“We should not prescribe specific functionality for the EHR other than interoperability and security.” - John Halamka

“We should not prescribe specific functionality for the EHR other than interoperability and security.”
 - John Halamka

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Updated, annotated: on the (misnomer) “interoperability” side, from my recurring blog rant.

One.Single.Core.Comphrehensive.Data.Dictionary.Standard

One. That’s what the word “Standard” means -- er, should mean. To the extent that you have a plethora of contending “standards” around a single topic, you effectively have none. You have simply a no-value-add “standards promulgation” blindered busywork industry frenetically shoveling sand in the Health IT gears under the illusory guise of doing something goalworthy.

One. Then stand back and watch the private HIT market work its creative, innovative, utilitarian magic in terms of features, functionality, and usability. Let a Thousand RDBMS Schema and Workflow Logic Paths Bloom. Let a Thousand Certified Health IT Systems compete to survive on customer value (including, most importantly, seamless patient data interchange for that most important customer). You need not specify by federal regulation (other than regs pertaining to ePHI security and privacy) any additional substantive “regulation” of the “means” for achieving the ends that we all agree are necessary and desirable. There are, after all, only three fundamental data types at issue: text (structured, e.g., ICD9, those within other normative vocabulary code sets, and unstructured, e.g., open-ended free-form SOAP note narratives), numbers (integer and floating-point decimal), and images. All things above that are mere “representations” of the basic data (e.g., text lengths, datetime formats, Boolean/logical, .pngs, bmps, .tiffs, .jpegs etc).

Actually, all digital data are simply collections of “representations” of values coded in the binary ASCII (or the legacy EBCDIC) collating sequence (“under the hood” of all this stuff at the bit/byte level). Yeah, I’m givin’ away my age.

You can’t tell me that a world that can live with, e.g., 10,000 ICD-9 codes (going up soon by a factor of 5 or so with the 2014 migration to ICD-10) would melt into a distraught puddle on the floor at the prospect of a requisite standard data dictionary comprised of perhaps a similar number of metadata-standardized, “strongly typed” data elements spanning the gamut of administrative and clinical data definitions cutting across ambulatory and inpatient settings and the numerous medical specialties. We’re probably already a good bit of the way there given the certain overlap across systems, just not in any organized fashion.

Think about it.

Why don’t we do this? Well, no vendors want to have to “re-map” their myriad proprietary RDBMS schema to link back to a single data hub dictionary standard. And, apparently the IT industry doesn’t come equipped with any lessons-learned rear view mirrors.

That’s pretty understandable, I have to admit. In the parlance, it goes to opaque data silos, profitable “vendor lock,” etc. But, such is fundamentally anathema to efficient and accurate reciprocal data interchange (the “interoperability” misnomer) that patients ultimately need and deserve.

Yet, the alternatives to a data dictionary standard are our old-news, status quo, frustratingly entrenched, Clunkiness-on-Steroids, Nibble-Endlessly-Around-the-Edges Outside-In workarounds — albeit quixotic efforts that keep armies of Health IT geeks employed starting and putting out the fires they themselves started.

Resources better devoted to actual clinical care.

Visualize going to Lowe’s or Home Depot to have to choose among 800+ ONC Stage 2 CHPL Certified sizes and shapes of 120VAC 15 amp grounded 3-prong wall outlets.

Imagine ASCII v3.14.2.a.7. Which, uhh…, no longer supports ASCII v2.05.1 or earlier…

Ya with me here, Vern?

NIST/ANSI/ISO Health IT ICDDS – Interoperability Core Data Dictionary Standard.

I’m still awaiting substantive pushback (my Twitter pal Chuck Webster thinks an ICDDS would “inhibit innovation”). And, I know – ok? -- that there will still be much programming work to do, even with a truly uniform Data Dictionary Standard in place (that’s a good thing). Moreover, as with any comprehensive, prevailing standard, there will be necessary advances requiring revisions. But, there are conceptually really only two alternatives given the current paradigm: [1] expensive n-dimensional custom point-to-point data mapping, from EHR 1 to EHRs 2-n, or [2] a central data mapping/routing “hub,” into which EHRs 1-n send their data for translation for the receiving EHR.

The complications arising from these two alternative scenarios ought to be obvious, data truncation or otherwise misinterpretation, or “not-found” chiefly among them.

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As I wrote back in November while attending the NYeC conference:

I have some lingering Interop questions. One goes to the humorous phrase proffered by one of the presenters:

“Smiling Almighty Jesus.”

The point was miscommunication resulting from information garble over time between people. The above refers to a dx of “Spinal Meningitis,” which the fictional elderly patient in the slide got wrong. As it goes to HIE, this aligns with my chronic rant about a data dictionary standard. As I have observed by way of analogy:

True interoperability requires a comprehensive data dictionary standard. Without it, information can become “garbled.” That is, altered during iterative/sequential transmissions. For example, what if you took these sentences and ran them through Google Translate from one language to another — say, [1] from English to Spanish, [2] then from Spanish to French, [3] then from French to German, [4] then from German to Greek, [5] then from Greek to Swedish, [6] then from Swedish to Portuguese, and [7] then back to English?

