Very Cool New Product: Choosing Wisely with Stanson Health

I recently gave a presentation to a regional HIMSS meeting in Austin, Texas and in that lecture, I talked about "closed loop analytics"-- that is, presenting data in the workflow of decision making, such that the data optimizes the outcome of the decision. Amazon.com does it all the time to influenc our decisions when buying their products. I was lamenting our lack of closed loop analytics in EHRs to help inform and influence physicians and patients at the point of care.

In the audience of that HIMSS meeting was Kimberly Denney, Vice President at a company Stanson Health. She called me afterwards and said, "Hey, I think we have what you're talking about. I think we have closed loop analytics."  And so began my familiarity with Stanson Health.  I soon found out that Stanson was founded by Dr. Scott Weingarten, one of the most respected, nice, humble CMIOs in healthcare, and also the founder of Zynx. Cedars-Sinai is the development lab for Stanson Health, much the same as it was for Zynx before being sold to Cerner.

Stanson Health provides Epic health system users with targeted, real-time clinical decision support that notifies physicians when and where they need guidance most: at the point of care.  Using closed-loop analytics, Stanson informs clinical and technical stakeholders about specific provider ordering behaviors because monitoring provider adherence to evidence based guidelines is crucial in helping organizations reduce variation in care, reduce overutilization of high cost interventions, and safely improve care quality over time. 

Studies have shown that EHRs alone, without clinical decision support, have minimal impact on quality and cost of care. EHRs with the appropriate forms of clinical decision support, however, can have a substantial impact.  Imagine the power of having intelligent clinical logic embedded in the EHR that helps physicians make appropriate decisions at the point of care while substantially reducing waste from inappropriate or unnecessary care.  Physicians are 15 times more likely to adjust their decisions if presented with evidence-based data at the point of care, compared to seeing the same data off-line, in a clinical quality improvement meeting.

Leveraging the American Board of Internal Medicine’s Choosing Wisely® campaign, Stanson has transformed static societal guidelines into real-time, actionable CDS. What sets Stanson apart from other CDS vendors has been their dedicated approach to testing and refining each new piece of CDS in a live EHR environment. As part of a quality improvement initiative at Cedars-Sinai Health, Stanson clinicians have audited patient charts to validate the accuracy and positive predictive value of their rules.  Designed to be “fatigue proof” the Stanson alerts when triggered to a provider in the ordering workflow represent a patient-specific, evidence-based recommendation. With over a year’s experience at Cedars, Stanson has validated $4M in savings from reductions in ordering volume and cancelled orders for a number of imaging tests, labs, procedures, and medications. Reducing overutilization of Benzodiazepines in the elderly, for example, also translates into reducing patient harm by reducing the risk for falls, hospitalization, long-term care or possibly death.  

Stanson’s closed-loop analytics enable important insights for C-suite stakeholders on where their focus may deliver the greatest benefit and savings. Stanson knows every dollar invested in a provider using their CDS will be returned a minimum of 3-4X. As health systems move from fee for service to outcomes, Stanson Health’s solutions provide much needed guidance for that journey by enabling crucial conversations and the transparency needed to support physicians as they begin to compare their practice with their peers.

Stanson Health is providing specific and measurable ROI from their Choosing Wisely CDS, but they are also providing a general role model example of closed loop analytics at the point of care. Choosing Wisely is just the beginning.

Bigfoot Spotted Near Durango

This article appeared in a recent edition of the Durango Herald, which spawned a discussion on Facebook about an earlier version of Bigfoot sightings in the area.

Here's the story of the Durango Bigfoot that came along a few years before this recent sighting.

In 1977 or so, Herb Newbold and I climbed up into the big cottonwood tree at Cottonwood Campground on Lightner Creek and stole the fake, stuffed gorilla that was sitting on one of the branches. We had to attempt the caper twice, because we didn't realize on the first attempt that the gorilla was chained and locked to the tree. So we came back the second night with bolt cutters from Herb's Dad's shop and climbed back up the tree with those-- that wasn't easy. We cut the gorilla out and gave him back his freedom. The gorilla was stuffed with pillows, but the feet were filled with concrete-- we didn't know that-- and when we cut him free, he plummeted to the top of a metal picnic table, making quite the racket as everyone was trying to sleep in their campers. The lights came on and the dogs started barking... and we ran down the road carrying our prized and mostly limp gorilla. By the way, we didn't really consider it "stealing" since the campground and gorilla belonged to a member of Newbold's family. That's called rationalized truth. :-)

