8-1&keywords=Whack-a-Mole%3A+The+Price+We+Pay+For+Expecting+Perfection" target="_blank"><u>Whack-a-Mole: The Price We Pay For Expecting Perfection</u></a> (Kindle Locations 64-174). By Your Side Studios. Kindle Edition. </span></blockquote>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg4P2aDE4TJVeYL9WkQQWT8HQTVmw7v6LpKESfPrSKqil88R3MUfK7vokOBbloBEl1XzE_uYlXBT6wptlQ0RATSUEWBqd8K8rF1PWs0tFmYkuqV_TAWAykeMf1dze_RhzRDp1hdX4VJgs9v/s1600/whack-a-mole.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg4P2aDE4TJVeYL9WkQQWT8HQTVmw7v6LpKESfPrSKqil88R3MUfK7vokOBbloBEl1XzE_uYlXBT6wptlQ0RATSUEWBqd8K8rF1PWs0tFmYkuqV_TAWAykeMf1dze_RhzRDp1hdX4VJgs9v/s1600/whack-a-mole.jpg" /></a></div>
<br />
Marx in a nutshell here:<br />
<blockquote class="tr_bq">
<ul>
<li><span style="color: #0c343d;"><span style="font-family: Georgia,"Times New Roman",serif;">Console the human error.</span></span></li>
<li><span style="color: #0c343d;"><span style="font-family: Georgia,"Times New Roman",serif;">Coach the at-risk behavior.</span></span></li>
<li><span style="color: #0c343d;"><span style="font-family: Georgia,"Times New Roman",serif;">Punish the reckless behavior.</span></span></li>
<li><span style="color: #0c343d;"><span style="font-family: Georgia,"Times New Roman",serif;">Independent of the outcome.</span></span></li>
</ul>
</blockquote>
<blockquote>
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">It’s a path that we see innovative regulators and corporate managers beginning to take. It’s known in high consequence industries, such as aviation and healthcare, as a “just culture.” We teach our employees that we are all fallible human beings. We expect them to learn from their mistakes, to help us design the safest possible systems around them, and we expect employees to try to make the safest possible choices in those systems. It’s about setting aside the severity of harm and the actual inadvertent errors, and looking instead to the quality of the systems we have designed and the quality of the choices made in those systems. Console the error, coach the at-risk behavior, punish the reckless. Then, get on with the task of building a better system: changing performance shaping factors that subtly alter the rate of human error; adding barriers to prevent some classes of error; adding recovery steps to catch errors downstream before they lead to harm; and incorporating redundancy to minimize the impact of a failing system—these are the efforts that are going to produce better outcomes...</span></span> (Kindle Locations 636-647). </blockquote>
You just have to study the entire book. It's excellent.<br />
<br />
<span style="font-size: large;"><b>Maccoby</b></span><br />
<br />
Michael Maccoby's book could serve as a graduate semester text in "Leadership for Healthcare QI." Among other things, Maccoby and Marx are Deming 101.<br />
<blockquote class="tr_bq">
<span style="color: #073763;"><span style="font-size: large;"><b><span style="font-family: Georgia,"Times New Roman",serif;">Learning and Continuous Improvement </span></b></span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">People on all levels of an organization may have ideas to improve processes, increase efficiency, or cut costs. In most organizations, they don't communicate their ideas, because they don't believe anyone is listening. Typically, suggestions put into a suggestion box don't lead to results. A lower-level employee opens the box and has to decide about passing the suggestion up the hierarchy. If the suggestion means criticizing someone or changing their practices, it is better not to stir a hornets' nest. The suggestion goes nowhere. </span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">All too often executives are surrounded by courtiers who flatter rather than challenge them. An example: a CEO was presented with survey findings that reported wide distrust of top management by the rest of the organization. He turned to his VPs and said, “This can't be true. I go around and talk with people all the time, and no one has told me this.” The VPs, who knew that no one, including themselves, dared to bring bad news to the CEO, all agreed that there must be something wrong with the survey or the way the questions were phrased. </span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Furthermore, experts will often resist new knowledge that devalues their experience and expertise, and few experts are willing to learn from anyone other than a certified subject matter expert. Maccoby was once introduced at a meeting of telecom engineers as an expert on leadership, with the implication that anything he said on any other subject should be discounted. </span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Being open to ideas regardless of their source can lead to improvement innovation. When Maccoby visited a Toyota factory in Nagoya, Japan, a supervisor told him that he had received an average of fifty ideas for improvement per year from each member of his team and 85 percent were implemented. This remarkable result was achieved by instituting a process whereby all ideas were evaluated weekly by a team of supervisors. Ideas might be as simple as improving illumination or expanding a particular job. When ideas were implemented, workers received points which could be used for rewards such as dinner for a couple. </span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">You cannot expect that experts at any level will transform themselves and become respectful to nonexperts and be willing to learn from them, whether they be employees, customers, or patients. To learn from everyone in an organization, you must establish processes for continuous improvement that are integrated with the organizational system and the practical values that further its purpose. </span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">People will also resist change when it challenges their values or interests. They become closed to learning, and they ignore or find reasons to distrust evidence that conflicts with their beliefs. Some physicians at a medical school refused to consider changing their practice to adopt proven pathways, saying that the vice president who was promoting evidence-based medicine was only interested in saving money, not caring for patients. To overcome this resistance, the vice president had to clarify his philosophy, emphasizing that his purpose was both better care and cost savings and that the practical values needed to achieve this purpose included evidence-based practice and continual learning. </span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Of course, people can also resist knowledge that threatens their interests. Typically, product managers at companies resist learning about and supporting innovations that will draw customers away from their products. IBM had to create a new business for laptop computers located far from the managers of mainframes who felt threatened by the new product and who argued that it had no future. In similar fashion, a Norwegian oil company had to create a new company to protect ships that explored for oil from the managers of the much more costly platforms who saw the ships as a threat to their control of oil exploration. </span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Fear— whether of losing money, power, status, or of being punished for mistakes— blocks learning. Health care providers learn from morbidity and mortality rounds, but they will resist reporting mistakes and learning from them if they are punished for honest mistakes. </span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;">Organizations will learn only if, as Deming emphasized, leaders drive out fear...</span><br /><br />Maccoby, Michael; Norman, Clifford L.; Norman, C. Jane; Margolies, Richard (2013-07-29). <a href="http://www.amazon.com/Transforming-Health-Care-Leadership-Population-ebook/dp/B00E99975M/ref=tmm_kin_title_0?ie=UTF8&qid=1402790136&sr=8-1" target="_blank"><u>Transforming Health Care Leadership: A Systems Guide to Improve Patient Care, Decrease Costs, and Improve Population Health</u></a> (Kindle Locations 3611-3645). Wiley. Kindle Edition. </span></blockquote>
<blockquote class="tr_bq">
<span style="font-size: large;"><span style="color: #20124d;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>The Leader as Learner and Teacher </b></span></span></span><br />
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">The best leaders are passionate learners. When needing to decide about developing a new product or acquiring a company, GE CEO Jack Welch wanted to learn everything he could about the matter. He would take what he called a “deep dive” into the available material. Microsoft CEO Bill Gates took two weeks off each year to study a new area. When he heard of a new surgical technique, William Mayo would go to where it was being practiced and stay there until he had learned it. He would then return home to teach the technique to the surgeons at his clinic. </span></span><br />
<br />
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">However, in a complex health care organization, leaders cannot know everything they would like to know to solve problems and make decisions. They need to combine humility with confidence. Humility means that they don't have to know more than anyone else, that they are willing to learn from others. It is also recognition that they may never have all the information needed to make a rational decision. But leaders also need to develop confidence that they can learn enough to make good decisions, and to modify their theories if necessary. </span></span><br />
<br />
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">The leader of a learning organization will be a mentor and teacher who motivates others to learn by driving out fear, welcoming new ideas, and instituting processes that facilitate learning. These include open dialogue where no one fears punishment or humiliating put-downs. Also, experiments that test new approaches will be encouraged. Everyone in the organization will learn that all work is a process that includes planning, doing, evaluating or checking, and acting or adapting according to what has been learned. More important, everyone should learn how their work processes and roles contribute to the achievement of the organization's purpose. </span></span><br />
<br />
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">The leader will communicate a philosophy with values that determine decisions. But he or she also will be a principled pragmatist who tests these values to make sure they further the organization's purpose and produce the expected results. And if they don't, the values will be modified. In this way, the leader will model the qualities essential for continual individual and organizational learning. </span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #351c75;">Information in a bureaucracy is supposed to flow upward to the executives who should make decisions. The leader in a bureaucracy is supposed to be the person who has all the answers. In contrast, information in a collaborative knowledge organization is constantly accumulating on the front lines. The challenge for executives is to learn from people who are closest to the customers, patients, and clients. Leaders will not learn unless they are able to ask useful questions and use the learning to help design effective processes...</span><span style="font-family: inherit;"> (Kindle Locations 3808-3830). </span></span></blockquote>
__<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>ONE ENCOURAGING NOTE IN THE PCAST REPORT</b></span> <br />
<blockquote class="tr_bq">
<span style="color: #0c343d;"><span style="font-size: x-large;"><b><span style="font-family: Georgia,"Times New Roman",serif;">Recognizing successful use of systems engineering— </span></b></span></span><br />
<span style="color: #0c343d;"><span style="font-size: x-large;"><b><span style="font-family: Georgia,"Times New Roman",serif;">Baldrige Performance Excellence Program</span></b></span></span><br />
<br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">The National Institute of Standards and Technology (NIST) Baldrige Performance Excellence Program is a U.S. public-private partnership program designed to recognize and promote performance excellence. The program was established to identify and recognize high-performing companies, develop criteria for evaluating improvement efforts, and share best practices broadly. The Baldrige program raises awareness about the importance of performance improvement and provides tools and criteria to help organizations undertake that work. The program was expanded to include health-care and education organizations in 1999 and to nonprofit/government organizations in 2005. </span></span><br />
<br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">There are seven categories of criteria to help organizations identify their strengths and opportunities for improvement: leadership; strategic planning; customer focus; measurement, analysis, and knowledge management; workforce focus; operations focus; and results. The criteria focus on results—not procedures, tools, or organizational structure—in order to encourage creative, adaptive, and flexible approaches. Most importantly, the criteria support a systems perspective both to align goals across an organization and to encourage cycles of improvement with better feedback between improvement initiatives and its results. </span></span><br />
<br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Over the past decade, an increasing proportion of these awards has been to health-care organizations. Last year, all of the winners were from the health-care and education sectors, which shows the appetite for improving the ways health care is organized and delivered.</span></span></blockquote>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJTOcUdV5rb99zJ51o4PHq80Eq7cCmDP6A9yK36tbWMEgxpUwrWXJzyT3slmKIRLVJMVp64f8qVkk6tnwTi4joJQkhAdKXt8BoG2aB31zGIQ5AvEvzYAdlHolSiQQaYzF82L4uxwKiYnPk/s1600/BaldrigeHealthcareCriteriaCover.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJTOcUdV5rb99zJ51o4PHq80Eq7cCmDP6A9yK36tbWMEgxpUwrWXJzyT3slmKIRLVJMVp64f8qVkk6tnwTi4joJQkhAdKXt8BoG2aB31zGIQ5AvEvzYAdlHolSiQQaYzF82L4uxwKiYnPk/s1600/BaldrigeHealthcareCriteriaCover.png" height="357" width="400" /></a></div>
<br />
From the current Baldrige Health Care Criteria document. Below, note the areas of [1] <i><b>Leadership</b></i>, and [2] <i><b>Workforce Focus</b></i> (annotation mine).<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJpwaCh9dv5EfMET2zSftIsoLLcPypioyaxrXFhyphenhyphenTR9yg7E7O337SDnfTlSPvlMJo4DQ5gRdSB5WV3I87OVQXRTvdDDyBmKB9WLRDLcgEwHo3pB7V-uDFQNjaMRuId5BWV9wuHxwVL5Cnn/s1600/BaldrigeMatrix.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJpwaCh9dv5EfMET2zSftIsoLLcPypioyaxrXFhyphenhyphenTR9yg7E7O337SDnfTlSPvlMJo4DQ5gRdSB5WV3I87OVQXRTvdDDyBmKB9WLRDLcgEwHo3pB7V-uDFQNjaMRuId5BWV9wuHxwVL5Cnn/s1600/BaldrigeMatrix.png" /></a></div>
<blockquote class="tr_bq">
<span style="color: #073763;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><b>1. Leadership (120 pts.)</b></span></span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />The Leadership category asks how senior leaders’ personal actions guide and sustain your organization. It also asks about your organization’s governance system; how your organization fulfills its legal, ethical, and societal responsibilities; and how it supports its key communities...</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;">NOTES:</span></span></span><br />
<span style="color: #20124d;"><span style="font-family: Georgia,"Times New Roman",serif;">1.2a(2). The evaluation of leaders’ performance might be supported by peer reviews, formal performance management reviews, reviews by external advisory boards, and formal or informal feedback from and surveys of the workforce and other stakeholders. </span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #20124d;">1.2b(2). Measures or indicators of ethical behavior might include the percentage of independent board members, instances of ethical conduct or compliance breaches and responses to them, survey results showing workforce perceptions of organizational ethics, ethics hotline use, and results of ethics reviews and audits. They might also include evidence that policies, workforce training, and monitoring systems for conflicts of interest and proper use of funds are in place. </span></span></span><br />
<br />
<span style="color: #073763;"><span style="font-family: Georgia,"Times New Roman",serif;"> <span style="font-size: large;"><b>5. Workforce Focus (85 pts.)</b></span></span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />The Workforce Focus category asks how your organization assesses workforce capability and capacity needs and builds a workforce environment conducive to high performance. The category also asks how your organization engages, manages, and develops your workforce to utilize its full potential in alignment with your organization’s overall mission, strategy, and action plans...</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;">NOTES:</span></span></span><br />
<span style="color: #20124d;"><span style="font-family: Georgia,"Times New Roman",serif;">5.2. “Elements that affect workforce engagement” refer to the drivers of workforce members’ commitment, both emotional and intellectual, to accomplishing the organization’s work, mission, and vision.</span></span><br />
<span style="color: #20124d;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />5.2a(2), 5.2a(3). Understanding the characteristics of high-performance work environments, in which people do their utmost for their patients’ and other customers’ benefit and for the organization’s success, is key to understanding and building an engaged workforce. These characteristics are described in detail in the definition of high-performance work (page 46).<br />5.2a(3). Compensation, recognition, and related reward and incentive practices include promotions and bonuses that might be based on performance, skills acquired, and other factors. Recognition can include monetary and nonmonetary, formal and informal, and individual and group mechanisms. Recognition systems for volunteers and independent practitioners who contribute to the organization’s work should be included, as appropriate.</span></span><br />
<br />
<span style="color: #20124d;"><span style="font-family: Georgia,"Times New Roman",serif;">5.2b(2). In identifying improvement opportunities, you might draw on the workforce-focused results you report in item 7.3. You might also address workforce-related opportunities based on their impact on the results you report in other category 7 items.</span></span><br />
<span style="color: #20124d;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />5.2c. Your response should include how you address any unique considerations for workforce development, learning, and career progression that stem from your organization. Your response should also consider the breadth of development opportunities you might offer, including education, training, coaching, mentoring, and work-related experiences.</span></span></blockquote>
I served on a HealthInsight team in Nevada in 2006 that performed a state-level program Baldrige model assessment of a hospital, for the <b><i>"<a href="http://www.bgladd.com/NvQA/" target="_blank">Nevada Governor's Awards for Performance Excellence</a>"</i></b> (a program I co-founded), so I can attest first-hand that Baldrige Criteria are comprehensive, exhaustive, and useful for assessing the health of an organization.<br />
<br />
Were an enterprise to synthesize a Maccoby/Marx/Bowles-Cooper methodology for "Workforce-Focused, Just Culture Leadership," it would likely sail right through these sections of the Baldrige Criteria assessment with high scores.<br />
<br />
More importantly, it would likely also have a big leg up on the competition.<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>CODA</b></span><br />
<br />
With regard to all of the foregoing, it helps to recall some of the questions posed by consultants and authors Julie Winkle Giulioni and Beverly Kaye:<br />
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0c343d;"><b>Do you want to </b></span></span></span><br />
<ul>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Raise engagement levels? </span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Uncover and activate previously unknown or underutilized talents that can help the business? </span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Establish a culture of continuous learning and development? </span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Build the skills and knowledge needed so employees will be prepared when broader moves become available? </span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Generate loyalty and the kind of leadership reputation that will have the best talent standing in line to work for you?</span></span></li>
</ul>
</blockquote>
Then "<u><b><a href="http://www.amazon.com/Help-Them-Grow-Watch-Conversations-ebook/dp/B009448CIU/ref=sr_1_1?ie=UTF8&qid=1387296263&sr=8-1&keywords=help+them+grow+or+watch+them+go" target="_blank">Help Them Grow, or Watch Them Go</a>.</b></u>"<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqf34bnm0MbkNhmRjLGEVVEKy6mPFbYdm9_XWpWDIHzvJJX6tqj9B1aOgQXRpAhVAyPgy5Xh6ZgG4pK7xW8KsbWeyXBCGRRaN33hI_IYGC9KvpZfsZ69eny77oIhmG6FAa4XboqOd4vHnJ/s1600/HelpThemGrow.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqf34bnm0MbkNhmRjLGEVVEKy6mPFbYdm9_XWpWDIHzvJJX6tqj9B1aOgQXRpAhVAyPgy5Xh6ZgG4pK7xW8KsbWeyXBCGRRaN33hI_IYGC9KvpZfsZ69eny77oIhmG6FAa4XboqOd4vHnJ/s1600/HelpThemGrow.png" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLKRv6V3i7pjG8__9y0NYaJONJopen2n57mnrCSEDuHsGJWjCLKO2Ks-xnVkK5UZF5mpFxy0oUYrEUFe3MlHvtotUBuYzlUMCzv-eRhyphenhyphenzXLm7Kmb6PhFvwDbCcymDY8p9VdDoUHzFSqqh2/s1600/GreenStool.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLKRv6V3i7pjG8__9y0NYaJONJopen2n57mnrCSEDuHsGJWjCLKO2Ks-xnVkK5UZF5mpFxy0oUYrEUFe3MlHvtotUBuYzlUMCzv-eRhyphenhyphenzXLm7Kmb6PhFvwDbCcymDY8p9VdDoUHzFSqqh2/s1600/GreenStool.jpg" height="284" width="320" /></a></div>
<br />
___<br />
<br />
More to come...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-17903500412977282772014-06-11T09:34:00.003-07:002014-06-11T09:37:45.178-07:00Jon Stewart on the VA IT<div style="text-align: center;">
<div style="background-color: black; width: 520px;">
<div style="padding: 4px;">
<div style="text-align: center;">
<iframe frameborder="0" height="288" src="http://media.mtvnservices.com/embed/mgid:arc:video:thedailyshow.com:ae5cded3-088f-49fe-b793-35f258eefbaf" width="512"></iframe></div>
<div style="background-color: white; font-family: Arial, Helvetica, sans-serif; font-size: 12px; margin-bottom: 0px; margin-top: 4px; padding: 4px; text-align: left;">
<b><a href="http://thedailyshow.cc.com/">The Daily Show</a></b><br />
Get More: <a href="http://thedailyshow.cc.com/full-episodes/">Daily Show Full Episodes</a>,<a href="http://www.facebook.com/thedailyshow">The Daily Show on Facebook</a>,<a href="http://thedailyshow.cc.com/videos">Daily Show Video Archive</a></div>
</div>
</div>
<div style="text-align: left;">
<br /></div>
<div style="text-align: left;">
Ouch.</div>
</div>
___<br />
<br />
More to come...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-71782946157692391312014-06-09T07:39:00.003-07:002014-06-09T10:03:12.224-07:00The ONC Ten Year Plan, comrades<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhFLFAaRpShhRi_pOwygp1R9L_SWOHR_OJpqtO3PZ6etY89HkgRE90bzsGX-fJghZbSEmYhJPZ-jXqABrTQplqiJKq-woDplJWowHy1MTb0-Cu7QSO5gjk8olvbnpalqWlVXN-oj2hR5ALp/s1600/ONC10yrInteropBanner.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhFLFAaRpShhRi_pOwygp1R9L_SWOHR_OJpqtO3PZ6etY89HkgRE90bzsGX-fJghZbSEmYhJPZ-jXqABrTQplqiJKq-woDplJWowHy1MTb0-Cu7QSO5gjk8olvbnpalqWlVXN-oj2hR5ALp/s1600/ONC10yrInteropBanner.png" /></a></div>
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">In the past decade, there has been dramatic progress in building the foundation of a health IT infrastructure across the country that is resilient and flexible to accommodate many types of change. Through deliberate policy and programmatic action, the majority of meaningful use eligible hospitals and professionals have adopted and are meaningfully using health IT. This progress has laid a strong base upon which we can build. However, there is much work to do to see that every individual and their care providers can get the health information they need in an electronic format when and how they need it to make care convenient and well-coordinated and allow for improvements in overall health. There is no better time than now to renew our focus on a nationwide, interoperable health IT infrastructure – one in which all individuals, their families, and their health care providers have appropriate access to health information that facilitates informed decision-making, supports...</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">This significant progress has created a growing demand for interoperability that not only supports the care continuum, but supports health generally. Electronic health information needs to be available for appropriate use in solving major challenges such as providing more effective care and informing and accelerating scientific research. Despite significant progress in establishing standards and services to support health information exchange and interoperability, it is not the norm that electronic health information is shared beyond groups of health care providers who subscribe to specific services or organizations. This frequently means that patients’ electronic health information is not shared across organizational, vendor and geographic boundaries. Electronic health information is also not sufficiently standardized to allow seamless interoperability, as it is still inconsistently expressed with vocabulary, structure, and format, thereby limiting the potential uses of the information to improve health and care. We must learn from the important lessons and local successes7 of previous and current health information exchange infrastructure to improve interoperability in support of nationwide exchange and use of health information across the public and private sector...</span></span></blockquote>
What's not to love? Below, graphic prediction of their model.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjv3neuzvs3oXLvLr0jmesBShRDfGiNdZEtUm3mjK6HqZQOLg1MZk-d946gSjES0dLHGUiKg_WH_0nNKrT6C7Cs5hQ8Ub3yrU1vfm06HYMZnIPcQpnKPuPiYaWftkzfUedUkBn292zVtv4o/s1600/ONC10yrInteropModel.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjv3neuzvs3oXLvLr0jmesBShRDfGiNdZEtUm3mjK6HqZQOLg1MZk-d946gSjES0dLHGUiKg_WH_0nNKrT6C7Cs5hQ8Ub3yrU1vfm06HYMZnIPcQpnKPuPiYaWftkzfUedUkBn292zVtv4o/s1600/ONC10yrInteropModel.png" /></a></div>
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><b><span style="color: #073763;">BUILDING BLOCK #1: CORE TECHNICAL STANDARDS AND FUNCTIONS</span></b> </span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Through our Standards & Interoperability (S&I) Framework, ONC will continue to work with industry stakeholders and federal and state governments to advance core technical standards for terminology and vocabulary, content and format, transport, and security. These standards will enable, at a minimum, the following essential services for interoperability:</span></span><br />
<ol>
</ol>
<ol>
<li><span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">Methods to accurately match individuals, providers and their information across data sources</span></span></li>
<li><span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">Directories of the technical and human readable end points for data sources so they and the respective data are discoverable</span></span></li>
<li><span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">Methods for authorizing users to access data from the data sources</span></span></li>
<li><span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">Methods for authenticating users when they want to access data from data sources</span></span></li>
<li><span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">Methods for securing the data when it is stored or maintained in the data sources and in transit, i.e., when it moves between source and user</span></span></li>
<li><span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">Methods for representing data at a granular level to enable reuse</span></span></li>
<li><span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">Methods for handling information from varied information sources in both structured and unstructured formats.</span></span></li>
</ol>
</blockquote>
<ol>
</ol>
You can't question the necessity of any of these. But, frustratingly, what you will <i>not</i> find in <a href="http://www.healthit.gov/sites/default/files/ONC10yearInteroperabilityConceptPaper.pdf" target="_blank">this entire ONC paper</a> (pdf) is the word "dictionary" or phrase "data dictionary." See my earlier tilting-at-windmills blog post on <a href="http://regionalextensioncenter.blogspot.com/2014/02/we-should-not-prescribe-specific.html" target="_blank"><i><b>The Interoperability Conundrum</b></i></a>.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYeLKonNb08qb5prOVgCX6yW92n3Dt78L-f_-P4jiY7cv3XfNeGMhUnJ62Tp9zTp2aJNNsW7AEknmLXk5gCrk7uif2MBgxkWaGZinqqrmbDG9cKBcYWGtsXocISeLXlqkWNjxu7_Bve37I/s1600/InteroperaBabble.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYeLKonNb08qb5prOVgCX6yW92n3Dt78L-f_-P4jiY7cv3XfNeGMhUnJ62Tp9zTp2aJNNsW7AEknmLXk5gCrk7uif2MBgxkWaGZinqqrmbDG9cKBcYWGtsXocISeLXlqkWNjxu7_Bve37I/s1600/InteroperaBabble.jpg" height="225" width="400" /></a></div>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>ERRATUM</b></span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgaMqB4CRjfFwJbxx2A0Ts85ZmSQuLJzi9mO7Y-4xist5yA4epKpBesDmoR3f5iZ8NNrV6AUrMlquIrBT-iZp8T5qZ5ODL3OA41uLBnsvF8XuNKngUqfKTtzB5PBnat22JGqHz3KnzZfWJf/s1600/food-pyramid-3D.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgaMqB4CRjfFwJbxx2A0Ts85ZmSQuLJzi9mO7Y-4xist5yA4epKpBesDmoR3f5iZ8NNrV6AUrMlquIrBT-iZp8T5qZ5ODL3OA41uLBnsvF8XuNKngUqfKTtzB5PBnat22JGqHz3KnzZfWJf/s1600/food-pyramid-3D.jpg" height="236" width="400" /></a></div>
<br />
LOL From<i><b> <a href="http://theincidentaleconomist.com/" target="_blank">The Incidental Economist</a></b></i> blog.<br />
___<br />
<br />
More to come...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-21378911658334661062014-06-06T07:08:00.000-07:002014-06-07T09:13:33.504-07:00KHIT Blog Milestone<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5fSASvI52nAGEAU07EpldK09IDen6DSNWCUmgKfjzZrsyZ1Gvk_bKQsNSUaMVpnJ22L93CvyVOQYO0MQjgcE1SRQYV3nH-4OWTSetgnHG05F3KWuldsjM_oY3XlVCMZnFFK0gvFdFrIVs/s1600/250357.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5fSASvI52nAGEAU07EpldK09IDen6DSNWCUmgKfjzZrsyZ1Gvk_bKQsNSUaMVpnJ22L93CvyVOQYO0MQjgcE1SRQYV3nH-4OWTSetgnHG05F3KWuldsjM_oY3XlVCMZnFFK0gvFdFrIVs/s1600/250357.png" height="130" width="400" /></a></div>
<br />
Thanks to everyone who keeps coming by. It's probably somewhat more than that, as I didn't even install the blogger.com javascript tracking code in the blog template source html code until about a year after launching this blog.<br />
<br />
On toward a half million.<br />
__<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>MEANINGFUL USE UPDATE</b></span><br />
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.bna.com/meaningful-program-payments-b17179891093/" target="_blank"><span style="font-size: x-large;"><b>Meaningful Use Program Payments Approach $24 Billion; Enrollment Still Lags Behind 2013</b></span></a><br /><span style="font-size: x-small;">by Alex Ruoff</span></span></span></blockquote>
<blockquote class="tr_bq">
<span style="color: #0b5394;">As
of April, the federal government has paid more than $23.7 billion in
incentive payments to health-care providers and hospitals through the
meaningful use program, which pays Medicare and Medicaid incentives to
providers and hospitals that adopt electronic health record systems,
according to Centers for Medicare & Medicaid Services data released
June 4.</span></blockquote>
<blockquote>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Enrollment
grow in the meaningful use program is slower than in previous years,
however, particularly for hospitals, the data show.<br /><br />In April, the
latest month for which data are available, 7,057 providers and 13
hospitals newly registered to participate in the meaningful use program,
according to the data. In April 2013, 4,445 providers and 38 hospitals
registered to participate in the program, according to earlier CMS data
reports.<br /><br />The largest share of the incentive payments—$13.83
billion—has gone to hospitals, according to the data. Nearly $2 billion
was paid in 2014.<br /><br />Provider registrations were down compared to
March and February of this year, when, respectively, 12,461 and 9,378
providers registered to participate...</span></span></blockquote>
___<br />
<br />
More to come...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-84566542458133567932014-06-04T09:42:00.001-07:002014-06-05T07:35:50.869-07:00Whither ONC?<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgud3lT_jY60WCrmRaQmAHdVe72hiS7UXA-K4R2m1BI6MZXhJbcGlsIZcacK2X3bRFrO4a7u_QVZzpgekr7wKaxf2RHmuKQ5M7V9hdxWWuMaftKs-uZ60zdP6GO4zlfThI-JzlgE-l8bynd/s1600/ONCtoast.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgud3lT_jY60WCrmRaQmAHdVe72hiS7UXA-K4R2m1BI6MZXhJbcGlsIZcacK2X3bRFrO4a7u_QVZzpgekr7wKaxf2RHmuKQ5M7V9hdxWWuMaftKs-uZ60zdP6GO4zlfThI-JzlgE-l8bynd/s1600/ONCtoast.jpg" height="400" width="396" /></a></div>
<blockquote class="tr_bq">
<span style="color: #073763;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;"><a href="http://www.modernhealthcare.com/article/20140603/BLOG/306039995/oncs-structure-gets-flatter-as-its-2b-stimulus-appropriation-ends" target="_blank"><span style="font-size: x-large;"><b>ONC's structure gets flatter as its $2B stimulus appropriation ends</b></span></a></span><br />By Joseph Conn </span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">It should have come as little surprise that Dr. Karen DeSalvo, in announcing last week a reorganization of the Office of the National Coordinator for Health Information Technology, said she was aiming for a “flatter” reporting structure.<br /><br />One reason for the reorg is obvious. A massive bulge in ONC funding is deflating because most of the $2 billion that was directly appropriated to the ONC by Congress in 2009 for health IT programs under the American Recovery and Reinvestment Act has been spent over the past four years. The appropriation was part of the economic stimulus during the Great Recession.<br /><br />DeSalvo, in a recent memo to her staff, noted that the ARRA's “health IT infrastructure and program investments are ending and it is our responsibility to take this opportunity to reshape our agency to be as efficient and effective as possible, never losing sight of our primary accountability—the people of America.” There were no layoffs with the reorganization; the ONC head count remains at 191 full-time equivalents.<br /><br />Back in February, in an on-camera interview soon after her appointment to head the ONC, DeSalvo talked about operating with less money than her two immediate predecessors, Drs. David Blumenthal and Farzad Mostashari, both beneficiaries of ARRA funds...</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Most of that stimulus law money went to health IT workforce development programs, the Beacon Community program, state health information exchanges, higher education in health IT and the regional health IT extension center program.<br /><br />Fifty-five of the 60 extension centers in the first two rounds of grants have applied for and received permission from the ONC to keep spending remnants of their funds, according to the ONC. Two other RECs in the third round of grants have requests pending for similar spending extensions. But in no case will spending continue after five years from their original grant date, the ONC maintains.<br /><br />Grants for the REC program totaled $688 million or a little more than one-third of the ONC's appropriation under the stimulus law.<br /><br />DeSalvo, a professed fan of the RECs, has said she'd like to see their work continue.<br /><br />The original plan called for the popular RECs to be financially self-sustaining after four years, but a program to extend federal financial support to them has not materialized.<br /><br />In March, Mat Kendall, who headed the ONC's REC program since its inception in 2010, stepped down as director of the Office of Provider Adoption Support.<br /><br />That office did not make the cut as DeSalvo's reorganization plan pared the ONC structure from 17 offices and suboffices to 10. Those duties now fall under the new Office of Programs.<br /><br />According to a survey of executives of 37 RECs published in April and conducted by the Healthcare Information and Management Systems Society, leaders were optimistic they'd achieve sustainability, but only “a handful” indicated their organizations “have already been generating revenue streams to sustain operations going forward.”</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Aside from the anomalous 2009 appropriations bubble, the ONC's budget over the rest of its history has been repeatedly flattened by Congress. In fact, for the agency's first year, fiscal 2005, its budget was zeroed out by legislators.<br /><br />Since then, ONC budgets have been remarkably flat, averaging slightly less than $61 million a year, according to the ONC's latest report to Congress.<br /><br />For fiscal 2015, HHS' budget request to Congress is $74.7 million, well below the average request over the years at $81.6 million, with the average cut to an ONC budget request running at 22.3%. For the current year, ONC asked for $77.9 million and—after a 22% whacking by Congress—was given $60.4 million.<br /><br />The great bulk of the spending on health IT under the ARRA was actually controlled by the CMS, not the ONC, coming from the electronic health-record incentive payment programs under Medicare, Medicaid and Medicare Advantage...</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">__</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0c343d;"><a href="http://energycommerce.house.gov/press-release/committee-pursues-policies-foster-health-care-innovation-leaders-question-agency-plan" target="_blank"><span style="font-size: x-large;"><b>As Committee Pursues Policies to Foster Health Care Innovation, Leaders Question Agency Plan to Increase Health IT Regulation and Fees</b></span></a><br /><span style="color: #134f5c;">June 3, 2014</span></span><br /><i><span style="font-size: small;"><b>Members Question Authority and Rationale for Expanded Regulatory Approach, Underscore Commitment to Safe and Innovative New Approaches for Technology in Health Care</b></span></i><br /><br />WASHINGTON, DC – House Energy and Commerce Committee leaders today sent a letter to Karen DeSalvo, National Coordinator for Health Information Technology in the Department of Health and Human Services Office of the National Coordinator (ONC), questioning the ONC’s authority to expand its regulatory role in the Health IT space. The leaders are concerned that a report released in April 2014 “suggests that the Office of the National Coordinator for Health Information Technology would, among other things, create a Health IT Safety Center for the purposes of regulating software and other Health IT products. In addition, the ONC 2014 budget suggests it will impose a new user fee on Health IT vendors and developers to support ONC’s certification and standardization activities.”<br /><br />The leaders write, “it is not clear to us under what statutory authority ONC is now pursuing these enhanced regulatory activities, including the levying of new user fees, on Health IT.”<br /><br />The Office of the National Coordinator was legislatively established in 2009 as part of the Health Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009. Late last week, ONC announced a leadership structure that, among other things, creates an Office of Standards and Technology. As the ONC is poised to reorganize itself, committee leaders want to better understand how the agency believes it can carry out a host of new functions amid concerns that it might be overstepping its statutory authority. Fostering and promoting better integration of technology, innovation, and health care has been a central tenet of the committee’s 21st Century Cures initiative. Members are concerned that another layer of bureaucracy could hamper such efforts.<br /><br />The letter was signed by full committee Chairman Fred Upton (R-MI), Health Subcommittee Chairman Joe Pitts (R-PA), full committee Vice Chairman Marsha Blackburn (R-TN), and Communications and Technology Subcommittee Chairman Greg Walden (R-OR).</span></span></blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;">Read the complete letter online <a href="http://energycommerce.house.gov/letter/letter-hhs-office-national-coordinator-regarding-expanded-regulatory-authority" target="_blank">here</a>. Also</span>, from <i><b><a href="http://www.govhealthit.com/blog/4-questions-energy-and-commerce-are-demanding-onc%E2%80%99s-desalvo-answers#.U5B_BhbJs6k" target="_blank">Government Health IT</a>:</b></i><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #351c75;">DeSalvo
on Tuesday received a letter from the Energy and Commerce committee
demanding answers. Specifically, they want DeSalvo to address these four
questions:</span></span><br />
<ol>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #741b47;">When
the authorization for the Medicare and Medicaid Incentive program
expires, under what statutory authority does ONC believe it is able to
regulate health IT and electronic health records, particularly in (but
not limited to) non-Meaningful Use areas?</span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #741b47;">The
FDA is provided with the authority to regulate medical devices by the
Federal Food, Drug and Cosmetic Act. What similar authority does ONC
point to, going forward, to participate in regulatory activities in
coordination with the FDA and FCC?</span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #741b47;">To
what extent does ONC’s notice of proposed rulemaking on 2015 EHR
certification represents a broader shift in focus from coordination and
promoting efforts related to interoperability, privacy and security, and
quality reporting criteria, to the regulation of data collection,
functionality requirements, and other areas where market forces are more
likely to promote innovation and efficiency?</span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #741b47;">What
role does ONC plan to play moving forward on issues including, but not
limited to, health IT safety and EHR certification requirements? How
will the recommendations of ONC’s Federal Advisory Committees guide
these plans? Will ONC’s role be limited to the scope of these
recommendations?</span></span></li>
</ol>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #351c75;">At
the heart of those questions are ONC’s intentions to create a Health IT
Safety Center to regulate software and other HIT products, the
committee explained, and the fact that ONC’s “2014 budget suggests it
will impose a new user fee on health IT vendors and developers to
support ONC’s certification and standardization activities,” as well as
whether or not ONC actually has the authority to carry out its
intentions. </span></span></blockquote>
Recall my Q&amp;A with Dr. DeSalvo <a href="http://regionalextensioncenter.blogspot.com/2014/02/himss-day-four.html" target="_blank">at HIMSS14 back in February</a>.
