Tuesday, February 2, 2010
Tuesday, July 7, 2009
Ego and Metrics Gone Awry
It's not good karma to take pot shots at someone after they pass away, but I started this blog several months ago and never finished it, so I find at least some relief in that. The core message in this post: Beware the leader too comfortable in the role, too adept at eluding the grasp of humility.
Robert McNamara died last Monday. For those interested in studying and learning about leadership and management, independent of industry or purpose, he's a character worth knowing. My father, brother, uncle, and cousin all served in the McNamara War; my father at the most senior levels of the Air Force. And, of course, in my own Air Force professional education, we studied his style, strategies, and outcomes in-depth. Bless him and the hearts of his left behind family, his life offers poignant and painful lessons in leadership that we should all note.
He had all the right academic credentials, corporate pedigree... and haircut. He was a data wonk before it was fashionable. He came into his role as Secretary of Defense with an ego only rivaled in modern times by characters such as Patton and MacArthur. He created a dream team at the Pentagon and set out to change the stodgy US military. To that end, he had remarkable vision and management skills, and his thinking and fingerprints remain to this day in the DoD. But... his great successes fed his great ego and the egos of his aides and staff. Like an engine of pride consuming itself for fuel, it was only a matter of time before it all came apart. Ironically, for truly great leaders, their successes lead to successively greater connections to gratitude and humility. They see that, were it not for the grace of God and subtle random events to their favor, their great successes would have been great disasters.
In McNamara's War, number crunching, organizational theory, "systems engineering", academic credentials, and money were all trumped by the heart and will of a culture not inclined to change from the influence of a superpower consumed by its own self-righteousness. One of McNamara's metrics-gone-wrong legacies: The Daily Body Count, mandatorily reported up-channel from the lowest level troops in the field. Can you imagine being a 20-year old platoon leader, pausing after a jungle battle to count bodies--the enemy's and your own troops--and coldly radioing them into headquarters to ensure that the numbers made it to the next morning's briefing for the Secretary of Defense? Do you really think those metrics were accurate or reflected anything meaningful about success or failure? McNamara's ego convinced him that his pedigree could out-think, out-manage, and out-measure the lowly peasant Communists. But, as they say, not all things can be measured and not all things measurable should be measured.
The best leaders walk the thin line between confidence and uncertainty... between egotism and humility. You want a leader who shows evidence of falling to both sides of the line because all of those behaviors are appropriate at the right time and right place.
Beware the leader too comfortable in the role, too adept at eluding the grasp of humility.
Robert McNamara died last Monday. For those interested in studying and learning about leadership and management, independent of industry or purpose, he's a character worth knowing. My father, brother, uncle, and cousin all served in the McNamara War; my father at the most senior levels of the Air Force. And, of course, in my own Air Force professional education, we studied his style, strategies, and outcomes in-depth. Bless him and the hearts of his left behind family, his life offers poignant and painful lessons in leadership that we should all note.
He had all the right academic credentials, corporate pedigree... and haircut. He was a data wonk before it was fashionable. He came into his role as Secretary of Defense with an ego only rivaled in modern times by characters such as Patton and MacArthur. He created a dream team at the Pentagon and set out to change the stodgy US military. To that end, he had remarkable vision and management skills, and his thinking and fingerprints remain to this day in the DoD. But... his great successes fed his great ego and the egos of his aides and staff. Like an engine of pride consuming itself for fuel, it was only a matter of time before it all came apart. Ironically, for truly great leaders, their successes lead to successively greater connections to gratitude and humility. They see that, were it not for the grace of God and subtle random events to their favor, their great successes would have been great disasters.
In McNamara's War, number crunching, organizational theory, "systems engineering", academic credentials, and money were all trumped by the heart and will of a culture not inclined to change from the influence of a superpower consumed by its own self-righteousness. One of McNamara's metrics-gone-wrong legacies: The Daily Body Count, mandatorily reported up-channel from the lowest level troops in the field. Can you imagine being a 20-year old platoon leader, pausing after a jungle battle to count bodies--the enemy's and your own troops--and coldly radioing them into headquarters to ensure that the numbers made it to the next morning's briefing for the Secretary of Defense? Do you really think those metrics were accurate or reflected anything meaningful about success or failure? McNamara's ego convinced him that his pedigree could out-think, out-manage, and out-measure the lowly peasant Communists. But, as they say, not all things can be measured and not all things measurable should be measured.
The best leaders walk the thin line between confidence and uncertainty... between egotism and humility. You want a leader who shows evidence of falling to both sides of the line because all of those behaviors are appropriate at the right time and right place.
Beware the leader too comfortable in the role, too adept at eluding the grasp of humility.
Wednesday, June 10, 2009
Leadership for New Leaders
After a recent guest lecture, one of the students approached me afterwards and asked me for advice about leadership and management. She was about to become a first-time manager and leader for a six-person team. Later, she emailed me about the same topic. Below is my reply to her.
"Simply because you care about these issues of true leadership and are willing to study, think, and put forth the effort to become a good leader, immediately places you in a favorable position. You will succeed, almost certainly, as a natural consequence. But, whatever advice you take or book you read, ask yourself, "Do I serve those I lead, or do those I lead serve me?" It's a pretty simple question that boils everything extraneous about leadership and management away.
