intelligent healthcare information integration...plus

No More Snowmen Sliding on a Sled

2010-12-16T22:13:00.002-05:00

Health Nuts Media - using the high tech tools kids "get" and
language they understand to help them "get" healthcare - wishes
you and yours a very, wonderful holiday season! The fun, little
animation above can be personalized with your favorite photo
or logo and a couple of your messages and, then, easily sent to
anyone and everyone you know. No ads, no email addresses
collected, no strings - just fun and free!

Happy Holidays!

EMR Hunting: 20 Questions (well…5, plus)

2010-12-16T11:22:00.016-05:00

Q) Why is hunting for an EMR like looking for a new smart phone?

A) Because there are a ton of them from which to choose, most of them look and feel pretty much the same, they can all do a lot of the basics, there are some pretty cool features even in some of the less-developed ones, and even the best ones don’t do everything you might want.

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Q) Why is vendor EMR enhancement sometimes akin to moving from a pig pen to a mud puddle?

A) Because when a vendor gives their old users a new feature or a slightly better interface, the users will rave and crow about how cool the new feature(s) is/are, not realizing their lot in life has only minimally improved.

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Q) Why aren’t all vendors offering free online demo tool access where users can “test drive” an EMR?

A) Not sure. I only know that if I’m buying something to “drive” for the foreseeable future which may make or break my bottom line, I sure as heck am not going to pony up after a spin around the block with the salesperson doing the driving. Plus, I’m much more prone to appreciate a vendor who provides such access.

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Q) What makes for a great EMR demo experience?

A) Vendor reps who really know their product, who don’t assume that they know more than their customer, who take the time to try to deliver a personalized experience and not just a rote spiel, and who TRULY understand the value of time to a busy physician.

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Q) What can providers do to enhance their EMR product compatibility?

A) Look for a system “look and feel” that suits you, yes, but also look for a corporate philosophy and history that is compatible with your values. Glitz and sham abound; don’t be blinded by pseudo-science, salesmanship, or “the show.”

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Q) What about those products mentioned in the post of November 30^th?

A) Not forgotten. (And by the way, I really appreciate the Comments and emails I’ve received suggesting products and features I may not mention or even be aware of – thanks, and please keep ‘em coming!)

SRSsoft’s Hybrid EMR – One of the things I like best about SRSsoft isn’t just their new “app store” which allows users to add new parts and pieces in the user-friendly fashion of iPhones and Droids (which I truly, dearly love!) No, perhaps the best thing about them is straight-shooter Evan Steele, company CEO and all-round good guy. Evan actually took the time to personally show me around the SRSsoft block and describe their tool, their new app store, and their pending new version features (very cool!) What really makes him unique in my book, though, is his honest, no BS approach. Case in point: Evan has been rather outspoken in his opinion of Meaningful Use certification and its lack of value to specialists (one of his special foci.) He has maintained a clear vision about wanting to provide physician-friendly tools which are “workflow-driven.” However, as this ever-evolving process has unfolded, he has re-evaluated their corporate stance and will now get on about obtaining an ONC-certified diploma. The value to his clients of such has changed and he is open and frank about seeing the need for providing this and changing his approach. As he gave me a explanation of his changed views, I sensed no sales guy schmooze, just a plain-spoken “I’ve reconsidered.” I like his lack of guile and straight up manner.

Medicity’s iNexx – Well, I’m not sure what to say now about Medicity and iNexx. I have gotten to know several of their corporate bigwigs and really enjoy and respect them. I like their primary product a lot and am very intrigued by their approach with the open source, app-able iNexx (though it’s really still in alpha and not yet ready for prime time.) The recently announced buyout by Aetna is something that makes the physician in me cringe. Nothing particularly personal to Aetna, but after years of aggravating experience after aggravating experience, my overall insurance company Gestalt is, well, probably pretty commonplace amongst providers and not all that wonderful. I do try to maintain the bigger picture view I espouse, but whether it’s Aetna or UnitedHealth Group or MomsAndPops Hometown Insurance, most physicians don’t really feel too good about having more insco involvement in between their patients and them. It’s a “once bitten, twice shy” thing. I read on HIStalk that Medicity would stay as a separate biz unit “under the company’s current management.” I hope so. I really like those folks - and their tools.

So many products, so little blog space. Next up: Fun folks (expanded,) excitement, a true helpmate, the power of views, plus.

To be continued, from the trenches…

“Dreams are today’s answers to tomorrow’s questions.” – Edgar Cayce

Time for the Cheese, Please

2010-12-01T06:17:00.008-05:00

“Thought provoking EMR comment. Don't be sparing us the details of the cool features you've seen and which companies are providing the cool features you've found...show me the good stuff!”

That’s a compilation of a couple of quotes from John over at EMR and HIPAA after a recent post here where I mentioned I was starting to find some pretty cool pieces and parts amidst the waterfall of EMR/EHR demos I’ve been drenching myself within of late. I promised I would “stop the tease and show the cheese.” (John requested sharp, but it may be more along a Muenster.)

Four up front caveats:

1) I am in no way receiving any remuneration from any of the vendors I will be mentioning.

2) I have really enjoyed many, if not most, of the people who have taken their time to show me their solutions. Part of me wishes I didn’t have to end up choosing but one answer/company for our office’s needs.

3) While I am certainly keeping self-interest at the fore, I try to consider the needs of my heretofore undigitized colleagues and what my understanding of their needs might include.

4) There’s only one of me and I have a day job (well, often a day and night job,) so I wouldn’t even begin to imply I’ve seen all there is to see – but I’m trying!

OK, here we go, and in no particular order of coolness…

Ultimate Usability

Unfortunately, there’s not a system in existence today that has this feature – yet – but the hands down winner in my book goes to Medicomp’s CliniTalk and its yet-to-be-named Type/Write/Click cousin. Using their medical knowledge engine of “260,000 coded clinical concepts mapped to CPT®, DSM, ICD, LOINC®, RxNorm, SnomedCT®, and other billing codes and clinical reference terminologies,” this middleware allows truly smart data capture, integration, manipulation, and utilization. It’s coming very soon to some pretty good systems which it will help to make great. I’m so enamored with this functionality that I’m doubtful I’ll be able to choose a new system that doesn’t have it incorporated – or at least one with plans to do so. (Seriously, it does for clinical data what I’d always thought a computer should: it adds an intelligence and a level of association-making that a busy clinician really needs while helping to minimize the “Wow, I went to med school to become a data entry clerk for insurance companies” feeling.) Unconfirmed, but I hear Sage Intergy will be one of the first to engage this hyper-enhancement.

Eye-Friendliness

This is one of my personal “gotta be there” criteria. (It was a huge factor in my love at first site with Bond Clinician, the now life-support-plug-pulled Peak Practice.) If my “blink” upon first view of an EMR isn’t one of “OK, that’s kind of pretty,” then I know the demo from there on out will likely only yield ideas for features or functions I might want to see in the other system I do eventually choose.

Prettiest faces in this category are all iPad-ian: Quest’s Care360 and ClearPractice’s Nimble. Right up there, too, is Dr. Chrono, but I admit to enjoying the warm feel of faux leather, even if only digital, which Care360 and Nimble use. This familiar view might even assuage some of the anxiety of docs who are still pen-and-paper bound. (I especially like the slightly askew desktop look-and-feel of Care360, perhaps because my desk is usually pretty askew, too.)

Desktop systems could learn a thing or three from these iPad implementations. I mean, really, isn’t there a whole science about HCI (Human-Computer Interaction) and how to make visual content appealing, productive, and efficient? My take: Many EMR vendors could use a few less Chief Marketing Officers and a few more humanistic computer interface designers.

That said, I have seen a couple of desktop systems worth noting. SOAPware’s EMR has come miles from when I first remember its rather basic layout. athenahealth’s athenaClinicals also has evolved nicely since I joined Inga and John Smalling in a group demo about a year ago in an ill-fated jaunt into product demo reviews. (I liked it then; its look and feel is even better now.)

As this is a long, ongoing, often sleep-inducing process, I guess it’ll have to be a “to be continued.” But, before I go, here’s a few I’ll be discussing next time:

· We “get” the “App Me, Baby” idea: SRSsoft’s Hybrid EMR and Medicity’s iNexx.

· EHR vendor team who seems to have the most creative fun: Nuesoft.

· Most exciting new non-EMR EMR: Mitochon Systems mEMR.

· Best digital office preparation tool: Welch Allyn’s EHR Prep-Select.

· The value of views: DIS.

· Using exo-EMR stuff, mostly iPad apps, as really useful patient education and engagement tools: Blausen Medical’s Human Atlas, Pampers’ Hello Baby – Pregnancy Calendar, CHADIS, and Text4baby. (Pseudo -exception to caveat #1 above: I also like start-up Health Nuts Media for whom I am the unpaid CMO.) Heavy prejudice toward pediatrics, I know, but remember the source here.

· Vendor web sites: what attracts and what repels.

· “The Good, The Bad, and The Ugly” of demos and vendor/client connections.

So, while not meaning to continue the tease as I’m really trying to dole out the requested cheese, I’ll close here with the promise to grate some more fresh Parmesan soon.

From the trenches…

"The early bird gets the worm, but it's the second mouse that gets the cheese." - Jeremy Paxman

Dually posted on HIStalkPractice.com.

Oh…So, That’s Cool…

2010-11-15T07:19:00.003-05:00

After my last set of whines and gripes, I have been gifted with a wonderful slew of wake up slaps to the face. There are – thank you, Jesus – some pretty cool new developments in the world of EHRs. I feel as if I have been given a Moses-ian view of the EHR Promised Land and the view up here is pretty pleasant, much brighter than my first assessment may have perceived.

I’ve gotten demos and descriptions of some EHR 2.0- to 4.0-ness that are flat out encouraging. CEOs and development VPs and idea men and sales folks have all shared some very cool new approaches and system enhancements which have me feeling almost giddy with possibility.

I said I wanted to see apps: apps there are a’poppin’. I mentioned my new iPad love (even though as a PC guy from way back it feels almost elicit): there’s more iPad approaches a’brewin’ than I a’knew. I noted WebOS moves so smartly: some EHRs are now a’hoppin’. And, though my desire for EHR “beauty” may still be more a part of the “Promised” than the current “Land,” the scenery is showing some springtime buds a’bloomin’.

So, now that my bipolar swinging is apparent, I have to admit that my prior gripes may have been somewhat stilted, probably secondary to my exogenously-induced IEDD: Impending-EHR-Death Depression. (By the way, if it isn’t yet, I hereby suggest a new DSM-IV entry of just such a disorder; I am certain we’ll see many more such cases in the coming years. Successful treatment of IEDD – for which Xanax helps, I should add – is primarily dependent upon a fast bolus of Innovation and Value: an “IV bolus.” I am blatantly pilfering this term for the new IEDD rehab center I’m founding.)

As I move higher into my mania, I’m almost moved to a mental meltdown by the mention of a not-so-minor bit of minutia: the dreadful awareness of “you can’t have it all.”

Smart pieces and parts from here or there all swim within my mental imagery of the world of EHR possibilities which are upon us. They dance and dodge about in my mind as the number of demos mounts and the differences among them melt into one gigantic “what could be” mélange. I can see the future, the EHR Promised Land, but as many a pioneer’s dissuaders have portended, “You can’t get there from here.” I can see little snippets of the path to the land of EHR Shangri-la, but I can’t see how to tie them together into one consistent path. The road to HIT nirvana is still hit AND miss.

I didn’t want to have to change systems, but now that I’ve been blessed with a deeper view of what’s been cooking on EHR stoves all about – much of it still percolating under boiling pan lids – I’m starting to get a little bit excited about what functionalities and innovations my next system might provide. In fact, I’d place my order right now, if I could P.F. Chang it – you know: one from column A, two from column B, one from column C…

From the curiously intrigued trenches…

“We want the world and we want it now.” – Joey Ramone

Co-posted on HIStalkPractice.com

But What Do I Know?

2010-11-05T15:28:00.006-04:00

I've been looking at a whole lot of EHRs and their web sites lately, looking for my "next great system." Maybe they're just starting to blur together in my brain, but it looks as if every single EHR out there will improve my workflow, decrease my errors, increase my productivity, improve my bottom line, get me home earlier, make my life easier, and guarantee my MU bucks. Somehow the redundancy of hype doesn't increase my interest...but what do I know?

Back in 2004, I remember thinking that the majority of EHRs looked a whole lot like Windows 95. Not much has changed. I used to think that most EHR developers would soon learn the value of style, of "eye friendliness" for meeting the wide variety of end user tastes or that at least they'd develop "skinning" for their systems to help solve the problem of ugly EHR user interfaces. I remember thinking how much better they'd all look within the next five years…but what do I know?

I remember when you moved from one medical practice to another, from one type of paper chart to another, and it took all of about thirty seconds to figure out what went where and how to find the info you needed. Seems that the multitude of "modern" electronic charting systems could stand to be reminded of that...but what do I know?

Seems as if every report I receive via fax or hard copy from (fill in the blank) EHR is either way too long and filled with mostly irrelevant "filler" data or way too short and lacking essential, clinically valuable elements. Seems as if very little effort is being spent, at any level, on truly defining what clinicians actually "need" and how to make that information apparent, easily visualized, and perhaps even somewhat standardized when it comes to knowing where to look for any given piece of info...but what do I know?

Doctors used to be paid for their knowledge, for their experience, for their clinical skills, and their wisdom. Nowadays, it seems we're paid mostly for data capture. I think patients still want good “doctoring”...but what do I know?

It may just be me, but there appears to be an increasing similarity between how insurance companies deal with clinicians and how more and more EHR vendors are starting to treat us...but what do I know?

I read that independent providers aren't flocking to EHRs quite as much or as fast as hoped despite the ARRA/HITECH incentives. I'm thinking it might be because of some of the above concerns and just how difficult it is to actually change virtually everything about how you work while you're busy actually trying to do the work...but what do I know?

For myself, I'm also hesitant to make another EHR choice. Having lived through three EHR company acquisition-mergers which eventually led to the Kevorkianization of a really smart, sexy system that was just reaching a respectable maturity, I'm pretty sure more this same digital tragi-drama will happen to many other decent systems over the next few years...but what do I know?

Don't get me wrong; I see systems which do some things very well and I know a whole lot of EHR vendor folks who I think are just plain wonderful. Good people and good intentions are important, but I'm still thinking I want a beautiful system that works as easily as my iPad and as intelligently as WebOS, one that I can start using as simply as I need and which can then be "apped" silly at my discretion, one that is actually as good and as smart as all the hype...but what do I know?

From the trenches…

"Committee - a group of men who keep minutes and waste hours." - Milton Berle

Co-posted on HIStalkPractice.com.

EHRrrrggh!

2010-10-21T16:29:00.002-04:00

When I still had fewer candles on my birthday cake than teeth or toes or even ears, I was introduced to the concept of pencil and paper – well, initially, it was crayons and paper. I have only the foggiest of recollections, but I’m told it was a similar introduction scenario to the classic “Fish Meets Water.” Pretty soon, the walls next to my crib – once I had mastered the art of the tape dispenser – were covered with masterpiece piled upon masterpiece. My thoughts, expressed graphically, flowed as freely as the breeze. (I was going to say “as freely as the urine within my diaper,” but maybe only other pediatricians would think that semi-amusing.)

A few additional teeth later, I was introduced to the slightly more difficult chore of organized and standardized pictograms known as “letters” and two of the three “Rs.” It took a while, and I had a more spongey-esque brain, but within less than a year or so I was a’readin’ and a’writin’ to my little heart’s content. And, of note, the ROI hasn’t been matched by anything else in my life except perhaps the art of breathing (which was also pretty easily mastered.)

Time travel out of the Stone Age and here I am with a staff that has just spent over five years (and their boss who has spent oodles of dollars in the process) finally starting to feel pretty comfortable with a much less standardized and drastically less organized part of the “healthcare information management” system. And, now, that part of the system – our EHR of choice – is getting shut down.

Not that our particular EHR is bad or that it doesn’t meet certification criteria or anything that would imply it was not up to HIT snuff, not at all. It’s actually very technologically savvy, often called a very “sexy” system by HIT folks in the know. No, it’s just that the whole, bigger picture HIT schema is about as well thought out as Saddam’s claim of WMDs.

Virtually no standardization exists in HIT, not even something as simple and as helpful as a standardized way to display laboratory data (which, for all you tech-heads out there looking for a great idea to incorporate into your next version, is something that would really, actually help providers deliver better, faster healthcare.) Far too much emphasis has been placed upon the data capture for the Inscos or the profit margin of the vendors and far too little has been given to the actual users of the tools.

And, now – especially now that there are HITECH chum-churned waters filled with every size EMR-sales-shark you can imagine threatening that if you don’t get on board right away, the boat’ll be gone and you’ll be paddle-less up Poop’s Creek – now we’re all being told we have to learn to use these typically less than elegant tools that are often cumbersome and non-intuitive – STAT. To borrow (and then bastardize) a nautical phrase, in many quarters it’s “Providers be damned; full steam ahead!”

Add to this the almost almighty power of the HIT vendor executives (quite often more MIT Sloan’ers than Harvard Med-ites) making shareholder or financial positioning decisions which may empower the bottom line while castrating the clinician and you have a situation likely to end with a medical navy full of provider pirates all running around, as I am right now, shouting “Arrrrrggggh!!!” all day long rather than the standard, and gentler, “Say, ‘ah’” …or maybe, “bend over,” depending upon your specialty.

That’s it! I sorta feel like a proctologized pirate these days. (And, by a fellow Rotarian…double Arrrggh!)

From the swarthy trenches, matey…

“Even pirates, before they attack another ship, hoist a black flag.” – Bela Kiraly

EHR Data Sharing – No Manhattan Transfer

2010-08-28T14:09:00.003-04:00

A recent change in working arrangements led to the need to look into the exchange of a few hundred patients’ records, from one well-known EHR system to another very prominent company’s system. To say such an exchange is easy or, especially, to say it is cheap would be the understatement of the month.

Don’t get me wrong, it is possible – in some format or another. Demographics only via .CSV or full CCR/CCD transfer of medical data are possible. But, for small practices who want to share large chunks of data from one well-built system to another, it is certainly cost-prohibitive and not a simple “have your peeps call my peeps and set it up”-type of deal. You’d think that by this time we might have had enough such transfers that the cost would be decreasing and the intercourse would be, well, more satisfying.

You may not be a fan of vocal jazz as put forth by “The Manhattan Transfer,” but they have been putting out some pretty silky songs for some 40 years. Their sustainability is founded upon their ability to incorporate and appropriate from many diverse styles and formats. They bring in elements from many great musical genres and meld them into their own particular musical system.

EHRs must be able to share amongst the many, many digital “genres” now fairly entrenched throughout the country and do so in a way that isn’t another bloodletting point for small practices. If not, the whole NHIN (or whatever version or flavor or name du jour it is) concept might as well be called the Big Organization EHR Information Network. Add “Group” at the end and it’s BOEING. (Hmmmm… Big government contracts, mega-corporate mindset and attitude…there’s some association there.)

Us little guys don’t have the overhead room to afford playing in the big digital sandbox if simplicity and small guy costs aren’t a part of the plan. I know, I know – healthcare data is complicated and these multi-siloed, often incompatible systems and system architectures argue against simplicity and inexpensive costs. But, you know, we let it get built that way. There’s no rule that says we can’t reengineer.

I hope so. The more I use our EHR, the more value I see within it. It has its problems, sure, but they’re far more acceptable than the hassles associated with pen and paper. It just shouldn’t make such off key squawks when all I want is syncopation.

From the trenches…

“Beauty of style and harmony and grace and good rhythm depend on simplicity.” - Plato

Help for an Amazing Pioneer

2010-08-16T22:34:00.003-04:00

Like most of you, I try to accomplish a few things during my time here on this earthly coil. Every now and again, I start getting a little full of myself and start getting a Steve Martin The Jerk-esque “I’m somebody now” sort of feeling. You know, a “look at me, look at me” moment just like every little kid shouts to their mom or pop at some point to achieve a little validation of their worth.

