Tech

Why You Should Ditch Your IT System

flying cadeuciiSo you spent millions to billions of dollars on information systems over the past few years, right?

How’s that working out for you?

For a large percentage of you, whether or not you admit it, not so well. What you bought needs some serious tweaks, re-engineering, re-thinking, re-vamping.

For an even larger percentage, maybe most of you, the best advice is: Junk it. Throw it out and start over.

Poorly designed and poorly implemented information systems are worse than useless, worse than a waste of those millions and billions of dollars. As we go through rapid, serious changes in health care, poor information systems will strangle your every strategy, hobble your clinicians, kill patients and actually threaten the viability of your organization.

A lot of health care executives dismiss the complaints about the new systems as the carping of stubborn technophobic doctors and nurses who should just get with the program. If you are tempted to do that, you need to take a step back. You need to get real. The complaints and concerns are too widespread, too deep and indeed too frightening for that kind of blithe denial. And they are not just coming from disgruntled docs.

Dr. Clem McDonald of the National Institutes of Health, a true pioneer in pushing for electronic medical records (EMRs) over the last 35 years, has called the current implementations a “disappointment,” even a “tragedy.” He is far from alone in this assessment.

In the rush to digitize and automate, we’ve made a botch of it across much of health care. What was supposed to be a new fast track of efficiency and effectiveness has become a hemorrhage of money, efficiency, personnel and the most important of all management tools: trust. You must deal with this, you must deal with it fast, you must deal with it effectively. The future of your organization is on the line.

Questions to Ask

Ask these questions about your electronic health record (EHR). Don’t just ask your IT people, and certainly don’t ask your vendor. Ask the users.

Does it slow clinicians’ workflow?

  • • Is it transaction based, rather than patient based? If a patient, for instance, is admitted from the emergency department (ED), is the ED information in a different record? If the patient is coding and your intensivist wants to know what the blood pressure variation was in the ED, does she have to close one record and go hunting for the other one?

A Medical Economics survey published last February showed that over 70 percent of physicians would not buy their current information system, if they had the chance to make that choice again, because they hate the way it works. Nearly 70 percent have seen no improvement in care coordination with the hospitals. And 45 percent believe it has actually hurt patient care.

Were clinicians involved in its design?

  • • Did anybody ask them what they needed in the major tool that runs their entire work life?

In a recent Black Book survey, 98 percent of 13,650 registered nurses polled said nurses in their facility were never asked to help design the system; it was just imposed on them. As a result, 85 percent say the system is flawed and gets in their way, 94 percent feel that it has not improved communication among the care team, and 90 percent feel that it has damaged communication with the patient.

Do you worry about recruiting and retaining skilled, experienced nurses? In the same survey, 79 percent of RNs put the reputation of the information system among the top three reasons they would choose to work at — or avoid — a particular institution.

Does it require more work, rather than less, from your clinicians?

  • • Does it allow billing codes to be derived directly from the medical record, or does it make coding a separate activity — which often means a “coding assistant” hired just for that?
  • • Does it ask your clinicians to do more documentation?

The best estimate is that, on average, documentation demands have doubled in the last decade — and much more of those demands fall on clinicians rather than on transcriptionists and assistants.

A study by Woolhandler and Himmelstein in the International Journal of Health Services reported the following: “Although proponents of electronic medical records have long promised a reduction in doctors’ paperwork, we found the reverse is true. Doctors with fully electronic medical records spent more time on administration than those using all paper records.”

Similarly, Dr. McDonald has just released a survey that estimates these new systems add a full 48 minutes of work to each doctor’s day — at a time when physician services are becoming a more and more scarce and precious commodity.

Does it hide critical information?

  • • Does it, like most EHRs, have a “flat” structure, in which the salient data is mixed in with tons of data that is not important for the clinical moment? While your clinician, in his head, is rapidly structuring the diagnostic information and going through his decision tree, is the information presented in a way that helps him, or in a way that fights him every step of the way?
  • • Is there a way for a clinician to flag, on the presenting page, in neon lights, an unusual but highly important piece of information — for instance, a patient’s recent travel history from West Africa and his exposure to Ebola?
  • • Is it easy to get lost in the system, entering data in the wrong patient record or putting information in the wrong field?
  • • Do your clinicians feel that the software increases or decreases the possibility of “never events” and medical misadventure? Does it increase or decrease the clinician’s and the system’s exposure to malpractice suits?

