HIPAA, HITECH, EMR -- half cooked soup..

With the recent push by Obama administration to incentivise adoption of EMR, a whole new cottage industry has blossomed. Everybody is jumping onto the bandwagon, with physicians focusing primarily on the incentives, the EMR vendors focusing on pushing their products and a whole slew of middlemen figuring out how to get their share from all this. Healthcare in general has been a slow adapter of technology, although you may find an occasional example of an individual provider taking the lead and being at the forefront of technology frontier.

There is no denying the usefulness of adopting technology to increase availability, efficiency, and manageability. However, the "incentive" and deadlines have forced provider to jump in relying on peer references, and pharmaceutical products like marketing tactics, which more often than not ends up as a sour pill which is stuck in the esophagus, that can neither be spit out or swallowed in. This whole scenario is being repeated all over the country, alongside another major "initiative" being forced by the administration, aka the ECO model. I don't doubt the intentions behind either of the two major initiatives, i.e. EMRs and ECOs, as the the objective is to make this industry more efficient in terms of performance, availability and cost-effectiveness. The problems emanate from a lack of industry-wide standard for the business models, work-flows and long-term incentives (remember the incentives on offer are much less the cost of implementing either of these two initiatives).

Let's take a closer look at the history of EMRs, in order to understand my point above. A 1000 ft. view of a doctors office operations 20 years ago would show a paper appointment book maintained by a front office administrator, patient walking in at appointed time, registering, waiting, a nurse preparing the patient for the doctor, filling out basic information and recording some basic health information, doctor walking in, going over the available information, checking the patient and diagnosing the problem and recommending/ordering remedial actions including  medications, tests, referring to a specialist, etc. Everything gets recorded in the patients medical record, filed in a colorfully coded folder and onto the medical record storage shelve. if a specialist or hospital needed the medical records, they would ask the patient to have these faxed over to them by the doctor's (primary care) office. Now, all this seems standard across any doctor's practice, however, every office, while utilizing similar forms/tools, had slightly modified version of this workflow. The modifications resulted from the personalities involved in the process, office layouts, patients/doctor's/staff demographics sometime forced certain deviations or creative processes being introduced. Once an office starts following a certain process, it becomes hard to make them change old habits. Whatever the flow, any person even with a basic technical knowledge, would consider this model a prime candidate for "computerization" or "automation". And that's exactly what happened. Either the providers hired programmers to develop systems (ancestors of present day EMRs) which after a while evolved in to Practice Management Systems, OR enterprising programmers decided to develop systems themselves and sell them to providers. The most prominent factor here which differentiates this industry (Practice/Medical Records automation) was the direct interaction between the end user and developer. End user defined what was required, and the developer produced exactly that. Even, when there was a pre-built program, it was modified to match the practice workflow as much as possible.Even if it wasn't a customized program, the market penetration was so low that an industry wide standard work flow wasn't developed or it never evolved. This is not unique to healthcare industry, as many other industries have so many disparate systems within different companies within them. But, the case here is that in Healthcare, the administration is forcing (with timelines/penalties) to implement a solution which might suit one practice and may result in complete disarray in another for a variety of factors that include personnel training (not comfortable working on computers, especially the old trusted front office administrator), management motivation (older gen vs. younger gen or gen x) etc. Come to think of a situation where every automaker in the country is asked to adopt a similar workflow management system. This will never happen, companies have their own systems, cultures, management styles, preferences and so on. The only thing that can be mandated in our auto-maker example would be to ask for certain standard reports, with the ability to authenticate when required. If similar mandates (reporting) are enforced ( we already have these), in healthcare industry, then all one has to do is to have the system vendor to make sure relevant information is captured and reports generated as per the administration requirements. Having spoken to a few physicians and working in this industry for almost 10 years, focusing on the technology and information systems, I can see a clash of three cultures here, the administration, the providers, and the techies. Each one of them feels they know what needs to be done and the others should conform to these. Taking everybody on board is also not possible. Every regulation goes through an extensive process of development, debate with concerned/effected parties, and final approvals. In our case the real issue is the involvement of silent majority who do not participate in the regulations development process for various reasons, but are the most important factor in successful implementation. Majority of providers or physicians are entrepreneurs and manage their own shops who are too busy to focus on anything other than looking after their core business.  The sheer number of healthcare providers/businesses make it impossible to "please everyone", but at the same time their represntation have been unable to provide adequate remedies to the core issues.

(TO BE CONTINUED...)

Principle of Minimum Required

The Minimum Required Principle (PMR) states that :

“to achieve a goal one need to set a specific measurable target, and then plan to achieve that utilizing minimum effort”

Let me clarify one thing right at the beginning. Minimum effort should not be confused with minimum standards. For example, to achieve an A in a certain subject at college you may determine that a score of 90% is required. At the same time to pass through that subject you may be required to score 50%. So “attaining a grade A in Applied Mathematics” and “passing Applied Mathematics” are two different specific goals and should be treated as such. This means the minimum required effort does not mean to “pass” the subject, but to “achieve a specific grade” can be treated as specific goals. Also, I may decide that I want to achieve 98% in a subject irrespective of what grade I would be given. So for each of these three goals (scoring A, D, or 98%) the minimum required effort would be different. I hope this analogy clarifies what minimum required means. My standard could be an A grade, while yours could be a 95% score.

Once a specific target has been set, next comes the plan “to achieve the goal/target utilizing minimum effort”. Here, again, minimum should not be confused with the standard definition of just enough, although that’s exactly what I am implying here but in a different sense. I am actually trying to say that to achieve a specific goal, our plan should not carry any extra baggage that does not contribute towards achieving that goal. So we are not putting in minimum effort, but in fact are focusing everything in our plan towards achieving the goal. I will go over a couple of examples to elaborate on this principle in my follow-up posts.