Through some of what I do in the realm of HIT, and especially through some of my writing here on HIStalk Practice (thank you, again, Mr. H and Inga,) I have made some pretty wonderful contacts and some even more wonderful friends. These folks come from across the gamut of healthcare, from all over the U.S., and even from around the world. When I start thinking about how fortunate I am to have such a breadth of colleagues and acquaintances and start to consider how I’ve maybe been able to have some impact upon the growth of this fledgling industry, I can sometimes actually feel my cranium getting fuller as it begins to swell. Until…

Until I remember Sid.

Dr. Sidney Nesbitt, to be precise. Sid is a pediatrician in Nairobi, Kenya. He is one of the “blessings” I have been granted through my time in the HIT realm. He runs the Muthaiga Pediatrics Clinic located on the grounds of the Gertrude’s Children’s Hospital, a charitable trust founded over 70 years ago to help the children of East and Central Africa. Sid’s working very hard to develop and employ advanced office design, practice management, and especially healthcare information technology techniques and tools at Muthaiga Pediatrics. His goal is to set a standard, an example that he can share with physicians all around East/Central Africa. He even engaged the interest of MIT Sloan’s Global Health Delivery “G-Lab” which worked with him for months helping him evaluate and deploy better business tools specific to the needs in Nairobi. I was lucky enough, along with the wonderful Drs. Dan Feiten of Denver and Larry Rosen of New Jersey (himself, an MIT alum) to consult with their project.

On top of this, he is the director of their pediatric endocrinology fellowship, sponsored by the World Diabetes Foundation, which brings volunteer visiting professors from Canada and the U.S. each month to help train African pediatricians. He is pioneering similar initiatives to establish fellowship programs in Africa in Infectious Diseases, Emergency Pediatrics, and Pediatric Cardiology, Gastroenterology, Neurology, and Pulmonology over the next five years.

There is more work with charitable and volunteer efforts to advance child health in Africa with which Sid is engaged than I could begin to cover here. He is planning on sharing some his amazing work this year at the American Academy of Pediatrics (AAP) National Conference and Exhibition (NCE) in October, specifically, at the “Pediatric Office of the Future” (POF) educational exhibit in a section called “Future Pediatrics International.” (I am the director of the POF, for full disclosure’s sake.)

He is truly an inspiration for me and, I’ll wager, for many, many more folks around his native Kenya. He’s a joy with whom to talk and constant source of “what others are striving to do with far less resources and far greater challenges.” He helps me remember what’s important.

But, Sid could use some help. He is springing to bring himself to America for this event, but as any pediatrician anywhere in the world will tell you, we’re not the rich boys of medicine. So, if any of you good folks out there would be able to help my friend by helping him cover just the costs of the exhibit expenses, I will do everything I can to help promote your sponsorship. Expenses cover his presentation, PC, exhibit accessories, large screen monitor rental, etc. – pricey exhibit hall fees – at the conference site, totaling around $3,000. (FYI - The POF is doing well and getting so much love from the AAP, we’re just finishing our own web site within the NCE site – somewhat unique – which highlights, and links to, our generous sponsors. The site’s a work in progress, but you’ll see the foundation. Plus, the AAP blasts emails to some 60,000 pediatricians and has great onsite marketing providing great exposure.)

Besides the marketing potential you’ll receive, you’ll be helping one very good man. His vision and his tireless efforts to advance HIT as he seeks to help the children of Africa are those of a true pioneer.

If you can help my friend, please contact me as soon as possible here in the trenches…

(PS - We've received a commitment for $1,000 so far and would be very grateful for other partial sponsors - a bit of a time crunch in order to get sponsors included into print ads.)

“There has to be this pioneer, the individual who has the courage, the ambition to overcome the obstacles that always develop when one tries to do something worthwhile, especially when it is new and different.” – Alfred P. Sloan

Not So Strange Bedfellows

2010-08-10T13:14:00.001-04:00

An article in the Wall Street Journal recently reported on the increasing cohabitation of health insurers and electronic medical record companies. In moves that would surprise most of us about as much as hearing that Coke and Diet Coke are actually made by the same company, several large inscos have joined forces with EHR vendors to “help” docs with the transition to digitization.

OK, I admit that last sentence sounds as if I’m skeptical of the reasons behind these collaborations. And, well…I am…but, maybe not as much as I would have thought. After also reading about Surescripts partnering with Microsoft to offer web-based access to prescription histories for consumers and about the health units of both GE and Intel getting together to form a new company focused upon “telehealth and independent living,” it occurred to me that in this mountainous mishmash we call our healthcare system here in the U.S., perhaps a little more collaboration might be a good thing.

Seriously, I think the majority of companies currently having even a foot within the healthcare sandbox would get Fs on their report cards to date in the “learning to work and play with others” category. Between proprietary this and antiquated that, it’s downright impossible to move along down the digital roadway until more players (and payers) learn that we all gain when we work together. Remember that little thing we all portend to care about: patients? Aren’t they better served when your tool plays well with mine? (Keep your minds out of the gutter.)

In her WSJ piece, author Avery Johnson (out of the gutter, I said) quotes the illustrious patient privacy rights advocate, Dr. Deborah Peel, who has concerns about conflicts of interest which may put personal health data at risk. I see her point, but I also feel there is just way too much to gain and far too much we could do with all this data, medically, if we could access it more effectively. The inscos already have oodles of patient data; I’d love to be able to actually see what they see to see if I see what they see the same as they see it. See?

Aetna and IBM say their system will pool patient records, lab, and claims data to help docs “measure their care against national quality standards” and that the insurer won’t have access to the data, just the docs will. Wellpoint plans on helping rural hospitals build out IT, but won’t tie their billing into the EHR the hospital chooses.

Humana and athenahealth are getting even more skin into my game (“my” meaning the collective physician world) by helping to cover 85% (Stark?) of the costs of implementation and then actually paying up to 20% more if users show they can hurdle certain performance standards. (This is, I’ve heard, above and beyond any HITECH funds, but don’t quote me on that.)

Deborah, I agree that we really need to keep a very close eye on folks who have access to our patient data. But, if they are going to share what data they gather back with me so that I can watch them watching me, I think that way beats out the current system where they have it all and I’ve no clue about what data they’re using to make payer decisions.

Like it or not, until we have a monogamous, single payer relationship (coughs, harrumphs heard all around,) these are the Bobs and Carols and Teds and Alices with whom we are snuggled. We’re polygamous; we might as well admit it and figure out how to make this ménage a multitude work. Unless you want to start talking seriously about that single payer idea…

From the trenches…

“When I played in the sandbox, the cat kept covering me up.” - Rodney Dangerfield

EHR Speak

2010-08-01T06:43:00.003-04:00

Recently, I learned that a friend, someone whom I admire and highly respect, was dealing with the impending loss of a parent. Combining that with some of my own recent life difficulties, both at home and in the workplace, it got me to thinking about the one truism I have noted when it come to the really tough life experiences we all endure: there are no magical words of wisdom, no empathizing phrases that really help.

Indeed, most of those often well-intentioned clichés usually sound trite and often even minimize the emotional suffering of the sufferee. They may be the expressee's way of trying to show support, but beyond “That really sucks” and “I'm here for you,” nothing much else conveys the meaning which may have been intended. They may make the expressee feel as if they're trying to help, but they often result in making the sufferee feel worse. (I'm betting that any of you who have experienced loss or major life trauma know just the phrases of which I speak, so I'll forego examples.)

My perverse, geekoid, HIT brain, of course, took this melancholic consideration and immediately made a connection with the world of EHRs. (This is actually sort of sad to admit, that I find HIT-ness even in the face of human suffering...I really need a vacation!)

Here's sort of how the neuronal path went:

Saying what we mean and having what we say actually provide the information – and especially the intended meaning behind it – is often quite the challenge.

I notice the same difficulty in the electronic medical record reports I receive from other providers.

From one particular emergency room, I used to get five page EMR-generated reports to tell me that a patient was seen for an ear infection, prescribed amoxicillin, and told to follow up with me in two weeks.

From that same ER, I now get two page EMR-generated reports about a child who presented with skull fracture, cerebral contusion, and seizure-like activity who was admitted to the hospital and the amount of info is about as limited as what is in this sentence.

Formatted, templated, pre-made medical descriptives seem about as adequate as the pre-made clichés so many people try in trying times to convey their sympathies over someone's personal loss or other tribulations.

So, what does work? (For medical info conveyance, not personal sympathies.)

Thinking back, the best descriptive, by far – by leaps-and-bounds far – which I ever receive about patient-provider interactions come from the dictated narratives, most typically from consulting specialists. They may have basic formatting, often following SOAP note style or some variant thereof, and they provide a colorful picture, a conceptualization complete with supporting details and even the thought patterns which led to the diagnoses and/or treatment decisions. If there is vagary (which is still so frequently unavoidable in medical evaluation and diagnosis,) that is also conveyed with the reasoning which makes the vagaries necessary. These dictated notes, most often with a lower page count than even the best EHR-generated document, paint a picture which is easy for my brain to understand and which conveys the complete, pertinent patient encounter information, subtleties and all.

I’m not saying I think every EMR/EHR system and user should use some form of dictation or speech recognition. But, perhaps system designers could start focusing more on “EHR speak,” on how they can enable capturing and relaying the subtleties, the nuances of medical descriptives. These so often provide the real “color” of a patient’s situation rather than just clichéd, templated, rowed-and-columned, formatted data. It’s sort of a Van Gogh versus a paint-by-numbers thing.

To my friend: It really does just suck and my thoughts and prayers are with you.

From the trenches…

“Never does one feel oneself so utterly helpless as in trying to speak comfort for great bereavement. I will not try it. Time is the only comforter.” – Jane Welsh Carlyle

“Next Generation” HIT

2010-07-25T21:00:00.005-04:00

My dad was a big fan of the phrase, “Do as I say, not as I do.” Of course, the not so subliminal message was simple: I want you, my children, to do better than what I can seem to do.

What parent doesn’t want their kids to “outwit, outplay, and outlast” the parent’s best efforts? Once we’ve had our neurological hardwiring soldered firmly into solid pathways, it’s much harder for us old dogs to establish those new tricks. (Yes, “old dogs” includes even those 24-ish years plus – which is most of you, I’d wager.)

Our kids, though, have pleuripotentiality out their young wazoos. They glean, gather, garner, gain, and grow like little black holes scooping up all the light and matter within their reach. If you’ve ever seen an iPad in the hands of a two year old or watched a five year old zip through master levels of (fill-in-the-blank) video game which you can’t even understand past Hit Start to Begin, then you know how these little sponges take to technology like yuppies took to Starbucks.

After struggling these past several decades through the birth pangs of this giant HIT baby we’re all trying to deliver and listening to doctors and techies and vendors and politicians all accuse each other of being the cause of the slow progress of this birthing process, it makes me wonder if we’re not all missing one huge point: maybe this “baby” isn’t meant to be born “for” us; maybe it’s meant to be birthed by us, but for the next generation.

So, why aren’t more efforts being directed at giving our little learning maestros tools to help prepare them for a better healthcare life through technology? Well, it warms my little pediatric heart to see that some folks out there have started to understand that building a better healthcare future can be reached not by trying to push and prod us old mules, but by giving our children a way to “do what we say, not what we do.”

“Let’s Move!” and the US Department of Agriculture have teamed up to sponsor the “Apps for Healthy Kids” challenge. This competition seeks to inspire app makers to build kid-friendly tools (i.e., games) which will help our progeny think healthier, act healthier, and associate technology with healthcare in ways we probably can’t even imagine.

HealthNutsMedia, a start-up, is one of the competitors. They’re two very successful and talented animators building some amazing new animations and games designed to teach kids about complex healthcare issues via kid-friendly language and kid-engaging media choices. (I love what they’re developing so much, I’ve even agreed to help guide their pediatric perspective.) They’ve entered this challenge with a memory game app (you know, like “Simon” where you had to slap the flashing lights in the appropriate order, in the mean time driving your folks’ bonkers with the obnoxious, repetitive tones it emitted.) Theirs is called “Parrot Pyramid.” It’s kid fun that also teaches them about food groups and making healthier food choices.

OK, granted, this is barely scratching the proverbial surface for what healthcare information technology can actually do in the hands of our children. But, I think using child-friendly media technology (animation, games, apps) and child-level language to promote health awareness and HIT savvy in our children is perhaps the smartest use of HIT I’ve ever seen. If they “do as we say” and build upon these meager beginnings, I’ll just betcha their version of HIT will be light years beyond what us old fogies can ever even hope to imagine.

I hope you’ll consider voting in the Apps for Healthy Kids contest; it only takes a minute to register and vote. (My friends at HealthNutsMedia have asked me to say “thanks” in advance if you decide to drop your vote for their Parrot Pyramid!)

From the future-hopeful trenches…

“He's not pining, he's passed on. This parrot is no more. He has ceased to be. He's expired and gone to meet his maker. He's a stiff, bereft of life, he rests in peace. If you hadn't have nailed him to the perch he'd be pushing up the daisies. He's rung down the curtain and joined the choir invisible. This is an ex-parrot!”

– one of my favorites from Monty Python

Musings on EHR Usings

2010-07-18T08:58:00.005-04:00

By now, most of you know I’m a small town pediatrician in private practice with an IT department consisting of me. (Not to take anything away from the great job my wonderful EHR VAR support people do, but their 1,000 mile reach has its limitations.)

As the chief cook and bottle recycler, it sometimes amuses me just how challenging this EHR/EMR proposition is – especially when I think of others trying to pull this off who may not be so tech-star-struck. I mean, really, how many doctors really care if they’re using pen and paper or mouse and keyboard? From what I see, most of my colleagues just want to provide healthcare help. All that charting stuff is more often seen as a way to get paid than as a real necessity for patient well-being and ongoing care.

I know, I know – in bigger institutions and large practices where patients may see multiple providers thereby necessitating better legibility and patient care communication, and, when you consider data usefulness and sharing, I think most physicians understand that digitization is the way to go. However, I’ll betcha that outside of CMIO and geekoids such as me/we, very few really want to be bothered with the technicalities of .NET or MUMPS or SQL or even CCD/CCR. They just wanna be docs. And get paid reasonably. And get home some.

We had a recent episode where our EHR kept slowing to a crawl just before freezing completely, again and again and again, over several days. A server reboot would fix it, but it’d come back within hours, maybe minutes. My VAR support team finally figured out that a driver needed updating, but we really struggled for a coupla few days there.

Then we had one of our touchscreen registration desk kiosks act up recently…well, actually, it turned out to be the flexible, spill- and child-proof keyboard, but there wasn’t much my 1,000 mile VAR could help with on that one. Seems simple now, but the strange effects of the partially-working keyboard caused a diagnostic dilemma for weeks.

The other day I realized I had been using a poorly finished EHR template for many months which necessitated my rewriting pieces of each note that should have been auto-populated. I waste many seconds every time I have to do that, but during a busy day, who has time to stop and edit a template? Then, by the time the day has beat you into submission, you don’t even remember the little template nuisance when it is overshadowed by the many, much larger issues of the day. You just want to get home…or even just “away.” Thus, the template remains a constant reminder of the inadequate allotment of 24 hours within which to scramble.

As you can glean, the “Musings” title is befitting as I’m really not too focused here on any particular issue. Within some of the other roles I juggle, be they doctor-y or HIT-ish, I have very little time for wistful reflection. Maybe that’s part of the point and maybe that’s what I hope more of the vendor-programmer-developer folks out there will hear:

Being a physician these days isn’t about HIT. It’s still about being a doctor and it is harder than ever. When you sit inside your protected HIT worlds and talk tech-ese with other technophiles, please remember – the peeps you’re trying to serve, for the most part, couldn’t care less about scripting, unless you’re talking prescripting. Keep it stupid simple…and easy to fix.

From the trenches…

“The most potent muse of all is our own inner child.” – Stephen Nachmonovitch

Also posted on HIStalkpractice.com and ModernMedicine.com.

EHR Push Answers “Can We All Get Along?”

2010-06-18T21:10:00.010-04:00

I just returned from a meeting of the OHA (Ohio Hospital Association) which was centered around OHIP (Ohio Health Information Partnership,) the HITREC (Health Information Technology Regional Extension Center) as well as the HIE (Health Information Exchange) developer for the state of Ohio.

After de-acronyming my brain from these and many other much-bandied non-words, I started to debrief myself on all I had just heard over about four hours of presentation and discussion. What I came to realize was pretty doggone cool: this incredibly complex and almost overwhelming task of redesigning healthcare is bringing people together in ways I can barely believe!

Here we have competing hospitals, competing healthcare insurance carriers, competing professional organizations, and competing healthcare docs/providers all talking – and, I must emphasize, talking civilly – about how we can all work together in a very fast time frame to bring some of this much needed change to the entirety of healthcare in Ohio. (Granted, some of this realization comes from other meetings and other conference calls which weren’t focused just upon the OHA, but the truth of the cooperative nature is evident in them as well.)

Way before Rodney King rose to public consciousness, I remember always wondering why my nerd friends (you know, the science geeks who built model rockets, played with amateur radios, and thought chemistry sets were great Christmas presents) and my cool friends (who played basketball, football, kick the can, and just hung out being…well…cool) couldn’t all play together. I mean, really, I liked both groups equally. I really wanted to have both elements at my birthday parties. But, as the years wore on, it became increasingly obvious that geeks don’t mingle well with cools. Always bummed me out.

Leaving my ancient childhood behind and moving into the modern era, I am absolutely in awe of the power that this huge challenge (brought about by the acronyms, HITECH and ARRA) has become such a unifying force, at least here in Ohio, bringing together folks who have been known to work at one hundred and eighty degree odds in past confrontations..er…conversations. I’m not sure all the federal funding in the world could have done this for my nerds/cools dilemma, but, at least for healthcare, it has been almost as motivational as a 9-11 or Pearl Harbor for bringing disparate parties to a mutually agreeable consensus.

Though the healthcare crunch is putting people’s lives in jeopardy every day, I realize equating our healthcare crisis with an attack upon our nation may be stretching it. But, darned if I’ve ever seen anything else, or even heard of anything else, which comes as close to the powerful sense of community cooperation for the common good as what I’ve been witnessing here. It has my sense of snarky skepticism all balled up in almost pie-eyed optimism…and I am in awe!

"Can we all get along?” Apparently, we can…at least for a while.

From the pie-eyed trenches...

“I find nothing more depressing than optimism.” – Paul Fussell

Also posted on HIStalkPractice.com and ModernMedicine.com.

EHRs: It’s Business, But…

2010-06-09T21:51:00.000-04:00

Here we go again! Over the past two years, I’ve discovered a new least favorite phrase: “So, what does this acquisition mean for my EHR?”

I started with Eclipsys’ PeakPractice back in the days of yore when it was Bond Technologies’ “Clinician.” In fact, I was one of their earliest adopters. I lived through the February ’08 acquisition by MediNotes and was a little less “plussed” when later that fall MediNotes itself was acquired by Eclipsys. (’08 became dubbed “The Year of the Acquisitions” by Clinician devotees.) Clinician was redubbed “PeakPractice” by Eclipsys. (I personally preferred “Apollo” or “Solstice” or some other thematically consistent, astronomically-related name, but what do I know?)

Now, about a year and a half later, just when it was really feeling as if the solar dust was settling, here we go again playing “Owner, owner, who’s now the owner” with the Allscripts acquisition of Eclipsys announced this morning. Two to three years ago, I remember talking with some good industry folks about the coming deluge of acquisitions, mergers, and vendor disappearances coming in the EHR vendor world, but, boy, oh, boy, I never thought that lightening would hit my home so many times so often in so short a time!

Over the years, I‘ve grown quite fond of many of the folks behind this product. They have been “berry, berry good to me.” So don’t get me wrong: I’m not looking to bite the hands I feed. (Yes, I remember that I paid them, not vice versa.) But, despite my concerns for both my friends there and for the going forwardness of my current EHR, I’d like to offer a bit of advice to Phil Pead and Glen Tullman. (Maybe I should now alter that billing to Tullman and then Pead.)