Newbold would get dressed up in the suit, wearing a football uniform and shoulder pads underneath for bulk, and I would drive him up in the woods and drop him off, usually on Test Track or behind Perrins Peak. Then I would go back to town and pick up the unsuspecting victims and ask them if they wanted to go offroading in my Jeep CJ5, a very popular ride among teenagers in the mountains of Durango, Colorado. Sometimes I'd have the cloth top folded down, which would make for even better theatrics, as the victims were entirely exposed to the Bigfoot monster that was about to set upon them. I would drive back up to the woods where Newbold was waiting and he would jump out, run in front of the headlights and make a crazed Bigfoot scene with growls and roars and flailing arms, then run off into the woods again. I would swerve back and forth and do my part for an Academy Award, and drive past in a panic of dust. The unsuspecting victims were, 100% FREAKED OUT. Uncontrolled, blood curdling screams were the norm. After adding to their freak out with my fake freak out ("Did you see its fangs?!?!"), I would turn the Jeep around-- "We have to escape and get back to town!!" Taking a chapter from all horror movies, the Jeep would occasionally and coincidentally lose power and lights, and there we were, sitting in the dark, helpless lambs to the monster, cranking the engine to no avail. Then Newbold would jump from the woods and repeat the scene and the screaming would start all over again. One of the victims, Eileen Mahoney, screamed, "Just run it f****g over!!!"... but I thought that might be taking the acting a little too far. Everyone that we took along for a ride, fell for it-- hook, line, and sinker. Steve Janes and Paul Harmon called the sheriff's office when we got back to town and the next morning, they showed up at my parent's doorstep, armed with rifles, ready to go back and hunt the beast. They were aghast when I told them that I couldn't go because I had to mow the lawn. Mowing the lawn vs. hunting Bigfoot seemed like an easy choice to them. We probably scared 20-30 people, total. We made the police blotter, which we considered a major coup, as well.

The gorilla suit spent its last days in Mom and Dad's attic.  Or at least I thought it did until now. :)

Eleven Habits of Passionate People

Most of this blog and much of the inspiration originally appeared in LifeHack, one of my favorite web sites, written by Sarah Hansen, one of my favorite writers. I made a few edits and added one more entry-- passionate people have a sense of humor.

There are a number of clinical studies in the field of neuroplasticity that prove beyond a doubt that the brain is malleable-- it can change and adapt throughout our lives and that our thoughts and emotions function as a feedback loop to that plasticity. For most of us, our thoughts are within our control and what we think has a physical effect on the structure and function of our brains.  Even more amazing, there is a growing body of evidence that our thoughts can also affect gene expression.

If you lack passion in your life, and you would like to have more, you CAN have more. All you need to do is change your thinking, change your attitude, nurture these habits and the passion will follow.

Of course, the opposite is true, too. The choice is ours. But is what kind of choice is it? To lead an engaged life, with passion for the beauty that constantly surrounds us, not ignoring the ugliness that also surrounds us, but rather working determinedly to eliminate it... or not.

I don't claim to live up to these principles of passion, but I try and will keep trying until they put me in ground, kicking and screaming. One thing's for sure...It's really hard to live a passionate life if you're surrounded by those who aren't interested in the same. It's like playing tennis with somebody who never returns a volley, unless it comes straight at them and they don't have to run. Passion begets passion. I'm so incredibly lucky to be surrounded by family and friends who choose to live a passionate life. Thank you so much for returning the volley.

0.  Passionate people have a sense of humor.

Laughter is a great source of creativity and passionate people are naturally creative. Laughing when times are good is easy. Laughing when times are stressful is not, but passionate people will always find a way to see the humorous side of life. Above all, passionate people have the ability to laugh at themselves and the silliness of their shortcomings and mistakes, rather than be being defensive and regretful. They move forward and bring others with them in the wake of laughter.

1. Passionate people are doers.

While passionate people often enjoy talking a mile a minute about what excites them, they back up their claims with action. Bring on the blood, sweat, and tears! The devoted will do whatever it takes to accomplish their dreams.

2. Passionate people are excited.

Passion is contagious! It’s hard to be around a fiery person and not get swept away in their excitement, even if it’s about something that you never thought could interest you. Passionate people live every day with the anticipation of great things.

3. Passionate people are courageous.

“Chase your passion, not your pension.” – Denis Waitley

Passionate people are willing to do anything to get the job done. They face their fears head-on because they are committed to eliminate anything that holds them back from what they most desire.

4. Passionate people are positive.

Passionate people often don’t hang out with negative people. They come to value positivity in themselves and others, and don’t have time to entertain failure long. They have the ability to bounce back from setbacks quickly without losing enthusiasm. After all, they didn’t really fail, they just learned one more way to avoid attempting their mission. They still have thousands of attempts still untested.

