19th Hedda Gabler's Lessons for 21st Century Health Information Technology

It's the 17th of May, which means it's Norway's Constitution Day.  Sort of like July 4th.  Which reminds the Population Health Blog.....

If you are in D.C. in the coming weeks and have an interest in health information technology (HIT), you may want to check out the Studio Theatre production of Norwegian playwright Henrik Ibsen's Hedda Gabler. 

 

The Population Health Blog explains.

In the two and a half hour production, Hedda struggles to reconcile her human dysfunctions with the rigid etiquette of an aristocratic age. As her dilemmas unfold, her academic husband George delights in analyzing societal trends while being unable to see the disaster unfolding in his own home. George ironically delights in knowing more, but is aware of less and less. 

 

There's far more to the play, but what can this 19th century masterpiece teach about HIT?

While Hedda has her issues, she's still being victimized by a complex set of external social determinants.  The PHB suspects playwright Ibsen was intrigued by the impact of rigid social norms in late 19th century Europe.  His play examines their implications for otherwise smart people who can't and/or refuse to adapt. 

Is Hedda's resistance to be reviled, or admired?

Sound familiar?  Instead of a mansion decorated with dying bouquets, we have hospitals filled with the fading economics of piecemeal work. Physicians are working harder than ever to help their patients, but a new technocracy is advancing a new set of expectations.  And the mainstream HIT Georges are so fascinated by making meaningful use meaningful, they are likewise unable to see the forest past all the trees. 

The Personalized Healthcare Ecosystem of the Future: Welcome to the Year 2030

Against your better judgment, you've just checked your contact lens-enabled news feed. You're annoyed, because President Meghan McCain has just used the Trump Doctrine to "fire" Medicare's lead administrator over the botched roll-out of the Agency's block-chain claims payment system.  The mild spike in sweat stress chemicals detected by your clothing sensors prompts a boost in the transcutaneous dosing of the blood pressure pharmaceuticals from the networked skin patch on your thigh. 

 

It's the year 2030, and personalized "eDxTx" (ecosystems of Diagnosis and Treatment) has arrived for a lucky few who are able to afford it. That has created political headaches for the President and her campaign promise to bring Medicare out of the 20th century. Your decision to opt out of "Medicare for All" (a.k.a "TrumpCare") has been expensive, but worth it because your Geico insurance plan includes eHealth as a covered benefit.  Geico's ability to automate all underwriting and claims handling means high service standards and keeping costs down. Plus, those video ads are still cool.

Thanks to ubiquitous wireless connectivity, cloud-based machine intelligence and mass-personalized medicine, you and your private doctor's team were able to configure a suite of customizable off-the-shelf apps that meet your goals for living well as well as long.  The first step was your $2 psychometric, biomic and genetic testing (the expense of a mitochondrial analysis was offset with an agreement with the laboratory, Theranos, to pool your data with other customers) that spotlighted the optimum mix of nutrition and pharmaceuticals to blunt your risk of Type 15 Hypertension and GAB15a-linked gastrointestinal cancer. 

As you sit down and use the heads up display in your lens to ponder the short-list of candidates to replace the fired administrator (a well-placed leak suggests it reportedly includes Elizabeth Holmes), the patch modulates your drug dosing to account for the change in body position.

You're hungry and looking forward to your specially tailored evening meal that is being drone-delivered to your patio in.... your contact lens again... 28 minutes. 

This is one of the five days out of the week that you adhere to a configured meal of calories, carbs, proteins, fats, nutraceuticals, probiotics and prebiotics that's adjusted to meet your taste preferences. It will also achieve an optimal body fat percentage, and reduce your risk of cancer and a host of other chronic conditions. The other two days use competitive gamification that is linked to your online preferences to reward you with a real burger for meeting your nutrition goals.  Not for everyone, but your behavioral reward profile suggested that that would help motivate you to stick to the diet. Who knew?

