Death by a thousand clicks

I have traveled to several nations in order to directly experience very successful adoptions of health information technologies. Interestingly, when other nations follow a typically American approach to implementation of electronic medical records, they are equally prone to failure. Here is an interesting example from Australia

From 6 minutes Blog in Australia (Emphasis, added, is mine)

"... of e-health ventures - they assume that information is everything, and that doctors and other healthcare providers must change their practice to fit in with the new efficient systems that they deliver..."

"..., this multi-million dollar system was bought 'off the shelf' by the state health department and imposed on doctors from above. The feedback from those who have to use it is not good. Among them is the complaint that a lot more clicks are needed to enter information, and this means more time for each consult and less time spent treating patients..."

"...The reality is any change causes anxiety in human mind. The transformation of health care delivery system from traditional to technological is inevitable. As a medical fraternity we have to accept this reality. We doctor need to upgrade ourselves beyond the "email savvy" personality.
The more relevant question is how best we can facilitate this change. I agreee with the author that anything that is resource (time, labour, knowledge, money) consuming is not going to work. And it should not. The basic principle in accepting something new is that it has to be user friendly and resource efficient.
Unfortunately, the software developer in most instances do not have adequate understanding of the context, scope and process of healthcare services delivery. Software developers are brilliant in technical aspect of technology but they need to work in co-operation with medico to understand their both physical and emotional (you may laugh, but this is true!) requirement and come up with the best solution to meet the end objective and those are efficiency and effectivity in health care delivery.
Health care system is evolving- there are new generation of doctors who are proficient in management and leading the health care institution. Similarly we need doctors/nurses etc who are proficient in IT..."

"...New technologies require an open mind. One has to adapt to the improved methods and procedures they could provide but it is also good if they can adapt to users' wishes and styles and maybe this is the major problem with the States' health systems..."

"... medical practice is actually very knowledge intensive - and to get it right - on behalf of the patient - you need to be an expert in collecting and handling both patient information and clinical evidence. Failure to use both well is not good for either patients or their carers..."

"...e-Health can help. Its not the total answer but used well it can assist in my view...

"

The "free EMR from the hospital" Field of Dreams

The so-called safe harbors or relaxation of the “Stark Rules” has proven to be a mixed blessing for physicians and their patients. The intent of the relaxation was to make it easier for physicians to acquire information technologies by having it provided by local hospitals and health care delivery systems. Local hospitals providing EMR technologies can be beneficial if precautions are taken. The following includes some of our observations and suggestions:

Accept no return on investment analysis (ROI) from a vendor that does not include line items calculating physician productivity losses over time (based on your own measurements). Determine who absorbs the expense and consequences for the increased clerical time associated with the documentation tasks in your practice. For example, if the system adds an additional minute per encounter, and you average 25 patients daily, who absorbs the extra 25 minutes each day of lost "productivity?" This is most often the real cost to physicians for EMR systems. The cost savings to have a "donated" system often pales in proportion to the cost of lost physician productivity. If an employer is necessitating that employed physicians use an EMR, is the physician to be paid extra for working another 25 minutes each day? Or, will the physician's salary be cut because they are seeing fewer patients? Get written answers that deal with the consequences over the long-term after the initial implementation.

Many physicians are being pressured to use donated-sponsored EMR's that typically add an extra hour of clerical work each day. To physicians, these "free" systems can sometimes be terribly expensive.

Many systems being chosen for these projects are difficult to customize to meet physician’s unique needs. Count the steps and the seconds required to make some type of simple edit to the system that will be unique but important to your practice.

We have had several physicians report that they are having to replace an EMR that takes 2-3 steps and 20 seconds to generate a prescription with one that takes 5-10 steps and 1-2 minutes. Count the steps and the seconds required to create and send a typical prescription for your practice.

In these “enterprise-focused” systems, physicians are often forced to collect data in a fashion that detracts from patient care and well-being. For example, it is common for physicians to have to focus on capturing and reporting 10 to 20 clinical data elements for every patient (even for every influenza patient during influenza season). Count the steps and the seconds required to document a simple influenza encounter (or one typical for your practice).

The normal outcome in many of these projects, to date, has been that many (perhaps even a majority) of physicians report they are being forced to use systems that greatly increase their charting time, makes them less efficient, and it lowers their productivity.

Check the evidence rather than listen to the sales pitches. The reality is that many systems marketed as "enterprise EMR's" are often very unfriendly to physicians and patients. They are more friendly to the billing and administrative departments.

Understand that all vendors (even those experiencing de-installation rates of 30-40%) can send you to "satisfied" installations. Conclusions made from site visits arranged by vendors are likely to be in error.

Physicians not having and/or making the final decisions regarding EMR vendors are setting themselves up for disaster. This is one decision where delegation results in a disaster rate of 30 to 40% based on industry surveys.

Well designed and implemented EMR systems should not result in decreases in physician productivity, but all require a stage of customization that will need to be budgeted (time and expense). Planning for fewer patient encounters or for income loss during implementation is a key sign of either a flawed EMR, a flawed implementation plan, or both.

All physicians know of sites where systems were implemented resulting in significant losses of physician productivity. This does not mean all vendors deliver systems causing productivity losses.