Have to wonder whether ONC is now effectively finished. Probably too
early to say. Upton's hearing is not likely to do much more than his
prior ones have. I think it's a safe bet, though, that if the GOP
retakes the Senate this fall, Congress will do nothing beyond
Impeachment hearings and related stuff like "Benghazi" -- and now the
new POW trade "Berghazi" dustup.<br />
<br />
<br />
We shall see.<br />
__<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>WHEN YOUR MAC CRASHES</b></span><br />
<br />
I have been mostly offline for blogging the past few days.
Last Saturday my aged 2004 desktop iMac finally gave up the ghost. I'd
bought a Canon Pixma Pro 100 oversize-print (13 x 19) color printer, and
after I'd installed it, I think it was just too much for the old
machine to handle. It went squirrely, and then finally refused to boot
up clean (it had been randomly locking up and crashing multiple times a
day of late).<br />
<br />
So, I went to the Apple Store in
Walnut Creek and forked over the AMEX card for the baddest new 27" iMac
they make: 32 gigs of RAM, a 3 TB hard drive, 3.5 GHz quad CPU chipset, 8
gigs accelerated graphics RAM. Brought it home, took it out of the box,
set it up on the desk in my office, plugged it in, hooked it up to my 2
TB Time Capsule, turned it on, and selected "migrate."<br />
<br />
Took
about 6 hours (I had about 600 megs of apps and data on the old iMac,
including my more than 40,000 photos). Pretty flawless, though I <i>did</i>
have to engage Adobe tech support to get my subscription Creative Suite
6 working properly, and had to re-download the ~120 books in my Kindle
reader.<br />
<br />
It went about as smoothly as I could have asked for.<br />
<br />
A 2004 iMac. LOL. A friend wagged me on Facebook: <i>"that's like putting 500,000 miles on a Honda." </i><br />
<br />
The effective useful life on the PC side is about 3 years.<br />
<br />
I
am now more of a "Mac Snob" than ever. When I was with the REC, it
always cheesed me off that there were only one or two native Mac EHR
platforms.<br />
___<br />
<br />
More to come...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com1tag:blogger.com,1999:blog-4383209658183339757.post-25463247866395358582014-05-30T09:04:00.000-07:002014-05-31T11:18:24.126-07:00dx MachinaI spend a lot of time studying the cognitive processes of "experts," most notably those in the professions of medicine and law (the only two disciplines traditionally accorded the characterization; nowadays we've defined the appellation down to the point where your garbage truck driver is touted as an <i>"Environmental Management Professional"</i>).<br />
<br />
So, I read everything I can concerning "how doctors think," "how to think like a lawyer," etc. I've been studying legal reasoning since my senior undergrad year at UTK in 1985, when I took <i>"Senior Seminar in the Psychology of Law,"</i> a course taught by a psych prof who also had a Juris Doc, a degree he acquired while researching the salient elements of eyewitness testimony (bottom line, it's <i>egregiously</i> unreliable; nonetheless, if you are charged with but innocent of some crime but have an eyewitness against you at trial, you are probably <i>so</i> screwed).<br />
<br />
I just finished <a href="http://www.amazon.com/Good-Lawyer-Seeking-Quality-Practice-ebook/dp/B00JI2IH5G/ref=sr_1_2?ie=UTF8&qid=1401463884&sr=8-2&keywords=The+Good+Lawyer" target="_blank">this book</a> the other day:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJ4Ybfi6jX9CagdeKlyu63s6qI9wInub3T-qPBnhi4q9-SAoTWLE8GRSAQ86MTlbbgylJ_yT3BwVl51elcsQ-LYylFIAS2turHBEj1CbMbv5ZFzoVudsdpwUcfLIJ-OQwS_0TBbTx5lQLM/s1600/TheGoodLawyer.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJ4Ybfi6jX9CagdeKlyu63s6qI9wInub3T-qPBnhi4q9-SAoTWLE8GRSAQ86MTlbbgylJ_yT3BwVl51elcsQ-LYylFIAS2turHBEj1CbMbv5ZFzoVudsdpwUcfLIJ-OQwS_0TBbTx5lQLM/s1600/TheGoodLawyer.jpg" /></a></div>
<br />
Ran across a couple of interesting tidbits. e.g.,<br />
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0c343d;"><b>HERE COME THE COMPUTERS </b></span><br /><br />Recently a new tool for improving predictions about case outcomes is making waves: computers. “Lex Machina” is Latin for “Law Machine.” It’s also the name of a tech startup that emerged in 2009 from a Stanford Law School project to help “companies anticipate, manage, and win patent and other intellectual property [IP] law suits.” The idea to create a sophisticated database with reliable information about IP suits came to Stanford law professor Mark Lemley after he grew tired of hearing unsubstantiated assertions about patent litigation. “People would make all kinds of claims in policy debates that were presumably testable but were radically different from each other, you know with one saying patent suits are 50 percent of all lawsuits and another saying, no, it’s 1 percent.” A team of lawyers and engineers put in over 100,000 hours categorizing, tagging, and coding information to produce a database of 150,000 IP cases, 134,000 attorney records, and information about 1,400 judges, 63,0000 law firms, and 64,000 parties from the last decade. Every day the database grows. Lex Machina’s crawler, using natural language processing and machine learning tools, continues to extract new data from all ninety-four federal district court sites, the Patent and Trademark Office site, and other sites with IP litigation data.<br /><br />According to an executive of a venture capital fund that poured more than $ 2 million in funding into the project, Lex Machina offers clients “previously impossible insights” that “inform winning IP business and legal strategies.” Sasha Rao, a partner in the Palo Alto firm of Ropes & Gray, says Lex Machina’s rich and easily searchable data “fundamentally improves an IP litigator’s chances of winning” by facilitating everything from “initial investigations through trials and appeals.” Vicki Veenker, an attorney with Sherman & Sterling, praised the data that “reveal a judge’s entire case decision history” in IP cases, information she finds “invaluable for choosing venue, drafting motions, preparing oral arguments and advising on settlement.”<br /><br />For every company executive contemplating initiating IP litigation, the question they want answered is “What are our chances of winning and how much will it cost?” According to the Federal Judicial Center, the average cost of taking a patent case to trial is about $ 5 million per patent, so companies have strong incentives to carefully assess the odds of success. Joshua Walker, co-founder of Lex Machina, is confident that the technology his company provides will “revolutionize how corporate finance looks at litigation. We’ve done a number of use cases where we’ve said, ‘Here are the settlement patterns and win rates for these companies’.”<br /><br />Predictive computer databases are likely to make their mark first in legal fields that, like IP, are complex and involve high stakes. (Don’t expect public defenders or legal aid lawyers to be using tools like this anytime soon.) The trend, however, is unmistakable. Company executives hoping to hold down litigation costs will have more access than ever before to data that will empower them to participate with their legal counsel in strategizing. Lawyers whose predictions about litigation outcomes reflect overconfidence or other biases can expect to be exposed by the data and abandoned by increasingly sophisticated clients. The lesson for attorneys is clear: make better predictions or lose clients.<br /><br /><span style="font-family: inherit;"><span style="color: #444444;">Linder, Douglas O.; Levit, Nancy (2014-04-06). <u>The Good Lawyer: Seeking Quality in the Practice of Law</u> (Kindle Locations 2805-2847). Oxford University Press, USA. Kindle Edition.</span></span></span></span></blockquote>
Yeah. <i>apropos</i> of medicine and health IT, think messrs Weed. Recall my 2012 post <i><b>"<a href="http://regionalextensioncenter.blogspot.com/2012/01/down-in-weeds.html" target="_blank">Down in the Weeds'</a>"</b></i><br />
<blockquote class="tr_bq">
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">A culture of denial subverts the health care system from its foundation. The foundation—the basis for deciding what care each patient individually needs— is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new, secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical information.</span></span><br />
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />Electronic information tools are now widely discussed, but the tools depend on standards of care that are still widely ignored. The necessary standards for managing clinical information are analogous to accounting standards for managing financial information. If businesses were permitted to operate without accounting standards, the entire economy would be crippled. That is the condition in which the $21⁄2 trillion U.S. health care system finds itself—crippled by lack of standards of care for managing clinical information. The system persists in a state of denial about the disorder that our own minds create, and that the missing standards of care would expose.</span></span><br />
<br />
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">This pervasive disorder begins at the system’s foundation. Contrary to what the public is asked to believe, physicians are not educated to connect patient data with medical knowledge safely and effectively. Rather than building that secure foundation for decisions, physicians are educated to do the opposite—to rely on personal knowledge and judgment—in denial of the need for external standards and tools. Medical decision making thus lacks the order, transparency and power that enforcing external standards and tools would bring about...</span></span></blockquote>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi2Lt_uRgHRH7YWUL4xdB-w1HSULvF_4k9taozIKdC7BBr1DZFr_Oo-FTIz2q9kALSRQ0mat8HQ-Fq_83B-GxJmzkyYeKkNJBNJEN2hWIClhhOOV8Qdz_0sldLjot5pna4fBqMiFKuSKUXV/s1600/MIDcover300h.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi2Lt_uRgHRH7YWUL4xdB-w1HSULvF_4k9taozIKdC7BBr1DZFr_Oo-FTIz2q9kALSRQ0mat8HQ-Fq_83B-GxJmzkyYeKkNJBNJEN2hWIClhhOOV8Qdz_0sldLjot5pna4fBqMiFKuSKUXV/s1600/MIDcover300h.png" /></a></div>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><i><b>"dx Machina"</b></i></span><br />
<br />
Everyone wrestling with the myriad contentious issues that continue to bedevil Health IT should <a href="http://www.amazon.com/Medicine-Denial-Lawrence-L-Weed/dp/1456417061/ref=sr_1_1?ie=UTF8&qid=1401462395&sr=8-1&keywords=Medicine+in+Denial" target="_blank">read this important book</a>, IMO. I also commend to everyone the works of Dr. Jerome Taylor on his blog <i><b>"<a href="http://ehrscience.com/" target="_blank">EHR Science</a>,"</b></i> specifically his two posts entitled <i><b>"Is the Electronic Health Record defunct?"</b></i><br />
<i><b></b></i><br />
<blockquote class="tr_bq">
<span style="color: #073763;"><span style="font-family: Georgia,"Times New Roman",serif;">When building software, requirements are everything. And although good
requirements do not necessarily lead to good software, poor requirements
never do. So how does this apply to electronic health records? Electronic health records are defined primarily as repositories or
archives of patient data. However, in the era of meaningful use,
patient-centered medical homes, and accountable care organizations,
patient data repositories are not sufficient to meet the complex care
support needs of clinical professionals. The requirements that gave
birth to modern EHR systems are for building electronic patient data
stores, not complex clinical care support systems–we are using the wrong
requirements...</span></span></blockquote>
Excellent stuff, if a bit abstract and theoretical at times. Important, all of it.<br />
<br />
Beyond data systems and data availability, equally important are the "soft" cognitive elements of expert judgment. Another interesting excerpt from <u><b>The Good Lawyer</b></u>.<br />
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;"><b>CAN LAWYERS LEARN TO BE MORE EMPATHETIC? </b></span><br /><br />We’ve seen that empathy allows lawyers to better understand their clients’ problems, reduces miscommunication, and provides the basis for telling the stories of clients in more effective and compelling ways. Lawyers short on empathy might well ask whether they can increase their empathy, or whether their bad “empathy genes” or deficient family bonding have set their empathy quotient in stone. The honest answer is that the jury is still out on that question. Role-playing techniques, such as the psychodrama used at the Trial Lawyers College, might well increase empathy over the longer term, but there have been few, if any, controlled studies to justify drawing that conclusion with confidence. Sure, many graduates of TLC might say they now have more empathy, but do they really?<br /><br />Research provides stronger evidence that emotion recognition, one of the two main components of empathy, can be improved than exists for the other component, empathetic response. It seems that it is easier to teach people to pick up on the emotions another is experiencing than it is to teach them to respond to that person with an appropriate emotion of their own. Better emotion recognition will reduce miscommunications between a lawyer and client, but without appropriate emotional responses, your client might still think you an insensitive jerk. Even though no training program can guarantee that it will turn a low empathizer into a high empathizer, there are simple steps to make the most of the empathy we do have<br /><br /><span style="color: #073763;"><b>How to Make the Most of Your Empathy: A Checklist</b></span></span></span><br />
<ol>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Give your client your full attention. Do not multitask when meeting with clients. Take steps to avoid interruptions and external distractions, such as noise. </span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Listen actively. Avoid thinking about what you will say next when your client is talking. Understanding should precede being understood. </span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Pay close attention to clients’ clues (body language, tone of voice) so as to appropriately respond to their concerns. </span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Reflect your understanding of your client’s emotional state. Acknowledge how your client’s legal problem makes him feel. </span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Think of your client as a person, not just as a source of income, and be curious about your client’s entire story. </span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Think of yourself as a coach as well as a provider of legal services. Recognize that part of your job is to move clients toward more positive emotions. </span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Avoid legal jargon, lectures, and long-winded answers. Pause between paragraphs to give clients time to process your explanations and their own emotions.</span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Ask clients open-ended questions. Ask for explanations and examples. Don’t just ask leading questions. </span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">If possible, meet clients in their environment rather than in a sterile law office. </span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Role-play and engage in simulation scenarios with colleagues to improve your empathetic response. </span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Communicate regularly with clients. Respond to their emotions and their expressed regrets. Ask them frequently if you are accurately perceiving their concerns and desires. </span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Use resources such as personality inventories to become more aware of your own strengths and weaknesses as a communicator.</span></span></li>
</ol>
</blockquote>
Change "lawyer" to "doctor," and "clients" to "patients." While #9 is
impractical in all but the rarest of circumstances and #10 is not really
relevant to the practice of medicine, the other ten might well be
applicable -- <i>if</i> you feel that empathy is an important clinical skill component. I do.<br />
<br />
<i>apropos</i>, I point you back to the writings of <a href="http://www.amazon.com/What-Doctors-Feel-Emotions-Practice-ebook/dp/B008ED6AGS/ref=sr_1_1?ie=UTF8&qid=1401463688&sr=8-1&keywords=What+Doctors+Feel" target="_blank"><b>Dr. Danielle Ofri</b></a>:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0-rhyphenhyphenoyaO1OSl5mytytEP_ATN3v0D9wB4LedKJDeijNhyxC-oQ3QJgidU8KpRLH2rrMcT_-TVPcfmZS85FdO7etrLN2rV3fLCVSbwhNqAUiE_3aWzZbVFg6a-pxaIzh65Y83qd_F7h3_g/s1600/WhatDoctorsFeel.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0-rhyphenhyphenoyaO1OSl5mytytEP_ATN3v0D9wB4LedKJDeijNhyxC-oQ3QJgidU8KpRLH2rrMcT_-TVPcfmZS85FdO7etrLN2rV3fLCVSbwhNqAUiE_3aWzZbVFg6a-pxaIzh65Y83qd_F7h3_g/s1600/WhatDoctorsFeel.png" height="320" width="221" /></a></div>
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;">...Smack square in this debate over whether empathy is innate or learned is the consistent and depressing observation that medical students seem to lose prodigious amounts of empathy as they progress along the medical training route. Something in our medical training system serves to stamp out whatever empathy students bring with them on day one.</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;">The research appears to conclude that it is the third year of the traditional medical curriculum that does the most damage. This is a dispiriting finding, as the third year of medical school is the one in which medical students take their first steps into actual patient care. For most students, the third year of medical school is eagerly awaited. After two long years sitting in classrooms, you get to actually do what it is that doctors do— be in hospitals, take care of patients. One would think that these first steps into real patient care would bring forth all the idealism that drove students to medical school in the first place— idealism that is sorely tested in the first two years of memorizing reams of arcane facts.</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;">But the reverse seems to occur. After their seminal clinical experiences involving real contact with real patients, medical students emerge with their empathy battered. Their ideals of medicine as a profession are pummeled by their initiation into the real world of clinical medicine. And it is in this demoralized state that we send them into residency to accrue what are arguably the most influential and formative experiences of becoming practicing physicians.</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;">Why do medical students lose empathy during the clinical years of medical school? There are likely many reasons. Some are related to the disorientation and fatigue experienced by students as they are thrown into the fire of hospital life— so different from the orderly, clean, controlled classroom life in which they have existed for two years. That student world is cemented along predetermined schedules, explicit curricula, definitive tests. Even if the knowledge requirements are overwhelming— as they are— medical students at least know what to expect, down to nearly every second of their waking hours. </span></span><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;">Wednesday, 8: 30 a.m.– 10: 00 a.m., Pathology class; Topic: Peptic Ulcer Disease, room 203, Professor O’Brien, pages 237– 54 in Robbins’ Pathologic Basis of Disease, Exam on December 15. </span></span></blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;">This elaborately structured world of lectures, labs, classrooms, tests, and professors is a heliotropic universe with the medical students squarely at the fiery center. Everything exists for their sake. Their medical education is the raison d’être of the entire enterprise.</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;">When the students enter the wards, however, the tables are not just turned, they are upended entirely. Temperamentally, the world of the hospital is a different planet from the medical-school lecture hall. To the greenhorn, it is sheer anarchy. Some of this is the nature of medicine: human beings and their illnesses do not trouble themselves with schedules, flow charts, or textbooks.</span></span><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;">Chemotherapy infusion protocols conflict with CT scanner availability, but bronchoscopy can only be done after the CT scan, however the pulmonologist was called away to an emergency so the bronchoscopy needs to be rescheduled. Mrs. Baradi spiked a fever so chemo needs to be canceled and the patient in the next bed over just developed an unusual rash so needs to be moved to an isolation room, but the ER is backed up with admissions so five new patients are coming to the ward at the same time and no isolation beds are available. Mr. Langley’s family is here and needs to speak to his doctor, but 15-West is short-staffed today so two nurses will have to be “floated” over there, and if the ambulette forms aren’t filled out immediately then Ms. Gemberson’s discharge will be delayed another day. There’s a code on 17-North— drop everything!</span></span></blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;">Hospital life— with its byzantine array of moving parts layered atop the unpredictable rhythms of illness— is a permanent state of flux. Seasoned doctors and nurses are accustomed to working with a certain amount of ongoing bedlam. But new medical students, used to the orderly scheduling of academic life, are overwhelmed. They are easy to spot on the wards, not just because of their short white coats but because of the befogged expressions on their faces as clinical medicine swirls around them. They stand awkwardly on the edges of the ward as people, stretchers, emergencies, hospital lingo, and rapidly changing clinical priorities zing past them at bewildering speeds.</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;">To add to their discomfort, the students are astute enough to know that they don’t actually have any real purpose on the wards, no definitive job description like the doctors, nurses, pharmacists, phlebotomists, respiratory therapists, X-ray technicians, clerks, orderlies, dietitians, housekeepers, and electricians. Medical students are there only to learn. The inherently self-centered nature of their existence in a setting that is not specifically designed for their education— as the classroom part of medical school had been— creates an intensely uncomfortable state of being.</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;">They did choose a career in medicine to help others, didn’t they? Most medical students desperately want to help out on the wards— to ease some of their guilt, to “pay back” the interns and residents who are teaching them, to do some good for the patients in need they see all around them. But it’s hard to know where to start when your skills are minimal and everything is moving at breakneck speed with a paradoxically anarchic efficiency that you are sure to jam up. Indeed, the help that medical students earnestly offer often slows things down, a point that is painfully obvious to all parties involved.</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;">Although medical students eventually acclimatize somewhat to the clinical tumult, most retain that awkward sense of feeling useless, of being a constant fifth wheel. This difficulty in finding purpose, in finding a justified place in the beehive, can cause many students to unconsciously curtail their desire for engagement and hence their empathy.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;"><br /></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;">A second and perhaps even more significant factor in loss of empathy is what has been termed the hidden curriculum of medical school. The formal curriculum— what is taught in the lecture halls, what is embodied in the school’s mission statement, what is intoned by the deans and senior faculty who usher the students into the sacred world of medicine— can be trounced in a thrice by the hidden or informal curriculum that the students are submerged in once they enter the clinical fray.</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;">The students’ true teachers are no longer the august, gray-haired professors who practiced medicine in “the days of the giants” but harried interns and residents in grubby white coats stained with the badges of medicine in the trenches. These younger doctors are the immediate interface with clinical medicine for the students. The students trail their interns and residents every waking minute and absorb from them how medicine is done— how it is spoken, thought, written, performed, attired, and equipped.</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;">Residents and interns are the grunts of the medical profession, tasked, simply, with getting everything done. The practical side of the clinical buck stops with them (even if the ultimate clinical and legal responsibility rests with the attendings), and the house staff do whatever it takes to get everything done. With their scut lists in hand, their coat pockets doubling as supply cabinets, they are the embodiment of the pragmatic. While many still retain their interest in the theories and mechanisms of disease, the overriding modus operandi is utilitarian, because unlike the electricians, housekeepers, therapists, technicians, orderlies, dietitians, even the nurses and senior doctors, their job description has no bounds.</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;">If an X-ray needs to be done and transport is not available, it is the intern who wheels the patient down to radiology. If a form needs to get to the social worker’s office immediately because a discharge is riding on it but the fax machine is broken, there is the intern galloping down the stairs, paper in hand. Although house staff are not enamored of the clerical, administrative, transportation, and nonmedical miscellany that falls into their laps, they would rather do it themselves than suffer the time delays inherent in waiting for the regular channels to creak forward.</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;">They don’t want time delays for their patients because they do genuinely want the best, timeliest care for them. But they don’t want time delays for themselves either, because time delays translate to more work. And more work translates to less sleep. (One doctor recalled a board game he and his colleagues used to play during residency. It was called the Intern Game. Instead of money, the units of the game were hours of sleep, and this is what you would “spend” for any activity or item in the game.)</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #660000;">There is a baseness to this, but it’s the natural outcome of putting smart, competitive, perfectionist people in a high-stress system with myriads of ever-changing tasks for which they feel professional responsibility, coupled with sleep deprivation and the granite-hard fact of only twenty-four hours in the day . . . even in a sleepless one.</span></span><br />
<br />
<span style="color: #660000;"><span style="font-family: Georgia,"Times New Roman",serif;">This whatever-it-takes-to-get-it-done attitude breeds an efficiency that often dispenses with niceties.</span><br /><br /><span style="color: #444444;">Ofri, Danielle (2013-06-04). <u>What Doctors Feel: How Emotions Affect the Practice of Medicine</u>, Beacon Press. Kindle Edition.</span></span></blockquote>
Indeed. See also my December 4th, 2013 post <i><b>"<a href="http://regionalextensioncenter.blogspot.com/2013/12/philosophia-sana-in-ars-medica-sana.html" target="_blank">Philosophia sana in ars medica sana.</a>"</b></i><br />
<br />
Perhaps if physicians were paid more like lawyers, some of these problematic cognitive burden issues would be attenuated.<br />
<br />
Good luck with <i>that</i> proposition, I know.<br />
__<br />
<br />
<b><span style="font-family: Georgia,"Times New Roman",serif;">UPDATE ON THE VA CUSTERFLUCK </span></b><br />
<br />
Interesting <a href="http://www.slate.com/articles/news_and_politics/politics/2014/05/shinseki_resigns_here_s_how_to_fix_the_va.single.html" target="_blank"><b>Slate.com</b></a> article by Phillip Carter.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3-ywrWtvEvVuSvCLD4jg4E3Gwa34Iw62B4IbS4lMsxfFJ1wN78pGe3Tmo_QeEz99MvaFEX9z1TLE6rEJnbP6HeqHrY1k2kjHNy3mGN4P7Rtn8bEFVeEcSlFEBIgH28xMbyA2A2h2rKr_v/s1600/FixTheVA.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3-ywrWtvEvVuSvCLD4jg4E3Gwa34Iw62B4IbS4lMsxfFJ1wN78pGe3Tmo_QeEz99MvaFEX9z1TLE6rEJnbP6HeqHrY1k2kjHNy3mGN4P7Rtn8bEFVeEcSlFEBIgH28xMbyA2A2h2rKr_v/s1600/FixTheVA.png" height="229" width="320" /></a></div>
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">President
Barack Obama had no choice but to accept Veteran Affairs Secretary Eric
Shinseki’s resignation. The VA inspector general’s interim report
issued this week contained too many damning findings of “systemic”
problems that grew under Shinseki’s watch. Key among these was the
finding that the actual VA primary care wait times in Phoenix averaged
115 days—more than four times the VA’s previously reported average of 24
days. That discrepancy revealed a gap between reality and official
reporting, and suggested questions about the VA’s integrity ran all the
way up to the secretary’s office.<br /><br />More broadly, the growing VA
scandal cast doubt on the ability of the government to deliver health
care, a major Obama administration priority. If the White House could
not deliver on this promise to veterans, a key constituency for whom the
president and vice president have frequently described health care as
part of a “sacred trust,” then how could the administration be trusted
to provide care for all Americans? Coming after the legal and practical
challenges to the Affordable Care Act, the White House could not afford
another health care failure. And so Shinseki had to go.<br /><br />Unfortunately,
his departure will do little to fix the broader problems in the massive
VA health care system—and may even set the quasi-leaderless agency back
as it waits for a new secretary to be appointed and confirmed.</span></span></blockquote>
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #134f5c;">The
VA is the second-largest cabinet agency, and the nation’s largest
health care and benefits provider, with an overall fiscal 2015 budget of
$165 billion (greater than the State Department, USAID, and entire
intelligence community combined), including $60 billion for health care.
