So I'm trying out google+ for blog posting today.
I've spent a number of hours today reviewing the ONC HIT Workforce Curriculum materials, and since I've seen many tweets referencing them .. I've seen little substantive narrative on their value - so I'll offer a bit here - with the caveat that this is the product of ~ 4 hours of review of only one component. There is a mountain of material here - and while I had previously flipped through a handful of PowerPoints - today was the first time I sat down and listened to the presenters talk through each module from start to finish.
It's an impressive set of work. I was assigned component #12 (Quality Improvement) to review. I can say with certainty that this isn't how I would have approached educating a group of HIT students on this topic. Why not?
Way back in the "dark ages" (10 years ago) when I was a full-time educator, I worked hard to make sure that I deeply understood the needs of my learners before I launched into "covering" material for them. I think that's a core problem here: the faculty who developed these materials were developing them for an audience with whom they have had little interaction - and the reviewers of the materials (generally informatics experts) are looking at this from a perspective of completeness with respect to informatics education curricula that exist today. At one point - one of the faculty mentions a book that he has written on the topic of patient safety: "as you may have read in my book on this topic .. " Oh please. Really? Do you expect that these folks have read your book? Unlikely. Have I? Well .. yes I have - and it's a good book. But this isn't a forum for pitching a book. I would suggest that this sort of narrative offers little value - and may actually detract from the curriculum. It's easy to remove - and probably should be.
While I am certainly looking for gaps (as I've been asked to do) - my overall sense so far is that the flaws are the opposite: too much detail - and too much expertise - with too much of a focus on what the educator KNOWS - and too little focus in the foundational material that the learner must UNDERSTAND.
Having said all of this - I need to be clear that I think these materials are a great resources - and a great foundation for a strong training program.
This post on the-blog-that-used-to-be-kevin's-blog (alas, Kevin Pho writes rather few posts these days) ... is accurate, but I wish that the medical community was saying the same thing. In general - we are not. Patients who have guts will say this - but on the other side of the stethoscope - we continue to use such terms as "noncompliant" and "adherence" on a daily basis - and nobody recognizes how offensive it is. I blogged about this in 2002. Same story today. This is a nomenclature is symptom of a problem - not the problem itself. Care providers who have been taught to expect patients to "comply" are not learning the skills they will need to really help patients meet their treatment goals.
It's been nearly a week since the big announcement and I've read a herd of thoughtful reviews of why google decided to shutter their health experiment.
But I've not yet seen anyone say what was obvious from the outset: It was a dumb idea.
Google Health is a classic case of a solution looking for a problem.
When we apply technology thoughtfully - we need to be solving a problem! No problem = no adoption. No adoption = no revenue.
Case in point: Tim's got a survey up on histalk at the moment. Who reads HISTalk? Health IT disciples. How many of us have PHRs? 13%.
If WE don't use them .. nobody will.
Some think that "portals" will be the answer - and will succeed where PHRs have failed.
I wouldn't bet on it. A portal may work in a setting like Group Health / Kaiser or Geisinger - but it's not likely to work in the real world. Patients see too many physicians - go to too many care facilities and have changing relationships with all of the above. EHR-tethered portals simply can't scale in a way that they would need to in order for patients to embrace one or another. As a way to communicate with a practice or a hospital - fine - I'll use a portal instead of a phone. But as a trusted place for my medical information to "live?" No way.
So - if Google Health was a solution looking for a problem - what problems might we solve so that the next iteration of health 2.0 entrants aren't so confused.
So let's focus on some real problems ... and stop worrying about why Google killed a little beta project before it came to market.
I've been blogging for a very long time. Tweeting since before Twitter had an "e" .. (it was called twittr) .. Blogging since Blogger was just a little feature of a long-dead product called Pyra. Raise your hand if you remember Pyra. Ok ..you get 10 extra nerd points today!
That doesn't make me an expert - but it does give me a perspective on the whole thing that may be .. umm .. mature.
I was on a conference call the other day and I was surprised when a colleage made a remark about tweeting as somehow inherently exhibitionistic. I've heard this before from people I respect - and didn't give it much thought. That's not how I view tweeting ... so I've mistakenly lumbered away with my anachronistic (naive?) view of tweeting to simply be an efficient way of educating ("FYI - there is important news"), modeling ("I'm thinking about a topic in a certain way you may find valuable") or (less often) informing (" I ran 15 miles today"). And I understand how others may view it as something with less value and less integrity - but they are only seeing the treetops. There is depth to Blogging and tweeting that remains at its core - valuable and important. You just have to know where to look.
