Docnotes

12 years of blogging .. about medicine, technology and their intersection ...

This post from November 26th, 1999 - was the first on this blog.  There were a few months of previous posts, but due to several platform changes back then - these seem to be lost.  

No matter.  12 years is a long time.  My blog is now officially an adolescent.  I wonder what it will be when it grows up!  Long-time readers are of course observant that I've been remarkably quiet for the past few years.  This is due to my evolving work for an HIT vendor and now the Federal Government.  

So I've been operating with this in the background for the past six years:

The opinions expressed on this blog are my own and do not represent the veiws of my employer.

And there is a rough "social media policy" (google docs - you have edit rights .. feel free to steal or enhance ... ) that I have in my head as well .. so in general I have done my best to observe and occasionally point to important publicly available information, but take care not to comment too deeply - for fear that others would interpret my commentary as a telegraph of my employer's next steps.  This wouldn't be appropriate for me to share - and increasingly - I am concerned that most of my public thoughts could be interpreted in this way - so I've been holding back from any public commentary.

So for now - here we are. 

I'll push the envelope a teensy bit and comment on some events of the past few months:

Tim HISTalk covered my arrival at ONC in a post about a month ago.    He asked the right questions about the topic at hand - but he didn't get to the one that I am hearing often these days - which is .. "Why did you leave your leadership role at one of the top health IT companies, choose to spend weekdays away from your family, AND (with two kids in college) take a giant pay cut?"  

The answer is easy:   It's the right thing to do.  

Health Care in the United States  is at a turning point.  It is well known that despite great advances - we don't provide the quality of care that we would.   It is also self-evident (to me) that technology - carefully applied - will improve both the quality of care - and the efficiency, sensitivity, and ease with which it is delivered.  Yes - some of those words may not be familiar to you - but why WOULDN'T we want it to be EASY to deliver great care?  Why shouldn't we deliver SENSITIVE care (sensitive to your hopes, religion, fears, preferences) - in addition to efficient, evidence-based and (of course) cost effective) care?

 So I have always tried to focus my work on helping others meet their true potential.   In my first career - as a 16 year old sailing teacher, I helped kids find the freedom and autonomy that a good breeze and a sunfish will provide.   As a teacher of junior high school kids - I witnessed breathtaking intellectual growth in a herd of 12 year olds who were otherwise distracted by adolescence and its daily challenges.  Working with (some say "caring for") patients as a family physician - I found that my most important work was not to take control and "fix" my patients (as some of my mentors had advised in medical school) but to partner with my patients - serving as a resource - without any judgment or critique.  As Bill Miller and James Prochaska have demonstrated (motivational interviewing, transtheoretical model) - people change when they choose to - and no sooner.  Can we facilitate growth in others?  Of course we can.  But "facilitate" and "cause" are inherently different.

As a leader in a large health IT software company - my role was often to help our teams align the software products we were producing with the needs of our customers.  This is not unlike the role of a good physician:  we need to listen carefully and critically so that we understand the needs (which will sometimes differ from the "wants") so that we can facilitate success.

And isn't that the role of government too?   Perhaps that's a political question.  Some would argue that government should get out of the way, while others would argue that there is an important role for government to provide an infrastructure with which success can be facilitated.  Is a healthy happy nation something that is important?  Are there ways that government can facilitate a migration toward these goals? 

I think so.  Keep an eye on my occasional tweets , g+ posts (rss), and posts here on this blog.  It will continue to be sparse here on the blog. 

Can we solve these problems with IT?

My fax machine has too many faxes in it every morning

 

Analog office:  .. My fax machine has too many faxes in it every morning

which my staff put on a pile on my desk and then I try to read them and act on them  by scribbling illegible notes on them and putting them in piles on someone else’s desk. 

 

Digital office:  My fax machine has too many faxes in it every morning .. which my staff scan into my EMR and then I try to read them, and act on them often using a separate system functionality – so need to leave the “reading” work stream, do the action, then return to “reading”

 

Reassuring Lab Results just arrived (by fax, mail, local printer, etc)

 

When I get labs back – most of them are normal.  I can:

 

Initial them (digitally or pen/paper) and put them in the chart (paper or digital) Tell the patient that “no news is good news” (which is  terrible customer service, BTW)

But some will call (they should!)

So the chart gets pulled (paper office)

And someone calls them back (usually nurse)

And sometimes answers the questions

And sometimes the patient still wants to talk with the provider

So now it comes to me Like 50 other ones

I stay in the office until 8 PM calling my patients back And they ask other questions when we are on the phone Or they are not home so I leave a message So there is a loose end that I have to manage tomorrow.

