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Clearing The Deck

June 18, 2010
by Joe Bormel
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Clearing The Deck

Four Steps to Lead, Survive and be Relevant in the HCIT Storm

Those of us who work in healthcare IT, by whom I mean to include the readers of this blog, are
intensely aware of how long it takes to get simple tasks accomplished. We're unapologetically obsessive about doing small things fast, or even not doing them at all, if they can be automated. We have more sympathy than we let on when our end-users complain about the seemingly unnecessary extra keystroke or click for something we do multiple times per day, or the four-second hourglass entertainment we don't value.

This is an extremely important topic that impacts, or should impact, system selection, implementation, testing, use and adoption marketing campaigns. It's initially about the user experience and usability, but still more than that. This is evolving into our psychology and the psychology of those we serve. There are
legitimate times to be intolerant. So, let's delve into it a bit further.

The two-minute rule: All of us have more to do than we have time to do. If this weren’t the case, we'd be getting home, work completed, before dinner. And it’s true, whether we're practicing physicians, managers, executives, or any other knowledge worker. Our EMRs, as well as life itself, deal us a list of things that need to be addressed. Results review, patient sign out, knocking delinquencies and deficiencies from whatever the source. When faced with each task, we all know the drill: do it, delegate it, or defer it. The three Ds. And, anyone of those three might require a hand-off, face-to-face, by phone, e-mail, or moving the task to a tracking list or process. If we can’t complete the task within two minutes, and it wasn't adequately scheduled, that usually means that we must delegate or defer it . . . in under two-minutes. (See GTD work flow map section graphic,
full map here)

There’s no such thing as focusing on everything: That brings us to the fourth D, don't do the task. Well, many of us are obsessive compulsive, retentive, MBTI
Js, or DISC High
Cs. Whatever the profile, deleting things from our “to do” list, undone, is painful, and at times, unsafe. Most of you readers will appreciate that “unsafe” is a code word for avoiding getting to know our in-house legal council face-to-face! It's the responsibility and imperative of clinical and technology leaders to ensure that the predictable two-minute tasks in our worlds, and those of our users, can be done in under a hundred seconds. Otherwise, we won’t be able to “clear the deck” for the next wave of incoming, unavoidable tasks coming our way.

Doing things fast and reliably is more than a nice-to-have: The magic of clearing the deck is system-level awareness, design and training. Each is worthy of its own post, article or book. To get you started, this post seeks to raise "Clearing the Deck" to the level of an explicit goal,
worthy of a page or two in your project charter. The design needs follow two required parallel courses.

First, we need to explore our own habits and bring them into the 21st century. Read "
Death by Meeting." Most organizations can dramatically reduce e-mail traffic simply by instituting good meeting hygiene. Another great technique is experimenting with a
Personal Quality Checklist (from the book, "Quality is Personal" by Harry Roberts), a technique used by Thomas Edison among others to raise the quality of self-management through focused awareness. This was first recommended and used by Don Berwick in his Quality Improvement teaching 15 years ago. Every year, Don brought Harry to lecture at Harvard about how to improve on personal quality. If you don't maintain personal quality, forget about coaching your subordinates!

Second, have you inventoried your own two-minute tasks and those of your key stakeholders? Have you optimized today's three D paths in your world? Just do it!

4. It's all about a trusted system: (




Good piece, agree with all but I have a question /concern about the last part, the statement about a system you can trust? You define it as a system that can be deployed on almost anything, even as hand held technology goes thru rapid changes? My concern here is if a user /purchaser can only trust systems that are infinitely flexible in there deployment and that they will continuously meet the changing technology platforms, then to my mind it will require an unimaginable level of design (and cost), if it's at all possible.

Second, if I can only trust a vendor that can accomplish that gargantuan task, then in fairness look at it from the other side. Can a developer 'trust' a user to fix a design and say 'that's it, it won't change' (kind of like saying the practice of medicine today is changes for the next X years). If the clinical user /buyer can't make that statement, which I firmly believe he/she can't, how can we ask a developer /vendor to make it?

Frank Poggio
The Kelzon Group

Joe, The link to the David Allen site was fairly non-specific. Can you save me from wandering around?

Thanks Scott.

I'll add that to my list of questions for the CMIO's I work with:

"Under what condition would your organization want (pay for, install, and sanction) an automated system to track providers and patients response to clinical communications, like results (lab, radiology)?"

Thanks for surfacing the issue of time spent staring at an hourglass. "... the four-second hourglass entertainment we don't value."

Your "trust" point is important but even more difficult to get across. Let me offer another, quite different, example, from an SBIR proposal I once wrote:
When a radiologist or clinical pathologist discovers something that must be reliably handed off to a responsible clinician (e.g. a suspicious mass or an out-of-whack potassium), our electronic systems today can generally not be trusted to do so. They fail in several ways, but most significantly they don't behave appropriately when the communication isn't received (and responsibility accepted) by an appropriate person, in a time frame matched to the situation. So radiologists and lab folks still have to use the telephone to ensure that such critical hand-offs work.

Electronic systems could be designed to do this in a trustworthy fashion, but to date they haven't been.

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Thanks for the kind words and the validation.

Regarding trust, I agree that trust can quickly become an un-obtainable standards (as you pointed out, and as has been demonstrated recently with, for example Google's unintended trust violations.)

In the context of personal self-management, trust is more a kin to the trust you can have in a piece of paper in your pocket. If you trust that it will be there when you reach for it, to either record a task, or retrieve information, then you can trust your system.

If it isn't always there, always readable, always usable, then you simply cannot trust that system. Excluding the paper manufacturer and distributor, no vendors are involved.

Also, and very importantly, if you cannot rely on yourself to review your system after you put stuff in that you intend to review, then you cannot trust your system.

In the world of delegation, if you cannot rely on your administrator or the recipient of a task (a support ticket, email or voicemail message, or clinical result to review) to do the task, then you're got a trust issue to manage.  That's a professional conduct trust.

The technologies I referenced address technical issues, in part by reducing the dependencies on a single device (such as a blackberry or a PC) by pushing the storage and service issues into the cloud. That makes the system more trust-able because you can lose your device or have a hard drive crash in your PC and still trust that your system is accessible through an alternate device or service.  And, you wont lose time, for example to restore or rebuild your computer.  Your system access is still within the two minute rule (described in the post above).

Thanks for asking for the clarification. And, you're absolutely right, trust is a big deal and it's not simple.