Beyond Medical Informatics

Here’s 2 bits of news about texting in healthcare:

Text4baby receives high grades

Surveyed participants in text4baby, a health information text messaging service for pregnant women and mothers of newborn infants, reported high levels of user satisfaction, according to researchers from the University of California San Diego (UCSD) and the National Latino Research Center (NLRC).

…

Additionally, 63 percent of respondents reported that text4baby reminded them of an appointment or the need for an immunization; 75 percent reported that text4baby informed them of medical warning signs that they’d been unaware of; and 71 percent reported speaking to a physician about a topic they learned of through text4baby.

This is great use of texting for consumer health IT purposes. The text4baby site is here.

However…

Joint Commission- Doc ordering via text is unacceptable

Here’s the original post at the Joint Commission site.

Is it acceptable for physicians and licensed independent practitioners (and other practitioners allowed to write orders) to text orders for patients to the hospital or other healthcare setting?

No it is not acceptable for physicians or licensed independent practitioners to text orders for patients to the hospital or other healthcare setting. This method provides no ability to verify the identity of the person sending the text and there is no way to keep the original message as validation of what is entered into the medical record.

I know this practice is somewhat common here in the Philippines.

What do you think?

(This is Part 2 of a modified version of a loooooong comment I posted in the FB group page of the Philippine Medical Informatics Society. Read Part 1 here.)

Making national policies on the Health IT tools and frameworks without identifying the target results and objectives is a mistake.

This mistake of a centralized level/policy of mandating technology is evident in recent news articles shared with the FB group. Here are quotes:

From Dismantling the NHS National Programme for IT | Media Centre (bold emphasis mine):

In a modernised NHS, which puts patients and clinicians in the driving seat for achieving health outcomes amongst the best in the world, it is no longer appropriate for a centralised authority to make decisions on behalf of local organisations.  We will continue to work with our existing suppliers to determine the best way to deliver the services upon which the NHS depends in a way which allows the local NHS to exercise choice while delivering best value for money.

The Department of Health said:

“The exchange of information between patients and clinicians and across the NHS is a fundamental part of how we are centring care on patients and making sure innovation and choice are fully supported.  The NPfIT achieved much in terms of infrastructure and this will be maintained, along with national applications, such as the Summary Care Record and Electronic Prescriptions Service, which are crucial to improving patient safety and efficiency.  But we need to move on from a top down approach and instead provide information systems driven by local decision-making.  This is the only way to make sure we get value for money and that the modern NHS meets the needs of patients.”

Sir David Nicholson, Chief Executive of the NHS, said:

“A modernised NHS needs information systems that are driven by what patients and clinicians want.  The NPfIT has provided us with a foundation but we now need to move on if we are going to achieve the efficiency and effectiveness required in today’s health service.  Restoring local control over decision-making and enabling greater choice for NHS organisations is key as we continue to use the secure exchange of information to drive up quality and safety.”

The Managing Director for Informatics at the Department of Health, Katie Davis, said:

“There are two important things we must achieve – the development of a vibrant marketplace for healthcare IT and clarity that we no longer manage delivery centrally unless there is a single, clear requirement across the NHS.  We have a great opportunity to build a new way of working which helps patients and clinicians gain the best value for public money.  I am instituting a full review of all Department of Health informatics applications and services to ensure that everything we do is compatible with these aims.  Later this autumn, I will announce what work will continue, alongside a framework for providing IT support to the NHS as it modernises.”

From Government to scrap NPfIT NHS IT programme today – ComputerworldUK.com (bold emphasis mine):

Health Secretary Andrew Lansley put the blame on the previous government. “Labour’s IT programme let down the NHS and wasted taxpayers’ money by imposing a top-down IT system on the local NHS, which didn’t fit their needs.

…

“We will be moving to an innovative new system driven by local decision-making. This is the only way to make sure we get value for money from IT systems that better meet the needs of a modernised NHS.’