You mentioned to me twice, once in our conversation and again in your email, that you wanted to be "respected." Exercise caution in your pursuit of that goal because it can quickly become motivated by pride and ego. The more you pursue respect from those you lead, the less likely you are to find it. Instead, exercise the behaviors which engender respect-- such as competence in your job, mutual respect for others, courage, a healthy lifestyle, creativity, integrity, humor, and honesty-- and let respect flow to you naturally, if it so chooses. Abraham Lincoln was a prime example of someone who was routinely insulted by those that he led, notably members of his appointed Cabinet and commanders of the Union Army. He would tolerate unbelievable levels disrespect from both groups, as long as he felt that their overall value to the mission overshadowed their insults against him. However, he had his limits of tolerance and would take swift action to remove people from the team when their impact on the mission became undeniably negative. Be watchful when yearning for "respect" from those you lead. It's a subtle and common road to hardship for many new leaders and managers.
From the perspective of traditional text books on leadership and management, my favorite books are "The Leadership Challenge", by Kouzes and Posner; "First, Break All the Rules: What the World's Greatest Managers Do Differently" by Buckingham and Coffman; and "The Toyota Way", by Jeff Liker. These books helped me realize that I wasn't crazy after all-- at least on issues of leadership and management. The philosophies which seemed so obvious to me, but so contrary to much of corporate America, were, in fact, what most employees hoped for from their business managers and leaders. These books gave me the courage to stand comfortably in the winds of opposition, oftentimes from my peers and occasionally from my supervisors.
From a non-traditional perspective, my favorite book is "Endurance: Shackleton's Incredible Voyage", by Alfred Lansing. This first-hand account of the crew's epic adventure embodies everything imaginable in selfless teamwork and leadership . It also highlights that, what appear to be great failures in life will, over time, be judged as the greatest of accomplishments. There is no such thing as failure when the people involved with a project or other undertaking are motivated purely and maintain a fierce attachment to those motives under the worst of conditions. Also, virtually any book which accurately portrays Abraham Lincoln is incredibly valuable as a reference for the pinnacle of leadership and management. My favorite of all time is, "Abraham Lincoln: A Documentary Portrait Through His Speeches and Writings", by Fehrenbacher. More recently, I enjoyed "Team of Rivals: The Political Genius of Abraham Lincoln", by Goodwin. Words can't express how much I admire Lincoln as a leader, nor would those words do justice to the man.
From a very non-traditional, philosophical perspective, my favorite book is "The Tao Te Ching", by Lao Tzu. It opened my eyes to the irony of success and leadership-- i.e., that sometimes, you need to try less to achieve the most. The teams and organizations which pursue "greatness" for the sake of notoriety and fame, will likely fail; or possibly achieve, but find no lasting fulfillment. But those who pursue greatness for the purity of pursuit and the betterment of human beings and Mother Nature are much more likely to find greatness-- quietly, peacefully, and naturally. This, of course, is a common theme in many philosophical and theological teachings. I was raised in a Christian Methodist family, but find wisdom and commonality in many other forms of theology and philosophy, too. The God in which I believe created all paths towards learning. Fallible humans have decided to make them exclusive and authoritative. But, the Tao Te Ching is not about religion; it's a philosophy. The only deity in Taoism is Integrity.
Helpful? I hope so... best of luck to you and keep in touch. Let me know how things go..."
"Simply because you care about these issues of true leadership and are willing to study, think, and put forth the effort to become a good leader, immediately places you in a favorable position. You will succeed, almost certainly, as a natural consequence. But, whatever advice you take or book you read, ask yourself, "Do I serve those I lead, or do those I lead serve me?" It's a pretty simple question that boils everything extraneous about leadership and management away.
You mentioned to me twice, once in our conversation and again in your email, that you wanted to be "respected." Exercise caution in your pursuit of that goal because it can quickly become motivated by pride and ego. The more you pursue respect from those you lead, the less likely you are to find it. Instead, exercise the behaviors which engender respect-- such as competence in your job, mutual respect for others, courage, a healthy lifestyle, creativity, integrity, humor, and honesty-- and let respect flow to you naturally, if it so chooses. Abraham Lincoln was a prime example of someone who was routinely insulted by those that he led, notably members of his appointed Cabinet and commanders of the Union Army. He would tolerate unbelievable levels disrespect from both groups, as long as he felt that their overall value to the mission overshadowed their insults against him. However, he had his limits of tolerance and would take swift action to remove people from the team when their impact on the mission became undeniably negative. Be watchful when yearning for "respect" from those you lead. It's a subtle and common road to hardship for many new leaders and managers.
From the perspective of traditional text books on leadership and management, my favorite books are "The Leadership Challenge", by Kouzes and Posner; "First, Break All the Rules: What the World's Greatest Managers Do Differently" by Buckingham and Coffman; and "The Toyota Way", by Jeff Liker. These books helped me realize that I wasn't crazy after all-- at least on issues of leadership and management. The philosophies which seemed so obvious to me, but so contrary to much of corporate America, were, in fact, what most employees hoped for from their business managers and leaders. These books gave me the courage to stand comfortably in the winds of opposition, oftentimes from my peers and occasionally from my supervisors.