Guys, I trust (or hope and pray) that you’re going to do right by Clinician…er…PeakPractice…er, whatever the new Allscripts tag may be. But, I listened to your webcast this morning and reviewed all the web sites and press releases. I understand that public companies have a responsibility to their shareholders and that, even with privately held companies, business is business. Still, we are dealing here with one of the most intimate of issues: people’s healthcare and its delivery. From the small end user’s perspective, I found the preponderance of information about the financials and the relative dearth of information about the actual, specific plans for the healthcare delivery tools somewhat disheartening. Goodness, I could barely even find a reference to PeakPractice in all of the available info. (One slide on the webcast, I think, mentioned it.) If you were selling hamburgers, I wouldn’t much care about the plans for mustard or special sauce. But, having been there before…and before…this has a huge potential impact on my practice, my patients, and what’s left of my general state of mind.

I was really glad to see the attention to the open Helios platform, very forward-thinking, I think. And, from my little viewpoint, I think this whole deal could end up as a good move all round. (He said, hopefully.) But, please, guys, remember this ain’t burgers and fries you’re vending.

Maybe these repeated buy-ups are an indication of Clinician’s strengths. Maybe PeakPractice will acquire some of the better parts and pieces of Allscripts products. Maybe I’m just getting "acquisi-dizzy," but I’d really just like to even out this rollercoaster EHR ride for a while!

From the dizzying trenches…

“Anxiety is the dizziness of freedom.” - Soren Kierkegaard

EHR Data: Privacy vs. Publicacy

2010-06-09T08:21:00.000-04:00

Lately, there’s a whole buncha buzz about on this digital healthcare data ownership versus sharing stuff. You know the issue of which I speak: Dr. Deborah Peel, et al, reminding us that the road to healthcare data integration is strewn with personal privacy landmines galore, and then, the NHINers and other data gatherers, like Jonathan Bush’s athenahealth with their recent touting of “athenaCommunity” as one arm of their mission “to make healthcare work as it should.”

This is a tough one, no matter which knife you use to slice it. On the one hand, Dr. Peel is correct that healthcare data once released to the digital winds is “like a sex tape that lives on in perpetuity in cyberspace.” People, especially us rootin’ tootin’ ‘Mericans want our personal privacy protected at virtually any cost. I don’t think any of us want our personal health histories “Paris-ized.” (Although, Ms. Hilton seems to have parlayed her randy exposure into a personal triumph. Regardless, I doubt that’ll work for any of us if our hemorrhoidal or high colonic histories get similarly YouTubed.)

J. Bush is also on the mark, though. Our personal healthcare information needs to be shared in order to be of value. Gone are the days when you have one doctor who spanks your butt when you’re born and follows you through “till death do you part.” We move, change providers, have multiple providers, use Minute Clinics and ERs – i.e., we roam. It is impossible to fathom our healthcare histories making it in timely fashion to the many destinations we do in any version of the old, tattered, paper chart. (Lord, just try to get a faxed report from another provider during the fifteen minutes you have a patient in your office!)

If we didn’t have such cultural issues as racism, ageism, sexism, and “sicko-ism,” maybe we wouldn’t care who sees our psychological or proctological profiles. If we had fully socialized medicine or if we had complete private pay healthcare sans insurance companies, maybe it wouldn’t matter who got what gross genital germ or mental misfire malady. If you get sick, either we all pay (socialized) or you do (tough break, buddy...thems the cards you’re dealt.)

But, we live here in the land of the free and the home of the individual. We hold our privacy sacrosanct (unless we wanna see what Paris has been up to and then the paparazzi have full sway.) We hold many of our prejudices, and the fears we have about others’ bigotry, nearly as holy. Yet, we also live in the land of the insurers/CMS and the home of McDonald’s medicine. We want our healthcare delivered on demand – done right without needless repetition or avoidable error and with minimal copays.

I was asked to write about this issue by a friend who’s a muckety-muck at a big EHR vendor. I was really hoping I could give him some unique, big toot piece. I’ve thought and thought about it and the wow-ness I’d hoped for seems less like a grand toot and more like an SBD. The eventual solutions for healthcare data privacy versus “publicacy” will be hard-fought and counter-punched for years.

This I know: I have met both Deborah Peel and Jonathan Bush. I’ve listened to each speak on multiple occasions. I like them both and think both are brilliant. I also think both are intimately and ultimately concerned about doing what’s best for patients, providers, and all of healthcare. In this very sticky wicket of personal privacy versus grand communal good, I’m very glad to see both are engaged in this battle, guarding opposite flanks of our healthcare ranks. Our vanguard is well-manned (-womaned.)

From the trenches…

"When it comes to privacy and accountability, people always demand the former for themselves and the latter for everyone else." - David Brin

Also posted on HIStalkPractice and ModernMedicine, June 8, 2010.

Boomers’ Usurpers

2010-05-30T23:08:00.000-04:00

We Baby Boomers have long thought we invented pretty much everything. If we didn’t actually invent sliced bread, we at least identified which side needed to be buttered. From the cultural and sexual revolutions of the Sixties with our hippie dippie, free love, free speech, flower power, no plastic, “Who needs more ‘stuff,’ man?” anti-establishmentarianism to the Eighties’ New Materialism where our mantra did a one-eighty to “Whoever ends up with the most stuff wins” to the New Right, Silent Majority, neo-conservatism, Family Values of the late 20^th and early 21^st centuries, we have always felt empowered to promote “our” values as “the” values.

God bless ‘em, our kids seem to have figured out to ignore our inflated mass sense of self importance.

While computers did come into their own on our watch, the powers of mass social networking were, whether we Boomers want to admit it or not, discovered and developed by our prodigy. They MySpaced out, friended up, and YouTubed down the mighty River Internet. They even seem to have evolved the species with a new developmental feature, TTA (Text Thumb Ambidexterity.)

OK, they blazed the trail, but B.B.s don’t like being out-maneuvered on social movements. So, we’ve jumped aboard the Facebook, et al, bandwagon full force. We’re all a-Twitter as we StumbleUpon Classmates who are LinkedIn to Slashdot and who Digg Xanga as we Friendfeed LiveJournal entries from Bebo that were Tagged on Ning as we Hi5 each other over that Delicious Last.fm recommendation once we’ve Reddit. A study on Pingdom posted in February showed a full 32 percent of social networking site users are undeniable Boomers with another 25 percent of users being from the Boomer “cusp” (ages 35 to 44.)

So, Boomers and their close associates are hitting the Web hard for social interaction. Granted, it’s those Boomer-cusp Middle-Agers (who were 20-somethings when the Web truly hit World Wide “wowness” in the 1990s) who are leading all packs for online sociability. But, they’re kin, not kids, to us full bore Boomers. Together, we account for more social internetting than our tech-brained children.

But, dagnabbit, them young whippersnappers are up to their rascally shenanigans again. After they scooped us with social media savvy, they are now securing their online profiles much more aggressively than we. The recent Pew Research Center report, “Managing Your Online Profile,” finds that Boomers are far more lax about managing their web “face” and less likely to guard their privacy and manage their online security than those 18 to 29 year old rapscallions. How dare they outperform us again!

Well, gang, we better get a grip or these young punks are going to trot us out to the old revolutionaries’ pasture right quick. We need to take heed, secure up, and get our web acts together or they’re going to out-revolutionize us again. We obviously followed the lead of the kids to web-based socialization. It looks like they’re scooping us on the need to look both ways as we cross the Information Highway, too.

Eh? What’s that you say, sonny? I need to watch my healthcare data as it goes digital, too? Clementine, call Dr. Peel…I think I need to have my “privates” examined.

Now, where’d I leave my cane?

From the crotchety, old trenches…

“Civilization is the progress toward a society of privacy. The savage's whole existence is public, ruled by the laws of his tribe. Civilization is the process of setting man free from men.” - Ayn Rand

Also posted on HIStalkPractice and ModernMedicine, May 30, 2010.

A History of the Future of EHRs

2010-05-23T11:33:00.000-04:00

Amid the carved skulls at the great Mayan monument of Tzompantli, a recently discovered hidden chamber revealed an amazing revision to the well known Mayan Calendar which describes the end of the world in 2012. Apparently cast aside for its heretical proclamations, this new Calendar is most impressive for both the time extension it allows humankind as well as the incredible glyphs just now decoded which appear to describe the tumultuous rise of electronic health records and the NHIN, known in Mayan as the MHIN.

For the first time, the heterodox Mayan timeline for the history of the future of EHRs is revealed:

2011 -- Vast turmoil as great masses of people are running willy-nilly under the misplaced perception that EHR adoption is a “do or die” decision.

2012 -- Multiple EHR vendors collapse or are subsumed by larger corporations as scrambling to meet federal guidelines has created near panic in the EHR streets. Many end users struggle with poorly researched EHR purchases and inadequate staff workflow change preparation. In conjunction with insufficient “boots on the ground” support, both in numbers and in abilities, massive installation failures ensue. (Some are disappointed that December 21^st, the predicted End of Days, passes without event.)

2014 -- Numerous HIT-RECs failing as greed, misappropriations, and planning failures waste billions of dollars. The unexpected bailout of the global oil giants diverts most of the remaining funds intended for Meaningful Use success leading to massive global flooding from the tears of the disappointed.

2015 -- The loss of funding leads to great innovation and a torrent of development of healthcare informational tool “apps.” The new ease of use and miniscule learning curves seem to assuage the fears and disappointments of discouraged end users. Massive installation failures abate.

2017 -- The rise of the “Age of Minority Report.” Freeing end users from mice, pens, and smudgy monitor screens, MR-style, floating in air, graphical displays along with air guitar-esque user input methods allow everyone to adopt digital health record technology. Seamless integration into healthcare provision workflows without loss of revenue stream or diminished patient care capacities lead to true “paper-less” healthcare. (The Mayan symbol for this Age looks uncannily like Tom Cruise.)

2019 -- Rejuvenated HIE efforts build upon the foundations of the only three surviving HIT-RECs remaining from 2010. The seeming HITECH debacle seems to have bottomed out and the refocus appears to be gaining momentum.

2020 -- Patients, providers, hospitals, and all sorts of associated players begin to reap amazing benefits from the integration of personalized medicine, advances in genomics, and (finally) a tremendous push toward patient-centric medical care and community-empowered health management.

2021 -- The NHIN (MHIN) reaches true “total integration.”

2022 -- December 21, 2012, brings about the recalculated end of the current b’ak’tun cycle and the true End of Days.

Well, heck, at least we get an extra decade and are granted enough time to see this frustrating HIT thing through to its eventual success!

From the modified Mesoamerican Long Count trenches…

“It's not denial. I'm just selective about the reality I accept.” – Bill Watterson

Communally posted on HIStalkPractice.com and ModernMedicine.com, too.

The Complexities of Stupid Simple

2010-05-17T09:46:00.000-04:00

Trying to follow, no less actually wrap your brain around, what’s happening in U.S. healthcare these days is somewhat akin to trying to follow the rope through the Gordian Knot. Just think about some of the currently running debates, most hotly contested and all fueled by the NOS of the Internet:

· Privacy versus data sharing

· HIT Best of Breed versus enterprise systems

· Payers versus players

· Institutions versus individuals

· McDonald’s medicine versus medical homes

· Evidence-based versus medical art

· Security versus usability

· Etc., etc., etc.

Goodness golly, Nurse Molly, if you have half a handle on even one of these momentous mental jigsaw-like messes, you’ve got more moxie than most. This stuff is just massive…and that doesn’t even touch upon the multitude of subtopics and permutations thereof!

The fact of the matter is, for most of us, whether big brain pan or small, such giant complexities are only conceivable via analogy, simile, allegory, metaphor, or imagery. Trying to follow and make useful sense of all the threads and nuances and twisty-turns will lead to mental meltdowns and the turning on of American Idol.

The difficulty arises when trying to take the pictures within one person’s head and make them similarly visible within another’s. Vulcan Mind Probes may one day yield such seamless data transfer, but until then we’re stuck with words and numbers, pictures and symbols, ones and zeroes. We typically gain and share knowledge linearly, but our minds process it conceptually.

We humans have processed images and concepts long before “communication” via symbols, and even pictograms, came about. A single “picture paints a thousand words” because it transfers information in an easier to process format for our brains, a format for which our brains have been wired for millennia.

Accepting our limitations is by no means accepting defeat. We just need to work within the constraints of our current design criteria. Malcolm Gladwell’s “Blink” is a wonderful explanation of the power within our conceptual capacities belied by our limited communication facilities and meager attempts at linear thought processing.

Thus, I am a firm believer in the power of Stupid Simple.

Stupid Simple is not a simplistic or light-minded concept. Rather, it is the acceptance of the reality of our actual mental processing powers. Stupid Simple is what brings “light bulb” moments. It says, “We are smarter than our communicational clarity capabilities. We can understand far more deeply than the extent of our dictionaries.” Thinking clearly, communicating clearly, is typically an outcome of Stupid Simple.

Look for the Stupid Simple solution and, more often than not, you’ll find answers. Whether it’s how to portray medical info on a computer screen so that it is at its most useful or how to pay for healthcare: the higher the complexity of the explanation, more often, the less the value. Our problems may be deeply intertwined and complex; our best answers most often come from Stupid Simple address.

According to legend, Alexander of Macedonian was confronted by the classic such knotted mess at Gordium in Phyrigia, then a province of Persia. The legend contends that when incapable of finding the Knot’s ends in order to untie it, he sliced through with a stroke of his sword. Historical debate argues he may have pulled the Knot from the pole pin to which it was tied, exposing the ends, thus enabling an actual untying of the knotty problem. Regardless of the exact method of solution, Alexander got one thing right: Stupid Simple rules.

From my stupid simple trench…

“I am dying from the treatment of too many physicians.” - Alexander the Great

First posted on HIStalkPractice.com, May 16, 2010.

Can EHRs or Health Reform Fix This?

2010-05-09T23:20:00.001-04:00

Some things just aren’t right. This one, this one is wrong on just so many levels.

Just after midnight today, very early Mother’s Day morning, I helped a first-time mom bring her too young son into the world. Within a very short period, I also helped her, along with this new mom's mom who had just become a first-time grandmom, deal with watching their brand new pride and joy die.

Too young and too small, at just over 21 weeks of gestation and an exact one pound birth weight, he stood no chance of remaining in our world beyond his birth day, Mother’s Day.

Wrong enough.

Before he was born, I assured mom and grandmom that he would be held for as long as it took for his final heart beat to occur. (It is amazing just how long such a tiny little muscle/organ can continue, far beyond any semblance of life or even blood flow.) I hoped they would want to hold him, but know better than to press the issue. As I have in before – fortunately, quite infrequently – I would hold their son/grandson if they were too overwhelmed or heartbroken.

The mother (at that moment, mother-to-be) was unable to even consider it and didn’t want to even see him. Thankfully, through an agonizing river of tears, mom’s mom said she would hold him.

He came quickly, with full, normal second trimester fetal development, some arm and leg movement, and a heartbeat. He was completely purple from the neck up with tissue paper skin. He was human, but somehow not. He was alive, but not fully. I suppose I’ll never know if he had awareness, on any level.

Within just a few (but exquisitely long) seconds, the only remaining semblance of life was the slowly fading, almost imperceptible tap-tap within his chest. The deep purple became all pervasive. There were no external movements as I finished wiping the blood and birth fluids away. I wrapped him and handed him to his grandmother, her tears almost a torrent.

During the next couple of hours, after his birth mom had been able to come to grips with her sorrow and decided to hold him – which she did right up until I could hear his little heart no more – family and friends, nurses and docs, all of us were moved in Mother’s Day ways we hadn’t could never have imagined.

The “Time of Death” was officially marked, the funeral home director was called, and the process of healing began for all of us.

Even when I was speaking to my obstetrical colleague and friend just before midnight as he told me the introduction to this Mother’s Day calamity, even as I was driving to the hospital wondering about the heart wrenching trauma to come, even as I walked away from this family I had never known and with whom I had shared one of their most intimate of family moments – through all these, I never once thought about charging for my services. I know it isn’t, but it just feels so, so very wrong.

But, as he had an official “Time of Birth,” he had to be officially admitted to the hospital. His departure was also an officially marked institutional moment. The hospital needed to bill for all they provided, sure. It just didn’t seem like I had to.

But, I remembered I am contracted with insurance companies. Those contracts state I am not allowed to charge anyone any differently (including, not at all) for any service. I am obligated to charge everyone I see just exactly the same for similarly provided services lest the payers fine me handsomely.

I am obligated to charge this family. Wrong. Just wrong.

They paid dearly enough this Mother’s Day.

From deep in the trenches...

"Sweet little flower of Heavenly birth, you were too fair to bloom on Earth." - Author Unknown

The Call

2010-05-07T02:48:00.000-04:00

Recently, I read a piece on the value of nurses written by a friend for whom I have tremendous respect. I completely agreed with his:

“The only critical people involved in patient care are nurses…Not too long ago, a hospital was basically a clean building in a peaceful setting (!) where patients could rest and mend. That and nurses were about all anyone needed. Hospital work was charity. No MBAs, no arrogant doctors, no government red tape, no formulary of 5,000 drugs, and no cadre of specialists making large salaries to do small tasks. Oh, and by the way, no computers either. You know what? Life expectancy wasn’t that much different (if you exclude the benefits of vaccinations and reduced infant mortality.) Costs were a lot lower. No one got rich in healthcare. Without all the research, the computerization, the fancy architecture, and the lack of John Wayne "I will not let this patient die" heroics, things weren’t really all that much worse when it came to living and dying.”

Agreed, that is, until now.

Right up until I got The Call.

Most of you will never get The Call, thank God. The Call can really suck.

The Call is one physician, usually a specialist, taking time to call another physician about special concerns they have regarding a mutual patient’s diagnostic or prognostic situation. The Call is made when it is deemed especially important to relay difficult-to-address issues as clearly as humanly possible. The Call is made when there is a significant dilemma or a suspicion of grave outcome potential. The Call trumps the consultant’s follow-up letter by several orders of magnitude.

The Call is intended to be a kindness, a professional-to-professional reaching out and respect. It is meant to help relay health information at a deeper level. It is medico to medico speaking very frank medical-ese, uncouched and direct.

The Call is OK, even helpful, when it helps you understand more clearly how to best counsel or treat a patient or parent that is facing a more difficult or a more complex or a higher-degree-of-chance-for-negative-outcome medical issue.

The Call has its sucky side, because it means someone you know, someone you help care for, has a more complicated problem.

The Call completely sucks when it is regarding your own child.

…

Right now, it is highly trained specialists and some high tech diagnostic and surgical tools including certain computer technology which stand between my youngest son and a lifetime of pain, suffering, and the disfigurement of his beautiful little face.

I love nurses and I fully “get” their value. But, right now, after The Call, I have a completely different take on the value of John Wayne.

Today, from the father, not the trenches...

"My grandfather always said that living is like licking honey off a thorn." - Louis Adamic

EMR Mythbusters

2010-05-02T11:08:00.000-04:00

Last autumn, at the annual meeting the Ohio Chapter of the American Academy of Pediatrics, I had the tremendous good fortune of giving a talk in tandem with Dr. Andy Spooner, CMIO of Cincinnati Children’s Hospital Medical Center.

I’m not sure I’ve ever felt that being asked to give a talk was a blessed event, but this one broke the mold. Perhaps it was the topic, perhaps it was the meeting, but most likely it was the partner, Dr. Spooner. (I like to think maybe it was a mutual camaraderie and synergism, but I’m pretty sure Andy deserves most of the credit!)

We had been asked to sit on a panel discussing “Technology in Pediatric Practice.”This morphed from the panel to just he and I discussing some of our favorite rumors, half-truths, and misconceptions about EMR adoption and use. We borrowed/adapted the title from one of my favorite geek TV shows. (Props to Jamie, Adam, and all the gang at M5.)

There was a pretty good-sized crowd and the talk seemed well received. Audience participation was enthusiastic and, afterwards, folks asked us how many times we’d done this before, if our “routine” was fully scripted, or if we might be taking this on the road. (“First time”, “complete ad lib”, and “our agents are taking a meeting on it”, respectively.)

I think what made it so enjoyable for me was the lack of formality and the easy give-and-take rapport between Andy and I. Plus, it was an interesting tête-à-tête: his CMIO, larger center experience and my small practice, trench gruntness. Perhaps most significantly, Andy’s just a very fun person despite his brilliance and a curriculum vita that’s longer than most PhD theses.

