Monday, November 26, 2012

Synergy in Health Care and Technology

noun, plural syn·er·gies.
the interaction of elements that when combined produce a total effect that is greater than the sum of the individual elements,contributions, etc.; synergism.
Physiology, Medicine/Medical the cooperative action of two or more muscles, nerves, or the like.
Biochemistry, Pharmacology the cooperative action of two or more stimuli or drugs.

Synergy is often listed as one of the most hated words in the corporate world. However, achieving synergy between clinicians and health care technology is a crucial element in achieving return on investment.

I have rarely been in discussions, meetings, or presentations where people are discussing how clinicians and technology are going to work together to produce the best outcomes. Most commonly, the discussion is centered on how we are going to tweak the technology to suit the clinicians... or motivate the clinicians to use the existing technology. Sometimes, the impact on the patient is part of the discussion, but rarely- if ever- is the benefit to the institution included. The content of these discussions are exactly why most institutions have not seen the return on investment that they expected from their health care technology.

Achieving synergy between clinicians and technology is absolutely necessary. Here's why. Clinicians are good at being clinicians: ambiguity and the unknown are acceptable and expected parts of their decision making. Computers, on the other hand, are good at being computers: they excel at making consistent and accurate decisions when provided with a full set of data. Most health care delivery involves decision making on both ends of this spectrum. When computers provide consistent and accurate information to clinicians  they are freed to make better decisions about the unknown. This facilitates optimal patient care, which of course benefits not only patients but creates value for institutions.

For anyone who has sat in a meeting like I described above, creating this needed synergy between clinicians technology may seem unlikely or even unattainable. The good news is that it is completely possible.

When I was involved in the project to decrease venous thromboembolism (VTE), it was clear to the team that interactions between clinicians and the EHR were synergistic. Recent research into the clinical decisions support tools we developed has actually quantified the effect of the synergy between providers and the EHR. While a computer-based algorithm could have been used to create reminders for clinicians about VTE prophylaxis, it would have only been 70% accurate in the population studied. However, without clinical decision support, providers were under-prophylaxing patients. By combining provider-based risk assessment with CDS to facilitate ordering prophylaxis, a greater than 50% reduction in nosocomial VTE was achieved. The synergy between clinicians and technology clearly improved care and outcomes for patients while also providing value to the institution by reducing never events.

Despite the sometimes negative connotations of the term "synergy," it needs to be on the agenda for any meeting discussing how clinicians and technology will work together to create the best outcomes.

Monday, August 20, 2012

Prioritizing End Users

Via tedytan on Flickr

Implementing an integrated electronic health record invariably results in competing priorities and competing end users. I've written before that I believe patients are the most important end user. However, that still leaves clinicians, technicians, support and ancillary staff- and the often-ignored institution- competing for high ranking in decision making and resource allocation.

In order to assist in decision making and set system-wide strategy, I utilize a three-tiered approach to ranking these needs. Growing up with a strong Star Trek influence, I've come to agree with the Vulcan notion that "the good of the many outweighs the good of the few."

With this belief in mind, patients, as a group, represent the top tier of importance. This means that with every decision that we make, we are asking "is this what is best for our patients?" If the answer is no, than another path must be chosen.

The second tier is the institution. The reasoning is two-fold.

Via puuikibeach on Flickr

First, the patients are best served through the success of high-quality institutions. The era of the individual physician providing comprehensive care is coming to a close in the US; it's simply too difficult for a single physician to organize and orchestrate the multiple facets of a patient's care. Although many are nostalgic for the days when a doctor made house calls with his stethoscope and bag, modern health care requires advanced diagnostics, multiple providers, nurse coordination, complex billing and an increasing technology.

Second, the institution exists as the governing body of the multiple individuals involved in delivering patient care. A successful institution will create an environment where conflicts are resolved and effective collaboration for the benefit of the patients is possible. The institution can arbitrate the wants and desires of individuals and groups of individuals to meet the ultimate goal of serving the patient.

Via janwillemsen on Flickr

The third tier are the individuals that are employed by or contracted by the institution. Many have tried to rank the importance of individuals and groups within this tier, suggesting that the desires of clinicians should receive greater weight in decision making than support and ancillary staff. However, in order to best meet the needs of the patients, the needs of these individuals must remain balanced. For instance, it does not serve the patient to purchase the fancy equipment requested by clinicians if it cannot be adequately disinfected by environmental services. Ultimately, the collective actions of every individual in the institution determine the quality of care that patients receive.

In order to realize the potential return on investment from integrated electronic health records, this tiered model must be embedded as a core value of healthcare institutions. By focusing efforts on benefiting patients, we will learn to use EHRs in ways that improve care and decrease cost, resulting in benefits for institutions and individuals.

Monday, May 14, 2012

For Immediate Release: #LiveTheGoLive via Live Tweeting

Chief Medical Information Officer Invites Public Inside Go-Live Experience Via Social Media

Dr. John Showalter, Chief Medical Information Officer at the University of Mississippi Medical Center is preparing to implement a fully integrated electronic health record on June 1, 2012. Thought to be the largest single-day go-live to date, 20+ applications will be implemented at 5 hospitals and 95 clinics throughout central Mississippi. As June 1 approaches, Showalter is sharing his experiences and insights on popular social media sites in an effort to demystify the “big bang go live.”

