Advice to the new National Coordinator

Two and a half years ago, John posted an entry with this title – and I recall that it was a good summary of the state of the industry.  While I didn’t agree with all of his suggestions, I enjoyed the review and it offered a good set of guiding principles.  Since I was Acting National Coordinator for about the same duration as Vindell will serve, (Fall of 2013 – after Farzad Mostashari departed, and before Karen DeSalvo arrived) I’ll offer some thoughts from one who has been in his position.

  1. Certification.  The health IT certification program is the core of ONC’s responsibility to the nation.  While some have called for the eradication or reduction of the certification program, I would argue that this would be akin to scaling back Dodd-Frank.  Yeh – crazy.  As a product of ONC’s certification program, we now have health IT systems that do what their developers claim they do.  Before this program existed, creative health IT salespeople would assure customers that systems had functionality that simply didn’t exist, or was nonfunctional.  The program, like certification programs in other industries (telecommunications, transportation, etc.) is in place to assure the purchasers of products that these products do what developers claim.   Is the certification program perfect?  No.  Of course not.  The program needs to iterate with the evolution of the industry and the standards that are evolving.  Revisions to the certification program must therefore continue, so that the certification requirements don’t point to obsolete standards.  A focused “2015R2” certification regulation would therefore be an appropriate component of ONC’s fall work – so that something can be “shovel ready” for a new administration for ~ February release – with final rule in ~ April/May of 2017.

  2. The 2017 Spend Plan.  The 2017 federal budget appears to be on track to pass @ some point soon – and ONC’s appropriation for 2017 is looking like it will land at a steady ~ $60M ($65M if the extra $5M for narcotic abuse prevention lands).  The National Coordinator defines the “spend plan” for how the organization allocates this money – and the plan needs to be developed and executed at the beginning of the fiscal year: October, 2016.  The new National Coordinator is therefore making decisions now about how the funds will be spent over the next 12 months.  Office Directors are preparing proposed budgets for the year:  new FTEs, new projects that they want to launch.  Every year, it’s the same – just as it is in any large organization – proposals are submitted and the proposals represent 2x-3x the $$ available.  Tough calls need to be made.  The NC makes these calls. It’s hard to do this when you don’t know who your successor will be in January – or what their preferences will be.  When I was in this position, I worked closely with the Office Directors and the ONC Chief Operating Offer (Lisa Lewis), to identify the components of the organization’s work that were essential, and which were not.  We delayed decisions on about $2M to give Karen some flexibility to fund programs that were important to her.  As I mentioned in my response to Politico’s request for comments on the next phase of ONC’s path, my view is that it’s time to wind down ONC’s grants and health IT evangelism activity.  Perhaps it’s just my personality coming through here – as I am a well-known introvert, with little interest in quadrant 1 of the sizzle-substance 2 x 2 matrix (kudos to Janhavi for its invention), but I am concerned that it’s not government’s role to convince the public of the value/need for health IT.  If health IT has value (and I believe it does) then this value will be tangible and self-evident to the public.  If not, then no annual conference, blog post, or challenge grant will change this fact – or anyone’s perception of it.  ONC’s annual meeting – an event that costs several hundred thousand dollars and attracts the same participants every year – adds rather little to the nation’s progress toward improved health through the strategic use of health IT.  Kill the conference.  Kill the health IT flag-waving.  There’s already plenty of that to go around, and the taxpayer need not pay for it.