Anyway, I bring this up here because we were asked to record our EMR Mythbusters talk for Nuesoft’s Monthly Podcast Series and it was just recently posted. With loads of providers still considering EMR adoption and trying to fathom our brave new healthcare information technology (HIT) world, especially with the nitrous boost currently being injected by HITECH, maybe you or someone you know might enjoy a sort of fun look at some of the HIT issues we’re all facing.

Warning: It is a retake of the full meeting version, around fifty-three minutes. You may want to bring some popcorn!

From the trenches…

“The first myth of management is that it exists. The second myth of management is that success equals skill.” - Robert Heller

Addenda:
1) Neither Andy nor I have any financial relationship with Nuesoft.
2) There’s a bit of a volume level change several minutes in.
3) Voices recorded on separate stereo channels; mono headsets may miss one channel.
4) While we’re both pediatricians, very little of the talk is pediatrician-specific.

Similarly posted on HIStalkPractice.com, May 1, 2010 and on ModernMedicine.com, May 2, 2010.

Intelligent EHR Help

2010-04-24T16:17:00.001-04:00

Many, if not most, of you reading these pages are already EHR savvy. You have either struggled through the process of swapping your trusty old pen and paper for some version of digital data collection or else you’re on the side of the suppliers of the necessary paraphernalia for HIT. While I hope you’ll enjoy this post, I really hope you’ll consider sharing it with one of your friends or colleagues who aren’t yet on the electronic bandwagon.

For those providers out there who’ve made the switch, remember back to the Days of Decision? (Maybe that should be, Days of Indecision.) Remember all the hours of frustration spent just trying to find out what information you needed in order to even begin to figure out what sort of system might best suit your needs? Remember when “you didn’t know what you didn’t know” about EMRs?

For the vendor folks out there, how much more valuable would a potential new client be if they were fully prepared to make the switch to an EMR? Wouldn’t a medical practice that had all its ducks rowed up be much more likely to have a successful install, one that doesn’t revert to the dreaded “Failed and De-installed” file?

If we’re honest with ourselves, there’s no such beast, yet, as a perfect EMR. They all have issues and areas of weakness. But, it isn’t the “not ready for prime time” phenomenon that derails many installations. The main circuit breaker to blow, preventing many, if not most, successful transitions from pen and paper to digital seems to me to be lack of adequate preparation and support.

So much emphasis has traditionally been placed upon EMR/EHR selection. If more practices were adequately prepared for the gigantic operational switch that is to come with an EMR, then failure rates would fall and purchased systems sitting on shelves collecting dust would be less frequent.

Of course, larger centers and institutions have IT departments, educational staff, and committees ad nauseam to assist in the preparatory process. (Some still don’t prep up very well.) But, smaller practices, where the vast majority of healthcare in our country is delivered, have no such support teams to task with these time-consuming chores. A doc or two, perhaps an office manager, is saddled with taking on the tremendous task of trying to determine what their little organization needs to get “digified” and then must sift through scores, hundreds even, of available products.

Consultants are available and can provide the help needed, but they are often somewhat beyond the means of smaller practices. This is especially true if a practice needs “full service” planning, selection, and negotiation assistance.

EHR selection tools are available, and I personally like several of them, but their roll is more limited, their focus being upon the actual selection of an EMR or EHR.

But, as many of us can attest, the planning portion is often the key element in successful EMR adoption. Poorly done, it can sink the most enthusiastic advocate’s plans. Taking the time before implementation to define the practice’s current situation, determine how key workflow and staffing issues will be altered, delineate technology needs, and calculate capital requirements can dramatically enhance the opportunities for successful EMR implementation.

This, however, is very tough to do when you’re busy taking care of patients and meeting the day-to-day demands of a small business. That’s why I got very excited when I discovered a new tool designed to fill this need, one that is both affordable and considerate of the needs of a small practice.

Having already implemented our EHR, I can’t bear first hand witness to this tool’s full prowess. I did convince the developers to allow me access to their web portal, a key component of the product, which gave me a deeper view than just a demo or white page. From this access, from my personal past experiences, and from the innumerable conversations I’ve had with colleagues seeking to demystify this digital dilemma, I can say that it appears to fit the old bill of “just what the doctor ordered.”

They have consolidated a ton of information, organized it into guided steps and phases, and built, essentially, a correspondence course for EHR preparation and eventual selection. It is a “hand holding,” but in the very best sense. Getting started with figuring out what you need is a huge hurdle; having an affordable tool to assist you in starting the race on the correct foot is huge. This product provides guidance, helps you find and organize the information you’ll need, and know what work within your own practice is necessary.

Not insignificantly, this particular instrument also includes real, live consultants, vetted by the MGMA, to assist with the inevitable questions and unique practice issues. Their time is used more efficiently as much of the legwork is done via the guided “homework” laid out in the online program. Additional consultant time is available, for an additional fee, if required. There’s even a higher end version where you can have the consultant act as the complete project manager.

The developer of this “homeschooler tool” is has their eye upon profit, to be sure. However, at the proffered price, they obviously aren’t going to ring any big bells at the NYSE from this product alone. The motive, which isn’t hidden or obtuse, comes from enhanced connectivity: the more digitally connected a practice is, the more likely they are to seek digitally-connected tools. Thus, Welch Allyn – you know, the folks whose name is probably on the otoscope you use every day – saw fit to try and assist practices with EMR adoption by developing their “EHR Prep-Select Program” as they now have a passel of products which you’ll only want if you’re down with things digital.

In preparing this piece, I Googled and Binged about a bit. There may be other such tools available, but I wasn’t able to find anything similar. Actually, the landscape doesn’t appear all that different from when I first began my EMR search earlier this decade. There’s lots of information to be found, but sorting through what is necessary and valuable for me and mine versus what is salesmanship and schlock appears just about as daunting as ever.

Having a full-time, industry-savvy consultant help walk you through this morass would, obviously, be preferable. Larger groups and institutions are well-served by such professional guidance. Even I used one for my final contract negotiations and was very satisfied with both the cost and the service. But, as a solo doc, I would never have been able to afford the five figures it would have run to engage a consultant for full preparatory planning. Such a tool as this, though, appears to be a “next best” option at a fraction of the price.

I have absolutely no desire begin the process again myself – believe me! – but I can say with unequivocated assuredness that, if I were, I would absolutely consider such a helpmate. The time savings alone would be well worth the investment.

By the way, if anyone knows of similar tools or services, I’d really appreciate hearing about them.

From the trenches…

“The rule is perfect: in all matters of opinion our adversaries are insane.” - Mark Twain

Dually posted on HIStalkPractice.com and ModernMedicine.com, April 24, 2010.

The Smartphone EHR Hoverboard

2010-04-17T10:00:00.000-04:00

Back in the heyday of hard copy Popular Science magazine, you could always read about the exciting future we were going to have. In the 21^st century, we’d all be commuting with personal jet packs or George Jetson flying cars, talking via videophones, and taking our “walks” on hoverboards.

Well, here we are in 2010, but few of those predicted ubiquitous gadgets are commonplace in the modern American home or garage. Regardless, I’d like to follow in Pop Sci’s famous footsteps and offer a prediction for the next great EHR, the “Smartphone EHR Hoverboard.”

The most notable features of the Smartphone EHR Hoverboard include:

· Mobility: the device will be as easy to carry as a current day smartphone.

· Functionality: everything a “smart” device should be, phone, email, text, Tweets, web, games, schedule, To Do tasks, music, pocket T.V., personal vibrator, and an easy to access and easy to use EHR built from multiple, end user-chosen apps.

· User Interface: touchscreen, flip out keyboard, voice recognition, air mouse, and see below.

· Smart Tools: Bluetooth, WiFi hot spot, high def video and still camera, bar code scanner, and genetically-specific personal pheromone detection user proximity login/logout security.

Now, as to the screen: this is one of the biggest drawbacks to current smartphones, limiting real EHR mobility. It is their “rate-limiting step.” Nobody wants to do full-scale web tasks, document authoring, or video viewing on a four inch screen. It’s nice we have what we have for now, but we all know we need a better view port for our mobile ocular comfort. Undoubtedly, “Minority Report”-style mid-air projection and “air touch” input will come, but I predict an interim step that is actually doable, or nearly so, today.

The next smart step for smartphone video displays will be an offshoot of the flip-out keyboard. Instead of the keyboard sliding out, the video display will slide open, perhaps as a fanfold, a rollout, or multi-fold pop out, to become a full blown 9 to 12 inch video display rivaling or surpassing the iPad’s. High def, touch sensitive, and durably flexible, this display will provide the full, beautiful end user experience of the iPad while empowering the web power of the Droid, the sturdy business backbone of the Blackberry, and the Zen Master design of the Palm Pre.

Flip it out for your patient work, pop it back in to hit the road to the next hospital or house call, and all the while you’ll be wondering how you ever put up with a crummy 3.7 inch display or what happened to those clunky old laptop PCs.

OK, so I lied about the hoverboard component. That’s still a toughie, but have you seen the Scarpar? Maybe, if the flip-out display could be strong enough…

From the trenches…

"Never bored on a hoverboard." - Scott Westerfeld

Sir Don and the CMS

2010-04-16T17:06:00.000-04:00

The pediatrician in me says, “Wahoo, one of us!”

The primary care physician in me says, “Yeah, someone who believes in reinvestment in general practice and primary care and that reimbursement should be based upon value, not volume!”

The small community advocate in me says, “Cool, a guy who believes in strengthening ‘local health care systems – community care systems – as a whole.’”

The doctor-geek in me says, “Yes, I like a healthcare leader who isn’t focused upon the technology; the tools need to return to where they belong, in the tool chest, not as the centerpiece of health care provision.”

The patient in me says, “Wow, his primary focus, keeping the patient at the ‘absolute center’ of the health care system, is heartening.”

The pragmatist in me says, “OK, he has some experience running a large bureaucracy, but nothing as huge as CMS. Maybe that’s not such a bad thing given the brain sludge which often accompanies those who become too mired within bureaucratic traditions.”

The worrywart in me says, “Well, perhaps the critics correctly warn that his propensity for idealism over EBM (Evidence-Based Medicine) needs tempering.”

The empathist in me says, “Sir Dr. Don Berwick has one helluva mantle to shoulder at CMS. Congress, insurers, lobbyists, lawyers, HIT vendors, providers, patients, and, of course, the entire healthcare blog world will all be nipping at his hide. Hope his is thick enough.”

From the trenches…

“A true knight is fuller of bravery in the midst, than in the beginning, of danger.” – Sir Philip Sidney

First posted on HIStalkPractice.com, 4/10/2010.

Going Full Blown EHR Sorta Sucks

2010-04-03T11:16:00.000-04:00

After such a title, please know this up front: I love my EMR…most moments of most days.

What I don’t love, not in the least little bit, is changing how I go about dealing with everything related to patient care information capture, manipulation, and sharing. Converting from a tried and true workflow that has allowed me to provide the best care I’m capable of providing (at least, that’s as true as it could be with paper-based data) to processes that feel foreign and kludgy and downright odd sorta… well… sucks!

After spending our formative years learning how to navigate paper and penmanship (deterioration of the later aside), we are now challenged by the transformation to an almost entirely different way to manipulate our information. Further, it isn’t just how the data goes from brain to storage; it’s how that info is accessed, viewed, and managed.

Sure, we (my staff and I) have all been using computers for a while now (from 3 to 40+ years,) but none of us were even remotely prepared for the overwhelming shift in processes and the enormous learning curves we encounter by going medically electronic.

I’ve tried to think of a comparable or analogous change. Changing how we do banking, changing how we access news and gossip, changing how we buy and window shop, changing how we research and do schoolwork, changing from viewing three television channels which closed shop at 2:00 A.M.to a bazillion — all of these were virtually effortless. We all do all of these things now, even though we weren’t “skillsetted” with them in our youths. None of them seemed like a mountainous climb.

But, changing from free flow data capture, be it for SOAP notes or lab orders, via the familiar pen and paper format to the seemingly simple point-and-click tech of a PC has been, without question, the greatest challenge of my life. (OK, aside from raising kids, maintaining a healthy marriage, dealing with cluster headaches, and remembering to put the toilet seat down, that is.)

It isn’t just how the data goes from head to storage — it’s how everything gets accessed, viewed, shared, and integrated into pre-existing mental categories. My synapses have been strained beyond their original design constraints trying to establish new neural connections and pathways for this completely queer new work style.

I hope I’m not alone when I admit to being exhausted by “change management.” Back in the “pre-EHR days,” it was really easy (relatively speaking) to go to work, see patients, and deliver myself home at the end of the day with some smidgen of energy reserve. Nowadays, my serotonin and dopamine stockpiles are so depleted that I barely have enough left over for fêting my youngest son’s latest fourth grade feat or catching a chuckle from my wife’s current chef-challenged concoction.

Why put myself and my longsuffering staff through all this? Simple. Because, as I said up front, most moments of most days, I absolutely love my EHR. I am daily astounded by the new capabilities I am gaining to deal with data. The upside usually outweighs the downside. It is, without question, worth it.

However, that doesn’t mean this transition time doesn’t sorta suck. It does, big time.

From the trenches…

“Always be yourself…unless you suck.” - Joss Whedon

First posted on HIStalkPractice.com, March 31, 2010.

EMR: Smaller Office, Longer Road

2010-04-03T11:03:00.000-04:00

What’s the absolutely, positively worst thing about converting to an electronic medical record? A few guesses:

Workflow disruption, redesign, and the general suckiness of changing all you know?
Template building and its inherent drudgery?
Loss of income from the reduction of patients seen as you relearn all your tasks?

Nope, nope, and nope.

The absolutely most dreadful part of adopting an EMR or EHR, even if it is a great one with tons of bells and whistles (and, perhaps, more so if it has tons of bells and whistles) is the ever-present knowledge that you aren’t even scratching the surface of this high tech tool’s multiplicitous talents.

Sure, I hate all that other yucky stuff mentioned above. Change is hard, templates and vast amounts of “clicky-clicks” aren’t fun, and, especially as one of medicine’s bottom feeders, income-wise, any pediatrician will tell you there just isn’t much room to tolerate revenue reduction.

Despite the gazillion and one well-documented difficulties with EMR adoption and despite the many, many times I’ve almost yanked the server up from its alternating current roots and sent it flying from one of our second story windows, I continue to be amazed, almost daily, by the tremendous tools I now have within my digital arsenal. But, therein you’ll find the source of my digital dismay.

In a small office (now with two, count ‘em, two, docs and six full or part-time staff) with no IT department (except me) and no education/training division, by far and away the most difficult part of transitioning to an EMR has been, and continues to be, finding the time to learn all about the tricks behind the tools we now possess.

It is sooooooo frustrating knowing we have the abilities to do so much more with what we have. I know we’ll eventually get around to many, hopefully most, of them. But, after a long day deciding how to keep asthmatic kids breathing in smoke-filled homes, deciphering the cryptic histories we often receive, deducing which weird rash we now face, and defending against the latest delay tactic of (fill in the blank) insurance company in preventing payments for services rendered, it’s really, really hard to justify more time away from home and hearth to decode another piece of our enormous EMR puzzle.

Yes, the training manuals are available online, and yes, my support peeps are really good and really friendly, but I want to be able to do this stuff NOW and my daggone limited brain and that stupid only-24-hours-in-a-day limitation are putting up roadblocks to my EHR happiness! (Delayed gratification, be damned!)

Alright, reality bites and I know we’ll get to all that good stuff just percolating away on my servers, waiting for our impending moments of discovery. I just wish my resources — time, brains, personnel — weren’t so “small office confined.” I suppose this is just one of the prices I pay trying to bring big city medicine to my small town and our small practice. Being a small business has its perks, but it sure has its pains, too.

From the (frustrating) trenches…

“Those are my principles, and if you don’t like them… well, I have others.” – Groucho Marx

First posted on HIStalkPractice.com, March 20, 2010.

“HOST YOUR EMR LOCALLY!” the Web Yelled Today

2010-04-03T10:52:00.000-04:00

Here I sit, typing away between patients, grateful that we haven’t had to yank the old pens and papers from their dusty shelves. We’re still seeing patients, still point-and-clicking away, capturing data and making appointments with ease, but not because we’re just so darned connected. Actually, we’re not.

I just got off the phone with our high speed DSL provider, a company with whom I’ve been well-pleased these past four years. After the expected interminable on-hold time, I was told by the very first rep with whom I was connected that she had just received word of a large area problem affecting our service. We had been issued a “Level 4” status (as if I’m supposed to know what that signifies) and the repair worker bees were busy getting to the problem. “They have three days to correct the problem,” she told me.

Not knowing just exactly who had granted them those three days and uncertain as to what little old me could do if the problem persisted beyond the allotted period, I gratefully thanked this pleasant rep, realizing she was just another worker bee who had no more she could offer. (She was likely on her way to many more calls about the very same issue and I didn’t envy her at all.)

Four more patients seen and digitally scribed since that last paragraph, four more who won’t need to have their info re-entered at a later time nor scanned in and, thus, essentially worthless, digitally speaking. Seven patients scheduled for follow-up or for a new appointment, work which won’t need duplicated once we rejoin the Web. In the meantime, the ISP home page which I had opened twenty minutes ago is about two-thirds loaded. (Dialup was never so slow.)

My EHR is Web-based. We could have gone the ASP route. Personally, I love the “cloud” concept and see real value for many “softwares” as a service. But, perhaps it is the geek in me who wanted his own servers, perhaps I’m more of a control freak than I care to admit, or perhaps I just knew I’d be happier with locally hosted speed and reliability. Any which way, I chose to host at home and, especially right now, I’m really happy with that decision.

Full disclosure here: Yes, we’ve had problems with our servers. Yes, we’ve had down time from RAID failure. The difference, and why I’m still a fan of local hosting for our purposes, is that when those occurred, I had some control. I could call for help, boots on the ground, and see what needed to be done, swapped, or replaced. Today, I just sit and wait while the worker bees are hopefully buzzing their way to the honeycomb cell which is the source of our hive’s disruption. I have no clue if three days will pass without being hotwired to the Web. Hector’s pup, I can’t even get my daily news jolt! That’s almost as bad as a lack of coffee. (Maybe I want to restart my daily newspaper subscription?)

Interestingly, Google searches still work like a charm, fast as ever. Score one for the cloud. Still, I’m listening to the Web yell, “Keep your hosting local!” while I handwrite another prescription that I am unable, today, to e-prescribe.

From the trenches (wondering when, or if, this will get through to the Web)…

"Who cares about the clouds when we’re together? Just sing a song and bring the sunny weather." – Dale Evans Rogers

First posted on HIStalkPractice.com, March 16, 2010.

EMR. Cart. Horse.

2010-04-03T10:05:00.000-04:00

Outcomes and quality reporting and meaningful use – cool.

I mean, really, is there a doc out there who doesn’t think improving patient outcomes or obtaining and sharing useful data or using any tool in their arsenal “meaningfully” isn’t just plain, old, common sense, good stuff?

However, all these sound just about as logical to a physician as “you need to eat your vegetables” sounds to a child. Sure, we all want to grow big and strong; we get that. But, if the veggies don’t taste good, if they aren’t presented in an eye-friendly way, if they make a medical practice “gag,” how many docs are going to be enticed to “eat what’s good for them?” Seems a lot like trying to inspire six year olds to eat plain Brussels sprouts.

What started out in with Dr. Larry Weed taking his POMR (Problem-Oriented Medical Record) and SOAP Note brilliance and extending it to digital “data acquisition and retrieval systems” which would extend the brains of physicians helping them make more accurate diagnoses and more effectively deliver “proper care” has gotten completely kerflobbled.

Instead of using computers to do what they do best in helping medical care providers do what they do best, we have skipped right over the logical progression that the good Dr. Weed envisioned some 40 years ago. We wonder why we are now trying to figure out why HIT isn’t being devoured by doctors. We’ve placed a plate of barely warm Brussels sprouts before the healthcare child; now we’re trying to bribe and even threaten punishment if he doesn’t eat.

