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Being John Glaser 11/10/09

November 9, 2009 News 20 Comments

While waiting for my annual physical, I enrolled in a research study. (About every other year, I participate in a research study. Two years ago, a sleep apnea study involved me spending the night in an iron lung with electrodes in my mouth and all over my head and chest. Not conducive to a good night’s sleep).

My current study centers on healthy behaviors. The study is intended to improve the health behaviors of people who are fundamentally healthy (my blood pressure, cholesterol, weight, etc. are fine) through a set of pretty modest interventions. Armed with a pedometer, a Web site for recording progress, and an every-other-week call from Maria (my “health coach”), I am supposed to:

Have one multi-vitamin each day. Duck soup.

Eat three or fewer servings of red meat each week. This takes some thought and planning, but is not that hard.

Eat five to seven servings of fruit or vegetables each day. Since I usually eat one meal a day, this has proven to be a real challenge. I tried to persuade Maria that onion rings were a vegetable. As was a cup of coffee (coffee beans come from plants) and vanilla ice cream (vanilla beans also come from plants). She wasn’t buying it. But I have been able to drink some fruit juice during the day and toss down a banana and apple, allowing me to meet this goal.

Walk 10,000 steps a day. During a normal day “at the office”, I will walk 3,000 steps. This means I have had to find an hour each day to walk to get the other 7,000 steps. Finding that hour takes some planning — for example, getting up early to walk before work. (This has turned out to be an enjoyable experience — it’s quite cool to watch the sun come up over the Capitol Building and the Washington Monument).

So far, three months into this six-month study, I have been pretty good at meeting my goals. Maria has not scolded me.

This experience has reminded me that maintaining health, restoring health, or ensuring that a disease does not progress requires that patients engage in “health behaviors.” And it has reminded me that instilling such behaviors is a multi-faceted undertaking. I am not as well versed as those that have deep experience in this area, but this study experience seems to indicate that four factors must be present.

Focus. You have to know which behaviors are the ones that must change or be performed. This can be different — lose weight, take medications, take it easy after surgery, or stop smoking — across patients and situations.

Information. The patient needs information. This information is diverse — the linkage between the behavior and health, specific data about the behavior (e.g., coffee is not a vegetable), and behavior alternatives (how many steps is a game of racquetball?)

Tools. For example, my pedometer and the Web site to daily record whether I met my goals. Depending on the behavior, there can be other tools. Some do not involve IT, like nicotine patches. Some do involve IT, such as measurement and transmission of blood pressure.

Motivation. The desire to alter one’s daily routine to adopt a more healthy routine is probably the most important factor. It is also the most complex and difficult factor. Why would I get up an hour earlier to walk when I can use that valuable time to sleep? Motivation requires motivators (desire to please, guilt, basic type A behavior to achieve a goal, interest in living long enough to play with grandkids). It requires the removal of barriers that could discourage a motivated person, such as limited access to providers. It requires feedback on progress. It requires a social structure of family or friends that are supportive. And it requires the other three factors.

We will never have a reformed or transformed health care system unless we are broadly able to engage patients in managing their health. Cost reductions and outcomes improvements in treating chronic diseases require a motivated patient. Reducing unnecessary treatments is greatly facilitated by an informed patient. Improvements in the quality of care are helped by patients who make good decisions about which providers and health plans to choose.

We can help engage patients. Clearly we can provide tools and support access to information. While recognizing its complexity, we can also help with motivation.

Motivation opportunities range from making whatever IT is involved easy to use (reducing a barriers for a motivated person) to offering graphs of progress and corny but effective “attaboy” generated phrases to avatars that exhibit motivating emotions such as disapproval to online communities of others who can offer support.

While the opportunities can be listed, we have limited understanding of how to apply IT to motivate.

I need to go eat an apple. Otherwise Maria will yell at me.

 

John Glaser, PhD, FCHIME is vice president and CIO at Partners HealthCare System and is also on temporary assignment as Advisor to the Office of the National Coordinator. He describes himself as an "irregular regular contributor" to HIStalk.

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Currently there are "20 comments" on this Article:

  1. John-

    Unlike you, I don’t have time as a physician to do personal things anymore. Obama has made sure with the HITECH Act that I must buy an EHR that I can’t afford, sit behind it wasting my time that I don’t have to waste, and alter my workload in a way that is unproductive.

