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ARRA Readiness Assessments

November 20, 2009
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In an October 16, 2009 letter to ten major healthcare IT vendors, Senator Charles E. Grassley (ranking member of the United States Senate Committee on Finance) initiated a US Senate investigation of the corporate practices of HIT vendors. The inquiry launched after the senator’s office received a significant number of complaints from patients, physicians, technologists, etc. regarding the safety of HIT/CPOE systems. A new study comparing 3,000 hospitals at various stages in the adoption of computerized health records has found little difference in the cost and quality of care between those organizations with electronic medical records and without automation. Last year, the Joint Commission announced a sentinel event alert holding health systems responsible for errors caused by the introduction of HIT.




With the exception of the last bullet, I, too, have seen your Red Flags very often. The last bullet might very well be true I suppose I'm just too close to see it.

At the AMIA meetings last week, I attended two sessions that are worth sharing and for which the materials are readily available.

One was a tutorial on assessment of clinical IT projects. It was work that was done with AHRQ funding. For the purposes of this comment, let's just say that an extensive set of assessment tools are freely available here:

One take-away for me is that medical directors should plan to review system log files from day one. If you dont make sure you know who is using the system and how they're using it, from day one, it's highly likely that you wont be collecting adequate information for ARRA-HITECH needed performance measure reporting and improvement. Although vendor systems usually can collect this information, unless there is leadership and project management clarity, vital data is often not collected. (This was an observation of AHRQ officers who did post-hoc reviews of grantee projects.)

The second session was from Jim Walker et al at Geissinger. A paper version with abstract is here: .

Jim demonstrated the hazard analysis to "errors caused by the introduction of HIT." I've known Jim since long before he was famous. He was always delightfully clear headed. Jim elaborated a process used in other industries which focuses on a pre-occupation with failure (prior to the systems failing.) The large, system diagram includes vendor and provider organization responsibilities to identify, document, and, where does manage out the hazards. This is ideally done with design or re-design, as opposed to work-arounds, "educating the user to the risks," etc. Everyone reading this can preach this topic better than I.

The only downside that my fellow attendees noted is that the resources to capture, track and respond to thousands of hazards is not in anyone's budgets or economic models. If Jim were commenting, he would probably agree that there is a point of "good enough" and, if we stopped and looked at the situation, we'd agree that we're nowhere close.

Thank you both for your valuable comments. My personal challenge these days is to raise the awareness of these issues throughout the C suite and Board. The "enterprise architecture" at both the organizational transformation (process, change mgt, physician adoption, etc.) and knowledge management (evidence based medicine, CDSS, clinical informatics, etc) is insufficient to pull off the requirements of HITECH one facility at a time. We are beginning to have multiple clients work together so as not to reinvent the wheel. Its slow, but a start....

I, too, scratch my head a lot and wonder 'what are they thinking?' Mark Paradis' use of the term "conservative" to describe hospital C-suite (and all of health care, frankly) is an understatement. The culture in hospitals seems to be wait for a government-mandated deadline to do anything it's the only safe course.

Real ROI is attainable there are enough success stories emerging at HIMSS and elsewhere.

But we tend to obsess about short-term fiscal risks and conveniently ignore the IOM studies that sparked the current HIT initiative our "good enough" paper system today is killing 100,000 patients each year through avoidable errors. HIT was the one solution found to move more toward a 6sigma environment. The bottom line here is just not about preserving financial margins it's about reinvesting those slim margins to intelligently harness the data organization power of computers and move at a deliberate pace to save 100,000 lives equivalent to the population of the entire city of Boulder, CO. And that is something that demands huge organizational change and that requires C-suite vision, long term commitment and willingness to risk becoming champions.

Thank you Pam - I hate to say it, and it may get me in trouble, but hospitals in general are stubbornly conservative. They tend to be years behind in business methodologies, they tend to be years behind in IT implementations and they tend to be blinded to emerging economic, cultural and political trends. I can't say what the underlying reasons are for this, but a quick survey of the current healthcare environment amply demonstrates this to be true.

Enterprise Architecture is a discipline that first arose in engineering, made it's way into government and which is slowly working it's way into the corporate world in general. Virtually every bullet point you have raised, Pam, is a key component of Enterprise Architectural approaches to alignment, change management, and process improvement.

I believe there is tremendous opportunity for healthcare, and specificially HCIT, to benefit enormously from rigorous and innovative implementation of Enterprise Archtiecture frameworks, principles and approaches.