I’m sure many of you are starting to see the point I am making: Having a clear set of results is MORE IMPORTANT than a clear set of tools. A centralized policy on goals and objectives that allow CHOICES in implementation tools is better than a centralized policy on tools and standards without clear goals.

But what about the HIT Standards Committee in the US? Why do they have that?

Well, the point of a policy is to create a call to action.

When government creates policies for target results and goals, what is the call to action? It is to stimulate problem-solving towards a common objective. It is about EFFECTIVENESS.

When government mandates processes, e.g. standards, technology and terminology, what is the call to action? It is to control proliferation of many solutions. It is about EFFICIENCY. When it comes to interoperability, the US is at this point for their HIEs.

So, what kind of policies does the country need most right now? Problem-solving or control?

Better yet, let’s go through our sample Health IT continuum (from Part 1) as a thinking exercise:

• What does a Health IT project for a single MD practice need? Problem-solving or control?
• What does a Health IT project for a group practice need? Problem-solving or control?
• What does a Health IT project for a small hospital with disparate systems need? Problem-solving or control?

How about a network of hospitals? A chain of ambulatory clinics? A network of government hospitals? A national EHR implementation? What do these Health IT projects need in the Philippine context? Problem-solving or control?

Go through each level and think:

• Have we identified common goals and results for each?
• Do we have the right information to start mandating a specific set of standards for each level of implementation?
• If we do have a National Set of HIT Standards or Framework, is this applicable for all levels of implementation?
• Finally, do we have a clear set of goals and results identified at the national level so that a National Standard or Framework makes sense?

I don’t think so.

Mandating the tools without first identifying the project objectives is like ordering a carpenter to bring only a hammer without first allowing him to ask, "What is it that you want to build? What do you want to achieve?"

Always, always, always use the right tools for the job. But show me the job first before I start gathering my tools.

(This is Part 1 of a modified version of a loooooong comment I posted in the FB group page of the Philippine Medical Informatics Society. Here is Part 2.)

Premise:
Some members of the group proposed that a National Health IT Framework with official standards, technology and IT systems design would improve the Healthcare IT situation of the Philippines. They compared how US HIT is in a mess because it did not have these national frameworks when they started working on their Health IT systems.

My short version reply:
The US situation statement is an oversimplification. And a source of wrong thinking. Everyone needs to get out of that thinking that IT-specific policies will ‘correct’ what’s wrong with the state of Health IT in the Philippines.

My long version reply:

Health IT implementations come in different sizes but should still reside in a continuum of complexity. Small scale implementations can start from 1-user EMRs to small hospital settings. Large scale implementations can go from hospital networks to national implementations.

The “IT Perspective” would be to look at the technology needs (frameworks, standards, etc.) that each level of implementation requires. But the “Management Perspective” knows that the critical factor is to identify the different goals, objectives and desired results for each level.

Here’s a good mental exercise at this point. What would be the goals and desired results of:

• a single doctor EMR system?
• an LIS-HIS integration project?
• a Cancer Center EMR?
• a clinical data repository for a network of hospitals and clinics?
• a National EHR implementation similar to Singapore?

Each one would have different goals, priorities and objectives as compared to the others.

My short version reply was about common misconceptions of the role of policies in Health IT. We compared the PH scenario with US scenario. And this is where most get it wrong.

Many advocated the creation of national level “IT Perspective” policies, e.g. what standards we should follow, what format, what technology, what system etc. But the US national policies did NOT start like that. They were crafted from a “Management Perspective”. They identified and mandated a set of results and goals. Here are over-simplified samples:

• Medicare required better clinical documentation. EFFECT –> This lead to boom in EMR and medical transcription. (Did they say how hospitals should implement it? Not really.)
• Health insurance required more accurate diagnosis codes. EFFECT –> This lead to adoption of DRGs, ICD9-CM, CPT. Will need software to manage.
• Joint Commission identified goals for different areas. EFFECT –> Different implementations possible to achieve results. Some use IT. Some do not. Using IT proved easier.
• HIPAA mandated security and privacy goals. EFFECT –> Mostly achieved by EMR software. (There is no HIPAA-compliant software, only HIPAA-compliant organizations. Organizations looked into IT to comply with regulations.)
• ARRA/Meaningful Use/HITECH defined goals—and incentives!—in use and adoption (NOT the technology or interoperability standards). EFFECT –> Increased rate of EMR adoption.

