Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter as a weekly “Best Of” series for HIStalk. This editorial originally appeared in the newsletter in October 2006. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.
I remember sitting in a hotel ballroom back in 2001 or 2002 hearing about The Leapfrog Group for the first time. I was both energized and worried. I liked their idea of pushing a short list of evidence-based quality measures for hospitals to follow. However, I was worried that my own hospital employer might not be able to meet their expectations, thereby raising the ire of the big-employer healthcare dollars behind Leapfrog.
Leapfrog didn’t sound like someone to mess with. The post-dot com era would be bleak, with too many hospital beds competing for the business of the newly savvy baby boomer consumers, capable of making shrewd healthcare decisions because they’d ordered books from Amazon.com.
If the IOM’s “To Err is Human” was embarrassing, Leapfrog was threatening. Their changes were downright prescriptive, encouraging no debate or deviation, and backed by the folks who pay the bills. Experts in their individual Leaps howled to see the evidence behind their choices, but it was not forthcoming.
Somewhere along the line, Leapfrog fizzled. Nowadays, they’re a quaint anachronism. Their role seems mainly to trumpet the accomplishments of other groups on their website.
In fact, I just compared their Members webpage with an archived version from 2004. Today’s count: 44 members. 2004’s count: 152 members. Among the missing: Allscripts, Cerner, Eclipsys, McKesson, Misys, Siemens. I hope no one got hurt in the mass exodus.
A new Leapfrog press release illustrates how little influence they have. They did a study that found over 90% of hospitals have ignored their CPOE mandate. Over 90% don’t meet their standards for two surgical procedures. 70% don’t use intensivists in the ICU as Leapfrog demands. Are they suffering from the financial retaliation of Leapfrog’s few remaining members? Not that I can tell.
Also unfortunate was their inclusion of Indianapolis’s Methodist Hospital as one of their Top Hospitals of 2006, fresh off headlines detailing the deaths of three newborns there due to a medication error. That could have happened anywhere, but the timing was terrible for Leapfrog. To cynics like me, that was yet another indicator of their irrelevance.
I’ll leave other experts to comment on some of the widely ignored Leapfrog standards, but I’m not about to pass up the chance to point out how ridiculous their CPOE requirement is.
CPOE prevents few patient errors. It prevents mistakes, but mostly those that would have been caught anyway by skilled professionals, such as transcription errors and clinically questionable orders. Just about every study done by AHRQ and others have said exactly that: there’s nothing wrong with CPOE, but just don’t expect it to make much of a difference in patient outcomes, particularly considering its immense cost and failure rate.
Leapfrog should have been smart enough to steer clear of the CPOE bandwagon. Maybe they didn’t look around at the available products, small in number and large in functional deficiencies. Maybe their healthcare IT members twisted their arms to sell a few CPOE systems by mandate. At any rate, Leapfrog’s urgings probably sold a lot of CPOE systems, but their own survey shows they aren’t being used. Millions spent with little to show for it, apparently.
It isn’t that healthcare won’t change, it was just that Leapfrog didn’t do it. For those making it happen, check out Don Berwick’s Institute for Healthcare Improvement. If you want to see research in action, look at AHRQ. If you want to see cutting-edge informatics, consider Kaiser or Intermountain Healthcare. For mass market mandates, even JCAHO’s core measures are getting the word out. And if you want to see a group living in its own formerly large shadow, check out Leapfrog.
This editorial is copyright-protected by Algonquin Professional Publishing, LLC., publishers of Inside Healthcare Computing. Please do not copy, forward, or reproduce this material without prior permission. To obtain permission or for more information about Inside Healthcare Computing’s reprint policy, please contact the Customer Service Department at 877-690-1871 or go to http://insidehealth.com/ihcwebsite/reprints.html.
Mr. HIStalk’s editorials appear each Thursday morning in the subscribers-only version of Inside Healthcare Computing’s E-News Update. To subscribe, please go to: https://insidehealth.com/ihcwebsite/subscribe.html or call 877-690-1871.
Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter as a weekly “Best Of” series for HIStalk. This editorial originally appeared in the newsletter in January 2007. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.
Happy New Year! Considering the alternative, be glad that you were alive and well enough to eat and drink too much over the past couple of weeks. Now get back to work!
You’ll notice your local newspaper, having slyly given many of the real news staff time off for the holidays, is padding out their already-slim editions with time-insensitive material written in advance or copied off the wire services: witless phony New Year’s resolutions for local politicians, tired rosters of the biggest local stories and celebrity deaths of 2006, and pleas for donations to community causes.
I can see why. Healthcare IT news is sparse this time of year. No one wants to bring out new products, start implementations, hire or fire people, or make changes in the strategic plan when no one is paying attention (hmm: that would actually be good time to announce bad news, wouldn’t it?)