The VA employs more than 320,000 personnel to run 151 major medical
centers, 820 outpatient clinics, 300 storefront “Vet Centers,” more than
50 regional benefits offices, and scores of other facilities. This
massive system provides health care to roughly 9 million enrolled
veterans, including 6 million who seek care on a regular basis... </span></span></blockquote>
<a href="http://www.slate.com/articles/news_and_politics/politics/2014/05/shinseki_resigns_here_s_how_to_fix_the_va.single.html" target="_blank">Read the entire piece</a>. Phillip Carter is an Iraq veteran who now directs the veterans research program at the <a href="http://www.cnas.org/">Center for a New American Security</a>. <br />
___<br />
<br />
More to come...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>
BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-54636507380759715862014-05-28T08:44:00.004-07:002014-05-28T15:46:52.730-07:00Joe Flower on the Health tech revolution<div class="separator" style="clear: both; text-align: center;">
<i>Cross-posted, with permission.<span style="font-size: small;"><span style="font-family: inherit;"> Joe is an important healthcare thinker.</span></span></i></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<img border="0" src="http://www.imaginewhatif.com/wp-content/uploads/2010/06/Joe-111_TinyHedShot.jpg" /></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;"><span style="font-size: x-large;"><b>Will Tech Revolutionize Health Care This Time?</b></span></span></span><span style="font-size: x-large;"><b></b></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;"><span style="font-size: x-small;">by <a href="http://www.imaginewhatif.com/" target="_blank"><b>JOE FLOWER</b></a> on MAY 27, 2014</span></span><span style="font-size: x-small;"><b><span style="color: #073763;"> </span></b></span></span><br />
<span style="font-size: small;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><b><span style="color: #073763;">First published in <a href="http://www.hhnmag.com/" target="_blank">Hospitals and Health Networks Daily</a>, the online publication of the American Hospital Association, on May 27, 2014.</span></b></span><br /><span style="color: #0b5394;"> </span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;">After decades of bravely keeping them at bay, health care is beginning to be overwhelmed by “fast, cheap, and out of control” new technologies, from BYOD (“bring your own device”) tablets in the operating room, to apps and dongles that turn your smart phone into a Star Trek Tricorder, to 3-D printed skulls. (No, not a souvenir of the Grateful Dead, a Harley decoration or a pastry for the Mexican Dia de Los Muertos, but an actual skullcap to repair someone’s head. Take measurements from a scan, set to work in a cad-cam program, press Cmd-P and boom! There you have it: new ear-to-ear skull top, ready for implant.)<br /><br />Each new category, we are told, will Revolutionize Health Care, making it orders of magnitude better and far less expensive. Yet the experience of the last three decades is that each new technology only adds complexity and expense.<br /><br />So what will it be? Will some of these new technologies actually transform health care? Which ones? How can we know? <br /><br />There is an answer, but it does not lie in the technologies. It lies in the economics. It lies in the reason we have so much waste in health care. We have so much waste because we get paid for it.<br /><br />Yes, it’s that simple. In an insurance-supported fee-for-service system, we don’t get paid to solve problems. We get paid to do stuff that might solve a problem. The more stuff we do, and the more complex the stuff we do, the more impressive the machines we use, the more we get paid.<br /><br /><span style="color: #073763;"><span style="font-size: large;"><b>A Tale of a Wasteful Technology</b></span></span><br />A few presidencies back, I was at a medical conference at a resort on a hilltop near San Diego. I was invited into a trailer to see a demo of a marvellous new technology — computer-aided mammography. I had never even taken a close look at a mammogram, so I was immediately impressed with how difficult it is to pick possible tumours out of the cloudy images. The computer could show you the possibilities, easy as pie, drawing little circles around each suspicious nodule.<br /><br />But, I asked, will people trust a computer to do such an important job?<br /><br />Oh, the computer is just helping, I was told. All the scans will be seen by a human radiologist. The computer just makes sure the radiologist does not miss any possibilities.<br /><br />I thought, Hmmm, if you have a radiologist looking at every scan anyway, why bother with the computer program? Are skilled radiologists in the habit of missing a lot of possible tumors? From the sound of it, I thought what we would get is a lot of false positives, unnecessary call-backs and biopsies, and a lot of unnecessarily worried women. After all, if the computer says something might be a tumor, now the radiologist is put in the position of proving that it isn’t.<br /><br />I didn’t see any reason that this technology would catch on. I didn’t see it because the reason was not in the technology, it was in the economics.<br /><br />Years later, as we are trending toward standardizing on this technology across the industry, the results of various studies have shown exactly what I suspected they would: lots of false positives, call-backs and biopsies, and not one tumor that would not have been found without the computer. Not one. At an added cost trending toward half a billion dollars per year.<br /><br />It caught on because it sounds good, sounds real high-tech, gives you bragging rights (“Come to MagnaGargantua Memorial, the Hospital of the Jetsons!”) — and because you can charge for the extra expense and complexity. There are codes for it. The unnecessary call-backs and biopsies are unfortunate, but they are also a revenue stream — which the customer is not paying for anyway. It’s nothing personal, it’s just business. Of course, by the time the results are in saying that they do no good at all, you’ve got all this sunk cost you have to amortize over the increased payments you can get. No way you’re going to put all that fancy equipment in the dumpster just because it fails to do what you bought it for.<br /><br />Is this normal? Or an aberration? Neither. It certainly does not stand for all technological advances in health care. Many advances are not only highly effective, they are highly cost effective. Laparoscopic surgery is a great example — smaller wounds, quicker surgeries, lower infection rates, what’s not to like? But a shockingly large number of technological advances follow this pattern: unproven expensive technologies that seem like they might be helpful, or are helpful for special rare cases, adopted broadly across health care in a big-money trance dance with Death Star tech.<br /><br /><span style="color: #073763;"><span style="font-size: large;"><b>Cui Bono?</b></span></span><br />But that is in health-care-as-it-has-been, not in health-care-as-it-will be. How we think about the impact of new technologies is bound up with the changing economics of health care.<br /><br />Under a fee-for-service system the questions about a new technology are, Is it plausible that it might be helpful? What are the startup costs in capital and in learning curve? And: Can we bill for it? Can we recoup the costs in added revenue?<br /><br />In any payment regime that varies at all from strict fee for service (bundled payments, any kind of risk situation), whether we can bill for it becomes irrelevant. The focus will be much more on efficiency and effectiveness: Does it really work? Does it solve a problem? Whose problem?</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;"><br /></span></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;">Many
times, extra complexity and waste are added to the system for the
convenience and profit of practitioners, not for the good of patients.
For example, why do gastroenterologists like to have anaesthesiologists
assisting at colonoscopies, when the drugs used (Versed and fentanyl) do
not provoke general anaesthesia and can be administered by any doctor?
The reason is simple: It turns a 30-minute procedure into a 20-minute
procedure. The gastroenterologist can do three per hour instead of two
per hour. In the volume-based health care economy, they make more money.
The use of the anaesthesiologist adds an average of $400 per procedure
to the cost without adding any benefit, lowering the value to the
patient. Altogether this one practice adds an estimated $1.1 billion of
waste to the health care economy every year.</span></span></span></span><br />
<blockquote class="tr_bq">
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">UPDATE
NOTE: Diane Brown, MD reminds me that for safety it is best to have a pair of eyes dedicated to monitoring the anesthesia. But it need not be an anesthesiologist. It can be a nurse trained to the task, a regular member of the endoscopy team.</span></span></blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;">So
in thinking about whether these new technologies will propagate across
health care, we can ask how exactly they will fit into the ecology of
health care, who will benefit from their use, and how that benefit will
tie in to the micro economy of health care in that system, with those
practitioners and those patients.<br /><br /><span style="color: #073763;"><span style="font-size: large;"><b>Change Is Systemic</b></span></span><br />A cardiologist in an examining room whips out his iPhone and snaps it into what looks like a special cover. He hands it to the patient, shows the patient where to place his fingers on the back of the cover, and in seconds the patient’s EKG appears on the screen. Dr. Eric Topol, speaking at last summer’s Health Forum Summit, performs a sonogram on himself on stage using a cheap handheld device. These things are easy to imagine in isolation, as something a single doctor or nurse might do with an individual patient.<br /><br />In reality, in most of health care, the things we need to do to incorporate such technologies are systemic. To be secure, reliable, HIPAA-compliant and connected to the EMR, they can’t be used randomly by the clinicians who happen to like them. They must be tied into and supported by the IT infrastructure.<br /><br />Similarly, in moving from “volume” to “value” we are talking about changes that don’t happen at the level of a single doctor or single patient. In most cases we cannot treat the patients for whom we are at risk differently from those we are treating on a fee-for-service basis. When you are paid differently, you are producing a new product. When you are producing a new product, you are a beginner. The shift from “volume” to “value” demands and dictates broad systemic changes in revenue streams, which dictate changes in business models, compensation regimes and governance structures. Getting good at these new businesses means changing practice patterns, collaboration models and cultures.<br /><br />Hospitals, integrated health systems and medical groups face a stark choice: They can either abandon the growing part of the market that demands a “value” business arrangement and stick to the shrinking island represented by old-fashioned “volume” arrangements. Or they can transform their entire business.<br /><br />The use and propagation of these new low-cost technologies are entirely wrapped up in that decision. In old-fashioned fee-for-service systems, they will be used only where their use can be billed for, or where they lower the internal costs of something that can be billed for. They will not be used to replace existing services that can be billed at higher rates.<br /><br /><span style="color: #073763;"><span style="font-size: large;"><b>“That’s a Lot of Money”</b></span></span><br />Dr. Topol in his talks likes to make the point that there are over 20 million echocardiograms done in the United States every year at an average billing of $800. As he puts it, “Twenty million times $800 — that’s a lot of money. And probably 70 to 80 percent of them will not need to be done, because they can be done as a regular part of the patient encounter.”<br /><br />Precisely: That is a lot of money. In fact, it’s a big revenue stream. It’s difficult to imagine that fee-for-service systems for which various types of imaging, scanning and tests represent large revenue streams are going to be early adopters of such technologies that diminish the revenue streams to revenue trickles. When you are paid for waste, being inefficient is a business strategy.<br /><br />In the “value” ecology of the Next Health Care, the questions are much more straightforward: Does it work? Does the technology make diagnosis and treatment faster, more effective, more efficient? Does it make it vastly cheaper?<br /><br />Imagine replacement bones (and matrices for regrowing bones) 3-D printed to order. Imagine replacement knee joints, now sold at an average price of €7000 in Europe and $21,000 in the United States, 3-D printed to order. (Imagine how ferociously the legacy makers of implants will resist this change, and how disruptive it will be to that part of the industry.)<br /><br />Imagine the relationship between the doctor, the nurse and the patient with multiple chronic conditions, now a matter of a visit every now and then, turned into a constant conversation through mobile monitoring.<br /><br />Imagine a patient at risk for heart attack receiving a special message accompanied by a special ring tone on his cell phone — a message initiated by nano sensors in his bloodstream — warning him of an impending heart attack, giving him time to get to medical care.<br /><br />Imagine all of this embedded in a system that is redesigned around multiple, distributed, inexpensive sensors, apps and communication devices all supporting strong, trusted relationships between clinicians and patients.<br /><br />Imagine all this technological change supported with vigor and ferocity because the medical organizations are no longer paid for the volume they manage to push through the doors, but for the extraordinary value they bring to the populations they serve.<br /><br />That’s the connect-the-dots picture of a radically changed, mobile, tech-enabled, seamless health care that is not only seriously better but far cheaper than what we have today.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">__</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span><span style="font-family: inherit;"><a href="http://www.imaginewhatif.com/blog/" target="_blank"><b>Joe Flower</b></a> is the author of <a href="http://www.amazon.com/Healthcare-Beyond-Reform-Doing-Right-ebook/dp/B007X5E1KA/ref=sr_1_1?ie=UTF8&qid=1401291295&sr=8-1&keywords=Healthcare+Beyond+Reform%3A+Doing+it+Right+for+Half+the+Cost" target="_blank"><b>Healthcare Beyond Reform: Doing it Right for Half the Cost</b></a>,
a widely acclaimed manifesto on where healthcare is and has to be
heading, based on his in-depth survey of healthcare trends and
innovation. He is also the author of hundreds of healthcare articles.
For over 20 years he was a contributing editor and regular columnist at
the Healthcare Forum Journal. When the Healthcare Forum became the
Health Forum of the <a href="http://www.aha.org/" target="_blank">American Hospital Association</a>,
he went on to a regular column in the AHA’s Hospitals and Health
Networks Daily. He is member of the AHA’s Health Forum’s speaking
faculty, and serves on the board of the Center for Health Design.</span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>CODA</b></span><br />
<br />
<span style="font-family: inherit;">Rest in peace, Maya Angelou.</span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgNO_FFL96ZSkI8EZNc6CLd4MfxgOjAkQTuDYJn5cXJpZFWlrRz_Y6x_F2SPNDaUfHxejJeD2fo8ptkrwanFpxxnjrc_2zQB-oGSaxJDsnK8ctyVXSciVOXh_UiGcn_0YE1TISlUvpTumBt/s1600/Maya.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgNO_FFL96ZSkI8EZNc6CLd4MfxgOjAkQTuDYJn5cXJpZFWlrRz_Y6x_F2SPNDaUfHxejJeD2fo8ptkrwanFpxxnjrc_2zQB-oGSaxJDsnK8ctyVXSciVOXh_UiGcn_0YE1TISlUvpTumBt/s1600/Maya.jpg" height="266" width="400" /></a></div>
<span style="font-family: inherit;">___</span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">More to come... </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span><iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>
BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-59597194252875306802014-05-26T08:03:00.002-07:002014-05-26T17:15:55.246-07:00A Memorial Day weekend reflection -- apropos of the VA scandal<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjwZYfk6_G2usiIBzuTN5rAiEwGbXJNedED3vXU3Z4lxBWky2io6mxbYOnv0Kt5LCQOU-hGRfK04hnidKUVf6ub3fZ24O068gJOmBp9yGveT3rcSs7fznU9g64YNoUF2_hBgLAV22SsqB21/s1600/670px-us-deptofveteransaffairs-seal-svg.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjwZYfk6_G2usiIBzuTN5rAiEwGbXJNedED3vXU3Z4lxBWky2io6mxbYOnv0Kt5LCQOU-hGRfK04hnidKUVf6ub3fZ24O068gJOmBp9yGveT3rcSs7fznU9g64YNoUF2_hBgLAV22SsqB21/s1600/670px-us-deptofveteransaffairs-seal-svg.png" height="319" width="320" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiurXn_MepFRwQ488sm-csaJ6lC82diUBUrmGQNDf6To3T4gkYY_sbgR3TQJC9TXc9PSQBvqHP8ZKK6EcpBwddVivSry6yVdG1fqT14YXGG7fvasYU-sReKvt__zDaL6IzDWMW_yoiW2kjq/s1600/Real_Band_of_Brothers.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiurXn_MepFRwQ488sm-csaJ6lC82diUBUrmGQNDf6To3T4gkYY_sbgR3TQJC9TXc9PSQBvqHP8ZKK6EcpBwddVivSry6yVdG1fqT14YXGG7fvasYU-sReKvt__zDaL6IzDWMW_yoiW2kjq/s1600/Real_Band_of_Brothers.jpg" height="640" width="516" /></a></div>
<br />
My late Dad and all four of his brothers were in WWII for the duration. Only Pop and my uncle Warren survived the war years. Three uncles I never got to meet and know.<br />
<br />
One of my Mom's brothers was in the D-Day invasion, coming ashore on one of those LSTs so horrifically depicted in Spielberg's <i><b>"Saving Private Ryan." </b></i>I did not find the movie's <i>cinema veritae</i> entertaining. It was, <i>"oh, shit; this is just what they described to me over the years."</i><br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="http://www.bgladd.com/Europe_trip_2004/D_Day_cemetery1.JPG" style="margin-left: auto; margin-right: auto;"><img border="0" src="http://www.bgladd.com/Europe_trip_2004/D_Day_cemetery1.JPG" height="300" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">I visited the D-Day Omaha Beach cemetery in 2004</span></span></td></tr>
</tbody></table>
Pop
left a leg behind on Sicily after his munitions glider crashed during a
night landing. He was pinned in the wreckage overnight, both legs
crushed up under him and badly broken. They had to amputate the right
one just above the knee. He subsequently spent a year in recovery and
rehab stateside, in Atlanta. He married my mother after that, walking
haltingly with the gimpy gait that came with the relatively crude
artificial leg of the time.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhc0zVdgTlEL8_2gxwpQfCgGIQt5W3JuonB_r2zOq33u_0TYL8bNW3dqd-Y0Egh_5V39W5O7VVVlTzTfbqtHc37KQlY1Jwx-mdUKaMSz3rv_fF5zt5iGUAtNWLJ4PFDmXWjc9tP0Y2Du5iW/s1600/My_Parents_wedding_1944.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhc0zVdgTlEL8_2gxwpQfCgGIQt5W3JuonB_r2zOq33u_0TYL8bNW3dqd-Y0Egh_5V39W5O7VVVlTzTfbqtHc37KQlY1Jwx-mdUKaMSz3rv_fF5zt5iGUAtNWLJ4PFDmXWjc9tP0Y2Du5iW/s1600/My_Parents_wedding_1944.jpg" height="320" width="400" /></a></div>
<br />
Had they had the battlefield triage MASH technology and tx's/px's of
Vietnam during WWII, my Dad would probably not have lost his leg.
Conversely, had they only had such technology during George W. Bush's
Afghanistan and Iraq wars of the 2000's, we'd have had <i>far</i> fewer
survivors -- the physically and psychically mangled survivors that will
now require ruinously expensive lifetime care in many, <i>many</i> cases.<br />
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Early
this month at the National 9/11 Museum opening ceremony, participants
recounted the litany of loss that day when nearly 3,000 innocent
civilians were murdered. In all the reporting on the opening, there was
much discussion about the challenge the curators faced in how to present
the Sept. 11 narrative.<br /><br />Thirteen years later it’s still hard to
wrap one’s head around the magnitude of the loss experienced that day.
One day, loved ones were here — the next they were not.<br /><br />Still
harder to comprehend: the staggering global bleed-out since the U.S.
decided to wage a global war on terrorism in response. More than 6,700
American soldiers have lost their lives and more than 57,000 have been
wounded. By some expert estimates, as many as 200,000 of the soldiers
that served in Iraq and Afghanistan are living with some form of
traumatic brain injury.<br /><br />And that’s just “our” people. <span style="font-family: inherit;"><span style="color: black;">[from <a href="http://www.salon.com/2014/05/26/americas_post_911_debacle_an_honest_reflection_on_memorial_day/" target="_blank">Salon.com</a>]</span></span></span></span></blockquote>
My sister's late husband, my beloved brother-in-law <a href="http://santafeandthefatcityhorns.blogspot.com/2007/10/heartsick.html" target="_blank">Tony Poggi, succumbed prematurely -- tragically -- to the after-effects of his Agent Orange exposure</a> during his "tour" in Vietnam.<br />
<br />
My Dad was a "WWII 100% Service-Connected Disability" bene. He took every penny they gave him. A <i>lot</i> of pennies, as it were. He always got good service and good care, to the extent I can determine. The VA even paid for his dementia-addled nursing home care from 2001 to his death in 2008. During my time looking after him after he'd gone senile, I was always able to get him prioritized, even before I became his legal guardian. One VA administrator told me "don't worry, WWII disabled veterans are a specialty of mine." Fair or not, there <i>is</i> a service pecking order within the sprawling VA bureaucracy.<br />
<br />
<br />
The VA is in the throes of scandal these days. Touted for
their EHR (VistA) and touted for their heretofore high patient
satisfaction scores (<a href="http://www.veteranstoday.com/2014/04/16/independent-2013-survey-shows-veterans-highly-satisfied-with-va-care/" target="_blank">see below</a>),
they now find themselves under serious partisan political assault --
over their apparent gaming of the scheduling backlog system.<br />
<blockquote class="tr_bq">
<span style="color: #990000;"><span style="font-size: x-large;"><b><span style="font-family: Georgia,"Times New Roman",serif;">Independent 2013 Survey Shows Veterans Highly Satisfied with VA Care</span></b></span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;"><b>Higher rating than Private-Sector Hospitals on Average</b></span><br /><br />WASHINGTON
— The American Customer Satisfaction Index (ACSI), an independent
customer service survey, ranks the Department of Veterans Affairs (VA)
customer satisfaction among Veteran patients among the best in the
nation and equal to or better than ratings for private sector
hospitals. The 2013 ACSI report assessed satisfaction among Veterans
who have recently been patients of VA’s Veterans Health Administration
(VHA) inpatient and outpatient services. ACSI is the nation’s only
cross-industry measure of customer satisfaction, providing benchmarking
between the public and private sectors.</span></span></blockquote>
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">In
2013, the overall ACSI satisfaction index for VA was 84 for inpatient
care and 82 for outpatient care, which compares favorably with the U.S.
hospital industry (scores of 80 and 83, respectively). Since 2004, the
ACSI survey has consistently shown that Veterans give VA hospitals and
clinics a higher customer satisfaction score, on average, than patients
give private sector hospitals. These overall scores are based on
specific feedback on customer expectations, perceived value and quality,
responsiveness to customer complaints, and customer loyalty. One
signature finding for 2013 is the continuing high degree of loyalty to
VA among Veterans, with a score of 93 percent favorable. This score has
remained high (above 90 percent) for the past ten years...</span></span></blockquote>
Politicians
on all sides of the aisles routinely laud "our sacred obligation" to
our veterans. They do not, however, routinely Walk their Talk. Flying
off secretly to photo-op with the troops in Afghanistan on Memorial Day
weekend doesn't constitute meeting the Sacred Obligation.<br />
<br />
<a href="http://thedailyshow.cc.com/full-episodes/r79kxv/may-19--2014---james-mcavoy" target="_blank">Jon Stewart unequivocally calls bullshit</a>.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiGkbNU_ocC3iNeYW4nloCxNWNBL7cXlMW5PMnH48fbZpXlRUDdDCMRVJ_Fl2rqMhdaRuN2pr6Z8LZfwbHiZD6FOSBqcOuJREZrYHyKJssANEUleP2qdSUoq1p2aZ0nR5yRf2rosqsAuJ8x/s1600/JonStewartVA.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiGkbNU_ocC3iNeYW4nloCxNWNBL7cXlMW5PMnH48fbZpXlRUDdDCMRVJ_Fl2rqMhdaRuN2pr6Z8LZfwbHiZD6FOSBqcOuJREZrYHyKJssANEUleP2qdSUoq1p2aZ0nR5yRf2rosqsAuJ8x/s1600/JonStewartVA.jpg" /></a></div>
<br />
Veterans with service-connected conditions and injuries <i>should</i> have <i>carte blanche</i>, IMO. They should be able to present their VA cards at <i>any</i> clinical site and get treatment. The closed system "government-run healthcare" comprising the VA is part of the problem.<br />
___<br />
<br />
More to come...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>
BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com1tag:blogger.com,1999:blog-4383209658183339757.post-42174699506320438912014-05-21T09:51:00.000-07:002014-05-22T07:22:17.557-07:00Just DO it<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhKAaM2oaoj4obkcn4xEGDzA-eiAHjmJIxNPq3aQHtKFG4bf_-h2H_EJV9Ga7pQ685krGX0FE-AtRnrykiG8qy-YPUT4EFM_tDA4kuJv2zRuIrt1cT3dfszWYCg-Dp-7wVZoYakTFo0NHXs/s1600/UncleSamStopWhining.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhKAaM2oaoj4obkcn4xEGDzA-eiAHjmJIxNPq3aQHtKFG4bf_-h2H_EJV9Ga7pQ685krGX0FE-AtRnrykiG8qy-YPUT4EFM_tDA4kuJv2zRuIrt1cT3dfszWYCg-Dp-7wVZoYakTFo0NHXs/s1600/UncleSamStopWhining.jpg" height="320" width="239" /></a></div>
<br />
Yes, there's a <i>lot</i> about the U.S. healthcare "system" comprising legitimate targets for criticism, complaining, and outrage. We all know that. Crappy, workflow-inimical, silo'd Health IT, intractable reimbursement system misalignments, maddening "government mandates," looming provider shortages, and on and on and on...<br />
<br />
I started blogging about the issues back in 2009. See, e.g., my post <a href="http://bgladd.blogspot.com/2009/05/us-health-care-policy-morass.html" target="_blank"><b><i>The U.S. health care policy morass</i></b></a>. <br />
<br />
But, given that we go to Rumsfeldian healthcare delivery "war" every day with the healthcare system we <i>have</i>, and not the one we'd like to have, it helps to give close study to the folks out there who are leading the way -- <b><i><u>doing</u></i></b> rather than bitching.<br />
<br />
I just finished this book.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyNR7OqFs8k88zNQUL4cuUhryOmLuWB0TCDQlnIWmCe9v9C96cNGPLy8vCK7_wCiFrwuemUCmaTi35Z5WRZyoNXT0CmOK2wZxnF_fG1E5bMSc5magF_X7Z23wrKrNvdBI3e0eStSYNoEp9/s1600/Drop-Shadow-Beyond-Heroes.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyNR7OqFs8k88zNQUL4cuUhryOmLuWB0TCDQlnIWmCe9v9C96cNGPLy8vCK7_wCiFrwuemUCmaTi35Z5WRZyoNXT0CmOK2wZxnF_fG1E5bMSc5magF_X7Z23wrKrNvdBI3e0eStSYNoEp9/s1600/Drop-Shadow-Beyond-Heroes.jpg" height="320" width="217" /></a></div>
<br />
This is the 3rd book release I've studied from the <a href="http://createvalue.org/shop/" target="_blank"><b>ThedaCare Center for Healthcare Value</b></a>, following these prior two:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0MOVBabNjuwf6CFzOCHVEvDE0TJj9e8iHjYo3AkmqSs0OEzElmMo7H38gRPndcaAxtMewmiVpkEFKor8VuufX32Tq1_KqXeCvVErCjCpHGANW8_y_ol2H7TE2XVyzxAyV7t60ey2deCrm/s1600/OnTheMendBook.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0MOVBabNjuwf6CFzOCHVEvDE0TJj9e8iHjYo3AkmqSs0OEzElmMo7H38gRPndcaAxtMewmiVpkEFKor8VuufX32Tq1_KqXeCvVErCjCpHGANW8_y_ol2H7TE2XVyzxAyV7t60ey2deCrm/s1600/OnTheMendBook.jpg" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiAIKpiZexNI9oi6Nh_8FBefxWoRC1202i6veRLczRDzx0ZZcVL25LloQTJN0i1zYEUc1S1bDl6mJb7ouQa3EP3vSRQVeH9-qNI9J8YrxQ7LFEA4Lr0P8BAvMWxFz3yC4l6FuqnkZRDo-Hh/s1600/PotentMedicine.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiAIKpiZexNI9oi6Nh_8FBefxWoRC1202i6veRLczRDzx0ZZcVL25LloQTJN0i1zYEUc1S1bDl6mJb7ouQa3EP3vSRQVeH9-qNI9J8YrxQ7LFEA4Lr0P8BAvMWxFz3yC4l6FuqnkZRDo-Hh/s1600/PotentMedicine.png" /></a></div>
<br />
The reference to "heroes" goes to the notion of the valiant, adroit "firefighters" who repeatedly have to drop in to save the day in the dysfunctional healthcare delivery system. I call them "Quadrant One" people, those called upon to deal with the seemingly never-ending, chaotic "<a href="http://www.quadrant2associates.com/Quadrant2.html" target="_blank">Important and Urgent</a>."<br />
<br />
The layout of "<b><u>Beyond Heroes</u>.</b>"<br />
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Over the next eight chapters, we will examine each of the elements of our business performance system in detail, since all have been critical in helping us to create a business performance system that is transforming ThedaCare.</span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Here, I would like to draw a big picture, describing how each element links to the others to create a system, not just a pile of discrete tasks. Think of this as the engineering drawings, showing the bare structure of ThedaCare’s business performance system and how the elements become interlocking gears. </span></span><br />
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;"><b>1. Status Reports</b></span>. <span style="color: #351c75;">At ThedaCare, we call this a stat sheet meeting, and it is the most transformative element in our system. Short for “status of the business,” this conversation, usually between a manager and a supervisor or clinical lead, begins with a series of standardized questions on a single sheet of paper intended to provoke a dialogue about improvement opportunities and roadblocks. This daily, focused discussion about the business, taking place hundreds of times each day with different players all over our hospitals, is the cornerstone of our business performance system. This is about preparedness, about planning our days instead of firefighting our way through them.</span></span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;"><b>2. Team Huddle</b></span>. <span style="color: #351c75;">Every day, every leader gathers his or her team members into a huddle to widen the conversation about opportunities for improvement, roadblocks, and ongoing projects. This is where we teach and practice standardized problem solving using A3s and the plan-do-study-act cycle and then employ these tools to work through issues and improvements.</span></span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;"><b>3. Managing to the Established Standard</b></span>. <span style="color: #351c75;">This is the discipline of auditing standard work for both clinical and leadership processes in order to keep it from changing or falling to the wayside. By auditing or observing standard work, we also work to spread best practices. It is difficult to maintain any standardized process, clinical or administrative, so auditing must be hardwired into the business performance system and every manager’s day. This is where we emphasize that standard work is not a weapon or critique but is the best currently known way to do the work. Standard work is the best practice, and auditing or observing the work is a method for teaching and coaching.</span></span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;"><b>4. Problem Solving</b>.</span> <span style="color: #351c75;">We used the A3 or PDSA (plan-do-study-act) as our guide to problem solving with the scientific method. But these tools are as much about mentoring the team on ways to solve problems as they are about finding the best countermeasures for a specific problem.</span></span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;"><b>5. Transparency</b></span>. A<span style="color: #351c75;"> visual workplace— where area defects are as visible as team accomplishments— is difficult to establish, but it is the way we keep everyone focused on reality while looking for new opportunity.</span></span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;"><b>6. Advisory Teams</b></span>. <span style="color: #351c75;">For every manager we created a board-of-directors-style team of advisors to help fill in gaps in the manager’s areas of expertise and provide fresh perspectives. Advisors might be from finance, human resources, or pharmacy and are responsible for the overall performance of drivers in that area. At ThedaCare, drivers refer to the targets or goals on an area’s scorecard that lead much of the work of improvement teams. Every unit, clinic, or area has drivers that are tied to the organization’s main goals. In general, each advisor on the team “owns” one of the area’s drivers and is responsible for understanding problems that affect performance toward the goal. Advisors may come from inside or outside the manager’s area.</span></span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;"><b>7. Scorecard</b></span>. <span style="color: #351c75;">Every manager had a monthly scorecard developed and maintained by the advisory team to help keep track of progress against drivers. The scorecard’s vital few metrics help us focus deeply to solve problems and improve performance.</span></span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;"><b>8. Leadership Standard Work</b></span>. <span style="color: #351c75;">This is the most effective weapon available against heroics. When a supervisor, manager, or executive adopts standard work, she promises to be reliable and accountable to her team. Standard work tells the team where a manager will be and when, what questions she will ask and when she will be available to work through issues. According to Toyota, work is standardized when the precise elements of the job are done the same way every time and at a repeatable cycle time. Our stat sheet conversations and huddles are not as precisely timed or repeatable as a mechanized process, so maybe it is more correct to say that our standard work is more like a fixed schedule of activities. We are, however, still evolving, and our goal is a repeatable, reliable system of managing for improvement.</span> </span></span></blockquote>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Here is how it all fits together. We use stat sheets to see the business, plan our day, and see the trends developing. We widen the conversation with the team huddle, where we look for trends in performance and use standards to find the gaps between our goals and our performance. This leads directly to problem solving and using the scientific method to close the gaps. Information gathered in huddles and problem solving is then published to the area improvement center— whether that is in an outpatient clinic, an inpatient unit, or a finance office— allowing for transparency so that everyone can monitor progress. The advisory team gathers around the area improvement centers to monitor progress and advise the leader, who monitors the team’s performance through the monthly scorecard. Standard work at all levels ensures that everyone stays on track and that we have a measurable norm for leadership performance. </span></span></blockquote>
<blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;">Reduced to seven words, these elements add up to developing people, solving problems, and improving performance...</span></span></blockquote>
<blockquote>
Barnas, Kim (2014-05-09). <u>Beyond Heroes: A Lean Management System for Healthcare</u> (Kindle Locations 523-568). ThedaCare Center for Healthcare Value. Kindle Edition. </blockquote>
They're doing ACO. They use Epic. They consistently hit high on HEDIS. They have to comply with all of the regulations and clinical reporting measures that bedevil everyone else.<br />
<br />
They're obviously doing something right. This book and the other two antecedent works I cited will give you a good idea of precisely <i>what</i>. Imagine going to work every day within an organization where an ongoing priority for <i>everyone</i> is scientifically improving the work processes.<br />
<br />
Imagine.<br />
<br />
Highly recommended, if a bit pricey (<i>that</i> ticked me off somewhat). I bought the $35 hardcover straight away ("First Mover Disadvantage"), but it's now <a href="http://www.amazon.com/Beyond-Heroes-Management-System-Healthcare-ebook/dp/B00K97O398/ref=sr_1_1?ie=UTF8&qid=1400690010&sr=8-1&keywords=Beyond+Heroes" target="_blank">available on Amazon in $9.99 Kindle edition</a>. Yeah, I bought that as well.<br />
<br />
Concluding observations from "Beyond Heroes."<br />
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><b>The future at our door </b></span></span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">...Just
a few decades ago, hospitals were the centers of catastrophe. We saw
victims of sudden illness and accidents. We generally offered short
courses of treatment that the patient either survived or did not. For
lesser maladies people saw a family doctor and, even there, care was
usually targeted at a particular complaint with a limited time horizon.</span></span><br />
<br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Now,
we have entered into long-term relationships with our patients.
Longevity is increasing. Diabetes, obesity, asthma, arthritis, and
mental disorders such as depression and bipolar disease now call for
regular, ongoing treatments that can last a lifetime. Many cancers are
becoming chronic conditions, joining HIV/ AIDS as a disease we can live
with for decades.</span></span><br />
<br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">This
means that much of healthcare will focus on helping patients to help
themselves in managing and improving their lives. Out of absolute
necessity, we will finally begin to focus— as an industry— on wellness
instead of illness. We will pay more attention to the life needs of the
patients, to keeping people independent and able to care for themselves
well into old age. This will require new tools and more time and
patience. We will spend more time counseling people on how, for
instance, specific diets and exercise affect their chronic disease, and
our information will be based on solid scientific evidence rather than
fads. We will talk more about staying out of the exhausting cycle of
hospitalization and recovery and less about what new, short-term
treatments we can offer.</span></span><br />
<br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">We
will focus on patient wellness because it is the right thing to do and
because we will be paid that way. In the near future, healthcare
organizations will most likely receive a pool of funds to look after the
healthcare needs of a population of patients, as I noted in the
previous chapter. A number of experiments have been running around the
United States and the value-based, or population-based, payment concept
has emerged as the most likely method for controlling costs while
improving patient outcomes and experiences.</span></span><br />
<br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Using
this system, independent healthcare providers will be profitable only
if they offer good care with a minimum of defects and waste. If
patients in an organization’s population pool suffer from runaway
obesity, asthma attacks that require hospitalization, and births
complicated by a lack of prenatal care, that will cost the organization.
