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50% are Happy and 50% Fail

December 24, 2008
by Joe Bormel
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50% are Happy and 50% Fail

50% are Happy and 50% Fail

EHR Implementation and Marriage

For my holiday reading, I chose "

Practical EHR - Electronic Record Solutions for Compliance and Quality Care" by Stephen R Levinson, MD. I met Steve for the first time a few weeks ago at the eHealth Initiative 2008 annual meeting in Washington, DC. He had an amazing understanding of the relationships between Advanced (electronic) Clinical Documentation, coding, compliance, and the broader context of quality care delivery and reimbursement. That led me to order this holiday reading which just arrived.

Steve was asked by the AMA to write an earlier book, Practical E/M. His

Practical EHR builds on that powerful base. He's been teaching physicians, administrators, software engineers and others for over a decade. I thought this group would appreciate this specific perspective:

EHR Implementation and Marriage The implementation of EHR systems in the United States has a track record like marriage: it has about a 50% failure rate, but that does not mean that all of the other 50% are happy.

To reduce physician-software incompatibilities, it will be important to include
  • a more constructive "courtship" phase, with physicians and coders defining their EHR design requirements [emphasis mine];
  • an "engagement" period, in which physicians conduct actual patient care trials to determine whether software systems meet their established benchmarks; and
  • a possible "prenuptial agreement" to protect medical practice assets in the event of a failed "relationship."

Any individual or organization that is planning their physician documentation initiatives should take a look at this book. It's chock full of guides, templates, exemplary cases, checklists, relevant quotes and helpful perspectives from many of the industry's thought leaders. Steve also asked some interesting questions at eHI, but I'll save that for another time.

Kate Gamble, as your most recent inductee to take the gamble, do you care to comment?



Fantastic posting, Joe. Steve sounds like a great speaker.

I found your suggestions on reducing physician-software incompatibilities to be really interesting. Before my husband Dan and I were "cleared" to be married in the particular church of our choosing, we had to attend a workshop, take a compatibility test and review the results. It didn't produce any surprises, but it did reveal one particular area in which we had very differing opinions (it involved managing money). We talked about it and came up with a solution that has worked very well so far. If we hadn't taken the test, these issues may not have been brought to the table. And maybe it's only been a few months for us, but we've already bought a home and came up with a method for managing our finances that works for both of us. So far, so good.

Maybe I'm being naive, but I wouldn't be surprised if the "courtship, engagement and prenuptial agreement" yield some of the same results.

Your experienced reminded me of "The Love Lab" chapter from the popular book,  "Blink: The Power of Thinking Without Thinking"
by Malcolm Gladwell.  The chapter is worth reviewing for anyone interested in the brain and marriage.

I grabbed the following summary text shown below in blue from here:

(Picture is of John Gottman)

...John Gottman has proven that we don't have to [observe couples for weeks or months]. Since the 1980s, Gottman has brought more than three thousand married couples-just like Bill and Sue-into that small room in his "love lab" near the University of Washington campus. Each couple has been videotaped, and the results have been analyzed according to something Gottman dubbed SPAFF (for specific affect), a coding system that has twenty separate categories corresponding to every conceivable emotion that a married couple might express during a conversation.

Disgust, for example, is 1,
contempt is 2,
anger is 7,
defensiveness is 10,
whining is 11,
sadness is 12,
stonewalling is 13,
neutral is 14, and so on.

Gottman has taught his staff how to read every emotional nuance in people's facial expressions and how to interpret seemingly ambiguous bits of dialogue. When they watch a marriage videotape, they assign a SPAFF code to every second of the couple's interaction, so that a fifteen-minute conflict discussion ends up being translated into a row of eighteen hundred numbers-nine hundred for the husband and nine hundred for the wife.

As I recall, the predictive power was extraordinary.  It sounds like your pre-marital compatibility testing was pretty extraordinary as well!

Here's another interesting excerpt, regarding the importance of Contempt:

"You would think that criticism would be the worst," Gottman says, "because criticism is a global condemnation of a person's character. Yet contempt is qualitatively different from criticism. With criticism I might say to my wife, 'You never listen, you are really selfish and insensitive.' Well, she's going to respond defensively to that. That's not very good for our problem solving and interaction. But if I speak from a superior plane, that's far more damaging, and contempt is any statement made from a higher level. A lot of the time it's an insult: 'You are a bitch. You're scum.' It's trying to put that person on a lower plane than you. It's hierarchical."

Gottman has found, in fact, that the presence of contempt in a marriage can even predict such things as how many colds a husband or a wife gets; in other words, having someone you love express contempt toward you is so stressful that it begins to affect the functioning of your immune system. "Contempt is closely related to disgust, and what disgust and contempt are about is completely rejecting and excluding someone from the community. The big gender difference with negative emotions is that women are more critical, and men are more likely to stonewall. We find that women start talking about a problem, the men get irritated and turn away, and the women get more critical, and it becomes a circle. But there isn't any gender difference when it comes to contempt. Not at all." Contempt is special. If you can measure contempt, then all of a sudden you don't need to know every detail of the couple's relationship.

The book or this chapter are highly recommended reading.