Vik and Al's post on THCB was e-mailed to me this AM with a request for a comment. My reply:
I completely agree. And I completely disagree.
I agree with Zeke (and the research he cites) that the "physical exam" is useless. Indeed, when I was a full-time family physician, I would refuse to discuss/schedule an "annual physical."
But Al and Vik have conflated the "annual physical" with a proactive interaction between a care provider and an individual. Notice that I didn't say "physician" (it need not be a physician) and notice that I didn't say "patient" as we need not think of ourselves - all of us - as flawed or "in need of care" in some way. We're individuals and not patients.
But planning our health, just as planning our finances, or planning our home/car/helicopter maintenance schedules sometimes requires the assistance of a person who has more training or expertise than the individual.
Appropriately managed, this is a regular event, which adds value as the foundation of a trusting collaborative relationship between an individual and a member of a care delivery team.
Just as we needn't gather evidence that parachutes save the lives of humans who fall out of airplanes, we needn't gather evidence that this relationship is important. Yes - text messages, e-mails, activity trackers, wifi scales and video chats are all appropriate adjuncts for the (ideally rare) face-to-face interaction. But they're adjuncts. Not substitutes. We do need time together because we're humans. A physical exam? No. of course not. A "check-in" every year or three? Absolutely.
It’s time to stop calling them EHRs. Yes - we also need to stop calling them EMRs. In 2011, ONC discussed the difference between the two terms, but I think that conversation missed the point: whethere it’s “medical” or “health” that is the focus, these aren’t (shouldn’t be) RECORD systems at all. We need to expand our expectations from CRUD to something that we really need: smart tools that help us collaborate toward improving health for individuals. In November, when I floated this concept, I was teased (corrected?) for focusing on terminology and missing the point that we need EHRs to do more than just store data.
But it’s more than just terminology. Our words mean a lot. A “record” system is for storage of records. It saves information. Our expectations will always focus on storing and retrieving information. That’s the core of the design. But in other industries - we’ve seen migration from information store/retrieve to intelligent platforms that anticipate our needs. Does storage occur? of course it does. But storage of information is the byproduct of collaboration and not the goal.
Let’s call it health IT - or even better - "IT for health.”
This appeared in my e-mail today. It’s an ad for some article that was supposed to prompt us to think about IT from a different perspective. Should IT be delivered from a clinician-centric approach? How is that new? I suppose it’s better than a “CFO-centered approach,” but we deserve even better. As an industry, we've lost focus on our priorities. The needs of the individual are getting lost in a maze of fee-for-service motivated check-boxes and auto-generated drivel. What's the foundation of IT that's best for a patient? THAT’s what should be delivered.
The AMA and 33 other organizations sent a letter to National Coordinator Karen DeSalvo last week. The letter has seven requests of ONC:
- Decouple EHR certification from the Meaningful Use program;
- Re-consider alternative software testing methods;
- Establish greater transparency and uniformity on UCD testing and process results;
- Incorporate exception handling into EHR certification;
- Develop C-CDA guidance and tests to support exchange;
- Seek further stakeholder feedback; and
- Increase education on EHR implementation.
Let’s take them one-by-one …
Decoupling EHR certification from the EHR incentive programs. One could argue that this is already happening, and we can expect it to continue to happen. Check.
Re-consider alternative software testing methods. I’m not sure that “re-consider” is what’s in order here. The letter asks ONC to re-consider the stance on scenario based testing. But ONC’s stance is (and always has been) that scenario based testing is a great idea. Is the goal of the letter to express enthusiasm for this model? ONC will share the enthusiasm. The harder part will be to create a framework that builds and maintains scenario-based test procedures. This is a shared responsibility. Shared by government (ONC and NIST) and industry (health IT developers) and - yes - the AMA and the 33 other organizations who sent the letter. ONC has invited everyone to participate (here’s the open test development site). So far - I don’t see much (any?) engagement from the AMA or the others who signed the letter. It’s relatively easy to write a letter saying someone else is responsible for solving problems. Time to step up to the plate and participate in the solutions, folks!