There are plenty more stories and samples from the history of Health IT in US and other countries that drive the point. Basically, they FIRST identified the RESULTS they wanted to achieve at the level they wanted to implement. The did not go and create a policy for standards and technology without first identifying the need for it.

Let me emphasize: Having a clear set of results is MORE IMPORTANT than a clear set of tools.

(Please proceed to Part 2 Conclusion.)

It’s been over a month since I last written for the blog.

My life as a CIO has been very busy. The past few weeks much more so. Some of my recent activities (I’ll write about them soon) include:

• Continuing development and design of TMC PRIME—the EMR platform we are developing.
• TMC Quality Fair Week where we had a booth that featured TMC PRIME.
• Implementation of Google Apps—Yes, TMC is now on GMail!
• Initial wrap-up of 2011 projects for Year-To-Date IT accomplishments (in preparation for budget planning).
• Initial project planning for next year’s budget.
• Initial brainstorming for restructuring of IT Department.

The last one has been in my mind for several months now—probably since I started work as CIO. I found our IT organizational structure to be rigid and unwieldy. I had a hard time responding to critical IT requirements and situations. Projects were not managed or monitored well. Some projects slip through the cracks of proper implementation.

Then it dawned on me. For several years, the main IT project was the hospital information system (SHAMAN). This system started out small but has since become the workhorse of hospital operations. And the IT department was almost exclusively organized around this application—to the detriment of other IT projects.

I shared this with my IT managers:

We have an IT department that is structured to support a single software.

That can’t be. We need to change that. We have other IT projects aside from SHAMAN, like:

• HL7 Integration Platform
• Clinical Data Repository Platform
• Clinical Documentation Platform
• Business Intelligence
• Document Management Systems

Our users also have other IT plans like:

• Improved charge capturing using mobile devices
• Improved medication management
• Online surveys and patient feedback forms
• Research and patient registries

So, I pose this challenge to my IT management team.

Let’s build an IT organization that supports the whole organization including the network of clinics and hospitals we serve.

It will not be easy. Our initial thoughts focus on the following areas:

• Strengthen the IT management team with focus on strategic planning, initiatives and relationship-building.
• Build project management and systems analysis core competencies among the staff.
• Build technical core competencies for the core technologies used.
• If possible, outsource some IT services, e.g. technical support, specialized programming.

Let’s hope we succeed.

Next year will be an exciting year!

This article, ONC releases five-year strategic health IT plan, provides some goals to get a National Health IT plan started. The goals include:

• Achieve adoption and information exchange through meaningful use of health IT
• Improve care, population health and reduce healthcare costs through the use of health IT
• Inspire confidence and trust in health IT
• Empower individuals with health IT to improve their health and the healthcare system
• Achieve rapid learning and technological advancement

These goals are definitely something we can use in the Philippines. I think the ICT4Health efforts have similar goals.

The best next step is to formulate an action plan for each goal.

On a more personal note, these goals are not "confined" to the national level. With their broad practical application, even hospitals and other organizations can adopt these goals.

Seems like my 5-year strategic Health IT plan for The Medical City is off to a good start.

Last Thursday, September 15, 2011, we had an IT Department (ITD) staff meeting. I wanted the IT staff to appreciate what the department accomplished for The Medical City in the past year. This was also an exercise to improve our intra-departmental communications.

After the managers of the different sections of the department—development, SQA, support and technical—shared their activities and accomplishments, I presented possible projects and activities for next year. I also expressed the need to be more focused and proactive to ensure successful implementations.

I also wanted to end the meeting with an inspiring message. So I shared the Serenity Prayer:

Grant us the serenity to accept the things we cannot change, the courage to change the things we can, and the wisdom to know the difference.

I highlighted the three concepts—serenity, courage and wisdom—and then told them that the prayer was wrong.