Instead of keeping the healthcare provider providing healthcare and extending his mental powers onto peripheral brains with tremendous storage and retrieval strengths, we’ve twisted the focus toward turning doctors into mere data input devices. Instead of empowering physicians, we’re eviscerating their strengths and training and minimizing their cognitive clout. Instead of using digitization to maximize our doctors’ capacities, we have seen it used to detract from their mission and delimit their mentations.

In 1997, Larry wrote:

“The meteoric shower of medicine’s scientific achievements can overwhelm a doctor’s mind. A patient has no assurance that his or her doctor is able to take into account all relevant scientific knowledge and integrate it with detailed data about the patient’s own condition. Yet few doctors, patients, or policy makers recognise that modern information tools can become the loom for weaving these two bodies of knowledge into a fabric. In fact, few recognise the dimensions of the problem.”

Recognizing “the dimensions of the problem” and righting the course we now follow won’t be easy, by any means. But, at least for the foreseeable future, computers won’t be able to make the myriad of associations and subtle nuance recognitions required for accurate medical diagnoses on a per patient basis. The brains of our healthcare providers still outshine the petafloppiest supercomputer.

You have a chance of getting a child to eat Caramelized Brussels Sprouts with Pistachios and Red Onions just as you have a real chance of broad EMR adoption if you present something attractive, tasty, and “good for them” if you keep the focus upon enabling doctors’ strengths, not detracting from them.

Before we start reporting, measuring quality, and worrying about outcomes, how about we enable the doctors’ mental machinery and figure out how to make their data capture requirements unrestricting of their abilities to continue to care for us as we go about gathering enough data to meaningfully use?

From the trenches…

“It is the good horse that draws its own cart.” – Irish Proverb

Originally posted on HIStalkPractice.com, March 12, 2010.

OHIP - The Ohio Health Information Partnership

2010-03-06T12:09:00.000-05:00

For those who haven't heard, the Department of Health and Human Services awarded nearly 1 billion dolllars in ARRA monies back in February to help advance the adoption of HIT. The monies are provided to help states establish HIEs (Health Information Exchanges) and RECs (Regional Extension Centers) to assist with implementation, training, and support.

Ohio was lucky enough to receive two REC grants: one for Greater Cincinnati Healthbridge, one of the few real success stories in the world of HIEs, and one for OHIP (the Ohio Health Information Partnership) which is a private-public partnership jointly organized by cooperation among several entities, including BioOhio, the Ohio Hospital Association, the Ohio Osteopathic Association, the Ohio State Medical Association, and state government.

OHIP received the largest of these 32 REC grants, $28.5 million dollars. This is due to a tremendous amount of effort upon the part of the planners, but also it is a recognition of their unique and insightful approach. You can read more about OHIP at their web site: OHIPonline.org.

This week, I agreed to serve on the working group for this project, OHIP's REC Committee. I am honored and excited by this challenge. I'll bring my small community and private practice perspective to these discussions and hope to provide a view often overlooked in large scale HIT considerations. Most importantly, the responsibilty of using that money - mine and yours - wisely will remain paramount for me.

I believe in transparency and open collaboration. I believe the good folks behind the OHIP initiative do, too. I will seek their blessing for keeping a dialogue running here about their progress (with appropriate discretion, of course!)

From the trenches...

"Patience and perseverance have a magical effect before which difficulties disappear and obstacles vanish." - John Quincy Adams

Meaningful Views

2010-03-06T11:35:00.000-05:00

“Meaningful Views” is a grand conglomerate term (not to be confused with the “Meaningful Ewes” from a prior posting.) It encompasses graphical user interfaces (GUIs) and workflow efficiencies and the minimization of “clicky-clicks.” (Props to Jonathan Bush for that term; it says so much in such a cutesy, snarky way!) Meaningful views are something we all seek, every day, whether via digital dazzlery or paper and pen.

Consider the ultimate goal of medical information: to lead to better heath. My goal, as a physician, is to help my patients lead better quality lives via better health choices and illness management optimization. To accomplish this goal, I need to: obtain data; aggregate, assimilate, and evaluate that data; add interpretive value to that data; and deliver the data’s meaning and true usefulness to the patient. Whether it needs to come from the patient, from a lab test or radiology exam, or from a textbook, professor, colleague, or website, the data I need to digest must somehow be “viewed” in order to be shared and used.

While auditory “viewings” of data are important, more and more in our modern world we are turning to visual information sharing portals. Televisions, faxes, lab/radiology printouts, computer screens – these are increasingly diminishing the verbal-auditory transfer of information.

The exponential growth rate of medical knowledge has long ago exceeded the mental capacity of mere mortals. Thus, how data is presented has become increasingly pressing. We need data views that facilitate our data comprehension. If we were not mere mortals – and perhaps the ultimate goal of all this techno-data-collaboration is to allow this – we could share knowledge via some form of Vulcan mind meld or Borgian collective consciousness. Until that time, in order for us to share the information we seek or need, the presentation of that data must improve.

Face it: we all only have so much time in a day. We need data delivery which is as fast as possible, as efficient as possible, and as easy to assimilate as possible, because we have a lot of things we need to do with that data. Personally, I also want to get home to see my family on occasion. (OK, I also want to have time to catch the latest Mythbusters.)

I want data “views” that make sense. I want data views where I have to do as little as possible to assimilate said data. I want views that allow me to do the things I really want to do, not views that require me to alter what I do in order to accommodate the viewing. If I have to learn how to view the data, if I have to work to visualize the data because it comes in a difficult format, if I have to constantly seek the data I need because it comes in non-standard views, then the data viewing becomes a barrier to my goals.

Workflow efficiency is enhanced by standardized patterns. In my office, for example, each exam room is set up identically and all of the necessary supplies are stored in identical locations within each room. I don’t have to spend any mental energy deciding which room I’m in and where the tongue blades are stored. I can spend that energy thinking about and talking with my patients. It’s little, but it adds up.

When I seek data from a lab report or from a radiology report or from the exam notes of a previous physician, you know where most of my time is spent? Yep. Looking for the data I need. Why? Because the “view” is either non-standard, sub-standard, or, sometimes, flat out crappy.

I recently learned of an initiative to provide cross-platform standardization of laboratory data. This means that whenever I look at a lab report, from whichever institution or provider or EMR or HIE, the data is presented in a regular, logical, and consistent format. The “view” is optimized. Time is spent in understanding the data, not in finding the data. (If you’ve ever had a new lab reporting system thrust upon you where you had to relearn where to look for lab data in the new system’s report forms, you’ll understand). If you can easily see it, you can use it. If you can easily see it, you won’t unnecessarily repeat it. If you can easily see it, you can make meaning from it.

Meaningful use, in my humble opinion, should always revolve about what helps us help patients. Help me spend less time looking for what I need, help me focus less upon data entry functions and clicky-clicks, help me make better decisions for helping more people faster, help me get home to see my wife, sons, and Survivor more often – that is meaningful use for a trench grunt. This standardized look for lab reports, one form of “meaningful views,” would be a great step in that direction.

From the trenches…

“Know where to find the information and how to use it. That’s the secret of success." - Albert Einstein

Dually posted on HIStalkPractice.com and ModernMedicine.com, March 3, 2010.

While the Gettin’s Good

2010-03-03T09:39:00.000-05:00

Here I sit, 6:10 AM, leaving the 2010 HIMSS conference, riding the shuttle toward Gate D25 here in ATL. (Typing that, I feel like Kenny Tarmac; respects to “The Bob & Tom Show.”) As I write this, I realize how freakin’ psychic I am, planning to leave just after one day of show. Not because of anything related to the HIMSS event; rather, because the last time Atlanta had a half an inch of snow, I was speaking to a friend there who was just about in a panic, as was pretty much the rest of lovely Atlanta, at the sight of frozen water. Wouldn’t you know, after arriving back at the hotel last night after a phenomenal HIStalk reception and excellent Eclipsys party with the still-spectacular B-52s, the local newscasters were abuzz with the news of, yup, snow.

Two to three inches was being forecast to hit starting just after my departing plane arrives safely away in Charlotte. Now, being from the frigid north, this piddly dusting doesn’t begin to worry me. However, if a half an inch frightens Atlantians into rolling up the sidewalks, I can’t imagine what enough to cover their shoe tops might do.

My post-HIMSS first-to-mind thought? As a mere grunt from the small town trenches, you might think the colossus into which HIMSS has morphed might be overwhelming. Would be, I suppose, if:

a) I hadn’t been watching all this HIT hubbub bubbling away for over a quarter century;

b) I didn’t know a bunch of really good people involved in this work who attend HIMSS who;

c) Keep introducing me to even more really good people.

Speaking of really good peeps, perhaps the most intriguing – and, perhaps, telling – comment I heard this year came from Pat Downing, one of those nice folks met via another nice folk. Pat, originally from Maryland, has now lived for over ten years in Thailand - Bangkok, to be specific. He’s the original brain behind what has since become Microsoft Amalga. Not being daily immersed in the U.S. HIT world, he notes how his infrequent visits allow a unique perspective upon what’s the haps here when he does make the rounds at HIMSS. This year, his take was disturbing, if not downright ominous.

To wit (paraphrased): I always find that walking the periphery of the HIMSS exhibit hall(s) gives me a view for the new, the innovators, always positioned around the outskirts of the show, those small guys who are bringing along the next big “pops.” This year, though, nothing popped.

Maybe it’s the scramble to address “meaningful use” (whatever that truly is.) Maybe it’s the ARRA funds which seem to have stalled - at least temporarily - the EHR purchase decisions of many potential adopters. Maybe we’re just out of idea men and women who can even pretend to wrap their minds around this ginormous, dysfunctional beast we call healthcare here in America.

But, maybe, just maybe, it’s the lull before the next great storm of disruption which will actually engage the masses of healthcare providers into actualizing the real horsepower of IT. Not technology for technology’s sake, nor technology for the sake of a carrot or the threat of a stick, but technology uptake based upon technology which excites and enthralls, technology which needs no incentives other than its own inherent value. Sort of like my palm Pre. (OK, sort of like the iPhone for the rest of you.)

The fun of the HIStalk reception still lingers, so I’m going with the latter, glass half full possibility. (Plus, I thought I saw some pretty cool things, especially as relates to mobility and decreased "proprietary-ness.")

Best of luck with the “blizzard,” y’all.

(On my way back to where I’m) From the trenches…

“The optimist proclaims that we live in the best of all possible worlds and the pessimist fears this is true” - James Branch Cabell

Hi Ho, Hi Ho, It’s Off to HIMSS We Go

2010-02-27T10:36:00.000-05:00

The setting: Outside of a small, storybook cottage in fairy-tale woods.

Camera zooms in, from a group of frolicking woodland creatures, through a too-cute cottage window to the hand-carved, kitchen table where four elfin men sit sipping steaming mugs of morning blend.

Sleepy: (yawning) I just can’t seem to get excited about this whole HIMSS thing.

Happy: What!?! How can you say that? This will for sure be one of the best events ever!

Doc: I concur. Not only is the whole country abuzz with HITECH fever, but the world is watching to see if the U.S. can actually mend its fractured and dysfunctional healthcare system, especially the informational component thereof.

Dopey: Hyuck, hyuck. I never quite know what you’re saying, Doc, but it shore sounds fancy!

Grumpy: (walking into the kitchen with a gruff and grumbly tone) You fellows never let a guy sleep in!

Happy: (with just a tad too much cheeriness) Good morning, Grumpy! Aren’t you excited about our trip to the big city in the land of peaches and Coca-Cola? Even you must be keyed up with all of the hubbub surrounding ARRA monies and HIT investment that’s brewing.

Grumpy: Harrumph! I most certainly am not. I don’t think those promised dollars will ever hit the hands of the physicians…sorry, Doc.

Doc: Oh, Grumpy, that’s not what this is all about. That money is designed merely to flow THROUGH the hands of the physicians into the hands of the vendors and developers to stimulate the growth of our digital healthcare information system.

Sneezy: (entering, with an ACHOO!) That’s not what everybody thinks, Doc. (sniff) I saw Dr. Doolittle on my way to the mine yesterday and he said he was heading down to Woodland Bank to arrange his new EMR system loan because (sniff) his vendor swore he’d make a bunch of money by adopting now.

Happy: (with his chronic big smile) Either way, don’t we all benefit if healthcare goes electronic? Isn’t the goal really about the benefits to us, the patients, and not who gets what piece of which pie?

Sleepy: (wiping sleep from his ever half-closed eyes) Pie? We’ve got pie?

Happy: (chuckling) No, you silly, sleepy little elf. We’re talking about the big EHR vendor ARRA/HITECH “pie.” I was thinking about what Snow always said, (in a girlish voice) “If your palm itches, you’re about to come into money.” (grinning ever bigger) I’ll bet there will be a lot of palm-scratching CEOs walking around the Georgia World Congress Center!

Doc: Well, I don’t begrudge them a nickel if they can actually create systems to make treating Bambi’s bunions easier and my days in AR dwindle.

Grumpy: Well, I think that is yet to be determined, Doc. Hey…how can a hooved creature have bunions?

Doc: Figure of speech, my dear dwarf.

Happy: Well, regardless, HIMSS will have lots of parties and lots of freebies and lots of happy people excited about the future. I hear even Eric Fishman will be there filming for EHRtv.com. Hope I get interviewed!

Sneezy: I just wish more HITECH money was going (ACHOO!) to big pharma. None of my nasal sprays help anymore. (sniff)

Doc: With all the great data we’ll soon be able to accumulate, aggregate, analyze, and share, Sneezy, I’m sure we’ll figure out better ways to circumvent your rhinitic condition.

Dopey: Hyuck. There you go talking all purdy again, Doc!

Bashful: (standing in the doorway, sheepishly twirling his big toe into the earthen floor) Aww…I’m just thinking about Monday night at the HIStalk reception. You think there’s any way I might meet Inga?

From the woodland trenches…

“From now on, Snow White and the Seven Dwarfs will be known as Person of No Color and the Seven Vertically Challenged Individuals.” – Argus Hamilton

First posted on HIStalkPractice.com and ModernMedicine.com, February 26, 2010.

10 Things I Hate About EHRs

2010-02-21T14:11:00.000-05:00

So many EHRs look so Windows 95-ish…or like an accountant’s spreadsheet. Why? I dunno about you, but my brain doesn’t thrive on constant rows and columns.
I shun EHR vendor Web sites that require me to provide my contact information just to see a basic demo. I don’t have to give the Piggly Wiggly my phone number just to see an apple.

Most EHRs want you to drink from a fire hose when all you really want at first is a sippy cup.

EHR sales pitches and their pitchers always assure you that their particular product can cure cancer … while watering your tulips. (My tulips have all wilted, by the way.)

Template creation. ‘Nuff said.

EHR support or sales people who know less than I do about the product.

I’m gonna be really P.O.’ed if Obama money allows all the latecomers to buy EHRs for a song while I’m still paying off the second mortgage I needed to buy mine.

Most EHR vendors/creators think “clicking” somehow beats writing. But, when it takes 4,357 clicks to complete a 99213 visit and you can handwrite the same 99213 note in under a minute — meeting all coding requirements — well, how do you convince anyone that the trouble of workflow and habit change is beneficial?

We’re going to have “Minority Report”-style computing interfaces while EHRs will still be clunking along awkwardly, clumsily, bound to those old rows and columns.

Why (virtually) no Flash or PHP? Wouldn’t a little panache and Web 2.0-ness work in EHRs?

Faxed reports from an EHR-enabled ER or urgent care for one of my patients with an earache that uses five sheets of my paper and toner to tell me they got amoxicillin.

I know. That’s more than ten. But, as I alluded to in number one, “Damn it, Jim, I’m a doctor, not an accountant!” (Props to Bones.)

From the trenches...

"Tip the world over on its side and everything loose will land in Los Angeles." - Frank Lloyd Wright

First posted on HIStalkPractice.com, February 18, 2009.

(Virtually nothing has changed any of my 11 opinions above since a year ago, but it's probably time to write a companion list of the things I like about EHRs...)

I Don’t Wanna Build the Hammer

2010-02-20T14:32:00.000-05:00

I build cabinets. They come in many shapes, colors, and styles. Each and every one is precious to me.

Despite how much I enjoy the art of cabinetmaking – yes, cabinetry is still far more an art than a science – I find building them has gotten harder and the process takes much more time and effort these days.

You see, I was originally trained with hand tools. I know how to use them and they feel very comfortable in my hands. But, I kept hearing about all these amazing new, modern tools and reading about how much more I could do with them than with my old chisel and rasp. I finally decided to try to keep with the times and convert to modern equipment. So, off to the hardware store I went to see what newfangled gadgets I could see.

Little did I know how many hardware stores there are these days: small mom-and-pop shops, national chains and megastores, even some which are strictly web-based. Since I didn’t really know what there was to know about the new wave of tool design, I figured I better look at them all.

Holy crud! What an eye-popping assortment of doodads, doohickeys, thingamabobs, and whatsits! You can twist and turn and join and curl and polish and trim any which way you might ever want. It looked to me as if there wasn’t anything I couldn’t do with a little piece of wood if I had a modern shop full of these fancy schmancy instruments.

The salespersons all showed such finesse in using these gadgets. With my extensive training in fine woodworking, I knew I could do much more still with these in my hands.

I asked about pricing: pretty steep, compared to my simple hand tools, but not unaffordable. (After all, I make enough cabinets to generate a livable income.)

I asked about training: regular classes, ongoing support, and even webinars were all available, though there were extra charges for some of these. (That was OK as I knew it would help me get up and sanding sooner if I had some personal instruction.)

I asked about productivity: as the sales people whizzed through their demos, they assured me I would be able to produce even finer cabinets at a similar rate, thus generating more income for similar effort. (My boys’ meager college funds would appreciate that!)

It all looked so good; I plopped down my plastic and went home to await delivery of my new, complete set of cutting edge, woodcutting tools.

Now we come to the rub, the glitch in this whole, new high tech gadget gitalong. After the delivery crew had dropped the boxes off on my woodbench, I learned a sad truth: every one of my shiny new implements appeared to have been designed by an engineer, not a craftsperson. Their instructions were written in tech-ese, not English. They seemed to have started with the assumption that the end user already had an in-depth knowledge of modern tool design and understood their inner workings.

After wading through pages and pages of almost indecipherable and convoluted instructions which asked me to remember minute details from chapters and chapters before, I finally realized that putting my new tools to use was going to be a phenomenal challenge, but, not for the reason you might think.

I can digest details and manage minutiae. (You should see some of the woodcrafters’ trade journals.)

I can learn new skill sets. (I’ve spent my life learning new ways to wrangle wood.)

I can even build a hammer if I have to. (I don’t want to; I prefer to use the hammer to create cabinets.)

The biggest problem? My new tool set came as a kit. All the pieces and parts are there, but to use them, to get on about the business of making cabinets, I have to put the entire toolset together. Sure, they’ve molded the plastic and hardened the handle shafts, but I am supposed to put the pieces together in a way they say “will work how I want them to work.”

(Shoot, my little Palm Pre is pretty complicated, but it only took a day to get fully up and running with it. Sure, I had to put the battery in and run through some guided setup routines initially, but they were “pre-thought out”; I barely had to think at all, just follow some very simple, well-designed, and regular human-ese instructions. It works how I want it to just fine.)

I am committed to mastering my new toolset. Overall, I love it and we will end up creating beautiful cabinets together. It’s just a lot harder than I think it should be. It takes a lot more effort because I’m still figuring out how to put the tools themselves together, which is not really where I want to be spending my time. I’m pretty sure most other cabinetmakers feel the same.

I want to create cabinets. I don’t wanna build the hammer.

From the trenches…

"Follow the grain in your own wood.” - Howard Thurman

First posted on HIStalkPractice.com, February 19, 2010.

Of Mice and…Ducks

2010-02-18T16:02:00.000-05:00

We recently left a long road behind us here in our little neck of the trenches. After years of what seemed like almost interminable “training,” one of my staff was caught adding a new network printer to her tablet PC – without any help!

