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Last week, I participated in the 17th annual AMDIS Physician Computer Connection symposium in Ojia, Calif. As Larry Stofko suggested in his blog post on reporting relationships, many of the other participants at the meeting were CMIOs, with a healthy balance of CIOs and other executives. Not surprisingly, the topic of Evidence-based Medicine (EbM) came up, again and again, as our industry moves from “how do we bring these systems live” to “how do we best use these systems to improve care and its delivery.”
There's a useful earlier dialogue and presentation on EbM that I assembled two years ago. The dialogue, then and at the AMDIS meeting last week, clarified that in medicine there is often the lack of scientific certainty (as well as social agreement) around what to do in many real situations. The consensus was, EbM is great when it exists. Something one notch less than EbM is even more valuable and practical in our real and imperfect world. This same point came up in Kate Huvane's recent post, described as “And when science fails, maybe art needs to step in.”
Almost ten years ago there was a fabulous related JAMA article, “Why Don't Physicians Follow Clinical Practice Guidelines?” by Michael D. Cabana, MD, MPH, et al.
I have a friend, Vi Shaffer, who currently serves as a research VP with Gartner. At the time Cabana's article was published, Vi commented that his approach to a serious subject was really quite profound. The reason, she said, was that he used a bit of humor to effectively describe why all of us, not just doctors, resist changing our behaviors even when the “evidence” indicates change would be a good thing for us personally. I strongly encourage everyone to read the article and to review the Figure at the bottom of page two, “Barriers to Physician Adherence to Practice Guidelines in Relation to Behavior Change.”
How do you discuss EbM with your community? Where do you see the role of executives starting and stopping in regard to bringing EbM to our institutions?
I had a “routine” flight delay and “routine” miscommunication between what the posted airport flight schedule stated and the intended airline's departure time. Flight delays are so routine that I should know better than to trust the airport departure time. But I guess I am still naive, even with years of traveling and maximizing my frequent flier miles, I still trust the information posted on the screen. I guess it's because I still believe that someone is doing their job efficiently and striving to improve processes. But in reality it's the 80-20 rule, they get it right 80% of the time, so why bother striving for perfection. Nobody is perfect, right?
The Lean methodology is founded on the principle of reducing waste while looking at the overall process and making tools available where they should be. Six Sigma focuses on defects and errors. I grew up with Deming and Steven Covey and I learned early on that you don't chase process deviation spikes. However, you do monitor data and determine if any of your processes are out of the norm using statistical analysis (which was early Six Sigma). So what is the proper percentage of defects? The answer of course is zero.
That is the answer that the patient wants to hear before going in for an operation. Zero defects. But somehow with all our quality improvement programs we still accept a margin of error. The percent of duplicate medical records, the number of improperly coded procedures, the lack of notifications of abnormal labs, the incorrectly filled prescription, and the list goes on. We react to the incident, we chase the spike in the process which caused the problem, we report on the improved solution for that issue and we move on. We treat the symptom and not the disease.
Why do we keep making the same mistakes? Is it that nursing works separately from labs, and labs from pharmacy? Are we so compartmentalized that we cannot look at the big picture? We keep saying that manufacturing is very different from healthcare. But is it really? Why do we continue to struggle to implement quality and succeed in reducing errors? Are we more like the airlines flight schedules than we care to admit?
HFMA published a study this month noting five common pitfalls hospitals make when calculating potential ROI for EMRs:
Fixed costs are used for ROI, when most hospital costs are variable. For example: census fluctuations, FTE staffing levels, OP volumes, etc.
Staff time savings are credited to EMRs when they might be due to other reasons, such as layoffs, hiring freezes, improved procedures, etc.
Savings for adverse effect are given, when in fact they are “incalculable” since they did not occur and create measurable costs.
Analyses often ignore revenue reductions from lower service utilization. For example: less duplicate tests, fewer admissions if MDs do not like the system, etc.
Hospital overall performance must be taken into account before and after implementation. For example: census increase/decrease, improved/decreased productivity, TQM/CQI programs, etc.
I'd quibble with number 3, as I have seen one pretty good ROI study take the average cost of past malpractice suits (both at this facility and national studies) and use averages since medication errors are such an issue and malpractice suits are so large. But overall, it is nice to see for a third time in a month that reality is setting in to balance the euphoria over EMRs. Granted, they do improve many things and are as inevitable as Gutenberg's printing press supplanting handwritten manuscripts from monks. However, to radically overestimate the benefits and ignore potential pitfalls can be as dangerous to a CIO's professional health as a medication error can be to one's personal health!