    I guess I can participate in a healthy behavior study wearing one of them neat “wearable computers,” but with the pending 21% physician pay cut expected in 2010, I may not afford even that. But that’s what they want us docs to do to show the world that we are “significantly using” and EHR, no? Everything that we do, from walking to having sex (can we say “sex” here?) must be communicated with CMS so that we get paid that paltry 2% or at least not get penalized and thus rot in Medicare hell, seeing old people for almost free.

    Or… I can become a “participating nonparticipating” provider within Medicare! Hmmm… that is tempting. No “significantly use” EHR stuff. I get paid 15% more per patient, who has to pay me up front. If Medicare loses the invoice sent in, like they do 20% of the time, it won’t be my problem anymore. I have 6 days left to decide what to do… pretty easy choice, I’d say.

    Which is why the HITECH Act will falter- you can’t single out a group of people (doctors) to pay for something that everyone, including patients, insurance companies, and big government will benefit except for the doctors themselves. Where President Obama has faltered on this is that he has paid attention to all of the vendor lobbyists that surround him (like yourself) but not to the clinicians themselves, which so far have shown to be “significantly use” adverse, using EHR only 4% of the time.

    It’ll be interesting how the next tea party- the “HIT 1115 Project” will turn out. Physicians need to get together and “walk” away from this beaurocracy.

    Al Borges MD

    “HIT 1115 Project” URL: http://www.hcplive.com/technology/blogs/the_hit_realist/0909/HIT_1115_project

  2. Awesome. Teabaggers come to healthcare I.T! Looking forward to more creative comparisons of the President and Hitler and “Obamacare” and the holocaust.

    Al I cannot help but think you need something catchier, a list of concise talking points and a fear factor to get your message across more effectivley. May I humbly offer some suggestions?

    If we have to see old people for free, doctors will flee!

    Emancipation from “nonparticipation”!

    No sex to CMS!

    No bureaucracy for the aristocracy!

    Significant use means Grandma gets the noose!

    Keep the socialist government out of Medicare!

    Blumenthal lied, grandma died.

    2% how will I pay the rent?

  3. Blah,

    Your comment above that begins with “Awesome. Teabaggers come to healthcare IT! Looking forward to more creative comparisons of the President and Hitler and “Obamacare” and the holocaust” is an ad hominem attack.

    Nowhere do I see you address any of the issues raised by Dr. Borges. An ad hominem argument, also known as argumentum ad hominem (Latin: “argument to the person” or “argument against the person”) is an argument which links the validity of a premise to a characteristic or belief of a person advocating the premise.

    You can read about argumentum ad hominem and why such attacks are meaningless at this link: http://en.wikipedia.org/wiki/Ad_hominem

  4. Chicken Little (aka Al):

    * The cost of computing power falls 50% every 18-24 months, and has done so for the past 40 years – and computers have gotten better and faster.
    * Airline fares have fallen over 10% since 2001, and the skies are safer.
    * Telecommunication costs have declined by nearly 90% in the past 20 years – and the concurrent mobility provided is a game-changer.
    * Consumer electronic prices have dropped just as dramatically – and the quality is better.

    Forced revenue decline is a part of modern-day business – sometimes regulated, sometimes imposed by competition – but it is almost always healthy. Price reductions are not unique to physicians. Imagine the day when doctors actually have to compete on price, quality, service, and innovation like the rest of the free-world markets. That might then require innovatative business practice, hiring quality people, treating patients like consumers, and perhaps even making use of technology like EMR’s!

    The sky is only falling on those who aren’t forward thinking enough to take advantage of the paradigm shift.

  5. >>> Looking forward to more creative comparisons of the President and Hitler and “Obamacare” and the holocaust.

    Hitler? After hearing Anita Dunn (Obama’s communications director), and some of his czars, I’d compare him to Chairman Mao.

    URL: http://www.youtube.com/watch?v=X2FVEe7wCzs

    Other possibilities include Chavez, Castro, Ortega and Che. Some in Obama’s camp actually prefer Che- http://www.wauseon.com/images/obama-che_judge.jpg (note wall posters)

    The holocaust has already been taken by Democratic Senator Grayson: http://www.youtube.com/watch?v=iDtoGzQUTu0 when he compared the situation without Obama/Pelosicare as a “holocaust.”

    I’m just stating how I, a physician in clinical practice who finds himself in the middle of all of this poliitical meandoring feels.