Those of you reading this little saga are all pretty techno-hep and probably don’t think too terribly much of someone performing such a relatively minor and rather simple task. However, here it was celebrated with hoots and haws and all manner of revelry. You see, this was a signpost that we had left a years-long trail behind and were now embarking upon a different path – completely duck-free.

When we started our new, little high-tech, rural pediatric office back in 2006, I had a staff of three: a nurse, a receptionist, and a medical assistant. The receptionist knew just enough on the computer to be dangerous, my nurse didn’t even know how to turn a computer on (literally,) and, during one of our first group computer discussions, my M.A. asked if we would have to use a one of those “ducks, you know, those things you click” with our pen tablets.

We never ended up using any ducks, though we did enjoy a recurring chuckle over that comment. We did begin, from that day, a very long, slow path toward computer literacy which, at times, seemed almost interminable. It began with the basics.

One of the first tasks I assigned was quite simple: play solitaire. They were each given a pen tablet PC and told to take it home and practice playing simple games just to get the hang of using the pen or the TrackPoint. (We kept the focus off of ducks.)

That was a pretty fun way to start engaging their computing experience. Once they had some cursor awareness, we moved on into simple messaging using an in-house messaging system. Email was an easy extension from there and then we clicked right on into full blown patient scheduling, sans paper and pen backup. So far, everything was just ducky.

Zoom ahead a bit on the time continuum and, after a few fits and failed starts with full-blown EHR usage, we became “paperless” and left our crumbled, old paper chart crutches for good. (I say that with only a momentary hesitation as, honestly, there are still days when I just want to grab a pen and scribble a couple of quick notes the old-fashioned way, committed geek though I am.)

Full EHR usage doesn’t mean we are free of performance struggles related to basic PC usage, just that I felt it was time we made the leap. Watching my nurse has, at times, been almost painful; she’s done pediatrics via pen and paper for 30 years. She is a sharp cookie, but PC-ing just doesn’t come naturally to her. She is never one to shrink from a challenge, though, so she continues to plug away. (She is the true salt of the earth and one of the greatest blessings of my life.)

Anyway, the other day I noticed she had a new printer in her “Devices and Printers” folder. I had recently upgraded an older printer, but I hadn’t yet had the chance to add it to her tablet. I asked our office manager (a PC-savvy youngster) if she had added that and she said my nurse had done it all by herself, without asking anyone! I looked over and saw my nurse grinning the biggest, proudest grin and I knew: we were officially beyond the era of the duck!

From the trenches…

“Not the cry, but the flight of the wild duck, leads the flock to fly and follow.” – Chinese proverb

First posted on HIStalkPractice.com, February 12, 2010.

The Curse of an Active Mind

2010-02-16T08:42:00.000-05:00

During an interview the other day, I was told I must spend a lot of time thinking about how this thing or that thing affected this other thing or some such. My response was a bit of a stubble-bum ramble filled with a few ums and hums. Frankly, I wasn’t quite prepared for that particular query and it threw me for a rather long loop.

The loop-inducing question wasn’t all that bizarre or off-putting; rather, it was thought-provoking. (Here goes, more time thinking.) Believe it or not, it seems strange to me to consider that someone might not spend time thinking. What else happens betwixt and between synapses all day? Is it possible for them to pause? I can’t seem to do anything else with mine, short of pharmaceutical- or liquor-induced alterations. As those just seem to cause a synaptic slurry, not so much a neuronal numbing, and as I have this little issue with chronic cluster headaches that don’t seem to cotton to such interventions, I’m left with the persistent zap and swoosh of nerve ending electricity sparking out chemical trans-synaptic messages. Who am I not to listen to their call?

Thus, I suppose, the allure of meditation. At least in the midst of my mental mantra murmurings, there seems to be a momentary quell amidst the constant onslaught of what-ifs and why-nots.

Knowing that most folks spend little to no time of a day pursuing transcendental mental inhibition, what, then do people do all day with their excess neurotransmitter processes? Is there some secret I’ve missed that helps control the above-the-brainpan banter? Or is it just that through repetitive squelching via you-can’t and you-shouldn’t socialization, people have been trained to tune out their why-couldn’ts?

Don’t get me wrong; overall, I’m happy to have my mental monologue. I like seeing this thing that reminds me of that thing and that maybe an unbefore seen intersection which might bring about some other thing. Sometimes those connections really “hit.” Granted, sometimes, they most definitely do not. Regardless of my average brain’s batting average, I really enjoy when I put the wood on the ball and knock one into distant center, over the wall and into the stands.

Granted, again, hitting such cerebral homers doesn’t happen all that often; I’m no Babe Ruth of Brainstorms. Still, the serotoninal rush of those moments is better than any Big Pharma concoction I’ve ever encountered. Its addictive powers are heroin-esque. The endorphin release which follows, that “ahhh” satisfaction you feel when you know you done thunk something new that done did something good, is exquisite.

Therein lies my rub. Just like any self-respecting, certified junkie, I want more. More hits, more often, more bigger. And, the only way to get more is to think more. Which leads me right back to my original, powerless position: how can I not heed their call?”

I guess I really don’t mind too much. I just wish their call could be quieted more readily; even committed addicts need the occasional breather.

Wonder what’s on TV?

2010-02-15T13:25:00.001-05:00

I must apologize...I have not posted here for some time. To be honest, while I know the audience probably isn't losing too much sleep about my absence (and likely doesn't number beyond a digit or two!) I have been made to see that at least one or two folks "have missed" my postings here.

I am honored and flattered that anyone at all might be reading, so I'll try to keep up better. Most of what I post here is also posted on HIStalkPractice.com and, now, some will also be found on ModernMedicine.com, but, upon occasion, I have a strange thought or three that may not be applicable to those sites.

Thanks to any and all who take the time to stop by...and especially to those who write.

Gregg

Cash for Clunkers?

2009-08-16T05:45:00.000-04:00

“Cash for Clunkers”? Hot diggity dog! What a great new idea to adapt into the whole new ARRA/HITECH EHR adoption drive!

I mean, think about it...we’re trying to drive users to EHR adoption, right? We’re hoping to encourage “meaningful use” which could sort of be interpreted as improved mileage, yes? We want every new EHR driver using a system which will participate and share safely on the health information sharing multilane highway, no? And, ultimately, we’d like to see all those non-CCHIT-certified, non-government-approved EHR clunkers off the road, eh?

So, if you read or watch any news lately, you know the auto-selling industry has had a landslide success with the government’s “big bucks for your trash trade-in program” formally known as the Car Allowance Rebate System or CARS. (Cute, huh?) Intended to run until November, the billion dollar budget appears to have been blown in only one week. Talk about end user adoption!!!

Such blazing success should not go unimitated. You want an EHR in every provider pot? Let’s take a lesson and forget the whole 44K reimbursement nonsense. Here’s the new deal:

First, we pick a catchy name like “Every Human Receives Something” or EHRs.
Next, we choose a cute-ish informal moniker, say, “Moolah for Medicine.”
Third, we decide upon a set of high mileage models worthy of reimbursement...of course, CCHIT-certified systems will likely be the defacto choice.
Finally, we offer cold, hard, trade-in cabbage to all clunkers out there – those notoriously antiquated non-CCHIT systems and, obviously, anyone still driving the prehistoric pen-and-paper monstrosities.

If $4,500 for a running, drivable, used car inspires sufficient adoption of new, high-mileage models to burn through a billion bucks in one week, I’ll betcha an upfront $44K to turn in old, gas-guzzling EHR junkers or paper-based jalopies for sleek, new, energy efficient health record roadsters will tear through 19 billion greenbacks in two, three days, tops.

First posted on HIStalk, August 11, 2009.

What I lack in decorum, I make up for with an absence of tact. - Don Williams, Jr.

Drink To Me Only With Thine Eye(s)

2009-08-14T17:19:00.000-04:00

- or - The Window to the EHR Soul

I’ll betcha Ben Johnson, back in 1616, never dreamed his sweet, though somewhat melancholic “To Celia” would ever become the basis for the musings about a relationship with a machine. Yet, here it is almost 500 years later and as I stare into the giant baby blue of the EHR with whom I have become so enamored (or at least familiar), that is the love song I hear swimming betwixt my ears.

It isn’t just the soulless machine or LCD whom I find myself adoring in virtual and intellectual romance; it is the essence within which drives my love and from which her true beauty derives. It is her spirit, her life force, her anima, her élan vital. It is her software GUI, from her EHR underpinnings, which inspires my adoration and supplies the muse to my mental poetry – for she, her eye, is beautiful.

The first thing that attracted me to her was her eye. Beautiful blue with gorgeous splashes of color, clear whites with few lines, and an aura of serene simplicity which almost belied the wonderful depth of her inner complexities. She was stunning. Still is.

She is still the only eye I want to look into every working day. She still fulfills most of my manly medical needs. The soul I see within as I am constantly drawn to her never-wavering gaze each day is still one of passionate concern trying to be my all, to meet my every desire. Her countenance still pleases my gaze, her eye still beauteous to mine.

But, just as with every great love, time and familiarity reveal undeniable cracks in the veneer of loveliness which first bedazzled completely. Not that she isn’t still beautiful and not that there is another out there who has caused my eyes to wander; it’s just that all of the promise, both implied and assumed, never quite matches fully with time-revealed reality. The talents presumed and the best-foot-forward finesse of the early infatuation days yield to the actuality of the true.

Will this beautiful eye, this rectangular optical window to the true soul of my EHR machine, ever fulfill all of my desires? Will she grow with the refinement of age and experience into the dream with which my mind’s eye beheld her when infatuation first flowered?

Or, will I join the ranks of the unfaithful, becoming enamored by the sultry lines and sinuous curves of a younger, newer beauty? Will one with the flexibility of youth and the promise of new love distract my eye from my first, now aging, love?

Frankly, I don’t know. Our cohabitation, after all, is solely at my discretion. I do know that it was love at first sight with my first EHR love. The beautiful GUI, her “eye,” drew me in helplessly. Her understanding of my needs was deep, but her visual splendor captured my soul. This was an eye I knew I could gladly gaze into daily for many, many years to come. (Others before – and most, so far, since – appear lifeless and cold and uncaring of my visual happiness.)

While many are perhaps far more pragmatically oriented, I believe beauty engages us all. If you’re going to spend years, perhaps a professional lifetime, gazing upon a quadrangular “eye” to your EHR machine’s soul, it should be a gaze returning pleasure and visual “vavoom.” Superior EHR GUI design can lead to love.

First posted on HIStalk Practice, August 11, 2009.

Talent hits a target no one else can hit; genius hits a target no one else can see. - Arthur Schopenhauer

The Elegant Palm Pre Cereal Box Top EHR

2009-08-06T21:12:00.000-04:00

Yep. Pretty happy with the new Palm Pre. Simple, nonetheless powerful. Stylish, yet practical. Hip, though perhaps not iHip. Zen, and so much so, that I quit maintaining my motorcycle.

But, regardless of the number of contemplatory eggs gracing Palm developer desks, it isn’t perfect. Battery life is abysmal unless you keep all the apps closed. This kind of diminishes the glamour of being able to keep a bunch of ‘em open and switch in and out at will. Of course, if you have a bunch of chargers scattered around, you can keep up and the new magnetic grab-n-go charger helps this. (Thank you, yet again, Mr. Tesla.) Still, I’m used to having my digital six-shooter on my hip and jumping about at will. Remembering to grab the little beauty when I run off to an emergency or bathroom break proves challenging.

Also, the Palm Data Transfer Assistant could use some work. You’ll find lotsa online tales of woe about Palm Desktop or Outlook data migration. (Thank you, Chapura PocketMirror.) Another noticeable weakness is Sprint’s cellular coverage, at least here in my little burg. Verizon had me covered and I could always hear you now. Sprint doesn’t want me getting calls in the surgery center or even sitting at my office desk. (I won’t bore you with why Sprint doesn’t want new business customers to have AIRAVEs to enhance their signal, but will freely give them to established customers – I have to endure crap coverage until them deem me worthy, I guess.)

Still, challenges and foibles aside, I realized the other day that I could pretty much do every common little computer thing I need from wherever I happen to be (within cell tower range.) This is phenomenal! The integrative nature of the Pre and the beyond-iPhone-friendliness of my new pocket-sized phone-calendar-contact database-camera-GPS locator-weather center-web browser-videocam-pager-planner-game system-younameit tool made me realize the future had hit. This was a, “Wow, I can actually do what I’ve always wanted to do,” light bulb moment.

Then, this morning, I was putting my Raisin Nut Bran cereal box away when I noticed the box top. Remember how cereal boxes always had that little semi-cut-out slit you had to punch open to stick the opposing flap’s tab into? Remember how it invariably would not be well cut and your attempt to pop it apart would, also invariably, lead to the little connector piece tearing such that the tab would never hold the flaps closed as intended? Well, some cardboard engineering whiz kid has figured how to cut the tab and its opposing flap indentation such that the punch is eliminated and my little box top stays untorn and closes right every time. Genius, though it took decades to discover.

So, a two-and-two flash strikes. That’s what I want from my EHR. I like my system well enough; it has lots of the gadgets and gizmos I need. The problem is it isn’t Pre slick yet. Close. Kind of like the difference between the Palm Treo and the Pre. Functional, but kludgy. Close, but still not quite brass ring worthy. Missing the box top simple solutions for functionality. I’m guessing many EHR users feel similarly. We know what we need, but no one has the truly elegant answer yet.

I would like to know if anyone out there knows the “Geniuses of the Box Top” and a couple of Palm Pre developers who might be interested in constructing the new Palm Pre Cereal Box Top EHR? To make the next generation EHRs, the ones we really need, it’ll take these types of Zen master geniuses, those who can make all the work underneath appear simple and elegant. Maybe I should ask Fred Astaire.

First posted on HIStalkPractice, August 4, 2009.

You don't get anything clean without getting something else dirty. - Cecil Baxter

Postscript : Since submitting this piece, I came across a tremendous article, The EHR ‘killer app’, by Jeff Marion on EHRWatch.com. If you haven’t seen it, it is well worth a read.

The Six Degrees of Integration

2009-08-02T00:10:00.000-04:00

Tipping points and network theory. Malcolm Gladwell and Kevin Bacon. If short books and the Science Channel have taught me anything, it’s these: While I may not have all the answers, it is only a hop, skip, and a jump to where the answers lie and simple things may have the biggest impact. (T.V. and the Web reaffirm this daily.)

Have you noticed that no matter where you look, someone is promising the grand digitization of healthcare in the oh, so near future. I’m starting to chafe from the tipping point upon which we’re supposedly perched. However, a look at the percentages of full-blown HIT users, either provider side or consumer, doesn’t seem to tilt the impression that mass adoption is all that imminent.

Still, with Facebook at nearly a quarter of a billion users and Twitter plotting their plan to become the first Internet site to reach a billion users, it is apparent that providing people with a tool they: a) understand; b) find simple to use, and: c) find real, immediate use for has major power to quickly topple a tool over into mass adoption. If healthcare IT could get off its high horse and learn a lesson or three from these more “common” contrivances, maybe we could actually reach the Promised Land of Healthcare Information Integration.

Enter Kevin Bacon. HIT struggles virtually non-stop to understand how to integrate all the data we derive daily, be it patient care info, new medical knowledge, or business numbers management. And, from Kalamazoo to Cocoa Beach, everyone is trying to figure it out almost independently. Well, Kevin says we are all only separated by some six degrees or less. What if we take a part of Mr. Bacon’s recipe, sprinkle in some of Facebook’s Gladwellian success spices, stir it all up within the HIT pot, and then dump the whole stew out upside down?

Instead of Six Degrees of Separation, what if healthcare information integration chose to focus upon the reverse view that we are all within “Six Degrees of Integration”? We are not separated so much anymore as we are integrated. A quick breeze about the HIT blogs brings up some pretty interesting observations along these lines from both the more notorious as well as some lesser known HIT brainstormers. Many of them are now bandying about notions related to direct-to-consumer healthcare information integration management beyond PHRs and EHRs. After all, every person on the planet has health which needs care at some point or another, just as most everyone has social networks with whom they want to keep connected. If simple social networking tools are able to empower such rapid adoption and end user deployment, then haven’t they demonstrated the fast, focused force available for integration of healthcare info if we only harness similar motivating energies?

To promote this reverse view of the Six Degrees for HIT, I propose a new organization: Pursuers of Integration’s Six Degrees, to be more affectionately known as PISD. If you don’t want to wait for the trickle down of big, siloed systems, consider becoming a PISD member. Help all of America, even all of the world, become PISD so we can get beyond the abrasive point upon which we tip.

The unwitting modern day Moses, Kevin Bacon, has shown us the Promised Land past the HIT Tipping Point. Now, if we could just pass over.

First posted on HIStalkPractice, July 20, 2009.

“If you're not scared or angry at the thought of a human brain being controlled remotely, then it could be this prototype of mine is finally starting to work.” - John Alejandro King

You Have To Let It All Go, Neo

2009-07-26T09:18:00.000-04:00

Just for fun, let’s say you have 19 billion dollars and a tremendously philanthropic heart. Let’s say you decide to devote your vast fortune to solving the healthcare crisis in America. As you also have a geeky soul, you settle upon healthcare information technology enhancement as the vehicle you deem most likely to have give you that big bang for your many, many bucks.

You look around the HIT realm and see many, many players providing many, many digital solutions, but realize that the vast majority of them are siloed, they don’t work and play well with others. There are some really wonderful systems, many of which have the potential to provide the electronic underpinning to your truly national health care project; however, very few, if any, have all of the tools with all of the interoperability you seek. Virtually none have the diversity of user interface that end users’ widely divergent personal preferences demand. (People do want their own style.)

It appears to you that no current system can provide the be-all-end-all tool that works for everyone, no system yet has the easy and highly individualized personal customization required to entice everyone into adoption with a tool that works for their unique needs and their unique eyes. Thus, you begin to ponder, “I wonder what kind of a broadly attractive system I could build from scratch for my 19 billion dollars?”

Pursuing this thought train, you muse:

How many top notch developers could I hire? (2,000 X $150K = $300 million)
How many designers could I employ to make user interfaces that are easy with thousands of skins so everyone can look at whatever suits their eyes? (2,000 X $150K = $300 million)
How many educators could I deploy throughout the country to make sure “no child is left behind” – or any adult? (10,000 X $150K = $1.5 billion)
How much of my money pile could I afford to give to individual smaller communities across the nation to help them step across the digital healthcare divide? (Micropolitan areas: 577 X $3M = $1.73 billion)
How much could I give to schools to help educate the young so that, going forward, this digital healthcare stuff becomes second nature? (94,000 X $100K = $9.4 billion)
How many really great support personnel could I hire and deploy to every corner of the land in an effort to insure uptime? (10,000 X $250K = $2.5 billion)
How large a chunk would be left over for various loose nuts and bolts, including quality CEOs, COOs, CIOs, and all the little “o”s? ($3.27 billion)

2,000 developers; 2,000 designers; 10,000 support personnel; 10,000 educators; big, no huge, chunks of money to help small communities join the party and teach our children how to be digital healthcare thinkers using existing Web and cell phone technologies which already reach every knook and most every cranny? “Hmmmmmm...,” you further muse, “I bet this money could really do some good.”

First posted on HIStalkPractice, July 13, 2009.

“You have to let it all go, Neo...fear, doubt, and disbelief. Free your mind.” - Morpheus

KISS, Please

2009-07-22T04:03:00.000-04:00

Simplicity. As complex as healthcare is, if we try to add the density of technology to it, perhaps it is counter-intuitive to think of ‘simplicity’ as a key operating principle of the NHIN construct. However, I believe this is the must have nuclear core for the successful initiation of the broad masses of both consumers and providers to the adoption of healthcare information technology. It is also key to their subsequent and sustainable utilization of these tools.

Everyone who has been listening to the widely broadcast cachet attributed to HIT has at least some appreciation for the extensive list of advantages we all envision for our future digitally-enabled healthcare provision. Seeing what tech has done for shopping, banking, communications, social networking, political campaigns, and general information sharing, it is virtually impossible to imagine that such benefits would not also transcribe well into the realm of healthcare. Indeed, it is the very complexity of healthcare that makes it seem such a likely candidate for technology enhancement.