1. Verdadero interoperabilidad requiere un amplio diccionario de datos estándar. Sin ella, la información puede llegar a ser “confusa”. Esto es, alterado durante las transmisiones secuenciales. Por ejemplo, ¿qué pasa si usted tomó estas frases y las pasó por Google traducir de un idioma a otro – por ejemplo, del Inglés al Español, a continuación, del español al francés, después del francés al alemán, después del alemán al griego, luego del griego al sueco, luego del sueco al portugués, y luego de nuevo a Inglés?
2. Véritable interopérabilité requiert une vaste série de dictionnaire de données. Sans elle, l’information peut devenir “confus”. C’est, séquentielle modifié pendant la transmission. Par exemple, si vous avez pris ces mots et a traversé Google traduire d’une langue à l’autre – par exemple, de l’anglais à l’espagnol, puis l’espagnol vers le français, puis du français en allemand, puis de l’allemand vers grec , puis du grec au Suédois Suédois Portugais après, puis revenir à l’anglais?
3. Echte Interoperabilität erfordert eine breite Palette von Data-Dictionary. Ohne sie können die Informationen zu “verwirrt”. Dies wird sequenziell während der Übertragung verändert. Zum Beispiel, wenn Sie mir das Wort und ging durch Google übersetzen von einer Sprache in die andere – zum Beispiel aus dem Englischen ins Spanische und Spanisch in Französisch und von Französisch ins Deutsche und Deutsch auf Griechisch, dann aus dem Griechischen ins Schwedisch Portugiesisch nach dann wieder auf Englisch?
4. True διαλειτουργικότητα απαιτεί ένα ευρύ φάσμα του λεξικού δεδομένων. Χωρίς αυτά τα στοιχεία για να “σύγχυση”. Αυτό είναι διαδοχικά αλλαχτούν κατά τη μεταφορά. Για παράδειγμα, αν η λέξη και μου περπάτησε μέσα από το Google μετάφραση από τη μία γλώσσα στην άλλη – για παράδειγμα, από τα αγγλικά στα ισπανικά και ισπανικά στα γαλλικά και από Γαλλικά σε Γερμανικά και Γερμανικά σε Ελληνικά, στη συνέχεια, από τα ελληνικά στα Σουηδικά Πορτογαλικά σε συνέχεια πίσω στα Αγγλικά;
5. Verklig driftskompatibilitet kräver ett brett spektrum av data dictionary. Utan denna information till “förvirring.” Detta successivt förändras under transporten. Till exempel, om ordet och promenerade mig genom Google översättning från ett språk till ett annat – till exempel från engelska till spanska och spanska till franska och från franska till tyska och tyska till grekiska, sedan från grekiska till Svenska Portugisiska in sedan tillbaka till engelska?
6. Plena interoperabilidade exige uma ampla gama de dicionário de dados. Sem esta informação a “confusão”. Isso mudou gradualmente em trânsito. Por exemplo, se a palavra e me atravessou tradução do Google a partir de uma língua para outra – por exemplo, de Inglês para Espanhol e Espanhol para Francês e de Francês para Alemão e Alemão para o grego, depois do grego para o Português Sueco em seguida, de volta para Inglês?

And, finally full circle back to English:

7. Full interoperability requires a broad range of data dictionary. Without this information to “confusion.” This gradually changed in transit. For example, if the word and I went through Google translation from one language to another – for example, from English to Spanish and Spanish to French and from French to German and German to Greek, then from Greek to Portuguese Swedish in then back to English?

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Ouch.

Pull up Google Translate, try it yourself. Pick additional languages. The results can often be quite amusing. (Broadly, Google “Sapir–Whorf hypothesis” for the more general linguistic implications that go to the point.)

As it goes to HIE/”Interoperability,” what I don’t yet know is whether a CDA-compliant CCD/CCR ePHI transmission arrives as “read-only” in every instance, or whether it can go from the incoming HL7 message and be parsed into the destination EHR database fields where the data can subsequently be edited (“read-write” — I would require appending a new record in order to preserve the original data. It’s an ePHI “chain of custody” issue).

There are HIPAA considerations here, specifically 45 CFR 164.312 (Technical Safeguards — data authentication), and requisite audit log capture. Moreover, given the lack of a single HIT RDBMS Data Dictionary standard, might ePHI undergo slip-through-the-cracks modifications strictly resulting from point A to point “n” sequential transmission? Now, if a HIE CDA transmission is read-only, garble concerns would be allayed (assuming a data dictionary standard), but…

I will defer to others further down in the weeds on this issue.

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CODA:  Perhaps a condition of ONC/CHPL EHR certification ought be the handing over of your data dictionaries comprising yor RDBMS schema – with confidentiality stipulations, of course – so that ONC/NIST could study and assess precisely how much de facto metadata standardization already exists informally, in order to obtain a clearer picture of just how much full interop data standardization work needs to be done.

It might well be less than we think. But, until we examine the data dictionaries, we cannot know. Something worthy of federal study, IMHO.

Below, OpenEMR dictionary/schema snippet, from my July 2012 post "Analytics - SAS, R, SQL, EHR database schema. An old school data miner's ramble involving the intersections of workflow, audit logging, and CER, etc."

 
UPDATE 

Tangentially apropos?

5 examples of how the languages we speak can affect the way we think___

More to come...

#HIMSS14 - Let's ROLL!

Busy, interesting week ahead. Twitter hashtag #HIMSS14. Conference site main page here. Of particular interest to me are "Interoperability," "ICD-10," "Meaningful Use", and "Value of Health IT." Other topics not on the above list include "workflow" and "HIPAA." And, then, there's always our friend "ObamaCare" -- the PPACA.
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More to come, as always...

ONC - REC Spin Cycle 101?

ONC: RECs have 'surpassed their goals'
February 14, 2014 | By Marla Durben Hirsch

The nation's 62 regional extension centers have outdone themselves in their efforts to increase electronic health record adoption among physicians, rural hospitals, federal qualified health centers (FQHCs) and others, according to the Office of the National Coordinator for Health IT...

"RECs have far exceeded their goal to support the adoption and use of health IT by 100,000 small practices, community health centers, and rural and public hospitals, and while continuing to support providers to reach meaningful use, are now focusing their efforts on helping these healthcare providers use the technology for care delivery transformation and improvement," they wrote...

From the ONC blog post cited in the article:

 "RECs have played a critical role in this transformation, working with over 136,000 (nearly half) of the nation’s primary care providers (PCPs), helping 90 percent (over 123,000) of those providers adopt an EHR system and 62 percent (over 85,000) demonstrate stage 1 meaningful use."

123,000+ have "adopted EHR" with REC help? And, all of these were using paper charts prior to the Meaningful Use initiative and REC engagement? Or, was it the case that many/most of them were already using HIT, just not ONC-CHPL certified EHRs? Not clear.

Maybe they'll clarify.

Why even question this? See, e.g., The AcademyHealth Listening Project: Improving the Evidence Base for Medicare Policymaking (pdf)

IV. The Politics of Evidence and Medicare Policymaking
The interviews underscore the importance of politics and ideology in shaping the perception and use of evidence in Medicare policymaking. Comments from respondents suggest that the political or ideological perspective underlying a piece of information affects whether and how it is used in the policy process. Grey literature – which in some forms can blur the lines between research and stakeholder self-promotion – is increasingly gaining the attention of policymakers and presenting new challenges for the analysts charged with separating evidence from opinion. Importantly, the interviews also suggest that health services researchers must consider the political feasibility of the policy options and ideas they explore if they wish for their research to be useful...

Respondents also pointed to political or ideological undercurrents in stakeholder reports and noted the skill of interest groups in getting their self-funded research in front of policymakers. For their part, policy analysts are spending more of their time trying to assess the value of stakeholder reports, as well as the other forms of grey literature described earlier in this report...

Finally, interviewees noted that traditional research studies, even those appearing in the peer-reviewed literature, can also reflect a particular political perspective or unacknowledged set of assumptions. According to one individual, many research funders have a worldview that influences the types of projects they support. This worldview may ultimately distort research findings, or whether and how those findings are received in the policy and political arena.