May 14, 2012

JACKSON, Miss. – John Showalter, MD will be live Tweeting his experiences as CMIO during the upcoming big bang go-live. On June 1, 2012, Showalter will lead the implementation of 24 applications at 5 hospitals and 95 clinics with over 6,500 users in the University of Mississippi Health System.

Showalter will be Tweeting from @JohnShowalterMD and using #LiveTheGoLive to convey the experience of the CMIO before, during, and after a go-live. He will also be fielding questions submitted via Twitter and engaging in discussions on Facebook at

‘While many healthcare leaders realize that a big bang go-live is technologically best for their institution, they remain apprehensive because of the operational challenges,’ Showalter said. ‘I am sure we will have our share of challenges, but I hope that by being open and honest about my experience, others will have less anxiety about large scale go-lives. Ultimately, it’s about doing what’s best for our patients and the community we serve.’

Showalter’s Twitter and Facebook communications will be separate from the official UMMC Twitter and Facebook updates.

Showalter has already begun Tweeting his take on the implementation process. He will continue to dialogue on both Twitter and Facebook leading up to and following go-live on June 1, 2012.

About John Showalter:
Showalter is a board certified Internal Medicine physician. He also holds a Master’s Degree in Information Systems and completed fellowship training in Medical Informatics. Showalter joined the University of Mississippi Medical Center last year to assist in leading the implementation of the electronic health record. He also practices Internal Medicine as a hospitalist.

John Showalter

Thursday, May 10, 2012

What is #GoLiveGetCKM?

Doctor, Patient, and EHR. Source

Going live with 20+ applications at 5 hospitals and 95 clinics is a big deal. But a fully integrated electronic health record isn’t the end game.

#GoLiveGetCKM is about keeping the patient in the forefront of our minds during the intensity and mayhem of a big-bang go-live.

#GoLiveGetCKM is what happens when we leverage our EHR in every way possible to benefit our patients through research, practice-based evidence, improved efficiency, improved quality and decreased cost.

#GoLiveGetCKM is not about getting the system working, it’s about working the system.

Follow me on Twitter and follow #GoLiveGetCKM to see where we are headed!

What is #LiveTheGoLive?

There are go-lives. There are big go-lives.  There are really big go-lives.

Big Bang Source

And then there are truly EPIC go-lives.

June 1, 2012 will be the dawn of an EPIC go-live at the University of Mississippi Medical Center. At 5am CST we are going live with 20+ applications in 5 hospitals and 95 clinics with over 6,500 end users. 

As the CMIO, I will be on the front-lines as we revolutionize health care in Central Mississippi. I will be live tweeting my experiences with this EPIC go-live. I am sure there will be challenges, but I’m also sure our team is poised for victory. Follow me on Twitter and follow #LiveTheGoLive to get the latest scoop!

Friday, April 20, 2012

Featured Post at Health Data Management Magazine

“Know the enemy and know yourself, and your victory will never be endangered; know the weather and know the ground, and your victory will then be complete.”
 Sun Tzu 500 B.C.

Twenty-five hundred years ago, Sun Tzu asserted that with sufficient knowledge about yourself, your opponent and the environment, your victory would be assured. In our battles against rising health care costs and medical errors, this wisdom has been lost...

Wednesday, March 28, 2012

PapPap, the Talking Scale, and Readmissions

My PapPap and my son. October, 2010

Geisinger Health Plan recently reported that the use of interactive voice response and telemonitoring technologies facilitated a 44% reduction in hospital readmissions for patients with congestive heart failure, diabetes, and hypertension. This reduction was demonstrated in a clinical trial studying the technologies above versus the standard post-hospitalization follow-up. My PapPap happened to be a participant in the pilot group that led to this study. 

Upon discharge from the hospital, my PapPap was given a "talking scale" and instructed to plug it into the power socket and phone line (the pilot group was not wireless.) Each morning, he was to stand on it and have his weight measured. Each morning, the scale would capture his weight and ask him a series of standard questions about how he was feeling.

This led to a great deal of cursing.

Being the man he is, my grandfather attempted to have a conversation with the scale. He wasn't trying to be difficult... he was just being himself. Let me replay a typical exchange between my PapPap and the scale:

Scale: Are you short of breath?
PapPap: Naw, my breathing's fine.
Scale: Are you short of breath?
PapPap: I already told you my breathing's okay.
Scale: Are you short of breath?
PapPap: Bernice! This damn thing's not working!
Scale: Are you short of breath?
PapPap: Bernice! Call Elaine and tell her this idiot scale's not working again!
Scale: Are you short of breath?
PapPap: No! Now, how many times do I have to tell you?
Scale: Okay. Do you have any swelling?

This type of exchange happened fairly routinely until we explained to him that the scale only wanted yes and no answers. After several days, my PapPap and the scale came to an understanding. One day, his weight and responses were outside of the acceptable standards and he received a call from his nurse. He was instructed to make some changes to his medications.