You ponder getting a burger tonight, but fight the temptation by triggering a mindfulness app through your lens.  The lights in your living space also dim and a riff made up of an pleasing artificial jazz-indie chord progression offers a well-placed distraction.

Diet and risk reduction are not the only an ingredients you use to achieve your goal of living 105 years, but also participating in next month's Goggle Spartan Race.  Come to think of it, time to tailor a set of 3D printed sneakers. You look forward to you and your personal life-drone (your spouse suggests it's more evidence of your narcissism; you've named it "Donald" to confirm her suspicions and annoy her) competing in a mix of virtual and real obstacles in a course of that includes real rope climbing and a virtual 3-D avatar obstacle course. The drone and wearables will network, monitor and heads-up display your neuro and cardiovascular dashboard for optimal performance. It will also use the same technology that they used in hospitals to anticipate any medical emergencies that could happen to you.

Naturally, your drone will use artificial intelligence to image, edit and securely post the race video for friends and family to view.

That's what you did last year, when the video also showed you twisting your ankle.  You had to go to a treatment center and be evaluated the old fashioned way, where a doctor treated you.  Some things never change, but avoiding those opaque bills and paying your deductible using virtual currency was so convenient.

As your pour yourself your recommended 1.2 ounces of bourbon (personalized by the distillery with a proprietary combination of esters and lactones to create your preferred finish), you reflect on how healthcare has changed since the days of in-home monitoring and physician teleconferencing. It worked well while it lasted, but was soon eclipsed by the cloud-based technology that combined physician intelligence ("physint") with Watson (artificial intelligence) that "scaled" in an era of fully automated care. 

Sort of like the driverless car that will take you to next month's race.

Speaking of old fashioned cars, that eDxTx medical alert last year reminded you of that old fashioned "check engine" light.  It seems a biochemical marker profile was consistent with the presence of an early stage tumor.  Based on your past medical data, the calculated Bayesian risk that the tumor was real approached 1%.  Watchful waiting using Medicare's IPAB guideline recommendations was raised as an option by your doctor, but you decided to undergo the additional testing to rule it out.  Naturally, your insurance covered most of that cost.

You finish your bourbon after you get an alert that the pizza has arrived.  You silently wish President McCain good luck. Some things never change.

Image from Wikipedia

2016 is the Breakout Year for mHealth: Savings vs. Value

In this post, the Population Health Blog predicts how and why mHealth will be covered by more commercial health insurers in 2016, and why the retail "over the counter" mHealth market outside of insurance coverage will also continue to grow. 

 

While you're reading, consider this simple question: What are the revolutions per minute (RPMs) of your automobile's engine as you ascend from stationary idling to freeway speed?

 

The Definition of mHealth: "the delivery of healthcare services via mobile communication devices." Other definitions can be found here.  Elements include handhelds, wireless communications, software, hardware, networking, social media, sensor technology, apps and cloud-based services. The World Health Organization says it's global and much is still in its infancy.

 

Three Population Health Blog predictions for mHealth in the United States:

 

1) 2016 will be a breakout year, because both the savings and value propositions will be clarified.

 

What does the PHB mean by this? 

 

The ultimate question for health services buyers, payers, providers and patients is whether mHealth technology is: 

 

Substitutive: achieving savings from displacing present or future high cost services,

 

or

 

Additive: co-existing with present, or increasing future utilization.

 

The same is true for many pharmaceuticals, population health programs and the medical home.   

 

2) Faced with the reemergence of unsustainable health care cost inflation, commercial health insurers will deploy today's premium to sponsor tomorrow's substitutive mHealth cost reductions.

 

Commercial insurers will look for mHealth that is "S³" or Smart, Synergistic and Scalable.

 

1. Smart: addresses the tailored needs of selected population segments; instead of being all things to all patients, think focusing mHealth on high risk patients with special needs. 

 

2. Synergistic: enhances, not replaces other incumbent resources, such as one-on-one care management or outreach telephony.  

 

3) Scalable: uses the economies of scale to provide a lower-cost service to larger numbers of consumers.  As more patients in a select population use mHealth, the cheaper it becomes. 