In other words, you will get called on "spin," so avoid it. It just gums up the works.

So, the RECs have "outdone themselves" and their reward is to be allowed to wither on the vine? RECs are said to be loosely modeled on the U.S. Agricultural Extension Centers.

Those are now 100 years old.

Divide the aggregate 62-REC four year funding allocation by the 136,000 PCPs assisted by RECs. It's about $1,200 a year. That will buy you maybe one week of low-end private consultant time.

UPDATE: INTERESTING INFOGRAPHIC

From the folks at BestMedicalDegrees.com. "Are Robot Doctors In Your Future?"

Click here for the full size image on their site.
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A CRUSHINGLY SAD PERSONAL NOTE

My wife has a group of girlfriends I call "the Ya-Ya Sisterhood." They are all former colleagues who worked together for years in Vegas when Cheryl was head of QA for the Environmental Remediation Project at the Nevada Test Site. A dazzling power cohort of female smarts and executive management chops, they are now scattered all around the nation, but remain tight friends who gather several times a year to party hearty. A couple of years ago they all went to Scotland together. Next up on their schedule is a Rhine River cruise boat / biking trip this spring.

Several days ago, Margo, who'd been leading the cruise trip planning, was found unconscious and unresponsive at home in New Mexico.

Bacterial spinal meningitis. Apparently strep-caused, originating from a mundane prior sinus infection.

Massive irreversible brain damage. She died yesterday. We are all just stunned.

Hold your loved ones close every day. You just never know. ___

More to come...

ROI - Health IT Return On Investment 101

Continuing with the "relative value" riff from my prior post.

A lot of late-mover docs still get "sticker shock" when presented with the nominal costs associated with moving from paper charts to EHRs. It's not as jarring as it was back during the DOQ-IT era, but buying into health IT is still a formidable undertaking, one not to be taken lightly.

Nonetheless, you really need to start with a quantitative assessment of your current state in order to determine, well, "relative value" (marginal differential).

to wit...

Assume the simplest case (solo ambulatory primary care practice). Assume

• 25 patients per day;
• 5 days per week;
• 48 weeks per year;
• An average chart handle time of just 5 minutes per year, inclusive (pulling, reviewing, updating, re-filing, etc);
• A blended, fully G&A cost-adjusted average labor expense of $40 per hour (i.e., pay and benefits and full per capita apportionment of all expenses of running the business).
• 25 x 5 x 48 x 5 = 30,000 minutes per year, divided by 60 minutes per hour.
• 500 hours, at $40 per hour.
• That's $20,000 per year simply in labor expense just shlepping charts around the office.

To which you add

• Cost of the medical folders and associated office supplies;
• Cost of the clinical square footage and furnishings devoted to chart storage;
• Cost of photocopying;
• Cost of secure offsite backup storage for all of those boxes of charts.

etc. Again, this is "101," not meant to be exhaustive. Contact your local REC for help with that.

Now consider two successful, mature (but by no means dated, lock-in "legacy"), well-regarded mainstream ONC-certified EHRs with identical pricing plans -- eClinicalWorks and e-MDs.

$599 per month subscription ("Cloud" model, using the internet and remote data storage). Full systems, replete with "PM" (Practice Management) functionality spanning scheduling to billing. (Note: eCW and e-MDs principal competitors offer similar pricing plans. You can pay more, but you need not, and there are less expensive yet still functional alternatives -- all the way down to "free.")

$7,188 per year per doc (includes support staff user licensing). About a third of what you're paying for your paper operation. But, in fairness, you have to add into that cost of your PCs, laptops, tablets, peripherals, etc, the price of a high-speed T-1 internet connection and secure WiFi installation, costs associated with initial data transition from paper to EHR (i.e., populating your new system with necessary patient data), the expense of staff EHR training, the cost of backup operation capability for times when the internet is down, the cost of vendor support, etc.

Yes, there will inevitably be a "productivity dip" across the transition period. And, again, your REC can help you minimize that pain.

I used to work in profit modeling and credit/operations risk management in a credit card bank. Our CEO, who rose to Prez from being our CFO, made us use his "Spreadsheet from Hell" "Profit Model" for vetting all proposed marketing and ops initiatives. You had to be able to demonstrate a stress-tested 10% or more net profitability across a five-year look-ahead or your little pet project didn't get funded, period. (My White Papers from that era can be found here.)

Similar rigor should apply to vetting the inevitable Health IT transition. But, in the end, you have to ask: is it necessary and reasonable that you spend roughly 4 bucks per chart per year (or less)  -- whatever method you use -- to accurately and efficiently capture, retrieve, and manage the patient information that is the very essence of your business.

I don't see how there can be any rational debate about that. It's maybe 2-4% of your gross revenue.

We'll talk about other aspects of this shortly -- usability implications, workflow improvements, "soft benefits" and so forth.

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"TEN SECONDS TO LOGIN?" 
WHY SHOULD WE CARE ABOUT THAT?

I've been watching health care workers do this for years, first while tending to my now- late mother during one of her many hospitalizations. I've also stop-watched myself numerous times. ~10 seconds, login name + password.

Recently I had my first visit with my new Primary, at Muir in Walnut Creek. They use Epic. The M.A. came in, and I watched her log in to the wall-mounted terminal, silently counting as she did so.

Ten seconds. OK...

Assume 

• 6 logins per hour on average;
• 8 hours per day;
• 5 days per week;
• 49 weeks per year.

That's one minute login time per hour, 8 minutes per day, 40 minutes per week, times 49 weeks (assuming zero login errors).

117,600 seconds of login time. 32.67 hours.

Stay with the $40/hr fully G&A'd labor cost. ~ $1,307.

Provide her with an iPad. Roughly 90% of that time goes away.

Bank the savings.

And, yes, I know there will be other issues, such as lost/stolen iPads, perhaps risking a  HIPAA breach. Enable them with auto-logout and remote "kill switches." They're talking about doing kill switches for smartphones.

Jus' sayin'... The little stuff adds up.

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KAISER PERMANENTE ON "ROI"

More from the book I reviewed at length on February 6th.

The Business Case and Board Involvement

In addition to putting together his senior executive team, however some had helped make some changes in the Kaiser foundation health plan and hospitals board of directors, adding several seasoned healthcare executives, senior business executives, and consultants. They would be understandably rigorous in their review and oversight of the largest capital project in the history of the organization, an estimated $3.2 billion investment (a figure that grew to over $4 billion) over 10 years for the initial implementation and ongoing maintenance of the EHR system. As Halverson told the board of directors, it truly was a "bet the farm" decision for the organization and would provide major budgetary competition with the already significant investments needed for new facilities and seismically required enhancements for the California hospitals. Very few healthcare organizations had implemented electronic health records to the extent planned by Kaiser Permanente, and none had solid information on the value realized by their systems.

