What matters now

This post is not so much about health care technology as communication and interesting ideas, which are no less important in HIT than elsewhere.

I have been following Seth Godin in my RSS reader for a while. His posts tend to be interesting and he hits it almost every day. As my web has expanded, I have been reading several people that he may have originally pointed me to, or else it's just a small world in the blogosphere.

Seth just published an ebook: What Matters Now.


It's got 70 essays and it's worth reading. I love that it's free; so does the Harvard Review. I follow Penelope Trunk and Chris Anderson. I've read Dan Ariely's book and I listen to Dave Ramsey on occasion. I didn't know Merlin Man, but really like his essay, Enough (pg 73).

Try the download; I think you'll like it.

Watch users stumble with Healthcare Technology

I saw this video on HIS Talk, so you may have seen it already, but it is worth sharing.

It's too easy to forget the end-user experience. If what we do doesn't make that experience work for the clinicians, we can't get the data we need.

Making Health Care Better

This article in the New York Times earlier this month is long, but worth reading. If the ads are distracting, try Readability.

David Leonhardt writes about Dr. Brent James of Intermountain Heathcare and how he is using data to improve the practice of medicine. A number of things have to be done to make this useful. And meaningful.

1) You have to have good data which shows concrete improvement in outcomes based on specific changes in health practices.
2) You have to give the practitioners that data as part of their regular workflow, making the preferred action easy to accomplish.
3) You still have to allow doctors to do what they feel is best for a specific patient. Meaning #2 above is not required, but suggested.
4) You have to measure which clinicians are following the suggestions and what the outcomes are in a continuous feedback loop.

It's a lot of work and it's complicated, which is why most medicine is not done this way.

Unfortunately, we also still have a system that doesn't reward some of the quality improvements that can be achieved using data like this; that's a subject for another post. It is easy to see how health care costs keep rising when preventing exacerbations and adverse events can cost a health system money, however.

Forget all the hype about healthcare IT and read this article. The potential we have for improving patient care is tremendous.

Speech by Dr. Robert Kolodner

The recent National Coordinator for Health Information Technology gave an interesting talk at Georgia Tech last Wednesday, 11/4/09. You can watch all 80 minutes here. Thanks to GA Tech and Emory and their Health Systems Institute for sponsoring the discussion.

A lot of the talk was about health as opposed to health care. We tend to forget the accomplishments of public health in the last decade.

Dr. Kolodner spent several years at the VA before his time with the feds. As such, he understands what a good EMR can do for data collection and analysis. Late in the talk, he showed a graph of hypertensives and how well controlled their blood pressure was. With the VA patient population, there were several hundred thousand data points. The fascinating part was the discovery that BPs were better controlled in the fall than in the spring. What you can learn when you have the data...

Dr. K. quotes Peter Drucker as describing health systems. Drucker says they are "very complex". Dr K's un-named mentor always told him that "Beginning are messy". We need to at least be at the messy beginning of beginning to use the data we gather about this complex system which is US healthcare.

Social Media at work

I've been spending more time networking lately, and have been thinking about the use of social media sites. I've written a little about it here before, but the topic is far from exhausted.

One of the blogs I follow, Candid CIO, just posted a piece on Ministry's new policy regarding social media at work. Like everything thing else in the workplace, you'd like to think that a policy isn't necessary if everyone is working with the best interest of the institution at heart. Unfortunately, that isn't always the case. I'm sure Will had to work hard to get the policy they have, and it will certainly need to evolve over time.

A web developer buddy has a pretty strong Twitter presence, but he's paying someone to do it for him. The new UK basketball coach, John Calipari, clearly has a professional web site, tweets, blog, facebook, etc. It's overwhelming, yet an interesting way to access information.

It really is a process of building a persona, whether you're an SEC basketball coach, a healthcare CIO, or just a college student.

Time for me to go update my facebook page...

Low Hanging Fruit

The articles that always get me are ones that focus on getting the software RIGHT. If it works, and you follow up to get the information out of it, it can be a really great thing. If the software looks like programmers thought it up, it won't get the adoption it needs to be useful (or meaningful).

If you subscribe to the Archives of Internal Medicine, you can see the original. Otherwise, enjoy the abstract pointed to above.

With EMR system notifications, just as with email, you can't send a missive to a group and hope that one of them decides to act. All recipients, especially if they are busy doctors, will assume that someone else will do the responding.

The real lesson, post-implementation, be sure to circle back and see what is really being used and how effectively.

P4P in Physician Group Practice

CMS recently published interim findings on the use of Information Technology to achieve measurable improvements in the quality of care for patients with chronic diseases. They have 29 measures for Diabetes, Coronary Artery Disease, CHF and preventative care. The results are very strong; the participating practices consistently achieved improvements. In the first year, all the practices achieved benchmark or target performance on at least 7 out of 10 diabetes clinical quality measures. Similar results are posted for subsequent years.