From a non-traditional perspective, my favorite book is "Endurance: Shackleton's Incredible Voyage", by Alfred Lansing. This first-hand account of the crew's epic adventure embodies everything imaginable in selfless teamwork and leadership . It also highlights that, what appear to be great failures in life will, over time, be judged as the greatest of accomplishments. There is no such thing as failure when the people involved with a project or other undertaking are motivated purely and maintain a fierce attachment to those motives under the worst of conditions. Also, virtually any book which accurately portrays Abraham Lincoln is incredibly valuable as a reference for the pinnacle of leadership and management. My favorite of all time is, "Abraham Lincoln: A Documentary Portrait Through His Speeches and Writings", by Fehrenbacher. More recently, I enjoyed "Team of Rivals: The Political Genius of Abraham Lincoln", by Goodwin. Words can't express how much I admire Lincoln as a leader, nor would those words do justice to the man.
From a very non-traditional, philosophical perspective, my favorite book is "The Tao Te Ching", by Lao Tzu. It opened my eyes to the irony of success and leadership-- i.e., that sometimes, you need to try less to achieve the most. The teams and organizations which pursue "greatness" for the sake of notoriety and fame, will likely fail; or possibly achieve, but find no lasting fulfillment. But those who pursue greatness for the purity of pursuit and the betterment of human beings and Mother Nature are much more likely to find greatness-- quietly, peacefully, and naturally. This, of course, is a common theme in many philosophical and theological teachings. I was raised in a Christian Methodist family, but find wisdom and commonality in many other forms of theology and philosophy, too. The God in which I believe created all paths towards learning. Fallible humans have decided to make them exclusive and authoritative. But, the Tao Te Ching is not about religion; it's a philosophy. The only deity in Taoism is Integrity.
Helpful? I hope so... best of luck to you and keep in touch. Let me know how things go..."
Thursday, April 23, 2009
Epic EMR Adoption, Utilization, and Cost
The point of this blog is: Purchasing and installing an EMR and hoping that you’ll realize a positive return-on-investment is not enough. You need to dedicate the time and resources to constantly iterate, refine and improve the utilization of that EMR over time, far beyond its installation and go-live. It’s a race without a finish line so you might as well train, budget and plan for that accordingly-- up front.
At Northwestern, we take great pride in being one of the first fully-institutionalized adopters of an EHR in healthcare. We’ve had an ambulatory EMR (Epic) for 12 years and an acute care EMR (Cerner) for 10. For the past 18-24 months, we’ve been studying not just the adoption of the EMR, but also studying the utilization of the EMR. Drawing upon an analogy to illustrate the point, if a carpenter buys a pneumatic nail gun, I call that “adoption” of a new tool. But if that carpenter is still using the nail gun to manually pound nails as if it were a hammer, has he achieved “utilization” of the tool? If you believe there is added value to an EMR over a paper chart—or even a word processor-- where does that added value reside and are we using it for those purposes? I’ve been slowly polling and collecting data in an attempt to understand EMR “utilization.” I doubt my data collection process would pass Gallup’s scrutiny, but I still believe that it paints an informative picture. Here’s what I have so far…
Qualitative Assessment of Epic EMR Utilization
“Do you personally use the Electronic Medical Record for the following purposes?”
Remote, Internet-based access to the EMR for the benefit of physician convenience and faster patient treatment: 87%
Data-driven reports and analytics which benefit patient care, such as disease management: 34%
Data-driven clinical research: 73%
Data-driven compliance, regulatory, or accreditation reporting: 19%
Referral communications through a clinical In-Basket or automatic letter generation: 94%
If you are a physician or other clinician who uses an EMR and want to add your 2 cents, go ahead and fill out this survey: EMR Utilization.
Quantitative Assessment of Epic EMR Utilization
Based on data from the EMR itself, we run queries in an attempt to objectively measure how the EMR is being utilized in a few key areas of “added value” over a paper chart. To me, those key areas of added value of an EMR reside in the computable data that’s collected in medication orders and management; allergies management and awareness; problem list management and awareness; and family history of disease Below are the questions we asked in the queries of our data. The reporting period for the queries is December 2008 through April 23, 2009.
Medications: What percentage of encounters included a medication order during the reporting period?: 68%
Clearly, not all patient encounters will include a medication order, so we would expect this number to be less than 100%. What we are really trying to find here is the denominator of all Rx orders to better understand utilization. That’s a tougher number to find-- we’re looking at prescription pad utilization as an indicator.
Allergies: What percentage of encounters included a review of patient allergies during the reporting period?: 68%
Ideally, this should be 100%; there is a checkbox in the Epic EMR to indicate “Allergies Reviewed”, but note that the metric seems to be tightly correlated to medication orders, which is the most important issue, i.e., Are physicians reviewing allergies when they prescribe medications? It would seem so.
Problem Lists: What percentage of patients have an entry in their EMR Problem List during the reporting period?: 64%
Again, not all patients will have an entry in their problem list, but common sense tells me that it should be higher than 64%. Therefore, this metric hints that we are underutilizing our Problem List.