First off, the prayer got the order of the 3 concepts wrong. Starting with “accepting things we cannot change” is not serenity—it is surrender.

Second, it’s misleading to call it the Serenity prayer when what we need to change the world is courage. It should be the Courage prayer. I wanted my IT Department to have balls!

Lastly, the wisdom part assumed it was easy to know the difference. It is not.

So, how do we know which ones we can change and which ones we cannot?

The answer: We don’t know—and won’t know—until we try.

Therein lies the true wisdom: Going through life with the conviction to MAKE a difference is the only way to KNOW the difference.

So, I rewrote the prayer for our IT Department. I rewrote it matching the order of things we need to continually support the operations of the hospital, contribute towards better patient care and forge the way into the future.

Here it is:

Grant us the wisdom to make a difference, the courage to change the things we can change and the serenity to accept the things we cannot.

Our work in Health IT is not easy. We should first be wise enough and brave enough to challenge the status quo. Serenity should be our last resort.

Amen?

Amen.

There are many news about National Healthcare IT Plans for different countries.

• Australian state forms e-Health agency
• Health minister highlights Taiwan’s e-health services
• Sri Lankan govt to computerise patient information
• First phase of Singapore National EHR goes live
• NZ creates national health IT plan

But the Philippines also has its initiatives. I just hope it’s on a more national scale.

• The Philippines to deliver rural e-health services
• Philippine city automates health centres

Dr. John Halamka, in his blog, describes some of the ways healthcare is different from other industries—and these things help explain why Healthcare IT is more challenging.

It’s a two part post: Healthcare is Different and Healthcare is Different Part II.

Here are some of the ones I found interesting:

• Workforce: Many doctors are not hospital employees. It’s not easy to get compliance.
• Funding: Healthcare has complex funding and payment structures. This makes it challenging to fund IT innovations.
• Product Standardization: Clinical quality is hard to standardize. Many results are based on patient response and not all patients respond the same.
• Domain expertise: It takes years to be an expert in a particular field.

He ends his first post with an optimistic outlook of the challenges facing Healthcare IT. He ends his second post with this:

My personal goal is to build software and workflow processes that make the complex seem easy, reducing the burden on providers so that they can focus on what’s really important, the patient.   That’s why the work for a Healthcare CIO will never be done.

I have to agree completely.

Here’s a list of HIT news and bits I found interesting:

A Healthcare IT Plan for Japan – Dr. John Halamka lists down several recommendations to help develop a national healthcare IT plan for Japan.

JAMIA: Canada has advice for U.S. on national health IT policy (via CMIO.net) – Now, Canada gives recommendations to US on National Health IT Policies.

JAMA: Health IT has a larger role to play in patient safety (via CMIO.net) – EHRs can help achieve the 2011 National Safety Goals of the Joint Commission according to JAMA.

Telemedicine: Know why you’re doing it (via CMIO.net) – Here’s the advice: Thoroughly understand why you’re doing it, and know what problems you’re trying to solve.

From Techcrunch Google Shuts Down Medical Records And Health Data Platform:

Google is shutting down Google Health, which enables you to store and manage all your health information in one place on the Web. Google says the platform simply wasn’t having the ‘broad impact’ necessary to sustain the product.

From Google’s blog post: There has been adoption among certain groups of users like tech-savvy patients and their caregivers, and more recently fitness and wellness enthusiasts. But we haven’t found a way to translate that limited usage into widespread adoption in the daily health routines of millions of people. That’s why we’ve made the difficult decision to discontinue the Google Health service.

Google says that it will continue to operate Google Health until January 1, 2012, will allow people to export their health data for an additional year beyond that. Any data that remains in Google Health after that point (January 2013) will be permanently deleted.

I’ve always been interested in the business case for PHRs. In an ideal world, patients can be proactive partners in managing their health. But is this sustainable for many patients and healthcare providers? Will PHRs help lower cost and improve quality of healthcare?

So, does this bit of news answer my questions?

I’m still not sure. Let’s wait and see.