Thursday, March 20, 2008

Internet, health information technologies, health 2.0. clinicial innfovations,Twelve Random Observations on Innovation and Information Technologies

“Seek simplicity and distrust it.”

Alfred North Whitehead (1861-1947, English Philosopher

"Complexity. It is a concept that is imposing in its very name. In fact, even the idea of explaining complexity (making complexity simple), is, at its heart, paradoxical.”

Brenda Zimmerman, phD, Curt Lindberg and Paul Plsek, Edgeware, VHA, Inc, 1998

I often talk to people about health care innovation and its main catalyst – health information technology systems. Usually these conversations flow from those who read my book Innovation-Driven Health Care; 34 Key Concepts for Transformation (Jones and Bartlett, 2007) or my blog, with its tag line, “Observations of a Health Care Innovation Watcher.” Out of my conversations with innovation leaders has arisen 12 observations. I present them in no particular order.

1. No single EMR fits all specialties – Indeed, in multispecialty and hospital settings, an EMR commonly clogs work flow, confounds physicians, and angers them because it distracts from practicing medicine. More often than admitted or publicized , EMR systems are jettisoned or reconstructed into simpler pieces to fit individual specialty needs.

2. Innovation means different things to different specialists -- For cardiologists, innovation may mean pumps, implantable devices, left ventricular assists, atrial ablation; for orthopedic surgeons, it may mean mechanical devices, rods, screws, artificial discs, joint prostheses; for oncologists, it may mean infusion techniques, off- label use of chemotherapeutic agents, new protocols. For technophiles in other disciplines, innovation often means different key strokes for different folks.

3. Young doctors tend to be enamored with the magic and promise of new technologies: older doctors tend to more impressed with the impact of technologies on practice work flow and quality improvement. These differences may exist because young doctors have nothing in the past to compare with; older doctors do, and they can see new technologies do not automatically improve care or outcomes.

4. Innovation is the current rage, and innovation centers and programs are popping up all over the country in major medical and academic centers - Kaiser, Group Health, Virginia Mason, U. of Kansas Medical Center, Northwestern, Johns Hopkins, U. of Pittsburgh Medical Center, and Partners in Boston, to mention just a few. Some innovation meetings convene innovation summits, others address the latest fad; still others introduce new information technology products.

5. Doctors do not make good or willing documentalists - Clinicians often view documentation as something done for the benefit of payers, not themselves, as time consuming, and as a “hassle,” which in my dictionary is defined as “as a source or the experience of aggravation or annoying difficulty,” and something that slows productivity without any particular benefit accruing to patients or their caregivers. .

6. Data entry is an expensive , distracting, and sometimes degrading proposition, best left to others – patients themselves, scribes, nurses, or other staff members. The doctor should be thought as the final arbiter, the Vice-President , the Commander-in-Chief, of the office or group information system, not a data-monger. Data may be superior for tracking population health improvement, but in doctors’ minds, doesn’t improve individual quality of care at ground zero.

7. “Chunking” should be the order of the day in building information systems. Allowing complex systems to emerge out of the links between simple systems that work well and are capable of operating independently and efficiency is the way to go. For example, patient e-mail is a form of chunking; so is an email from doctors to the emergency room telling them what ticks or what’s sick about an incoming patient.

8. Innovation is never done: it is complex, ongoing, frequent interaction between caregivers to tweak, improve, and re-invent some care process. This process is the essential building bloc of workable evolving information systems and of constantly “learning” organizations. The idea is dawning that constant, constructive, and synergistic learning between doctors is the only way to fix the system and pull practices up by the bootstraps.

9. Anything that adds “hassle” to an overworked clinician and distracts from the primary mission of seeing patients, even if presented in code language speaking of “financial incentives, “” pay-for -performance,” or the more homey “medical home,” is likely to fail if it is too complex or time consuming. It is also likely to be expensive with indifferent outcomes, as the British Health Service has learned from its cash for data program.

10. “Informed” health care consumers, acting alone without doctor advice. Or, on basis of consumer Internet information , cannot be counted on to make consistently good decisions. There is some truth to the old maxim, “He who treats himself has a fool for a doctor.” Patients acting in concert with their doctor is better. It takes two to tango. A third party instructor does not customarily advance the tango, give it a more measured cadence, or make it more rhythmic.

11. Retail clinics, even though run by nurse practitioners or physician assistants armed with EMRs and protocols, are probably a good thing, even when backed by remote physician advisors and overseers, but harbor dangers stemming from inadequate knowledge of patient history and context. Some observers say malpractice landmines lie ahead for these clinics. Physicians may counter and compete with these clinics by various means – longer hours, lower prices for minor problems, and convenient and paid email communication.

12. The “transparency” movement among doctors, posting prices on websites and in offices, may soon be a wave of the future. The reason is quite simple. If consumer driven care is real, and I just read 24 million Americans now have high-deductible plans with HSAs, and the economy tanks, as some predict, uninsured or uner-insured consumers will want to know in advance what charges to expect and what they can afford.


Unknown said...

Dr. Reece,
You've been noticed by for this blog. Dr. Incognito has placed you on his honorable mention list of his weekly wrap-up. The scrubby award winner of each weekly wrap-up receives a free pair of red scrubs.

ShimCode said...

Wow! These are more than 'observations' - to me they're the foundation on which all health care providers, payers, and IT and care management firms must build their futures on top of.