Family History: What percentages of patients have an entry in the Family History section of their EMR during the reporting period?: 59%
It’s possible that a patient has no knowledge of family history or nothing worth noting, but common sense tells me that this number should be higher than 59%. This metric suggests that we are underutilizing the Family History section of the EMR.
$$-- Total Cost of Ownership
Finally, to gain some idea of the cost-to-benefit ratio, we measured the total cost of ownership for Epic-- hardware, software, network connectivity, and labor-- Total Cost. The analysis for this TCO took about 3-4 months and the involvement of over 20 people. It was a very thorough analysis. The TCO for the Epic EMR on our campus, including patient registration and scheduling, is $856 per physician per month, or $10,272 per physician year. We have 640 physicians in our physician group, but over 3,000 Epic users on the campus including staff in the Hospital, private physicians, and researchers who benefit from Epic, but do not expressly support it, financially.
In Conclusion
We are working hard to increase the valuable utilization of Epic at Northwestern, while reducing our costs. In addition to our day-to-day Epic support staff, I have a dedicated team of four “Epic Optimization” specialists who are tasked with cycling through each of our 30 Departments to achieve “Epic Optimization.” I can’t imagine that team ever going away. To lower our central support costs while still improving our utilization metrics, we have an active “Epic SuperUser” program consisting of physicians and nurses in the Departments who receive a higher-level of training and system privileges than a typical user; it’s an official, recognized part of their job description.
Remember: An EMR project never finishes. Train, fund, and plan accordingly… don’t short-change the investment!
Thursday, April 9, 2009
Amazon.com to Build New EHR
Amazon.com announced today that it will develop a new Electronic Health Record based upon the same user interface experience and underlying information technology that it uses to support its global ecommerce business.
Said Amazon braintrust, Jeff Bezos, “Our experience with user interfaces and high performance computing are ideally suited to help healthcare. We nudge people’s decision making and behavior with the gentle push of data. When you buy a book on Amazon.com, your user interface is different than my user interface when buying the exact same book. Amazon generates the user interface based on the analytics of the broader context of the customer’s profile, purchasing history, geographic location, and other similar customers’ profiles. The parallels in healthcare are numerous and obvious, such as, “Other physicians who treated this type of patient also ordered these other medications” and “Read how other similar patients rated this treatment protocol” and “These are the other physicians in your social network who treated patients like this most often” and “This MRI is in stock and can be schedule immediately” and “This medication is available at your patient’s preferred pharmacy. Here are some other options and costs” and “Add this patient to my Diabetic Registry” and “Add this patient to my Watch List.” In addition to our unique Amazon user interface, we also have a very flexible, open services oriented software architecture that allows us to work easily with our partners and adapt quickly to changes in the market-- and our systems perform—they are fast and never go down. We will also bring this technical skill set to healthcare, which is hampered by stodgy, unreliable systems that are integrated with fragile message-based data interfaces. This foray into healthcare is not about Amazon. It's about our one billion customers and 21,000 employees. ”
The Amazon story is a spoof, though I wish it weren't. :-)
Lots of us have been planting the seeds of change around the certification of EHRs; that is, they should be certified on something more than simply interoperability-- namely usability, patient safety, and an EHR's impact on quality of care, efficiency of care, and cost of care. Future EHRs must blend patient treatment, patient management, and patient economics in the same user interface, and that EHR user interface must be dynamically generated to suit the personal context of the patient, the provider, and the healthcare system at the provider’s and patient’s disposal. It doesn’t do any good to suggest an advanced and expensive lab test in an EHR’s decision support system if the patient can’t afford it or the healthcare setting is in a remote clinic of the Navajo Nation with no lab facility.
Said Amazon braintrust, Jeff Bezos, “Our experience with user interfaces and high performance computing are ideally suited to help healthcare. We nudge people’s decision making and behavior with the gentle push of data. When you buy a book on Amazon.com, your user interface is different than my user interface when buying the exact same book. Amazon generates the user interface based on the analytics of the broader context of the customer’s profile, purchasing history, geographic location, and other similar customers’ profiles. The parallels in healthcare are numerous and obvious, such as, “Other physicians who treated this type of patient also ordered these other medications” and “Read how other similar patients rated this treatment protocol” and “These are the other physicians in your social network who treated patients like this most often” and “This MRI is in stock and can be schedule immediately” and “This medication is available at your patient’s preferred pharmacy. Here are some other options and costs” and “Add this patient to my Diabetic Registry” and “Add this patient to my Watch List.” In addition to our unique Amazon user interface, we also have a very flexible, open services oriented software architecture that allows us to work easily with our partners and adapt quickly to changes in the market-- and our systems perform—they are fast and never go down. We will also bring this technical skill set to healthcare, which is hampered by stodgy, unreliable systems that are integrated with fragile message-based data interfaces. This foray into healthcare is not about Amazon. It's about our one billion customers and 21,000 employees. ”
The Amazon story is a spoof, though I wish it weren't. :-)
Lots of us have been planting the seeds of change around the certification of EHRs; that is, they should be certified on something more than simply interoperability-- namely usability, patient safety, and an EHR's impact on quality of care, efficiency of care, and cost of care. Future EHRs must blend patient treatment, patient management, and patient economics in the same user interface, and that EHR user interface must be dynamically generated to suit the personal context of the patient, the provider, and the healthcare system at the provider’s and patient’s disposal. It doesn’t do any good to suggest an advanced and expensive lab test in an EHR’s decision support system if the patient can’t afford it or the healthcare setting is in a remote clinic of the Navajo Nation with no lab facility.