A lot. That means we will see a major push by the healthcare industry
to offer better preventive care.<br /><br />Physicians and administrators
will have a vested interest in knowing which tests and procedures are
the most effective for patients, as opposed to the most billable. So how
does this relate to the business performance system? Healthcare
organizations that practice continuous improvement will have the
advantage in this system because they are already accustomed to
increasing profit margins by eliminating waste and creating more
efficient processes. If medical group A investigates its treatment path
for stroke victims and creates better outcomes by reducing the time it
takes to administer clot-busting drugs, for instance, it will spend
fewer resources on patient recovery time than group B and therefore earn
a better profit margin and reputation. (This will also save the family
and community from the costs and heartbreak associated with long-term
care of a person who can no longer function at full capacity.) Saving
money by offering better treatment also means a medical group could
afford to attract the best providers and reinvest in its facilities and
people... </span></span></blockquote>
One nice thing about the
book is the way these Lean deployment principles, management strategies,
and process improvement tactics are illustrated via the stories of
individuals at work, doing their jobs and working to improve their jobs
as a matter of course. It's a good, conversational read.<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>SPEAKING OF EPIC AND DOING THINGS RIGHT</b></span><br />
<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYAtRuQNAOCgbZBc1VgEMG16XniAjFlGvRF78B7X5ngixNuWHYBKFyn9Fy-I5aZOFGv6Qiy4ZkaTzHLPIz4pPiEZgux5X9_72ACPSbvb-Fa2lN3baDlFZchFoEz-7bxoaED1WMR5YbDWlp/s1600/Connected4Health.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYAtRuQNAOCgbZBc1VgEMG16XniAjFlGvRF78B7X5ngixNuWHYBKFyn9Fy-I5aZOFGv6Qiy4ZkaTzHLPIz4pPiEZgux5X9_72ACPSbvb-Fa2lN3baDlFZchFoEz-7bxoaED1WMR5YbDWlp/s1600/Connected4Health.jpg" /></a></div>
<br />
Recall my February 6th, 2014 review of this book? See <a href="http://regionalextensioncenter.blogspot.com/2014/02/meaningful-use-2013-review-and-hitpc.html#KP" target="_blank"><b><i>Meaningful Use 2013 review, ONC Working Group Stage 3 draft report, and discussion of KP's book "Connected for Health"</i></b></a><br />
<br />
Another bunch out there successfully <b><i>doing</i></b>.<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>AND, THEN THERE ARE THOSE <i>NOT</i> DOING THINGS RIGHT</b></span><br />
<blockquote class="tr_bq">
<a href="http://thehealthcareblog.com/blog/2014/05/22/the-va-scandal-implications-for-health-reform-and-a-call-for-clinical-research-into-the-reported-death-rate/" target="_blank"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: x-large;"><b>The VA Scandal: Implications for Health Reform and a Call for Clinical Research into the Reported Death Rate</b></span></span></a></blockquote>
___<br />
<br />
More to come...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>
BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-19337675550497177232014-05-19T08:25:00.000-07:002014-05-19T08:25:02.442-07:00Has regulatory compliance become an end in itself?<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJehYhRfRkrJKmUveF95Slk6US5-r4snUmd_rFpDj7V22-Doeeld6kmyYybjahPpVUMn7fEbs5ZXL-gKwKM_ZAF3yyc8x6Z7RHVJvK1wimswLVQsoqzB6LbqZNc9Hmq5uHLmRPVlz2nZcn/s1600/2014HITpriorities.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJehYhRfRkrJKmUveF95Slk6US5-r4snUmd_rFpDj7V22-Doeeld6kmyYybjahPpVUMn7fEbs5ZXL-gKwKM_ZAF3yyc8x6Z7RHVJvK1wimswLVQsoqzB6LbqZNc9Hmq5uHLmRPVlz2nZcn/s1600/2014HITpriorities.png" height="331" width="400" /></a></div>
<br />
From <a href="http://www.informationweek.com/healthcare/policy-and-regulation/healthcare-it-priorities-no-breathing-room/d/d-id/1252816" target="_blank"><b>InformationWeek.com</b></a><br />
<blockquote class="tr_bq">
<span style="color: #073763;"><span style="font-family: Georgia,"Times New Roman",serif;"><b><span style="font-size: x-large;">Healthcare IT Priorities: No Breathing Room</span></b><br /><b>Regulatory requirements have gone from high priority to the only priority for healthcare IT.</b></span></span></blockquote>
<blockquote>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Healthcare has always been a highly regulated industry, but in the last few years requirements for implementing and documenting digital healthcare systems have been piling up so fast that IT organizations have little time for anything else -- including making sure the systems they already have in place are being used effectively. The InformationWeek Healthcare IT Priorities Survey of 322 technology pros at healthcare providers shows "meeting regulatory requirements" is the No. 1 initiative on participants' minds. Most of the other items at the top of the list, such as implementing or upgrading electronic health records (EHR) systems, are also largely driven by federal government requirements.</span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"> "The priorities we're trying to deal with right now are those being mandated," says Randy McCleese, CIO of St. Claire Regional Medical Center. "We can't do anything else. We have put everything else on the back burner except for those things that absolutely have to be done."<br /><br />Against the crushing wave of requirements, what's most neglected by IT organizations is optimizing how healthcare providers use all the technology they've bought of late -- "and we've been provided with a lot of functionality in the last three to four years," says McCleese, who's also chairman of CHIME, the College of Healthcare Information Management Executives. "We've put all this technology in place quickly to meet the requirements, but we have not had a chance to make sure it's working effectively."...</span></span></blockquote>
Register to get the free pdf paper. Nicely done. Sample size is a bit small, though.<br />
<br />
The grousing about MU continues apace of at THCB: <i><b>"<a href="http://thehealthcareblog.com/blog/2014/05/17/the-case-for-dropping-mu-stages-2-and-3/" target="_blank">The Case for Dropping MU Stages 2 and 3</a>."</b></i> From the comments:<br />
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">I was one of the leaders in the EMR arena for many years, and was initially really excited about meaningful use. Yes. I admit that with some embarrassment now. I even was part of a CDC public health grand rounds regarding meaningful use and why it would be a good thing. Over time, however, I saw what you see now: meaningful use is not a definition of using the EMR productively; it is simply another bureaucratic layer doctors must get through before they can focus on patient care.</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />I do agree with items on your list, but the real benefit of the EMR is not one of documentation, it is about work-flow. Computers are good at remembering things we don’t remember, and are good at organizing information more efficiently. I would add several things that would make EMR systems more meaningfully useful:</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />1. Task managment. Why don’t any products focus on team management of tasks, as it is clearly one of the bigger barriers to good care. I believe that a system that focused on this would gain adoption without incentive, as it would actually make doctors’ jobs easier.</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />2. Information prioritization. It’s not what is put into the system that is important, it is what you can get out of it. Most EMR systems are a jumble of useless information that hides the useful information.</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />3. Better communication tools. We are using iChat in our office (locally hosted) and have found it to be incredibly useful to answer questions while the patients are on the phone. We can handle problems with fewer steps. There are many tools out there to make this kind of thing work. Patients could, for example, record MP3 files on their portable devices and have that upload to an EMR for handling by the office staff (in lieu of the overworked phone system).</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />4. Risk assessment and reduction – this is the overall goal of care: to make patients healthy and prevent problems from happening. The problem is that risk assessment tools are scarce in most EMR systems.</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />Our success at EMR implementation was due to our focus on it as a tool to improve patient care by transforming our workflows. As the burdens of meaninful use came on, however, the ability to do that was hampered enough that I not ony abandoned Meaninful Use, but I left the system altogether. My home-grown EMR is far more useful than anything I could find on the market.</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">__</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #0c343d;"><span style="font-family: Georgia,"Times New Roman",serif;">MU is meaningfully useless for patient care,. No, it is worse than that. It is an additional impediment to patient care.</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0c343d;"><br />Medical care is about ambiguity and shades of gray. EHR systems depreciate the nuances of care, and meaningful ruse destroys care processes by focusing on the irrelevant.</span><br />__</span></span></blockquote>
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">It can be an odd combination of naive and doggedly determined, both of which might apply to this situation.</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />I agree that politicians being what they are, they are unlikely to pull the plug on MU because that means an admission of fault and a loss of money to the constituents that are benefitting from MU. But… I’m naive enough to believe that, with enough groundswell, we could do something, even if not outright cancellation, that would improve the Frankenstein that we created, especially if we redirected the money to better HIT uses and sustained the appeal to constituency.</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />I’ve always dreamt of an EMR that was designed from the beginning to support clinician efficiency; quality of care; and cost of care. And then rolled all of that together into something that looked like a project management tool, like Base Camp, that recognized healthcare as a long term project involving several project teammates that need to interact and communicate. Dropping a bill would become a natural functional outcome, but wouldn’t be the primary motive of the design.</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />It’s amazing to me that those of us who procure EMRs don’t insist on a downloadable, transferable patient record. How did the music industry manage to pull off the MP3 standard without a government mandate? Maybe there’s a lesson in there for us, somewhere.</span></span></blockquote>
Critics have been griping about these issues since I started in the DOQ-IT program back in 2005. I've been addressing them since I started this blog four years ago.<br />
___<br />
<br />
More to come...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>
BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-6344747961767259132014-05-16T17:56:00.001-07:002014-05-19T09:55:22.508-07:00I'd planned to put up a thoughtful, meaningful post today, but...<i>Nah</i>. Today is the day that our nation's capitol was be be occupied by a reported 10 to 30 <u><i>million</i></u> "patriots" intent on "forcibly removing" the President and a long list of congressional leaders from office, at the behest of some group calling itself "<b><a href="http://operationamericanspring.org/" target="_blank">Operation American Spring</a></b>" (they eventually dialed back the "forcible" part that was central to the initial proffer).<br />
<br />
Well, what would be the point, in light of the incipient overthrow of the government? So, I turned to Photoshop for a bit of OTC medications fun.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_xP0gYLgRTwzyVjXl-2Ya-exeGG9HQlmsHYcQQYOrqgkGBej-8Cfp16ZZdM7uhGqN3OCIOvIwMPzwgbrTB_TXowpadVtUP0rKZ2MEumx-yuvHC_p9tiMEFTGCkcyHIKaVi60fTSfNSLo/s1600/BenGayZi.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_xP0gYLgRTwzyVjXl-2Ya-exeGG9HQlmsHYcQQYOrqgkGBej-8Cfp16ZZdM7uhGqN3OCIOvIwMPzwgbrTB_TXowpadVtUP0rKZ2MEumx-yuvHC_p9tiMEFTGCkcyHIKaVi60fTSfNSLo/s1600/BenGayZi.jpg" /></a></div>
<br />
Turnout was disappointing, by all accounts, but, hey, all several hundred or so actual attendees got a free tube. ;)<br />
<br />
The twitter hashtag <a href="https://twitter.com/search?f=realtime&q=%23AmericanSpringexcuses&src=hash" target="_blank"><b>#AmericanSpringExcuses</b></a> is pretty funny. <br />
___<br />
<br />
More to come. Back on topic shortly...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>
BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-85125938016383712152014-05-14T12:15:00.003-07:002014-05-21T18:28:55.096-07:00We're about to be BushwhackedRead an <a href="http://thehealthcareblog.com/blog/2014/05/14/government-or-how-my-cousin-the-president-nearly-killed-my-company/" target="_blank">interesting post by athenahealth CEO Jonathan Bush on <i><b>THCB</b></i> this morning</a>. Led me to <a href="http://www.athenahealth.com/jonathan-bush/where-does-it-hurt.php" target="_blank"><i>this</i></a>:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDIJVdz1Jc-bFzrpZOxxnLxRwdOSBpnpn8st5GGAs7mEKDwo4brHI2Ie-bf8WWsMmyfsgUDxfMC80ejwf4IUIrcG8gKwiXQ3narec7-uQCTRmH4e6gEr7cV2xsoejShObx7u5oLo0JKkzW/s1600/WhereDoesItHurt.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDIJVdz1Jc-bFzrpZOxxnLxRwdOSBpnpn8st5GGAs7mEKDwo4brHI2Ie-bf8WWsMmyfsgUDxfMC80ejwf4IUIrcG8gKwiXQ3narec7-uQCTRmH4e6gEr7cV2xsoejShObx7u5oLo0JKkzW/s1600/WhereDoesItHurt.png" /></a></div>
<br />
Interesting. I bet it's one long (ghostwritten?) riff on this well-known theme of his (from his <i>THCB</i> post):<br />
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">...To create a modern, caring and efficient health care economy, we have
to create more spaces where entrepreneurs can compete in the
marketplace—and not in the corridors of Capitol Hill.</span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Unlike many entrepreneurs, I had reason to feel comfortable in
Washington. Even though I couldn’t call my presidential cousin for help,
I had my political name, fancy venture firms behind me, and my equally
fancy business degree from Harvard. That gave me the confidence—or
hubris—to assume I could get in there and make a difference. I was an
outsider with insider status. I’d guess that 90% of businesses that get
blown up by government mis-steps, or even prevented from being born, are
run by outsiders with outsider status. That is why it’s so hard for an
activist government to be effective. It works with known players—while
the future should be in the hands of <i>unknown</i> players working to make the household names obsolete.</span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">The government, by regulating industry, actually ends up protecting
the incumbents. Here’s how. Let’s say the news comes out that insurance
companies are taking advantage of customers in an especially awful way.
Because this a service that society views as vital, the government comes
in and says, “Whoa, what’s going on in here?” Now the best thing to do
at this point would be to make it as easy as possible for new entrants
to come into the system and disrupt these guys—clean their clock, kill
them, or at the very least force them to change. But instead the
government looks to control them. They do this by writing up cumbersome
regulations. These discourage newcomers from the market. Many of the
best would-be competitors don’t employ a single lobbyist or lawyer. They
take one look at a market regulated up the wazoo, and conclude, wisely,
that they’re not built to play that game. They’re better off building a
new video game or a dating app. So instead of making the bad incumbents
vulnerable, the government leaves them fat, lame and stupid—but with
formidable lobbying power. Since these companies employ a lot of people,
they become untouchable...</span></span></blockquote>
From <b>CNBC</b>:<br />
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">[David]
Einhorn, co-founder of Greenlight Capital, called Athenahealth a
"bubble" stock that could fall 80 percent or more from its peak share
price of more than $204 in March. He also said the company's potential
products are being overvalued.</span></span></blockquote>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhePj94twJwU_yoQywFkjw6CHTYuKhADdmMWhASUwr0Xm7c4un9ptUZPTV4OhoOERl6oEMGSSg-uI_5n3dJhgXFFXFgqD-GxKHaV4TGB0JDGafQi98EERgWS4vtmjs1x32Atb4A5iKRKh0N/s1600/ATHN.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhePj94twJwU_yoQywFkjw6CHTYuKhADdmMWhASUwr0Xm7c4un9ptUZPTV4OhoOERl6oEMGSSg-uI_5n3dJhgXFFXFgqD-GxKHaV4TGB0JDGafQi98EERgWS4vtmjs1x32Atb4A5iKRKh0N/s1600/ATHN.jpg" /></a></div>
<br />
<a href="http://www.cnbc.com/id/101654089" target="_blank"><b>Einhorn</b></a> has been advising investors to short ATHN.<br />
<br />
UPDATE:
I emailed athenahealth asking for a comp review copy. They blew me off.
No reply. The gall of some pissant small-fry curmudgeon independent
blogger.<br />
<br />
Just checked; the price of the Kindle edition
has already dropped $3, from $14.99 to $11.99. I don't think I'm gonna
buy it, even though it's probably pretty well done. Competing
priorities for my dollars.<br />
<br />
Once we get past the 5-Star effusive "Friends and Family"
hagiographic Amazon shill "reviews," we'll see what people actually
think.<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>FROM THE AMAZON "LOOK INSIDE" SAMPLE</b></span><br />
<br />
I used Dragon to transcribe this little excerpt.<br />
<blockquote class="tr_bq">
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">In
the lumbering healthcare industry that we have come to know in the last
half-century, information is a scarce resource. Patients rarely have
access to the records. No one can hazard a guess as to what an
operation, a medicine, or even a Band-Aid might cost. Keeping this
information button and up benefits the incumbents, who thrive within
what we might call and ignorance economy. Some, as we’ll see, are still
attempting to control their local markets by limiting access to data. It
sooner or later, data promises to turn this status quo on its head,
ushering in a slew of new digital startups and — most important —
delivering vital and timely information to the patients, or customers.<br /><br />And
what will they do with this information? It can be summed up in a
single word: shopping. This has to do with making choices. We weigh
countless options in the rest of our lives, but not nearly enough of
them in healthcare. Shopping, whether it’s driven by an individual, a
retail buyer, or a wholesaler, creates the market, and the market
responds with choices and innovation. What’s more, in markets driven by
shopping, losers figure out how and where to change their fortunes, or
they disappear.<br /><br />We need shopping, I believe, not only to fix
healthcare, but also — and I know this may sound strange — to express
our own humanity. Think about it. We shop for clothes to express our
tastes and personality. We do the same for music and food. Some of us
trick out our cars, put them on mega wheels, or hang big, fuzzy dice
from the mirror. We express we are with these choices. And yet for the
care of our bodies, for some of the most important decisions we make in
life, we rely on a handful of menu options and lists drawn up by
bureaucrats. What I want is for people to have a dizzying array of
options in healthcare, so they can care for themselves and their loved
ones in a way that suits them best, that makes them happy and proud.
Some of the choices will be simple, of course, others delightfully
convoluted. But in my vision, each of us will fashion the health care we
want and deserve. We'll express ourselves. </span></span></blockquote>
Go <i>shopping</i>? Where have we heard <i>that</i> before? Right,
health care purchases are no different from buying clothing or CDs or
cars. We don't want actual health care, we want "choice," via which to
make fashion statements?<br />
<br />
From the Amazon blurb on another of my favorite books, <u><b><a href="http://www.amazon.com/Paradox-Choice-Why-More-Less/dp/0060005688/ref=tmm_hrd_swatch_0?_encoding=UTF8&sr=&qid=" target="_blank">The Paradox of Choice: Why More Is Less</a>:</b></u><br />
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Whether
we're buying a pair of jeans, ordering a cup of coffee, selecting a
long-distance carrier, applying to college, choosing a doctor, or
setting up a 401(k), everyday decisions -- both big and small -- have
become increasingly complex due to the overwhelming abundance of choice
with which we are presented.<br /><br />As Americans, we assume that more
choice means better options and greater satisfaction. But beware of
excessive choice: choice overload can make you question the decisions
you make before you even make them, it can set you up for
unrealistically high expectations, and it can make you blame yourself
for any and all failures. In the long run, this can lead to
decision-making paralysis, anxiety, and perpetual stress. And, in a
culture that tells us that there is no excuse for falling short of
perfection when your options are limitless, too much choice can lead to
clinical depression.<br /><br />In The Paradox of Choice, Barry Schwartz
explains at what point choice -- the hallmark of individual freedom and
self-determination that we so cherish -- becomes detrimental to our
psychological and emotional well-being. In accessible, engaging, and
anecdotal prose, Schwartz shows how the dramatic explosion in choice --
from the mundane to the profound challenges of balancing career, family,
and individual needs -- has paradoxically become a problem instead of a
solution. Schwartz also shows how our obsession with choice encourages
us to seek that which makes us feel worse.<br /><br />By synthesizing
current research in the social sciences, Schwartz makes the counter
intuitive case that eliminating choices can greatly reduce the stress,
anxiety, and busyness of our lives. He offers eleven practical steps on
how to limit choices to a manageable number, have the discipline to
focus on those that are important and ignore the rest, and ultimately
derive greater satisfaction from the choices you have to make. </span></span></blockquote>
__ <br />
<br />
BTW: Got my hardcopy of the ThedaCare Center book "<a href="http://createvalue.org/product/beyond-heroes/" target="_blank"><u><b>Beyond Heroes</b></u></a>" yesterday. Started on it in earnest last night.<br />
<br />
<br />
Just downloaded this as well:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEge9MbCeVPfjX0ZRAb9I0rp2FpTzPgRJbLKZADJBS4gY0IP-kQMB2J-RG5x3CgmvhMDXHqEn25FLUIGsdQOwoovsDP9wv_2C9onLGMxcMFWUHxPtkbKKZyJnSzLCk29KPNb-Y3M3oFSbeWn/s1600/TomorrowsMedicine.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEge9MbCeVPfjX0ZRAb9I0rp2FpTzPgRJbLKZADJBS4gY0IP-kQMB2J-RG5x3CgmvhMDXHqEn25FLUIGsdQOwoovsDP9wv_2C9onLGMxcMFWUHxPtkbKKZyJnSzLCk29KPNb-Y3M3oFSbeWn/s1600/TomorrowsMedicine.jpg" /></a></div>
<br />
The <i><b>Scientific American</b></i> eBooks are excellent, and inexpensive. I have a bunch of them.<br />
<br />
Stay tuned...<br />
__ <br />
<br />
<span style="color: #990000;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><b>AND THE HITS JUST KEEP ON COMIN' </b></span></span></span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1EycQKW92a6HskPVHpd9wBCRtQ_8wa2TPJIeBtCL9-LWS6T4ktzv8m8avM_LxuZ730hx8KGZ6yEKJLVDKnoGf4Y99zg3qDnNK89hqOJZuitWczCSwrP73OoUY4Xws97iyKroTIFLL6F66/s1600/MUboxing.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1EycQKW92a6HskPVHpd9wBCRtQ_8wa2TPJIeBtCL9-LWS6T4ktzv8m8avM_LxuZ730hx8KGZ6yEKJLVDKnoGf4Y99zg3qDnNK89hqOJZuitWczCSwrP73OoUY4Xws97iyKroTIFLL6F66/s1600/MUboxing.jpg" /></a></div>
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;"><span style="font-size: x-large;"><b>How Meaningful Is Meaningful Use?</b></span></span></span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"></span></span></blockquote>
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">The government's Meaningful Use program mandating electronic health records is out of touch with reality. EHRs bog down process and can even worsen care. Despite the existence of a government program called Meaningful Use, as a doctor I have yet to see a meaningful, positive impact on care from electronic health record (EHR) systems.<br /><br />Regulators pushing for better and more cost effective medicine have decided that electronic technology, which has revolutionized many industries, is the solution needed to revolutionize medicine. We have been told that EHRs will make us better doctors, and they will make patients more responsible and engaged in their care. They go so far as to claim that EHRs will save doctors and hospitals time, that they will provide better coordination of care and save lives. While I can envision a world where this could be true, those of us living in the real world struggle with the disconnect between what is touted and what we experience every day.<br /><br />It is true that some studies have shown specific benefits on selectedmeasures when EHRs are used. Unfortunately, this is not true in all studies. Some studies have failed to show improvement of any kind when an EHR system is implemented. Some show an increase in adverse outcomes, including death. The EHR is not a proven technology. It is an experiment, and hospitals and clinics are beta testing new ways of doing things every day. The en masse adoption of EHRs into hospitals is akin to forcing car makers to make all vehicles from a new plastic that theoretically could make them safer without having shown that it really works.<br /><br />High expectations for a new technology are typical, but pushing adoption of a technology that hasn't proven itself yet is inappropriate and flawed. Many haven't seen improvement in care coordination, efficiency, or patient engagement. In fact, some think things are worse with EHR. Patients now have to compete with computers to get their provider's full attention. Good documentation can take more time to input, and coordination of care still requires highly motivated teams. It is not clear if the EHR is more effective that a cohesive team with a spreadsheet. Additionally, health information exchanges are years away from truly interconnecting institutions and are not adding proven benefit to many.<br /><br />Part of the problem is the menagerie of disconnected proprietary systems, all trying to solve problems in their own way. They don't speak to each other. Many are plagued with poor design and poor usability. These problems can be solved, but they should have been solved before we bought the software, not after.<br /><br />In an effort to push EHR adoption and use, the Center for Medicare and Medicaid Services (CMS) has created the Meaningful Use (MU) incentive program, which defines what people should be doing with their EHR and pays them for doing it. The CMS has also instituted penalties for those who would remain on the sidelines. MU Stage 2 is ongoing, with the goals of increasing use of health information exchanges and patient engagement by enabling patients to access and transmit their own data. It also requires more intense use of EHR by physicians who must order tests, e-prescribe more consistently, look at labs in an electronic format, and keep everything safe from hackers.<br /><br />On the surface, these seem laudable. Yet the technology remains cumbersome and disconnected, making many of these tasks difficult at best. Some tasks require someone else to act -- the patient or the health IT vendor. Even with a certified product, meeting MU Stage 2 requires overcoming some major hurdles. It is not clear that any of these things are improving care or saving time, money, and lives, as claimed by the CMS...</span></span></blockquote>
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;">I am all for advancement, but trying to push a technology that is not mature nor the best one to solve the problems at hand is ill-conceived and foolish. Many of the current EHR systems are simply inadequate. Continuing to put energy into making these systems do tasks they can't isn't helping anyone. We are wasting time and resources trying to fit a round peg in a square hole. MU is pushing adoption of technology, but it is not improving the technology. It is simply making people use systems they wouldn't use without incentives.<br /><br />Our institution is striving to meet MU Stage 2. I am not sure if we will be able to. Our push to meet the required metric for patient engagement is not going well. Perhaps we are doing it wrong, or we have a lot of apathetic patients. Additionally, getting staff to go out of their way to use a very time-consuming CPOE process is more than challenging. Using CPOE makes it harder to look back and see what the current orders are. In order to care for patients, we have to keep separate notes outside of the EHR, creating more than twice the work as doing it on paper. Consultants can't figure out what is going on without talking to the other providers in person. This adds to the challenge of providing good care. If an EHR fails to achieve its No. 1 objective -- being a well-organized repository of information that is pertinent to a patient -- it is of little value, even if it can meet MU.<br /><br />EHRs need to be measured by usability and functionality, not whether they can achieve Meaningful Use metrics. Right now, we need to be focused on usability. Certifications mean nothing when a product doubles or triples the workload. Our EHR is a roadblock to providing well coordinated, evidence-based, efficient, and compassionate care. MU might have merit, but it is taking the focus off the bigger issue of usability.<br /><br />We shouldn't be pushing for universal measures until they can be met -- and until we have evidence that they are truly beneficial.</span><br />__<br /><br /><i>David M. Denton is a board-certified pediatrician and member of the American Academy of Pediatrics. He is a partner of the Pocatello Children's Clinic in Pocatello, Idaho, and is affiliated with Portneuf Medical Center where he currently serves as the medical staff</i></span></blockquote>
<a href="http://www.informationweek.com/strategic-cio/executive-insights-and-innovation/how-meaningful-is-meaningful-use/d/d-id/1252711?page_number=1" target="_blank"><b>Link to full article here</b></a>.<br />
<blockquote class="tr_bq">
<span style="color: #0c343d;"><span style="font-size: x-large;"><b><span style="font-family: Georgia,"Times New Roman",serif;">AMA Wants Major Overhaul of Meaningful Use</span></b></span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Warning that many physicians will not be able to advance to Stage 3 of the electronic health records meaningful use program, the <a href="http://www.healthdatamanagement.com/news/AMA-Wants-Major-Overhaul-of-Meaningful-Use-48049-1.html" target="_blank">American Medical Association is suggesting radical changes to all three stages</a>.<br /><br />Absent significant changes, more physicians--already struggling with the first two stages--will drop out of the program or be unable to move to Stage 3, the association contends in a letter to Centers for Medicare and Medicaid Services Administrator Marilyn Tavenner and National Coordinator for Health IT Karen DeSalvo, M.D...</span></span></blockquote>
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #134f5c;">AMA sharply criticized a HIT Policy Committee certification workgroup last week for being "unwilling to make a recommendation on making the overall program more manageable for physicians." Mari Savickis, AMA's assistant director for federal affairs, told the workgroup about 40 percent of eligible professionals have never participated in the meaningful use program and, of the 60 percent that have, 20 percent have dropped out. "The way to keep physicians from dropping out today or keeping them from making a decision to not participate is to make the program criteria more flexible," said Savickis.</span></span></blockquote>
<blockquote class="tr_bq">
<span style="color: #20124d;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: x-large;"><b>Fear and loathing in meaningful use</b></span><br /><b>'I cannot stress this enough: It is fear that drives this process – fear of audit, fear of penalty.'</b></span></span><br />
<br />
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.healthcareitnews.com/news/fear-loathing-meaningful-use?topic=,08,29" target="_blank">When it comes to the topic of meaningful use, Colin Banas, MD, is driven by fear</a>. And he's far from being the only one.<br /><br />The chief medical information officer at the Virginia Commonwealth University Medical Center's concern is the potential to fail meaningful use requirements because VCU sometimes tailors a vendor's certified product in order to make it more usable.<br /><br />Whereas such customization is a common practice in the world of enterprise software, in the realm of electronic health records it has become the veritable equivalent of stepping into a rather cloudy area wherein it is very hard to discern whether they’ve gone so far that an auditor might say VCU did not achieve meaningful use.<br /><br />What's more, Banas said that it would be impossible to estimate the resources VCU has used to readjust clinical workflows and codes to follow the letter of the law, when it was already clearly following the intent of the measure.<br /><br />"I cannot stress this enough: It is fear that drives this process – fear of audit, fear of penalty," Banas said, "and fear of vendor abandonment should a client choose to forge a different path."...</span></span> </blockquote>
<i>Man! </i>Where's the love?<br />
<br />
<a href="http://ehrintelligence.com/wp-content/uploads/2014-05-13-CMS-ONC-Letter-Stage-3.pdf" target="_blank">Read the full AMA letter here</a> (pdf).<br />
<br />
<b>BUT WAIT! THERE'S <i>MORE!</i></b><br />
<blockquote class="tr_bq">
<span style="color: #073763;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.fierceemr.com/story/john-halamka-80-providers-wont-meet-mu-stage-2-deadline/2014-05-15" target="_blank"><span style="font-size: x-large;"><b>John Halamka: 80% of providers won't meet MU Stage 2 deadline</b></span></a><br /><span style="font-size: x-small;">May 15, 2014 | By Susan D. Hall</span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Reiterating
his belief that the federal mandates for the healthcare industry are
"too much, too soon," Beth Israel Deaconess Medical Center CIO John
Halamka predicted that 80 percent of hospitals will fail to successfully
attest to Meaningful Use Stage 2 within the allotted time.<br /><br />He
told those attending the iHT2 Health IT Summit in Boston this week that
he expects many provider organizations to opt out of the program,
according to <i>Healthcare Informatics...</i></span></span></blockquote>
___<br />
<br />
More to come...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>
BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-49753078706681617252014-05-12T08:26:00.003-07:002014-05-12T17:33:18.631-07:00The future of Meaningful Use?<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhqfi5Ky73ZS-f7UX1fovSjq54It5DAPnuMZLHnkyWwushl8CIOiJUEthrQksNZelpoutwbOWnfcsugafMe3VT_0ONyu9EKkQwBDeRaCp8e5nwxezD391BNx1fo9hhvdygv8yRjUVdyZsGg/s1600/BBKing-Thrill.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhqfi5Ky73ZS-f7UX1fovSjq54It5DAPnuMZLHnkyWwushl8CIOiJUEthrQksNZelpoutwbOWnfcsugafMe3VT_0ONyu9EKkQwBDeRaCp8e5nwxezD391BNx1fo9hhvdygv8yRjUVdyZsGg/s1600/BBKing-Thrill.jpg" /></a></div>
<blockquote class="tr_bq">
<span style="color: #073763;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: x-large;"><b>Thrill is gone as meaningful use strains</b></span></span></span><br />
<span style="color: #073763;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>'I’m telling you, it’s really, really hard out here.'</b></span></span><br />
<a href="http://www.healthcareitnews.com/news/thrill-gone-meaningful-use-strains" target="_blank"><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: x-small;">Dana Manos, WASHINGTON | May 9, 2014</span></span></span></a><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">It seems just about everybody has a gripe or two concerning the meaningful use program: software vendors that make electronic health records systems, hospital CIOs, the very people charting the related committees and, of course, physicians.</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Whether that means it’s time to trim the EHR program’s sails, turn the boat around, or abandon ship entirely is becoming a matter of increasingly winded debate...</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #073763;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: x-large;"><b>Is meaningful use driving eligible providers off course?</b></span></span></span><br />