Establish greater transparency on UCD testing. Yep. I agree. ACBs need to enforce this, and ONC needs to get serious with those who don’t comply. UCD testing results not posted on the CHPL? Give them 60 days warning (more than enough!) and de-list the product.
Incorporate exception handling & C-CDA guidance and tests. These requests expresses AMA’s ambition for ONC (and NIST?) to do full interoperability testing. But as defined by congress in ONC’s authority - the certification program does conformance testing. That means the products conform to the standards. It doesn’t mean they have been tested with full end-to-end interoperability tests. If we want ONC and NIST to do that - there will need to be an expansion of ONC’s authority and budget. Asking ONC to do this is barking up the wrong tree. AMA should lobby Congress on this one, not ONC. Yes - there is some low-hanging fruit here with the C-CDA. ONC could offer more explicit guidance to limit some of the optionality that exists in the HL7 standards. I agree on this point.
Seek stakeholder feedback. I think they do a pretty good job with this. ONC’s FACAs are open to the public, transcribed, and always invite public comments.
Increase EHR implementation eductaion. Well, ARRA funds are depleted. While I agree that there is work to continue here - but ONC and the RECs and the developer community - I’m not sure that this can be increased in context of the current fiscal situation.
I’ll enable comments on this post - as I’m interested in how others view this letter.
Or maybe I should call it "Reider's block?" ..
Despite 15 years of blogging - this time, I've written and re-written a post so many times I can't count them. So here's one to get me started.
I had dinner last night with a former colleague who has had a long track record of success in government, health care, and education. He’s getting close to retirement, and we talked about what has driven him – what he sees in himself as a leader, and why some people seem to find success so consistently, while others do not.
His goal after retirement is to teach in community colleges. A community college grad himself – he reflected that these schools are special places that help others succeed. Period. The faculty are not arm-wrestling for status or grandeur. Students often have had other careers, or had less-than-stellar high school performance.
He is a noble guy – with altruistic goals – and I think that this demeanor is what’s helped him succeed throughout is career. I observed that his interest in teaching community college students aligns perfectly with how he’s approached every other job: to help others succeed. It’s not about himself or his own personal achievements.
This demeanor is uncommon. But it’s certainly aligned with how I’ve tried to be throughout my career as well. Success as a physician wasn’t ever measured by my income, or the number of patients I saw in a day – it was measured by my patients' success. I served them. Period. To help them reach their own personal goals of health and happiness.
And then – at some point fairly late in my career – I realized that this approach – helping others succeed without judgment – without invoking MY agenda - was the same set of attributes that would align with success in other domains.
Fast forward to January 2015. My dad has been in the hospital and I’ve once again witnessed the dysfunction of our care delivery system from the other side of the stethoscope. It’s a sobering reminder. The culture of health care that I witnessed in Boston (at the “best “ hospital in the world) remains disconnected, distracted, and aligned on the wrong incentives:
- Revenue. Fee-for-service models push care providers to maximize charges rather than care quality, patient experience, or best outcomes.
- Recognition. Smart, assertive heroes who do more, and write more papers and get more national or international recognition are perceived to be "better" physicians than folks who listen, share decisions with patients, and really focus on the right stuff.
Despite many efforts to change the way we pay for care, educate our physicians, or create stage 4 cultures - so far, it's not working.
But we can't stop trying.
And so my next chapter will be focused on a few guiding principles:
- Work with great people who want to do what's best for others - to really add value to the world in a way that will empower others to find health and happiness.
- Facilitate new cultural norms in health care that focus on shared decisions, collaboration, transparency, and compassion.
- Avoid people and organizations who want to be "rock stars" and succeed for the sake of success - either in status or revenue or power.
Have you ever noticed that when baseball players hit a single and land on 1st base, they can be seen chatting with their "enemy" on the bases?
I enjoy watching them - and wonder what they're talking about. It reminds me that despite the animosity often expressed by fans, baseball is just a game. The players are all players. They may switch sides sometimes, but they are really all the same - working toward the same goals, with the same methods.
Players in every industry change teams. It's normal, common and in fact it's a good thing. When we leave one "team," we bring the culture, values, passion and insight that we built into another organization. Such diversity of thought, values, vision and culture is what keeps us all growing as people and as teams - working toward shared success.