Tuesday, April 7, 2009
Live from HIMSS: Northwestern Buys BCBS of Illinois
Following the model of healthcare systems that have managed to optimize the cost of care with the quality of care—such as Kaiser, Intermountain, and Geisinger—Northwestern Medical announced the purchase of Blue Cross Blue Shield of Illinois today for $3.3B, making Northwestern the only medical center in the US with a fully-integrated delivery system with a University academic mission.
In the press release, Northwestern emphasized that “…the acquisition will enable us to personally balance the economic tension between providers-- who are economically motivated by patient volumes-- and payers --who are economically motivated by disease prevention and health maintenance.” The press release went on to say, “Owning our own insurance company will also allow us to contract directly with employers and patients, thus creating a more direct economic relationship with our patients. Any profits derived from the insurance arm of Northwestern will be funneled directly back into the teaching, research, and care delivery missions of our enterprise.”
All the above is a spoof… prompted by my wandering mind during George Halverson’s keynote address yesterday at HIMSS. He presented simple but compelling data about balancing the economics of care and the quality of care at Kaiser, which reminded me of similar presentations from another great system, Intermountain Healthcare. During Mr. Halverson’s address, I pondered, “Hmmm… wouldn’t it be a powerful healthcare delivery model if you could combine the best elements of Kaiser and Intermountain’s “quality vs. cost” economic incentives with the best elements of Northwestern’s specialty expertise, research, and academic missions?”
Hmmm… :-)
In the press release, Northwestern emphasized that “…the acquisition will enable us to personally balance the economic tension between providers-- who are economically motivated by patient volumes-- and payers --who are economically motivated by disease prevention and health maintenance.” The press release went on to say, “Owning our own insurance company will also allow us to contract directly with employers and patients, thus creating a more direct economic relationship with our patients. Any profits derived from the insurance arm of Northwestern will be funneled directly back into the teaching, research, and care delivery missions of our enterprise.”
All the above is a spoof… prompted by my wandering mind during George Halverson’s keynote address yesterday at HIMSS. He presented simple but compelling data about balancing the economics of care and the quality of care at Kaiser, which reminded me of similar presentations from another great system, Intermountain Healthcare. During Mr. Halverson’s address, I pondered, “Hmmm… wouldn’t it be a powerful healthcare delivery model if you could combine the best elements of Kaiser and Intermountain’s “quality vs. cost” economic incentives with the best elements of Northwestern’s specialty expertise, research, and academic missions?”
Hmmm… :-)
Wednesday, April 1, 2009
Privacy Protection: 92% vs. 8%
Several days ago, I passed around a survey to gauge people's concerns about protecting their private information. The survey is now closed and you can see the results and comments here: Survey Results. In summary, 92% of respondents were more concerned with “Protection of my personal identity and financial data” vs. 8% with “Protection of my electronic health record data.”
I appreciate everyone's participation. Although certainly not a "Gallup Certified" survey, the breadth of people responding was very wide and, IMO, very representative of our society.
Clearly, we must and will protect both types of information, particularly in healthcare—this is not an “either/or” situation. However, as we spend limited time and money protecting our private information in general, it would seem that we should take these perceptions of public concern in mind. In healthcare, we’ve spent significant resources protecting personal health information as a consequence of HIPAA, and rightly so, but only recently have we focused similar attention on personal identity theft, as required by the Federal Trade Commission’s “Red Flag” rule.
Thanks again to those of you who participated!
I appreciate everyone's participation. Although certainly not a "Gallup Certified" survey, the breadth of people responding was very wide and, IMO, very representative of our society.
Clearly, we must and will protect both types of information, particularly in healthcare—this is not an “either/or” situation. However, as we spend limited time and money protecting our private information in general, it would seem that we should take these perceptions of public concern in mind. In healthcare, we’ve spent significant resources protecting personal health information as a consequence of HIPAA, and rightly so, but only recently have we focused similar attention on personal identity theft, as required by the Federal Trade Commission’s “Red Flag” rule.
Thanks again to those of you who participated!
Tuesday, March 31, 2009
Personalized Medicine: The Process
I have this theory that we (healthcare) could learn from retail in terms of customer relationship management, in a variety of ways. For example, in retail, almost every store has a “Top Customers” report that lists their top customers over the past year, month, and week. They calculate “top” by total purchases and by the number of customer visits to the store or web site. In theory, retail companies treat these “Top Customers” differently, either through targeted marketing or in some cases, “red carpet” treatment and gratis benefits. I sense that the leaders in the hospitality industry engage in this type of personalized process behavior, too.
We could easily produce a report in most ambulatory healthcare settings which lists our “Top Patients.” It’s not exactly the best name for the report, but it gives us insight to the same concept as retail, i.e., Who are the patients visiting us the most often? Which patients are spending the most money on their healthcare? My theory is, these are our sickest patients and potentially the most financially challenged. Their families feel a heavy burden, too. We should keep a close eye on these patients… treat them differently… be more aware of their appointments and encounters… make life easier for them in terms of their encounters… maybe offer preferred scheduling and parking… maybe proactively reach out to them and their families to manage their experience better… process their claims differently…work with their employers and insurance companies more closely… and proactively target them for financial assistance if needed. Of course, I’m not so sure it would be a good idea to tell these patients that, “Congratulations! You are one of our Top 50 Patients!” The awareness on our part should be subtle and in the background, but patient treatment in the foreground should be noticeably different and more personalized.
