Monday, December 28, 2015

Make Health Care Great Again

Click here to view: Reading of the Donald J. Trump children's book by Jimmy Kimmel
We don’t win anymore in health care. After repeatedly drilling in our heads that America’s sick care system is a disaster, that those who care for the sick are incompetent and stupid, and that the sick themselves are losers, Meaningful Use was advertised as the means by which technology will make health care great again. The program has been in place for 5 years and the great promise of Meaningful Use is just around the same corner it was back in 2011. The only measurable changes from the pre Meaningful Use era are the billions of dollars subtracted from our treasury and the minutes subtracted from our time with our doctors, balanced only by the expenses added to our medical bills and the misery added to physicians’ professional lives.

Meaningful Use, a metastasizing web of mandates, regulations, exclusions, incentives and penalties, is conveniently defined in the abstract as a set of indisputably wholesome aspirational goals for EHR software and its users, which stands in stark contrast to the barrage of bad news flooding every health related publication, every single day. Health care in America used to be the best in the world, but now our health care is crippled. Meaningful Use of EHR technology will improve quality, safety, efficiency, care coordination, and public and population health. It will engage patients and families, and it will ensure privacy and security for personal health information. With Meaningful Use leading the way, health care will be winning so much that your head will be spinning. You won’t believe how much we’ll be winning.

Be afraid, be very afraid

Bombastic? Laughable? Easily dismissible by educated people? Not so fast. According to Dr. David Blumenthal, president of the Commonwealth Fund, and former National Coordinator for Health IT, “we probably have the worst primary care system in the world”. Yes, worst system in the whole wide world, worse than Niger, Malawi and Somalia. Probably. According to a hobbyist “study” that extrapolates its “results” from a handful of other studies based on an admittedly inaccurate tool intended for different purposes, 440,000 people are killed in hospitals due to preventable errors each year – “that's the equivalent of nearly 10 jumbo jets crashing every week”. Or, with a little more math, half of all hospital deaths, and one in six US deaths, are due to negligent homicide perpetrated by psychopathic doctors and nurses.

How is that for buffoonery? I suspect that the beautiful minds appalled at populist or outright racist fear mongering rhetoric claiming that thousands of Muslims were dancing on rooftops on 9/11 in New Jersey, have zero problems with self-servingly stating that “hospitals are killing off the equivalent of the entire population of Atlanta one year, Miami the next, then moving to Oakland, and on and on”, based on equally valid he-said-she-said evidence. Both virulent strains of outlandish demagoguery are insisting that they, and only they, can keep us safe from things that go bump in the night. Supersizing the ghoulies and ghosties and long-leggedy beasties makes us more likely to relinquish control of our lives to those who might deliver us from terror.

The Meaningful Use program rests on a narrative where medicine is witchcraft, our doctors are murderers, our hospitals are cesspools teeming with death, our citizens are Lemmings unable to wipe their noses, and the machines of the illuminati are our only salvation. When the premise of an action is delusional, one cannot expect the outcomes to be anything but.

Smoke and mirrors

When you read “studies” advertising that Meaningful Use increased the rates of mammography by 90% in three months, you should assume that the only thing that was increased is the rate of ticking boxes for stuff that was not documented before, and practically no material changes have occurred. When you feel vindicated by the 99% rate of patients given a clinical summary after each visit, keep in mind that the vast majority of those summaries were posted to a portal that nobody uses, or just fake-printed to PDF, and the few actually given out were dutifully tossed in the recyclable trash bin. When you read about the billions of dollars in tax money successfully spent on Meaningful Use, you should understand that this is just the tip of the iceberg, and the indirect costs to each and single one of us are larger by orders of magnitude.

For most of us simpleton believers, who mistook fiery demagogues for brave-hearted visionaries, the disappointment is a throbbing daily humiliation, manifesting itself in polite low-energy petitions to powerful bureaucrats to take pity on us and roll back some of the most onerous aspects of the program. There are signs indicative of some forthcoming acts of mercy, but those are as disingenuous as the original false narrative of Meaningful Use. After five years of Meaningful Use of EHR technology, the initial hope has failed to translate into promised change. Or has it?