 

3) But.....Value-driven mHealth will also flourish in the direct-to-consumer, over-the-counter or retail market for three reasons:

 

1) Consumer notions of value: 

 

Interest in personal wellness, a cultural belief in the pervading merits of technology and the allure of every more innovative gadgetry will continue to outpace the underlying mHealth abandonment rate.

 

2) As Obamacare acquaints consumers with real healthcare costs, #mHealth will be viewed as a relative bargain.

 

Comparatively pricey physician encounters, emergency room visits or a hospital stays - especially for Bronze Plan enrollees - will only increase consumer appreciation for  mHealth's "over the counter" benefit-to-cost ratio: for a few extra bucks, why not have that weight-loss, blood-pressure, medication-management app or wearable, especially when you already have a handheld smart device and the bandwidth?

 

3) Some commercial insurers will "cover" wellness #mHealth, not because their actuaries support it, but because their customers (purchasers, brokers and consumers) demand it. 

 

"Coverage" will be in the form of a volume-based discount pricing borne by the consumer, not a value-based benefit covered by the insurer. If it increases customer loyalty/"stickiness," all the better.

 

Plus there's the mHealth "X-Factor." mHealth sponsors and their allies will collect, sell and use consumer data for marketing and surveillance.   The PHB calls it mining and monetizing. 

 

Back to the tachometer: Even though its dashboard displays it, the PHB doesn't know the vehicle's RPMs either. Aside from  the use of the tachometer by some car enthusiasts  to optimize manual gear shifting, it adds little to car performance or safety. 

 

Yet, it's standard and in the dashboard of just about every automobile being sold in the U.S.A.  Could gadgets, wearables, apps and mHealth physiologic monitoring become the healthcare tachometer?  Useful to a critical few and standard for everyone else?

 

So, What is the the Basis of the PHB's Predictions?

 

Growth potential:

 

None other than Eric Topol says "Until now, most of the effect of the digital era in the practice of medicine has been confined to electronic health records. But that is about to undergo a radical transformation in the next 5 years." As in $50 billion by 2020.

 

If you think it's all about "Fitbit" or managing diabetes, think again. How about promoting mindfulness, monitoring medication compliance, home-based high-risk pregnancy monitoring, in-home safety for the frail elderly, heart rhythm management, and home-based "pervasive" monitoring. Plus, mHealth style technology is being used outside of healthcare, such as in the automobile, for elite athletes and to promote safety in high-risk worksites

 

S³  = Savings

 

Smart: Here's a just-published JAMA study of a randomized clinical trial (RCT) that showed text-prompts had an clinically relevant impact on blood pressure in a group of select persons with coronary heart disease. Here's an rigorously conducted RCT that showed persons with Type 1 diabetes mellitus achieved better blood glucose control.  How about socioeconomically vulnerable patients with diabetes? Or patients with heart failure being discharged from a hospital?  The list of special populations with special needs goes on and on.

 

Synergy - This exhaustive peer-reviewed publication examining the merits of wellness mHealth for weight management, physical activity promotion, tobacco cessation, and cholesterol control shows that there's little evidence that it's better than existing therapies over the long-term.  Rather, the greatest promise appears to be in complementing existing interventions.  By the way, synergy does not mean overwhelming the system with data, but assisting the system with insight.

 

Scalable: While economists, policymakers and pundits legitimately worry whether bigger is better for healthcare in general, health system C-suites and boards of directors and their consultants are counting on information technology to drive economies of scale.  Papers like this and this suggest mHealth can be a part of that, especially if it can mitigate manpower constraints.

 

And an easy way to assess whether the insurer  really believes that it's sponsoring an S³ initiative is asking whether it pays for a handheld device for consumers that don't have one

 

Value:

 

Consumerism? Call it "the quantified patient." Here's a telling survey that shows the abiding faith in health information technology and a lack of privacy concerns.

 

 Bargain? The title of this peer-reviewed paper says it all" "It's like having a physician in your pocket!"