Therein lies the rub: We know what technology can achieve, yet we are seemingly overwhelmed by its application to so complex an arena as healthcare. We want all the benefits which we know it can provide, yet we are stymied by the vastness of healthcare as well as the currently available information technology solutions, most of which have trouble working and playing together.

I propose we let the big players continue to duke it out over who shares what with whom and how they’re going to solve their big center issues. I mean, while they have helped to push HIT along the past quarter century or so, they’re also the ones who have enabled the ‘silo-ization’ with which we are now hamstrung. They have oodles of money and should be the ones to fix the dilemmas they’ve enabled.

In the mean time, for the rest of us (consumers, small providers, ancillary healthcare delivery providers,) let’s do simple. Already familiar tools. Real, immediate value. Attractive, intuitive user interfaces. Internet as the backbone, no silos. Easy-to-use cell and smart phone push-pull data collection and dissemination apps. Work with the individual end user in mind, both consumer and provider – together, not separate. Important pieces first, add complexities as mastery grows. Small sips to start; avoid the overwhelming drink-from-a fire-hose phenomenon.

As John Gaule said, “A complex system that works is invariably found to have evolved from a simple system that works.” Couldn’t agree more.

Keep it simple, stupid? No...Keep it stupid simple.

First posted on HIStalkPractice July 8, 2009.

It is almost a miracle that modern teaching methods have not yet entirely strangled the holy curiousity of inquiry; for what this delicate little plant needs more than anything, besides stimulation, is freedom. - Albert Einstein

A Willing Suspension of Magical Thought

2009-07-16T20:30:00.000-04:00

Actors and playwrights know that “a willing suspension of disbelief” is essential for the successful acceptance of any fiction. Such faith allows us to enjoy the greatest of entertainment, be it Samuel Beckett’s “Waiting for Godot” or Matt Groening’s “The Simpsons.” Without a willingness to forego our skepticism and socially inculcated, rules-based orientation, we would forever be ingrained in a world of columns and rows and formulaic drudgery.

This is the essence of “magical thinking.” It allows us escape from our cubbyholed, preconceived mindsets. It enables flights of fancy, free association, and the perception of the possible. It is enabled from birth (genetically programmed?) as evidenced by watching any child at play. It allows us some of our greatest kidhood fantasies and fears. (Think: Santa, Tooth Fairy, Easter Bunny, Boogey Man, and all those monsters under your bed.) Magical thought allows magicians to amaze us and artists to enthrall us.

Unfortunately, that same ready power of mental delusion is what also allows us to believe that politicians really do mean what they say this time, that bankers really can self-regulate themselves adequately, that insurance companies are there for our protection, that technology can solve our healthcare crisis. It permits the fantasy that ARRA money will wind up helping heal healthcare and not just bulking the bankrolls of EHRco bigwigs and bolstering Insco bottom lines.

I love my fantasies as much as anyone. I would absolutely love to believe that information technology will put a period to my pen-and-paper-based problems, end my seemingly ineluctable non-electronic errors, provide instant access to the information I need as I need it, give me gobs of great evidence-based new brain power, and stop the shrinkage of my already skinny sliver of practice profit. However, I am unable to relinquish the disappointing deduction that the current rush toward IT as the “end all, be all, cure all” for healthcare is poorly planned at best and an impending catastrophe at worst.

For those who live and work in highly technical worlds, where the people you see daily are digitally oriented and adept, it is probably not an unreasonable reach to assume all things digital are possible. But, when I drive around my little corner of middle America, I see loads of folk whose electronic skill sets are likely limited to TV remotes and ATMs...at best. Where I work, I encounter colleagues who would love the aforementioned techno-advantages, but who barely have enough time to unravel the mysteries of CPTs and ICD-9s, no less the quandaries of an entirely new EHR-demanded workflow. Where I practice, I live the daily dilemmas of bringing the non-techno-literate along as we endeavor to navigate our way across the digital divide.

In considering this piece, I Googled “magical thinking” which brought me immediately to a great article by

Gilles Frydman with comments and links to related pieces by such HIT notables as David C. Kibbe, Sarah Greene, John Halamka, and e-Patient Dave. Agree or not, all are worth a read, though perhaps the best, from the view of a grunt in the trenches, was a shorty by e-Patient Dave where he highlights the neglect of the everyman in this HIT stampede.

I want this brave, new, digital world for healthcare as much as anyone, but authentic and concrete, with real value for everyone, not just the fat cats and CEOs. Let’s suspend the magical thought and deliver truly “meaningful use” to my neighbors, Joe and Josephina Sixpack, not just the technorati.

First posted on HIStalkPractice June 27, 2009.

Delusions of grandeur make me feel a lot better about myself. - Jane Wagner

Pool Pumps and EHRs

2009-07-16T07:17:00.000-04:00

Never having owned a swimming pool before – kiddie blow-up pools notwithstanding – I had no clue about anything pool when we moved to a home with our first “cement (pronounced “see-ment”) pond.” Being in Smalltown, Ohio, where ‘pool guys’ are something we only hear about on Nip/Tuck, I had no options other than to learn my way around pool care, including chemistry, biologicals, skimmers, hoses, filters, jets, and pumps.

Turns out the pool pump we inherited, besides being old and inefficient, had been wired poorly and was using far too much juice. When our summer electric bills pushed us toward bankruptcy, I studied up on newer pools pumps and decided to purchase a “smart” pump which promised “up to 90% savings” on our electricity tab.

Savvy enough to have a certified-smart, real electrician convert my wiring run and circuit breakers from 120 volt to the required 240V, I chose to do the actual pump installation and final wiring to the outdoor switch on my own. (No, this isn’t leading to a tale of emergency squads and defibrillations!) With a broad smattering of electrical and electronic training and a general understanding of electrical codes, hots, grounds, and safe wiring habits, the job was not the greatest of challenges but was still not the simplest or least nerve-wracking of installations. Fortunately, it powered up without a spark and seemed to work.

Afterwards, I relaxed in the hammock listening with some small sense of self-accomplishment to the much more muted hum of our new, high tech, energy-saving, self-adjusting, computerized pool pump. But, now, with the new, high end tool online and operational, I still had to figure out just how to decipher and adjust all of those new pump-puter settings and codes to optimize my chances of achieving the 90% savings advertised.

The manual seemed complete, all 60 pages of it. Predictably, though, the typically poor tech writer-to-lay person interpretation skills were in full swing, so I found myself looking online for deeper insights and better explanations. This did help, but I’m still not sure if I am using, or even understanding, all of the available digital tweaks and tools this of fancy new gizmo.
You see, I’m sure, where this is heading. With something as relatively simple as a pool pump and with someone who has a generally workable background in electronics and computers, the challenges of digitization and the learning curve for its incorporation are not irrelevant, not even minor. Why, then, is it such a surprise that medical providers, who typically boast minimal-to-no I.T. background, have such trouble adopting, no less understanding, VASTLY more complex electronic healthcare tools?

How are healthcare providers ever going to achieve HIT competency and EHR satisfaction...two weeks of on-site training, hard-to-reach support call centers, and a written-by-techies manual? These are the typical answers which most EHRcos have concluded are sufficient to bring healthcare workers across the digital divide. That’s about what most of us could use to competently install and utilize one of these fancy-schmancy, cement pond pumps. I’m thinking a better training, support, and ongoing education plan might be required for the complexities of HIT.

First posted in HIStalkPractice, June 20, 2009.

No problem can be solved from the same consciousness that created it. - Albert Einstein

From DVR-Challenged to an EHR?

2009-07-03T22:55:00.000-04:00

Bringing real change to healthcare information integration will never happen until the focus is off of the “technology” and onto the training, education, implementation, and ongoing usage support of such complicated tools. Period.

Of course you can force the horse, but he he’ll die of dehydration if he can’t figure out how to drink. Geeks docs get it, but most clinicians are not geeks and couldn’t care less about technology if it doesn’t:
1. Make their lives easier;
2. Strengthen their profit margins;
3. Help them be better doctors, AND;
4. Come with ongoing, easy-to-access, stupid-simple support.

Number 4 is probably the most important, yet most often shortchanged component of these quadrangular conditions. Both the technology and the issues it is trying to support (healthcare issues) are far too complex for the general masses of providers to wrap their brains around all together. Just being a clinician is hard enough. Giant new learning curves for techno-tools which – let’s face it – don’t really hold much fascination for most normal folks are off-putting, even repulsive.

Here’s what I hear: “With pen and paper, I can be a decent doctor (#3), get by financially (#2), and I already, almost innately, know how to use them (#1). Sure, paper has a ton of associated problems, but until there are sufficient helpmates (#4) to hump me over that technological learning curve mountain, I’ll do what I know and spend my extra time trying to get the hang of my DVR. By the way, speaking of computers, what’s this Twitter thing? Is it … (hushed) … sexual?”

First posted on HIStalk, May 27, 2009.

Where all think alike, no one thinks very much. - Walter Lippmann

Ficos and Inscos and Autocos and EHRcos

2009-07-03T22:41:00.000-04:00

I don’t drive an American-made car. Sorry. Kind of wish I did as I’m a big fan of supporting the local economy, whether it’s that of my little community or that of my country. But, with the recent Detroit disasters, I’m not exactly feeling like the town idiot for my automotive purchasing decisions.

GM, Chrysler, and pretty much the whole gamut of American automobile companies are reaping their sown seeds of self-interest, self-righteousness, and strong-handedness. From the arrogance and disrespect shown as they invented and promulgated “planned obsolescence,” to the shortsightedness of designing for short-term profit versus sustained planetary and population wellbeing, the U.S. car manufacturers, the autocos, are just now getting a taste of the comeuppance which they have for so long unwittingly (and perhaps dimwittingly) sought. Too large, too little insight at the top, too light on listening to the real needs of the world around them has left many of these automakers reeling from real reality. (Didn’t you just love their scolding for flying in on private jets to ask for handouts?)

Looking at the U.S. healthcare mess, a certain parallelism appears to be brewing. Healthcare insurance companies, inscos, have also grown too large, they are dictatorial in their manipulation of healthcare monies, their lobbyists have long been far too powerful an influence upon our nations elected leaders, their roles as guardians and watchdogs of healthcare monies have devolved into self-perpetuating protectionism, and their top-heavy, middleman, leech-like drain upon true healthcare priorities is becoming increasingly, obviously, unsustainable. We’ve seen what this did for finance (ficos.) How long before the healthcare inscos’ bailout funds become the Twitter topic du jour?

Well, if my eyes don’t deceive me, there appears to be another TBFTB (too-big-for-their-britches) phenomenon a-brewing. When it comes to healthcare dollars these days, probably only second to the inscos in financial water cooler conversations are EHR vendors, the EHRcos. (Indeed, they may be the top conversation piece as the inscos seem to be trying to keep their collective heads down.)

In the midst of the early stages of the predicted EHR industry consolidations, acquisitions, and small player demises, the ARRA/HITECH funds have promised to fertilize the growth of yet more egoistic behemoths. And, some of these large EHR vendors are starting to show signs of forgetting that, in the end, it’s the little people for whom they work, it’s the individual customer whose support and favor they ought to continually seek and curry.

Lest the bigger EHR players forget, behemoths are not indispensable. Remember such relative giants as TWA, Pan Am, Circuit City, Enron, Egghead Software, Coleco, Pullman Palace Car Company, RCA, and the Coca Cola Corporation? (I’ll let you look up that last one.)

Just as the inscos started out to help consumers obtain affordable healthcare and keep care costs controlled, EHRcos started as grand ideas to help healthcare providers provide better care. If they are not careful, they will also follow the unfortunate footsteps of the TBFTB inscos and turn away from their genetic principles. I really don’t want my grandkids having to also pay for the bailout of the NexEpiMisyCentricMcKeGEclipeCliniCernitech Conglomerate while still paying off Ficos, Autocos, Inscos, et al.

First posted on HIStalkPractice, June 12, 2009.

When I was born I was so surprised I didn't talk for a year and a half. - Gracie Allen

Feeding the Fire of Non-Participation

2009-07-03T07:55:00.000-04:00

Amid all of the hubbub around ARRA incentives, federally-mandated disincentives for non-EMR adoption, and best-practices-outcomes-based-evidence-based medical standards with which to comply in order to be ‘allowed’ to be a paid player in healthcare provision, did anyone ever stop to consider the huge – and I mean HUGE – motivational log being thrown onto the fire of non-participation?

I mean, come on, I’m committed to provide the best care possible for my patients. Plus, I’m a techno-geek-gadget-guy from way back. I love and encourage the intersection of healthcare provision and technology. But, when you consider the following, even I have to wonder if the conjuncture of the two worlds might best be promoted outside of the current realm of ONCHIT, CCHIT, and a variety of other ‘chit.’

To wit:

In order to remain profitable, I participate in around 40 private insurer programs.
If I generate $4-500,000 yearly, I take home somewhere just into the six figures.
In order to maintain those numbers, as a primary care pediatrician with a heavy dose of Medicaid patients, I have to see somewhere around 30 patients per day in order to pay my bills and make a decent living. (“Decent living,” by a pediatrician’s standards, as you can see, is not what most specialists would tolerate.)
If I didn’t have to chart, make phone calls, review labs and other assorted outside medical data, attend hospital meetings, assist my staff, and otherwise run my practice, that’d give me 16 minutes face time per patient average in a 40 hour week. (“40 hours!” Wouldn’t that be nice?)
I’ll now have to consider 155,000 ICD-10 codes instead of the paltry 17,000 from ICD-9.
None of this even mentions hospital rounds, emergency C-sections, or 24/7/365 availability.
I rush through most days and barely know some of my families. (Not to mention my own family.)
Studies suggest physicians spend at least 1/3 of their time in non-direct patient care work. (I’d suggest that is lowballed.)
After all of this, in order to “follow my bliss” and pursue technological enhancements of my medical services, I need to detract yet further from my family time, my personal time, or sleep. (Guess which goes first.)

So, follow me here, if I wasn’t a genetic geek, if I didn’t enjoy the thrill of resolving “Blue Screen of Death” issues, if I was like the majority of non-techno-minded primary care docs who lead very similar lives to the list above, how much do you think I would want to add a giant new learning curve into my scheduled chaos? How much do you think I’d want to risk my already meager monies on an electronic health record system that might get reimbursed in a few years?

Now, instead of maintaining 3-4,000 active patients with the life- and work-styles mentioned in Part 1, what if I abandoned all of those who can’t pay or who pay poorly and who place excessive non-medically-related demands upon me (both patients and insurers) and switch to an old-timey, doctor-patient-only practice? (Some call the new version, “concierge medicine.”)

I mean, if I didn’t have to answer to insurer and CMS requirements and wasn’t worried about “meaningful use:”

I would still chart, make phone calls, review labs and other assorted outside medical data, attend hospital meetings, assist my staff, and otherwise run my practice;
Instead of 30 patients a day, I might see 15 (maybe 5!) – and I would know all of them;
I could limit my total number of families to a handful of hundreds charging less than $100 per month each;
Prepayment could include the costs of vaccinations, simple labs, and all office work and procedures, and;
Hell’s bells, I could even do house calls while still more than doubling my take-home pay!

All of this would be allowed without worrying whether or not I have the necessary number of bullet points, if a vision screening or required immunization will get paid or not (or enough), if my receptionist got the co-pay upfront, or if my EMR was being used meaningfully.

Guilt for not helping those less financially endowed? Why? Don’t the families who can pay also have legitimate healthcare needs? Plus, wouldn’t I actually be serving those for whom I work better, with care from a more relaxed, and ergo more focused, medical brain? With the reduced restraints on my time, wouldn’t I have even more ability to help out at the local free clinic or some other philanthropic venture?

Remind me again why I continue to participate with all the restrictions and requirements and rules imposed by sometimes even non-medical people. Jog my memory as to why possible reimbursement of $44-64,000 of my hard-earned moola for the privilege of learning a whole new way to record my work is considered an “incentive.” Tell me once more why participation in a broken medical model, now about to add – oooo, ahhhh! – “Technology,” something often hard to understand and even harder to use, makes sense.

Seriously. Remind me. I think I’m starting to forget as I feel the warm glow from the growing fire of non-participation.

First posted on HIStalkPractice, June 8, 2009.

Reality is something you rise above. - Liza Minnelli

Life in a Little Trench or Supply Side HIT

2009-06-06T05:26:00.000-04:00

A “grunt in the trenches.” That’s a term I’ve used to describe who, what, and where I and thousands of healthcare providers like me are, occupationally speaking. It is probably a different perspective than many you’ll see on these pages. Please allow me a moment to offer a few descriptive moments to sketch out that picture a bit more.

• I’m a solo pediatrician in a small town (pop. ~9,500) in the rural flatlands of central Ohio.
• I’m on call for neonatal emergencies and C-sections 24/7/365.
• I love living in and serving my small community; I’m the medical director for the county health department, a member of the town planning commission, a local United Way board member, a Rotarian, a member of the local hospital Foundation Board, and have a spot on our town’s Bicentennial planning group.
• In the last three years, my true “vacations” have totaled 3 days.
• Our busy little practice serves a rural populace: about 65% of our families are Medicaid.
• I locally host our EHR on two servers and am it locally as far as IT for our office.
• My three wonderful employees started off almost fully computer-illiterate. (OK, one knew how to turn a computer on, one didn’t, and one called the mouse a “duck.” Seriously.)
• I spent hours upon hours researching more than 200 EHRs, demoed scores of systems, and went into deep detail on the finalists before deciding upon an EHR for our office.
• Life in my trench includes traffic “jams” of six cars and friends who know me before I’ve ever seen them. It allows for a trip to the post office, a bank deposit, picking up a prescription from the pharmacy, grabbing a forgotten paper from my home, and being back to the office, literally, in less than twenty minutes. There are Scout meetings, sports, school functions, and homework. I insist upon family time and some (admittedly brief) down time.
• I don’t miss big city life in the least.

I’m not offering this description to glorify myself nor anything I do. Rather, I am a very run-of-the-mill, small community, primary care physician. There are thousands more like me out there, working hard to care for our communities and families. We have wonderful, fulfilling lives and enjoy our labors.

There is, however, something missing from our great little lives. We need inclusion in this great big HIT discussion going on. With very few exceptions, nobody’s talking about us – even though we serve the majority of U.S healthcare needs. Systems and plans are almost completely focused upon the Mayos, the Clinics, the HIEs centered around giant centers, etc. Doesn’t anyone care about all us little grunts out in the frontline trenches?

It seems most everyone’s focused on the big guys and their bigger pools of money. Even the purported Keynesian liberals in political power now seem to be counting on the “Trickle Down Effect” (or its precursor, the “Horse and Sparrow Theory” from the 1890’s) to spread HIT from the big centers to all us little guys. Last time it was the conservatives telling us grunts how well we’d all be served by supplying the big boys’ side and letting us little fellows feed off the crumbs that fell.

OK, so that was finance, not healthcare IT. I suppose it’ll work better this time.

First posted on HIStalkPractice.com, May 27, 2009.

Ray Says, “It’s Not My Fault”

2009-06-06T05:12:00.000-04:00

During my weekly channeling session with our local psychic (Palm Reading - $5.00,) we received a surprise visit from none other than Mr. Big Mac himself, Ray Croc. He had one main message that he asked me to pass along: “It’s not my fault.”

Curious as to the origin of his defensiveness, I prodded him for elaboration. Paraphrased here, Ray said, “The whole freakin’ world [he used ‘freakin’ a lot] has gone mad. Everyone wants what they want at the exact moment they want it. ‘News’ is now obtained in sound bites and 140-character ‘Tweets.’ Entertainment is always two ‘clicks’ away. Social skills are nurtured without any face-to-face society. Dinner is drive-thru or RadarRange [sic] ready. OK, maybe I did contribute to that last one, but, the point is, I’m freakin’ sick of everybody saying the current excessively fast-paced and shallow civilization is ‘a McDonalds World.’”

Curious, too, as to why he broke in on my séance with the good Doctor Theodor Geisel, I asked for a bit more. He said, “Healthcare is the last great bastion of common sense. Where else can you see such tremendous amounts of time and money spent on providing longwinded and often redundant information? Only healthcare, with its vast reach into every corner of humanity can possibly stop this freakin’ onslaught of the digitization demons. Only healthcare can restore sanity to a too fast world. I need you doctors to spread the word so people will stop blaming me and start remembering what it’s like to actually go slow, to experience deeper thoughts, to wait for what you want.”