<a href="http://ehrintelligence.com/2014/05/12/is-meaningful-use-driving-eligible-providers-off-course/" target="_blank"><span style="color: #073763;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: x-small;">Kyle Murphy, PhD, May 12, 2014 </span></span></span></a><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">The concept of meaningful use has many supporters. Its execution, however, has its fair share of detractors. Even the most ardent proponents of meaningful use recognize the deficiencies present in the certified EHR technology required by the EHR Incentive Programs...</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Meaningful use involves a big amount of money: billions in incentives to eligible providers, more so to the EHR vendors whose systems they had adopted. As the industry shifts toward a value-based approach to care delivery, patients will more and more assume the role of consumers which in turn will require providers to be more discriminating in how they treat their customers.</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">“If reimbursement is going down, we have to always vet our decisions about how they provide value and we can recover that cost. There’s a very serious value proposition we’re having to make, and that’s good. It should be that way — we should be good stewards anyway,” says Reid.</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Meaningful use is only in its second phase, but early results from Stage 2 are underwhelming. Could it be the case for providers that the meaningful use journey is already.</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #073763;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: x-large;"><b>4 hospitals, 50 EPs have attested to Stage 2 Meaningful Use</b></span></span></span><br />
<a href="http://ehrintelligence.com/2014/05/07/4-hospitals-50-eps-have-attested-to-stage-2-meaningful-use/" target="_blank"><span style="color: #073763;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: x-small;">Jennifer Bresnick, May 7, 2014</span></span></span></a><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Only four eligible hospitals (EHs) and fifty eligible providers (EPs) have attested to Stage 2 of Meaningful Use so far, said Beth Myers on behalf of CMS during the latest Health IT Policy Committee meeting this week. While Myers stressed that the “slim amount of data” is too little to form an opinion about the success of Stage 2 so far, she was optimistic about the outlook for the second stage of the EHR Incentive Programs despite ONC Acting Director, Office of Economic Analysis, Evaluation, and Modeling, Jennifer King, noting that small rural and critical access hospitals (CAHs) are significantly lagging behind their peers in adopting EHR technologies ready for the new challenges ahead... </span></span></blockquote>
I have never really liked the phrase "Meaningful Use." Too easy to mock. Meaningful to <i>whom</i>? The clinicians who have to use the technology, or the payers and policy wonks?<br />
<br />
We need <i><b>Effective Use</b></i> of health IT by those who must use it. That assertion implies a ton, obviously, and it goes way beyond capturing a relative handful of measures in "structured data" formats.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizD5Pi-Tt9OgVTuAnNe3wAoEwH2L0Fj8n59VqH2y_-u4y5lFDR6Zi4NNgX98TJ3IQZJbcwJRx8loV8txAgvAO1hMlSXRy4IIAWk0bMEdzAqR7O8HD9bakXB41scKpU-1K7yCg3fueF8eQm/s1600/meaningful-use-choosing-program-documenting-auditing.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizD5Pi-Tt9OgVTuAnNe3wAoEwH2L0Fj8n59VqH2y_-u4y5lFDR6Zi4NNgX98TJ3IQZJbcwJRx8loV8txAgvAO1hMlSXRy4IIAWk0bMEdzAqR7O8HD9bakXB41scKpU-1K7yCg3fueF8eQm/s1600/meaningful-use-choosing-program-documenting-auditing.jpg" height="199" width="200" /></a></div>
__<br />
<br />
Oh, yeah, btw...<br />
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0c343d;"><span style="font-size: x-large;"><b>EHR Hardship Exception Deadline Is July 1</b></span></span><br /><a href="http://www.healthitoutcomes.com/doc/ehr-hardship-exception-deadline-is-july-0001" target="_blank"><span style="font-size: x-small;">By Christine Kern</span></a></span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"></span></span></blockquote>
<blockquote>
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">CMS provides update on EHR Hardship exceptions for eligible professionals who haven’t applied yet.<br /><br />Those eligible professionals within the Medicare EHR Incentive Program who did not successfully meet meaningful use in 2013 may still submit a hardship exception application for payment year 2015, according to the Centers for Medicare and Medicaid Services.<br /><br />As HealthData Management reports, the CMS deadline for eligible professionals to apply for 2013 reporting year-2015 payment adjustment year hardship exceptions is July 1. To date, 600 eligible professionals have applied for hardship exceptions, according to a CMS official who made a presentation during the Health IT Policy Committee's May 6 meeting.<br /><br />Elisabeth Myers, policy and outreach lead for the CMS Office of E-Health Standards and Services, told the committee that "We have received a number of hardship exemption applications. I know that that's been a big question of how those are going."<br /><br />Acceptable conditions for applying for the hardship exemptions include EHR vendor issues, lack of infrastructure and unforeseen/uncontrollable circumstances, "lack of control over the availability of Certified EHR Technology" and "lack of Face-to-Face Interaction." Hardship exceptions are valid for one payment year only; new applications must be submitted each year to continue a hardship exception claim for the following payment year...</span></span></blockquote>
See <a href="http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/PaymentAdj_HardshipExcepTipsheetforHospitals.pdf" target="_blank">the relevant CMS site here</a>. <br />
__<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>UPDATE</b></span><br />
<br />
From NBC News. Who owns your health data?<br />
<br />
<div style="text-align: center;">
<iframe frameborder="0" height="490" scrolling="no" src="http://player.theplatform.com/p/2E2eJC/nbcNewsOffsite?guid=p_30stk_healthdata_140430" width="615"></iframe>
</div>
<br />
I posted on health data ownership <a href="http://regionalextensioncenter.blogspot.com/2011/12/facts.html" target="_blank">back in 2011</a>. <a href="http://regionalextensioncenter.blogspot.com/2011/06/use-case.html" target="_blank">Here as well</a>.<br />
<br />
<b><i>apropos...</i></b><br />
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;"><span style="font-size: x-large;"><b>Hospitals overcharge med records by $7M</b></span><br /><b>Lawsuit alleges three New York hospitals and business associate overcharging up to $0.50 per page</b></span><br /><a href="http://www.healthcareitnews.com/news/charging-data-how-much-too-much" target="_blank"><span style="font-size: x-small;">Erin McCann, May 5, 2014</span></a></span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">A
triad of big name hospitals have come under fire recently for allegedly
overcharging patients for copies of their medical records. <br /><br />Back
in March, New York-based Mount Sinai Hospital, Montefiore Medical
Group, Beth Israel Medical Center and release of information service
company HealthPort Technologies were slapped with a class action lawsuit
for reportedly violating New York State's public health law regarding
medical record request fees. <br /><br />The group of plaintiffs
representing some 100 members alleged the three hospitals and HealthPort
Technologies, the company responsible for handling the record requests,
overcharged patients and clients by up to $0.50 per page. New York
Public Health Law stipulates fees for medical records are not to exceed
$0.75 per page and that fees are not to exceed the actual costs incurred
by the provider. <br /><br />[See also: <a href="http://www.healthcareitnews.com/news/charging-data-how-much-too-much" target="_blank">Charging for data: What is too much?</a>]<br /><br />According
to the lawsuit, clients were charged around $0.75 per page when the
incurred costs only calculated to $0.25 per page...</span></span></blockquote>
___<br />
<br />
More to come...<br />
<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>
BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-44105775140252153472014-05-10T10:41:00.003-07:002014-05-11T13:14:36.763-07:00The Blog turns 4<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjgnBYERebAc6OwbVwAJmEpkdyAaU2pXUTOjYmZDYDl84fGlJNX0qt4gC-rwRcQZdih4tUeMWNTJ-Jga3X10KdjVEu5jgvodZkPGKp7gXpkbWfrDukhxhc6aBKOAvioctJQajzQWKK_IEMp/s1600/KHITblogConversion.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjgnBYERebAc6OwbVwAJmEpkdyAaU2pXUTOjYmZDYDl84fGlJNX0qt4gC-rwRcQZdih4tUeMWNTJ-Jga3X10KdjVEu5jgvodZkPGKp7gXpkbWfrDukhxhc6aBKOAvioctJQajzQWKK_IEMp/s1600/KHITblogConversion.jpg" /></a></div>
<br />
With the REC initiative winding down -- heading quietly off the national
health IT stage in "no-cost extension" mode, and given that I have
retired from the program, it is time to finally execute a name change. I
will continue to use the old URL while I lock down the explicit URL
custom domain, but the re-direction URL "<b>Blog.KHIT.org</b>" will get
you here. I've been mirroring these posts at KHITblog.blogspot.com, but
that seems like a duplicative waste of effort and bandwidth, so I may
soon quit doing that. Too much hassle to migrate everything in my
right-hand Links column.<br />
<br />
I
originally registered both "RegionalExtensionCenter.blogspot.com" and
"RegionalExtensionCenters.blogspot.com" (I use the free Blogger.com),
with the latter simply "squatted" to prevent someone else from getting
it and causing confusion with my active REC blog work. My masthead title
was <i><b>"The HHS Regional Extension Center Blog,"</b></i> but I always noted that it was <i>not</i>
a HHS project, but was a in fact private, independent undertaking. This
is what the marketing peeps call "positioning." Today, the simple
phrase "REC blog" entered into a Google search (even absent the quotes) returns <i>this</i> blog as the first search result. Didn't pay a penny for that. Meta-tags, baby (among other SEO things).<br />
I launched this effort four years ago today. My initial post was entitled <a href="http://regionalextensioncenter.blogspot.com/2010/05/opportunity-for-collaboration-asq-and.html" target="_blank"><i><b>Opportunity for collaboration? ASQ and the RECs</b></i></a>. I have to admit to disappointment that I never got any traction with the collaboration. I am a senior member of ASQ and continue to believe it could bring a lot to the healthcare and health IT tables. ASQ Healthcare Division Chair Dr. Joe Fortuna agreed, and invited me into the <a href="http://regionalextensioncenter.blogspot.com/2010/12/my-excellent-adventure-into-mecca-of.html" target="_blank">Division Leadership Council</a>, and we made repeated proposals for <i>pro bono</i> collaboration with ONC.<br />
<br />
ONC, though, exuded a <i>"not-invented-here,-not-interested-here" </i>indifference,
and the various relevant ASQ Divisions seemed equally uninterested. In
fact, the only feedback I got early on after pitching the idea around
the Society was a that of being admonished by some dope in the Software
Quality Division for "using the ASQ logo without permission" on my
blog.<br />
<br />
<i>Seriously</i>, bro'? That the best you can do?<br />
<br />
We see how far <i>that</i> got him.<br />
<br />
I attended seven major healthcare and Health IT conferences and events in 2013 for the blog (<a href="http://regionalextensioncenter.blogspot.com/2013/01/himss13-new-orleans-march-3-7.html" target="_blank">HIMSS13</a>, <a href="http://regionalextensioncenter.blogspot.com/search?q=Refactored" target="_blank">Health 2.0 Refactored</a>, <a href="http://regionalextensioncenter.blogspot.com/search?q=California+State+HIT" target="_blank">California State HIT Day</a>, <a href="http://regionalextensioncenter.blogspot.com/2013/06/lean-healthcare-transformation-summit.html" target="_blank">Lean Healthcare Summit</a>, <a href="http://regionalextensioncenter.blogspot.com/2013/10/health-20-2013-final-day.html" target="_blank">Health 2.0 2013 Annual</a>, <a href="http://regionalextensioncenter.blogspot.com/2013/11/nyec-2013-digital-health-conference-day_16.html" target="_blank">NYeC 2013</a>, and the <a href="http://regionalextensioncenter.blogspot.com/search?q=IHI+25+Forum" target="_blank">IHI 25th Forum</a>). I was apparently the <i>only</i> ASQ member at <i>any</i> of them. <i>Sigh...</i><br />
<br />
The other weird thing that went down at the launch of this blog was the upshot of my mistake in having had the impolitic temerity of directly contacting my CEO, Marc Bennett with the good news of Dr. Fortuna's interest in helping the REC initiative. I got immediately and publicly upbraided within HealthInsight by <a href="http://healthinsight.org/ut-about-us/healthinsight-blog/blogger/listings/140-sdonnelly" target="_blank">our then-REC Executive Director</a> for <i>"exceeding your scope."</i> The soap opera Uproar was pretty lame.<br />
<br />
I thought I was gonna get fired after only two months into the job. It
was stressful. It sucked. I was blindsided. My relationship with Marc
went back to the early '90's, when the Utah Peer Review and Nevada Peer
Review were merged to form the bi-state <i><b>HealthInsight</b></i>. Marc was on the Communications team and I was an analyst. <i>Way</i>
antedated the tenure of this particular ED. I was unaware that I was
now not to directly approach His Most Serene High CEO-ness.<br />
<br />
Cooler heads prevailed, though, and she never brought it up again. The Big Emergency Inquisition Meeting never happened. 314 posts later I am still blogging, still supporting the now-mostly moribund REC program, and still trying to add content and perspectives of value to the healthcare and Health It spaces. My interests, as regular readers of this blog know full well, go way beyond just IT to process improvement and rational healthcare and Health IT policy.<br />
<br />
I don't get paid for any of this. I do it because it's important. I'm "retired" now, and have been joyfully catching up with life with<a href="http://www.pinterest.com/pin/559572322421330374/" target="_blank"> my awesome wife</a> after five years of difficult work separation (and dealing with some of the inevitable chronic health issues that come with my age). I'm behind on some of my prospective KHIT work, but I will catch up. I have two books to finish writing, and more reading to do than I can possible ever keep up with. Some KHIT stuff remains under wraps 'til I get them done.<br />
<br />
<a href="http://busking.bgladd.com/" target="_blank">Spending some quality time with my guitars, too</a>. And, last night I exercised <a href="http://santafeandthefatcityhorns.blogspot.com/" target="_blank">my live performance photographer chops</a> by attending a benefit performance in Mill Valley at the Throckmorton Theater for the <b>"<a href="http://www.3stillstanding.com/" target="_blank">3 Still Standing</a>"</b> documentary project. I'll be dumping, triaging, and posting my shots from last night to my Facebook page and another of my blogs as soon as I finish here.<br />
<br />
Lots of important stuff to continue to write about. And, if <u><i><b>you</b></i></u> would like to write for/cross-post with the KHIT blog, just let me know. My traffic numbers are pretty decent; you'll get good exposure.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgD1mO9YPP7G8WjtcuJNbHfaK3KMBEB9RBT4hICalRh7nc0tkmJWBiy8DopzlzcYxpBaIL7WHKaw3xJhMO8dGKR3oVQWDhLhDc_MEJtAdJ0bwTpiHDG5ZMHr43VzUCAYxE0-jFViURI8iwF/s1600/BobbyG_2012.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgD1mO9YPP7G8WjtcuJNbHfaK3KMBEB9RBT4hICalRh7nc0tkmJWBiy8DopzlzcYxpBaIL7WHKaw3xJhMO8dGKR3oVQWDhLhDc_MEJtAdJ0bwTpiHDG5ZMHr43VzUCAYxE0-jFViURI8iwF/s1600/BobbyG_2012.jpg" height="273" width="320" /></a></div>
<br />
Thank you for your continued interest.<br />
<blockquote class="tr_bq">
<i><b>- BobbyG </b></i></blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;"><b>UPDATE:</b></span><br />
<br />
<a href="http://tinyurl.com/lhssaqx" target="_blank">Some of my shots from last night</a>, uploaded to my Facebook site.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrWeqhp0WKScKS_kTKonCVv8yQlaiT81qeyfImIooNCjVhzmc2ml4k_cOZeXoQQ0MnL07aB5zj7M70iOMFIN_k4Ni4lFFHxTOAk3RFJEVMTN6IREWRd-96ahf64A-xr4ohVqBOaqOzeRMH/s1600/3StillStanding.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrWeqhp0WKScKS_kTKonCVv8yQlaiT81qeyfImIooNCjVhzmc2ml4k_cOZeXoQQ0MnL07aB5zj7M70iOMFIN_k4Ni4lFFHxTOAk3RFJEVMTN6IREWRd-96ahf64A-xr4ohVqBOaqOzeRMH/s1600/3StillStanding.jpg" height="320" width="213" /></a></div>
___<br />
<br />
More to come...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>
BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-47292036701475817742014-05-07T14:23:00.003-07:002014-05-07T17:32:40.881-07:00ICD-9: E922.9, E955.4, E956, E970, Health IT, public health, and the Second AmendmentImagine coming across an EHR Social History sub-template like <i>this:</i><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjGpmZAMlsi_ryaoIhrSg7ckGPTcS73PBBD03-10t1PW5IRp4OgHIYp3s93kUIt4w_okvj5TI2lPzD-vrPrDBi5FgCgh8aAWH5Mh0yFaTkItXOLUcpabiTNJ05xcMUc3iGUkUo7L3yBghWI/s1600/eCWfirearmsSHtemplate.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjGpmZAMlsi_ryaoIhrSg7ckGPTcS73PBBD03-10t1PW5IRp4OgHIYp3s93kUIt4w_okvj5TI2lPzD-vrPrDBi5FgCgh8aAWH5Mh0yFaTkItXOLUcpabiTNJ05xcMUc3iGUkUo7L3yBghWI/s1600/eCWfirearmsSHtemplate.png" /></a></div>
<br />
Preposterous. First of all, notwithstanding the potential public health data mining utility of such information, it's <i>illegal</i> for a clinician to ask a patient about firearms possession and usage. The gun lobby made sure to have such a proscription inserted in the PPACA. <i>to wit:</i><br />
<blockquote class="tr_bq">
<span style="color: #073763;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><b>PPACA, consolidated:</b></span><br /><br /><span style="font-size: large;"><b>SEC. 2717 [42 U.S.C. 300gg–17] ENSURING THE QUALITY OF CARE.</b></span><br /><br />(b) WELLNESS AND PREVENTION PROGRAMS -- For purposes of subsection (a)(1)(D), wellness and health promotion activities may include personalized wellness and prevention services, which are coordinated, maintained or delivered by a health care provider, a wellness and prevention plan manager, or a health, wellness or prevention services organization that conducts health risk assessments or offers ongoing face-to-face, telephonic or web-based intervention efforts for each of the program’s participants, and which may include the following wellness and prevention efforts:<br /><br />(1) Smoking cessation. <br />(2) Weight management. <br />(3) Stress management. <br />(4) Physical fitness. <br />(5) Nutrition.<br />(6) Heart disease prevention. <br />(7) Healthy lifestyle support. <br />(8) Diabetes prevention. <br /><br />PROTECTION OF SECOND AMENDMENT GUN RIGHTS -- As added by section 10101(e)(2) <br /><br />(1) WELLNESS AND PRIVENTION PROGRAMS -- A wellness and health promotion activity implemented under subsection (a)(1)(D) may not require the disclosure or collection of any information relating to—<br /><br />(A) the presence or storage of a lawfully-possessed firearm or ammunition in the residence or on the property of an individual; or<br />(B) the lawful use, possession, or storage of a firearm or ammunition by an individual.<br /><br /><b><span style="color: #990000;">(2) LIMITATION ON DATA COLLECTION -- None of the authorities provided to the Secretary under the Patient Protection and Affordable Care Act or an amendment made by that Act shall be construed to authorize or may be used for the collection of any information relating to<br /><br />(A) the lawful ownership or possession of a firearm or ammunition;<br />(B) the lawful use of a firearm or ammunition; or<br />(C) the lawful storage of a firearm or ammunition. <br /><br />(3) LIMITATION ON DATABASES OR DATABANKS -- None of the authorities provided to the Secretary under the Patient Protection and Affordable Care Act or an amendment made by that Act shall be construed to authorize or may be used to maintain records of individual ownership or possession of a firearm or ammunition.</span></b><br /><br />(4) LIMITATION ON DETERMINATION OF PREMIUM RATES OR ELIGIBILITY FOR HEALTH INSURANCE<br /><br />A premium rate may not be increased, health insurance coverage may not be denied, and a discount, rebate, or reward offered for participation in a wellness program may not be reduced or withheld under any health benefit plan issued pursuant to or in accordance with the Patient Protection and Affordable Care Act or an amendment made by that Act on the basis of, or on reliance upon—<br /><br />(A) the lawful ownership or possession of a firearm or ammunition; or<br />(B) the lawful use or storage of a firearm or ammunition.<br /><br />(5) LIMITATION ON DATA COLLECTIONS REQUIREMENTS FOR INDIVIDUALS -- No individual shall be required to disclose any information under any data collection activity authorized under the Patient Protection and Affordable Care Act or an amendment made by that Act relating to—<br /><br />(A) the lawful ownership or possession of a firearm or ammunition; or<br />(B) the lawful use, possession, or storage of a firearm or ammunition.</span></span></blockquote>
<blockquote class="tr_bq">
<span style="color: #990000;"><i>[Emphases mine}</i></span></blockquote>
Moreover, in today's acrimonious 2nd Amendment climate, irrespective of the foregoing PPACA clauses, any EHR vendor providing such a template would likely get death threats. I've gotten them simply for posting <i>this</i> (below) online in weapons rights-related article comments sections and advocating for repeal of the 2nd Amendment, which I view as a dangerous anachronism -- a relic of a distant and very different time, one whose benefits are nil and lethal risks are empirically incontrovertible and legion.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2OFHy7eX4-rFyIvIY_0quDw220y57dQh2bJbvgq9X5a6S1DRdimHkxbiax8ohx0cuz-2Sk7n3MKI1ABUYug6df149u1G19xmkcf7SIyh30GVF7vdYKW6ibuvJ_zWDDDCX8Tn057r5JjV1/s1600/Treason.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2OFHy7eX4-rFyIvIY_0quDw220y57dQh2bJbvgq9X5a6S1DRdimHkxbiax8ohx0cuz-2Sk7n3MKI1ABUYug6df149u1G19xmkcf7SIyh30GVF7vdYKW6ibuvJ_zWDDDCX8Tn057r5JjV1/s1600/Treason.jpg" height="514" width="630" /></a></div>
<br />
Not kidding. One Keyboard Commando comedian warned me that <i>"you'll change your attitude after we come and kick your front door down"</i> and sent me URL links to jpegs showing automatic weapons and ammo caches. Another wrote <i>"We'll be over to Antioch soon. Until then, sleep tight."</i><br />
<br />
<b>From <a href="http://www.salon.com/2014/05/07/look_at_my_gun_why_nras_scary_open_carry_craze_is_not_about_freedom/" target="_blank">a Salon.com article</a> this morning:</b><br />
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Imagine you’re sitting in a restaurant and a loud group of armed men come through the door. They are ostentatiously displaying their weapons, making sure that everyone notices them. Would you feel safe or would you feel in danger? Would you feel comfortable confronting them? If you owned the restaurant could you ask them to leave? These are questions that are facing more and more Americans in their everyday lives as “open carry” enthusiasts descend on public places ostensibly for the sole purpose of exercising their constitutional right to do it. It just makes them feel good, apparently.</span></span></blockquote>
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">For instance, in the wake of the new Georgia law that pretty much makes it legal to carry deadly weapons at all times in all places, parents were alarmed when an armed man showed up at the park where their kids were playing little league baseball and waved his gun around shouting, “Look at my gun!” and “There’s nothing you can do about it.” The police were called and when they arrived they found the man had broken no laws and was perfectly within his rights to do what he did. That was small consolation to the parents, however. Common sense tells anyone that a man waving a gun around in public is dangerous so the parents had no choice but to leave the park. Freedom for the man with the gun trumps freedom for the parents of kids who feel endangered by him.<br /><br />After the Sandy Hook elementary school massacre, open carry advocates decided it was a good idea to descend upon Starbucks stores around the country, even in Newtown where a couple dozen armed demonstrators showed up, to make their political point. There were no incidents. Why would there be? When an armed citizen decides to exercise his right to bear arms, it would be reckless to exercise your right to free speech if you disagreed with them. But it did cause the CEO of Starbucks to ask very politely if these gun proliferation supporters would kindly not use his stores as the site of their future “statements.” He didn’t ban them from the practice, however. His reason? He didn’t want to put his employees in the position of having to confront armed customers to tell them to leave. Sure, Starbucks might have the “right” to ban guns on private property in theory, but in practice no boss can tell his workers that they must try to evict someone who is carrying a deadly weapon... </span></span></blockquote>
Anyone recall Nevada's absurd <i>"Second Amendment Remedies"</i> Senate candidate <a href="http://sharraonangle.blogspot.com/" target="_blank"><b>Sharron Angle</b></a>? And more recently, we have the maudlin spectacle of the scofflaw Bunkerville Nevada rancher <b>Cliven Bundy</b>, the bumbling, inarticulate hero to a throng of fractious, equally delusional self-appointed "militia" irregulars?<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="http://www.bgladd.com/AllAboutFreeDumb.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://www.bgladd.com/AllAboutFreeDumb.jpg" height="263" width="400" /></a></div>
<blockquote class="tr_bq">
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">"The second amendment in effect prevents the national government from destroying the militias of the states and preserves a personal right that is centuries old. Joel Barlow, the Connecticut wit and writer, in 1792 sagely declared that a tyrant disarms his subjects to <i>"degrade and oppress"</i> them, knowing that to be unarmed <i>"palsies the hand and brutalizes the mind,"</i> with the result that people <i>"lose the power of protecting themselves."</i> But arms privately held can be dangerous to society. President George Washington once reminded Congress that <i>"a free people ought not only be armed but disciplined."</i> He meant that the militias of his time had to be under military authority or, in the frequently used phrase, should be <i>"a well-regulated"</i> militia. However, we no longer depend on militias, a fact that in some respects makes the right to keep and bear arms anachronistic. An armed public is not the means of keeping a democratic government responsible and sensitive to the needs of the people. As the Supreme Court said in 1951, in <i>Dennis v. United States: "That it is within the power of Congress to protect the government of the United States from armed rebellion is a proposition which requires little discussion."</i> Whatever hypothetical value there might be, the Court said, in the notion that a <i>"right"</i> against revolution exists against dictatorial government <i>"is without force where the existing structure of the government provides for peaceful and orderly change."</i> The Court added, <i>"We reject any principle of government helplessness in the face of preparations for revolution, which principle, carried to its logical conclusion, must lead to anarchy." </i><br /><br />The right to keep and bear arms still enables citizens to protect themselves against law breakers, but it is a feckless means of opposing a legitimate government. The so-called militias of today that consist of small private armies of self-styled superpatriots are entitled to their firearms but deceive themselves in thinking they can withstand the United States Army. The Second Amendment as they interpret it feeds their dangerous illusions. Even so, the origins of the amendment show that the right to keep and bear arms has an illustrious history connected with freedom even if it is a right that must be regulated."<br /><span style="color: #444444;"><br />Professor Leonard W. Levy. <u>Origins of the Bill of Rights</u> (pp. 148-149). Kindle Edition. </span></span></span></blockquote>
From my blog post <a href="http://bgladd.blogspot.com/2012/12/force-majeure.html" target="_blank"><i><b>Force Majeure?</b></i></a><br />
<br />
We routinely capture and risk-analyze all manner of "lifestyle" data: smoking, alcohol, drug use, motorcycle-riding, skydiving, etc. I would add firearms possession and use to the EHR SHx templates.<br />
<br />
I won't be holding my breath, though. In fact, I'll likely be threatened
yet again for even suggesting it. Meanwhile, ICD-9 dx codes E922.9,
E955.4, E956, E970 and their kin will continue to populate U.S. hospital EHRs <i>post hoc</i> at a rate of several hundred per day.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2GoeGHzanxcMzIsYdCUndVF2n2hss30vYW6BJ8bCCHTc61Iy7UQ-kHU8BykNVesMGkhSH1F3SoGAUkw6VUTlNFODfUNrPQIniullEKaEt4yopop5ItGjw6_Uhv4Ef7b23vSyEksAqZ-Fc/s1600/GunsGR615px.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2GoeGHzanxcMzIsYdCUndVF2n2hss30vYW6BJ8bCCHTc61Iy7UQ-kHU8BykNVesMGkhSH1F3SoGAUkw6VUTlNFODfUNrPQIniullEKaEt4yopop5ItGjw6_Uhv4Ef7b23vSyEksAqZ-Fc/s1600/GunsGR615px.jpg" /></a></div>
___<br />
<br />
More to come...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>
BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-85186271694762007522014-05-05T08:37:00.001-07:002014-05-06T11:19:04.462-07:00Meaningful Use: who's making bank here?<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikUEfbOcxO4IR9rcIHzpOOYCsECgjG9Csw-MATLSWtImr9PdqwsOo7tPkQNkSnVrNGuu86xBttPC6NeU0hzpFplkkKYuiei0aLsiVAKa4GhmiPftIAtlmjhhLqBna4tFnGjDRmK9TdXP_n/s1600/fund-flow_645x400.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikUEfbOcxO4IR9rcIHzpOOYCsECgjG9Csw-MATLSWtImr9PdqwsOo7tPkQNkSnVrNGuu86xBttPC6NeU0hzpFplkkKYuiei0aLsiVAKa4GhmiPftIAtlmjhhLqBna4tFnGjDRmK9TdXP_n/s1600/fund-flow_645x400.jpg" height="198" width="320" /></a></div>
<br />
The feds just released <a href="http://hub.healthdata.gov/dataset/medicare-medicaid-incentive" target="_blank">a huge dataset comprised of Meaningful Use attestations by EHR vendor to date</a>. The dictionary:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhV1LU5EQ4A342Y7Vai5BOudwtc-IV2Xnc8eH-LVwy6vTGFHv_AQ3uOYU2srt4mVfspMuWqIngbIeS0w7KGFhlWmzw18c9RDsuMqfwR6AvA-X7XqUth0QPBm1WdYap8MQAk89pbaAtMws4y/s1600/MU_by_Vendor_Dictionary.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhV1LU5EQ4A342Y7Vai5BOudwtc-IV2Xnc8eH-LVwy6vTGFHv_AQ3uOYU2srt4mVfspMuWqIngbIeS0w7KGFhlWmzw18c9RDsuMqfwR6AvA-X7XqUth0QPBm1WdYap8MQAk89pbaAtMws4y/s1600/MU_by_Vendor_Dictionary.png" /></a></div>
<br />
552,406 data rows in the main sheet. You can grind these sixteen ways to Sunday for useful substrata. Here's my quick Excel tally of the aggregate ranks to date, all years, all programs (EPs, EHs, Medicare, Medicaid), top 25:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmU6w6JM4tk2IyolfmMhSeo3_aWy_oDsRM6pZ6A5x8HXBoKQOWrWoKGO_O1PgKtDPPaaiwbZxs2f-d3M8pihm7TJ45oQLzRfAJ025YqcuWnlLY6hcO2VOaLbfmE0OeBFXqL0Y5YMjtfuww/s1600/MU_report_data.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmU6w6JM4tk2IyolfmMhSeo3_aWy_oDsRM6pZ6A5x8HXBoKQOWrWoKGO_O1PgKtDPPaaiwbZxs2f-d3M8pihm7TJ45oQLzRfAJ025YqcuWnlLY6hcO2VOaLbfmE0OeBFXqL0Y5YMjtfuww/s1600/MU_report_data.png" /></a></div>
<br />
An "EPIC situation," no? While their relative share has decreased as the program has matured, they still rule, far and away.<br />
<br />
Note that the top 10 comprise ~2/3rds of the attestation action and the top 25 nearly 80%. Interesting that the freebie <b>Practice Fusion</b> is ranked 9th (beating out even Jonathan Bush's anti-REC <b>athenahealth</b>).<br />
<br />
I wonder how much of the $22.9 billion MU money paid out to date [1]
passed through to the vendors, and [2] cycled back around in taxes? To
the latter question, were it, say, ~20%, you'd have a bit more than $5
billion coming back to the Treasury.<br />
<br />
I'd also like to know
how much the Meaningful Use program has cost the taxpayers in total,
net (incentive payments, RECs, administrative costs at ONC and CMS,
etc). <br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>HIMSS ON THE REC FUTURE</b></span><br />
<br />
<b><a href="http://himss.files.cms-plus.com/FINAL%20REC%20Survey%20042914%20April%20Cover.pdf" target="_blank">Just out</a></b> (pdf).<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyJZAvfy1CjxuvVnuextQiWB5H4c48s0yHZ2Rtp3rwmHfxit4p6Ir8NmTLSD_yxo0l_p8-Vm7a9Ju3qpQMMs-8Q507C7jTEKuTyZXJzyOjVo8NIy-sob1NGF5-dPKAUwKd5HxylIrL-8BE/s1600/HIMSS2014_RECreport.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyJZAvfy1CjxuvVnuextQiWB5H4c48s0yHZ2Rtp3rwmHfxit4p6Ir8NmTLSD_yxo0l_p8-Vm7a9Ju3qpQMMs-8Q507C7jTEKuTyZXJzyOjVo8NIy-sob1NGF5-dPKAUwKd5HxylIrL-8BE/s1600/HIMSS2014_RECreport.png" height="400" width="396" /></a></div>
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">In August of 2013, the Office of the National Coordinator for Health Information Technology (ONC) announced the opportunity for a no-cost extension of the remaining funds available through the American Recovery and Reinvestment Act of 2009 (ARRA).</span></span></blockquote>
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">In order to assess how Regional Extension Centers (RECs) are going to prepare for a future in which funding was uncertain, HIMSS developed a study to evaluate organizations’ preparedness to sustain operations in the future. This survey assesses a number of factors including key information technology (IT) priorities, the business issues impacting RECs, and the types of strategic relationships organizations are creating to sustain viability...</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">By all accounts, the REC program has been extremely successful to date. Over 147,000 providers are currently enrolled with a REC. Of these, more than 124,000 are now live on an EHR and more than 70,000 have demonstrated Meaningful Use. Additionally, 872 Critical Access Hospitals (CRHs)/SRHs have been paid for MU1. Yet, as the ARRA funding winds down, there are questions around the financial sustainability of these organizations.</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />Findings from the 2014 HIMSS Regional Extension Center Study suggest executives are optimistic about the future of RECs. For example, 85 percent of executives responding to the survey indicated they did not expect to close their doors, despite the fact that 28 percent of the 36 executives responding to the 2014 HIMSS Regional Extension Center Study indicated that their funding ran out prior to the end of February 2014.</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />Indeed, RECs are moving forward with a number of strategies in which to ensure they can continue to fulfill their mission. Approximately three-quarters (72 percent) had applied for a no-cost extension of their ONC funding. Nearly half are creating strategic partnerships with other organizations in their service area. Finally, approximately half reported that they have received state funding to maintain operations...</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">...[A] handful of the RECs responding to this study noted that they have already been generating revenue streams to sustain operations going forward. One respondent noted that they are earning money from “provider membership fees, consulting services, selling IT resources and IP to other RECs and government entities”. This is not an easy model to achieve, and not all respondents believed that this model will yield full-blown sustainability. One respondent suggested that “the level of interest remains high among providers to continue with Stage 2 and embark in PCMH (patient centered medical home) recognition; the revenue generation from such activities is insufficient to maintain full-blown REC services”. Another noted that many organizations, including “RECs are not accustomed to looking for sustainability models nor have the infrastructure to operate as a for-profit entity. This has been the biggest concern with being a REC”. Finally, a respondent commented that “their organization will not commit to building a sustainable model”.</span></span></blockquote>
I continue to bemoan the short-sightedness of HHS not infusing the RECs with funding sufficient to get them and their clients through Stage 2.<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>A NEW BOOK ON ORDER</b></span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyNR7OqFs8k88zNQUL4cuUhryOmLuWB0TCDQlnIWmCe9v9C96cNGPLy8vCK7_wCiFrwuemUCmaTi35Z5WRZyoNXT0CmOK2wZxnF_fG1E5bMSc5magF_X7Z23wrKrNvdBI3e0eStSYNoEp9/s1600/Drop-Shadow-Beyond-Heroes.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyNR7OqFs8k88zNQUL4cuUhryOmLuWB0TCDQlnIWmCe9v9C96cNGPLy8vCK7_wCiFrwuemUCmaTi35Z5WRZyoNXT0CmOK2wZxnF_fG1E5bMSc5magF_X7Z23wrKrNvdBI3e0eStSYNoEp9/s1600/Drop-Shadow-Beyond-Heroes.jpg" height="320" width="217" /></a></div>
<br />
From the <a href="http://createvalue.org/product/beyond-heroes/" target="_blank"><b>Thedacare Center for Healthcare Value</b></a>.<br />