  3. Focus on quality.  No – not quality measures.  Quality of health, quality of care, quality of decisions.  Do these need to be measured?  Of course they do – and with the growth of value based payment in federal programs upon us, measurement of quality is imperative.  But we have conflated the concepts of quality and measurement.  As many know, I’ve long been concerned that the way that we use clinical quality measures in health care is fundamentally flawed.  Indeed, it was my concern about these flaws that led me to join ONC in the first place:  as the CMIO at Allscripts, I was responsible for helping our EHR development teams meet the requirements of Stage 1 of the EHR incentive programs (“meaningful use”) and it became clear that the accuracy of quality measure reporting would be terrible across the industry.  Why was this?  Because the 2011 certification criteria and Stage 1 meaningful use requirements were too vague about the data that would be used to measure quality.  For example, a quality measure might express that patients with “severe congestive heart failure” would be expected to be on a certain class of medications.  But there was no clarity for how “severe” was to be assessed, and many EHRs didn’t even formally capture ejection fraction, which would be an imperative component of an assessment of the severity of one’s CHF.  For Stage 2/2012 certification, we changed all of this, and while most readers don’t know or care about the details, these quiet changes represent the first important step toward improved quality measurement:  the data elements that are required for quality measures are explicitly identified in the certification regulation, and no measures are required that exceed the scope of these data elements. Read the last sentence again if you need to – as it’s very important and this guiding principle remains ignored by NQF, by many commercial health plan quality measures, and by many state Medicaid programs that are trying to implement quality programs.Simply put:  it’s impossible to report on data that was never captured.  A “quality measure” that assumes the presence of information in an IT system that is not present will be an invalid quality measure.  Period.  I thought / hoped we solved this problem in 2012.  Unfortunately, we did not.  Quality measures are still proposed without consideration for the data that EHRs have captured.  It’s now easy to know what the EHR can capture (what it can capture and what it has captured may of course differ).  Start with the NLM’s Data Element Catalog (Jesse James won the naming competition).  If the concept that you want to measure isn’t in here, then re-design your measure, because the EHRs don’t capture the data in a uniform manner.   If it is there, then the likelihood is high (but not certain) that the data can be captured, queried, and transmitted.

    Recall that I said our method of measuring quality is flawed.  Why is it flawed?  Because all of our focus is on quality measures rather than quality improvement, and improvement is a product of measurement and decision support.  Let’s parse this statement, beginning with the difference between measures and measurement.  A measure is an explicit logical statement about care delivery and its alignment with a very specific expectation.  For example, there is some evidence that individuals with diabetes will live longer if their blood sugar is well controlled, so there is a quality measure for this:  IF (individual has diabetes) AND (blood sugar is well controlled) THEN (quality measure satisfied).  Each of the logical expressions can be defined explicitly.  This measure can then be applied to thousands of care providers and their “scores” on the quality of care they presumably offer can be compared.  But what if blood sugar control isn’t so important?  What if there becomes a better way to measure individuals’ optimal health?  Measuring care quality with a list of measures is like having a speedometer in your car that measures 10, 15,25, 37 and 55 miles-per-hour and nothing in between.  It’s a set of measures -hard-coded into the system rather than measurement:  a fluid, adaptable system that enables us to see how we are doing and therefore enabling us to adjust our work dynamically if necessary.   How do we adjust?  With clinical decision support (CDS)!  As you will read in the chapter I wrote for Eta Berner’s just-published book on CDS, the federal government has done a great deal of work to enhance CDS capability in health IT systems, and to align it with quality measurement.  We’re not there yet – but we are well on the way.  Keep this on the front burner, and the path to the triple aim will be shorter and much less bumpy.

  4. As my friend Jerry Osheroff always says – focus on the most important things:  TMIT.  Are we helping improve the health of people?  That’s most important.  Don’t lose sight of it.  Karen DeSalvo taught me many things – but the one I’ve internalized the most was something that she taught me very early in her time at HHS:  we need shift our conversation from how to improve “health care” to how we improve health.

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. 

Usability again ;-)

Anticlue responded to my post from yesterday and missed my arguement entirely, while stepping back and lecturing me on what to do.

Here's my response.  For the readers who don't know … Elyse and I are colleagues, and I have a great deal of respect for her … which is why I'll let loose a bit here … all in the interests of continuing a good debate between friends .. 😉

Elyse, you make some good points .. but by working so hard to figure out what was wrong with what I was saying .. you miss the forest for the trees, and don't seem to acknowledge the importance of the concept that that I was discussing – that usability is important.  

1) Asking if usability was in the RFP is insulting .. and misses the point that I was talking about most point-of-care products .. not one in particular.   The argument that I have consistently made is that usability is the "bullet point" most often ignored on functional matrices … and due to its subjectivity … most vendors can wave their hands about how easy a product is to use .. but it's not.  Measuring how long it takes to do a lookup (patient, dx code, medication, procedure code, allergy) is one way to measure usability, since these lookups occur many times during a given provider/computer interaction.  How many keystrokes or mouse-clicks does it take to accomplish a given task?  Do you argue that it is better to accomplish something with more rather than fewer actions?  I don't see how this would make something safer – as you imply.