    Even if a fraction of the 1 million USA physicians participate in the tea party, it’ll be one big group indeed!

    Al

  6. Chicken little? I’ve been called many names, including “EMR antiChrist,” but never that! Borrowing a quote from Winston Churchill: John, tomorrow I may wake up with yellow feathers yelling like a rooster, but when YOU wake up, you’ll STILL be ugly!

    URL: http://i38.photobucket.com/albums/e103/alborgmd/Jokes/heugly.png

    >>> * The cost of computing power falls 50% every 18-24 months, and has done so for the past 40 years – and computers have gotten better and faster.

    Ahhh- but the cost of “certified” EHRs continues to increase about 5% a year even though there are few buyers. The average cost of a certified EHR is slightly less than $34000 up front, and the average monthly maintenance cost is $1800. This is mostly due to extraneous factors, including CCHIT.

    Al

    Al Borges MD
    My Anti-certified-EHR Website: http://www.msofficeemrproject.com

  7. The cost of computing power falls 50% every 18-24 months, and has done so for the past 40 years – and computers have gotten better and faster.
    * Airline fares have fallen over 10% since 2001, and the skies are safer.
    * Telecommunication costs have declined by nearly 90% in the past 20 years – and the concurrent mobility provided is a game-changer.
    * Consumer electronic prices have dropped just as dramatically – and the quality is better.

    These are not valid comparisons, since most of these are commodities, whereas physician services are personal services. Almost all personal services have risen in cost; which is why when your twice-as-fast PC crashes, you have to call India and talk to someone reading from a script. But I guess if saving money is your goal, this may be acceptable for your health problems.

    Hmm…more customer service complaints. I treat my patients like adults. The problem is, most don’t exhibit adult behavior. We have been conditioned since childhood that illness permits us to regress, act like children. So they walk in without appointments, are rude to busy staff, whine that they can’t get a cheap pill for a lifestyle problem, and feel imposed upon when having to get the checkbook out. Trying pulling that in the grocery line.

    This discussion degenerated in record time, by the way, to meet Godwin’s law criteria http://en.wikipedia.org/wiki/Godwin%27s_law. It’s probably due to the overall rational level of discourse that typifies present political discussions in our country.

  8. “* The cost of computing power falls 50% every 18-24 months, and has done so for the past 40 years – and computers have gotten better and faster.”

    True, but that power increases and although prices are still going down, the important points are missed. We get these devices built overseas in cheap factories, require extra work per worker or pay incredibly low rates. Until an iPhone is 20 bucks straight from Apple with no contract there will still be huge profit. And that money is mostly wasted instead of being used wisely (regarding most large consumer electronics businesses, of which PC’s and the like are a part).

    * Airline fares have fallen over 10% since 2001, and the skies are safer.

    That is because these companies will make MORE money by getting more people to fly at a cheaper rate. It makes more sense to have fully booked flights at $80 a seat than half fill the plane for $140 a seat. The market relies on what people are willing to pay in this situation.

    * Telecommunication costs have declined by nearly 90% in the past 20 years – and the concurrent mobility provided is a game-changer.

    Cost to the providing company has dropped. However, price to the customer fluctuates but has been pretty similar over time. Consider AOL for 10 bucks a month for limited access at first. Then came unlimited providers for around 20 a month. Then came cable and DSL for $30-60 a month, and those prices have largely stayed in that range. I currently pay $45 a month simply for 3Mbit cable because I live in a small town with no competition nearby with old and unstable phone/DSL lines.

    * Consumer electronic prices have dropped just as dramatically – and the quality is better.”

    True, but the cost of making them has dropped, the businesses that make them have become more streamlined to make larger profit margins way before this economic turmoil. And the best part is that competition drove this to be the way it is.

    In all, competition is a good thing for a free consumer market based on wants and niceties. Beyond that, when you get to basic needs people have to LIVE, then I think that market should behave differently.

    Your points are not valid arguments. My own personal opinion is that doctors should just drop the insurance and the government. Go private pay only and let the patient take care of getting reimbursed. Charge less (somewhere around the percentage you wish the insurance paid) and less the people causing the problem hear from the healthcare recipient population, not the very small number (in comparison) of doctors and their billing staff.