From its inception, the Meaningful Use program had two sets of requirements. One set defines what EHR vendors must build to stay in business, and another set specifies what doctors and hospitals must do to collect gratuity payments from Medicare. Over time these requirements sets began to diverge. Once clinicians became conditioned to compulsively collect data, overt reporting is being replaced with covert extraction through the backend (i.e. application programming interfaces, or APIs). The Certified EHR Technology mandated by the program was never intended to extend abilities of clinicians as much as it was designed to generate standardized measures of their performance. Administrators and regulators cannot control an industry from afar without incessant measurement and the power to reward and punish individual practitioners. Meaningful Use is designed to enable remote control of medicine, its doctors and the people they serve.

We are not alone

Back in 2001 our rulers identified another field where America was losing big time. Education was a disaster, a huge mess with rampant disparities and across the board low quality. Like health care, education of small children is an ideal place for intervention if your aim is to control populations and increase the value derived from each person. With overwhelming bi-partisan support the ruling class passed the No Child Left Behind Act, mandating that all children are above average by 2014. An avalanche of funding for computers, measurements of schools and teachers and incessant standardized testing of students descended upon our schools. For the last fifteen years, schools were engaged in life and death accountability games of reward and punishment, and our children became merely biometric indicators for school and teacher performance assessments.

As 2014 came and went, with many children still stubbornly below average, with multitudes of teachers still burnt out, and education morphing into a misnomer for the standardized testing doomsday machine consuming all but the rich and privileged, the federal government took a step back and passed the Every Student Succeeds Act of 2015. Leaving aside the downright idiotic terminology used for naming acts of Congress, the new legislation is reluctantly beginning a process to diminish federal control of schools. Considering the cumulative damage to our education system, perpetrated by toxic bureaucratic ineptitude which is  crowding out the ability of real educators to address real problems, this halfhearted attempt may very well be too little too late.

Failure is not inevitable

I don’t know about you, but I am getting tired of having to live up to Winston Churchill’s image of America. We don’t always have to try everything else before we do the right thing. We shouldn’t have to wait fifteen years before declaring that in retrospect Meaningful Use was meaningless. We know now that it is. Removing a few reporting requirements for physicians, while beefing up patient scoring measures, is not enough. Playing with reporting periods at the last minute and granting ad-hoc exclusions to make people shut up, is not enough either. Randomly linking physician fees to Meaningful Use EHRs may be enough, but it’s beyond disgusting.  The Meaningful Use program must end. Plain and simple. And most importantly, the underhanded EHR certification schemes must be halted immediately.

Standardization, quantification, computerization, gamification, engagement, and infantilization of the populace in general, do not produce better educated or healthier citizens. Education reform has failed us on a grandiose scale. Health care reform, to which Meaningful Use is foundational, is based on the same failed concepts as education reform. It will also fail in due course and spectacularly so. It is actually failing as we speak and with the exception of elite institutions, which are benefiting financially from as much health care reform as can possibly be inflicted on the rest of us, we all know it’s failing badly. 2016 presents the perfect opportunity to demonstrate to the entrenched perpetrators that in America accountability is a two way street, and value is a freely defined personal concept.

American health care has been hijacked by very bad people, and it’s time for us to quit being sad little losers who just sit there and bitch. It’s time to take our health care back and it’s high time to deliver to those horrible people the thorough schlonging they so richly deserve. It’s time to make American health care great again.

In 2016, resolve to go out and vote. Vote in the primaries, vote in local and general elections, ignore the propaganda, educate yourself and as old Harry Truman advised us all, vote for yourself, for your own interest, for the welfare of the United States, and for the welfare of the world.