I'm not a prolific "tweeter" or "blogger" these days - but when I do post - I generally try to make it something that would be of value to others. I don't say much that's already "out there" and I avoid "re-tweeting" unless it's something that is outside of my domain. For example - since most of my followers work in health care and Health IT - I try not "re-tweet" something to that "circle" - as it would just be redundant to them. For example - I tweeted on Friday that Google Health was closing .. as it was breaking news at the time that I saw it .. but I never tweeted that ONC was releasing (great) ediucational materials on HIT because it's been tweeted hundreds of times since last Wednesday when they were released. How would this tweet add value to the world? Precious little.
So blogging or tweeting for the sake of blogging or tweeting IS a waste of everyone's time. Yet careful, deliberate use of these powerful tools will contibute meaningully toward the education of our communities.
Mitch Joel's posting: "5 Ways to survive your inbox" describes a set of habits one might use to maintain control:
See his post for the details and editorial. None of this is a new idea - though I like the way he describes #5 quite a bit - and will admit that I have used this tactic myself.
But why should we work so hard to apply these principles? Shouldn't the software facilitate this work? As care providers - isn't it ESSENTIAL that the software do this FOR us? One shouldn't have to think like an IT expert. Mitch describes a set of technical tasks. Let's change the terms a bit - and consider this from the perspective of a care provider interacting with patients electronically.
What it might look like:
Now it's audience participation time! What OTHER suggestions do you have for Clinical Inbox Management?
I'm here in Gaithersburg Maryland today at NIST - where the clocks are always accurate.
The context is a "Community Building Workshop" on usability of Electronic Health Records.
Longtime Docnotes readers know that I've been thinking/writing/talking about this for a long time. Most recently - I testified (pdf) to the HIT Policy Committee's Implementation Workgroup on this topic.
It's impressive that this has come to be a compelling topic for discussion - but there remains quite a bit fo work to do.
Notes from today's meeting:
Jodi Daniel from ONC gave a nice little intro on ONC's rationale for being involved here. Bottom line:
Matt Quinn gave a good intro from NIST. What NIST is - why NIST is engaged - and what is NISTs role in this work. Like Jodi - I've grown to know and respect Matt of the the past few years. His pitch:
David Brick, a cardiologist from NYC gave a well-intoentioned talk on some problems he's onserved in EHRs. He provided examples of how EHR-derived growth charts can cause both displeasure and safety problems. David's keystone example was a system in which a 5.5 POUND patient's data could be expressed as 5.5 KILOGRAMS when a user toggles between Metric and English systems. While I agree there is a usability issue here - his example is a bit of a straw man. As one considers the continuum of user experience from functional - through usable - to meaningful - this example isn't even functional. It's flawed deign - or falwed implementation. Period. It's a bug that needs to be fixed.
So while one might argue that this is ALSO a usability issue - we need to be careful not to lower the bar so much that such examples become part of the usability conversation. Would user-centered design have prevented this flaw? Sure .. but I would suggests that we need to assume or even demand functionality in this conversation - and sink our teeth into usability - the next hurdle that the industry needs to jump.
Ben Shneiderman from University of Maryland up next.
Ben is a dynamic and outspoken speaker on these topics.
He describes the industry leading works of several vendors such as Apple. I recall the early Apple usability guidelines well - and Ben makes a good point that design guidance is a good thing. But should an industry have design requirements? He doesn't go so far as to say that - but he actually comes rather close.
Ben makes a set of suggestions:
Ben expressed frustration that vendors have not shared with him any examples, access to demonstration systems without signing NDA, access to documentation, or even details screenshots of EHRs.
Ben is a passionate and articulate guy - and his heart is clearly in the right place - but it's simply not all so simple as he portrays - and I would argue that the vendor community may not be so cooperative with him as he would like - because his demeanor is combative rather than collaborative. How can one trust that a collaboration with Ben won't turn into a marketing tragedy?
Next up ...
Mohammed Walji - SHARP-C
SHARP-C is an ONC-sponsored grant program @ UT - Houston. I was an advisor for the project for a while - and I find it to be incredibly interesting - yet somewhat academic and therefore not quite ready to inform the industry. Yet. Perhaps they will at some point and that will be valuable indeed.
Mohammed outlined a general approach that their team is taking to usability:
TURF framework for usability:
Facets of usability:
Arien Malec from ONC - descibes the successful method that government and industry worked togethersuggests that a process here enables us to:
Raise objections and concerns early in the process
Ensure the resulting usability test approach supports multiple modalities (eg dicataion)
Learn from each other and creat UX and design best practice that create superior usability and UX
Measurement may not capture the nuances of heatlhcare
Reply: Help us define the instrucments and measurements and methodilogies
ONC suggests that the community can help define the workflow and context - sensitive tests
"vendor community says: don't let he government tell us what is good or bad - we want the market to tell us what is good or bad"
Users "we don't want the govt to incent us to use stinky software"
Community - not ONC - can define what this is - through the (proposed) Marketing Usability Workgroup
Workgroups comprised of:
- academic researchers
- Users / Implementers
- Human Factors professionals
Edna Boone - HIMSS
Speaking about advantages of professional collaboration community. Good dovetail with Arien's talk.