5. Passionate people strive to be their best.

People with passion always want to offer their best to the world. They can be slightly perfectionist in their thinking, but it’s only because they see their output as a direct reflection of them. If they place their personal stamp upon it, it will be infiltrated with their essence.

6. Passionate people are motivating.

Need help getting started with a new project? Find a passionate person to get you off the couch! Passionate people are great coaches and motivators. They often care deeply for others and do everything they can to help them succeed.

7. Passionate people are happy.

Most passionate people who follow their life longings are happy and fulfilled individuals. They focus on their blessings and give back to others. They are glass-half-full people who choose to enjoy making lemonade with the lemons life throws at them.

8. Passionate people are accountable.

One of the best bits of advice I’ve ever received was that passion was a powerful driving force that must be channeled. If left unchecked, it could cause an explosion causing great destruction. However, if properly utilized, the same fire that once ruined could also be captured to power a steam engine for positive change. Passionate people learn to have others hold them accountable to channel their energy in the best possible way.

9. Passionate people are focused.

“Skill is the unified force of experience, intellect, and passion in their operation.” – John Ruskin

Passionate people know they have a job to do, and they do it with gusto. They run in the rain. They smile through the most menial tasks. No matter what distractions life throws their way, they remain laser-focused on their final objective. They don’t take easy detours, but plow in at full speed. The driving force within them won’t let them lose sight of the end goal.

10. Passionate people love to grow.

Passionate people never stagnate in the pool of despair, feeling they are finished. They always look for ways to improve upon themselves and their surroundings. Passionate people keep their childlike wonder about life. They are always learning, always growing, always experiencing new things. They squeeze every last drop out of life that they possibly can!

Cost Reduction & Clinical Quality Improvement: Where Do You Get Started?

Below is a diagram with real data from a real healthcare system in the US, that shows the top clinical processes in terms of cost. The results are almost identical, across Health Catalyst clients. The notion with this data is, if you are trying to organize yourselves around a cost reduction and clinical improvement strategy, it’s probably a good idea to choose the top 3 or 4 of these to get started in the first year, then simply work your way through the list after that. It’s the same basic problem solving framework that the FAA uses in the United States for steadily improving airline safety and reliability.

The unique aspect of this data is that it combines inpatient and outpatient data into one perspective. In the past at Intermountain, we looked at inpatient and outpatient care processes as separate processes, and we called them Clinical Programs. Also, we didn’t have an effective algorithm for grouping these inpatient and outpatient data sets into a single view of the patient care process. That approach was definitely effective, but this new perspective is based on the availability of new data, mashed together with new grouping algorithms, plus the evolution of our awareness about how best to optimize the delivery of care, with the goal of extending inpatient/outpatient concepts into true population health in the community— that is, the outpatient experience will eventually include the socio-economic data environment of the patient.

This diagram is a reflection of work at Health Catalyst over the last three years. Dr. David Burton, who hired and partnered with Dr. Brent James on Intermountain's Clinical Programs, is the brainpower behind these new inpatient/outpatient grouping algorithms.

EHR Interoperability, Part 2

The following comment was posted on the Mr HISTalk web site, in response to my earlier blog about interoperability:

"Dale, why hasn’t Health Catalyst published its data model and algorithms to the world? You want all the EHR vendors to bow down and provide their Intellectual Property to you for free so that you can make money building on it?

Where are your APIs Dale? Where is your data model published Dale? Get it published and make it available to all your competitors, other startups and innovators in general and then feel free to throw stones.

You’re just one more self interested wanna be in the healthcare start up game talking tough while holding yourself to a different standard."

This is my response:

Your comment is a little snarky, but the underlying theme has merit—I cannot expect from others what I do not expect of myself.

My blog was written as a practicing CIO, motivated by the best interests of our country, our patients, our physicians, and… get ready… EHR vendors. As evidenced by Epic’s recent decision to create an app store, I’m by no means the only person in the industry who believes that open APIs are the right thing to do for interoperability and innovation, as does the DoD. The DoD has been the historical leader of open systems in the world—ASN.1, SGML, DCE, CORBA, Ada, POSIX, TCP/IP and many others. Epic’s app store decision in light of the DoD procurement is a great recognition of that DoD legacy. The Epic app store will benefit the entire industry.