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">If the history of revolution around the globe has taught us one thing, it is this: leadership succeeds only when it learns to evolve. No matter how necessary and just the rebellion, when the dust clears, the leaders need to govern, to make systems work in order to keep a country or an organization running. And that requires an ongoing willingness to change and adapt.</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />For nearly a decade, the lean revolution in healthcare centered on improving quality and reducing costs in advance of the huge systemic changes we all knew were coming.With healthcare bills bankrupting families and threatening to do the same to the United States, major hospitals and health-system leaders began experimenting with various improvement methods. A healthy percentage of those organizations embraced lean thinking and adopted tools and methods from the Toyota Production System...</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">It turns out that revolutionary change is necessary, but it is not sufficient.</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />The kinds of change that come from rapid process improvements are essential but are only the first steps of a lean journey.The core work of the transformation is changing the culture—changing how we respond to problems, how we think about patients, how we interact with each other. This is an issue not only in healthcare organizations; we have also seen manufacturing, service companies, retailers, and government agencies all struggle with the same issues.When lean thinking goes only skin deep and management does not change, improvements cannot be sustained, and savings never quite hit the bottom line.</span></span>..</blockquote>
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">We are finally moving beyond the age of heroes chasing exceptions and are looking forward to innovations in management that will move us even further ahead.The faster we can implement these ideas, the better it will be for all of us—patients, physicians, nurses, managers, and everyone who pays for healthcare.</span></span><br />
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0c343d;">—John Toussaint, MD Founder and CEO,ThedaCare Center for Healthcare Value, January 2014 </span></span></span></blockquote>
</blockquote>
Not available in eBook format. Yet.<br />
__<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>OFF-TOPIC ERRATUM ON "MAKING BANK"</b></span><br />
<br />
I recently finished Nomi Prins excellent, best-selling history of the modern U.S. financial system, "<a href="http://www.nomiprins.com/presidents-bankers/" target="_blank"><b>All the Presidents' Bankers.</b></a>"<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgkBk0Ibk1TyRqcWsh7QygldlDNEL8wkW-2JKu67UFtSFA62_RufZJvB3h7ZjBdyK-uutx2AN9P-mJijvm5eftMXfBT3VSqdQVZngrfqinrANYDB9F0Jg01NQ07ORySkP0JEeoN1VFlnb-l/s1600/AllPresidentsBankers300h.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgkBk0Ibk1TyRqcWsh7QygldlDNEL8wkW-2JKu67UFtSFA62_RufZJvB3h7ZjBdyK-uutx2AN9P-mJijvm5eftMXfBT3VSqdQVZngrfqinrANYDB9F0Jg01NQ07ORySkP0JEeoN1VFlnb-l/s1600/AllPresidentsBankers300h.jpg" /></a></div>
<br />
<a href="http://www.amazon.com/review/R1N91CX4NLNZDA/ref=cm_cr_pr_perm?ie=UTF8&ASIN=156858749X" target="_blank">Read my Amazon review here</a>. Highly recommended. I have <a href="http://bgladd.blogspot.com/2008/12/tranche-warfare.html" target="_blank">some personal history with the often slimy FIRE Sector</a> (Finance, Insurance, and Real Estate).<br />
<br />
Playing off the phrase <i>"making bank,"</i> I've been bugging Ms. Prins and her agent with <i>this</i> idea.<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgjwgFbwDelRnswACgpfHNYpUjF7EAS5UZhX8ai3_PO0Wp4FQUpcVvS6agelWmLdA9aTah2gjLrrZSrVve598yV4yOXJ6COwywIrVmdwv41lGaNaU8q0Of3PITLeoU7hMCnbkUxJI_mKA8h/s1600/NomiPrinsMakingBank.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgjwgFbwDelRnswACgpfHNYpUjF7EAS5UZhX8ai3_PO0Wp4FQUpcVvS6agelWmLdA9aTah2gjLrrZSrVve598yV4yOXJ6COwywIrVmdwv41lGaNaU8q0Of3PITLeoU7hMCnbkUxJI_mKA8h/s1600/NomiPrinsMakingBank.jpg" height="283" width="400" /></a></div>
My quickie Photoshop. A no-brainer, this one. She is utterly gracious to put up with (and respond to) my emails.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijFbnQfuAX4RDLT7FqtAN9-ZKT3GLwixY353kJq44KJ1CHyTp1-IAqLNZPGxG7ayqsNNJQ7toZa8VTW_qxxymZVzvfpqV8hl7MjT-tadJ4kh9rzMP4XjpgsPkzstIDD1GehR71haMeliUn/s1600/Sachs.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijFbnQfuAX4RDLT7FqtAN9-ZKT3GLwixY353kJq44KJ1CHyTp1-IAqLNZPGxG7ayqsNNJQ7toZa8VTW_qxxymZVzvfpqV8hl7MjT-tadJ4kh9rzMP4XjpgsPkzstIDD1GehR71haMeliUn/s1600/Sachs.jpg" /></a></div>
I can't help it; I just have ideas all the time. I mostly just give them away, e.g., <a href="http://theworkshopclub.blogspot.com/" target="_blank">see this one</a>. <a href="http://www.bgladd.com/NextFlightHome.com/" target="_blank">And this old one</a>.<br />
__<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>MU INFOGRAPHIC</b></span><br />
<div style="text-align: center;">
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="http://www.nuemd.com/blog/meaningful-use-helping-or-hurting-ehr-adoption-infographic" style="margin-left: auto; margin-right: auto;"><img alt="Is Meaningful Use hurting or helping EHR adoption? [infographic]" border="0" src="http://www.nuemd.com/sites/default/files/u104/meaningful-use-infographic.png" width="600px" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://nuemd.com/" target="_blank"><b>nuemd.com</b></a></span></span></td></tr>
</tbody></table>
</div>
___<br />
<br />
More to come...<br />
<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>
BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-41436442265643921192014-04-30T16:50:00.003-07:002014-04-30T17:03:05.740-07:00$22.9 billion in MU payments through March 2014Data just released. Billions with a "B":<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYZHKRLlfD-WwGYa5RN20u67Fp0NgW_bjtyXreU7lBWyHSQEmlEWF8MBSoN26NnjdmB_NOgrA1xg3NLuXvKXVIaEPed-ISCH2b7ntoPRP_javdCUIIwEN4V73jjYX1N7S9NQa7QKbg78ax/s1600/MU032014.1.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYZHKRLlfD-WwGYa5RN20u67Fp0NgW_bjtyXreU7lBWyHSQEmlEWF8MBSoN26NnjdmB_NOgrA1xg3NLuXvKXVIaEPed-ISCH2b7ntoPRP_javdCUIIwEN4V73jjYX1N7S9NQa7QKbg78ax/s1600/MU032014.1.png" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg1EOvqcKZtf3JdoF3GeaV5NyO-1FCxcNoGbbCAo_Rz24HwUw1CDyqG_K6I0KQPsPMxOh7LeXgbAtshDuqcCtplo3hHlfUMEn7pDo8xUjuB3zhjGYNg6BMlxToiGvNRtaV5kxiw5WOdRi8c/s1600/MU032014.2.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg1EOvqcKZtf3JdoF3GeaV5NyO-1FCxcNoGbbCAo_Rz24HwUw1CDyqG_K6I0KQPsPMxOh7LeXgbAtshDuqcCtplo3hHlfUMEn7pDo8xUjuB3zhjGYNg6BMlxToiGvNRtaV5kxiw5WOdRi8c/s1600/MU032014.2.png" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhpMOEnXfiW8nsPDwb4LbasypRSX3-kZ8vLro6-AM7c9PzvS8aIxIfrsDGhS2HA1LHhtuLLtsqbXoqHuElpTXt8f78m1gE13LTAZSx_sezyGPSvcUMA7HjxCXH0ggE1k8m_p2q2RER26EzK/s1600/MU032014.3.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhpMOEnXfiW8nsPDwb4LbasypRSX3-kZ8vLro6-AM7c9PzvS8aIxIfrsDGhS2HA1LHhtuLLtsqbXoqHuElpTXt8f78m1gE13LTAZSx_sezyGPSvcUMA7HjxCXH0ggE1k8m_p2q2RER26EzK/s1600/MU032014.3.png" height="615" width="615" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtoxLPXu6Y-UTXU5lfJX-P5ogwcvVNX-8Ywm9xIPDFmjuX8YTsPZLFwHPoCI7RMPEU4duuHlE3QOzpExaYSH-E-dxOu75YQ5U7ZqFNPi69Eci7RibT2_7vn-iMcVMtcB_LojMWmQcu2lDa/s1600/MU032014.4.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtoxLPXu6Y-UTXU5lfJX-P5ogwcvVNX-8Ywm9xIPDFmjuX8YTsPZLFwHPoCI7RMPEU4duuHlE3QOzpExaYSH-E-dxOu75YQ5U7ZqFNPi69Eci7RibT2_7vn-iMcVMtcB_LojMWmQcu2lDa/s1600/MU032014.4.png" height="615" width="615" /></a></div>
<div class="separator" style="clear: both; text-align: left;">
</div>
<div class="separator" style="clear: both; text-align: left;">
<br /></div>
<div class="separator" style="clear: both; text-align: left;">
Notice the aggregated registrant counts for 2011 and 2012, after which they only give monthly registrations for 2013. Hmmm... 123,648 Medicare EPs in 2011, and 113,658 in 2012, for example. Maybe they just don't want you to easily see the dramatic fall-off in 2013 registrants. There were only 54,062 Medicare docs registered for MU in 2013, less than <i>half</i>, relative to 2012.</div>
<div class="separator" style="clear: both; text-align: left;">
<br /></div>
<div class="separator" style="clear: both; text-align: left;">
In fairness, there's been an uptick thus far in 2014: 19,237 through Q1. Last Chance for Romance, I guess.</div>
<div class="separator" style="clear: both; text-align: left;">
<br /></div>
<div class="separator" style="clear: both; text-align: left;">
Below, another interesting graphic, this one from a HITPC presentation.</div>
<div class="separator" style="clear: both; text-align: left;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQwMorqAd0cnT6ZR8Dpo_xh7c-0JrmKucjmI9SckUqQ6G22tVa8kkoHvgcKEFEIlYloaJXOhMabSJdZKzUwLkJvOlntFr3pGrMDMGXoNd2Pf6HAUOY3t9zq_UdHEbwHrRyqdFV2f06nQ_v/s1600/2011cohort.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQwMorqAd0cnT6ZR8Dpo_xh7c-0JrmKucjmI9SckUqQ6G22tVa8kkoHvgcKEFEIlYloaJXOhMabSJdZKzUwLkJvOlntFr3pGrMDMGXoNd2Pf6HAUOY3t9zq_UdHEbwHrRyqdFV2f06nQ_v/s1600/2011cohort.png" /></a></div>
<div class="separator" style="clear: both; text-align: left;">
<br /></div>
<div class="separator" style="clear: both; text-align: left;">
Early adopter attrition. Pretty severe, I would think. <u><i><b>Twenty five percent</b></i></u> of 2011 Attesters bailed in 2012 after picking up their Yeah 1 Stage 1 money? What cannot be clear at this point is how many of the 2011 cohort who made it through 2013 will stick around for the relative chump change of Stage 2 Year 1.</div>
<div class="separator" style="clear: both; text-align: left;">
<br /></div>
<div class="separator" style="clear: both; text-align: left;">
Also
unclear form the above is the Medicare vs Medicaid mix of the dropouts.
Are a significant proportion of them the Free Money "A/I/U"
registrants? On the Medicaid side, recall, an EP or EH can take "a year off."</div>
<div class="separator" style="clear: both; text-align: left;">
___</div>
<div class="separator" style="clear: both; text-align: left;">
<br /></div>
<div class="separator" style="clear: both; text-align: left;">
More to come...</div>
<div class="separator" style="clear: both; text-align: left;">
<br /></div>
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>
<br />
<div class="separator" style="clear: both; text-align: left;">
<br /></div>
BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-69408543191988278712014-04-29T08:11:00.002-07:002014-04-30T13:40:05.171-07:00You want some cheese with that whine?<a href="tp://ehrintelligence.com/2014/04/29/is-it-time-to-%E2%80%9Cdamn-the-mandates%E2%80%9D-and-forget-meaningful-use/" target="_blank">Continuing with a recent theme</a> (re: my <a href="http://regionalextensioncenter.blogspot.com/2014/04/maybe-we-should-cancel-stage-2-and.html" target="_blank">April 25th</a>, <a href="http://regionalextensioncenter.blogspot.com/2014/04/electronic-medical-charts-have-become.html" target="_blank">April 22nd</a>, and <a href="http://regionalextensioncenter.blogspot.com/2014/04/unhappy-news.html" target="_blank">April 15th</a> posts).<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYvgkPoQYpbFlXmGPvHoYuJkfcLQYZqM0u1fn7k5VRizzBXUmRbexr4Jo4Ztup_ofKbYc02dB_GTFa-NHEiZhLoKj3SBKxKpXEtRYoMoSe_-ENHbvU_Nfgw0dVPnJja3E0rGjVmwbajK4E/s1600/Barricades.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYvgkPoQYpbFlXmGPvHoYuJkfcLQYZqM0u1fn7k5VRizzBXUmRbexr4Jo4Ztup_ofKbYc02dB_GTFa-NHEiZhLoKj3SBKxKpXEtRYoMoSe_-ENHbvU_Nfgw0dVPnJja3E0rGjVmwbajK4E/s1600/Barricades.png" height="240" width="320" /></a></div>
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: x-large;"><b>Is it time to “damn the mandates” and forget meaningful use?</b></span><br /><span style="font-size: x-small;">Jennifer Bresnick, April 29, 2014</span></span></span></blockquote>
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"></span></span>
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Even as the healthcare industry marches dutifully into Stage 2 of Meaningful Use, there are still plenty of physicians that have not yet accepted the requirements put forth by CMS in the EHR Incentive Programs. Dr. Daniel F. Craviotto Jr., an orthopedic surgeon in Santa Barbara, California, <a href="http://online.wsj.com/news/articles/SB10001424052702304279904579518273176775310?mg=reno64-wsj&url=http%3A%2F%2Fonline.wsj.com%2Farticle%2FSB10001424052702304279904579518273176775310.html" target="_blank">took to the Wall Street Journal</a> this week to protest the restrictive chains of EHR adoption, quality penalties, shrinking Medicare reimbursements, and bureaucratic red tape that prevent a physician from focusing on what’s really important: engaging with and treating patients.</span></span></blockquote>
<blockquote class="tr_bq">
<blockquote class="tr_bq">
<span style="color: #660000;"><span style="font-family: Georgia,"Times New Roman",serif;">“In my 23 years as a practicing physician, I’ve learned that the only thing that matters is the doctor-patient relationship,” Craviotto writes. “I acknowledge that there is a problem with the rising cost of health care, but there is also a problem when the individual physician in the trenches does not have a voice in the debate and is being told what to do and how to do it. When do we say damn the mandates and requirements from bureaucrats who are not in the healing profession? When do we stand up and say we are not going to take it anymore?”</span></span></blockquote>
</blockquote>
<b>Aaron Carroll</b> has a <i>beaut</i> of a response in <a href="http://theincidentaleconomist.com/wordpress/once-more-unto-the-breach/" target="_blank"><i><b>The Incidental Economist</b></i></a>.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizXEOgcOrtwRs0DkEon_6jkf71KZ7wwwLWOOjWbmG1nWg95-3RXC8afeNf9x9zzo0t6K-SPvTJjYa6T8n25cD1p1Dd_9UwXP1w2yW8yRob1fcDwWiqgNdH6jtTpcGcNp7iUm770KHxgFEM/s1600/WWE-Smackdown.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizXEOgcOrtwRs0DkEon_6jkf71KZ7wwwLWOOjWbmG1nWg95-3RXC8afeNf9x9zzo0t6K-SPvTJjYa6T8n25cD1p1Dd_9UwXP1w2yW8yRob1fcDwWiqgNdH6jtTpcGcNp7iUm770KHxgFEM/s1600/WWE-Smackdown.jpg" height="169" width="320" /></a></div>
<blockquote class="tr_bq">
<span style="color: #073763;"><span style="font-size: x-large;"><b><span style="font-family: Georgia,"Times New Roman",serif;">Once more unto the breach...</span></b></span></span><br />
<span style="color: #0b5394; font-size: x-small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;">April 29, 2014 at 10:15 am Aaron Carroll</span></span></span></blockquote>
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Austin has been working on his trolling skills. He’s alerted me to another op-ed in the WSJ written by an orthopedic surgeon threatening to walk away from it all.<br /><br />Look, I’m not suggesting that we limit anyone’s free speech in any way. I’m not suggesting that we shouldn’t hear from unhappy doctors. But I’m going to offer them a bit of (unsolicited) advice. You’re starting to be the docs who cried wolf.<br /><br />In the interest of providing some media strategy, I’m going to go through this bit by bit. Let’s begin:</span></span><br />
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #351c75;">In my 23 years as a practicing physician, I’ve learned that the only thing that matters is the doctor-patient relationship. How we interact and treat our patients is the practice of medicine. I acknowledge that there is a problem with the rising cost of health care, but there is also a problem when the individual physician in the trenches does not have a voice in the debate and is being told what to do and how to do it.</span></span></span></blockquote>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">OK, right off the bat, you’re claiming that you have no voice in the debate as you are being published in one of the most read op-ed pages in the country. You know who doesn’t have a voice? The 300-plus million people who don’t get to have their thoughts heard in the WSJ...</span></span></blockquote>
Ouch. <a href="http://theincidentaleconomist.com/wordpress/once-more-unto-the-breach/" target="_blank">Read the whole thing</a>. An utter smackdown.<br />
<blockquote class="tr_bq">
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">Across the country, doctors waste precious time filling in unnecessary electronic-record fields just to satisfy a regulatory measure. I personally spend two hours a day dictating and documenting electronic health records just so I can be paid and not face a government audit. Is that the best use of time for a highly trained surgical specialist?</span></span></span></blockquote>
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">I’m totally with you here. I think this kind of thing sucks. But do you really think that the average American doesn’t spend a whole lot of time doing things at work that they don’t enjoy? Do you really think lawyers don’t hate billing? Do you really think educators don’t hate teaching to tests and grading essays? Do you really think that small businessmen don’t hate regulations? I think many, if not most Americans, will read this and say, “Wait a minute. You only have to do two hours of crap a day? Lucky ducky!” </span></span></blockquote>
Again, read all of it.<br />
__<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>UPDATE</b></span><br />
<br />
Just in. Relating to the environmental factors of health:<br />
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0c343d;"><span style="font-size: x-large;"><b>Supreme Court Upholds Air Pollution Regulation</b></span></span></span></span></blockquote>
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">The Supreme Court has given the Environmental Protection Agency an important victory in its effort to reduce power plant pollution that contributes to unhealthy air in neighboring states.<br /><br />The court's 6-2 decision Tuesday means that a rule adopted by EPA in 2011 to limit emissions from plants in more than two-dozen Midwestern and Southern states can take effect. The pollution drifts into the air above states along the Atlantic Coast and the EPA has struggled to devise a way to control it.</span></span></blockquote>
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Power companies and several states sued to block the rule from taking effect, and a federal appeals court in Washington agreed with them in 2012.<br /><br />Justice Ruth Bader Ginsburg wrote the court's majority opinion. Justices Antonin Scalia and Clarence Thomas dissented. </span></span></blockquote>
Wow. 6-2. That rarely happens at SCOTUS these days. The smell in the air today is that of climate-denier wingnut hair on fire.<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>ERRATA</b></span><br />
<br />
Funny.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEieKhe5l-hsTgMqUh4igsYzfMbXBPVCpkLmzdspRUAOFZTllEaFYCfw6iEyuclIAwa9naXWEhXtRTG_F8PqCRghWf8uFTgj4a-K5Y-WZuP6rZfB4h_EhritLJMic3Bm-G5f0FHCJhhhsli3/s1600/vax.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEieKhe5l-hsTgMqUh4igsYzfMbXBPVCpkLmzdspRUAOFZTllEaFYCfw6iEyuclIAwa9naXWEhXtRTG_F8PqCRghWf8uFTgj4a-K5Y-WZuP6rZfB4h_EhritLJMic3Bm-G5f0FHCJhhhsli3/s1600/vax.png" /></a></div>
<br />
<b><span style="font-family: Georgia,"Times New Roman",serif;">COMMONWEALTH FUND INTERACTIVE MAP: <br />STATES' HEALTH SYSTEM PERFORMANCE</span></b><br />
<br />
<div style="text-align: center;">
<iframe height="665" src="http://www.commonwealthfund.org/embed/scorecardembed.aspx?ind=1&w=550&h=500&xmlUrl=%2fssc%2fssc_map.axd%3find%3dXXX&vt=RankingMap&urlOpener=blank" style="border: none;" width="615"></iframe>
</div>
<br />
"Interactive." Move your mouse, stylus, or finger around the map for state-by-state data.<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>DESIGN FLAW</b></span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbfAHqjQh-8jbZ_DfLvtmr9SrVuoTzFF_NxpJM_hSFFD3LJFNVd00mIjZkKLPwcRsYMiLr-8txe0IpjO2OL25QOF3bQ0Y20QvD4DGVDvLTfFYvmqB4PunzcmIrOYT5wjHR8ByDmi6ETrNu/s1600/FileZillaFlaw.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbfAHqjQh-8jbZ_DfLvtmr9SrVuoTzFF_NxpJM_hSFFD3LJFNVd00mIjZkKLPwcRsYMiLr-8txe0IpjO2OL25QOF3bQ0Y20QvD4DGVDvLTfFYvmqB4PunzcmIrOYT5wjHR8ByDmi6ETrNu/s1600/FileZillaFlaw.png" height="163" width="320" /></a></div>
<br />
I use the free open source FileZilla FTP upload utility. Very handy. But, twice now I have slipped with my mouse and inadvertently wiped out all of my logins and passwords. Those "clear" items should either be moved elsewhere or backed up with a yes/no "are you <i>sure</i>?" pop-up warning.<br />
___<br />
<br />
More to come...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>
BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-16530939677987522172014-04-28T09:42:00.001-07:002014-04-28T12:22:12.037-07:00"TwittEHR?"<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjGqyedOv1PoNjjcFkFYIHq8oOYPyNSQ-iJMH13-8BFUB9ug0nsLrJ3irdV8Et1ibgHOS_b1TZZx2HvbsuzOMs_zn8fI-oKHLiY5f_GKbHrJ04o4bx_YUZejWEIao9J4tatc2tfZ03qyUGp/s1600/TwittEHR.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjGqyedOv1PoNjjcFkFYIHq8oOYPyNSQ-iJMH13-8BFUB9ug0nsLrJ3irdV8Et1ibgHOS_b1TZZx2HvbsuzOMs_zn8fI-oKHLiY5f_GKbHrJ04o4bx_YUZejWEIao9J4tatc2tfZ03qyUGp/s1600/TwittEHR.jpg" height="320" width="319" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">(Not a real logo, just an allusive BobbyG Photoshop quickie)</td></tr>
</tbody></table>
In light of my last couple of posts dealing with the continuing issues of EHR dissatisfaction, there's interesting post on <a href="http://thehealthcareblog.com/blog/2014/04/27/what-an-emr-built-on-twitter-would-look-like/"><i><b>THCB</b></i></a>.<br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;"><span style="font-size: x-large;"><b>What an EMR Built on Twitter Would Look Like</b></span><span style="font-size: x-small;"><br />by DAVID DO, MD</span></span></span></blockquote>
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">WILD PREDICTION: It won’t be long before every patient has a Twitter feed, and doctors subscribe to them for real-time updates.</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />This is a time when the demands of being a physician are changing, and we need to leverage technology to maintain awareness of a huge number of patients. There is also increasing need for handoffs and communication between providers.</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />Here’s the bottom line: how can we improve technology when doctors seem so resistant? They are not happy with their EMRs, and rightly so, because they were built to do too much for too many.</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /><b>Current system is inefficient</b><br />The EMR has become essential for documentation, billing, medical reasoning, and communication, among other things. Currently, documentation is built on a system of daily progress notes. If I consult a cardiologist about a case, he needs to go through each note, containing narratives, laboratory values, vital signs, and physical exams.</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />A patient with a seven-day hospital stay may have twenty notes that need synthesis to put together the story–this can take hours per patient!</span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />In an age where more providers are involved in a patient’s care (whether due to duty hour restrictions, or the increasing presence of specialists for every problem), this inefficiency is not acceptable...</span></span></blockquote>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtz0Z1BZxwSWbWti32vn10bXUs_rJ2vMkMmnwTz_o2x8927ZDMe78Tr2KLfOD3BDLtiEiidAdAW5DVd1EKgJaITYjLmwZ7OWCiyWyLqGVunBGUVGL53S5KEcCNAQ70yQY9IApM7yZtVgGY/s1600/Screen-Shot-2014-04-27-at-6.18.39-AM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtz0Z1BZxwSWbWti32vn10bXUs_rJ2vMkMmnwTz_o2x8927ZDMe78Tr2KLfOD3BDLtiEiidAdAW5DVd1EKgJaITYjLmwZ7OWCiyWyLqGVunBGUVGL53S5KEcCNAQ70yQY9IApM7yZtVgGY/s1600/Screen-Shot-2014-04-27-at-6.18.39-AM.png" /></a></div>
<br />
One THCB commenter noted a company proposing to do this very thing. <a href="http://medyear.com/" target="_blank"><b>Medyear.com</b></a><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqUfkfVaoPFmWtg7RYfFNWxjRNEQ_ukOg_zobEK6y4g7D7clma99nRuUusTxLLSgdzxRRFHNiln0pbBVps13t4zc7IS7-4UHZLDjBx6cNVesy4RxrECuyF4vyTpdbBuz2to0lX-yt1STei/s1600/Medyear.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqUfkfVaoPFmWtg7RYfFNWxjRNEQ_ukOg_zobEK6y4g7D7clma99nRuUusTxLLSgdzxRRFHNiln0pbBVps13t4zc7IS7-4UHZLDjBx6cNVesy4RxrECuyF4vyTpdbBuz2to0lX-yt1STei/s1600/Medyear.png" height="312" width="400" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjImcUazudKabnJmrCaUXP8olZfC8BcAQh7sTDK0rhg3T_FWA4eqnusFn3q1JX-ILAn8BvdiDUCFmHzDH3-xvtCLrVRAM5Gr552jEeGlYdT4YIpSI7jQahb97XMnumoWtwIVU4yu98FYwsg/s1600/Medyear2.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjImcUazudKabnJmrCaUXP8olZfC8BcAQh7sTDK0rhg3T_FWA4eqnusFn3q1JX-ILAn8BvdiDUCFmHzDH3-xvtCLrVRAM5Gr552jEeGlYdT4YIpSI7jQahb97XMnumoWtwIVU4yu98FYwsg/s1600/Medyear2.png" height="419" width="630" /></a></div>
<br />
<br />
<br />
From their FAQs:<br />
<blockquote class="tr_bq">
<ol>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0c343d;"><b>Is Medyear secure?</b></span><br />Yes, very. Medyear is HIPAA-compliant and would not be able to accept your clinical records in the first place if it did not meet strict government regulations (HIPAA) and standards (Blue Button) for handling healthcare data. Moreover, we apply very powerful database technologies that allow us to secure information at a granular level. No system is perfectly secure, but we obsess over security so you don't have to.</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0c343d;"><b>Is my information private?</b></span><br />It depends on you. You can share your information however you want. You might share with a friend, a doctor, an insurer, a stranger, or with science. You might share just one small part of your health record, or the entire thing. You might share for one hour, or one year. Your privacy is your prerogative, and its up to you to decide.</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0c343d;"><b>What is the logo a snowflake?</b></span><br />We are all unique as individuals, like snowflakes. So we know our body and our lives best. It is up to us to take charge of our healthcare destiny. Medyear is a people's movement to claim our uniqueness and let the healthcare system evolve around us, to suit our unique needs.</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0c343d;"><b>How is Medyear related to health reform?</b></span><br />Many of the key changes in the law and regulations that now make Medyear possible did not exist a few years ago. The government has played an important role by implementing policies like HIPAA-HITECH, Blue Button, Meaningful Use, and Affordable Care Act. As such, we embrace government leadership.</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0c343d;"><b>What's in it for patients?</b></span><br />Typically people will share health information for one of two reasons: to give help, or to get help. Perhaps your sharing can help a family member manage a chronic condition because you have had it yourself. Or perhaps you are the one who needs to share information frequently, in order to get the best medical care possible. Whatever the reason, empathy powers when we share to help, and empathy powers the help we might also someday receive.</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0c343d;"><b>What's in it for doctors?</b></span><br />Medyear allows patients and healthcare professionals to collaborate directly and privately through Consults. The Consult works a lot like other types of encounters (phone calls, office visits, emails). But instead of recapping your health issues, fumbling with paper records, or expressing concerns in one sitting, you can simply share the information you've already collected. This makes everyone's life easier.</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0c343d;"><b>What's in it for scientists?</b></span><br />Scientists working at the very bleeding edge of research need LOTS of data to make important discoveries that lead to the life-saving drugs or procedures of the future. But getting this valuable patient information is not easy, and often when data is obtained it is without patients knowing. With many people perhaps we should just let people share their data voluntarily.</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0c343d;"><b>Where can I get my records?</b></span><br />In late February, the US Government has published a directory, known as Blue Button Connector of the healthcare organizations that currently adopt Blue Button. Over time, it is estimated that over 500 organizations - from small clinics, to lab companies, to large hospitals, to the largest insurers - will adopt Blue Button and be listed in the registry. If your healthcare provider is listed, you simply provide them with your Medyear address and your records are securely transmitted into you private Medyear account.</span></span></li>
</ol>
</blockquote>
Intriguing stuff. You have to applaud people for attempting viable,
disruptive, value-adding things. This is not materially different from <a href="http://regionalextensioncenter.blogspot.com/2013/01/breaking-hipaa-omnibus-final-rule.html" target="_blank">the "Health Record Bank" idea I've written of before</a> (scroll down in the linked page).<br />
<br />
I just have a couple of concerns. As I noted in a comment (fixed my typos):<br />
<blockquote class="tr_bq">
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">For both “Covered Entities” and (now with the Omnibus Rule) their
“Business Associates,” EVERY time “protected health information” (PHI –
specific legal definition) is, created, viewed, updated, transmitted, or
deleted, there must be a date-time stamped transaction log of the event
identifying the authorized person who “created, viewed, updated,
transmitted, or deleted” the PHI.</span></span><br />
<br />
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">Moreover, once an episode of care note is finished and “locked” for
billing, it becomes a legal record, “updates” to which can only be done
via appended addenda (and those too must be HIPAA-logged).</span></span><br />
<br />
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">No small undertaking to make an app such as the one proffered here
fully HIPAA-compliant. Yes, some of the PHI “tweets” are their own
“transaction log entries,” but that is likely to not be the entire
story. Anyone developing or using such an app had better have done their
legal due diligence.</span></span></blockquote>
Medyear may claim to be "HIPAA compliant," but I'd want to review the gamut of their Business Associate 45.CFR.164.308 <i>et seq</i> documentation. The audit log requirements here would span multiple individuals and organizations. I don't just sanguinely assume that clinicians using a service like this would uniformly not be in violation of their own Covered Entities' HIPAA Policies (and, we must recall, "privacy" [164.5 <i>et seq</i>] is separate from "security" [164.3 <i>et seq</i>]. ePHI privacy is subject to the potential HIPAA-trumping laws and regulations of <i>every</i> state in the U.S. (not to mention the international privacy ramifications). <br />
<br />
Moreover, being able to connect and merge various individual time-sequential, subject-disparate medical "tweets" into efficient and necessary synthesized clinical "views" is likely to be a significant RDBMS challenge that is no different, really, than those at the heart of traditional EHRs. Anyone routinely using <a href="https://www.twitter.com/BobbyGvegas" target="_blank">Twitter</a> knows that tweets fly by at warp speed. Medyear clients (in particular, clinicians) will need near-instant access to reassembled "old" pertinent information "100-500 screen-scrolls down" at the point of care. Moreover, might there not be the equivalent of random "inbox overload" with medico-legal liability concerns? I'm just sure my Primary wants to be hammered 24/7 with "medical tweets" ranging from the consequential to the trivial.<br />
<br />
Nonetheless. let's wish these folks well. Whatever helps.<br />
<br />
I couldn't help one other THCB comment:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEisf2vWbNJIWGz3qy1BFFF2rMeLK0ceeYerWpF397k1ls9qI81sTkCKUV7W4dfI1GOi4wi1gtgYCehVzYEQaNC5_Ktj5_JPeGLRC-FRIcD6nRMYc8D8G_-JcscsKWQNePcpm49Tiqytn0e_/s1600/MedyearFlip.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEisf2vWbNJIWGz3qy1BFFF2rMeLK0ceeYerWpF397k1ls9qI81sTkCKUV7W4dfI1GOi4wi1gtgYCehVzYEQaNC5_Ktj5_JPeGLRC-FRIcD6nRMYc8D8G_-JcscsKWQNePcpm49Tiqytn0e_/s1600/MedyearFlip.png" height="140" width="630" /></a></div>
<br />
They appear to be privately held. Time for a VC-assisted IPO?<br />
___<br />
<br />
More to come...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>
BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-82976687346237672062014-04-25T13:32:00.001-07:002014-04-28T13:53:58.819-07:00"Maybe we should cancel Stage 2 and Stage 3"<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3D2zpDqNWp7mHfOTHweeMF21zaatvm72tAHIDptn9wNcI-aPLxFdMzaBLQ4qMtFMKGK7S9L-aQ8HskyvlgMNDUuJywWe9P0jU4cbtEQTwe_F2sx2chiOuI0uG1cwwll9nhJJYyBEsxb5Y/s1600/Piling-On-MU.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3D2zpDqNWp7mHfOTHweeMF21zaatvm72tAHIDptn9wNcI-aPLxFdMzaBLQ4qMtFMKGK7S9L-aQ8HskyvlgMNDUuJywWe9P0jU4cbtEQTwe_F2sx2chiOuI0uG1cwwll9nhJJYyBEsxb5Y/s1600/Piling-On-MU.jpg" /></a></div>
<br />
<b>The critics are again piling on.</b><br />
<blockquote class="tr_bq">
<span style="color: #134f5c;"><i><b><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;">In the early days of EMRs, the pioneers like Intermountain, Vanderbilt, Duke, and Partners differentiated themselves by developing their own proprietary EMRs and then using them in a meaningful way, without any financial incentive except their own to do so. Meaningful Use Stage 1 served a valuable purpose; it jump-started the adoption of commercially supported EMRs in an industry that needed jump-starting. Maybe we should cancel Stage 2 and Stage 3, spend some of that money to seed true innovation (think DARPA for healthcare IT), and let survival of the fittest play a role in deciding which organizations will utilize their EMRs, and subsequent data, most effectively to improve healthcare.</span></span></b></i></span></blockquote>
From <i><b>"<a href="http://healthsystemcio.com/2014/04/22/time-eliminate-meaningful-use/">Is It Time To Eliminate Meaningful Use?</a>"</b></i><br />
<br />
<b><i>"Spend some of that money to seed true innovation"?</i></b><br />
<br />
<br />
Seriously? <i>What</i> money? In case you've not been
paying attention, the bulk of the MU money has already been dispensed,
with the largest proportion of the relatively little that remains
earmarked for late-adopting Stage 1 participants. You're not going to
"seed" anything of substance on a national scale with remaining MU
funds.<br />
<br />
Do people even <i>listen</i> to what they're saying?<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif; font-size: large;"><b><i>OUTCOMES</i> MEASURES, ANYONE?</b></span><br />
<br />
Process measures like Meaningful Use, <a href="http://regionalextensioncenter.blogspot.com/2014/04/cqm-amphiboly-mfb-li.html">CQMs</a>, PQRS, etc, as I've noted before, are tangential <b><i>proxies</i></b>
for effectiveness in health care. It's assumed that if you are doing
and reporting on X, Y, Z, A, B, C, D, E, and F, improved outcomes will
eventually follow.<br />
<br />
How about if we lay on a concerted effort to measure <i>actual</i> outcomes directly? And, in that regard, a1c (the gamut of lab results, actually), BP, BMI, etc are themselves still <i>proxies</i>, not "outcomes" in terms of end-results health.<br />
<br />
Virtually <i>every</i> dx of a suboptimal medical/health condition
has an associated prognosis and tx plan (the "P" component of the
"SOAP") aimed at improved outcome/resolution (even if it's sadly limited
to the palliative for the fatal dx's). We should be mapping realistic
interim and end-state "outcomes" goals to <i>every</i> dx. Some will be
simple, others maddeningly complex and often problematic. But, without
them, we will simply continue to argue endlessly and fruitlessly about
health care effectiveness and "value."<br />
<br />
Time to seriously get off the dime.<br />
<br />
<br />
<a href="http://www.ahrq.gov/research/findings/factsheets/outcomes/outfact/"><b>AHRQ</b> website</a>, on "outcomes" -<br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;"><span style="color: #073763;"><b>What is outcomes research?</b></span><br />Outcomes
research seeks to understand the end results of particular health care
practices and interventions. End results include effects that people
experience and care about, such as change in the ability to function. In
particular, for individuals with chronic conditions—where cure is not
always possible—end results include quality of life as well as
mortality. By linking the care people get to the outcomes they
experience, outcomes research has become the key to developing better
ways to monitor and improve the quality of care. Supporting improvements
in health outcomes is a strategic goal of the Agency for Healthcare
Research and Quality (AHRQ, formerly the Agency for Health Care Policy
and Research).<br /><br />The urgent need for outcomes research was
highlighted in the early 1980s, when researchers discovered that
"geography is destiny." Time and again, studies documented that medical
practices as commonplace as hysterectomy and hernia repair were
performed much more frequently in some areas than in others, even when
there were no differences in the underlying rates of disease.