The business case was based partially on assumptions and experience from the Southern California region, and spotty reports of specific savings from outside organizations. In reality, the expanded fully integrated EHR and related IT systems would support almost 80% of the clinical and administrative workflows in the organization, and no one could predict the full nature of the changes, much less the value, that could be gained. Making no assumptions related to increasing member satisfaction, competitive advantage, or growth, a conservative business case made a defensible case that the investment would break even and pay for itself in roughly 8 1/2 years. However some told the board that the actual payback would happen in half that time.

Make no mistake; this was a strategic decision, not one based on return on investment. [emphasis mine] The Board of Directors and the executive management of Kaiser Permanente believed that successful implementation and effective use of any HR would streamline administrative and clinical operations and enhance performance in quality, service, the HR would connect and leverage the Kaiser Permanente care delivery system the seamless information flow across all facilities. At the same time, it would connect to members via the Internet with features that could not be duplicated by its insurance or provider competitors. All of this was reflected in the project name, Kaiser Permanente HealthConnect. and cost.

The board gave KP HealthConnect much more than financial backing. It designated KP HealthConnect the number one priority in the organization's business plan for three consecutive years, and it linked the achievement of development and deployment milestones to every health plan and hospital executive’s performance goals and compensation...

 "[T]his was a strategic decision, not one based on return on investment."

How about that? In other words, deploying Epic was integral to the overall KP strategy and corporate Ends; the "business case" went beyond simple estimated quantification of isolated ROI. You don't "invest" in tools simply as a means of making money -- a nominally "positive ROI." While you don't blindly throw money around and buy a technology that causes you financial grief long-term, your decision should be based on your ethos and goals.

I think KP's results speak for themselves.
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LOL

Just saw this on Facebook.

NEWS UPDATE

On the wires. From Healthcare IT News:

2017 and beyond: When meaningful use winds down, what's next?
Feb 17th, 2014

Although the federal government’s meaningful use incentive program has been a driving force for healthcare IT innovation and adoption, it has also been a distraction—encouraging organizations to invest in technology with certain characteristics and capabilities rather than systems that fully address provider and patient needs.

Come 2017, the MU program will begin winding down, at which point it will be interesting to see what will happen with healthcare technology adoption and innovation. While public funding will dry up, by all accounts, a massive wave of private venture capital funding is on its way. The central question is will the industry be fatigued and resistant to change as in the past or will it embrace further advances?

Entering Uncharted Territory

No other industry has gone through a similar experience, where public policy and law incentivized and then obligated large-scale IT implementation. In fact, prior to Meaningful Use, healthcare IT adoption was slower than in other industries because clinicians were hesitant to change workflows and rally behind automation. MU launched a  swell of technology adoption, pushing the industry to innovate faster—and not always with the best results. In many cases, technology vendors designed systems to meet specific requirements and failed to deliver when it came to system usability and functionality...

Yeah. Good article. If the current SGR Fix bill (HR 4015) gets passed into law, Meaningful Use is essentially done. We shall see.

UPDATE: 
WHAT IF THERE WAS NO "MEANINGFUL USE" REQUIREMENT?

A nice follow-on the the foregoing. Fellow blogger John Lynn has thrown down an interesting challenge question to the Health IT community.

Here’s the question I asked:

If meaningful use were gone (i.e., no more EHR incentive money or penalties requiring meaningful use), which parts of meaningful use would you remove from EHR immediately and which parts would you keep?

The concept is simple. If there wasn’t some outside influence (i.e., government money) influencing the requirement to do meaningful use, which elements of MU actually provide value to the users of an EHR. Those that provide value will continue to be embraced by an EHR vendor and those that don’t will be removed. Plus, this is the reality of what’s going to happen once the EHR incentive money runs out, so let’s find this info out now...

What do you think? I'll have some thoughts shortly. For starters, I love John's use of the phrase "some outside influence." At least half of U.S. healthcare expenditures are paid for by the "outside influence" of government. Indeed, roughly 40% of U.S. GDP in the aggregate is comprised of public expenditures.

The people, via their government, have every moral and economic right to insist on regulation that may very well "distort" private markets where the public interest is at stake. Whether the regulatory regime known as "Meaningful Use" is a wise and effective thing is a separate question. My irascible views on it are fairly well known. And, while I find some of the Meaningful Use particulars squarely in the Bozo Column, we simply cannot argue that it was for lack of stakeholder input. The regulatory process has been as open and inclusive as one could possibly expect.

I don't know John's politics. He touts himself as a "Health IT entrepreneur." To what extent his "free market" success is directly coupled to ARRA/HITECH spending is probably unknowable to any degree of accuracy, but I would speculate that it's highly significant.

One of the docs who took up John's MU challenge wrote

...Replacement of stable, natural market forces with MU incentives drove immediate, explosive short-term growth in the EMR market.  But these MU-driven EMR purchasers are not like the practices before 2008 that freely chose to purchase a system. These practices had decided against EMR initially, at least partly because they lacked the IT resources to make EMR work for them.   MU coerced them to purchase EMR against their better judgment.

I have spoken with many of these physicians.  They do not share the inspiration and vision of the early adopters.  They are rightly unhappy and cynical, forced by MU to spend huge amounts of money on unproven, underdeveloped EMR products that they did not want and were not prepared to properly use. To these practices the question of EMR’s potential is irrelevant....

The MU program gave EMR vendors what they wanted – legislation requiring hundreds of thousands of providers to buy EMR products, with no need to prove that those products do anything useful.  But here’s the bad news: the Feds got what they wanted as well.  Through MU they created an EMR industry that is dependent on government incentives and penalties to maintain a stream of new customers.  This gives them complete control of the EMR market.  There is more bad news.  MU also destroyed the base of satisfied EMR customers from 2008, replacing it with a much larger base of unhappy, resentful customers.

So what happens as MU payments decrease with each passing year as MU requirements go up?  Who can argue that the market won’t collapse without another EMR stimulus package?  John Lynn’s question is appropriate and timely.  MU incentives will indeed disappear over the next couple of years.  How the EMR market will survive is not clear.