 

 Insurer discounts? The same thing happened to health club memberships.

 

The X-Factor: CIOs everywhere agree that they're not only apps, but software "vacuuming up data."

 

Image from Wikipedia

 

 

Three Health App Lessons from the James Bond Movie "Spectre" - Shaking and Stirring Health Care

The Population Health Blog took time out of its busy schedule to check out the latest James Bond movie. While posting anything that refers to a months-old movie is inconsistent with standards of modern social media, Spectre has some important lessons. 

 

The PHB begs its readers' forgiveness as it is filters out the improbable car chases, dubious gadgetry and staged fisticuffs and examines the underlying health app technology insights. 

 

Without revealing too much of the plot, Mr. Bond continues to recklessly expose himself and others to STDs while battling a global conspiracy that is led by a cryptic master criminal.  The bad guys want to exploit the weaknesses that come with combining the intelligence data of the world's democracies. 

 

And what are three cinematic health app teaching moments?

 

Health Information Technology vs. People is a Classic False Choice: In Spectre, British Intelligence seems ready to invest in a global big-data initiative and jettison the "Double O" programme; Whitehall apparently fails to realize combining both would be greater than either alone.  Think Deep Blue "versus" Kasparov, or Dr. Watson "versus" Dr. House. Yet, Bond prevails precisely because Ms. Moneypenny is his 24-7 data muse.  Smart health app designers understand that the best apps are the ones that synergistically enhance, not replace, what doctors and patients bring to their care planning.

 

For example: Asynchronous two-way HIPAA-compliant communication that allows consumer concerns to be mutually addressed in partnership with a nurse-provider before the emergency room becomes the best option.

 

Health Information Technology Needs Good People: No Bond movie is complete without legions of pistol-wielding bad guys who can't hit the side of data warehouse, which is why Bond prevails. Think putting an Acela locomotive on decades-old train tracks under AMTRAK's ossified management. The health technology insight here is that any health app that perpetuates health workers' can't-shoot-straight business-as-usual will enable incremental, not transformative change.

 

For example: During a recent health plan launch involving the medSolis app, the PHB had the pleasure of working with expert professionals who knew the purpose of the program (er, programme) initiative was to enable informed patient decision-making.  In response, we also began to alter long-standing health plan policy and procedure.  

 

All Things Equals No Outcomes: Other than pooling the intelligence data, none of spy-administrators seem to be able to articulate the purpose of their joint data initiative. While cleverly branded and all-purpose apps strive to "be" the intended outcome, truly successful health apps will be those that can be purposed for a defined population and prospectively aimed at a limited set of clinical, financial and patient-centered outcomes.

 

For example: Once the generic coding/architecture is set, a winning app's content, channel and outcomes can be tailored for, say, a precisely defined group of high risk persons with diabetes.  And, to borrow from the concept of "parallel processing," the app should also be able to be altered to simultaneously serve a parallel population that is prone to rehospitalization (outcome: reduce avoidable readmits), or who would benefit from weight loss (outcome: reduce BMI).

 

Conclusion: Health concerns aside, perhaps nothing signals Bond's adaptability better than his willingness to forego his long-standing "shaken, not stirred" workflow in favor of quaffing a "dirty" martini with the sultry Dr. Madeleine Swann.  Even the Bond franchise is not immune from the adage that "change happens."

 

The same should be true for traditional health care as it continues to import an emerging ecosystem of health apps.  Delivery systems, hospitals, clinics, ACOs and networks that understand that will win.

 

And "Cheers!" to that, Dr. Swann.

 

Image from Wikipedia

The Turing Test Falls: Implications for Health Care Decision Support

In the futuristic movie Blade Runner, Detective Rick Deckard's (played by Harrison Ford) skill at "retiring" renegade robotic replicants depends on a series of trick questions that are designed to detect an "empathic" response. While the soulless robots routinely fail the test, the highly advanced Nexus-6 models still seem to be eerily human. While Deckard violently terminates three of the robots, lingering questions over just what is "human" leads him to fall for vulnerable sexy replicant Rachael.