You can try to discredit my comments about interoperability by firing back at Health Catalyst, but the criticism just won’t hold up. Health Catalyst is a tiny little startup, fighting it out in the best interests of our clients, in the trenches of American capitalism. We are economic and market influence gnats on the rump of today’s EHR vendors—the same EHR vendors that have benefitted from billions of tax dollar subsidies. And when you benefit from that sort of tax money, along with that benefit comes a new level of scrutiny and accountability back to those tax payers to do the right thing. When and if the healthcare analytics market benefits from $25B in tax subsidies, the bar of national accountability will raise for Health Catalyst, too.

You would be surprised at how little influence I have on the way that Health Catalyst operates. I cannot and do not speak officially for the company. My contract with Health Catalyst stipulates that I can continue to speak, publish and blog on matters that reflect my personal opinion about the healthcare industry, which is the case in this discussion. In that context, I sit on the Canada Health InfoWay External Advisory Panel for Interoperability and that panel is in the midst of developing Canada’s roadmap for healthcare interoperability. We are hoping to help Canada avoid the ills that have plagued the US.

I will go out on a limb and offer speculation—I bet Health Catalyst leadership would love nothing more than to publish all sorts of open APIs around their platform and products. As soon as any other vendor, including EHR vendors, asked or wanted to build products around the edges of the Health Catalyst platform, Health Catalyst would open the API doors– and not out of naïve altruism, but out of common business sense. The bigger the ecosystem of products that can interact with Health Catalyst, the better for Health Catalyst and the better for Health Catalyst clients and the industry. The Health Catalyst web site is an open cookbook for analytic success in healthcare. Take a look at any other healthcare IT vendors’ web sites and compare it to Health Catalyst. We don’t even offer a login-protected portion of that web site for clients. Everything we do is in the open because that type of openess raises everyone’s game, including ours.

The only thing that Health Catalyst wants from EHR vendors is EHR data and data tags so that Health Catalyst clients can analyze their own data. It’s interoperability at the data warehousing level. I don’t see how EHR data can be considered IP that belongs to the EHR vendors. That data belongs to EHR clients and their patients, and I bet patients would like to know that their data is easy to access for analysis that benefits them clinically and financially.

I will close by asking: Is there anyone out there who genuinely believes in their heart that our national healthcare IT interoperability and innovation strategy is working? Is there anyone out there who believes that anything in my blog is asking or expecting too much of EHR vendors? I guess one person does, but would guess that most do not.

As usual, my thanks to Mr. HISTalk for providing this unique forum.

Respectfully,
Dale

Barriers to EHR Interoperability Are Contractual and Cost

The barriers to EHR interoperability are not just technical. They are contractual and cost, as well.  I’m speaking as a first-hand source of knowledge about this, as a healthcare CIO.

EHR vendors who enjoy the benefit of our tax dollars under the HITECH act are preventing interoperability-- and innovation around the edges of their EHR products by third party developers-- by placing limitations and restrictions in their contracts with clients. The vendors who are engaged in this type of exclusive behavior can point to their technology and say, "See? We can share data. We follow data sharing technical standards. Quit criticizing us." But when you look into these vendors’ contracts, the license fees associated with interoperability are cost prohibitive, and the interoperability clauses are surrounded by onerous contractual obstacles that are veiled to protect the vendors' intellectual property, yet are actually ensuring the vendors' continued stranglehold on data and preventing innovation around their products.

This behavior on the part of some EHR vendors is strikingly ironic, given the enormous success of open source, easily accessible APIs that benefit interoperability.  The more open your products are, from a software architecture perspective, the more value you accrete to your products’ intellectual property.  Open, transparent APIs create a greater dependence and ecosystem around your products, not less.

Several years ago, I sponsored a meeting with senior executives from four large EHR vendors, lobbying them to open their APIs and migrate their software engineering architecture from tightly coupled, difficult-to-modify-and-upgrade, message oriented architectures; to loosely coupled, flexible, services oriented architectures (SOA) with open, published APIs, so that my engineering teams could write innovative products around the edges of these EHR products.  We even sketched the architecture of an SOA-based EHR, along with about 20 core services-- it was easy; it is not rocket science. Within 18 months after those meetings, three of the four vendors launched formal initiatives in their companies to create more open, friendly APIs, both technically and contractually, and they’ve stayed the course.

I will never forget the response from the fourth of those EHR senior executives.  That person said, “We see ourselves as more than a database vendor.”  Meaning, of course, “Our closed APIs are a market and proprietary advantage.”  Bill Gates and Microsoft used to think the same thing about Windows, Office, and Internet Explorer.  You can see how that worked out for them when you compare what’s happened with the openness of Android, iOS, the browser market, and office suite products; and you can also see Microsoft’s amazing pivot towards open architectures and interoperability in the last few years.  SalesForce.com is the supreme example of business success based upon an open API and open culture.