UI — the user interface — is an art, and it is a big deal in medical information. Bad UI kills patients and lands you in court. CRICO, the patient safety and medical malpractice company for the Harvard medical community, recently released a study that identified 147 cases, costing more than $61 million, related to EMR mistakes — incompatible information systems, faulty routing on test results, faulty data entry and mistakes in “copy and paste.” That’s one year, one medical community, one insurer.

How opaque is it?

  • • Does it maintain different records for the same patient even within your system?
  • • Can other providers read the records from your system?
  • • Can your partners in any accountable care organization (ACO) read each other’s patient records? Can they use the system to actually coordinate care? Or do they have use work-arounds — faxes and Post-It notes?

In the Black Book survey, 67 percent of the nurses said they have to use work-arounds to make up for the flaws in the system.

Is it secure?

  • • Can it be hacked? How easily? How do you know?

A survey by the Identity Theft Resource Center showed that medical records were the leading route for identity theft, accounting for 43 percent of all cases. This does more than bother your customers and cost them money. When the thief is actually stealing health care by posing as someone else, it can lead to harming patients when new false information is added to their medical records.

Is it impermeable to data-mining?

  • • Are the vast amounts of data about your system available to you to help you analyze, for instance, where the outliers in expense are, or how much a given procedure actually costs?
  • • Can the software help you characterize all inputs and costs for any given procedure or class of procedures to assist activity-based cost accounting and lean efforts?

Interoperability

Care coordination is the whole idea behind accountable care organizations. Can ACOs actually coordinate care? In September, Premier’s eHealth Initiative published a survey of 62 ACOs. How many of them reported difficulty getting data from external organizations? Every single one. How many reported difficulty integrating data from different sources within the ACO? 88 percent. How about difficulty going beyond data to actual interoperability across the ACO? 95 percent. This is a huge roadblock in the way of any real, serious care coordination.

According to eHealth Initiative’s CEO, Jennifer Covich Bordenick, “The cost of interoperability can be prohibitive for many organizations.”

Why? Let’s be clear about this: Interoperability and the secure, reliable, accountable exchange of data is not some kind of wild, impossible fantasy that vendors are struggling to make real. It is in fact the norm in electronic communication today. It’s why you can put apps from thousands of different vendors on your iPhone or Android tablet and they can all read the same data and talk to each other. And if you want to make your communications secure, and available only to the appropriate person, you can do that with free, off-the-shelf applications.

Imagine what the financial world would look like if their IT vendors had convinced each bank and brokerage to build software that would not talk to anybody else’s. Interconnectivity is normal. The reason it’s not normal in health care is that some or most of the vendors don’t want it to be normal.

Building good software on an enterprise scale for something as complex as health care is extremely hard. But this is not the hard part. You can design the software to produce data to industry standards, with entry ports built in so that other systems can read it, just as my Mac produces .pdfs and .xml files and .wav files that can be read by machines running Windows or Linux or Unix. Or you can make a different design decision, using proprietary coding that cannot be read by any other company’s software.

Why would they make that decision? Because they want you to stay in their walled garden, buying only their products. They do it for market share, that’s all.

The idea that interoperability is difficult or impossible is a con. In a classic case of an industry driving government decisions, neither the HiTech Act, nor the Affordable Care Act, nor the regulations implementing “meaningful use” have disallowed the con and demanded true interoperability.

We, as an industry, have largely fallen for the con. Some of us have been running our own con, trying use a lack of interoperability to build our own “walled gardens” and gain market share. In a world of ACOs, population health management, and shifting partnerships and affiliations, that attitude is frustrating our doctors, hobbling our strategies and killing patients.

Zane Burke, the president of Cerner (which just bought Siemens), made a strong point about interoperability in a recent interview with H&HN Daily’s Matthew Weinstock:

“We all owe it to the country … to really perform true interoperability and create openness…. You need platforms that don’t just open up your APIs [application programming interfaces] but actually create ecosystems for other players … to perform well. We can’t use the operating system at the EHR lever as a competitive advantage. It just can’t be that way.

“The industry community shouldn’t compete on the platform layers. And we need our provider community to not compete based on connectivity of their organizations, even where they compete in their market. We need our provider community to come together and say we need patient identifiers, interconnectivity, and interoperability to be ubiquitous across the U.S.”

It’s Time

It’s not like this is new. It’s not like we didn’t see this coming. I have been writing about and advocating for the digitization of health care for 30 years, as have many others. I have to tell you: We knew back then that interconnectivity through industry standards — and smart user interfaces that assist clinicians in their normal workflow rather than hinder them — were hard problems that needed solving.

It never occurred to me or anyone else who was writing about it at the time that the industry and its vendors would deliberately turn away from smart, clean, highly usable, highly interconnected design simply because of a fruitless quest for the lowest bid and a greed for market share. We did not imagine it because this deliberate turn away would be so manifestly stupid, so wasteful of our money, of the time and talent of our clinicians, and of the lives and suffering of our patients.

It cost us millions to billions to get into this mess. It will cost as much, maybe more, to get out of it. It’s time to quit digging the hole we are in, toss what does not work, start in again and do it right.

First published November 20, 2014 in the American Hospital Association’s Hospitals & Health Networks Daily.

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  8. Message to CEO’S

    If you buy any system IT, Radiology, Ect, and do not have the users of the equipment in those purchase meetings you should be fired by the board.

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  9. The answer is YES. It appears that we are on the same page. As a physician who has been on the front lines, clinically, in an outpatient setting as well as one that has developed an open-source EHR to address issues such as user interface for the physician, patient safety, and interoperability, I’ve written some blog posts that hopefully. One was recently published on KevinMD a couple of days ago: http://www.kevinmd.com/blog/2014/11/money-nothing-dire-straits-ehrs.html

    and this one from this site:
    https://thehealthcareblog.com/blog/2013/12/18/why-ehr-design-matters/

    and also this one from last year: https://noshemr.wordpress.com/2013/09/07/omg-why-the-user-experience-for-an-ehr-is-everything/

    As a physician that saw this coming prior to the MU legisltation, I had ideally thought that interoperability would have been the foundation for the legislation. Boy, was I wrong. Now we’re here and we’ve got horrible user interfaces and poor workflow – both causing physicians to hate their EHRs and making it unsafe for patients. But the legislation has made physicians a captive victim for EHR vendors…add all this up and you’ll probably come up with the same conclusion.

  10. New thinking: Make a system where the doctor NEVER touches a computer. We are supposed to care for patients. I spend more time creating a piece of useless computer drivel just to get paid.

    Either verbal orders or voice recognition as input.

    Recognizes patterns in patient presentations and anticipates and assists me in decisions without endless flags and warnings.

    Searches the patient’s old records for info I need when I ask for it.

    Get me away from a keyboard and mouse.

    Don’t take forever to display the next screen on whatever I am looking at.

    I will touch a screen once in a while.

    Must free nurses from keyboards as well.

  11. Yes

    And CPOE and ERx and Coding for payment and ICD 10 and any other thing forced by government edict.

  12. “So everyone one agrees that our HIT is an unmitigated disaster, and needs to be totally scrapped and replaced, no matter what the cost.”
    __

    No, “everyone” does not agree. With the “unmitigated disaster” concern troll hyperbole.

  13. So everyone one agrees that our HIT is an unmitigated disaster, and needs to be totally scrapped and replaced, no matter what the cost.

    Who thinks that’s going to happen?

  14. The Government confused meaningful use with safety, efficacy, and usability, just as it was hoodwinked by C$HIT to think that certification equated to safety.

    But the HIT disaster began long before the meaningfully useless MU rules were spawned.

    The HIT disaster was expected and is a wonderful example of the free and unfettered market place for systems of devices ostensibly directing care.

    It would have been avoided with systematic pre and post market surveillance by the FDA.

  15. Right on. The perfect storm caused by the interaction of the CPT codes (AMA), the E/M codes (CMS) and deference to data mining rather than clinical care. Sickening.

  16. Joe, love this post! Getting out of this mess requires that we acknowledge and address what got us here.

    1) EHR Systems were conceptualized and designed to be electronic replacements for paper charts, not to assist in clinical care. Those design goals are fully evident in current systems. However, with the advent of MU, these same systems were reconceived, but not redesigned, as clinical care assistants that intimately support clinical work. Of course, since they were neither conceptualized nor designed to support clinical workflows or collaboration, usability in many systems is poor (Is the Electronic Health Record Defunct? http://ehrscience.com/2014/04/28/is-the-electronic-health-record-defunct/ (http://ehrscience.com/2014/11/10/the-amas-usability-initiative-is-a-nice-start-so-what-comes-next/ ). Which brings up the next point.

    2) MU requires frequent changes to software features. Changing complex software systems is difficult and time-consuming; yet, certification rules require such adjustments. Few EHR developers have the resources to keep up with MU while reengineering systems to support clinical work (EHR Certification 2014—Darwinian Implications? http://ehrscience.com/2012/09/17/ehr-certification-2014%E2%80%94darwinian-implications/ ). However, once there is a general acceptance that merely tweaking current systems will not be sufficient to intimately support clinical work, another problem arises.

    3) There are no standard, computable models of clinical work available. Even though workflow research has been ongoing for years and has yielded a huge amount of practical technology, workflow technology it is nearly unseen in health care. It is difficult to build flexible, scalable electronic systems that support clinical care processes without workflow technology. (Building Clinical Care Systems, Part V: Supporting Clinical Work http://ehrscience.com/2014/08/11/building-clinical-care-systems-part-v-supporting-clinical-work/ ). Which brings up the final issue of EHR design.

    4) The software design/architecture used for electronic record systems is not suitable for systems that support clinical work (which I call clinical care systems). A new architecture is required that cleanly separates data, workflow, record, and user-interface functionality. (Is the Electronic Health Record Defunct? An Architecture for Clinical Care Systems http://ehrscience.com/2014/05/19/is-the-electronic-health-record-defunct-part-ii-an-architecture-for-clinical-care-systems/ )

    With current knowledge it is possible to build systems that support clinical work. However, it will require shaking off the prevailing records/archive mindset and approach to clinical care systems.

  17. We are in full agreement. MU is a problem, but it is simply icing on the cake of a system that was already terrible. ACO’s are doing the same thing to hospital records (my “Transition of Care” documents I get from the ACO hospital are hideous heaps of computer vomit). Overall, though, the reason records suck is that the payment system requires that they do for payment.

    This is the same reason that PHR systems and mobile medical apps won’t be adopted to any significant degree: they are not rewarded by the payment system (doctors spend MORE time doing non-reimbursed things with these applications). The current system’s solution will be to add a layer of documentation complexity and allow coding of these things for reimbursement. As you stated with MU, the cost of implementation will outweigh (or at least offset) the financial gains. The net result is more complexity for no improvement in care.

  18. Nice comment.

    “I can say without any doubt that the FIRST thing that must change is the payment system.”

    I’ve been arguing that for a LONG time.

    “Meaningful Use,” btw, is a red herring whipping boy. The typical ambulatory EHR houses close to 4,000 variables in its RDBMS, with hundreds or more having to be accessed, viewed, updated, transmitted, synthesized etc during a conventional pt visit (and, yeah, to your point, a lot of them just to get paid). The subset numerator/denominator MU vars comprise less than 2 dozen (including the CQMs), most of which can be handed at the sub-MD support staff level.

    Just to be clear: I’m no big MU fan, btw. I mocked the bozo-ness of it even while working in the MU program. See my Clinic Monkey (a “Survey Monkey” riff) http://ClinicMonkey.blogspot.com

    The fact that it may take 5-8 clicks to get to a MU data target is stupid (e.g., in eClinicalWorks there are 4 different workflows for doing CPOE, ranging from 5 to 8 clicks). EVERY MU criterion should be macro-accessible in 1 click (or Dragon voice command). It’s not much to have to learn. I’d have insisted on macro capability within every ONC certified system as a condition of cert. Windows no longer has a macro utility, but there are 3rd party vendors of inexpensive macro utilities. Still, no one wanted the added expense and hassle of going 3rd party macro. And, in fairness, even optimizing MU workflows might still result in an additional $4,000 a year in labor cost ( even if it only added minute or less to a note; I could show you the math).