While the Population Health Blog ponders that, along comes the news that a Russian chatbot computer passed the Turing test. More than 30% of the humans who engaged in a text-only "conversation" with the program thought it was being controlled by a 13 year old boy. Not only was the computer able to organize facts and sentences, it also responded with the subtle nuances that underlie typical "human" communication.

While the PHB is weirded out, it is not surprised. In the book The Second Machine Age, authors Erik Brynjolfsson and Andrew McAfee note the doubling of computers' processing power can be likened to the ancient story of doubling wheat seeds on the squares of a chess board.  They point out that the amount of wheat (or processing power) can be grasped until you get to the "second half" of the board: that's when the amounts become staggering and the implications start getting weird.

They point out that computing power has now entered that second half. Quadruped "mule pack" machines can carry payloads across unfriendly landscapes, entire factories can manufacture complex items at a fraction of the cost and Watson can win Jeopardy matches. 

And now, Turing has fallen.

This is good news for health care.  "Second half" decision support in electronic health records is better able to focus on a more likely differential diagnosis, suggest a more accurate series of tests and tailor treatment at the point of care. The good news is that medicine will finally become faster, better and cheaper.  While some may fret about the loss of the "human touch" (or jobs) in this brave new world of the doctor-patient relationship, Brynjolfsson and McAfee point out that when human intelligence is combined with the resources of high performing information technology, the product is better than either alone.  For example, a chess master plus a high-end chess program can beat either alone. 

The same will be true in medicine: smart doctors plus nuanced health information technology will be better than either alone.

Just like in Blade Runner. Thanks to each other, both Deckard and Rachael are better... humans.

Image from Wikipedia

How Does the Office of the National Coordinator for Health Information Technology (ONC) Think About EHR Portals?

EHR portals at work?

The Disease Management Care Blog had this thoughtful reply logged onto its "Follow-Up" post on the topic of EHR patient portals. Logged by Rebecca M Coelius MD, Medical Officer for Innovation at HHS/ONC, the DMCB recognized that this was important enough to warrant its own separate page.

While we wish that the results were more conclusive and positive, the Office of the National Coordinator for Health Information Technology (ONC) applauds the meta-analysis and the recent upswing in articles on patient portals and other patient-facing technologies. The number of patients and caregivers who desire greater participation and transparency in their healthcare makes continued research in this area vital. Yet, in a close read of the full Annals of Internal Medicine meta-analysis article and in many of the studies it cites, there were unquestionably statistically significant positive clinical outcomes, as well as positive patient experiences, associated with certain patient portal functions.

The ONC does not believe that Health IT alone is a panacea, or that meeting the form of Meaningful Use, while not embracing the new functions the technologies it enables, is likely to result in measurable improvements. The study authors caution that it was case management that tipped the utility of portals from unclear or small to more substantial, but it is important to note that the case management activities happened via the portal itself. This is a perfect example of Health IT as an enabler of new ways of reaching and caring for patients; we would not separate the two concepts.

To the study’s described limitations, we offer two significant additions. First, the definition of a patient portal remains loosely specified, so it is difficult to make conclusive statements about the entire category. The meta-analysis did attempt to list which functions were present for each study, but half of the studies that looked at patient outcomes gave only a partial description of portal features, and a deeper assessment of the quality of functions and their relevance to the outcomes measured was not present for any study.

A more illustrative future approach would be to evaluate individual functions of portals for impact on patient participation in their care and specific health outcomes, and then ask what design principles and organizational contexts were necessary to make that function successful. For example, the impressive OpenNotes project demonstrated that patients with access to provider notes had a better understanding of their health and condition, improved recall of their care plan, and increased likelihood of taking medications as prescribed. In a New England Journal of Medicine study on weight loss interventions, over twice the number of patients in the remote support intervention groups (telephone, website access, and e-mail support) lost more than 5% of their weight versus the control group. Secure messaging and the ability to view personal health information are two cornerstones of portal functionality within Meaningful Use.