This isn't always apparent to those off the field. A few years ago - a good friend of mine was diagnosed with a serious illness. Some of the greatest support for her (and her family) was provided by her counterparts at competing companies. It was touching - but not surprising - to see others rally around her and support her as she fought back to complete recovery.
And what a privilege it has been for me to work within a community of government leaders, industry leaders, community leaders, consumer advocates, informaticists, and researchers as we strive toward better health for all.
I started this blog fifteen years ago on November 15th. Here's the first post. Stay tuned for (much) more from me in the next few weeks - toward a 15 year anniversary post on 11/15/14, and a re-launch of Docnotes for its 15th year.
I got a call from a friend last night. He's the CMIO for a large hospital. He's smart, works 80 hour weeks, and he's passionate about getting his EHRs to work right, the providers trained right, the order sets configured right, and (most importantly) the patients treated right.
He's been in the role for a number of years - and he's good at his job. Very good at his job. He knows the systems (from two EHR vendors - an inpatient system from company A and an ambulatory system from company B) better than many employees of the companies. He's memorized the criteria for Meaningful Use down to the section and subsection numbers. It's amazing. I had a similar role once - about ten years ago - and I vividly recall mentoring him into his new position back then - thinking that his hospital would do so much better than mine - as he'd see the puddles we had already stepped in. ..
He's an incredibly gifted physician too - and continues to see patients at least 20 hrs a week - with a full call schedule.
But tonight he called me because he wants to quit his IT job and go back to being "just a doctor."
Because the politics of the IT world have been too much for him.
"The analysts didn't finish the order sets and blamed the doctors for not reviewing them."
"And the doctors insist that they WANT to review them, but the analysts tell them that they're not ready to be reviewed!"
"We're behind schedule and all they do is blame someone else."
"Why are they lying? Why do they get mad at me when I point out what's going on?"
I listened. And listened. It sounds dreadfully challenging. He's implementing TWO EHRs, and getting CPOE up and running in an outlying hospital, and migrating a community of physicians to new workflows, new processes and new habits. This is no simple task - and he's got the technical details down cold.
And he's done a great job with all of it ...
Except his relationship with the IT team.
This is not uncommon. But there is a solution. An easy one, in fact.
"Your should pretend you're a doctor." I said.
"I am a doctor!"
"You're a doctor when you are with your patients. But it doesn't sound like you're a doctor when you're with the IT team. It sounds like you are an angry parent!"
We talked about this for a while. He wasn't sure where I was going - but he was intrigued. He knew that somehow I have found it less difficult to navigate the political mine fields of hospitals, academia, industry and government. Indeed - his minefield is my Fenway Park! Am I serious that I want him to treat the IT team like they are his patients?
"If your patient tells you that they have been dieting and exercising but they are still gaining weight - what do you say?"
"I would say that I believe them 100% - that they are dieting and exercising and that I want to find ways to help them."
"Do you really think they have been dieting and exercising as much as they say?"
"No. Of course not."
"So why do you not challenge them? Why don't you point out how wrong they are - and that they are fibbing?"
"Because it's not important if I am right. That won't help them."
"So why is it important that you are right that the analyst streched reality a bit about doing the order sets for Dr PooBah?"
"Because they didn't do what they are supposed to do. I need to point that out."
"OK - I can see what you are saying but it still doesn't make sense. How will my NOT judging them make them get their work done?"
So this is the key leap of faith for him. It seems like these are different settings, different goals, and he should use different skills.
But it's not necessary. The same skills that make a great empathic physician will also make a great empathic results-oriented CMIO.
He's built a (medical) career of great habits that we can leverage. The habits he'd built are the ones he uses every day to care for his patients in a collaborative, meaningful, non-judgemental way.
The key to his success in the IT world is to say (to himself) just what he says to his patients:
"Because it's not important if I am right. That won't help them."
The focus shifts from blaming them for being lazy, lying IT enemies - to "folks who need my support."
Dr CMIO - you already know how to do this!
I could tell he was interested - but still wasn't quite at the point where he could make the leap. We talked about the dysfunctional team of IT analysts, how they gossip and argue and sidestep work.