I’m not exactly sure what this looks like operationally, but I do think that we should be more aware of and adaptive to these patients and their families, and do something different with their treatment and experience. There might be opportunities for research, too, assuming that these patients represent a significantly different, outlying health experience than other patients.
It’s a step towards Personalized Medicine, but from a process perspective, not from a genomics perspective.
Maybe some organizations are already doing this?
We could easily produce a report in most ambulatory healthcare settings which lists our “Top Patients.” It’s not exactly the best name for the report, but it gives us insight to the same concept as retail, i.e., Who are the patients visiting us the most often? Which patients are spending the most money on their healthcare? My theory is, these are our sickest patients and potentially the most financially challenged. Their families feel a heavy burden, too. We should keep a close eye on these patients… treat them differently… be more aware of their appointments and encounters… make life easier for them in terms of their encounters… maybe offer preferred scheduling and parking… maybe proactively reach out to them and their families to manage their experience better… process their claims differently…work with their employers and insurance companies more closely… and proactively target them for financial assistance if needed. Of course, I’m not so sure it would be a good idea to tell these patients that, “Congratulations! You are one of our Top 50 Patients!” The awareness on our part should be subtle and in the background, but patient treatment in the foreground should be noticeably different and more personalized.
I’m not exactly sure what this looks like operationally, but I do think that we should be more aware of and adaptive to these patients and their families, and do something different with their treatment and experience. There might be opportunities for research, too, assuming that these patients represent a significantly different, outlying health experience than other patients.
It’s a step towards Personalized Medicine, but from a process perspective, not from a genomics perspective.
Maybe some organizations are already doing this?
Friday, March 27, 2009
"Doctor, your EHR is killing me."
If you haven't read the March 27 JAMA commentary from Ross Koppel and David Kreda, you should track it down. In summary, they point out very appropriately, that there are patient safety issues associated with the use of EHRs, and that HIT vendors should not be allowed to contractually walk away from their safety obligations in the design and implementation of their products. I agree with the commentary and add that the obligations for patient safety don't end with the vendors; we HIT customers are obligated, too.
There is ample precedence for regulated safety among us--e.g., the Federal 510(k) process for medical devices includes a safety analysis. Laboratory information systems safety is regulated by CLIA. The software systems in the utility and transportation industries are regulated for software safety. Military command and control and information systems are regulated for software safety.
There are several layers of software safety risks associated with today's EHRs, from point-of-care decision support to the back end spaghetti of interfaces that populate a typical EHR. I'm not a fan of Federal overkill on regulations, but you have to admit that HIPAA finally drove our industry towards much better practices in patient data security and privacy protection. Without HIPAA's influence, I bet we'd still be piecemealing HIT information security and privacy. We need the equivalent of HIPAA for HIT’s impact on patient safety. Today's EHRs play a major role in the safe (or not) treatment of patients, every bit as important as medical devices. Now is the time to start planning for this as a culture. We can do it in parallel with the push for an EHR in very office.
With all these concerns in mind, it’s important to remember that the benefits of a properly implemented EHR to patient care still far outweigh the risks to patient safety. Driving a car safely is a complex process and prone to many errors, but we haven’t stopped buying and driving cars. We just keep making the car-driving process safer.
There is ample precedence for regulated safety among us--e.g., the Federal 510(k) process for medical devices includes a safety analysis. Laboratory information systems safety is regulated by CLIA. The software systems in the utility and transportation industries are regulated for software safety. Military command and control and information systems are regulated for software safety.
There are several layers of software safety risks associated with today's EHRs, from point-of-care decision support to the back end spaghetti of interfaces that populate a typical EHR. I'm not a fan of Federal overkill on regulations, but you have to admit that HIPAA finally drove our industry towards much better practices in patient data security and privacy protection. Without HIPAA's influence, I bet we'd still be piecemealing HIT information security and privacy. We need the equivalent of HIPAA for HIT’s impact on patient safety. Today's EHRs play a major role in the safe (or not) treatment of patients, every bit as important as medical devices. Now is the time to start planning for this as a culture. We can do it in parallel with the push for an EHR in very office.
With all these concerns in mind, it’s important to remember that the benefits of a properly implemented EHR to patient care still far outweigh the risks to patient safety. Driving a car safely is a complex process and prone to many errors, but we haven’t stopped buying and driving cars. We just keep making the car-driving process safer.
Wednesday, March 25, 2009
Data Security: Which Matters More?
I'm running a little experiment here to see how people feel about protecting their personal data. Mostly I'm motivated by curiosity, but also by the recent Federal interest in Red Flag events in healthcare. The Federal Trade Commission (FTC) issued a regulation in 2007 to address identity theft. Known as the "Red Flag Rule", it requires “covered accounts” to develop an identity theft prevention program. Here's a one-question survey on the topic.
Click here to take the survey
I'll share the results in a few days.
Click here to take the survey
I'll share the results in a few days.
Thursday, March 19, 2009
We Lost a Leader: The Passing of Al Pryor
Let me begin by saying that, in reality, I’m not worthy of honoring Al Pryor. Such honor is bestowed upon his family and friends who knew him much longer and deeper than I did. My fond appreciation and respect for him are all that I have to offer.