Other bloggers have written about it as well.

Having the data available really works; the trick is to get people to recognize that the pain of implementation and the challenge of change are worth it.

High Tech and High Touch

Kaiser Permanente recently published an interesting study. They did a two year trial of patients with prior coronary artery disease. Approximately half the patients got their intense follow up program (including regular direct calls to the patient from a specialty pharmacist). The other half got electronically generated reminder letters to schedule the blood checks on their cholesterol.

The fascinating result was that both of these groups showed dramatically better results that patients without any reminder system. The difference between the "high touch" version and the simply "high tech" version was not very high. But the difference between nothing and either reminder system was very high, meaning the cheaper solution was highly effective.

Most institutions are not yet at the point where their EMR could be generating the reminder letters that Kaiser did. But it appears that processes like this may be where the meat of the cost savings promised by Healthcare IT will come from.

Real doctor using an EMR and building a PHR

I really like what Stasia Kahn, MD, had to say about Electronic Medical Records.

She is now "exporting PDF Healthcare files to my patients for the purpose of populating an untethered personal health record (PHR). I believe that a patient-directed PHR that has been pre-populated with authoritative data from a primary care physicians’ electronic medical record is the quintessential, longitudinal health record..."

See my earlier post about how hard it is to enter the data yourself. People should begin to see the value added from practitioners that will contribute to the record for them and let those become the more popular providers.

EMRs and Meaningful Use

He's a horror story that is clearly not meaningful use.

Doctors and other clinicians are busy. EMRs have to have an obvious benefit to attract use. Complaints that providers would rather go back to paper just says we aren't paying enough attention to good design in the data flow of the EMR.

Social Media

It's all the rage to talk about using new forms of media for selling your goods and services. To be seen as a cool company by many, you need a facebook and Twitter presence. Despite the countless Tweets about how to make social media pay, the people I have talked to are having a hard time quantifying the payback.

Personally, I have found facebook to be a great way to reconnect with old friends, as well as keep in better touch with local friends I only see every month or so. As the piece of flair that one of my cousins sent to my 72 year old father said, "facebook - now with old people".


My personal experience with Twitter has been much less satisfying. Perhaps I'm not following the right people, but it doesn't seem to be adding much. Although the NYT says that Twitter is not for teenagers, I haven't found it to be for many of my contemporaries yet either.

Dave Winer suggests that Twitter and facebook are too ephemeral, and is especially upset about the possibility that all the shortened URLs in Twitter will disappear someday. He wants us all to blog, and to store the content is a simple text file.

My 20 year old daughter, on the other hand, thinks no one is interested in blogs. But she does read my family blog, which has been the greatest pleasure I get from social media.

So, where is all this going? For my post, I'm not so sure. For social media itself, no one is sure. There are a lot of different ways to communicate today, both personally and professionally. In both contexts, we need to choose the media that's right for the message and use it.

Leaders

Leadership is scarce because few people are willing to go through the discomfort required to lead.

Seth mostly talks about marketing, but after reading this excerpt from his book Tribes, I'll be buying that (on the Kindle for iPhone)

Home Care's place in the Health Care debate

Despite my obvious bias after 18 years serving the home care industry, it is simply unavoidable that care in a patient's home is cheaper AND better than forcing people into other places to live when they need care.

Please read the information on this site:
Help Us Choose Home

Health data entry

In an earlier post, I talked about how much work it takes to enter your own data directly into Google Health. Wired magazine had an article recently about how Nike has changed that for thousands of runners. Chris Anderson, author of Free, would like the way they used free software to sell shoes.

The trade off that people make by giving away their data and by sticking with a certain brand seems to be worth it to them to have their running history easily accessible. We need our health records to be as easy...

Enjoying the job

As a leader, a big part of what you need to do is recognize what people are good at, even if they don't recognize it themselves. Putting people in a position to utilize their strengths will enable them to do good work, and they will enjoy that work. Which will, in turn, inspire them to do even more of it. Aside from watching your boss put in a good day's work, there is nothing more inspiring than getting up in the morning knowing you will able to contribute to your organization's success on that very day.

Health insurance reform instead of Health Care reform

Toby Cosgrove, CEO of the Cleveland Clinic, has a great perspective on the debate going on (from Newsweek).

The local paper has an interview with him as well.

Our job is to share ideas

Seth Godin has some very interesting insights into marketing. It's long but worth it.

Shared EMRs

I know medicine and I know computers. Since I started tracking my cholesterol in 2002, I've kept a spreadsheet on my computer. Since physical devices come and go, I switched it to Google Docs a year or so ago. In my current explorations of EMR technology, I've gotten a Google Health account and have started to enter my data into it.