Freakin’ honored by his mission bestowment, I couldn’t help feeling, though, somehow partly responsible for the problems Ray worried over. I have an EHR, and a smart phone, and a DVR, and a microwave, and have even digitized my children. I have used many a drive-thru and I’m LinkedIn and Facebooked and Twittered. I, too, can barely read emails past the “two sentence rule.”

But, as Ray spoke (through Madam Blavatsky,) I began to see his point. Healthcare, with its typical foresight was actually the best place to restore some sanity to our too-fast-paced world. Where else, except maybe newspapers, do you see centuries-old technology still the primary tool? Ink-and-paper continue to rule the vast majority of healthcare and, with relatively minor exceptions, have shown the true value of grindingly slow communications, agonizing wait times, and almost limitless redundancy of information. If we get on it now, before this mad rush to techno-health really takes hold, we in healthcare services could actually stop the insanity and help restore Ray’s good name.

So, Mr. Croc, here’s my first salvo for you: Healthcare peeps, let’s slow this world down. As leaders in this return to common sense, let’s keep our repetitive forms and impossibly illegible paper charts (and, of course, 3 X 5 cards.) Let’s sign off of Sermo, leave LinkedIn, face only real books, and Tweet ta-ta to technomania. EHRs? Forget ‘em. As vanguards of health, we medical folks need to stand firm in our resolve to turn back this maddening rush life has become and keep our noses firmly buried up our Luddistic derrieres.

Thanks, Ray.

First posted on HIStalkPractice.com, May 16, 2009.

Corporate Conversation

2009-05-21T16:10:00.000-04:00

Patricia Sueltz recently wrote, on Forbes.com, about the Sun-Oracle (Oracle-Sun, if anybody's keeping PC score) deal. Besides being a very saucy-looking lady who would probably be a joy with whom to converse, she prompted a question or two with her recounting of a corporate interaction between Scott McNealy of Sun Microsystems and Larry Ellison of Oracle.

"I recall a moment during my tenure with Sun when we wanted Oracle to join us on an important software announcement to the market. We had Scott's approval to move forward, but the Oracle team needed the final OK from Larry, who was traveling. Scott had to use his magic to reach Larry. Even that had left us on edge: We were at the "witching hour," literally moments before the announcement and had not heard from Larry. As Scott walked onto the podium, his cellphone rang. He answered it. 'Great, thanks, Larry. I love ya, man!' The deal was done.

Intrigue, excitement and a passion for winning played out live, in real time. The crowd cheered; everyone loved it."

This immediately brought to mind a corporate-to-client email I recently received that began "Dear Valued Client" and ended with "Your [Company] Support Team." In between those two phrases was more corporate-speak, such as "a solutions' lifecycle" and "with the indication of accepted or not accepted to the release roadmap."

Why is it that two corporate VIPs like Larry Ellison and Scott McNealy can be warm and personal, using first names and lovely...er, I mean, macho...endearments while corporate underlings feel so enamored (intimidated?) with Corporate Culture that they can't even sign a friggin' email with a real name or take the time to generate a more personalized salutation, no less speak in human-ese?

You know, all businesses start out as two or so people talking to each other, working together, using first names and normal English. Once you reach the corporate upper echelons, apparently the same etiquette rules also apply. My question is this: at what point do people become corporations or bureaucracies accepting corporate-speak as normal and corporate protocol as proper? Since we don't need that PC crap to start success and the most successful don't need it, what the hell do we need it for in between?

Leave your insecurites, your inability to accept responsibility, and you baby binkies at home; let's talk to each other like reasonable adults, not hide behind corporate castle walls and politically nauseating correctness, regardless of our ladder rung.

Equalizing the Playing Field

2009-05-04T07:16:00.000-04:00

(“Open” is not a Four Letter Word)

If open-sourced crowdsourcing hasn’t shown you its formula is successful, you’re not paying attention. Look at Apache HTTP Server, look at Linux, look at Mozilla Firefox, Java, MySQL, Thunderbird, OpenOffice; open source and crowdsourcing enhance innovation; support of open source allows profit. Healthcare needs such public/private cooperation to stimulate the innovation necessary for its salvation.

Of the open source EHRs currently available, such as OpenEMR, OpenMRS, VistaA & Vista-Office EHR, FreeMed, tkFP, and Care2x, thus far, they are unusable for most of the masses. Still typically Windows 95-ish, very boxy with lots of columns and rows, their support sites are often heavily laden with tech-head jargon and formatted such that perusing them is laborious. Documentation is usually cumbersome or scanty, often difficult for the lay person to assimilate.

Wouldn’t it be great if a polished, open source EHR could incorporate a “best practices” approach for included elements/design? Everyone’s got their favorites, but from down here in my trench, standouts include:

Eclipsys’ Peak Practice - best visual candy, great customizability and workflow
Jay Parkinson and his creative Hello Health - Web 2.0 style, “intuitivity”
Doctations - online implementation, share-the-sandbox inclusivity
TeleAtrics - little known with one of the best physician or patient/parent visit summary note formats – not too big, not too small, juuuuust right
Medicomp’s new CliniTalk - simpler, yet far more powerful coded data collection via voice, type, or pen click
athenahealth’s athenaCollector - exudes billing and practice management power
Medicity’s Care Collaboration Platform - share, share, share

Why hasn’t some clever bizhead figured out that the potential for a really slick open source EHR/PM, marketed and supported correctly, is astronomical? Vendors say up front fees are not the moneymakers, that ongoing support services are what generate profit. Still, the majority of my non-tech physician colleagues cringe far more at initial EHR cost figures than at the support fees. Lower the threshold for entry; make a visually pleasing tool designed for normal peeps, not gadget geeks; provide education and support par excellence – these would seem a recipe for sweeping adoption and profit.

Small community docs and hospitals could certainly use a truly functional, low entry threshold product to help them cross the digital divide for their two-thirds of U.S. healthcare provision. They need a playing field equalizer, because current vendor offerings are built mainly for the big boys. It’d might be nice if some bIg BeheMoth-sort would see the value in thousands of small community sales globally, but if not (and not meaning to be insensitive) then come on, all you out-of-work developers and designers out there…wake up! During the current economic slump: 1) band together; 2) steal a few from column A, a few from column B, etc.; 3) put together an EHR that really will help the befuddled medical masses with a healthcare tool we could all actually use; and 4) create yourselves some jobs while helping save the entire U.S. healthcare system – hell, the whole global economy – to boot!

First posted on HIStalkPractice, May 3, 2009.

The Creatively Maladjusted

2009-04-29T11:54:00.000-04:00

One of the most famous doctors of all time – a true visionary and a tremendous healer – once offered what I believe to be one of his finest insights:

“Human salvation lies in the hands of the creatively maladjusted.”

Personally, I know very few creatively maladjusted folks. I know a slew of the maladjusted, and a peck or two of the creative, but rare is the convergence of the two. If information technology is to “save” healthcare, there is no doubt that it will be HIT’s creatively maladjusted who bring about its salvation.

Let me flesh that notion up a mite:

"Healthcare” is a mess – way too many middle men who have way too little “care” for health between me and my patients
Healthcare information technology has become pretty much a similar mess – way too many “solutions” which only seem to broaden the chasms between me, my patients, and good healthcare provision
For one mess to rescue another mess, it’s going to take people from beyond the pale who are free of institutionalized bias and restraints to deliver us to the HPL (Healthcare Promised Land)

Sadly, the business of HIT has now been around long enough to have become institutionalized. Sad, this is, because instead of becoming a functional, helpful, advancement that delivers powerful new tools for improving people’s lives, it has become more like a writhing swarm of locusts all looking to feed upon the crops of our lives and our economies. And, the Stimulus monies are essentially a non-pesticided entire Corn Belt of fresh feed for these ravenous grasshopper hordes.

Historically, the use of electronic technology to advance healthcare was envisioned by some pretty smart people for some pretty durn good reasons. I’ve been fortunate enough to have met a few of these pioneers, like Drs. Larry Weed and Ron Pion. Larry early on saw the value of the “peripheral brain” for doctors and Ron enabled patient education via television. They “got” the value of technology in improving the provision of healthcare. Unfortunately, many since have seen fit to merely “get” the “value ($)” portion of HIT. Thus, the institutionalization (and degradation) of originally noble ideas began.

A similar institutionalized situation used to exist until the above-quoted famous doctor (and a few others of his ilk) brought forth some seriously creative maladjustment to dislodge acceptance of the then accepted norms. Those normative notions, most of now see, were pretty seriously twisted despite their widespread promotion. However, “normal” has never been synonymous with “correct.”

Racism was once a major institution, in both thought and deed. But, in living up to his famous quote, Dr. Martin Luther King, Jr. helped us see through his creative maladjustment that a better way was possible. Healthcare now needs some maladjusted creators to step up and call out the institution of healthcare IT.

There are a few of these miscreants, these heretics, around. Again, I’ve been lucky enough to have met a few. But, in the deafening drone of the institutionalized swarm, their visionary voices are hard to hear. Occasionally, I read some other blog brat promote attacking the walls of the HIT establishment as they discuss some of these innovative disrupters, but they, too, are small voices amidst a roar.

I suppose the important thing for the small voices is to keep talking, keep envisioning. To again quote the good Dr. King:

“Our lives begin to end the day we become silent about things that matter.”

First posted on HIStalkPractice.com, April 29, 2009.

The Entitled Generation

2009-03-28T09:33:00.000-04:00

Get serious, people.

Turn off the friggin’ light switch. Change the daggone toilet paper roll…preferably, recycle the cardboard, too. Don’t throw your trash on my street…or anybody else’s.

And, while you’re at it, let’s kill off this virulent infestation of psyche that permits us to ignore the needs of others and focus only on the “Entitled Generation” and its abhorrent manifestations.

E-Generation examples:

Corporate execs of failed or failing firms who have the audacity to accept bonuses for ineptitude. (Hey, man, it’s in my contract!)

Sports stars who make 200 TIMES as much as the firefighter who rescues even family pets from burning homes or the EMT who daily helps obliterated people not feel so obliterated. (My agent says I’m worth it, man!)

Medicaid and Medicare recipients who have no incentive, financial or otherwise, to make smart healthcare decisions. (Runny nose? Let’s go the ER. There’s an emergency. Don’t feel like getting up yet? Blow off the doctor’s appointment; it doesn’t cost us anything if we do. Who cares if they waste the doctor’s and their staff’s time and prevent other patients from betting a timely appointment?)

Health insurance companies who have no interest in “insuring” people’s health, only healthy corporate profits margins. (Health insurance as a “benefit?” Seems more a burden these days.)

EHRs, PHRs, HIEs, RHIOs, etc. too big from which to walk away yet with so many “functions” that they don’t function well for anyone. (Let’s throw more money into poorly designed gigundo systems because… well… just because they already ‘are,’ they’re some big companies, and there’s money being made. Where’s disruptive innovation when you need it?)

Me? I’m sick of the “what’s in it for me”-ness of modern America. Obama’s right, it can’t be just the leader, or leaders, who are going to right this listing ship. We all need to get serious and do the right things. Make better choices. Don’t do stuff just because “that’s how it’s always been done.” (God, I despise that one!)

Most people, I believe, have a fair idea of what’s right and what’s not. But, most choices are not made from an “Is it right?” perspective. Most moment-to-moment choices seem based upon expediency, greed, or entitlement. The impossibly large welfare system and the failures of the banking and home mortgage markets blossomed from the very same seed: entitlement. And, as the seed has a rotten core, so, too, the blossom reeks.

This isn’t an exclusive generation, by the way. Baby boomers, X-geners, Me-genites, et al – we are all apart of the E-Gen. It’s a generational association which is non-exclusive, crossing all age groups. It knows no socioeconomic or religious bounds. It doesn’t preclude gays, straights, or trannies. It is one of the most all-encompassing groups ever. Yet, it should be an extreme embarrassment every time any of us pays our E-Gen dues.

How much does it really take away from your precious TV or Twitter time to put the cap back on the toothpaste, pick up the canvas grocery bags on the way to the store, or give someone a meaningful thank you. Maybe, next, you could actually vote. Or volunteer. It’s a start. (And, you can Tweet about it!)

Stop grabbing and start giving.

First posted on http://www.histalkpractice.com/, March 28, 2009

God 2.0 (non-heretically speaking)

2009-03-13T19:02:00.000-04:00

A recent viewing of the Flixxy.com video, “Education and the Future of Technology,” plus the "IBM Love" post below got my Nostradamian juices surging. I gathered my futurecast tools – brass tripod upon which to sit, brass bowl of steaming water and pungent oils upon which to gaze, a sniff of nutmeg – and began to prophesize...or at least hallucinate.

What came through, at some point in the sinus-clearing session, was an amazingly clear view of where computerization and evolution are headed: God 2.0.
Consider these facts stolen from the above-mentioned video:

The number of Internet devices had grown from 1,000 in 1984 to over 1,000,000,000 today.

The first commercial text message was sent in 1992. Today, more text messages are sent every day than there are human beings on the planet.

It is estimated 1 week’s worth of the New York Times contains more information than someone in the 18th century would likely encounter in their entire life.

The amount of new technical information is doubling every 2 years. (Remember, the “would you rather have 2 million dollars or 2 cents doubled every day for a month” question from basic algebra? Comes to over a billion bucks in 30 days, by the way.)

An estimated 4 exabytes (4.0 X 1019) of unique information will be generated this year, more than the previous 5,000 years combined.

A fiber optic cable has been developed that can push 14 TRILLION bits per second down a single fiber strand (that’s 210 million phone calls per second) and the rate of data push-ability is tripling every 6 months.

It is estimated by 2013 that a computer will be produced which can exceed the computational capabilities of the human brain and by 2049 a $1,000 computer will exceed those of the entire human species.

If these amazing and exponential growths are not dumbfounding enough, consider the discoveries in carbon nanotubes, bionics, genomics, nanobiology, silicon replacement advances, etc. So vast are the leaps and bounds of both knowledge and capabilities across virtually all fields of endeavor that even considering a future as mundane and plodding as the past 5,000 years seems laughable. We had all best buckle up for it’s going to be one helluva ride.

And, the end result? Maybe my nutmeg-induced trance has me giddy, but the steaming waters and pungent oils just offered up a vaporous vision too clear to be ignored. Follow with me as I summarize the future of mankind:

Wearable computers and Internet devices will merge with biomimetic and neurostimulatory advances to produce full-time global computerized access to the Global Web;

All information within the Human Web will become as readily available as thought;

Bionics will merge with nanobiology to produce replacement parts (whole organisms?) easier to replace than today’s light bulbs;

Computerized manufacturing and replication will allow the thought-connected brain to produce desired material manifestations on command;

Computer graphics and virtual reality will intertwine with the Human Web allowing Holodeck-type experiences not limited to a room or machine, but in real time from any locale;

The common experiences of the entire human species (why stop there?...all life will be included) will become 100% accessible to all;

Once such omniscience, omnipresence, and omnipotence are realized, have we not then recreated that from whence we came? In other words: God...2.0

Whoa. The nutmeg has run out and the steaming waters have cooled. The mind clears and my enormous human mental limitations have reengaged. I read what I just wrote and...whoa.

But, you know what? I have tremendous faith and belief in a Higher Power or a Cosmic Connectedness. (I call mine God.) And, interestingly, I find no sacrilege in those spice-induced words. I mean, if we were created to “Go forth and multiply” and, in both numbers and abilities, that is exactly what we are doing, then given enough time, doesn’t it somehow make sense that we would “multiply” into the very Infinity from which we were born?

Personally, I don’t believe God has limitations. I strongly believe those same freedoms were endowed upon us as His creations. Given enough time, if we don’t destroy ourselves or induce some cataclysmic global environmental calamity, we will “multiply” our way back to the Oneness. I believe that is exactly what God would want us to do.

IBM Love

2009-03-13T18:47:00.000-04:00

Seems it wasn’t all that long ago when ‘IBM’ and ‘computer’ were almost synonymous. Then, kaboom, IBM almost became a non-player for most everyday folks’ considerations. Recent developments from Big Blue may not bring it back into daily household conversations, but I think they may be generating some new computing leadership love.

Learning to mine the gold yet untapped by the major computing power we now have at our beck and call is where computer-minded innovators must focus their efforts. One of those potentials is the ability to organize information and make it more easily accessible to the human brain. While the ability to access oodles of data is growing daily, it still is mostly presented in the form of words via articles, charts, columns, rows, etc. When I think, the “eye” of my brain doesn’t see words; I think in pictures, images, cloudy little dreams. That is also how the text I read is usually stored, despite the actual ability to mentally “photograph” some of the written words I see.

Thus, Apple has thrived by being aware of the human-computer interaction via wonderful GUIs. (No, I am a PC, though I sometimes wonder why.) But, there is still so far to go. Knowing this, when I saw that IBM had recently announced the Thy-Mors (West Denmark) 3-D patient record software, and, their new “Sametime 3D” virtual business meeting software publicized this morning (03/13/2009), I got a little excited.
(respectively at: http://www.reuters.com/article/technologyNews/idUSTRE5294X720090310 and http://www.digitaljournal.com/article/269107 )

While neither of these may be fully actualized tools that can send thought-like information straight from computer to brain, I see a real step in that direction. Both, I believe, take a nice stride toward the eventual Borg...which in some form is, let’s face it, where computer brains and human brains are headed.

Chumming the Sharks

2009-02-28T13:52:00.000-05:00

Did you happen to catch the Mythbusters episode where, off the coast of South Africa, they chummed a shark feeding ground at breakfast to see if a dolphin could deter these ravenous beasts from chowing on a helpless little seal? (Don’t fret, PETA people, both the seal and dolphin were manmade.) The fake seal was always chomped within seconds without its mammalian mate, but whenever it was in the water nearby, the incredibly real-looking robo-dolphin was 100% effective keeping the sharks at bay.

Well, I waste your time discussing a T.V. show because I see an ominous analogy.

As you well know, Obama has now set his signature to the Grand Economic Stimulus Package promising over $19 billion dollars to healthcare info tech (not to mention the 100-some billion for CMS, et al.) Even before the pen hit the paper, you could see the HIT waters churning with the frenzied maneuverings of all the “sharks” scurrying to see their version of healthcare digitization fed. Since the signing, the “seas” have been virtually bubbling with their voracious intrigues. (Imagine what’s happening behind the scenes if we can see this much commotion above the surface!)

Me? I feel like one of thousands of helpless little seals swimming along, looking for my buddy Flipper to keep my fur firmly affixed to my hide. The giants of this sea – big centers, big RHIOs, big HIEs, big insurance, big EHR/technology vendors, and big governmental groups – are all thrashing about, stirred by the perceived problem-solving chum of the Obama bucks.

Here I sit, in my little town, in our little community hospital, knowing full well that virtually all of the solutions the sharks are promoting are oriented toward the big boys in the big cities in the big centers. All the while, they ignore that nearly 70% of the NHIN will be comprised of small communities, their associated small hospitals, and their affiliated docs. We, the seals of the U.S. healthcare information technology world, desperately need a dolphin to help us avoid becoming the aftertaste of the sharks.

Maybe Barry (did you know Barack was called ‘Barry’ in college?) and company could be our dolphin. We don’t need all the HIT bells and whistles the sharks are selling, just a little seal’s basic model. A truly end user-oriented, patient-centric but community driven solution, a little “HIT Mini Cooper” - if you will - for the MAJORITY of us, instead of one of those sharky Rolls Royce or Humvee big center/HIE/RHIO/CHIN thingies.

I have a plan for such a system which, for a relatively small chunk of the Stimulus Stash, we could implement for some 70% of the country and …

Aw, crap…did I just sprout big teeth and a dorsal fin?

First posted on http://www.histalkpractice.com/, February 28, 2009

Up Next: “Official Grunt-in-the-Trenches Complete U.S. Healthcare System Overhaul and National Health Information Network in Five Easy Steps Disruptive Innovation Package”