"It sounds like they are very unhappy" I say.
He got quiet.
"Yes - they are - and they make everyone else unhappy."
"So what do you think would happen if they felt like you were an ally? Like you wanted them to be successful?"
We went on like this for an hour or so. It's a hard shift - but quite powerful. He remarked that I was soundling like a buddhist - and I pled guilty - but pointed out that this is not just a buddhist principle to avoid judgment - it's a core component of many of the "success in management" books too - most of which avoid invoking religeon or spirituality. A few good ones to consider - probably required reading for any CMIO:
I'm giving a talk to a bunch of CMIOs in a few weeks. Maybe I'll leverage this vignette into a little sermon powerpoint.
Like you - I get (and send) more e-mail at work than I would like. E-mail is a great communication tool, but it's hard to manage. Many add-on tools and processes exist to help people manage their own e-mail, but I've adopted some processes that (I hope) are helpful to the people who are RECEIVING the e-mails that I send.
A core principle of great communication is that we must meet the recipient of our message where they are.
- In education - this means we focus on the needs of the STUDENT rather than the needs/skills/ knowledge of the teacher.
- In health care - this means we focus on the needs/readiness/goals of the PATIENT rather than the skills/knowledge/bias of the provider(s).
- In journalism, fiction, poetry, art - the creator is most sucessful when they focus on expressing things in a way that will be MEANINGFUL the audience.
- In software and technology design - the best products understand and ANTICIPATE the needs of the intended user.
So in e-mail - how can we help the recipient(s) who already have 329 unread messages in their inbox. We need to help them understand what we expect them to do with this message - so they can "done" it right away and get on with their day.
Seven Rules for Sending E-Mail
- Always clearly define an "owner" for a requested action. If you are asking for something to be done - only one person should be in the "To:" line - and you should be clear that this person is the one you're asking to be responsible for getting it done.
- Prepend "FYI" messages with "FYI-" in the subject line. This lets the recipient know that they an review it later - or that reading it will be quick and won't necessarily cause new work. If you are not asking anyone to do anything - then there is no task for anyone. An "FYI" e-mail just informs others of something that they may need to know - so that they can (if they so choose) incorporate it into their future decision-making, or so that they are not surprised. You may find that you often send "FYI" notes to your boss. A wonderful mentor once taught me never let your boss be surprised. An "FYI" note should be short and clear. If someone has to scroll an FYI note when it shows up on their screen - it's probably too long.
- Private messages should be clearly identified with "DNF" (Do Not Forward) in the Subject Line. This is clear request to your recipient(s) that you want the information in the message to remain private. Use this sparingly and with people you trust - since of course there is nothing that technically prevents them from sharing your message. Nonetheless - "DNF" makes it very clear to the recipient that you trust them with this confidential information, and that you want them to keep it to themselves. Use this sparingly.
- Use Whitespace. The "return" key is your friend. It's much easier for your recipient to read a message (especially on a smartphone) when you use short paragraphs of no more than three sentences.
- Use spaces or hyphens for numbers greater than four digits. English readers have a hard time keeping more than a handful of digits in working memory. Conference lines often have a dial-in number and then a four to eight digit access code. While you may have memorized the access code - your recipient has not - and will struggle as they finger it into their phone if you don't break it up into three or four digit chunks. Extra credit here for adding the number in a form that smartphones can parse with one "press" on the screen.
Blackberry, iPhone and Android can all parse a sequence where the conference line follows (with no spaces) the dial-in number and a lower-case "x" like this: 800-123-4567x123-456-7890. Note that you can/should still use hyphens here so the humans reading this number can do so easily too.
- Use "out of office autoreply" sparingly. Offer clear feedback for when you will be able to return messages (not just when you will be online again), who is your delegate while you are offline, and how you can be reached in an emergency. People don't need to know if you are "away on business" or the name/location of the conference/meeting you are attending or where you will be on vacation. Keep such details out of the "autoreply" message.
- Keep it short. "I would have written a shorter letter, but I did not have the time." - Blaise Pascal. Take the time to make it short. This shows respect for your reader and their time.
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?
This is one of the best essays on software product definition/ direction etc. that I've read in a very long time.