  19. Great article and discussion. While meaningful use might be the elephant in the room, there’s a dinosaur sitting on and crushing the house: the payment system. EHR systems didn’t go astray for no reason; they are this way because it is less profitable to use clinically-oriented records. If we were to adopt records centered on patient care designed to the clinicians using them, the profits of hospitals and doctor’s offices would decrease. Health care as a business is not about doing what is clinically right for the patient or making the quality of care better, it is about coding properly and supporting codes (I include meaningful use in this) with copious documentation. I’ve been living outside of this malignant system for nearly 2 years now, and I am still trying to figure out what of what I do is driven by my prior 18 years of working for the system and what is truly for the patient. Do I really need to include a review of systems in every note? (No). Do I really need to have patients come in for office visits to document care? (No). Do I need to give the thought process of every decision I make? Can I string together related narrative that happens in different encounters (phone, electronic, and in-person) to make a cogent narrative, rather than break it up in separate notes?

    If you built this perfect EHR, would there be significant adoption? I think not. I think the fact that doctors are so used to charting with computer vomit, and the fact that payors require computer vomit for payment (including Meaningful Use) and so would pay doctors (and hospitals) less, would drive adoption of the “perfect” EHR system. Having lived in both worlds, I can say without any doubt that the FIRST thing that must change is the payment system.

  20. Bill, how could this have grown organically if the members of the committee are political appointees with only one physician mandated who might represent academia, the AMA, an HMO or some other vested interest?

    It is clear from the onset that this government controlled group could not effectuate appropriate policy and could only provide the perceived desired endpoint product conceived before any thought went into it. Almost everyone is represented here, but only 1 is responsible for the direct care of the patient and that is the physician. he doesn’t seem to count very much. Nurses also write copious amounts of information in the EHR and they don’t seem to count at all.

    Organic thinking is not something one should expect from a government that wishes to mandate the end product while controlling its development.

    (c) MEMBERSHIP AND OPERATIONS.—

    ‘‘(1) IN GENERAL.—The National Coordinator shall take a leading position in the establishment and operations of the HIT Policy Committee.

    ‘‘(2) MEMBERSHIP.—The HIT Policy Committee shall be composed of members to be appointed as follows:

    ‘‘(A) 3 members shall be appointed by the Secretary, 1 of whom shall be appointed to represent the Department of Health and Human Services and 1 of whom shall be a public health official.

    ‘‘(B) 1 member shall be appointed by the majority leader of the Senate.

    ‘‘(C) 1 member shall be appointed by the minority leader of the Senate.

    ‘‘(D) 1 member shall be appointed by the Speaker of the House of Representatives.

    ‘‘(E) 1 member shall be appointed by the minority leader of the House of Representatives.

    ‘‘(F) Such other members as shall be appointed by the President as representatives of other relevant Federal agencies.

    ‘‘(G) 13 members shall be appointed by the Comptroller General of the United States of whom—

    ‘‘(i) 3 members shall advocates for patients or consumers;

    ‘‘(ii) 2 members shall represent health care providers, one of which shall be a physician;

    ‘‘(iii) 1 member shall be from a labor organization representing health care workers;

    ‘‘(iv) 1 member shall have expertise in health information privacy and security;

    ‘‘(v) 1 member shall have expertise in improving the health of vulnerable populations;

    ‘‘(vi) 1 member shall be from the research community;

    ‘‘(vii) 1 member shall represent health plans or other third-party payers;

    ‘‘(viii) 1 member shall represent information technology vendors;

    ‘‘(ix) 1 member shall represent purchasers or employers; and

    ‘‘(x) 1 member shall have expertise in health care quality measurement and reporting.

  21. “Apple announces that it has cloned Steve Jobs, and one of the young Jobsclones goes to Stanford undergrad, then medical school, and subsequently invents a software company that creates a physician-friendly EMR platform . . .”

    If this new EMR has to be compliant with CPT, ICD, MU, PQRS, etc., it will be just as lousy as what we have now. It’s impossible to have a physician-friendly EMR in an environment that is so physician unfriendly.