Furthermore, there was often no information about the end results for
the patients who received a particular procedure, and few comparative
studies to show which interventions were most effective. These findings
challenged researchers, clinicians, and health systems leaders to
develop new tools to assess the impact of health care services...</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;"><br /></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;"><span style="color: #073763;"><b>Measuring Outcomes</b></span><br />Historically,
clinicians have relied primarily on traditional biomedical measures,
such as the results of laboratory tests, to determine whether a health
intervention is necessary and whether it is successful. Researchers have
discovered, however, that when they use only these measures, they miss
many of the outcomes that matter most to patients. Hence, outcomes
research also measures how people function and their experiences with
care...</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;"><br /></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;"><span style="color: #073763;"><b>Future Directions</b></span><br />No
longer just the domain of a small cadre of researchers, outcomes
research has altered the culture of clinical practice and health care
research by changing how we assess the end results of health care
services. In doing so, it has provided the foundation for measuring the
quality of care. The results of AHRQ outcomes research are becoming part
of the "report cards" that purchasers and consumers can use to assess
the quality of care in health plans. For public programs such as
Medicaid and Medicare, outcomes research provides policymakers with the
tools to monitor and improve quality both in traditional settings and
under managed care. Outcomes research is the key to knowing not only
what quality of care we can achieve, but how we can achieve it.</span></span></blockquote>
OK. In the same vein, how about this, from <b>Academy Health</b>, <a href="http://www.academyhealth.org/files/publications/healthoutcomes.pdf"><b><i>HEALTH OUTCOMES RESEARCH: A PRIMER</i></b></a> (pdf):<br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #20124d;"><b>What is outcomes research? </b></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #351c75;">Outcomes
research studies the end results of medical care – the effect of the
health care process on the health and well-being of patients and
populations. It spans a broad spectrum of issues from studies
evaluating the effectiveness of a particular medical or surgical
procedure to examinations of the impact of insurance status or
reimbursement policies on the outcomes of care. It also ranges from the
development and use of tools to measure health status to analyses of the
best way to disseminate the results of outcomes research to physicians
or consumers to encourage behavior change.</span></span></blockquote>
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #351c75;">The
field of outcomes research emerged from a growing concern about which
medical treatments work best and for whom. In large part because of its
potential to address the interrelated issues of cost and quality of
health care, public and private sector interest in outcomes research has
grown dramatically in the past several years...</span></span></blockquote>
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #351c75;"><span style="color: #20124d;"><b>The Setting It Studies</b></span><br />Outcomes
research evaluates the results of the health care process in the
real-life world of the doctor’s office, hospital, health clinic and even
the home. This contrasts with traditional randomized controlled
studies, funded mainly through the National Institutes of Health, which
test the success of treatments in controlled environments. These are
called efficacy studies. Research in real-life settings is called
effectiveness research.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #351c75;"><br /><span style="color: #20124d;"><b>The Health Status Measures It Uses</b></span><br />Traditionally,
studies have measured health status, or health outcomes, in terms of
physiological measurements – through laboratory test results,
complication rates (e.g. infections) or death. These measures alone do
not adequately capture health status. A patient’s functional status,
well-being, and satisfaction with care must compliment the traditional
measures...</span></span></blockquote>
That was published in <u><i>1994</i></u>,
twenty years ago. What are we waiting for? While I don't underestimate
the difficulties involved with establishing standardized "operational
definitions" of outcome measures, it is not impossible. Surely adding
uniform, basic quantitative progress/outcomes metrics to the "Active dx"
lists now a requisite staple of certified EHRs is do-able.<br />
<br />
"Innovation," anyone?<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>T</b><b>HE CLINICAL PROCESS AND "PDSA"</b></span><br />
<br />
We refer to the "SOAP" process, documented in the "SOAP note" now firmly in the center of the EHR.<br />
<ul>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>Subjective;</b></span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>Objective;</b></span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>Assessment;</b></span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>Plan.</b></span></span></li>
</ul>
The
subjective and objective data (including those comprising the relevant
aspects of FH, SH, PMH, Active Rx, Active dx, HPI, ROS, Vitals, Labs, PE) converge to underpin the physician's
"assessment" (dx) and resultant "plan" (Rx/tx/px) for mitigating (or
curing) the patient's current problem(s) and arriving at better health (the desired "outcome" from the patient POV).<br />
<br />
As
my HealthInsight Sup Keith Parker (an astute, Harley-riding former
Special Forces medic) always liked to admonish, there should be an
explicit "E" (evaluation) at the end of the traditional SOAP model. My
quickie Photoshop visualization of the process cycle:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiY60wvNc7bJz2-SdTUv_pfPOT_uvFChId8bDb4Eh-UmVnZhh5KYzPG-FikJRW7JyBe1ypoDmY7c0kGHvobx_ZjVdWzmhjDXBzJK0N1T4kvEtDxmrKtAQedH0oPG5Ho_cVDhg7bLi2zw8sC/s1600/SOAPE.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiY60wvNc7bJz2-SdTUv_pfPOT_uvFChId8bDb4Eh-UmVnZhh5KYzPG-FikJRW7JyBe1ypoDmY7c0kGHvobx_ZjVdWzmhjDXBzJK0N1T4kvEtDxmrKtAQedH0oPG5Ho_cVDhg7bLi2zw8sC/s1600/SOAPE.jpg" /></a></div>
<br />
In terms of the PDSA improvement model,<br />
<ul>
<li><span style="color: #073763;"><b><span style="font-family: Georgia,"Times New Roman",serif;">Plan;</span></b></span></li>
<li><span style="color: #073763;"><b><span style="font-family: Georgia,"Times New Roman",serif;">Do;</span></b></span></li>
<li><span style="color: #073763;"><b><span style="font-family: Georgia,"Times New Roman",serif;">Study;</span></b></span></li>
<li><span style="color: #073763;"><b><span style="font-family: Georgia,"Times New Roman",serif;">Act,</span></b></span></li>
</ul>
<b>S</b>, <b>O</b>, and <b>A</b> of "SOAPE" comprise the planning phase (you plan based on the analytic aggregation and synthesis of your current data), the "Plan" (<b>P</b>) is the "Do" phase, the "Study" is the "<b>E</b>" of SOAPE, and, -- most often -- recursively, we subsequently revisit the "<b>A</b>" (assessment" phase) of SOAPE. Did we hit the mark or not? If not, what next?<br />
<br />
<i>Fundamental</i> to experimental science broadly is the <u>explicit</u>
statement of the empirical (quantitated) goal in the planning phase,
answering the question "what will constitute a 'significant' improvement
<i>vis a vis</i> the <i>status quo</i>?" You don't get to run an experiment and <i>then</i> arbitrarily decide whether you've "improved" things or not.<br />
<br />
Maybe that's "the <i>'art'</i> of medicine," but it's not science.<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>4/28 UPDATE</b></span><br />
<blockquote class="tr_bq">
<span style="color: #0c343d;"><span style="font-size: x-large;"><b><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://thehealthcareblog.com/blog/2014/04/28/again-how-should-doctors-get-paid/" target="_blank">Doctors Should Be Paid for Outcomes. But Which Outcomes</a>?</span></b></span></span><br />
<span style="color: #0c343d;"><span style="font-size: x-small;"><span style="font-family: Georgia,"Times New Roman",serif;">By HANS DUVEFELT, MD</span></span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Should we be paid for outcomes?</span></span></blockquote>
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">This
is often proposed, but I have trouble understanding it. Real outcomes
are not blood pressure or blood sugar numbers; they are deaths, strokes,
heart attacks, amputations, hospital-acquired infections and the like.</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />In today’s medicine-as-manufacturing paradigm, such events are seen as preventable and punishable.</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />Ironically,
the U.S. insurance industry has no trouble recognizing “Acts of God” or
“force majeure” as events beyond human control in spheres other than
healthcare.</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />There
is too little discussion about patients’ free choice or responsibility.
Both in medical malpractice cases and in the healthcare debate, it
appears that it is the doctor’s fault if the patient doesn’t get well.</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />If
my diabetic patient doesn’t follow my advice, I must not have tried
hard enough, the logic goes, so I should be penalized with a smaller
paycheck.</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />The
dark side of such a system is that doctors might cull such patients
from their practices in self defense and not accept new ones...</span></span></blockquote>
Vik Khanna responds.<br />
<br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg1goMA4zxQe2ZIIq0owYxprpxCwzcvJP_NiIc9vUZatqmJZxtw9J8lSDgaD4jT5YvzSpZUo8FjTPJISfi-kD9DI6RL-fJUyP1aFKKEihOv-C7zuYZxvfmrjrgy-w9X7sFEr1Ae_UP5O2fp/s1600/VikOnOutcomes.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg1goMA4zxQe2ZIIq0owYxprpxCwzcvJP_NiIc9vUZatqmJZxtw9J8lSDgaD4jT5YvzSpZUo8FjTPJISfi-kD9DI6RL-fJUyP1aFKKEihOv-C7zuYZxvfmrjrgy-w9X7sFEr1Ae_UP5O2fp/s1600/VikOnOutcomes.png" height="300" width="630" /></a>___<br />
<br />
More to come...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>
BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-65957154661242680702014-04-22T08:34:00.003-07:002014-04-25T11:01:53.874-07:00"Electronic medical charts have become ground zero for deteriorating patient care"<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: x-large;"><b>Dr. Val Jones</b></span></span><br />
<blockquote class="tr_bq">
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">For the past couple of years I’ve been working as a traveling physician in 13 states across the U.S. I chose to adopt the “<i>locum tenens</i> lifestyle” because I enjoy the challenge of working with diverse teams of peers and patient populations. I believe that this kind of work makes me a better doctor, as I am exposed to the widest possible array of technology, specialist experience, and diagnostic (and logistical) conundrums. During my down times I like to think about what I’ve learned so that I can try to make things better for my next group of patients.<br /><br />This week I’ve been considering how in-patient doctoring has changed since I was in medical school. Unfortunately, my experience is that most of the changes have been for the worse. While we may have a larger variety of treatment options and better diagnostic capabilities, it seems that we have pursued them at the expense of the fundamentals of good patient care. What use is a radio-isotope-tagged red blood cell nuclear scan if we forget to stop giving aspirin to someone with a gastrointestinal bleed?<br /><br />At the risk of infecting my readers with a feeling of helplessness and depressed mood, I’d like to discuss my findings in a series of blog posts. Today’s post is about why electronic medical charts have become ground zero for deteriorating patient care.</span></span><br />
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>1.</b> Medical notes are no longer used for effective communication, but for billing purposes. When I look back at the months of training I received at my <i>alma mater</i> regarding the proper structure of intelligent medical notes, I recall with nostalgia how beautiful they were. Each note was designed to present all the observed and collected data in a cohesive and logical format, justifying the physician’s assessment and treatment plan. Our impressions of the patient’s physical and mental condition, reasons for further testing, and our current thought processes regarding optimal treatments and follow up (including citation of scientific literature to justify the chosen course) were all crisply presented.<br /><br />Nowadays, medical notes consist of randomly pre-populated check box data lifted from multiple author sources and vomited into a nonsensical monstrosity of a run-on sentence. It’s almost impossible to figure out what the physician makes of the patient or what she is planning to do. Occasional “free text” boxes can provide clues, when the provider has bothered to clarify. One needs to be a medical detective to piece together an assessment and plan these days. It’s both embarrassing and tragic… if you believe that the purpose of medical notes is effective communication. If their purpose is justifying third-party payer requirements, then maybe they are working just fine?<br /><br />My own notes have been co-opted by the EMRs, so that when I get the chance to free-text some sensible content, it still forces gobbledygook in between. I can see why many of my peers have eventually “given up” on charting properly. No one (except coders and payers interested in denying billing claims) reads the notes anymore. The vicious cycle of unintelligible presentation drives people away from reading notes, and then those who write notes don’t bother to make them intelligent anymore. There is a “learned helplessness” that takes over medical charting. All of this could (I suppose) be forgiven if physicians reverted back to verbal handoffs and updates to other staff/peers caring for patients to solve this grave communication gap. Unfortunately, creating gobbledygook takes so much time that there is less old fashioned verbal communication than ever.</span></span><br />
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>2.</b> No one talks to each other anymore. I’m not sure if this is because of a general cultural shift away from oral communication to text-based, digital intermediaries (think zombie-like teens texting one another incessantly) or if it’s related to sheer time constraints. However, I am continually astonished by the lack of face-to-face or verbal communication going on in hospitals these days. When I first observed this phenomenon, I attributed it to the facility where I was working. However, experience has shown that this is an endemic problem in the entire healthcare system.<br /><br />When you are overworked, it’s natural to take the path of least resistance – checking boxes and ordering consults in the EMR is easier than picking up a phone and constructing a coherent patient presentation to provide context for the specialist who is about to weigh in on disease management. Nursing orders are easier to enter into a computer system than actually walking over and explaining to him/her what you intend for the patient and why.<br /><br />But these shortcuts do not save time in the long run. When a consultant is unfamiliar with the partial workup you’ve already completed, he will start from the beginning, with duplicate testing and all its associated expenses, risks, and rabbit trails. When a nurse doesn’t know that you’ve just changed the patient to “NPO” status (or for what reason) she may give him/her scheduled medications before noticing the change. When you haven’t explained to the physical therapists why it could be dangerous to get a patient out of bed due to a suspected DVT, the patient could die of a sudden pulmonary embolism. Depending upon computer screen updates for rapid changes in patient care plans is risky business. EMRs are poor substitutes for face-to-face communication...</span></span><br />
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>3.</b> It’s easy to be mindless with electronic orders. There’s something about the brain that can easily slip into “idle” mode when presented with pages of check boxes rather than a blank field requiring original input. I cannot count the number of times that I’ve received patients (from outside hospitals) with orders to continue medications that should have been stopped (or forgotten medications that were not on the list to be continued). In one case, for example, a patient with a very recent gastrointestinal bleed had aspirin listed in his current medication list. In another, the discharging physician forgot to list the antibiotic orders, and the patient had a partially-treated, life-threatening infection.<br /><br />As I was copying the orders on these patients, I almost made the same mistakes. I was clicking through boxes in the pharmacy’s medication reconciliation records and accidentally approved continuation of aspirin (which I fortunately caught in time to cancel). It’s extremely unlikely that I would have hand-written an order for aspirin if I were handling the admission in the “old fashioned” paper-based manner. My brain had slipped into idle… my vigilance was compromised by the process.<br /><br />In my view, the only communication problem that EMRs have solved is illegible handwriting. But trading poor handwriting for nonsensical digital vomit isn’t much of an advance. As far as streamlining orders and documentation is concerned, yes – ordering medications, tests, and procedures is much faster. But this speed doesn’t improve patient care any more than increasing the driving speed limit from 60 mph to 90 mph would reduce car accidents. Rapid ordering leads to more errors as physicians no longer need to think carefully about everything. EMRs have sped up processes that need to be slow, and slowed down processes that need to be fast. From a clinical utility perspective, they are doing more harm than good...</span></span></blockquote>
<a href="http://getbetterhealth.com/the-medical-chart-ground-zero-for-the-deterioration-of-patient-care/2014.04.21" target="_blank">Props to GetBetterHealth.com for this article</a>. Read all of it.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZIvHLXZ4Cg03dTE32fN84yKIzuW21xq8LLNhPg_P35EhJqeFpp5jp-Sj9Tyaq3R3y4C-K26fMmX0anveYCd-3zEQ-DMKkJrVkUCrlGisyks7LWGh7w2ecG_vyPuQXEgCAtRGLw_N9OwOG/s1600/GetBetterHealth.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZIvHLXZ4Cg03dTE32fN84yKIzuW21xq8LLNhPg_P35EhJqeFpp5jp-Sj9Tyaq3R3y4C-K26fMmX0anveYCd-3zEQ-DMKkJrVkUCrlGisyks7LWGh7w2ecG_vyPuQXEgCAtRGLw_N9OwOG/s1600/GetBetterHealth.png" /></a></div>
<br />
Pretty stark indictment of EHRs. Her admonitions ought be taken seriously. <i>"Nonsensical digital vomit."</i> LOL, I am so stealin' that.<br />
<br />
I'm still trying to dispositively ID just who this "Dr. Val Jones" is. No bio associated with the article. The link cited for the doc's <i>"alma mater,"</i> though (Columbia), squares with her being <i>this</i> <a href="http://www.sciencebasedmedicine.org/contributors/val-jones-md/" target="_blank"><b>Dr. Val Jones</b></a>, affiliated with <a href="http://sciencebasedmedicine.org/" target="_blank"><b>ScienceBasedMedicine.org</b></a> (<b>SBM</b>), a daily priority surf-by and hang for me.<br />
<br />
Dr. Jones also produces <a href="http://getbetterhealth.com/healthy-vision" target="_blank">audio podcasts</a>.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjnfw8qjU-yeYYFUoPb97TTnVpsES_DsgWnYkKRelKZ-3yNiQpwwh5VYfOO70A-KEPUy48di3tK4b27C1C00UqmPKlXfx8NfvCLXv9pwMjbZozPyzw7DtD2sQfc1bfkjKNJMHzmK6FLyUvS/s1600/ValJonesPodcast.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjnfw8qjU-yeYYFUoPb97TTnVpsES_DsgWnYkKRelKZ-3yNiQpwwh5VYfOO70A-KEPUy48di3tK4b27C1C00UqmPKlXfx8NfvCLXv9pwMjbZozPyzw7DtD2sQfc1bfkjKNJMHzmK6FLyUvS/s1600/ValJonesPodcast.jpg" /></a></div>
<br />
Nicely done.<br />
<br />
Interestingly, in the article cited above, she <i>does</i> tout one EHR product, "<a href="http://www.md-hq.com/" target="_blank"><b>MD-HQ</b></a>."<br />
<blockquote class="tr_bq">
<span style="color: #351c75;"><span style="font-family: Georgia,"Times New Roman",serif;">*Note: there is at least <a href="http://www.md-hq.com/">one excellent, private practice EMR</a>
(for use in the outpatient setting) that is designed for communication
(not billing). It is in use by direct primary care practices and was
designed by physicians for supporting actual thinking and relevant
information capture. I highly recommend it!</span></span></blockquote>
Never heard of them. How many times have we heard that <i>"designed by physicians for physicians"</i> thing? They're apparently not <a href="http://oncchpl.force.com/ehrcert/ehrproductsearch" target="_blank">ONC 2014 CERHT</a> listed. So, however good the platform might be on its own usability merits, if you're in the Meaningful Use program, this is not your product.<br />
<br />
Nice "look and feel" aesthetics.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0CkWS8ln9vUSFKTtz-0u4VvJEdxi40hGO_SPSHp55wDke-w2IfLR9-kiZxeOUVES_1bq1fXhGmqz-50EOokdu_PLGk3zKH9SBixOPYB96z2GKjNfxqgS5ynJMvJ7OhkZyXgIpMKw6juYE/s1600/hera_dash_whover.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0CkWS8ln9vUSFKTtz-0u4VvJEdxi40hGO_SPSHp55wDke-w2IfLR9-kiZxeOUVES_1bq1fXhGmqz-50EOokdu_PLGk3zKH9SBixOPYB96z2GKjNfxqgS5ynJMvJ7OhkZyXgIpMKw6juYE/s1600/hera_dash_whover.jpg" height="455" width="630" /></a></div>
<br />
Click to enlarge.<br />
<br />
UPDATE: I cited this post on LinkedIn. One reply:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJJ4Bkb3uQEZPbNEWU_nXV1YKIHhxJvaBB0Sc307TptxIWqLe4kK8UEcO_Q0uIlcn-sVBtYhdBmIMv7Yxo2X3ynltfBnjAc83MqgI2j-XzhNjDTyCMQq0UbMSTmXH2Ll8FUEUwWnc5PVjU/s1600/LinkedInComment.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJJ4Bkb3uQEZPbNEWU_nXV1YKIHhxJvaBB0Sc307TptxIWqLe4kK8UEcO_Q0uIlcn-sVBtYhdBmIMv7Yxo2X3ynltfBnjAc83MqgI2j-XzhNjDTyCMQq0UbMSTmXH2Ll8FUEUwWnc5PVjU/s1600/LinkedInComment.png" height="167" width="630" /></a></div>
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
I tried repeatedly, to no avail, to get <b>SBM </b>to
take up the contentious issues (mainly re patient safety) related to
Health IT. But, they're too busy fretting loud and long over the
otherwise target-rich "woo" / "SCAM" ("So-Called Alternative Medicine")
environment. Necessary priorities, one supposes, in a world of so much <a href="http://press.princeton.edu/titles/7929.html">B.S.</a> at every turn.<br />
<br />
<br />
<b>SBM</b> turned me on to<b> <a href="http://www.sciencebasedmedicine.org/philosophy-meets-medicine/">Mario Bunge</a></b>. For that alone I have to always be quite grateful. See my December post <b><i>"<a href="http://regionalextensioncenter.blogspot.com/2013/12/philosophia-sana-in-ars-medica-sana.html" target="_blank">Philosophia sana in ars medica sana</a>."</i></b><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>UPDATE</b></span><br />
<br />
Renowned writer <b>James Fallows</b> has published an <i>excellent</i> <b><i>Atlantic Monthly</i></b> series on Health IT:<br />
<blockquote class="tr_bq">
<ul>
<li><span style="font-size: small;"><b><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.theatlantic.com/magazine/print/2014/04/the-paper-cure/358639/">Why Doctors Still Use Pen and Paper</a></span></b></span></li>
<span style="font-size: small;">
</span></ul>
</blockquote>
<blockquote class="tr_bq">
<ul>
<li><span style="font-size: small;"><b><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.theatlantic.com/technology/print/2014/04/but-seriously-now-why-do-doctors-still-make-you-fill-out-forms-on-clipboards/360308/">But Seriously Now, Why Do Doctors Still Make You Fill Out Forms on Clipboards?</a></span></b></span></li>
</ul>
</blockquote>
<blockquote class="tr_bq">
<ul>
<li><span style="font-size: small;"><b><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.theatlantic.com/technology/print/2014/04/if-doctors-dont-like-electronic-medical-records-should-we-care/360618/">If Doctors Don't Like Electronic Medical Records, Should We Care?</a></span></b></span></li>
</ul>
</blockquote>
<blockquote class="tr_bq">
<ul>
<li><span style="font-size: small;"><b><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.theatlantic.com/technology/print/2014/03/electronic-medical-records-a-way-to-jack-up-billings-put-patients-in-control-or-both/359880/">Electronic Medical Records: A Way to Jack up Billings, Put Patients in Control, or Both?</a></span></b></span></li>
</ul>
</blockquote>
<blockquote class="tr_bq">
<ul>
<li><span style="font-size: small;"><b><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.theatlantic.com/health/print/2014/03/on-the-ramifications-of-high-tech-big-data-medical-care/284579/">On the Ramifications of High-Tech, Big-Data Medical Care</a></span></b></span> </li>
</ul>
</blockquote>
<blockquote class="tr_bq">
<ul>
<li><span style="font-size: small;"><b><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.theatlantic.com/politics/print/2014/04/the-electronic-medical-records-email-of-the-day-no-1/360752/">The Electronic-Medical-Records Email of the Day, No. 1</a></span></b></span></li>
</ul>
</blockquote>
<blockquote class="tr_bq">
<ul><span style="font-size: small;">
</span>
<li><span style="font-size: small;"><a href="http://www.theatlantic.com/politics/print/2014/04/the-electronic-medical-records-email-of-the-day-no-1/360752/"><b><span style="font-family: Georgia,"Times New Roman",serif;">The Electronic-Medical-Records Email(s) of the Day, No. 2</span></b></a></span></li>
</ul>
</blockquote>
From the opening article:<br />
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><i>The
health-care system is one of the most technology-dependent parts of the
American economy, and one of the most primitive. Every patient knows,
and dreads, the first stage of any doctor visit: sitting down with a
clipboard and filling out forms by hand.<br /><br />David Blumenthal, a
physician and former Harvard Medical School professor, was from 2009 to
2011 the national coordinator for health information technology, in
charge of modernizing the nation’s medical-records systems. He now
directs The Commonwealth Fund, a foundation that conducts health-policy
research. Here, he talks about why progress has been so slow, and when
and how that might change... </i></span></span></blockquote>
The series is replete with numerous observations by physicians and
others. Required reading. Glad to see this, coming from someone of major
publishing stature outside the healthcare space.<br />
__ <br />
<br />
<b><span style="font-family: Georgia,"Times New Roman",serif;">UPDATE</span></b><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0c343d;"><span style="font-size: large;"><b>ECRI's 2014 top 10 patient safety concerns:</b></span></span></span><br />
<ol>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Data integrity failures with health information technology systems*</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Poor care coordination with patient’s next level of care</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Test results reporting errors</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Drug shortages</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Failure to adequately manage behavioral health patients in acute care settings</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Mislabeled specimens</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Retained devices and unretrieved fragments*</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Patient falls while toileting</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Inadequate monitoring for respiratory depression in patients taking opioids</span></span></li>
<li><span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Inadequate reprocessing of endoscopes and surgical instruments* </span></span></li>
</ol>
</blockquote>
<blockquote class="tr_bq">
<span style="color: #274e13;"><span style="font-family: Georgia,"Times New Roman",serif;">*These items were also included in ECRI's top 10 health hazards list. </span></span></blockquote>
Courtesy of <a href="http://www.healthcareitnews.com/news/hit-leads-list-top-10-safety-concerns?topic=08,12,19"><i><b>Healthcare IT News</b></i></a>.<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>SENIORS USING SOCIAL MEDIA</b></span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjlmzm1bVx9IhGcrsCqvpaPbfzFIoVGsSD1Fwajfb74V-XtgDwwowCO_ej7buKtNGFP6urncg6W-7J8a3jns0OCVUGeqhJC3OM7wmsCO-LVGsn8aeI929u-v1VnnqtIKkAAfvKVI9-6CR8D/s1600/SeniorsTextingCode.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjlmzm1bVx9IhGcrsCqvpaPbfzFIoVGsSD1Fwajfb74V-XtgDwwowCO_ej7buKtNGFP6urncg6W-7J8a3jns0OCVUGeqhJC3OM7wmsCO-LVGsn8aeI929u-v1VnnqtIKkAAfvKVI9-6CR8D/s1600/SeniorsTextingCode.jpg" height="320" width="320" /></a></div>
__<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>COMMENT</b></span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjIv70pzBmZrxKtsaDHM_J08BprVcJkoOXqgwsnceagfr-EjK0m887sGEnzLEBFaohmUgNOOtXitGUDG9vP-Pb0ayJR3hWy8daKatWjUGf3_9kHgrxvSogXC-AsTA_V4HX4T1QjwIOIDh4_/s1600/Comment.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjIv70pzBmZrxKtsaDHM_J08BprVcJkoOXqgwsnceagfr-EjK0m887sGEnzLEBFaohmUgNOOtXitGUDG9vP-Pb0ayJR3hWy8daKatWjUGf3_9kHgrxvSogXC-AsTA_V4HX4T1QjwIOIDh4_/s1600/Comment.png" /></a></div>
<br />
Gotta love it.<br />
___<br />
<br />
More to come...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>
BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-6231130863222839942014-04-19T18:28:00.001-07:002014-04-20T08:57:15.857-07:00Interoperabbable update<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTtFyaH7kL4XPtQRLjEoJI2A5gEsAcspogA3AUb13K6bbcAaczH1DSLWEsqQ6bEr3vh3vzeJBnI92-ZLK5n-Y9ApU3yreai49Ebaw6JdQ6GX25CXYiYc0iSHMZUCtDv-8cRUWDY6w-Aq30/s1600/InteroperabilityIsGood.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTtFyaH7kL4XPtQRLjEoJI2A5gEsAcspogA3AUb13K6bbcAaczH1DSLWEsqQ6bEr3vh3vzeJBnI92-ZLK5n-Y9ApU3yreai49Ebaw6JdQ6GX25CXYiYc0iSHMZUCtDv-8cRUWDY6w-Aq30/s1600/InteroperabilityIsGood.jpg" /></a></div>
<blockquote class="tr_bq">
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0c343d;"><span style="font-size: x-large;"><b>Report: Lack of Interoperability Limits Meaningful Use Program</b></span></span><br />April 17, 2014, <a href="http://ww.ihealthbeat.org/articles/2014/4/17/report-lack-of-interoperability-limits-meaningful-use-program" target="_blank"><b>iHealth</b>Beat.org</a></span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">Meaningful use stages 1 and 2 fall short of implementing the interoperability among electronic health records that is necessary to facilitate information exchange and develop a robust health data infrastructure, according to a new report from a task force assembled by the MITRE Corporation, Health Data Management reports...</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;">HHS released the report, which was developed by JASON, an independent task force that advises the federal government on issues pertaining to science and technology (DeSalvo, "Health IT Buzz," 4/16). The report was funded by the Agency for Healthcare Research and Quality.</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />In the report, the task force concluded that the criteria for meaningful use stages 1 and 2 "fall short of achieving meaningful use in any practical sense," adding that "large-scale interoperability amounts to little more than replacing fax machines with the electronic delivery of page-formatted medical records."</span></span><br />
<span style="color: #134f5c;"><span style="font-family: Georgia,"Times New Roman",serif;"><br />According to the task force, "most patients still cannot gain electronic access to their health information," and "rational access to EHRs for clinical care and biomedical research does not exist outside the boundaries of individual organizations."...</span></span></blockquote>
Link to the contractor's report here: <i><b>"<a href="http://healthit.gov/sites/default/files/ptp13-700hhs_white.pdf" target="_blank">A Robust Health Data Infrastructure</a>"</b></i> (pdf)<br />