It took me 10 minutes just to get the Total Cholesterol entered with appropriate history. I haven't even bothered with the HDL and LDL as separate data entry streams. My payoff was that it was easily graphed, but I could have gotten that out of my spreadsheet. My internist is a solo practitioner, which is somewhat of an anomaly. But even people going to a big practice today don't have their records at the Cleveland Clinic or Deaconess or one of the other small handful of forward thinking health care organizations that can be imported automatically into Google Health.

Isn't that where we need to get? I can't imagine those with less technical patience than we engineer-types would bother with direct data entry. And today, even if I entered it all, it's not clear that my doctor could or would use it. Nor would an ER doc know it was there. But the record may contain vital information that is relevant to my treatment.

We've got a long way to go, but the technology exists to get there. What we need is appropriate leadership that understands that.

Meaningful Use

There is still a lot of talk going on about what Meaningful Use really means.

Here is the AMA's interpretation.

People in Management

Many bright individuals are capable of supervising a small group of people, but the Peter Principle is alive and well. The best person for a supervisor position is NOT necessarily the person that does that job better than any of their peers. Certainly, that talent would put them in the extremely comfortable position where they as the boss can always instruct their staff in how to do a particular job. From there, a merely adequate ability to express themselves and a little bit of self-confidence are usually sufficient to achieve success.

The self-confidence requirement is essential, however, and I have personally overseen promotions of people without that. Its absence has resulted in definite management failure. I have not yet been convinced that self-confidence can be taught.

The next step in management, where you are supervising supervisors, takes a much larger view of the world. Most people do not excel at this. You must be able to instruct others, especially your next level supervisors, only here you are instructing them in how to lead others. You also must be an even better listener. The rule of exception (where you as manager deal only with the things that your staff is not used to seeing) comes into play much more strongly the higher up the organizational chart you go. The self-confidence requirement shifts from the need to be able simply to answer a question, to the need to really make a decision. A decisive manager, who takes the incomplete information at hand, the conflicting reports from different parts of the department and is still able to find a path to the truth, or at least his/her version of the truth, is a rare commodity. The best managers will also have the willingness and ability to go forward and implement that truth, with the understanding that if it doesn't work, he/she can and will try something else.

If you find yourself needing a manager, look for the person with self confidence who is not afraid to make a decision, even if they aren't the absolute best at doing whatever it is their staff will be doing.

Getting value from an EMR

This is a very reasonable approach to the implementation that many institutions need to be beginning soon. Carrie Vaughan says:

Commit to the project
Let clinicians take the lead
Make the data easily accessible to the end user
Emphasize quality and patient safety
Continue training.
Be deliberate
Define success

Service that delights

Everyone talks about the lack of transparency in health care pricing and the detriment that is to patients shopping around for the best price. Another problem caused by the lack of transparency is that customer service at a doctor's office is usually close to non-existent.

I got a call from American Express today. 3 calls, actually - home, work, cell. Also an email. When I answered the cell, they told me that there had been a $1800 attempt at a charge at Bed, Bath and Beyond. And yesterday, an attempt at a $700 ticket on United. As soon as I confirmed that I had nothing to do with those charges, they canceled my card and are sending a new one to me overnight. No muss, no fuss and no extra liability. They'll even transfer the automatic charges (Netflix, etc.) that have over six month's history to the new card.

I appreciate that their software correctly points out anomalies in my spending pattern and their diligence in contacting me. I will continue to be a loyal customer.

What have my doctors done for me lately? How free do I feel to change doctors based on the ease of getting an appointment, or how pleasant the receptionist is? Our work in improving health care should lead to a system where it matters how the doctor or institution treats the patient personally, in addition to how well they treat them medically.

An introduction

And so it begins. I've done some personal blogging, but it feels like time to add my voice to the throngs writing about health care and information technology. There is so much to be done in further automating health care, and at least as much mis-information as meaningful dialogue.

The AARA has folks in a tizzy. Certainly the feds are capable of throwing money at anything, but look what that has accomplished in our public education system over the last 25 years. What we really need to be discussing is where the real gains from IT spending can come.

Certainly electronic medical records eliminate mistakes caused by mis-reading physician handwriting. (I can talk about MDs - both my father and father-in-law are Family Practice physicians) A complete list of medications allows for real time drug-drug interaction checking. Patients really like not having to spell their name every time they start with a new health care provider. All of these seemingly simple things are what an non-health-care IT professional might assume is already happening every time in every health care environment. In fact, they're not.

We need to achieve those goals and move well beyond them. We need ease of use that gets even doctors willing to absorb the up-front data entry cost required to get the gains on the back end. We need systems as intuitive as the iPhone, and close to as inexpensive. We need connectivity that allows even rural home care workers access to their data while in the home. That's the kind of innovation that will get us to meaningful use that is really meaningful.

My goal is to clarify these and other thoughts, and have something of interest to add to the hubbub. I will work to keep my signal to noise ratio high, so keep on watching.