  9. Correct that 2 men left on base. Glaser states: “While the opportunities can be listed, we have limited understanding of how to apply IT to motivate.”….and how to apply IT to improve medical care, and how apply IT to help nurses function more efficiently, and how to apply IT so as to not waste doctors’ time, and how to aapply IT so as not to disrupt communication, and how to apply IT so as not to cause lab data to appear on the wrong patients’ charts, and how to apply IT so as to not confuse the pharmacist, and how to apply IT so as to not cause duplicate medication to be delivered to patients, and how to apply IT to find prior tests in the storage vats, and how to apply IT to avoid premature deaths of patients, and how to apply IT to not cause adverse events that injure patients, and how to apply IT so that it does not cause confusion in the users, and how to apply IT so that it does not facilitate absurd mistakes, and how to apply IT so that medications are given on time, and how to apply IT so that when there is a power failure patients do not die, and how to apply IT so that the hospitals do not hide the complications of the systems on which they just spent millions, and how to apply IT so that there are not thousand of false alerts, and how to apply IT so that farsighted professionals can read the information, and how to apply IT so that patients get the attention they deserve. Just a few deficiencies

  10. Yeah, is that the way to improve healthcare? Increase the cost to doctors of providing services (over-priced mandatory software and maintenance contracts) while cutting re-imbursement. And this directed at primary care docs, supposedly in short supply as it is, many of whom barely have a pot to piss in. Good luck!

  11. “While waiting for my annual physical…”
    What the heck? Annual physical? I thought our omniscient government-formed USPSTF and it’s Canadian wannabee CTFPHC did away with the annual physical in the 80’s in favor a periodic screening exams because of the low yield to dollar (or Looney as the case may be) ratio. Maybe you misspoke and meant every 2 year blood pressure screening, or every 5 year cholesterol measurement, or annual breast cancer screening for women over 50 (although you certainly don’t look over 50 in your picture). Regardless, if you are healthy and getting annual physicals you must surely have one of those Cadillac medical plans which will shortly be taxed out of existence.

  12. (1.) To Blah – I like your comments. I’m sick of hearing the MD’s that are only looking out for themselves, and not for the rest of the citizens. They’re not looking out for pt care, just thier wallets.

    (3.) To Mr. HIS Talk – I enjoy Mr. Glaser’s posts every ONCE in awhile, but they’re becoming VERY frequent. I find YOUR blog much more interesting. Maybe he should start his own?

    [From Mr. HIStalk] I have run John’s posts five times in six-plus months. I appreciate and enjoy his contributions. Thanks for the nice comment about HIStalk — that’s good to hear!

  13. Suzie RN,

    I like your post however after practicing for many years, I fail to see your point. IT is an improvement in itself. If you cannot give a concise answer regarding how you currently solve these problems on paper then what makes you so cynical as to think that IT cannot improve many of them? For example, I know you have done this before: You come into work. Things are crazy, someone is coding, you rush in to help, and hour later you look at the clock it is 8:15AM, damnit, your 15 minutes late on your meds. Please explain how you solved this with a paper based system for all of us IT users to understand and maybe we can include your solution. Point is, with most of what you discussed there appears to be a training problem, comprehension problem, or the problem lies between the computer and the chair. IT is expensive, it is a solution to moany of our issues in healthcare regarding quality, standardization, compliance and most importantly patient safety. IT venodrs who do not share 100% of their data via HL7 to competing vendors systems should be banned from the market, everyone should have an EMR. OBAMA is wrong, going to ruin our country, and if you voted for this dictator you should be ashamed

  14. Jon Patrick’s piece “A Critical Essay on the Deployment of an ED Clinical Information System ‐ Systemic Failure or Bad Luck?” is back online, now in ver. 5 at http://www.it.usyd.edu.au/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146 .

    Apparently the issues Down Under that led to its withdrawal have been resolved.

    Long Time RN, your statement “IT is an improvement in itself” seems to reveal a subtle overconfidence in these machines.

    They are most assuredly not “an improvement it itself.” They have potential to both improve, or to impair, any environment in which they are deployed.

    I would be interested in your concise explanation as to why you would think IT is an improvement in itself.