  22. Only two ways to fix this mess of “non-interoperability”:

    1) The geniuses in the federal government (like Jonathan Gruber) create an easy-to-use, intuitive, well-designed EMR, and then mandates that every physician, hospital, and clinic in the US use it. (obviously this is about as unlikely as obama giving a press conference to announce his gay marriage to John Boehner)

    OR

    2) Apple announces that it has cloned Steve Jobs, and one of the young Jobsclones goes to Stanford undergrad, then medical school, and subsequently invents a software company that creates a physician-friendly EMR platform . . .

  23. The question is whether the meaningful use requirements forced the poor design, horrible UI and lack of workflow focus — or whether the vendors took advantage of the law to create what they felt would be more profitable for them, and the healthcare execs who were nominally in charge of the process allowed that to happen.

  24. Palmer: You bring up several questions.

    1) Should every practitioner be able to access the entire data stream?

    I think access is not the problem, if the receivers are licensed and proper to receive the information. The problem, rather, is the UI. Practitioners should be able to customize their UI to see right up front the presenting issues for them — the PT sees that the patient has limited motion in the right knee, the psychologist sees a summary of presenting issues.

    2) Should doctors and institutions that are no longer relevant have access to all data?

    No. Except for emergency personnel, the patient ideally should be able to grant access to the records to the clinicians and institutions that are currently relevant.

    3) Can having all this data inhibit a clinician casting a fresh eye on the patient?

    It certainly can — and this is made worse in the case of erroneous data. Since this was published yesterday, two friends have told me stories of erroneous data following them around, one saying the patient had had a heart attack, another that the patient was HIV+. And I can see especially a diagnostician with a new patient wanting a fresh look. But they can get a fresh look just by doing their own examination and history before looking at the file. And I doubt they would really want to be deprived of the information in the file should it turn out to be relevant (such as the patient just got back from West Africa, or the patient has been to the ER ten times in the last year to get painkillers).

  25. Amen to your last paragraph, Allan. Let it grow organically, driven by what medicine needs. It’ll grow to serve us and the patients. Capital seeking its highest use.

  26. I don’t generally agree with what you say, but in this post you scored.

    It’s a great summary for one to read if they have any involvement in EHR’s. I think the last paragraphs summarizes the problem and puts us in the proper frame of mind to correct it. You also demonstrate how easy it is to fall into a trap and that statement of recognition is a powerful warning to anyone that cares about these things.

    “It never occurred to me or anyone else who was writing about it at the time that the industry and its vendors would deliberately turn away from smart, clean, highly usable, highly interconnected design simply because of a fruitless quest for the lowest bid and a greed for market share… It cost us millions to billions to get into this mess. It will cost as much, maybe more, to get out of it. It’s time to quit digging the hole we are in, toss what does not work, start in again and do it right.”

    Yokum quoted this as well and asks “how do we make that happen?” I think the best answer is to let the EHR grow organically. Government micro management can only inhibit appropriate growth as what the government wants and needs is something completely different from that of the physician.

  27. Why is there no mention in the article or the comments of the elephant in the room — meaningful use? All of this poor design, horrible UI and lack of workflow focus in these systems is because the vendors have spent the last 5 years jumping through hoops to meet the absurd MU requirements instead of focusing on the needs of the clinicians and the patient.

    How do we fix it? A good start would be to repeal the HITECH Act, possibly the most ill-conceived piece of legislation written since Hawley-Smoot.

  28. Excellent post. You describe exactly what those of us involved in patient care have experienced over the past decade.

    “It cost us millions to billions to get into this mess. It will cost as much, maybe more, to get out of it. It’s time to quit digging the hole we are in, toss what does not work, start in again and do it right.”

    And how do we make that happen?

  29. Excellent piece, Joe. Of courser, health IT is like the rest of health care. It has co-opted policy and has designed mechanisms that institutionalize excess at the expense of capability. Until we change policy or start voting with our purchasing power in the marketplace, we will be powerless to turn this around.

  30. Coordination of care is one of the principle reasons for the EHR effort. Is it a shibboleth? What does coordination mean? I think it means that every provider can know what every other provider knows about a patient and can therefore render more appropriate care. Something like this. But does it pertain to one episode of care or a patient’s full history? Or some lesser period, like five years? What about which providers? Is it important for all providers to have access to all data? Psychologists? PTs?