2) Replicating the functionality that google demonstrates (BTW – they are using XMLHttpRequest) can be done in many ways   .. and of course no one is going to load a full MPI for a large healthcare organization into the browser.  This would  be dumb, as you suggest .. and would likely be a security risk if any application were to be used through a browser remotely. (BTW – Dave points out that it's only one part of our app that loads it all .. the others re-poll the database with evey keystroke, like XMLHttpRequest).   But you CAN check in with the database and maintain a responsive user interface with every keystroke.  This is what Google demonstrates.  If they're doing it with a HUGE database (the Internet) .. and many more users than the typical healthcare organization would have at any given moment .. you can be certain that such functionality could be replicated on a smaller scale for a  healthcare application. 

Hundreds or even thousands of users is a tiny load compared to the load that Google's servers endure .. and recall that I was not only talking about patient lists.  When I use epocrates on my PDA to look up a medication, I can type the 1st few letters of a medication to find it.  This is good design.  Are you arguing that it would be better to have a 1980's style screen where I type in the medication name .. click "search" and then get back what I was searching for? (or not).  Your point about misspellings also misses the mark.  Indeed, it's the instant feedback that will REDUCE the likelihood of finding the wrong diagnosis, CPT code or patient name … not enhance it.  Let's take the example of your last name.  Let's say I don't recall whether it's IE or EI or EE or I or EA.  So I type N (space) Ely.  Done.  I found you. Now with a "old method" search: Type Neelsen, Elyse .. hit return .. find nothing.  Back to the search screen.  Nealsen .. nope .. back to search .. etc etc.  Giving the user feedback about what's in the black hole of the database is better.. not  worse.  Vendors are beginning to take advantage of this .. with windows tools .. and XMLHttpRequest .. which is good.  I applaud the use of such techniques, and I hope to see more of it in healthcare applications, as I would predict we will – so that we can focus more of our time on patient care .. and less of our time on typing and clicking and (in the age of The Tablet PC) .. pen-tapping.  I don't think I need to put this in an RFP .. or even build consensus for this concept.  It's a given.

3) Your suggestions about my making a list of issues for my practice organization, and your comment about working WITH the vendor (do you imply that I would work AGAINST them?) are again puzzling  … and I fear that you are making statements on your weblog about what you know (or think that you  know) about what I am doing for that organization … which is well beyond the scope of my post.  While it is true that I have been vocal about my concerns about the usability of a product in the past … I remain a passionate advocate for the user AND the vendor.   If we can't work together, there is no way for the product to meet the needs of the user.</rant>

On a lighter note …

I'll finish with a quiz about usability - posed by one of my heroes (who has a three-letter name that rhymes with DOG) .. and challenge my readers to go find the answer.

Which takes less time?

a) Heating water in a microwave for one minute and ten seconds.

b) Heating water in a microwave for one minute and eleven seconds.

I'll post the answer tomorrow if no one figures this out.

Google = Usabilty, Medical Software != Usability

Google Suggest is a new implementation of google that takes the search screen to the next logical step. 

When Dave and I built the "mini-EMR"  for our practice three years
ago – the search screen worked like this too.  Gmail works like
this .. and it's silly that all search fields don't.  If google
can do this with the whole Internet – there i sno reason that someone
can't do it with their database.

That am I talkin about?  Autocomplete/autoselect.

Follow the link above and you'll see what I mean.  Type the 1st
few letters of what you're looking for .. and you get feedback about
what's available. This makes your data entry task easier.

Now contrast that with the traditional seach screen.  Programmers
– stuck in the 1980's .. when there was 128k of RAM on the client …
create a search process like this: 

Type in what you are looking for
Click "submit" or "search"
Wait more
Now see a screen that lists theresults.  If you searched for
"Smith" in the phone book – you have too much info so you have to do it
all over again.  If you searched for "Smitj" because you can't
type very well, you get nothing and you have to do it again. 