  15. S.,
    Agreed that information systems can be a hinderance in charting however, the sheer automation and importation of discreet data elements into a patients record in a legible and actionable form are “an improvement in itself” from the paper based method. Remember now that I never mentioned a company as there are many large vendors wtih systems that still look and feel like dos.
    My point is this, human error accounts for a large percentage of the medical mistakes made, either from illegibility, non standardization of terminology, and a lack of checks and balances. This is what automation in itself can offer when used properly. Additionally, a lack of critical decision making tools to accurately intrepret all of a patients data on one screen and the inability to quickly complete research, and the lack of ability to incorporate JCAHO, CMS, complainces along with the quality intiiatives into an eletronic system for all users to comply simply cannot be done on paper with the same effect that electronic records can. There are IT choices out there that truly return the RN and MD to the bedside and eleminate the administrative duties that are often demended of them and a poor use of resources while helping to improve patient outcomes.
    So this is a brief explaination to my point the IT is an improvement in itself. The caviate is that there is no regulation forcing the small and large vendors to provide seamless web transactions between each other systems for the sake of continuity of care making things more difficult. This inhibits the user experience by not allowing for data to flow from one app to another requiring that the same questions be asked over and over.
    IT in it’s current form is not the absolute answer yet automation can virtually eliminate human error, streamline business practices, provide decision support and standardization and is “an improvement in itself”. No I certainly do not have an overconfidence in a machine becuase the machine has nothing to with the software package that has been deployed for clinical documentation. There is very good software out in the market. The best I have seen and used are from niche vendors that actually focus their attention on a limited scope of documentation. The big guys who sell light bulbs, mops and clinical documentation appear to be the safe bet and why the CIO who wants to be able to point a finger when things go badly chooses them. IT still has a ways to go in developing a solution that is perfect but if you shop around adn truly learn the market you will find a few vendors that are getting it right.

  16. “There are IT choices out there that truly return the RN and MD to the bedside and eleminate the administrative duties that are often demended of them and a poor use of resources while helping to improve patient outcomes.”

    Write it up and get it published in a peer reviewed journal.

    “My point is this, human error accounts for a large percentage of the medical mistakes made, either from illegibility, non standardization of terminology, and a lack of checks and balances. This is what automation in itself can offer when used properly.”

    The new mistakes facilitated by the “automation” overwhelm the ones that the HIT vendors claim to be correcting. Automation is the incorrect word to describe the process…try retardation of medical care.

  17. The new mistakes facilitated by the “automation” overwhelm the ones that the HIT vendors claim to be correcting

    Write it up and get it published in a peer reviewed journal.

  18. interior designer….thanks for your comment. It really sheds light on who you are because if you were as knowledgeable as your pretentding to be you would go out and search and find the exact articles that you are asking to be published. From my organization I would say that a dozen or so are our there.
    Additionally, you keep mentioning mistakes and calling it retardation of medical care. People wake the heck up. Medical Care is medical care. You are the medical profeccional and therefore you deliver the care, your mistakes have nothing to do with a computer. If you order the wrong drug, forget a critical assessment, or are flat out negligent in your practice then you are simple a terrible clinician who pays little attention to his/her job and as a result is a detrement to patient care. the EMR is never connected to the patient. The EMR is never in charge of making a decision regarding a course of treatment. Most computer mistakes like the one’s you mention are ID10T errors. Your hosptial either bought a shitty system which was probably a top down purchase where clinicians were not involved or your professional training predates the use of the compter.
    If you hospital installed a crappy system then your problem is not an indrustry problem. Get on a hosptial committee, look up the articles that have been published, which you requested, there are about 2 articles per year on our solutions efficacy in improving patient care so I am sure you can find hundreds of them and stop whining. ASk for a change, look for the vendors who are getting it right and take a stand for patient safety.
    The industry term as you so eloquently write “retardation of medical care” is really called “automating your problems”.
    It all boils down to one thing. The problems with drug errors, unbillable records, lost records, lab specimen mixups, infections from leaving lines in too long and not giving antibiotics for surgery are the reasons why electronic records were concieved. To remove your human error from the process as much as possible. Adn we should thank you because if you had cared enough to figure out a way to do it properly on paper then you would have been King and we would not exist. Instead you either passed the buck, ignored it, formed a committee of likeminded apathetic people whos end result was to create another peice of paper, a few stickers, and to take a highly trained RN to walk around and double check everyone’s work. We are kind of like giving you step by step directions adn hoping that you will pay attention, listen during training, ask questions when your unsure and take your time to document electronically correctly.
    Remember you mistake at the bedside and your mistake at the computer are still your mistake.







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