Second, more than 10% of these studies are ten years old, and over a third were published five or more years ago. We understand the necessity of adequate numbers for meta-analyses, but statistical significance does not necessarily confer relevant insights. Technology, and patient preferences and capabilities for using technology have fundamentally changed over the study time periods included, not to mention the maturation among health-care organizations themselves and the expectations of patients.

The very premise of the patient portal is a rapidly ageing one. As the ONC articulated in a 2013 Health Affairs article, there are shifting attitudes related to the traditional roles of patients and providers, and exploding demand and penetration of smartphones, health and wellness apps, and connected devices. We are moving the conversation from engaging people with our existing healthcare system through “portals”, to using technology to move outside our system to reach them every day where health truly happens. What we need to measure and incentivize in the future is not the value of portals, but the value of delivering the right information and intervention to the right person, at the right time, through the right interface based on an individual user’s context.

Health Affairs and Their Issue on Health Information Technology: Your DMCB Helps You Take A Tour

If you're mystified by the continuing folderol over electronic health records (EHRs), you may want to head over to your closest medical library and take a look at the latest April 2010 issue of Health Affairs. It has a good spectrum of informative articles on the Feds' efforts to promote adoption of EHRs, the debate on meaningful use, some of the usual pro-EHR fluff, what's going on in physician practices nationwide and - and kudos to the HA Editors on this - some warnings about where this technology falls short. You can read more about the issue at the Health Affairs blog.

Alternatively, since you are one of the thousands of savvy Disease Management Care Blog readers, all you really need to do is get a cup of an appropriately caffeinated beverage, adjust your monitor, sit back and quickly scan this encapsulated summary. THEN you can decide which articles warrant use of your precious time for closer inspection:

In her opening article, Editor in Chief Susan Dentzer points out that only 6% of hospitals and 2% of physicians rely on EHRs and that the Feds are banking on a combination of sticks and carrots to encourage them to adopt "meaningful use" EHRs. She notes the taxpayer's $29 billion investment in the HITECH legislation hinges on getting the definition of meaningful use right.

There's a Health IT Gold Rush Underway, says Nancy Ferris, thanks to HITECH's $750 million in grants and contracts going to 40 States and 30 non-profit organizations that, in turn, are supposed to facilitate health information exchanges and technical assistance. There'a another $225 million going to train people in information technology, courtesy of the Department of Labor. That's just for starters, and a pittance compared to the more than $14 billion that will go to physicians (as in $18,000 per doc per year) and hospitals. You can also get her summary of the five key goals of HITECH and wonder if it will be enough to prod physicians into spending an estimated $30,000 apiece for a functional EHR.

Want a screen shot of what the docs at Kaiser Permanente see when they're taking care of patients? It lists chronic conditions, immunizations, vital signs (including obesity), care suggestions ("flu shot due, Active tobacco use, advise quitting"), recent lab tests and a list of medications.

What happens when you put an ex-national coordinator for health information technology with the current coordinator for health information technology in the same room? After reading this exercise in mutual admiration and closed circular reasoning, the DMCB asks who really cares?

John Halamka is the blogging CIO Beth Israel and Deaconess and likes what he sees in the emerging definitions of meaningful use, but has some suggestions about increased governmental guidance without stifling innovation. Those suggestions include content specificity, creating better vocabulary subsets, better approaches to data transmission, and heightened secruity and quality reporting. This article - by someone well versed on how to use the written word - gives some insight as to why getting into the weeds of health information technology is not easy.

Sean Hogan and Stephanie Kissam of RTI International suveyed 4,484 physicians with a 2,758 responses (an impressive 62% rate). They found that 18% have at least a basic EHR and, depending on the which part you ask about, about 75-85% meet the various individual meaningful use criteria. The DMCB asks how many physicians met ALL criteria simultaneously, a number that was apparently not mentioned in the report. The DMCB also wonders if the other 82% of physicians, after reading this paper, might think they made a smart move by waiting.