If our industry was a sport, the season would actually begin at the HIMSS conference in late February. It sets the tone for the year to follow, as everyone saves up positive announcements to coincide with the annual bacchanal. Vendors who make a bad impression at HIMSS will find it difficult to recover throughout the year, with attendees critically evaluating their demonstrations, booth size, staff attire, and cheery spirit or lack thereof. Even those companies in imminent danger of collapse spend the equivalent of a small country’s gross domestic product on one glorious, go-for-broke HIMSS splash, hoping against odds to get their money’s worth in new business.
Hospitals, too, get busy after months of letting IT projects lie fallow. No wonder ROI is hard to come by when projects come to a screeching halt because of non-IT staff refusal to get involved during (a) the November to January holiday block; (b) summer vacations; (c) school spring breaks; (d) impending JCAHO or state inspection visits; and (e) local, state, or national conferences involving anyone remotely involved. No wonder implementations take forever – they’re on hiatus half the year.
CIOs have plenty of work to do. All those clinical systems projects still need to be finished. Celebrate the completion of major phases with some downtime and reflection, don’t forget to keep pushing at needed process changes and system improvements, and then jump into the next round of work. Clinical systems projects are like painting the Golden Gate Bridge: they’re never finished.
Speaking of clinical systems, if you haven’t yet made a commitment to bedside barcode verification of medications, then now’s the time. Same, too, with tightening up your Pyxis access with biometric security, override vigilance, and double-checked stocking procedures.
Microsoft has a new operating system and Office version – yay! Users will be upgrading at home, scornfully wondering why your IT department is holding them back in the Stone Age with systems they shamefully underuse anyway. You needed that non-strategic headache, right? At least PC hardware keeps getting cheaper, right about the time Vista will eat up more of it.
RHIOs will want your attention in 2007. Your data, too. Maybe now’s the time to catalog all the electronic data elements you have available and to develop a plan to move important paper-based ones to electronic formats.
If you haven’t already, let one of your computer geeks play around (officially) with Linux, both server and desktop. If you aren’t running it at all now, you will be soon.
Stark relaxation means you may need to support a new class of impatient, computer-illiterate users: doctors in private practice and the inconsistent employees they hire. Keep stats to get budget dollars since those support hours have to come from somewhere.
Lastly, if you’re in management, please make sure to recognize and reward those who work for you. When you get too full of yourself, make a list of which essential personnel would be needed in case of system failure, natural disaster, or clinical emergency. You’re probably not on it.
I hope our industry and all of us working in it have an excellent 2007. If in doubt about a particular course of action, remember WWIWAAP (which you may pronounce WEE-WEE-WAP, since I just made it up): what would I want as a patient?
This editorial is copyright-protected by Algonquin Professional Publishing, LLC., publishers of Inside Healthcare Computing. Please do not copy, forward, or reproduce this material without prior permission. To obtain permission or for more information about Inside Healthcare Computing’s reprint policy, please contact the Customer Service Department at 877-690-1871 or go to http://insidehealth.com/ihcwebsite/reprints.html.
Mr. HIStalk’s editorials appear each Thursday morning in the subscribers-only version of Inside Healthcare Computing’s E-News Update. To subscribe, please go to: https://insidehealth.com/ihcwebsite/subscribe.html or call 877-690-1871.
Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter as a weekly “Best Of” series for HIStalk. This editorial originally appeared in the newsletter in December 2006. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.
I’d never heard of the Clinical Data Interchange Standards Consortium (CDISC) until last week. That’s when that group announced the kickoff of a new interoperability project, this one involving linking EMR systems to the information systems of clinical investigators who are performing drug or disease research. The audience might be researchers, the Centers for Disease Control and Prevention, or registries for patients or disease. The IHE is involved in the testing and will demonstrate the results at the HIMSS conference.
I’m not usually interested in this sort of project. I’ve seen first-hand what an insurmountable effort it can be just to get hospital systems to swap clinical data across the hall, much less with national third parties. Still, this is an exciting indicator of how quickly the now-common idea of interoperability has taken hold. If nothing else, RHIOs have made hospitals think about the value of their patient information and how to exchange it in a standard electronic format.
Getting and keeping drugs and devices on the market is expensive and information-intensive. Several small, highly profitable companies have sprung up to help enlist patients in studies, to do the rigorous paperwork required, and to design research methodologies. Their key commodity is information.
Hospitals have patient information that’s available nowhere else, the kind that arouses researchers and manufacturers with far deeper pockets. Repurposing that existing information by making it available to those willing third-party customers, even when motivated purely by mission-supporting cash, is at least more beneficial to society than running a McDonald’s or building medical office buildings.
Let’s say your hospital implements a well-integrated, information-rich EMR system that can easily tie together everything about patients from medical history to demographics to procedure history. Suppose you add genomic data to the mix, storing information about family history, lifestyle, and a longitudinal history of disease, treatment, and outcomes. All of that could be used to the advantage of your own patients and institutions, but it has an equally high value to those third parties trying to assemble or execute big research projects.
Drug companies and device manufacturers need the data that lives in your clinical systems. How else will they be available to target research to a very narrow range of patient types, maybe even those with a specific genomic profile? It could help them identify appropriate research subjects, design post-marketing surveillance, study population-based outcomes, and catalog adverse events. The information you provide could either be de-identified or made available only if individual patients opt in. The benefit to patients is access to a wider variety of treatments and protocols, most likely free to them if tied to a research project.
