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Non-Goals

October 6, 2009
by Joe Bormel
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There's a tremendous irony about ARRA/HITECH. It comes in the form of non-goals.




Along with the clearly identified need for EHR technology to improve our healthcare delivery system came some concurrent observations, i.e. need for the current EHRs to improve. A recurring, big observation was that the user experience (the GUI, the number of clicks, the ease of use, the intuitiveness, etc.) of all EHRs, commercial, homegrown, and OSS offerings, were way behind that of the user experience for mainstream commercial applications. Many consumer Web sites are an absolute pleasure to use, and highly effective. Google, Amazon, and others will give you what you want, in addition to what you actually ask for. They'll correct your misspellings and make you aware of relevant options, based on the experience of other users with apparently similar intentions. (This is accomplished, of course, with zero human build work, and maintained in real time.) They've transcended a focus on automated basic workflows and associating decision support with process automation. They prefer to collect (with opt-out, of course) personal information. What do you commonly do? How do you seem to prefer to do it? There are often three or more options for how to get from here to there. If you try something reasonable, it's been thought through and will often work. If not, you're likely do get a "did you mean ...?" option. Most of us, as a result of these modern consumer user experiences, have more books (from Amazon.com), and perhaps many unread books, throughout our homes, because browsing and one-click ordering are so darn easy.




Modern consumer user experiences are a great thing. We can read and write (interact) news through newspapers, online everything, and of course, blogs like those at HCI. Wouldn't it be great if we had similar fluency with our healthcare information? As nurses and doctors, of course. And as patients, of course.




Instead, what we experience today is considerably more dated. My physician, for example, recently sent me the results of

my labs. He went out of his way to personalize the results with a handwritten note. That's nice. He's on one of the most popular ambulatory EHRs and has been for over five years. For at least three years, his group has had the most sophisticated ePrescribing solution integrated with its EHR. Here's where things apparently break down badly, relative to a consumer experience. The lab results are apparently not integrated, as suggested by the lab report he sent. The report is almost completely naive to my problems, medications, allergies and key clinical trends. Is my LIPID PROFILE getting better or worse? What, if any therapies are concurrently associated with these therapeutic results. Not clear from the printout or the handwriting. The note was subsequently scanned into the EHR. Again, this is one of the most automated practices in my area. They made the EHR investment years ago, and have stayed up to date with their releases.




With ARRA/HITECH, all vendors, both ambulatory and inpatient, have had an extremely strong incentive to stop developing according to their roadmaps, leading in part to more consumer friendly features like showing new lab results in the clinical context of problems, medications, and key trends. Most readers appreciate that this suspension of innovation is necessary and ultimately a good thing in order to gain the benefits of certified products and establishing a meaningful use threshold. That said, the work to deliver the consumer grade experience has clearly been put on the back burner.





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Joe,
I know exactly what you mean. At my institution, our research and development budget got whacked this year. Everything directed at improvement as we defined it was put on hold. Since projects, people and relationships are highly perishable, hold is a a euphemism for permanently canceled. If we decide to proceed forward, it will be 2011 at the earliest and our prior investments will be all but lost.
-IA

Jack,
Thanks for your kind words.

I know that we can make progress toward interoperability. Other industries have, with ebXML and other standardized exchange protocols. It's messier, of course in healthcare, in that, simply put ICD-9 is not SNOMED (which isn't ICD-10.) There isn't a lingua franca that's clinically sound and readily usable. ( http://en.wikipedia.org/wiki/Lingua_franca ) That said, we're making progress with medications and allergies, and we've got vehicle to move forward through problem lists. (ARRA/HITECH is helping here.)

Regarding achieving HROs, it is happening. It's just glacially slow. Today, you can often find best practices through a simple internet search. Weaving them into automation systems in a way that takes a six step process and turns it into one is critical.

One step processes have higher reliability and require less work. Opportunities are evident in many places. Our roll-out, however, is almost always done in those six steps, serially over time. (See my Hellfights post for the value of and need for bundling solutions together.)

Take the hospital discharge, for example. At that event, it's necessary to do several things:
1) medication reconciliation (meeting JC regs for example)
2) writing discharge prescriptions, aka eRx
3) creating a patient readable set of discharge instructions including that newly reconciled home med list
4) product a complete discharge summary, again, including elements of the above
5) producing a letter to the referring physician and
6) doing basic coding and chart abstraction, necessary to identify gaps that can be addressed before the patient leaves the hospital.

Jack, we do all six steps today. Parts are on paper. Parts are electornic but in free text. Parts happen hours after the patient leaves, precluding the opportunity to use decision support to get more HRO'y.

Can you see that these could be done as a coherent thought, with less steps, time and opportunity for mess ups? I thought so. As a practical matter, however, we usually have to replicate the familiar, before we can transcend to what's possible. (Thanks again, Marion Ball, for sharing that insight.)

Bottom line - with or without healthcare policy change and HIT offerings, it's going to take years before High Reliability Organizations will likely be commonplace. That does, however, require that high reliability goes from being a non-goal to being an explicit goal.

Joe,
Very interesting post, and I do agree with your conclusions. I found a couple of sentences in two consecutive paragraphs very well written to position the situation:

"With ARRA/HITECH, all vendors, both ambulatory and inpatient, have had an extremely strong incentive to stop developing according to their roadmaps, leading in part to more consumer friendly features like showing new lab results in the clinical context of problems, medications, and key trends.

"Most readers appreciate that this suspension of innovation is necessary and ultimately a good thing in order to gain the benefits of certified products and establishing a meaningful use threshold. That said, the work to deliver the consumer grade experience has clearly been put on the back burner."

In the second to the last paragraph of your post, you call for a "one-two sequence of EHR policy reform." It's the "one," namely, standardizing the platform, with which I have problems. Will certification really standardize the EHR platform, particularly in terms of making EHRs interoperable? And will measurable use of EHRs go far enough to ensure high reliability organizations? I just don't see all this happening, but perhaps you have another point-of-view that will change my mind.

I would also be very interested in reading comments from others, particularly those who blog on this site, as to what their opinions are on the non-goals of EHRs. Thanks,

Jack

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Joe Bormel

Healthcare IT Consutant

Joe Bormel

@jbormel

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