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Water Fountains In The ARRA/HITECH Era

June 26, 2012
by Joe Bormel
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Airports have a lot in common with healthcare delivery organizations in terms of needing to accommodate wide variations in volumes, in people’s needs, and the flow of people through the facility.  However, just as in healthcare IT, over-regulation and subsequent design can potentially complicate and impede progress. 


For example, water fountains pose one of the occupational hazards I face as I pass through dozens of airports during the course of a year.  Last week, I noticed what is shown in the picture below: a restroom entrance that was designed to be large enough for two travelers to pass one another while towing their carryon bags, but is nonetheless partially blocked by the placement of a water fountain.




It would be reasonable to presume the water fountain, developed to be handicapped-accessible, was an afterthought relative to higher level design.  It was probably required under the Americans with Disabilities Act, although not necessarily where it’s located.  This is a particularly poor design fixture in light of the increasing number of travelers who have turned to using rolling carry-on bags, the kind too big to fit under an airline seat. 


So there you have it: a set of rational requirements, regulations and essential features that devolved over time into a sub-standard design that every day negatively impacts thousands of people, regardless of gender.  And, as shown below under an ironic ‘Customer Service’ sign, it is also common practice for airport workers to leave additional obstacles blocking access to those already constrained passageways.




What does this have to do with HCIT, Meaningful Use, Care Delivery and Payment Reform?


As with my airport restroom example, we are continuously piling new requirements on existing systems, often in conceptual isolation.  It has occurred to everyone working in our industry that Medication Reconciliation overlaps CPOE, which overlaps maintaining up-to-date problem lists, which in turn overlap exchanging interoperable documents to facilitate safe hand-offs.  These things are explicitly essential to reduce unnecessary readmissions, provide care in coordinated medical facilities and pharmacies, and promote self-care where appropriate.  What worries us all is the potential for poorly designed or mandated placement of the obligatory “water fountains” without thoughtful consideration of unintended consequences.   


Here are a few recommendations to consider:


1.  Don't ignore design or take it for granted.  It's easy to look at the pieces of MU and ACOs, such as problem lists and CPOE, and fall into the same trap exemplified by water fountains at the airport.  In their landmark paper, “Anticipating and Addressing the Unintended Consequences of Health IT and Policy: A report from the AMIA 2009 Health Policy Meeting,” authors Meryl Bloomrosen, Justin Starren, Nancy M. Lorenzi, Joan S. Ash, Vimla L. Patel, and Edward H. Shortliffe provide both essential definitions and comprehensive guidance on this inevitable risk.


2.  Model and simulate workflow.  Adequately diagramming workflow that matches real use cases isn’t easy.  Real healthcare workflow is characterized by so many process interruptions and other variations that the primary analyses are often brittle.  In my recent three-part post on Medication Reconciliation (Part 1, Part 2, and Part 3), I noted Kamataris’ work on a combination of practices, including Lean Six Sigma and Constraint Theory that are necessary to design adequate workflows.  Characterizing a patient’s factors that burden the healthcare provider is essential to improve Medication Reconciliation compliance.  How often do your workflows explicitly reference the cognitive capabilities of both care providers and patients?  Most of us consider ourselves fortunate if we simply capture the “happy path,” a term used by many modelers to describe the easiest common case.


3.  Incentive alignment.  The majority of well-managed organizations have been incentivizing physicians to effectively use HCIT.  The goal: to support new, and sometimes unnatural, behaviors necessary for getting work done in a paperless environment.  Who among us really wants to be accountable to new reminders, alerts, and what can be seen as new and unprecedented dog collars?  But, that said, who is willing to have critical alerts not seen and addressed in a timely fashion?  Getting all this right accelerates adoption of HCIT.  Inattention or avoidance, while understandable on the surface, lead to apathy, resistance and failed implementations.  This topic has been studied and written about in-depth by researchers like Eric Ford (see “Resistance is Futile: But it is Slowing the Pace of EHR Adoption Nonetheless”), and industry best-practice observers such as The Advisory Board Company.


Last, and most importantly, I would like to direct you to a Viewpoint Paper, “EHR Safety: The Way Forward to Safe and Effective Systems,” by James M. Walker, MD, et al.  As with the Bloomrosen reference above, the authors lay out a specific and appropriately different set of definitions, followed by seven concise EHR safety steps.


Collectively, I believe my recommendations are necessary to effectively avoid putting water fountains in the middle of pathways leading to better health, healthcare and affordable care.


What do you think?


Joseph I. Bormel, MD, MPH

CMO and Vice President

QuadraMed Corporation

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