    Is this good? It sounds good. It’s probably good for a given episode of care, but is it efficient to enable transfer of data to doctors that were seen by the patient a long time ago? Ditto with communicating back to hospitals visited years ago, and previous inapplicable specialists like ophthalmologists, etc.

    Also, could it be unwise to inhibit a new physician’s quest to renew the investigation of a patient as if he were de novo? …as if there had been no previous care? Are we making ourselves too vulnerable to group think? Don’t we want new thinking from an internist who is the referral target for an PCP who needs help? Don’t we want a new review of the drugs?, new thoughts on the diagnosis?.. repeats on questionable labs?

    Now admittingly, it is critical to know previous oncological diagnoses and treatment. But does an diabetologist need to know what happened to a type 2 diabetic two years ago? Don’t we want a fresh look? Ibid for a thyroid problem or a rheumatoid patient.

    So it goes both ways. Rarely it is critical. Sometimes it is nice. Mostly a new provider can get by nicely by doing a fresh history and physical. But is this raison d’etre a tempest in a teapot?… to justify this tremendous national effort and cost of the EHR?

    There is a noisome quality to this movement that generates a feeling that we were conned by the non-medical folks who use and sell the data and by the policy and regulatory people who want to study it.

    If something is not useful, it won’t be used.

  31. Also of relevance:

    “TThe world is being rebuilt in code. Hiring computer engineers used to be the province of tech companies, but, these days, every business—from fashion to finance—is a tech company. City governments have apps, and the actress Jessica Alba is the co-founder of a startup worth almost a billion dollars. All of these enterprises need programmers. The venture capitalist Marc Andreessen told New York recently, “Our companies are dying for talent. They’re like lying on the beach gasping because they can’t get enough talented people in for these jobs.”

    The computer science taught in colleges still focusses more on theory than on commercial application; the business of teaching practical coding skills has the whiff of trade school. So-called coding “boot camps,” such as General Assembly, founded in 2010, are trying to fill the gap, teaching crash courses in how to design Web sites and write code. But Jake Schwartz, the co-founder and C.E.O. of General Assembly, told me, “There’s simply not enough senior people in the system.”…

    THE PROGRAMMER’S PRICE
    Want to hire a coding superstar? Call the agent.

    http://www.newyorker.com/magazine/2014/11/24/programmers-price

    Health IT development has to compete for top talent, most of whom can make far better money elsewhere in IT.

  32. apropos,

    Jerome Carter, MD:

    “A Question for EHR Vendors: What Is a “Real” Computer?”

    “Looking at clinical care and its computing needs, I see requirements that are distinct when compared to standard business computing. Clinical data are varied and numerous. Clinical work consists of interacting with patients to obtain information, consulting information sources (e.g., chart, guidelines, articles, other clinicians), making decisions, recording information, and moving on. Support for clinical work requires large, searchable data stores, fast networks, sophisticated communications functionality, and portable computers capable of displaying text, pictures, sound and video. Tablets and smartphones are the first computers to meet all of these requirements.

    Writing for mobile means stepping back from web and client/server applications and being willing to see a problem purely from the standpoint of mobile computing; that is, adopting a “mobile first” attitude.

    Mobile first requires a willingness to rethink past approaches. At the top of the list is use of cloud capabilities. Like mobile computers, the cloud is a new way of doing things. Building mobile applications that link to cloud storage and use APIs to interact with other applications is a new way of delivering functionality. There is no reason to have local terminology services if they can be obtained via a cloud application. The same is true of workflow engines or another service that supports clinical work. Mobile first also means not taking a client/server app and putting a mobile face on it. That will not work any better than putting a browser interface on a standard desktop app. It might work to some extent, but the original design limitations will show through…

    How many EHR vendors will bite the bullet and start serious mobile-first projects? Few, I imagine, because if the past is prologue, most will cling to the prevailing wisdom that mobile devices are not real computers. And we know how that story ends…”

    http://ehrscience.com/2014/11/17/a-question-for-ehr-vendors-what-is-a-real-computer/

    One of my regular required reading blogs (in addition to yours).

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