 "Stable, natural market forces"? I am reminded of the words of noted medical economist JD Kleinke from nine years ago:

HIT market failure
...If the state of U.S. medical technology is one of our great national treasures, then the state of U.S. HIT is one of our great national disgraces. We spend $1.6 trillion a year on health care—far more than we do on personal financial services—and yet we have a twenty-first-century financial information infrastructure and a nineteenth-century health information infrastructure. Given what is at stake, health care should be the most IT-enabled of all our industries, not one of the least. Nonetheless, the “technologies” used to collect, manage, and distribute most of our medical information remain the pen, paper, telephone, fax, and Post-It note.

Meanwhile, thousands of small organizations chew around the edges of the problem, spending hundreds of millions of dollars per year on proprietary clinical IT products that barely work and do not talk to each other. Health care organizations do not relish the problem, most vilify it, many are spending vast sums on proprietary products that do not coalesce into a systemwide solution, and the investment community has poured nearly a half-trillion dollars into failed HIT ventures that once claimed to be that solution. Nonetheless, no single health care organization or HIT venture has attained anything close to the critical mass necessary to effect such a fix.

This is the textbook definition of a market failure. All but the most zealous free-market ideologues recognize that some markets simply do not work. Indeed, reasoned free-market champions often deconstruct specific market failures to elucidate normal market functioning...

This was written way before ARRA/HITECH. The notion of stable, beneficent, efficient, and effective "free" markets across all economic sectors is as naive as it is nominally charming to the unreflective. Moreover, assume you could summarily cut back cut back "government spending" by a quarter -- from ~40% to ~30% of GDP. You'd have a national economic collapse of unprecedented severity. A mere 2% federal sequestration has produced visible downturns and gnashing of teeth. Even WalMart is now griping about how the failure to renew extended federal unemployment benefits is negatively impacting their earnings and stock valuation.

People need to get serious and get a Clue.
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FYI: below, a worthy website.

www.theusabilitypeople.com

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More to come...

Up next: #HIMSS14

Twitter hashtag #HIMSS14.

INTERESTING ARTICLE

Expect much exuberant talk next week at HIMSS14 about improving healthcare "value." OK, how about this?

STRAIGHT TALK ABOUT THE VALUE PROPOSITION IN HEALTH CARE
Paul H. Keckley, Ph.D.

...Relative value is a term rooted in investing: it compares the attractiveness of one investment over others in terms of risk, liquidity, and return. In healthcare circles, it’s most prominently used to set Medicare reimbursement rates for physicians using the complicated Resource-based Relative Value Scale, and more recently in the Affordable Care Act’s Comparative Effectiveness Research effort wherein treatments will be compared based on efficacy and effectiveness.

Healthcare in the U.S. does not have a value problem. Like higher education, it does not need to demonstrate that our system outperforms others of the world in availing caregivers the latest technologies and life-saving heroics. We are quite proficient in declaring our value; we are quite challenged to assert and validate our relative value. And that’s what our market is asking…

• What’s the value of health insurance? How do alternatives compare?
• Why do prices for routine procedures and tests vary so widely across communities and regions, and how can what’s paid be compared to alternatives when outcomes and underlying costs are unrelated?
• Why are there 1400 hospitals among the “Top 100”?
• Why does each insurance plan’s small print defy side-by-side comparison against others?
• Why do drugs with the same ingredients in the same amounts have different efficacy and different prices? And how do alternative remedies and over the counter options compare?
• Why do academic medical centers cost dramatically more than community hospitals for routine treatments with similar results? Or routine preventive health when delivered by nurses or physicians?
• How do end of life options compare versus expenditures and heroics that rob families and patients of resources and peace of mind?
• What differentiates between an “essentially equivalent” device that enters a market overnight and a similar that required years to get approval?
• Why does a nurse practitioner get paid half what a physician gets paid to diagnose a simple, uncomplicated medical problem? And what’s the difference in retail clinics operated by drugstores versus those sponsored by health systems?
• What’s the relative balance of a high performing system’s high tech, high touch investments in care?
• What are we getting for $9000 we spend on healthcare for every man, woman and child in the U.S. when outcomes of systems that spend significantly less rival ours?

And many others...

The relative value of the health care industry, like higher education, is an unfolding story. The industry is attracting new competitors that are unconstrained by the traditional ways we deliver and finance care. They break rules set by incumbents. They don’t worship sacred cows. They’re nimble and focused: they see the relative value issue opportunistically.

The U.S. healthcare industry does not have a value problem; it has a relative value problem. Others see it, perhaps better than we do. It’s a discussion we need. It requires straight talk.

Indeed. Myriad tough questions abound.
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DOC GURLEY UPDATE

Medical Homes Part III: The True Cost

As the Patient Centered Medical Homes (PCMHs) train charges forward along with implementation of the Affordable Care Act, dollars are taken directly out of our health care system to certify providers in a method with no proven benefit (see Medical Homes Part II: The Depressing Data). And, while there is a marked shortage of primary care providers nationwide, funds that could be used toward providing the direct provision of, or access to, health care are instead devoted to accreditation, surveys and assessments.

As we saw in Medical Homes Part I: The Reality vs. The Hype, estimates show that 27,500 clinicians and 5,700 clinics have already been certified. The cost of certification, which involves purchasing survey tools, consultations and site visits, vary but are conservatively $550 per clinician and between $275-$2,200 per site. Nationwide, those costs for accreditation translate into $15.125 million to certify clinicians and $8.55 million for sites (using an estimated $1,500/site and not including the jump in participants from 7/13-1/14)...
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[T]he price of being a PCMH becomes shockingly expensive, and represents a huge drain on our already struggling primary care system. The Commonwealth Fund’s summary of the operating costs of federally funded PCMH shows that the more regulatory PCMH rules are met, in general, the higher the operating cost. “A 10-point higher overall PCMH score was associated with a $2.26, or 4.6 percent, higher operating cost per patient per month,” which translates to “$508,207 annually for the average clinic in the study.” That amount could pay for 5 direct care nurses, or two full time primary care doctors, every year...

The data on the much-lauded PCMH approach, a cornerstone of ACA, shows that it is expensive, onerously bureaucratic, a drain on health care resources, especially for primary care providers, and a distraction from health care delivery. And, if cost savings ultimately materialize, they are likely to go to large health systems, and not to sustaining, much less expanding, primary care...

Jan poses  some questions that heath care journalists should be asking regarding PCMH. Click the linked title for her Part III post. See also my February 11th post. wherein I first reported on her work on this issue.
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OF SPECIFIC INTEREST TO THE REC BLOG NEXT WEEK AT #HIMSS14

• Summarize the current status of the Regional Extension Centers, the provider adoption agencies created under ARRA
• Describe and outline the future of Regional Extension Centers
• Assess various value propositions Regional Extension Centers offer

Noon - 1 pm. Education Session 227. I will certainly cover this one. Session handout deck is here (pdf).
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More to come...

“In wellness, you don’t have to challenge the data to invalidate it. You just have to read it. It will invalidate itself.”

Above: the headline of this post (from page 24) pretty much sums up the authors' assessment of workplace wellness programs. (Though, pedantically, get me Rewrite: “In wellness, you don’t have to challenge the data to invalidate them. You just have to read them. They will invalidate themselves.”)

This is the first e-book release by THCB (The Health Care Blog). They gave me a press review copy.

Al Lewis and Vik Khanna give me some reassurance that my own snarky, curmudgeonly inclinations are not too over the top. Their book is the Kindle version of The Daily Show for the increasingly intrusive Dilbert Zone Pseudo-Science authoritarian fad of "Workplace Wellness." Some excerpts:

Why Friends Don’t Let Friends Do Wellness

Summer, when most faculty are scattered to the four winds, is typically the time that university administrators send out bad news to their employees.  July 17, 2013 was no exception. Penn State Professor Matthew Woessner opened his email and learned that he was going to be fined $1200 if he didn’t disclose his drinking habits, any feelings of depression, whether he was having problems as a result of divorce/separation or financial problems, and whether he regularly examined his testicles. Further, he needed to have blood drawn and visit a doctor even though he was quite healthy, exercised regularly, drank only recreationally and wasn’t depressed (at least until opening this email).

He also learned all this information was going to be shared with WebMD, which promised privacy even as they were about to be ”outed”  by Bloomberg (“Your Medical Records Are For Sale,” August 8, 2013) for selling other allegedly private healthcare data that could readily be matched to individual patients.

About 100 miles away, Professor Maria Truglio opened the same email, making the same demands of her—and adding the requirement, to avoid the $1200, fine that she disclose whether she intended to become pregnant...

Welcome to the world of “workplace wellness.”

What is workplace wellness?  It’s the right question to the Jeopardy answer: “With a big assist from the federal government, this is the dumbest idea your employer’s human resources department has ever come up with.”

Maybe trying to get you and your colleagues to be healthier, to hold healthcare costs down for everybody, doesn’t immediately strike you as a dumb idea. What’s wrong with making the fat guy in the next cubicle go to Weight Watchers? Plenty, as it turns out.  First, that guy doesn’t want to be fat any more than you do, and fining him if he doesn’t lose weight isn’t going to make his fat go away, though it may embarrass him into leaving the company. Second, his health expenses probably aren’t much higher than yours during his working-age years, so there is nothing to be gained by fining him, bribing him, making him fill out forms, drawing his blood, or making him go to the doctor when he’s not sick.

Third, it isn’t just about him. Everybody is victimized by these schemes, just like at Penn State. Fourth, it is a massive invasion of privacy and, assuming you’re getting your job done, it’s not clear how it’s any of your boss’s business what goes on in your personal life. These intrusive programs benefit no one except the vendors and consultants who make their livings off them, at your expense...

It is possible that, unlike a Coke, there is a chance that a wellness program — for all its forfeitures, invasions of privacy, inconveniences, and false diagnoses—will result in a slight reduction in your cholesterol. In turn this reduction that might even more slightly reduce your (already slight) risk of a heart attack, but at what cost in the relationship between you and your employer? If your boss were a general, would he prefer an army with high morale or an army with low cholesterol? To put it mildly, morale is unlikely to receive a boost from the three most common things done to you in a wellness program:

1. Prying into your personal life to ask you about your drinking, drug,
2. and sexual habits, as well as general health issues, through a “health risk assessment”;
3. Poking you with a needle to test up to fifty different lab values for a “biometric screen”; and,
4. Prodding you to go to the doctor when you aren’t sick...

The most expensive benefit—and also historically the fastest growing—is healthcare. You have, no doubt, heard how paychecks for most people, possibly including you, have “stagnated.” But total compensation is far from stagnant—mostly because of the increase in health benefits. (These days, it’s popular to simply make you pick up more of the tab directly for your own healthcare expenses. In that case, your paycheck could rise, but so will your health expenses.)

If your company could actually control its benefit costs, it could pay you more and/or make you pay less of your health benefit, without changing the total compensation it pays out. Unfortunately, its wellness “solution” will do exactly the reverse, and raise the cost of benefits, thus squeezing your paycheck.

Surviving Workplace Wellness will prove this assertion two completely different ways:

1. The ideas are wrong: Much, if not most, of what is recommended by these programs is either self-evident or the other extreme—controversial or even the opposite of what actual experts recommend, and likely to increase your health spending, usually for diagnostics you don’t need or shouldn’t get. Hence medical experts who actually understand prevention recommend less testing, fewer screens, and fewer checkups. Yet wellness vendors recommend more testing, more screens, and more checkups. And, as you’ll see in Chapter 3, they themselves can’t coherently explain why they recommend these things despite overwhelming evidence to the contrary.
2. The outcomes are bad. As a result of doing the opposite of what should be done, no conventional wellness vendor has ever saved any company money. Eighty percent of pry-poke-and-prod wellness vendors don’t even pretend to. They just siphon money from the total compensation equation; but at least they’re honest about it. The other 20 percent simply lie, usually transparently, in order to separate your employer from your money...

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Epilogue:

Dr. Aetna Is In

Imagine how you’d feel if you got a letter saying basically:

Dear Fat Person,

We aren’t doctors and you’re not sick and you never asked for our help and probably never would, but we’ve got the solution for you anyway: obesity drugs made by companies we’re partnering with.  True, these drugs are expensive, have side effects that you may not tolerate (the nasty outcomes in clinical trials included a 20% incidence rate of paresthesia, a 5% incidence of high blood pressure and a 12% incidence of back pain) and lack a generally accepted treatment protocol, but nonetheless we’d like you to give them a try.

Sincerely,

Dr. Aetna

This is pretty much what Aetna has in mind. They essentially made a list of all the things wrong with wellness programs – unwanted interference in people’s lives, playing doctor, unproven therapies, opaque relationships with “recommended” suppliers, high expense, and “diagnosing” people who aren’t sick – and packaged them all into one press release (1/14/14).

A joy to read. Vik and Al and I exchange comments episodically in THCB post comments. I always find their observations spot-on.

My only lament goes to a paucity of positive recommendations for a broader and more rational definition of "workplace wellness," one that includes things like addressing and abating organizational psychosocial toxicity -- e.g., the "bully culture" that is all too prevalent, particularly in the healthcare space.

Search this book for the word "stress" and you get 13 hits, not all of them relevant to the problem of toxic stress in the workplace (e.g., "cannot stress enough..."). The word "morale" shows up 15 times. It's the better choice. Nonetheless, the book does not give enough attention to it, in my view.

Recall a post of mine during last December's IHI 25th Anniversary Forum:

Below, from a tweet during the Forum:

Indeed. I've been having some email discussions of late with some national nursing leaders about the patient safety implications of the adversarial, dysfunctional management cultures far too prevalent in healthcare, where one speaks truth to power at one's peril.

I've worked in about seven or eight different organizational settings across the span of my white collar career. Only one of them could be considered a "safe," non-toxic culture (somewhat ironically, a hardhat clientele digital industrial diagnostics company in West Knoxville, TN, where I was a writer and our Technical Editor). The rest were burdened by differing degrees of authoritarianism, back-stabbing, and org chart climbing machinations.

It remains a problem. One all the more ironic in the "health" domain. If you work in healthcare, you know exactly to what I'm referring.

I can see that I have two more expensive, apparently authoritative Kindle reads to buy: "Employee Morale: driving performance in challenging times," and "The High Engagement Work Culture: balancing Me and We." I'll let you know about my take-aways.

What, you might ask, does any of this have to do with Health IT?

Plenty. EHRs are necessarily highly complex applications requiring constant focus for consistent accuracy and efficiency of use amid high-stress, severely time-constrained settings, optimally via high-performance teams. Dysfunctional work environments are indisputably inimical to the cultivation and operation of high-performance teams. It behooves us to improve the health of healthcare operations themselves; a necessity every bit as important as improving the physical health of healthcare workers.

Buy a copy of Surviving Workplace Wellness at Amazon.com, decide for yourself. Read the reviews first if you like. Straight up 5.0.

I recognize a few of those names.
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THCB: VIK and AL UPDATE (Feb 19th)

What If Your Employer Gets Access to Your Medical Records?
By VIK KHANNA & AL LEWIS

T was never a star service tech at the auto dealership where he worked for more than a decade. If you lined up all the techs, he wouldn’t stand out: medium height, late-middle age, pudgy, he was as middle-of-the-pack as a guy could get.

He was exactly the type of employee that his employer’s wellness vendor said was their ideal customer. They could fix him.

A genial sort, T thought nothing of sitting with a “health coach” to have his blood pressure and blood taken, get weighed, and then use the coach’s notebook computer to answer, for the first time in his life, a health risk appraisal.

He found many of the questions oddly personal: how much did he drink, how often did he have (unprotected) sex, did he use sleeping pills or pain relievers, was he depressed, did he have many friends, did he drive faster than the speed limit? But, not wanting to rock the boat, and anxious to the $100/month bonus that came with being in the wellness program, he coughed up this personal information.

The feedback T got, in the form of a letter sent to both his home and his company mailbox, was that he should lose weight, lower his cholesterol and blood pressure, and keep an eye on his blood sugar. Then, came the perfect storm that T never saw developing.

His dealership started cutting employees a month later. In the blink of an eye, a decade of service ended with a “thanks, it’s been nice to know you” letter and a few months of severance.

T found the timing of dismissal to be strangely coincidental with the incentivized disclosure of his health information.

An HHS investigation months later showed that T’s employer got access to health data it had no right to see and the service manager, with a wink and a nod from the dealership’s finance office, fingered T as expendable. It was a nice bonus — literally — that T departure lowered the dealership’s medical costs both immediately and over the long term, which is what every wellness vendor promises.

This data breach story is fictional. But, it’s coming...

CODA:
PHOTOSHOP EDIT/UPDATE

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More to come...

īˈkänəˌklast

Feb 1
Patient-Centered Primary Care Medical Homes (PCMHs) are all the rage. A frequently-touted part of the Affordable Care Act (ACA), they have received literally hundreds of millions of dollars in federal incentive and demonstration-project funding. They’ve been around for decades. In fact, the more you know about the intention behind the creation of a primary care Patient-Centered Medical Home (PCMH), the more you want to ask, “Well, of course – how could that not be a good idea?”

But is it?...

Feb 6
Creating a medical home means building and using an integrated approach to health care where each piece of care is not treated separately and does not take place in isolation – nor is it all billed separately. Health care, communication, co-ordination, complications, follow-up and payment are all part of one system led by primary care...

As the Patient Centered Medical Homes (PCMHs) train charges forward along with implementation of the Affordable Care Act, dollars are taken directly out of our health care system to certify providers in a method with no proven benefit (see Medical Homes Part II: The Depressing Data). And, while there is a marked shortage of primary care providers nationwide, funds that could be used toward providing the direct provision of, or access to, health care are instead devoted to accreditation, surveys and assessments...

It’s hard to say exactly what this vast amount of money is buying for patients. But you may ask, even if there’s no clear benefit now, isn’t funneling some more money into primary care going to help our system? Can’t this program, in some way, help the lone primary provider?

Any savings realized through PCMHs will likely go to big systems. In addition to the economies of scale that PCMH accreditation and maintenance processes afford large health systems (making the initial “buy-in” and on-going bureaucratic support relatively cheap), the increase in operating costs for their primary care element are believed to be offset by the overall savings to a large health system. As the Commonwealth study points out, “A 2010 study of an integrated delivery system using PCMHs found savings of $18 per patient per month from reduced hospitalization and emergency department use. Yet under most delivery models, such downstream savings would accrue to health care payers, not physician practices.”...

The data on the much-lauded PCMH approach, a cornerstone of ACA, shows that it is expensive, onerously bureaucratic, a drain on health care resources, especially for primary care providers, and a distraction from health care delivery. And, if cost savings ultimately materialize, they are likely to go to large health systems, and not to sustaining, much less expanding, primary care...

 PQRS, MU, P4P, PCMH, ACO, PCORI, CER...

Are we simply wasting resources? Is this largely Wonkistan run amuck? Stayed tuned for Doc Gurley's next installment:

[I]n Medical Homes: Part III, The True Cost, I’ll examine how the certification and implementation process takes time and resources away from patient care.

Can't wait to read it.
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NEW BOOK FIND

Kindle edition only $3.99. Got wind of it through ScienceBasedMedicine.org. Very nice. Heavily slanted toward scientific/medical relevance.

Appendix 1 

The Wisdom of Not Thinking Too Much 

Sometimes it is better to stop thinking, stop gathering more data, and either wait or act.

We know that we have evolved to make quick decisions and that following our instincts has served the species well, at least in terms of survival. The Critical Thinker’s Dictionary focuses on the cognitive short cuts and logical fallacies that often accompany thinking that comes naturally. The focus is on the importance of reflective thinking for making good judgments and coming to decisions that we won’t regret. But there are times when a person will do better to stop thinking, stop reflecting, and simply act. Not everyone arrives at this stage where the wise thing to do is to put critical thinking aside. Those who do arrive at this stage have spent many years gaining knowledge, expertise, or performing ability. Their training, practice, and the skillful development of their talents have eliminated the need for reflection in order to do the right thing or make the right call. When it comes time to sing that aria before an adoring audience or swing at a 98 mph fastball in front of 50,000 baseball fanatics, thinking about what you are doing will hinder rather than help you succeed. When you have analyzed a problem to death in chemistry or physics, sometimes the best thing to do is to stop thinking about the problem and divert your attention to something else. There is no guarantee, but sometimes unconscious processes will provide you with the solution out of the blue. When an unexpected situation arises for which none of your years of training or experience has prepared you, following your instincts may be your best policy. All of these situations presuppose that you are extremely knowledgeable, have many years of experience, or have reached a performance level recognized as the highest level in your field. Herbert Simon, Nobel Prize winner in economics, put it this way: for the true expert, “intuition is nothing more than recognition.” For the true expert, the situation provides cues and the cues give “the expert access to information stored in memory, and the information provides the answer” (Kahneman 2011: 11). 

Experts in fields where reliable predictions occur with some regularity— such as physics, math, and chemistry— should be looked at differently than experts who make predictions in low-validity fields where long-term predictions are just guesswork because of the complexity of the system they are trying to master. Political and economic experts, for example, actually do worse than dart-throwing monkeys when it comes to making long-term predictions. (Tetlock; Tetlock is a psychologist at the University of Pennsylvania who studied expert predictions over a twenty-year period.) The intuition of such experts is about as reliable as the intuition of the “average citizen” when asked to make long-term predictions about politics or the economy. It should go without saying that having high subjective confidence in one’s knowledge or intuition is not a good sign of being accurate or wise.

People who are ignorant and have no experience and little talent but who follow their instincts are as likely to make bad decisions as stumble upon a good decision. But people who have vast amounts of knowledge, experience, or performing history should do little or no thinking while acting and should trust their instincts when working in their field of expertise. Outside their fields of expertise, of course, experts and talented artists are as vulnerable to the snares and lures of uncritical thinking as the rest of us.

There are also times when each of us should stop gathering more information to help us make a decision or judgment. Information overload can hinder our ability to make good judgments at times. Often we are better off making a decision by considering only a few obviously important factors rather than by introducing as many pertinent items as we can come up with. The more variables we bring into play, the greater our chances of giving more weight to minor items and less weight to important items. This point was made clear by Daniel Kahneman and Amos Tversky in experiments that showed giving people more information about a subject led them to poorer decisions. One example has become a classic. Subjects are told that Linda is “thirty-one years old, single, outspoken, and very bright. She majored in philosophy. As a student, she was deeply concerned with issues of discrimination and social justice, and also participated in antinuclear demonstrations.” Then they are asked which of several statements they thought would be true of Linda. In test after test, subjects thought it more likely that Linda was a feminist bank teller than that she was a bank teller. There is a fundamental logical error here, which Kahneman and Tversy called the conjunction fallacy. (A conjunction is the joining of two statements with words like ‘and’ or ‘but’.) It should be obvious that there is a greater probability of a single conjunct being true than there is of both conjuncts being true (Kahneman 2011: 156).

These conjunction error studies have been replicated by Christopher Hsee and John List with different scenarios presented to test subjects but with identical results to Kahneman and Tversky. (See Kahneman 2011: 160-161.) Gathering more and more information can give one the illusion of understanding. American psychologist and philosopher Paul Meehl compared the predictions of trained counselors versus a simple algorithm that used just two or three variables and found that the simple programs were significantly more accurate in their predictions than the more complex programs of the experts. A typical test might involve trying to predict the grade point average for various freshmen at the end of the school year. A simple formula that looked only at high school GPA and the results of one standardized college entrance test were compared with the predictions of counselors who had interviewed each student for 45 minutes and also had access to the results of several standardized tests and a four-page personal statement from each student. In that study, the simple algorithm outperformed 79 percent of the experts. American economist Orley Ashenfelter did a similar experiment involving predicting prices for fine Bordeaux wines. He pitted the experts against a simple formula that considered only weather, average temperature over the summer growing season, the amount of rain at harvest-time, and the total rainfall during the previous winter. Ashenfelter’s formula outperformed the world-renowned experts. (Ashenfelter’s work is discussed in Kahneman: 224ff.)

In matters of personal taste, the less information the better. Just drink the wine, taste the jam, let your feelings tell you which print you prefer. Don’t be influenced by how much the wine costs. Don’t get hung up on the various qualities one might list to distinguish different jams. Don’t get too many details about the various prints you have to choose from. If the one you like is affordable to you, buy it no matter what your friends or the critics say.

In decisions that are more or less trivial in the big picture— this would include everything from buying a new pen to deciding where to go on vacation or what new couch to buy— the less information the better. We’ve all heard the expression “paralysis by analysis.” When a decision is a minor one, the wisest path is often to focus on two or three important points, rather than drum up a list of every pro and con you can think of and then apply your list to dozens of possible choices.

In decisions that are monumental, such as the decision to send troops to fight in a foreign country or to take a loved one off life support, one should get as much information as possible from trustworthy sources that aren’t likely to be biased. In such cases, we should consult with both those who are likely to think in ways we are likely to agree with and with those who are likely to disagree with us. Important decisions require diversity of input. In the end, the evidence may seem to weigh equally for going to war and not going to war or for taking a loved off life support and keeping a loved one on life support. You may have no choice but to rely on your gut feeling at that point. The only other alternative I can see is to take a vote among one’s advisers or family members (or whatever group is relevant to the decision-making process) and go with whatever the majority thinks.

So, while wisdom requires devotion to critical thinking, it also requires knowing when to turn off critical thinking and rely on intuition, gut feeling, instinct, or whatever you choose to call that non-reflective preference percolating in our ever-fascinating brains. 

sources 

Kahneman, Daniel. 2011. Thinking, Fast and Slow.

Farrar, Straus and Giroux. Tetlock, Philip. 2006. Expert Political Judgment: How Good Is It? How Can We Know? Princeton University Press.

I am already fairly well-versed in the topic, having taught Critical Thinking at the collegiate level, but I'm finding this an excellent, value-adding review of the domain. You can't go wrong at $3.99 on Amazon.
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More to come...