Monday, December 7, 2015

Bingo Medicine

It was a dark and stormy night. My computer didn’t catch fire while typing the previous sentence. No alarms were triggered warning me about the quality of such opening. I wasn’t prompted to select subjects and predicates from dropdown lists. I typed the entire sentence, letter by letter, not at all dissimilar to its first rendering back in 1830. Computer software in general, and Microsoft Word in particular, magically removed the hassles of quills, ink, paper, blotters, sharpeners, ribbons, whiteout, carbon paper, dictionaries, and all the cumbersome ancillary paraphernalia needed to support authoring, but made no attempt to minimize the cognitive effort associated with writing well.  Authoring great literature today requires as much talent and mastery as it did in the days of Edward Bulwer-Lytton.

For several decades, software builders have tried to help doctors practice medicine more efficiently and more effectively. As is often the case with good intentions, the results turned out to be a mixed bag of goods, with paternalistic overtones from the helpers and mostly resentment and frustration from those supposedly being helped. Whether we want to admit it or not, the facts of the matter are that health IT and EHRs in particular have turned from humble tools of the trade to oppressive straightjackets for the practice of medicine. Somewhere along the way, the roles were reversed, and clinicians of all stripes are increasingly becoming the tools used by technology to practice medicine.

A common misconception is that EHR designers produce lousy software because they don’t understand how medicine is practiced. The real problem is that many actually do, and the practice of medicine is precisely what they aim to change. These high clerics of disruptive innovation would have you believe that “resistance to change” is equivalent to the resurrection of paper charts, thick ledgers, and medical information coded in secretive hieroglyphs. The truth is that physicians want to use modern computers, but they resent being used by computers. And the truth is that if we shed the orthodoxy imposed on us by self-serving “stakeholders”, computer software can indeed help address various problems in health care, some in the here and now, most in a distant future.

One thousand and one elements

This may sound strange to some, but the first step towards putting EHRs back on the right track should be to stop trying to help physicians practice medicine. Clinical decision “support” in the form of alerts, disease specific templates, mandatory checklists, required fields and rigid workflows are some of the things that must be removed from EHRs for two reasons. First, most of these “features” don’t work very well anyway. Second, more often than not, the real purpose of said support is not clinical in nature. For example, alerts about generic substitutes for brand name medications, data fields that must be filled and checkboxes that must be clicked to satisfy billing codes, PQRS or Meaningful Use, and the wealth of screens to be traversed before an order can be placed, have no clinical value.  And in most cases the opposite is true.

Some experts argue that EHRs are failing because they are nothing more than an old paper chart rendered on a computer screen. Many others are outraged by the fabled lack of interoperability (dissemination of information) or the lack of EHR usability, i.e. number of clicks, visual appeal, color schemes and ease of information retrieval. I would suggest that these dilemmas are peripheral to the one foundational problem plaguing current EHR designs – the draconian enforcement of structured data elements as means of human endeavor.

When Google mapped the Earth, it did not begin by mandating how to build and name roads and buildings. When we indexed and digitized books and articles, we did not require that authors change the way they write prose or poetry. When we digitized music, we did not require composers and performers to produce binary numbers at equidistant time intervals, and we did not make changes to musical instruments to allow for better sampling.  We built our computerized tools to ingest, digest, slice, dice and regurgitate whatever humanity threw at us, without inconveniencing anybody. This is why good technology seems magical.

EHRs on the other hand, are obnoxiously demanding that people change how they think, how they work, and how they document their thoughts and actions, just so that the rudimentary software prematurely thrust upon them can function at some minimal level of proficiency.  People don’t think in codified vocabularies. We don’t express ourselves in structured data fields. Instead of building computers that elegantly adapt to the human modus operandi, EHRs, unlike all other software tools before them, demand that humanity adjust itself to the way primitive computers work. The self-appointed thought leaders, who are taking turns at regulating the meaningful clicks of EHRs, are basically demanding that we discard the full spectrum of human communications, in favor of gibberish that supposedly serves a higher purpose.