 

 I am a specialist – seeing a new patient for the first time.

 

I don’t have any records – so my nurse or AA calls the referring provider, pharmacy (for medication list), and hostpial (for recent H & P/Discharge summary)

 

I wait Some of it arrives via fax Most of it arrives tomorrow I call the preferring provider’s office.

 

 wait The provider comes to the phone

 

Can’t remember much about the patient

 

Asks her staff to pull the chart We wait and talk about our kids in College

Our waiting rooms fill up with angry patients and well-dressed drug reps with too much cologne

Chart is “not found” – it must be in a big pile somewhere

We both get frustrated – referring provider hums a few bars from memory. 

We hang up. I make decisions with the patient based on incomplete data

I dictate my progress notes

I sign them (barely review them) when they come back in 3 days from the transcriptionist

They go into the chart (digital or paper)

My staff faxes a copy of my note to the referring provider.

 

I am a provider writing a prescription for Clarinex

The patient has seasonal allergies

Has tried “everything else”

The drug reps left a pile of these and I gave some to the patient last time she was here

They work “wonderfully”

She wants more

So I write a prescription

Which she takes to CVS 

And they want to charge her $107.50 

Because it’s not covered 

So she calls my office

And my nurse says she’ll work on it 

So she gets the chart 

So she looks up the insurance company (BlahBlah Healthcare)

And then she calls the “prior authorization” phone number 

And waits on hold 

Until a person answers  

Who sends a fax  

Which the nurse gets 4 hours later

And gets the chart again

And she fills out the form on the fax

And she puts it on my desk with a “sign here” sticky note on the signature line – and pointing to the (empty) justification section 

I get it on my desk the next morning  

I fill in the blank sections of the form and put back on the nurse’s desk

Who faxes the form   …

3 days later the patient calls and asks if this is done.

Different nurse pulls the chart and sees the copy of the fax that was sent to the insurance company – so she says yes.

Patient goes to CVS who tries to charge her $107.50 again

Patient goes home and calls the office

Nurse pulls chart again

Nurse calls BlahBlah Healthcare.  Turns out they haven’t processed it.  They will process it and will let us know if it’s denied (They won’t let us know it it’s approved).

Nurse calls patient and tells her to try CVS again in a few days.

Patient gets angry and yells at nurse

Nurse was depressed anyway and quits her job – slamming the door on her way out, hitting a child in the head as he comes in for his 3-year well-child visit.    He is conscious, but has a laceration on his forehead that will require repair.  The kid’s mother says she’ll sue the physician “for everything he’s worth” as she drags the kid off toward the emergency room.

She hits a raccoon on the way home, barely missing an Oak tree as she tries to avoid little Rocky.

She calls her physician and requests some Xanax to “calm my nerves” – beginning a life of dependence on benzodiazepines and poverty.  She stops making payments on her mortgage, loses her home, and was last seen living over a ventilation grate near the Misys offices in New York City.

Faughnan's a grown-up now!

John's recent post on my "medical office mashup" comment is, as my colleague Paul would say, "spot-on." What I learned from his discussion:

• Long ago in a Minnesota far-far away .. where Gopher was born .. and professional wrestlers were still wrestling ... John used to look up at that cold sky and dream of medical mash-ups.
• In a weak moment - you can still see that little kid in John - but he's been hangin out with the suits lately - and they make him say things like this:
  

  "Building a 98% reliable solution from x integrating parts requires (1- x*y*z...) reliability from each component."

Of course - he's right. That's the problem with the CIO types that he hangs out with -- they're usually right.  Too many points of failure, too many dependencies on "foreign" systems, etc.  Gotta do it the "enterprise" way. 

But we've got to be able to dream these dreams - because they are the right ones to have. Sure - Google's calendar API will change and I'll zig with their zag - because for a user base of 1 person - this software is neither "mission critical" nor 100% reliable.

If we did everything the enterprise way - there would be no Internet.  TBL's vision was that by connecting things - we can derive enormous value.  Consider this section of one of his most famous essays:

 ... For all these visions, the real world in which the technologically rich field of High Energy Physics found itself in 1980 was one of incompatible networks, disk formats, data formats, and character encoding schemes, which made any attempt to transfer information between dislike systems a daunting and generally impractical task. This was particularly frustrating given that to a greater and greater extent computers were being used directly for most information handling, and so almost anything one might want to know was almost certainly recorded magnetically somewhere.