Among his countless medical informatics achievements, T. Allan Pryor was one of the "inventors" of Intermountain Healthcare’s HELP electronic health record system, along with Reed Gardner and Homer Warner Sr. They started a discussion 40+ years ago which is now on the lips of our country's President, Congress, and every corporate leader and physician in America.
There will never be another Al Pryor. His personality would sense the vacuum of dullness and mediocrity and fill it in a flash-- with humor, insight, and intellectual provocation. He kept you laughing and he kept you on your toes-- you never knew what might come next... it might be a joke or it might be a brilliant thought, and quite often, they were delivered together. There is a lesson about leadership therein, one could suspect.
In the early and mid-90's, I was working on a computerized nuclear warfare decision support system for the Pentagon when I met Al Pryor and Reed Gardner. They didn't know what I was working on at the time-- I couldn't talk about it-- but in my research, I came across their publications regarding the use of computers in time-compressed and life-critical decision support environments, so we arranged a meeting with them at LDS Hospital in Salt Lake City. The meeting was so fun and they were so engaging, I returned to my boss at TRW and said, "Adios. Get me out of the nuclear warfare business. Healthcare decision support is the *real* frontier." Three years later, I was lucky enough to be working for Al Pryor and Intermountain. He gave me the chance to lead Intermountain’s Enterprise Data Warehouse initiative, which at the time, was a fledgling project with one of Al’s graduate students. We turned the EDW into an impressive success story for Intermountain and the industry, but along the way, the project had some seriously dark periods. Many people tried quite deliberately to undermine and kill it. During one of those more depressing and troubling periods, I sought his counsel. I can still remember sitting in his office when he shared advice with me that reveals his values as well as his frank, pioneering, and admirable style. It’s advice that sticks with me today-- “If what you’re doing is fundamentally right, then stick to it. Why all the worry? You’ll eventually overcome the critics. And always remember: Physicians run the roost in healthcare. They bring home the bacon. As long as you keep them on your side and make them happy, you’re in good shape. Don’t let the bean counters fool you into thinking that they’re in charge.” :-)
By the way, some of the knowledge gleaned from Al and Reed made it back into our country's processes for determining when to "launch on warning" and when not to-- it's all about false positives and false negatives, which, of course, is incredibly critical in the scheme of nuclear weapons command and control. Al and Reed’s influence is buried without reference in the President's "Black Book" and the Emergency Action Procedures of the Joint Chiefs of Staff, Volumes IV and V. Bizarre but very true tale.
You never know who will change your life, in what way, or how far the ripple of your influence will extend, but Al Pryor changed mine and the lives of many, many people for the better.
Among his countless medical informatics achievements, T. Allan Pryor was one of the "inventors" of Intermountain Healthcare’s HELP electronic health record system, along with Reed Gardner and Homer Warner Sr. They started a discussion 40+ years ago which is now on the lips of our country's President, Congress, and every corporate leader and physician in America.
There will never be another Al Pryor. His personality would sense the vacuum of dullness and mediocrity and fill it in a flash-- with humor, insight, and intellectual provocation. He kept you laughing and he kept you on your toes-- you never knew what might come next... it might be a joke or it might be a brilliant thought, and quite often, they were delivered together. There is a lesson about leadership therein, one could suspect.
In the early and mid-90's, I was working on a computerized nuclear warfare decision support system for the Pentagon when I met Al Pryor and Reed Gardner. They didn't know what I was working on at the time-- I couldn't talk about it-- but in my research, I came across their publications regarding the use of computers in time-compressed and life-critical decision support environments, so we arranged a meeting with them at LDS Hospital in Salt Lake City. The meeting was so fun and they were so engaging, I returned to my boss at TRW and said, "Adios. Get me out of the nuclear warfare business. Healthcare decision support is the *real* frontier." Three years later, I was lucky enough to be working for Al Pryor and Intermountain. He gave me the chance to lead Intermountain’s Enterprise Data Warehouse initiative, which at the time, was a fledgling project with one of Al’s graduate students. We turned the EDW into an impressive success story for Intermountain and the industry, but along the way, the project had some seriously dark periods. Many people tried quite deliberately to undermine and kill it. During one of those more depressing and troubling periods, I sought his counsel. I can still remember sitting in his office when he shared advice with me that reveals his values as well as his frank, pioneering, and admirable style. It’s advice that sticks with me today-- “If what you’re doing is fundamentally right, then stick to it. Why all the worry? You’ll eventually overcome the critics. And always remember: Physicians run the roost in healthcare. They bring home the bacon. As long as you keep them on your side and make them happy, you’re in good shape. Don’t let the bean counters fool you into thinking that they’re in charge.” :-)
By the way, some of the knowledge gleaned from Al and Reed made it back into our country's processes for determining when to "launch on warning" and when not to-- it's all about false positives and false negatives, which, of course, is incredibly critical in the scheme of nuclear weapons command and control. Al and Reed’s influence is buried without reference in the President's "Black Book" and the Emergency Action Procedures of the Joint Chiefs of Staff, Volumes IV and V. Bizarre but very true tale.
You never know who will change your life, in what way, or how far the ripple of your influence will extend, but Al Pryor changed mine and the lives of many, many people for the better.
Monday, March 2, 2009
Personalized Medicine at the Point of Care?