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;"><b>1.4 Facing the Major Challenges</b></span><br />A meaningful exchange of information, electronic or otherwise, can take place between two parties only when the data are expressed in a mutually comprehensible format and include the information that both parties deem important. While these requirements are obvious, they have been major obstacles to the practical exchange of health care information.<br /> </span></span><br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">With respect to data formats, the current lack of interoperability among the data resources for EHRs is a major impediment to the effective exchange of health information. These interoperability issues need to be solved going forward, or else the entire health data infrastructure will be crippled. One route to an interoperable solution is via the adoption of a common mark-up language for storing electronic health records, and this is already being undertaken by the HHS Office of the National Coordinator for Health IT (ONC) and other groups. However, simply moving to a common mark-up language will not suffice. It is equally necessary that there be published application program interfaces (APIs) that allow third-party programmers (and hence, users) to bridge from existing systems to a future software ecosystem that will be built on top of the stored data.</span></span>..</blockquote>
Open the pdf, hit Ctrl-F (PC) or Command-F (for us Mac snobs), search the document for keywords/phrases <i><b>"dictionary,"</b></i> <i><b>"data dictionary,"</b></i> <b><i>"schema,"</i></b> or <i><b>"RDBMS." </b></i><br />
<br />
Negative. Zip. Zilch. Nada. Nein. Nyet.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7W9Qtu3vR5laPzTEAjVXvVfslXYkipiiuNw8ShUOwscPSUL1kU4g0bbFQKPTYd4g02kFpFUCDHpcP2epk-C0z7jmWq8o7vAWNxlNxstXiM4SAFue5U1b70NgZygIH-MK8Kvt-Ii_Ij5lM/s1600/Zilch.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7W9Qtu3vR5laPzTEAjVXvVfslXYkipiiuNw8ShUOwscPSUL1kU4g0bbFQKPTYd4g02kFpFUCDHpcP2epk-C0z7jmWq8o7vAWNxlNxstXiM4SAFue5U1b70NgZygIH-MK8Kvt-Ii_Ij5lM/s1600/Zilch.png" height="76" width="320" /></a></div>
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;"><span style="color: #073763;"><b>1.5 A New Software Architecture</b></span><br />The various implementations of data formats, protocols, interfaces, and other elements of a HIT system should conform to an agreed-upon specification. Nonetheless, the software architecture that supports these systems must be robust in the face of reasonable deviations from the specification. The term “architecture” is used in this report to refer to the collective components of a software system that interact in specified ways and across specified interfaces to ensure specified functionality. This is not to be confused with the term “enterprise architecture,” referring to the way a particular enterprise’s business processes are organized. In this report, “architecture” is always used in the former sense...</span></span></blockquote>
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;">...There would be opportunities to operate within the new software architecture even as it is starting to be implemented. The APIs provide portals to legacy HIT systems at four different levels within the architecture: medical records data, search and index functionality, semantic harmonization, and user interface applications...</span></span></blockquote>
<i><b>"Semantic harmonization"</b></i>? Lordy. Recall <i>"<a href="http://regionalextensioncenter.blogspot.com/2011/02/poof-where-did-that-year-just-go.html#USABILITY" target="_blank"><b>Rigorability</b></a>"</i>?<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhOvPK8inQ2EbWla2vL0p-07P0jzhkY-W53xvv6P7oF2izeeBSIomDu5KlJukMKdmVbRzL5OLSkzM9CBzudgrIW6js_J5zfHcgHOObXqUYvVZHzGHTFiGRgfTyv3rRwRblDDhagnzhim5R-/s1600/BLUTO.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhOvPK8inQ2EbWla2vL0p-07P0jzhkY-W53xvv6P7oF2izeeBSIomDu5KlJukMKdmVbRzL5OLSkzM9CBzudgrIW6js_J5zfHcgHOObXqUYvVZHzGHTFiGRgfTyv3rRwRblDDhagnzhim5R-/s1600/BLUTO.jpg" height="320" width="261" /></a></div>
<br />
They finish up:<br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #073763;"><b>7 Concluding Remarks</b></span><br /><span style="color: #0b5394;">This report has expressed disappointment in current US progress towards the creation of a robust health data infrastructure, while praising ONC and HHS for their persistence in trying to tackle one of the most vexing problems of today’s society. JASON believes that the two overarching goals, improved health care and lower health care costs, can be achieved by moving to EHRs and the comprehensive electronic exchange of health information. JASON has provided a path toward realizing the promise of a robust health data infrastructure through the development of a unifying HIT software architecture that adheres to the following core principles, all embodying a focus on the patient:</span></span><br />
<ul>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Be agnostic as to the type, scale, platform, and storage location of the data</span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Use public APIs and open standards, interfaces, and protocols</span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Encrypt data at rest and in transit</span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Separate key management from data management</span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Include with the data the corresponding metadata, context, and provenance information</span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Represent the data as atomic data with associated metadata</span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Follow the robustness principle: be liberal in what you accept and conservative in what you send</span></span></li>
<li><span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Provide a migration pathway from legacy EHR systems. </span></span></li>
</ul>
</blockquote>
Yeah, "interoperability is good." All that're needed are yet <i>more</i> irrelevancies (<i>"encrypt data at rest and in transit"</i>), broad, vague cliches (<i>"robustness principle..." "atomic data..."</i>) and blinding glimpses of the obvious.<br />
<br />
In fairness, the report contains much of substantive concern, e.g., noting that there is <b><i>"a growing trend towards capturing large quantities of data associated with particular aspects of patient phenotype, analyzing those data, and reporting relevant information back to the patient. These come under the general heading of “omics” technologies, a designation derived from genomics, the first of such data types..."</i></b><br />
<ol>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #134f5c;"><b>Genome sequence</b>. The haploid human genome contains 3 x 109 base pairs of DNA. Humans are diploid, so each person has two copies of their genome, one maternal and one paternal. These two copies differ by approximately 0.1%, so it is necessary to sequence the DNA sufficiently deeply to capture all of the genetic variation of an individual in comparison to the reference human genome sequence. The current standard for individual genomes is to sequence to approximately 30-fold coverage, or approximately 1011 bases of sequence data. In the case of cancer, for which it is important to know the genotype of the tumor in comparison to that of normal tissue, a similar level of sequencing might be applied to a tumor sample, and this could include a sample of both the primary tumor and its metastases. Although these data can be compressed by denoting only the difference with respect to the reference human genome sequence, there is clearly a rapidly growing need to incorporate vast amounts of genome sequence information into individual EHRs.</span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #134f5c;"><b>Transcriptome</b>. The transcriptome is a quantitative description of the types and amounts of messenger RNA molecules transcribed from the genomic DNA. Most cells in the body have the same genome sequence, but differential expression of that genome allows cells to become differentiated. Differential expression also defines disease states; for example, breast cancers can be divided into subtypes based on gene expression patterns. The transcriptome can be assessed by microarray analysis or, increasingly, by “RNAseq,” in which DNA copies of the messenger RNAs are sequenced with high coverage. The amount of information generated in a transcriptomics experiment is typically similar to that of a genome sequence, although because every cell type is different and there are many possible variables of cell state, there is the potential for much larger datasets.</span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #134f5c;"><b>Epigenome</b>. The epigenome is a description of the modification states of the genomic DNA and the RNA and proteins that are physically associated with the DNA in the form of chromatin. These modifications are part of the basis for the differential expression of the genome that is manifested in the transcriptome. The epigenome is assessed by a variety of methods that allow for spatial resolution of particular modifications in the genome (e.g., “ChIP-Seq” for measuring modifications of histone proteins, bisulfite sequencing for determining sites of methylation along the DNA, and DNase I hypersensitivity analysis for assessing chromatin structure). Efforts are currently underway to establish reference epigenome information for all genes in all tissue types.</span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #134f5c;"><b>Proteome</b>. The proteome is a description of the types and amounts of proteins expressed from the genome; it is the protein analog of the transcriptome. The proteome is determined in part by the transcriptome from which it is derived, but also by the many subsequent processes that affect proteins, including their translation, transport, post-translational modification, and degradation. The proteome is usually assessed by mass spectrometry. Both the sensitivity of detection and the methods for determining the amount of each protein detected by mass spectrometry are improving rapidly.</span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #134f5c;"><b>Microbiome</b>. The human body contains approximately 10 times more microbial cells than human cells by cell number (although only about 1% by mass). The microbiome is the complete description of this microbial population, including commensal and symbiotic organisms as well as pathogens. The microbiome of an individual is a unique signature, changing with time and environment, and likely responsible for some elements of phenotype. Because many of the microorganisms living in and on humans cannot be cultured, the microbiome is usually assessed by deep sequencing of the genomic DNA of microbiome organisms. There is growing evidence that several pathogenic conditions are due to aberrant states of the microbiome, some of which can be corrected by altering or replacing an individual’s microbiome.</span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #134f5c;">I<b>mmunome</b>. The immunome is a description of the state of the immune system of an individual, focusing on the diversity of immune responses based on past exposures. In a narrower sense, such information has long been a part of health records. For example, the Mantoux (or PPD) skin test, and its predecessor the tuberculin tine test, assess the immune response to Mycobacterium tuberculosis antigens as a measure of previous exposure to this pathogen. High-throughput methods now allow testing for reactivity to thousands of antigens at once, in combination with deep sequencing to characterize the genome rearrangements that occur in each immune cell and define its reactivity.</span></span></li>
</ol>
Indeed. But, if we permit haphazard foundational dictionary specifications of "omics" data, things are only going to get <i>much</i> worse.<br />
<br />
I refer you to <a href="http://regionalextensioncenter.blogspot.com/2014/02/we-should-not-prescribe-specific.html" target="_blank">another of my posts</a>:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgm2E4mRx9vusizVNYRUD5qPy-rBsI9p6eo8MtZpq4u89VS3e636MKDjOgdRet8r-TPMN1nPwOkFDrX-T_7cHCytvSM8wGGHUW-VPj1QTP-LYaZgWaRDd2PhJ-KV68XKajPO4m-K6-T7rlR/s1600/ICDDS.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgm2E4mRx9vusizVNYRUD5qPy-rBsI9p6eo8MtZpq4u89VS3e636MKDjOgdRet8r-TPMN1nPwOkFDrX-T_7cHCytvSM8wGGHUW-VPj1QTP-LYaZgWaRDd2PhJ-KV68XKajPO4m-K6-T7rlR/s1600/ICDDS.jpg" /></a></div>
<br />
To coin a technical term,<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhXBD9iEtXxkLrFz9MIZvzff5KP3IckkFeqNv4vJO2Eo4CD1rf5v0FEMtDV7sm64APqeLrpC9n_mehrzU1UBp4rqMePS3Q5YEdCS2kDrx7nTidWmT2-9wGRkLferB5oDsB_UmT-7XqGbzwz/s1600/InteroperaBabble.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhXBD9iEtXxkLrFz9MIZvzff5KP3IckkFeqNv4vJO2Eo4CD1rf5v0FEMtDV7sm64APqeLrpC9n_mehrzU1UBp4rqMePS3Q5YEdCS2kDrx7nTidWmT2-9wGRkLferB5oDsB_UmT-7XqGbzwz/s1600/InteroperaBabble.jpg" /></a></div>
___<br />
<br />
More to come...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>
BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-31481628094267644522014-04-17T17:56:00.004-07:002014-04-20T08:16:11.786-07:00"There is no true value of anything"<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBKjw9LPJcWVZ4d3KkXTwjVGGAEPK70rkU54oezuTrtbOUq50jqTcp9WjWLVXnfIZtyvocZ4Ih2ig7epgXziQiueqyRDHN7wCHYSReh63mRFG9TfqHXyOStJM-LXa70rku8iUORHkhlzrI/s1600/DemingOnTrueValue.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBKjw9LPJcWVZ4d3KkXTwjVGGAEPK70rkU54oezuTrtbOUq50jqTcp9WjWLVXnfIZtyvocZ4Ih2ig7epgXziQiueqyRDHN7wCHYSReh63mRFG9TfqHXyOStJM-LXa70rku8iUORHkhlzrI/s1600/DemingOnTrueValue.png" height="255" width="630" /></a></div>
<br />
<span style="color: #274e13;"><span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>- The late W. Edwards Deming.</b></span></span></span><br />
<br />
The broader context of his observation is that, once you go beyond the mere "enumeration" (counting) of discrete objects (and even <i>that</i> gets fraught), you are <i>estimating</i>.<br />
<br />
<i>apropos...</i><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='425' height='266' src='https://www.youtube.com/embed/UF1T7KzRnrs?feature=player_embedded' frameborder='0'></iframe></div>
<div class="separator" style="clear: both; text-align: center;">
<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='425' height='266' src='https://www.youtube.com/embed/Ql2jEJ-6e-Y?feature=player_embedded' frameborder='0'></iframe></div>
<br />
Good stuff. Although some of the algebra will still lose a lot of people. A number of whom will be cherubically grinding healthcare "Big Data" in pursuit of The Next Big Epiphany.<br />
<br />
I know my <a href="http://www.bgladd.com/Total_Information_Awareness/" target="_blank">"Sensitivity vs Specificity" and "Bayes"</a> pretty well. <a href="http://www.bgladd.com/drugwar/chapter3.htm" target="_blank">See here as well</a>.<br />
<br />
Additionally, count me squarely a "<a href="http://www.fooledbyrandomness.com/" target="_blank"><b>Talebist</b></a>." And, a <a href="http://en.wikipedia.org/wiki/Chebyshev%27s_inequality" target="_blank">"<b>Chebyshev</b>"-ist</a>.<br />
__<br />
<br />
<span style="color: #274e13;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: x-large;"><i><b>"There is no true value of anything."</b></i></span></span></span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhkcBJcn0Dr_ctO2Q3pf8pHKuyRajVL589M07DDCWbXVxgdHlyuxB_AcSCxgQyJq-j_lgQU5L_zQyirH3SdlU_uZJGGYX9sttQvdkL6k8o6tiC7heSDeusVJFOgPzv20kD64tZ0ZbEFKEVk/s1600/normal-curve.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhkcBJcn0Dr_ctO2Q3pf8pHKuyRajVL589M07DDCWbXVxgdHlyuxB_AcSCxgQyJq-j_lgQU5L_zQyirH3SdlU_uZJGGYX9sttQvdkL6k8o6tiC7heSDeusVJFOgPzv20kD64tZ0ZbEFKEVk/s1600/normal-curve.png" height="221" width="400" /></a></div>
<br />
That applies to "probabilities" as well. When I hear people state <i>"the probability <u>is</u>..."</i> my reflexive reaction is that "you mean your probability <u><i><b>estimate</b></i></u> is..." Just as with any other type of statistical calculation, so too do "p-values" form <i>distributions</i>. No serious, competent modern analytics practioner takes undergrad axioms such as <i>"set alpha at 0.05"</i> etc seriously anymore. Such conveniences comprise naive methodological dilettantism. You are interested in <i>outcomes</i> differentials, i.e., "expected values" (the multiplied result of prob(x) times the payoff/payout of x) -- the estimated <i>benefit or cost</i>. Just knowing that two means (including regression trendlines) differ "significantly" is of little practical value. We need to be able, as "accurately" as possible estimate the upshot in terms of differential outcomes (be they scientific, clinical, or business/financial.<br />
<br />
Knowing
such things to finely-grained, stress-tested valuations -- inclusive of
assessing "normality" assumptions -- is how Las Vegas makes its money.<br />
<br />
The "normal curve" of undergrad stats angst is a <i>model</i>, the expression of a best-case theoretical bi-directionally asymptotically smooth curvilinear exponential <span style="font-family: inherit;"><span style="font-size: small;">function that exists only in theory.</span></span><br />
<ol>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #274e13;"><i><b><span style="font-size: large;">Chance is lumpy. </span></b></i></span></span></li>
<span style="font-family: Georgia,"Times New Roman",serif;">
</span>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #274e13;"><i><b><span style="font-size: large;">Overconfidence abhors uncertainty. </span></b></i></span></span></li>
<span style="font-family: Georgia,"Times New Roman",serif;">
</span>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #274e13;"><i><b><span style="font-size: large;">Never flout a convention just once. </span></b></i></span></span></li>
<span style="font-family: Georgia,"Times New Roman",serif;">
</span>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #274e13;"><i><b><span style="font-size: large;">Don't talk Greek if you don't know the English translation. </span></b></i></span></span></li>
<span style="font-family: Georgia,"Times New Roman",serif;">
</span>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #274e13;"><i><b><span style="font-size: large;">If you have nothing to say, don't say anything. </span></b></i></span></span></li>
<span style="font-family: Georgia,"Times New Roman",serif;">
</span>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #274e13;"><i><b><span style="font-size: large;">There is no free hunch. </span></b></i></span></span></li>
<span style="font-family: Georgia,"Times New Roman",serif;">
</span>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #274e13;"><span style="font-size: large;"><i><b>You can't see the dust if you don't move the couch.</b></i></span></span></span></li>
<span style="font-family: Georgia,"Times New Roman",serif;">
</span>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #274e13;"><span style="font-size: large;"><i><b>Criticism is the mother of methodology. </b></i></span></span></span></li>
<span style="font-family: Georgia,"Times New Roman",serif;">
</span></ol>
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #666666;"><b><span style="font-size: large;">-Abelson's Laws</span></b></span></span></blockquote>
__<br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0c343d;"><span style="font-size: large;"><b>OH, AND ANOTHER THING</b></span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #666666;"><b>Assessing Absolute vs Relative Risk</b></span></span><br />
<br />
Say the ambient prevalence of condition "c" is 1 out of 100, or 1%. We select an appropriate random sample of 2,000 subjects, splitting half via a double-blind RCT experiment into control group CG (no tx) and half into treatment group TG that gets tx "t".
We find that the post-treatment prevalence of "c" is 8 of out 1,000
(0.8%), whereas, true to form, there are 10 subjects with condition "c"
in the 1,000 person CG (1%).<br />
<br />
Well, our tx seems to have reduced the relative risk prevalence by 20%, ja?<br />
<br />
Yeah, but the <i>absolute</i> risk reduction estimate from this trial is just one one-hundreth of that, 0.2%<br />
<br />
Prevalence matters. Along with these other empirical considerations cited above.<br />
<br />
See "<a href="http://med.mercer.edu/libraries/mobile-ebm/calculators.htm" target="_blank"><i><b>Estimating the size of the treatment effect</b></i></a>."<br />
___<br />
<br />
More to come...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>
BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0tag:blogger.com,1999:blog-4383209658183339757.post-72843056247212847612014-04-17T08:36:00.003-07:002014-04-17T08:38:07.545-07:00Dispatch from the Irony-Free Zone<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjGmG7zH7YJxyf7GR3XPA4D5vmJ2vuhLaFXov6j7EuIudfMLqkMnFRZy1Fc9fTxrvuc3n8KqTjb5Wo_euTzZADENYLDvCStHZLPqr3ayh4_r4OaXqDpmOEiRS2DntYDXPEpcLvqEJheIiXz/s1600/KimIlBezos.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjGmG7zH7YJxyf7GR3XPA4D5vmJ2vuhLaFXov6j7EuIudfMLqkMnFRZy1Fc9fTxrvuc3n8KqTjb5Wo_euTzZADENYLDvCStHZLPqr3ayh4_r4OaXqDpmOEiRS2DntYDXPEpcLvqEJheIiXz/s1600/KimIlBezos.png" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
</div>
<br />
Recent post by Vik and Al on <a href="http://thehealthcareblog.com/blog/2014/04/16/amazon-shows-the-way-on-wellness-treat-people-like-adults/" target="_blank"><i><b>The Health Care Blog</b></i></a>. <a href="http://regionalextensioncenter.blogspot.com/2014/02/in-wellness-you-dont-have-to-challenge.html" target="_blank">I really like these guys</a>, but I had to call bullshit on this one in the comments.<br />
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>Kim il Bezos</b><br />
__</span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">"Amazon’s system of employee monitoring is the most oppressive I have
ever come across and combines state-of-the-art surveillance technology
with the system of “functional foreman,” introduced by Taylor in the
workshops of the Pennsylvania machine-tool industry in the 1890s. In a
fine piece of investigative reporting for the London Financial Times,
economics correspondent Sarah O’Connor describes how, at Amazon’s center
at Rugeley, England, Amazon tags its employees with personal sat-nav
(satellite navigation) computers that tell them the route they must
travel to shelve consignments of goods, but also set target times for
their warehouse journeys and then measure whether targets are met.</span></span></blockquote>
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">All this information is available to management in real time, and if
an employee is behind schedule she will receive a text message pointing
this out and telling her to reach her targets or suffer the
consequences. At Amazon’s depot in Allentown, Pennsylvania (of which
more later), Kate Salasky worked shifts of up to eleven hours a day,
mostly spent walking the length and breadth of the warehouse. In March
2011 she received a warning message from her manager, saying that she
had been found unproductive during several minutes of her shift, and she
was eventually fired. This employee tagging is now in operation at
Amazon centers worldwide.</span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Whereas some Amazon employees are in constant motion across the
floors of its enormous centers— the biggest, in Arizona, is the size of
twenty-eight football fields— others work on assembly lines packing
goods for shipping. An anonymous German student who worked as a
temporary packer at Amazon’s depot in Augsburg, southern Germany, has
given a revealing account of work on the line at Amazon. Her account
appeared in the daily Frankfurter Allgemeine Zeitung, the stern upholder
of German financial orthodoxy and not a publication usually given to
accounts of workplace abuse by large and powerful corporations. There
were six packing lines at Amazon’s Augsburg center, each with two
conveyor belts feeding tables where the packers stood and did the
packing. The first conveyor belt fed the table with goods stored in
boxes, and the second carried the goods away in sealed packages ready
for distribution by UPS, FedEx, and their German counterparts.</span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Machines measured whether the packers were meeting their targets for
output per hour and whether the finished packages met their targets for
weight and so had been packed “the one best way.” But alongside these
digital controls there was a team of Taylor’s “functional foremen,”
overseers in the full nineteenth-century sense of the term, watching the
employees every second to ensure that there was no “time theft,” in the
language of Walmart. On the packing lines there were six such foremen,
one known in Amazonspeak as a “coworker” and above him five “leads,”
whose collective task was to make sure that the line kept moving.
Workers would be reprimanded for speaking to one another or for pausing
to catch their breath (Verschnaufpause) after an especially tough
packing job.</span></span></blockquote>
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">The functional foreman would record how often the packers went to the
bathroom and, if they had not gone to the bathroom nearest the line,
why not. The student packer also noticed how, in the manner of Jeremy
Bentham’s nineteenth-century panopticon, the architecture of the depot
was geared to make surveillance easier, with a bridge positioned at the
end of the workstation where an overseer could stand and look down on
his wards. 23 However, the task of the depot managers and supervisors
was not simply to fight time theft and keep the line moving but also to
find ways of making it move still faster. Sometimes this was done using
the classic methods of Scientific Management, but at other times higher
targets for output were simply proclaimed by management, in the manner
of the Soviet workplace during the Stalin era.</span></span></blockquote>
<blockquote class="tr_bq">
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Onetto in his lecture describes in detail how Amazon’s present-day
scientific managers go about achieving speedup. They observe the line,
create a detailed “process map” of its workings, and then return to the
line to look for evidence of waste, or Muda, in the language of the
Toyota system. They then draw up a new process map, along with a new and
faster “time and motion” regime for the employees. Amazon even brings
in veterans of lean production from Toyota itself, whom Onetto describes
with some relish as “insultants,” not consultants: “They are really not
nice. . . . [T]hey’re samurais, the real last samurais, the guys from
the Toyota plants.” But as often as not, higher output targets are
declared by Amazon management without explanation or warning, and
employees who cannot make the cut are fired. At Amazon’s Allentown
depot, Mark Zweifel, twenty-two, worked on the receiving line,
“unloading inventory boxes, scanning bar codes and loading products into
totes.” After working six months at Amazon, he was told, without
warning or explanation, that his target rates for packages had doubled
from 250 units per hour to 500.</span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Zweifel was able to make the pace, but he saw older workers who could
not and were “getting written up a lot” and most of whom were fired. A
temporary employee at the same warehouse, in his fifties, worked ten
hours a day as a picker, taking items from bins and delivering them to
the shelves. He would walk thirteen to fifteen miles daily. He was told
he had to pick 1,200 items in a ten-hour shift, or 1 item every thirty
seconds. He had to get down on his hands and knees 250 to 300 times a
day to do this. He got written up for not working fast enough, and when
he was fired only three of the one hundred temporary workers hired with
him had survived.</span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">At the Allentown warehouse, Stephen Dallal, also a “picker,” found
that his output targets increased the longer he worked at the warehouse,
doubling after six months. “It started with 75 pieces an hour, then 100
pieces an hour. Then 150 pieces an hour. They just got faster and
faster.” He too was written up for not meeting his targets and was
fired. At the Seattle warehouse where the writer Vanessa Veselka worked
as an underground union organizer, an American Stakhnovism pervaded the
depot. When she was on the line as a packer and her output slipped, the
“lead” was on to her with “I need more from you today. We’re trying to
hit 14,000 over these next few hours.”</span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Beyond this poisonous mixture of Taylorism and Stakhnovism, laced
with twenty-first-century IT, there is, in Amazon’s treatment of its
employees, a pervasive culture of meanness and mistrust that sits ill
with its moralizing about care and trust— for customers, but not for the
employees. So, for example, the company forces its employees to go
through scanning checkpoints when both entering and leaving the depots,
to guard against theft, and sets up checkpoints within the depot, which
employees must stand in line to clear before entering the cafeteria,
leading to what Amazon’s German employees call Pausenklau (break theft),
shrinking the employee’s lunch break from thirty to twenty minutes,
when they barely have time to eat their meal…”</span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">Perhaps the biggest scandal in Amazon’s recent history took place at
its Allentown, Pennsylvania, center during the summer of 2011. The
scandal was the subject of a prizewinning series in the Allentown
newspaper, the Morning Call, by its reporter Spencer Soper. The series
revealed the lengths Amazon was prepared to go to keep costs down and
output high and yielded a singular image of Amazon’s ruthlessness—
ambulances stationed on hot days at the Amazon center to take employees
suffering from heat stroke to the hospital. Despite the summer weather,
there was no air-conditioning in the depot, and Amazon refused to let
fresh air circulate by opening loading doors at either end of the depot—
for fear of theft. Inside the plant there was no slackening of the
pace, even as temperatures rose to more than 100 degrees.</span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">On June 2, 2011, a warehouse employee contacted the US Occupational
Safety and Health Administration to report that the heat index had
reached 102 degrees in the warehouse and that fifteen workers had
collapsed. On June 10 OSHA received a message on its complaints hotline
from an emergency room doctor at the Lehigh Valley Hospital: “I’d like
to report an unsafe environment with an Amazon facility in Fogelsville. .
. . Several patients have come in the last couple of days with heat
related injuries.” </span></span><br />
<br />
<span style="color: #0b5394;"><span style="font-family: Georgia,"Times New Roman",serif;">On July 25, with temperatures in the depot reaching 110 degrees, a
security guard reported to OSHA that Amazon was refusing to open garage
doors to help air circulate and that he had seen two pregnant women
taken to a nursing station. Calls to the local ambulance service became
so frequent that for five hot days in June and July, ambulances and
paramedics were stationed all day at the depot…"</span></span><br />
<br />
<span style="font-family: inherit;">Head, Simon (2014-02-11). <u>Mindless: Why Smarter Machines are Making Dumber Humans</u> (p. 42-44). Basic Books. Kindle Edition.</span></blockquote>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEimos_buYeutBTJ6NeIx840RklSksPATM8IvP473sbCO7e91vEl7yJcDhrKXF73W5pmcvF8CAP5wknJf3H1q0-RqGwoej9jmyhcPqoR9F4DielzORhEigXyxxV2wCCkPEzm4x6dxVDy6gdW/s1600/Mindless.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEimos_buYeutBTJ6NeIx840RklSksPATM8IvP473sbCO7e91vEl7yJcDhrKXF73W5pmcvF8CAP5wknJf3H1q0-RqGwoej9jmyhcPqoR9F4DielzORhEigXyxxV2wCCkPEzm4x6dxVDy6gdW/s1600/Mindless.png" height="320" width="209" /></a></div>
<br />
It gets worse. Lots more about the odious management culture at Amazon. Walmart too.<br />
___<br />
<br />
More to come...<br />
<br />
<iframe allowtransparency="true" frameborder="0" scrolling="no" src="https://platform.twitter.com/widgets/tweet_button.html" style="height: 20px; width: 130px;"></iframe>
BobbyGhttp://www.blogger.com/profile/03807934795994985233noreply@blogger.com0