Design Criteria

The goal of the Web was to be a shared information space through which people (and machines) could communicate.

The intent was that this space should span from a private information system to a public information, from high value carefully checked and designed material, to off-the-cuff ideas which make sense only to a few people and may never be read again.

The design of the world-wide web was based on a few criteria.

• An information system must be able to record random associations between any arbitrary objects, unlike most database systems;
• If two sets of users started to use the system independently, to make a link from one system to another should be an incremental effort, not requiring unscalable operations such as the merging of link databases.
• Any attempt to constrain users as a whole to the use of particular languages or operating systems was always doomed to failure;
• Information must be available on all platforms, including future ones;
• Any attempt to constrain the mental model users have of data into a given pattern was always doomed to failure;
• If information within an organization is to be accurately represented in the system, entering or correcting it must be trivial for the person directly knowledgeable.

Lots of what TBL said in 1996 (about physics in 1980) still applies to healthcare in 2007.  shame on us!

So my tiny project (total time invested <2 hrs) is an example of how we might start thinking about the parts fitting together.   It's 2007 and there are companies out there that have already started to develop and deliver webservices that provide important parts of the EMR infrastructure.   They work today - and will do more tomorrow.

Of course I've been wrong before ... a professional wrestler as Governor?  Never.  :-)

technorati tags:EHR, EMR, Web, TBL, Faughnan

What makes a good doctor = what makes a good plumber.

Medical Decisions are hard to make.  Even when they seem easy.  

I'd say that the TV show "House" is popular because Dr House seems to focus on giving patients what they need (honesty, transparency, certain treatments) and not necessarily what they want.   In his case - the difference between the two are entertaining.   Does that make him a good doctor? 

In real life - this is much harder.   There's ample evidence that physicians' decisions are based on many factors.  What's best for the patient is simply one of these factors. 

We've had a medical student working on our office recently - and it's been interesting to see my practice style mirrored in her eyes:

• I "actually listen" to my patients (who doesn't?   I wonder ...)
• I spend lots of time with my patients (no wonder I come home late every day!)
• I hear what they mean - not just what they say (the hardest part)

I re-told this story to her - in abbreviated form.  I posted it nearly 5 years ago - but the principles I tried to highlight then remain important yet under-represented on the Internet today.  Medical blogs are now far greater in quantity - yet I still think there are rather few of them  that express the transparency that the initial work a few of us were striving for back then.   There are so many competing interests - for our time, our money, and our attention.  Without good principles - I'd argue that there is no way for physicians to stay the course - and really make the best decisions for our patients.

The National Physicians Alliance is a relatively new organization that's building steam - based on good principles.  It's great to see an organization that is committed to "Advancing the core values of the medical profession: Service, Integrity, and Advocacy."   You can also read the NPA’s ISSUE BRIEF outlining reasons why physician prescribing data should not be made readily available to pharmaceutical companies.  The issue brief mentions describes how to opt out of pharmaceutical industry data gathering by enrolling in the AMA's Physician Data Restriction Program (PDRP).  Cool.  Check.  Done. 

Integrity is so important - yet so often suspect when there is opacity.  Exposing our patients to the uncertainties of our profession is a cornerstone of shared decision making - yet it takes so much more effort - and so much more time - I'm not surprised that so few physicians actually do it. 

The same goes for plumbers.  We had a "free" cleaning of our furnace performed by these folks last week.  The service rep called my wife at work and told her we needed a new humidifier element for $45.  He happened to have one.  Said OK.  We also needed a new solenoid for the humidifier for $89 "on order."   Turns out - I replaced the humidifier element about 6 months ago (should be done once/year) and the solenoid seems to work just fine to me.  You can listen to  his explanation - left on our voicemail.   Now -  look at the picture. Water running pretty well, if you ask me!   I filled an 18 ounce cup in under 30 seconds.  If that's a "very small amount of water" - I think Gary needs to go back to plumbing school.

Either Gary is stupid - or he's lying.  Either way - I can't trust him or his company ever again - as I suspect that he's got his interests above mine.  I could buy the solenoid (see link above) for $45 if I really needed one.  And I'm a little mad that he took my 6 month old humidifier element with him when he sold me the new one (it's the honeycomb thing in the picture).  Either way - he can't be trusted.