One of my current colleagues, who has been deeply involved in the interoperability environment for many years, described his thoughts in an email to me, summarized below:

Current “Interoperability” standards, selected by the ONC and required by MU-S2 do not contain an adequate amount of data/data types to support the quality measurement requirements of the same MU-S2 program. This gap in data is what enables the EHR suppliers to continue the veil of “interoperability” while still protecting their proprietary intellectual property, serving the interests of the owners of these companies with little regard to what may be best for care, providers, patients or consumers.

Several EHR vendors are banning together around a new magic bullet technical standard called HL7-FHIR based on JASON technology.  While this new standard is great from a technical perspective (XML, REST, etc.), in its current form, based largely on existing HL7 v2, v3 and CDA concepts, it does NOT improve the accessibility of proprietary EHR data types, and those data types are needed for quality and cost performance improvement in healthcare.  While FHIR could be expanded to include this type of data, it appears the first efforts are focused on reinventing the technology for currently defined interoperability data types.

I’m not sure what, if anything, Congress can do at this point to fix the ills of Meaningful Use Stage 1, which, in effect, rewarded existing vendors with billions of dollars in tax money to maintain those vendors’ closed and proprietary APIs.  Decertification by ONC will become a bureaucratic mess, but I appreciate the symbolic stance taken by Congress around decertification, nonetheless. One thing that must happen—and maybe our legal courts are the only option for this—the contractual threats and cost barriers in EHR vendor contracts that stand in the way of interoperability and innovation must be removed.

Interoperability and innovation in healthcare IT are suffering, both technically and contractually, by old-fashioned, old-school thinking on the part of some EHR vendors.

And, as an outcome, our healthcare system and patient care are suffering, too. We can do better as a country, and the EHR vendors can actually profit from being more open, not suffer.

The Personal and Professional Downside to Gratitude

Gratitude has become a very mainstream trend in the last few years. That's generally a good thing, but I've come to realize that too much gratitude has had a downside in my life, both personally and professionally.  This is a giant and new insight for me, given my upbringing and philosophies of life.

I was born and raised in a family that exuded gratitude. My dear Mom and Dad lost two of their children, very early in life, to tragic accidents, but they remained strong, positive and grateful, and it carried over to their four remaining children, and innumerable grandkids, friends, and neighbors.

Every night, I go to sleep saying my 'gratefuls' not prayers. I spend the moments before drifting off, replaying the day, reviewing all the wonderful and fascinating things that occurred in my life that day. Inevitably, no matter what bad things the day held, there are always a larger number of things for which I can sincerely step back and give thanks. I love this practice and have no plans of changing it.

But...

Now reflecting back, at 55-years into life, I can see a number of situations, both personally and professionally, in which too much gratitude actually played a negative role in my life, not positive.

In abusive, unhealthy relationships, I kept expressing gratitude-- finding all the good things in those relationships-- to the detriment of my self-esteem, life potential, and happiness.  That happened twice, in significant ways.  I was simply grateful that someone loved me, even if that "love" came wrapped in psychological abuse and relationships that were clearly unhealthy. My gratitude kept me engaged in those relationships, much longer than was healthy.

In a number of business negotiations, usually involving employment compensation, sometimes also job titles and new responsibilities, I've been too grateful-- taking a very passive, trusting, selfless, and soft approach to those negotiations, but underplaying my value, skills, and contributions. In these cases, I was a combination of too grateful for the compensation or job offer, and to have any job at all, and also too humble. I failed to recognize and acknowledge the value of my own work.

It took many years for me to become aware of this tendency towards too much gratitude, and it's especially unusual that this awareness should arrive at a time when practicing gratitude is a cultural phenomenon. The popularity of gratitude in today's society is probably one of the reasons that my awareness of its downside became highlighted.

Be grateful, but be careful.  In any situation, personal or professional, if you are endlessly grateful, odds are, you are going to be a lot less likely to say, "I (or we) can do better." Don't let too much gratitude keep you in an unhealthy relationship or keep you from negotiating firmly and truthfully about your own professional value, or from improving a situation to achieve greater potential. And be prepared-- it takes courage to pull back on the reins of gratitude and declare, "Wait a second, I don't have to be grateful about this situation. There's nothing wrong with expecting a little more."

I can't believe I'm going to say this-- don't let gratitude hold you back.

When I Googled, "is it possible to be too grateful" I found a good, 11-minute video from Amie Gordon, a PhD researcher who has given this topic some very formal, academic thought: