The world is reeling from the massive ransomware attack on at least a hundred nations’ computer systems. The unprecedented malware spasm infected hundreds of thousands of computers, and would have infected millions more but for a 22-year old computer science student who found a vulnerability in the malware that he used to curtail the infection. He found it looked for a non-existent URL, so he a set up that URL and found he could stop it spreading. Of course, now the hackers know that, it is an easy matter to update the malware to use other URLs and other techniques. Clearly, this iconic malware attack is not going to be the last.
My big brother Bill, may he rest in peace, taught me a valuable lesson four decades ago. We were gearing up for an extended Alaskan wilderness trip and were having trouble with a piece of equipment. When we finally rigged up a solution, I said “that was harder than it should have been” and he quipped in his wry monotone delivery, “There are no hard jobs, only the wrong tools.”
That lesson has stuck in my mind all these years because, as simple as it seems, it carries a large truth. It rings of Archimedes when he was speaking about the simple tool known as the lever: “Give me but one firm spot on which to stand, and I will move the earth.”
Enter the Electronic Medical or Health Record (EMR or EHR) as it exists in most forms today. As information tools for clinicians, most EMRs have been purchased by administrators who know nothing of patient care or workflow, and most of these EMRs have been reverse engineered from billing and collection systems, because the dollar drives all.
Imagine that you want a boat. You tell someone to build or buy you a boat, and tell them to send you a bill. What would you get? A kayak? A windsurfer? A boat for waterskiing? A sailboat. A party boat? A cruise ship? A submarine? A battleship or destroyer? You probably would not get what you want. Very likely you would end up with something expensive – that you cannot use.
One of my advisors has a great perspective on healthcare delivery from the large system perspective. He served as the chief of staff to our last CEO. Recently, he posed an incisive question to me.:
“Joe, when are we going to take all of these digital health concepts from the 30,000 foot level and get them into that 10 minute window that the doctor has with the patient?” It is not hyperbole to say that this put the last 20+ years of my career in a whole different perspective.
I remember in the early 1990s, when it seemed we were just getting used to a new tool called voicemail. Fax machines had become popular in the late 1980s, and we’d all had answering machines that tape recorded messages, but voicemail seemed like a brand new concept with the potential to be a very robust messaging channel. It seemed like we were just getting used to voicemail when we got another new channel for communication–email. All the talk in the executive suite was about how we were being inundated with multiple communications channels which, for a while, were overwhelming.
I can’t recall exactly when things changed, but I have to ask: when was the last time you got a meaningful fax? How about voicemail? My children chide me, saying nobody uses voicemail any more. With caller ID, you can quickly decide if you wish to return the call. Our communications channels have narrowed considerably in the past 20 years, to voice and asynchronous text-based messaging.
Imagine attending private lectures and taking all your college exams in your professors’ offices individually, one-on-one. Your instructors lecture you, then pepper you with questions, grading your answers and recording your scores. This is not unlike traditional physician visits. Contrast this to attending classroom lectures and taking online multiple choice exams where a computer algorithm or Scantron tallies your answers and calculates your grade. Classroom instruction with standardized testing is much more efficient that private tutoring. Hundreds of students can learn and take their online exams simultaneously. What if medical productivity could be similarly improved?
Inefficient Physician Communication. When you visit your doctor you are engaging in what’s known as synchronous communication. You queue up in a waiting room and later both you and your doctor meet one-on-one in an exam room (at the same time). You may spend five minutes talking to a nurse and then 10 minutes talking to a doctor. A survey found with waiting and travel time, the whole process takes patients about three hours, on average. Furthermore, many doctors see only about 20 to 25 patients a day. The amount of information conveyed during an office visit is limited — as is the amount of information patients retain. Doctors also must take notes and update medical records during the exam. Fiddling with electronic health records further reduces the amount of useful information exchanged during a 10-minute encounter while your doctor hunts for pull-down menus. The way medicine is practiced is inherently labor intensive, not to mention inconvenient for patients.
Synchronous telemedicine is where you call your doctor or he/she calls back and you talk one-on-one. That may be a little more convenient for patients, but it’s still labor intensive. Asynchronous telemedicine is like email (or snail mail for that matter). You email your doctor or call your doctor and leave a message. Your doctor replies via email or by leaving voicemail. Asynchronous communication doesn’t require both parties to be present at the same time to communicate, but the information flow back and forth can be slow and inhibited compared to talking.
Last week I had a startup entrepreneur come to me with an idea about how to “pivot” his company strategy. The company, which had begun as a medical device company but couldn’t quite find it’s market, was considering re-emerging as a consumer-focused digital medical device company in an adjacent market. The idea was to create a device to measure a serious medical condition and market it to consumers directly. Their plan was to target mothers who would be paranoid enough to spend money on medical devices to diagnose an issue in their children.
Imagine my heavy sigh.
Ever the heart-breaker, I had to tell this person that this strategy did not make any sense to me. As his target market representative du jour, I mentioned that there is no world in which I would trust myself to diagnose a major medical problem. Rather, if I even suspected a hangnail I would rush my precious princess straight to the doctor, do not pass Go, do not pay iTunes fees.
Recently, the Harvard Chan School of Public Health, in their press release, reported about the effect of surgical checklists in South Carolina. The release was titled, “South Carolina hospitals see major drop in post-surgical deaths with nation’s first proven statewide Surgical Safety Checklist Program.”
The Health News Review, for which I review, grades coverage of research in the media. Based on their objective criteria, the Harvard press release would not score highly.
The title exudes certainty – “nation’s first proven.” The study, not being a randomized controlled trial (RCT), though suggests that checklists are effective, far from proves it. At least one study failed to show that surgical checklists improve outcomes.
The press release’s opening line is “South Carolina saw a 22 percent reduction in deaths.” It reports relative risk reduction (RRR). Reporting RRR is now considered a cardinal sin in healthcare journalism, because RRR inflates therapeutic optimism by making the intervention sound more efficacious than it is.
Now that it’s public, I’ll offer my thoughts on the next steps for Don and ONC. Don Rucker is a good pick for the nation, and will be a great National Coordinator. I’ve gone on record as saying that some others are not qualified, and as many of you know – I don’t mince words. Don is smart, focused, thoughtful, intentional, and will make good decisions for ONC and HHS. I have known Don for 20 years. He’s got a long track record of integrity, he’s a nice person, he deeply understands the challenges, limitations, and opportunities of Health IT. I have no doubt that he’ll do a good job. He’s got a lot on his plate.
Where should he focus?
- Stay the course with health IT certification. I disagree with the growing meme that ONC has broadened its certification scope too far. Certification has one purpose: to provide consumers with a way to be confident that the product they are purchasing will do what the seller says it does. Some people seem to have forgotten (or don’t know) that some of the companies that sell health IT solutions have claimed that the products do things they do not do. There needs to be a process by which these claims are tested, verified and, yes, certified. If this program is scaled back, health IT systems will be less safe, less interoperable, less usable, and less reliable. #KeepCertification.
2.Keep the Enhanced Oversight Rule in place. My former colleagues (and Don’s former colleagues) in the vendor community will disagree, as do some of the house Republicans. As Don will learn first hand in his initial few weeks as NC, some of the companies that have been selling certified health IT products have been misbehaving. In some cases, products have been de-certified. In other cases, there have been investigations and resolution of problems without de-certification. ONC is protecting the public by doing what Congress asked it to do initially. The certification program is more than testing of products in a petri dish, it’s about what happens with the products in the real world. Surveillance is therefore a necessary part of making sure that the products do what they were certified to do. #KeepOversight.
SAP is a giant of ERP but over a decade or so has been layering both new acquisitions in analytics (Business Objects, Success Factors) and developing the Hana “cloudfirst” data platform. They’re actually a quiet giant in health care, in part because of a partnership with Epic. But the next step is providing what they’re calling a “democratization of data analytics” allowing line managers & clinicians to really understand what’s happening at the coal face of care delivery. It’s a complex space, but one David Delaney, Chief Medical Officer at SAP, explains in this interview from HIMSS17
One of the more interesting guys in health tech is Dale Sanders who’s been data geek/CIO at multiple provider organizations (InterMountain, Northwestern, Cayman Islands), was in the nuclear weapons program in the US Air Force back in the day, and now is the product visionary at Health Catalyst. Health Catalyst is a very well-backed date warehousing and analytics company that has Kaiser, Partners, Allina and a host of other providers as its customers and investors (and has been a THCB sponsor for a while!). I’ve interviewed CEO Dan Burton a couple of times (here’s 2016) if you want to know more about the nuts and bolts of the company, but this chat with Dale at HIMSS17 got a tad more philosophical about the future of analytics–from “conference room analytics” to “embedded decision support.” I found it great fun and hope you do too!