James Ralson and other colleagues from Group Health report on that organization's experience with the system-wide implementation of an EHR, a patient centered medical home model of care and a web portal through which patients could view their test results, request medication refills and email their physicians. Before you take the time to read this, the DMCB warns there doesn't seem to be any new insights on how to pull this off outside of integrated delivery systems.

David Bates and Asaf Bitton of Brigham and Women's have some thoughts on how health information technology can be configured to better support the patient centered medical home. While they think the two are inseparable, they have some specific suggestions on how to achieve better clinical decision support, registries, communication capabilities that enable teaming, tracking of hospital discharges, patient friendly personal health records, enabling of remote monitoring and support of quality reporting. The DMCB agrees wholeheartedly, because much of this is already being used to great success in commerical disease management programs.

"Warning!" says Rushika Fernandopulle and Neil Patel, who describe How The Electronic Record Did Not Measure Up To The Demands Of Our Medical Home Practice. With great expecations, AtlantiCare started up a PCMH in New Jersey and found they were stymied by computer slow-downs, e-prescribing security glitches, inabilities to import lab data, clinical alert fatigue, increased physician busy work, too much effort reconciling medication lists, having to rely on an outside vendor, lack of a registry and inflexible on-screen templates unsuitable for non-physicians and group visits. They eventually turned to other software solutions to operate in parallel fashion.

Using "Analtyica 4.1 modeling software", Colene Byrne and colleagues from the "Center for It Leadership" performed a cost-benefit analysis of the Veteran Administration's $7.16 billion VistA EHR. Thanks to projected reductions in adverse drug events, diminished duplicate lab testing, reduced work, decreased operating expenses and more freed space, the cumulative yield in benefits net of costs was $3.09 billion. Before you take the time to read this, the DMCB again warns there doesn't seem to be any insights on how to pull this off outside of the VA, even if you accept the black box analysis.

Catherine DesRoaches and other colleagues from Mass General, George Washington University and Harvard find a poor correlation between hospital adoption of electronic health records and measures of quality. In a companion piece, Jeffrey McCullough and colleagues from the University of Minnesota found a better correlation in hospital quality but many of the outcomes failed to reach statistical or even impressive clinical significance. After reading this, the DMCB wonders if the other 94% of hospitals waiting on the sidelines are thinking they are doing the right thing.

But the debate about hospital-based computerized physician order entry (CPOE) is over, right? Well, maybe not exactly. While previous studies have shown CPOE without a full fledged EHR can reduce medication errors and save lives, Jane Metzger et al show the systems aren't perfect. Using a simulation tool in a sample of hospitals that volunteered to go through this, only 53 percent of the medication orders that would have resulted in fatalities and 10–82 percent of the test orders that would have caused serious adverse drug events were detected. Uh oh.

Oh, never mind says Susan DeVore and Keither Figlioli of Premier health care alliance. They surveyed their hospital members and found the road to EHR installation is lined with gradual implementation to account for objections and work-flow hiccups, clinical champions, lots of staff training, meaningful quality-based decision support and reporting, high security, clear policies and budgets that can handle the unexpected and pay the clinical champions.

Phyllis Torda, Easther Han and Sara Hudson Scholle of the NCQA interviewed 'knowledgeable people" about the implementation of EHRs and found no problem cannot be solved by assistance, consultants, trust, engagement, expertise, sophistication, realism, operational excellence, program redesign, selection of the right software and hardware and sustainability. See... it's that easy! Check out the list of insider knowledgeable people and you'll see why.

Alan Hinman and David Ross go back to the fundamentals and review the building blocks of EHRs, health information exchanges and immunization registries, suggesting the latter may be a good way to tie everything together. The DMCB thinks there may be something to this learn to walk before you run approach.

Good grief you made it to the end of this summary. If you are that interested in the topic, the DMCB suggests you head on over to Vince Kuraitis' e-CareManagement Blog where he has inaugurated a series of very informative posts on HITECH.