You wouldn’t just give that information away, of course. Hospital information is far deeper and more detailed than what’s available from any other source, with a wide scale to match. All you need is sophisticated EMR functionality and a relentless push to get every scrap of clinical information codified, categorized, and cross-referenced.
In the movie Wall Street, Gordon Gekko says, “The most valuable commodity I know of is information.” That is true of clinical data, especially when those who value it can afford to pay. Just don’t sign away too cheaply the rights to your treasure trove of data, even if the interested customer is a RHIO or third party data vendor.
This editorial is copyright-protected by Algonquin Professional Publishing, LLC., publishers of Inside Healthcare Computing. Please do not copy, forward, or reproduce this material without prior permission. To obtain permission or for more information about Inside Healthcare Computing’s reprint policy, please contact the Customer Service Department at 877-690-1871 or go to http://insidehealth.com/ihcwebsite/reprints.html.
Mr. HIStalk’s editorials appear each Thursday morning in the subscribers-only version of Inside Healthcare Computing’s E-News Update. To subscribe, please go to: https://insidehealth.com/ihcwebsite/subscribe.html or call 877-690-1871.
Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter as a weekly “Best Of” series for HIStalk. This editorial originally appeared in the newsletter in July 2006. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.
My colleague Ross Koppel, a sociologist and Penn professor, wrote an editorial in The American Journal of Managed Care (released today) titled “Defending Computerized Physician Order Entry From Its Supporters.” In it, he stresses that CPOE and clinical decision support systems (DSS) are separate systems, despite popular perception. Their implementation is often divergent and their benefits and shortcomings confused (or intentionally misrepresented).
Ross is right, and his sociologist’s view is important to our little world of geeks and IT-friendly doctors. We’re expecting a lot from immature CPOE and DSS systems that most hospital executives can’t define, even when they’re plunking down hard-earned capital dollars for them.
I should mention that Ross wrote another article awhile back that riled up vendors, consultants, and HIMSS, in which he described one hospital’s increased error rate with CPOE implementation, finding that his one, small discouraging word was met with choruses of indignation from the “CPOE is Nirvana” crowd.)
CPOE is a smart typewriter that, standing alone, has little ability to improve patient outcomes. It prevents transcription errors, although those seldom harm patients because they’re caught anyway. CPOE makes it easy to choose common order defaults instead of “winging it.” Beyond that, the benefits (both clinical and financial) come from DSS, not CPOE, even though the hospital executives signing a multi-million CPOE deal as their cornerstone of patient safety automation probably missed that point completely.
DSS systems are, unfortunately, mostly frightfully immature, even more so than CPOE. Early adopters share war stories of sky-is-falling alerting, inflexible third-party rules, the inability to customize and personalize, and performance-sapping rules engines incapable of delivering alerts of any more sophistication than the old hard-coded screen edits.
Still, the real problem is right down Ross’s alley. Hospitals usually buy CPOE and DSS because they’ve failed to control physician behavior otherwise, often euphemised as “reducing practice variation” or “practicing evidence-based medicine.” They want software to do the dirty work that they can’t or won’t: telling physicians that they’re wrong and forcing them to change. When docs don’t follow the new cookbook medicine rules any better than the old ones, CPOE and DSS get the blame and everyone involved in the project pretends to have been somewhere else when the vote was taken to buy it.
I’ve been involved in two CPOE/DSS implementations, both involving large IDNs and well-known vendors. In both cases, hospital administration ill-advisedly shot their patient safety technology wad on CPOE, confident that it would improve patient care better than any other investment. Physician adoption was universal in one, minimal in the other, but one element was common to both: 90% of the expected DSS benefit never materialized. The carefully but naively drawn up list of post-implementation metrics was hidden away once everyone realized that we hadn’t really changed anything of importance for our multi-million dollar investment. We had bought ourselves a smart typewriter.
No software contains a switch that turns resistant physicians into docile, rule-following sheep who make better decisions under the watchful eye of Big Brother’s can’t-miss medical guidelines. But if your hospital has already spent a few million on CPOE and DSS thinking that was the case, you’ve learned that already.
Maybe the next generation of systems will offer value that physicians recognize. After all, they want the best outcomes for their patients, too. Where they disagree is that we have the answer right now with these first-generation CPOE and DSS applications.
This editorial is copyright-protected by Algonquin Professional Publishing, LLC., publishers of Inside Healthcare Computing. Please do not copy, forward, or reproduce this material without prior permission. To obtain permission or for more information about Inside Healthcare Computing’s reprint policy, please contact the Customer Service Department at 877-690-1871 or go to http://insidehealth.com/ihcwebsite/reprints.html.
Mr. HIStalk’s editorials appear each Thursday morning in the subscribers-only version of Inside Healthcare Computing’s E-News Update. To subscribe, please go to: https://insidehealth.com/ihcwebsite/subscribe.html or call 877-690-1871.