I'm concerned that the speeding bullet of genomic discovery is going to outpace our ability to keep up with the demand for tests and our ability to fold the results and knowledge back into the EHR for consumption at the point of care and the process of delivering care. In fact, we already know enough about the effects of genetics on certain healthcare-related conditions, such as warfarin metabolism, that should be presented at the point of care, but largely are not.
This quest for "personalized medicine" seems like a supply chain of data-- i.e., Are we generating the data content in the machinery of healthcare to enable the production of personalized medicine? In my limited brain, the supply chain of data includes these data types and sources:
• Patient demographic data (Registration, patient reported, etc.)
• Clinical treatment data (Epic, Cerner, pharmacy, claims data, etc.)
• Clinical outcomes data (Epic, Cerner, pathology labs, diagnostic labs, other diagnostics, patient reported outcomes etc.)
• Familial data (Patient reported)
• Biological data (Labs)
Yesterday, at a demonstration of Xenobase at Childrens Memorial Research Center, as I was walking through this mental checklist of supply chain data content and sources, a couple of things struck me: (1) If I wanted my genome analyzed for inherited disease tendencies, I wouldn't know who to ask at Northwestern for that analysis; and (2) I didn't know if our hospital labs were running those tests or not and whether that data was somehow making its way back into our Cerner or Epic EHRs, or our Enterprise Data Warehouse. However, I do know that the Northwestern Core Genetics lab can run the tests... but how does that data make its way into my EHR? I can have commercial organizations like www.23andme.com run a personal DNA analysis... but I wouldn't know what to do with the results if they indicated a genetic risk of disease, nor would I know if I should trust the results, in any case.
It seems to me that we need to do a few things in the near term: (1) Engage EHR vendors in this discussion and ask, "What's your plan for incorporating the knowledge from genetic medicine into your decision support environment?; and (2) Move the collection and discovery of "genetic medicine" from the background of research into the foreground of healthcare operations. I think the term for this now is "translational" medicine. Genetic tests should be offered to those patients who are interested, but those patients should not necessarily be required to participate in a clinical trial in order to have their DNA analyzed for healthcare risks. Commercial ventures like 23andme are gearing-up in a free-market way to democratize the availability of these tests, and the knowledge associated with them.
Some geneticists argue that the emerging commercial genetic ventures are irresponsible and dangerous-- that they are releasing information that's "unsafe" to patients because the knowledge is not fully vetted and patients won't be informed enough to make informed decisions. Every time I hear someone espouse something akin to the general motive of controlling information to protect the consumer from their own ignorance, I can't help but reflect on the same motives for repressing knowledge, literacy, writing, language translation, etc. that come and go through human history, yet always are eventually doomed to failure. Rather than repressing knowledge, we should do everything we can to release the knowledge we have now as quickly as possible, and thus achieve greater knowledge, sooner.
This quest for "personalized medicine" seems like a supply chain of data-- i.e., Are we generating the data content in the machinery of healthcare to enable the production of personalized medicine? In my limited brain, the supply chain of data includes these data types and sources:
• Patient demographic data (Registration, patient reported, etc.)
• Clinical treatment data (Epic, Cerner, pharmacy, claims data, etc.)
• Clinical outcomes data (Epic, Cerner, pathology labs, diagnostic labs, other diagnostics, patient reported outcomes etc.)
• Familial data (Patient reported)
• Biological data (Labs)
Yesterday, at a demonstration of Xenobase at Childrens Memorial Research Center, as I was walking through this mental checklist of supply chain data content and sources, a couple of things struck me: (1) If I wanted my genome analyzed for inherited disease tendencies, I wouldn't know who to ask at Northwestern for that analysis; and (2) I didn't know if our hospital labs were running those tests or not and whether that data was somehow making its way back into our Cerner or Epic EHRs, or our Enterprise Data Warehouse. However, I do know that the Northwestern Core Genetics lab can run the tests... but how does that data make its way into my EHR? I can have commercial organizations like www.23andme.com run a personal DNA analysis... but I wouldn't know what to do with the results if they indicated a genetic risk of disease, nor would I know if I should trust the results, in any case.
It seems to me that we need to do a few things in the near term: (1) Engage EHR vendors in this discussion and ask, "What's your plan for incorporating the knowledge from genetic medicine into your decision support environment?; and (2) Move the collection and discovery of "genetic medicine" from the background of research into the foreground of healthcare operations. I think the term for this now is "translational" medicine. Genetic tests should be offered to those patients who are interested, but those patients should not necessarily be required to participate in a clinical trial in order to have their DNA analyzed for healthcare risks. Commercial ventures like 23andme are gearing-up in a free-market way to democratize the availability of these tests, and the knowledge associated with them.
Some geneticists argue that the emerging commercial genetic ventures are irresponsible and dangerous-- that they are releasing information that's "unsafe" to patients because the knowledge is not fully vetted and patients won't be informed enough to make informed decisions. Every time I hear someone espouse something akin to the general motive of controlling information to protect the consumer from their own ignorance, I can't help but reflect on the same motives for repressing knowledge, literacy, writing, language translation, etc. that come and go through human history, yet always are eventually doomed to failure. Rather than repressing knowledge, we should do everything we can to release the knowledge we have now as quickly as possible, and thus achieve greater knowledge, sooner.
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