This type of early and personalized response kept him and patients like him from needing to return to the hospital. Yet, it wasn't the scale that kept him out of the hospital. It was the way Geisinger Health Plan managed the knowledge about his condition.

Through the use of the talking scale, GHP collected standardized data at regular intervals to create information about PapPap's clinical course. That information was combined with algorithms to create knowledge about his clinical condition and generate clinical alerts that notified his providers about the change in his condition. These alerts represent actionable knowledge that allowed for early interventions to be performed and prevent further clinical decline in each patient.

While many are lauding the technologies used in this study, it was not the the Bluetooth, the interactive voice recognition software nor the talking scale that produced such dramatic improvements. It was the generation of individualized actionable knowledge for each participant that led to GHP's success and my PapPap's continued recovery.

Although, to hear him tell it, that damn idiot scale had nothing to do with it! 

Saturday, March 10, 2012

EMR Implementation Interview

Last month at HiMSS12 I gave a brief interview to HIT Exchange about the Epic implementation I am leading.

You can check out the interview here.

(If you think I'm looking tired, it's because the HiMSS exhibit space was massive- you could walk for days!)

(And also, I was in Vegas.)

Wednesday, February 29, 2012

Patients Need Actionable Knowledge

Meaningful use has defined the data that should be included in a clinical summary.  According to Stage I, the following demonstrates the minimum requirement necessary to qualify for this measure.

"Just the facts, ma'am." That about sums it up. This summary includes the required data and can easily be extracted from the EHR.

But it doesn't do much else. It certainly doesn't engage the patient, provide them with actionable knowledge or meet the spirit of the meaningful use measure.

However, with minimal provider data entry, well thought out templates and re-formatting with the goal of patient engagement, the clinical summary can be packed with actionable knowledge. That same visit could produce something like this:

Presenting patients with knowledge about their health is a key in engaging them as active participants in their care. As medical providers, we need to demand that EHR vendors provide us with tools that will meet this need.

Meaningful Use Stage II comment period opens next week. We need to provide feedback so that loopholes like the one above are eliminated. What good is meeting program requirements if we haven't met the needs of the patient?

Thursday, February 9, 2012

Meaningful Use and CKM


Meaningful Use: What Is It?

  • By definition, meaningful use refers to the use of certified electronic health record technology to perform certain tasks.
  • Meaningful Use Stage I is ultimately an outline for better and more affordable healthcare
  • While not yet established, it is hoped that Stage II and III will complete the first chapters of better and more affordable healthcare
  • Meaningful Use is an important infrastructure for improving healthcare
  • Meaningful Use limits its focus to using technology

 Meaningful Use: What Isn't It?

  • Meaningful Use is not a comprehensive plan to leverage technology for healthcare improvement
  • Meaningful Use is not focused on the use of data
  • Meaningful Use is not Clinical Knowledge Management

Meaningful Use and Clinical Knowledge Management

Meaningful Use is focused on the collection, storage, and reporting of data, not the creation of actionable knowledge. While MU creates outlines, paragraphs, and chapters in data collection, Clinical Knowledge Management creates volumes of knowledge to improve all aspects of healthcare. These volumes of knowledge are needed if we are ever going to bend the cost curve in the US healthcare system. 

MU needs to be built with this end in mind; if we don't take this opportunity to build the necessary infrastructure, we will not be able to generate the knowledge needed to make a sustainable US healthcare system. The conversations about MU need to expand beyond implementation dates, reimbursement, and vendor/physician concerns. We need to include discussions about which data needs to be captured to insure the generation of sufficient knowledge to allow optimal return from the investment in Meaningful Use.

Monday, February 6, 2012

Revealing Bias in Healthcare Decision Making


I've recently been reading the Song of Ice and Fire series (Game of Thrones) by George R. R. Martin. While the plot is engaging and intriguing, one of the things I enjoy about the book is that it is written from the third person multiple perspective. Each chapter is limited to a specific character's perspective, but many characters get to tell the story. With this narrator point of view, the story develops with more layers and nuance than other perspectives. Each character's biases are revealed, and the reader is able to develop their own opinion of the events in the story.

Bringing the bias of each character to the surface through the third person multiple perspective deepens the understanding of the setting of the book. Similarly, bringing the bias to the surface in healthcare decision making helps us develop better knowledge and make better decisions. Just as each character in the novel is limited by what they can sense and feel, so each type of healthcare knowledge is limited by the constraints of its data.

These constraints make the exclusive use of any single type of healthcare knowledge unwise. We need to use multiple types of healthcare knowledge to better understand the current environment. For instance, in any single healthcare decision making process, knowledge can be garnered through:

  • Institutional knowledge
  • Quality knowledge
  • Research knowledge
  • Financial knowledge
  • Operational knowledge
  • Medical knowledge
  • Direct Care knowledge
  • Transactional knowledge
  • Analytical knowledge
When we combine multiple types of healthcare knowledge we are able to develop a more layered and nuanced understanding of the challenge facing us and thus make better decisions and take more appropriate actions.