"Oh stop whining … this doesn't add minutes to the process .. only seconds"  you say

But if I do this 50 times a day … it may add minutes .. and if I do it 200 times a day … it adds many many minutes.

What's better? 

To implement what Google's done, you can apply one of two strategies:
a) maintain a connection to the database/server.  On every
keypress .. send the data back to the server .. and get back the
results .. showing the top handful of results.  As the user keeps
typing, the number of entries that meet the search critereia gets
smaller .. and the item they are searching for is found.  No
"back-and-forth" to the server for the user.  This is not very
hard to do anymore – and there are methods for doing this with
javascript, Flash, Coldfusion, PHP and I am sure many other web
technologies.  It's also rather straightforward to do this in the
Palm OS (epocrates does it) and in .Net.  Alas .. I don't know
much about Mac proceamming anymore .. but I'd bet that this is
supported there too.   Users should demand this sort of
functionality in search screens. for all of their applications.

b) The other way to accomplish this is without a background connection
to the database.  Instead of checking in with every keypress, load
the database into the application or into the browser when the
application (or browser window) opens.  Sure — this won't work
for big big databases, but it works better than you would expect for
databases of fairly significant size.  In our Mini-EMR at the
office, we have 5800 patients.  All 5800 firstnames, lastnames,
ages and id numbers are loaded into the browser when the user logs
in.  Searching for a patient takes only a few keypresses.  To
Search for Bob Jones, I would type "Jo Bo" and I'd probably see him as
one of my two or three results (along with Josie Boomerang, etc) .. and
it all takes me less than a second.    If a pair of
Geeks like me and Dave can figure this out .. so can the programmers at
GE (Medicalogic), PMSI( Practice Partner), A4 (A4 EMR) and Misys (Misys
EMR) .. and an array of others .. c'mon folks .. please help your users
search for patients, medications, diagnoses, allergies and procedures
much faster! .. You'll make our lives better .. and will imporve
patient care.

EMR Usability

We're still struggling with our EMR .. and beginning (again) the process of reviwing alternatives. 

When I read EMR evaluations, I'm often struck by the absence of usability studies.  While the vendors have lots of feature "bullets" … usability remains largely unmeasured and hard to compare.

I'm thinking of creating a survey to capture a few important usability metrics.

Something like this pilot survey … but with more questions.

I'm trying to think of what the questions should be.  Pelase leave comments if you have suggestsions for very simple questions .. and please do fill out the pilot survey and give me feedback about that too. 

Paper as a User Interface

The last session in this afternoon's adventure is a discussion of how OCR was used to populate an EMR.

It's a good talk.

He reviews how a paper template can be used to provide decision support and improve the quality of data entry.

They developed the concpt of "adaptive turnaround documents."

Aftern the patient checks in, a form is generated (based on a patient questionnaire that the patient fills out – and patient demographics) that the nurse and then the physician will fill out.  So the clinical staff get a custom developed form that helps them focus on issues that the rules engine thinks are important. 


So the kid with asthma gets a different form from the adult with diabetes.


  1. Patient checks in
  2. Patient gets the survey
  3. Nurse gets the patient (with the form)
  4. Nurse gets the form and scans it into the "Digital Sender" (HP4101mfp) and the device e-mails the scanned image to the OCR server.
  5. System reads the form and determines it slevel of confidence about each item.
  6. The system then creates a form based on the inputs from the patient survey

They did a fairily thorough of QA and observation of how the system worked from a workflow standpoint.  Research findings:

  1. 224 forms completed in a 6 day study period
  2. 98% or so were completed
  3. 98% were accurately scanned
  4. It took 25 seconds to generate the form
  5. 43% of the forms required some correction
    1. The software prompted the nurse for corrections and/or confirmation – the average was about 1 .4 fields per form. 
    2. This took about 10 seconds per form.

Soooo ..

Here's the punch line .. they can now alert the doc to clincial problems.   The doc is prompted:  "John has a BMI of 12 – you may want to consider malnutrition."

Interesting.  He's got other thoughts about faxing forms to teachers for ADHD evaluation, etc.  Cool.  Medical Informatics with paper.