We need trustworthy plumbers, doctors, bankers, lawyers, software developers, etc.    The principles of the profession  must guide our decisions.  If not - we will always be distracted or seduced by the many other choices on our path.  Plumbers who invent problems, doctors who self-refer, and software developers focus more on the icing than the cake - all compromise their integrity in the same way - and will ultimately lose.   

Relax NG

Dave says we should all Choose RELAX insteat of xsd.  I'm convinced.  It'll take a lot more than this to move HL7 and ASTM (among others) as WC3 is seen as 'the authority.'

Misys Healthcare Hiring Physicians for Clinical Insight Group

The Misys Clinical Insight Group Application is now online. This is a great opportunity for clinicians with interest and skills in informatics to work with a top-notch research and development team as the next generation of the Misys EHR and PM systems are designed and implemented.

It's a part-time role (as much as 5 hrs/week) that involves detailed analysis of clinical workflows, review and analysis of use-cases, user interface designs, business requirements, and functional specifications, brainstorming with graphic and functional design analysts, and a few days of travel roughly every 6 months. Ideal candidates will have informatics education and/or significant implementation and/or development experience, and have a good understanding of usability principles and appreciation for the importance of human factors engineering in clinical applications.

Questions? Fee free to contact me about the team and the work we're doing.

 

Do you need styled text in the EHR?

EHR Focus group in SF?

In San Francisco for the STFM meeting?

Want to help us understand what the next generation should look like/function?

Sign up here for a free dinner .. and you'll get an iPod Shuffle too!

 

More on usability

The "Fitts Law" quiz that Bruce (aka "tog") developed doesn't seem like it would have anything to do with user interface design for an EMR .. but it does.  An example:

Explain why a Macintosh pull-down menu can be accessed at least five times faster than a typical Windows pull-down menu. For extra credit, suggest at least two reasons why Microsoft made such an apparently stupid decision.

Answer:

Microsoft, Sun, and others have made the decision to mount the menu bar on the window, rather than at the top of the display, as Apple did. They made this decision for at least two reasons:

1. Apple claimed copyright and patent rights on the Apple menu bar
2. Everyone else assumed that moving the menu bar closer to the user, by putting it at the top of the window, would speed things up.

Phalanxes of lawyers have discussed point 1. Let's deal with point two. The Apple menu bar is a lot faster than menu bars in windows. Why? Because, since the menu bar lies on a screen edge, it has an infinite height. As a result, Mac users can just throw their mice toward the top of the screen with the assurance that it will never penetrate and disappear.

Unless, of course, I'm testing them at the time. I did a test at Apple where I mounted one monitor on top of another, with the menu bar at the top of the lower display. The only way the user could get to the top monitor way by passing through the menu bar enroute.

I then gave users the task of repeatedly accessing menu bar items. When they first started out, they penetrated into the upper screen by around nine inches on average, just because their mouse velocity was so high. Then they learned they had to slow down and really aim for the menu. By the time they adjusted, their menu-access times became so ponderously slow, they took around the same time as the average Windows user.

The other "advantage" usually ascribed to a menu bar at the top of each window is that they user always knows where to look for the items pertaining to the task they are carrying out. This is silly. Users may do various tasks within a given window, and the menu items may change. Not only that, but a great many perverse applications exist, particularly in the Sun world, where the menu bar you need to access is not even in the window in which you are working! That is truly bizarre and mind-bending.

Microsoft applications are beginning to offer the possibility, in full-screen mode, of a menu bar at the top of the display. Try this out in Word or Excel. It is much faster. Microsofts general cluelessness has never been so amply displayed, however, as it is in Microsoft Visual Studio, which has a menu bar at the top of the screen with a one-pixel barrier between the screentop and the menu. Talk about snatching defeat from the jaws of victory.

Tog has been writing about usability since the early 1980's.  He used to write a column in the Apple Developer's newsletter that I would turn to right away as soon as the newsletter arrived in the mail.   Ahhh ... the mail.  Not much of value arrives in the little white truck anymore ...

EMR Usability

I've written before about EMR usability.  It's the missing feature in many EMR evaluations.  They all have bullet points:

• Prescription Writing
• Problem Lists
• Medication Lists
• Allergy Checking
• Scanning support

And so on ... but

• Is easy to use

Isn't necessarily on anyone's list .. and even if it is .. this is hard to measure.  While usability is subjective .. there should be simple ways for us to define usability.  How many mouse clicks does it take to accomplish a task?  How long does it take to do something?  Vendors brag about ease of use ... but it depends on the context, the user's skill level, the hardware that the product is used on .. etc etc etc