All the pretty horses

What is the purpose of EHR documentation templates? There is practically no EHR in use today that does not include visit templates. Visit templates are a list of checkboxes, some with multiple nested levels, which allow documentation by clicks instead of by typing, writing, drawing or dictation. Visit templates are created for each disease and contain canned text for findings judged pertinent to that condition by template creators. In all fairness, many physicians like documentation templates because with just a few clicks you are able to generate all the documentation required nowadays to get paid for your work, pages and pages of histories, review of systems, physical examination, assessments and plans of care. Do doctors like templates because they believe this extensive documentation is necessary, or do they like templates because the checkboxes alleviate the pain of typing thousands of meaningless regulatory words? I suspect the latter.

Clinical templates, along with the automated clinical decision support they enable, are advertised as time savers for physicians. The time saved is the time previously spent with patients, and most importantly the time spent thinking, analyzing, and formulating solutions. For most, it’s also the time spent rendering thoughts in a manner that can be understood by another person. Furthermore, when your note taking is template driven, most of your cognitive effort goes towards fishing for content that fits the template (like playing Bingo), instead of just listening to whatever the patient has to say. Even in “efficient” practices where staff does the clicking and physicians have the luxury of asking “open ended” questions, the patient story, the quirky details that are irrelevant to the template, are not documented (highlighted, circled, noted on the margins, etc.) anymore. Is this a good thing?

If we proceed on the assumption that IBM Watson and the likes are eventually going to be artificially intelligent enough, and big data are eventually going to be big enough, to respectively analyze and represent a complete human being, then yes, we can safely dispense with old fashioned human expertise. However, we are most certainly not there yet, and regardless of industry rhetoric, we are not certain that we will ever be there, and we are not even sure that we want to ever be there. While this utopia (or dystopia) is portrayed by interested parties as “inevitable”, chances are that for at least several generations we will be forced to contend with imperfect digital renditions of medicine, instead of allowing EHRs to follow the growth of underlying technologies. This is akin to summarily confiscating and shooting all the horses, on the day Henry Ford rolled the first Model T off his assembly line. Where would America be today, if we did that on October 1, 1908?

Furthermore, what type of doctors are we producing when we teach medicine by template, supported by clinical decision aids based on the same template, and assessed by quality measures calculated from template data? Medicine does not become precise just because we choose to discard all imprecise factors that we are not capable of fitting into a template. Standardization of processes and quality does not occur just because we choose to avert our eyes from the thick edges were mayhem is the norm. Dumbing physicians down is not the optimal strategy for bringing computer intelligence closer to human capabilities. EHRs should not be allowed to become the means to stifling growth of human expertise, the barriers to natural interactions between people, or the levers pushed and pulled at will by greed and corruption.

Bildungsroman style

Instead, EHRs could be the scaffolding for IMB Watson and other emerging contraptions to grow and become truly useful tools for both doctors and patients, and yes, also for legitimate and beneficiary secondary uses of clinical information. Instead of mandating that doctors think and work in ways that serve Watson’s budding abilities, we should require that Watson learns how to use the normal work products of humans. Instead of enforcing templated thought and workflows, whether through direct penalties for doctors or indirect certification requirements for software, we should work on teaching Watson how to parse and use human languages in all their complexity. Watson should grow up to be the multi-media scribe behind the computer screen, the means by which the analog music composed by physician-patient interactions is digitized into zeros and ones without loss of fidelity and without interference with actual performance.

Billions of years of evolution endowed the lowliest human specimen with cognitive abilities that machines will most likely never attain. The glory is in the journey though. We need to accept delayed gratification, and we need to accept that the challenge will span centuries, not just one boom-bust cycle of a fleeting global economy. We need to accept the fact that we will all die long before the ultimate goals are achieved, instead of declaring victory whenever each negligible incremental step is taken. If we are going to create a new form of intelligent life on earth, we need to assume the same humility Nature, or God, has been exercising since the dawn of time and counting. Otherwise, we are all just a bunch of hacks looking to make a quick buck on the backs of our fellow men and women.