Usability industry - Human Factors, Design and Usability people ..
Proposal: A community of profession led by HIMSS Usability Taskforce - responsible for providing domain experttiese, leadership and guidance to activities, inittiateas and collaboration within the speciality of HF, usability and design ..
Ron Kaye - FDA devices human factors guy - here to describe how FDA manages human factors issues in the medical device arena.
Jorge Ferrer - VA
Jorge provided an interesting literature review on recent papers that have been published in the domain of usability - and focused on a usability framwork developed at the VA - with a (too long to for me to trascribe) list of recommendations for "next steps" in usability in HIT.
Janet Campbell - Epic
"What are the needs of software developers?"
Usability is a journey rather than a destination.
We are not (nor will we ever be) perfect.
"Our users are smart people. Physicians have hig standards and low tolerance for dysfunctional design."
What do providers need?
Dialogue between user and vendor is fluid and useful. When a third party gets involved in the conversation - it make it more complex - and sometimes the messages get less clear.
Concern about measurement, guidelines, standards .. measuring things that are un-measureable .. or comparing systems to some sort of idealized design. There exists a public-private partnership that is working. There is an unspoken message here that the industry has failed. In fact - it has not. Is the government barking up the wrong tree? Aiming to solve a problem that isn't in its scope to solve? A government assessment may send the message that a certain design standard will meet the needs of all users.
We think there is a role for ONC and NIST - let's look at the common requirements - as defined by Meaningful Use - to see how we can optimize THESE processes.
Mary Kate Foley. VP for User Experience at athenaHealth.
Educate, Motivate, Improve.
Mary Kate describes the challenges of implementing UCD principles in an organization that previously didn't use them.
EHRs lag in usability
Contributes to clinical risk
AHRQ report on EHR vendor practices and perspectives
Market factors will exert appropriate pressure
Can we anticipate and acellerate?
Apply our UCD principles to the problem - how can we do more UCD @ EHR vendors?
Understand the problem. Complex needs, complex user bases.
Focus on the target audience
Design with tartget in mind
Low - Educate
Medium Educate & Motivate
High - Motivate.
Get each vendor started where traction is likely to be greatest within vendors: usabilty TESTING ..
Shows the usability periodic table from HIMSS (see page 3 of this document)
Work has units .. Clicks .. Time .. Eergy. Effort, frustration, failure ..
Lana Lowry - NIST
Bob Schumacher, User Centric
Emily Patterson, Ohio State
Bob North, Human Centered Strategies
Chris Gibbons, Johns Hopkins
(editorial: I like Lana - I think she is a bright, passionate advocate for doing things right. Her slide deck, however, was the worst of the day. It violated nearly every principle of a "usable" presentation. She needs a copy of Presentation Zen. I think I'll buy her a copy. No kdding.
Lana's presentation was the first of a few sessions that got to the meat of why we were all here. All of the previous sessions were (I think) meant to set a level playing field and make sure that the audience was all on the same page (what is the definition of usability, etc) and had been exposed to various perspectives on the matter - HF experts, government folks, vendors, etc. In general - this worked - but it could have been done much more effiiciently. We could have had 2 hrs of intro rather than four - and I would have preferred to spend much more time on the "meat" of the matter rather than just a few quick presentations in the afternoon.
Proposed EHR Usability Evaluation Protocol
These presentation (I'll post later today in more detail about them) focused on the EUP and what it is. Key message:
a) EHRs should be tested by people with advanced training in usability, human factors, cognitive science.
b) The focus should be on testing for errors. The key here is patient safety
c) There will be a collaborative community effort that is created to define the details
Health Affairs arrived in the the mail today.
I pulled it open like an excited kid opening a birthday gift. Despite my affection for all-things-digital, there is something to be said for propping my feet up on the coffee table and reading insightful work on important subjects.
This paper describes a compelling story that I'll try to paraphrase - as it introduces the concept of PROTECTION that I'd not previously considered.
The authors consider three possible interventions to improve the health status of a population:
The paper describes the results of a modeling exercise in which a population receives one, two or all of these interventions. The results predict that expanding coverage would result in modest improvements in health status and cost, Coverage PLUS Care results in better health status and reduced cost - and (after a 3 - 5 window of increased cost) Coverage + Care + Protection results in MUCH better overall health status and reduced cost.
So what? This study reminds us that:
a) Expanded coverage is not the only answer. In countries with universal coverage - we see good validation of this unfortunate reality.
b) Better care is also a necessary but incomplete solution.
c) The hardest part - and likely most essential - is that we need a cultural shift in how we can create and maintain a healthy environment.
How do we get there from here?
My intuition is that we treat the nation (globe) as we would an addict. We have become addicted to certain behaviors that we know to be destructive. Yet we continue. Smoking, obesity, lack of exercise, over-eating ... these are all key components of our addicted nation.
Years ago, I became impressed with the work of William Miller, Marian Stuart, and James Prochaska - and used their techniques successfully in my practice. The common thread is that we understand and support our patient's interest in following a path toward better health. This is terribly hard to do in a manner that isn't judgmental. But when we judge ("this is bad behavior") we alienate the patient - and make collaboration more difficult. It is only when we are open to the outcome - but not focused on one outcome in particluat - that we collaborate toward success.
So when the patient is a globe or a nation or a community - how might we mive forward?
a) Recognize and reflect. "Is this how you want to be living? Is there anything you would like to be different?"
b) Celebrate Success. "How have you been successful in the past? What might you try again in the future?"
c) Offer tools and support. Reminders, suggestions for alternatives, skill-building.
I often notice that many communities have built such traditions that they don't even know how to behave differently.
In our industry - HIT - I think that be most productive use of our time is to focus on (c) - so that we can help providers and patients collaborate (a) and (b).
Readers have started asking me about my new company ...
Perhaps the change to my LinkedIn profile was the tip-off :-)
While we're not quite ready to publicly describe what we're doing, I CAN say that our focus is on creating great tools that providers and patients can use to communicate.
While e-communication has become pervasive globally - it has not become part of the routine in healthcare. I met with a colleague for lunch last week - and she described the pile of paper faxes and letters she receives daily from other physicians. She communicates with patients using e-mail "only rarely - for a small number of patients" and even limits phone calls as much as possible - delegating them to a nurse.
A face-to-face visit in the office remains a cornerstone of communication between patients and providers, and the fax machine remains the preferred route of communication between primary care provider and specialist.
Will this change? Of course it will. That's the bet we're making - and I don't think that it's a scary bet at all. e-communication between patients and providers is better, and it doesn't take longer. Provider satisfaction improves, patient satisfaction improves. Everyone is happy. Right?
Well .. no.
The key barrier here is ... money. HIMSS did a survey and found that lack of reimbursment was the key barrier.
Doug Fridsma (Long before be went to ONC) did a study way back in 1994 and found different barriers and a remarkably high level of use. Back in 1994 - it seemed like we were on the threshold of an explosion of e-communication. Why didn't it happen?
a) Insufficient financial incentives. Yes - I believe that lack of reimbursement is a key barrier. In places where this is part of a provider's job - the use of e-communication is pervasive.
b) The tools stink. I'm tempted to use a stronger word - but I won't. AOL (You've Got Mail!) didn't evolve into Facebook. AOL (and others) have been disrupted by Facebook. The existing software for this sort of communication was built long ago - and it simply didn't anticipate the needs of 2011. You can't build a skyscraper on the foundation of a four bedroom colonial. The current tools will not survive.
c) Timing. With the exploding interest in mHealth, and the ubiquity of communication devices - we now have methods of connecting that weren't imaginable ten years ago. As PCMH experiments such as those at Group Health Cooperative and others demonstrate - it's BETTER CARE to keep patients out of the office and out of the ER. One way to do this is to increase our availability. With much more data available - we should expect to see more payers experimenting with reimbursement models that are inclusive of e-communication. Is this a PCMH pilot? An ECO experiment? We'll have to see.
So at Twistle - we're honing in on what we think will be the best software solution to help solve these real problems. I've launched a 30 second survey to help us understand which specialties might have the most interest in using a new solution today - even without reimbursement changes.
Since I'm a family physician - I think with my "primary care" hat on by default. This isn't good. I need to try to pretend to be a specialist sometimes. So I schedule myself to spend time with other physicians on a regular basis so that I can better understand them. As this study demonstrates, in 2008, there are interesting patterns: 21% of female physicians e-mail with their patients vs 19% of men. 19% of primary care; 24% of specialists. 28% of those in a multispecialty group vs 17% in a single specialty group.
Why would a specialist be more likely to e-mail her patients than a primary care physician? One answer we're hearing a lot is "opportunity cost." Even though the providers aren't paid for the e-communication - a specialist's opportunity cost (especially a busy procedure-centric specialty) is significantly higher than that of a primary care physician. So if a busy gastroenterologist can e-mail with six patients in 20 minutes - and keep those six patients out of the office - then she has time to do one more colonoscopy!
This differs from the attitude of my family physician friend - who feels that she needs the face-to-face visit for all conversations - as she fears that e-mail would otherwise consume her day - without any reimbursement.
Much more to think about here. Please do take the survey and pass the link along to your friends & colleagues so we can get some good data. I'll share the results here in a week or so.