Before sign-on, have specifics (price, functionality and timing) in writing regarding any interfaces. Some systems marketed to enterprises may sometimes promise interfaces to other systems. However, the average cost to a small practice is $14,000 just for a simple exchange of demographics. The offering of more robust interoperability is rarely, if ever, a reality. From a patient and physician perspective, the relaxation of the Stark anti-trust rules, within an industry that has little to no affordable interoperability, may be doing more harm than good in some localities via the creation of monopolistic information systems.

Before sign-on, have a written, affordable exit clause with specifics. Most of these systems store (i.e. trap) your data in a proprietary database so that you can only get to it through the single vendor’s proprietary software. (This is the norm, and an average cost to be able to get your patient's data out of the system averages $10,000,if it is even possible.)

Some hospitals having a primary focus on good patient care and evidenced-based medicine simply can’t afford the expense associated with the systems being actively marketed to enterprises. They are increasingly being placed at a competitive disadvantage when they have to compete with delivery systems having a primary focus on enhancing their profit centers.

A rare but particularly egregious situation is that physicians wanting to use information technologies to promote more efficient use of resources (i.e. fewer unnecessary medical procedures) are sometimes being replaced with mid-level providers who are allowed to do little more than simply capture the necessary data allowing patients to be triaged to the appropriate “profit center.” (Note: We strongly advocate using mid-levels as a part of a team focused on delivering the best practices of evidenced-based medicine.)

Inevitably, our nation is on a course to burn through a lot more money and effort. What is a very high failure rate in enterprise settings where doctors are often hostage (but have more resources) will be no less than an 80% failure in the rest of the medical world where most practices exist.

Considering these issues can significantly increase the likelihood that sponsored EMR systems can better serve patients and the doctors deserving of their trust. The recommendations are based on direct observations and experiences over the past few years and at hundreds of sites.

The Open Source "Field of Dreams"

IMHO, expecting that an open source EMR is the solution is another example of the same flawed thinking that we can't seem to get beyond. It is still about starting with "what is the right technology?". The software is not where the big expenses come in, it is in the process of practice transformation where the expenses tend to rack-up. There are at least 6 fairly good open source EMR's already for the ambulatory EMR space, and then there is Vista from the VA. It simply costs too much to implement free software for most practices. And, no matter how much better the technology in the near future for these "free" software systems proves to be, they will still probably be too expensive because they have usually been designed by geeky types who are very dissimilar to what exists in most practices. They have little focus on designing the software with the proper focus of facilitating a non-disruptive implementation process. This is a far greater challenge than creating software that only does something!
In order for the software to be affordable, the core has to be fine-tuned to be able to be implemented as efficiently (start simple, then incremental evolutions) as is possible. So, the core of the "killer EMR" will not likely prove to be full OSS. However, the core should be completely accessible through an open SDK/API approach, so that it can be extended-interconnected with as few limitations as is possible and without introducing chaos and inefficiencies in the practice.
Implementing technology in a medical practice is very dissimilar to installing an Apache web server system. The latter does not require all the workflow and social re-engineering that is a far greater challenge.
I doubt it will be wise for SOAPware to turn our solutions into a completely open source project for these reasons as well as many others.

"Field of Dreams" Entertainment in HIT

Following up from the previous post, some were confused a bit as to what I meant when I referred to "fodder for entertainment." So, I thought I would post a link to an early video demonstrating a Health Information Technology Field of Dreams.
In all fairness, the video demonstrates technologies that include obsolete panel switches, and analog relays that have been replaced with "cloudy" terms such as RHIO, SOA, C##,.net, Java, etc. However... the more things change, the more they stay the same. We just get to play with cooler toys, and it gets more expensive.

Will it ever be understood that the technology is not the answer, no matter how "good" it is?

How many more iterations of the Field of Dreams can we endure?

Who has a clue?

The “Field of Dreams” Myth and the Health Information Technology Industry

The Myths:

“ If we build it, they will come.”

If only the technology is good enough, it will be purchased/adopted, and we will be successful.

Pressure from the government and payers will force the transition to electronic medial records.



The Realities:

The real customers are not wearing dark suites, do not have MBA’s, nor do they wear shiny shoes.

What may make perfect sense to the decision makers are commonly disastrous for those actually delivering the "care" as well as for their trusting patients. (In spite of good intents and visions)

No amount of incentives or pressures from above will succeed unless the solutions ease the pains of the caretakers in the white coats.

Implementation is a poorly understood term that is causing much confusion as well as misguided efforts. Thus, current EMR failure rates in the industry are in excess of 80% (if success is defined as comprehensive physician use).

Success with an EMR at a site or two does not promise the solution/approach can be generalized. This is especially true if the site has implementation resources greater than the norm.



The Consequences?

Great fodder for a movie or entertainment?

Billions more wasted dollars and more years of wasted effort?

Implementation Change Confusion

Main Points from EMR Implementations Change Workflow

"... if you don’t have an EMR, your current workflow is bound by the paper world in which you now live.

... adding an EMR to the mix provides some new ways to serve patients that were impossible to accomplish in the paper world.

...don’t confuse changes to your workflow with changes to how you treat a patient. "


Actually, how you treat patients is likely to incrementally improve as the possibilities become apparent. To successfully climb a ladder, start with the first rung rather than peering up to the one on the top.
Successful EMR implementation starts at the lower rungs rather than the last one at the top. The lower rungs may look and feel a lot as paper does. The upper ones are not likely to be very similar. But, the key is achievable, non-disruptive elevations of what doctors do best.