The Physicians' IT Symposium keynote was provided by Farzad Mostashari, MD, ScM from the Office of National Coordinator for Health Information Technology. Dr. Mostashari, in talking about his early experience with EHR projects, referred to “rookie mistakes,” which were common errors of misplaced exuberance with one's first major clinical transformation project.
There were no slides and I don't have access to the transcript yet, but I heard that one of the most common errors was trying to do too much, including using more features than necessary, and “continually insisting on adding new features/functionality” as go-live requirements. This set a wonderful tone, and several subsequent speakers contextualized some of what they had prepared to share what they learned from their rookie mistakes. There was agreement, at this symposium and others such as the CDS-based sessions, that the biggest recurrent rookie mistake was putting in EHRs as though they were technology (aka IT) projects.
Dr. Mostashari urged “simplicating” (the opposite of complicating, and a new word for me) as an important antidote to approach health care transformation and related technology-enabled modernization projects. He urged us all to remember “The Aim Makes The System.” You should always start planning sessions, awareness, acceptance and commitment phases of change management with “tell me what you want to achieve,” or a related “norming” discussion. This is, of course, great advice, because omission, i.e. starting meetings without clear framing on goals (or aims), is a common rookie mistake for people in all industries, not just HCIT.
Dr. Bill Bria, AMDIS representative and co-founder, pointed out several hours later that, as clinical leaders working in the space that includes technology-enabled process, workflow and quality improvement, we still have what seems like the majority of physicians seeing EHRs as technology transfer initiatives, not as essential tools for the practice of medicine. Arguably tools far more essential than the stethoscope. It's much easier to argue that technology is unusable than it is to argue it is essential to have adequate information about a patient and be able to reliably diagnose and treat a patient in a timely, and again, reliable manner. His message was that CMIOs and CMOs don’t routinely get out and advocate what the modern practice of medicine is, what’s needed and possible, framing clinical knowledge management and execution, not the EHR alone, as central.
Here are two important takeaways:
1. The Rule of 888 or less. This came up in a variety of contexts from easily a dozen different presenters. In simplicating your project, whenever it appears there are thousands of items to manage, work aggressively to get that number below 888. For example, one team studying the right number of order sets to roll out determined that just under three hundred ensured that the build, maintenance, revision and updating work was kept to a manageable number. Several of the smartest informatics experts, working independently, have advocated that creating data liquidity by reducing and agreeing on a manageable number of problems, allergies, medications, quality measures, lab findings, etc., can and should be published after rapid harmonization by NQF. Why NQF? They are the neutral conveners who are reconciling the quality measures to measures that will be capable of promoting safe, effective and stable measurement, comparison, and ranking of performance. This derives from active work on eMeasures underway from ONC sanctioned work being done by MITRE.
2. Usability. It was announced by Dr. Charles Friedman that usability will be part of Stage 2 Meaningful Use. This caused a drama explosion. There were several major components, all understandable and reasonable by themselves:
a) EHR usability is not at consumer-level usability. The oft-cited examples are one-touch ordering on Amazon, the tremendous usability improvements that have followed the iPhone and iPad compared to their predecessors, and the learning curve itself for any EHR.
b) The surprise factor. The idea that usability needs to be improved and the “what cannot be measured cannot be managed” doctrine suggest that we won’t be capable of improving usability until we can measure it. To break that code, we need an “objective, scientific method” to score or rank usability. It becomes clear quickly that this often isn't completely black-or-white. Look at this list of recently provided examples of some of the “proven” concepts:
- Adequate spatial separation between “Approve” and “Cancel” buttons
- Restrictions on a clinical user’s ability to have 2 patient records open simultaneously
- Minimum font sizes
- Prohibitions on displaying too much data on a single screen
- Grouping data into logical “chunks”
- Requiring row and column headings on tables and coloration to highlight selected cells
- Ability to customize alert levels for individual users
- Number of clicks
- … and more
These “proven” concepts are commonly discordant with practice in the real world. Customers routinely insist on violations of best practices, because of policy, usability, workflow requirements, etc. Usability, in my experience, rarely reduces to simple bromides in EHRs.
c) “Stifling innovation” and “teaching to the test.” As we've experienced with certification, an unintended consequence of it is that all vendors must write their code to pass the test. That's counter to the notion that market differentiation brings about different and better things; the key to innovation. And that would be true for disruptive, as well as non-disruptive innovation.
d) Adding complexity to Stage 2, which many feel already has an impossible timeline built in, has simply compounded the drama. Some of this is driven by legislated mandates that government agencies must, by law, take as given. The policies must follow the law. It's all very reasonable.
There appear to be limits to simplicating!
In summary, as one would predict, HIMSS is all about responding to the high-order call and five-year goal to improve healthcare delivery, its quality, costs and accessibility. And, tactically, the first step, the step to the starting line of this goal, is achieving Stage 1, and for planning purposes, preparedness for Stage 2 Meaningful Use. Understanding the rookie mistakes, applying the rule of 888 or less, and getting our hands around usability all play important roles for achieving success.
Watch for Part Five, the final chapter, of my “Blind Spots” series on February 28.
Joe Bormel, M.D., MPH
CMO & VP, QuadraMed
“If you are a year ahead, you are a visionary. If you are three years ahead, you are a martyr.”