Free EMR Newsletter Want to receive the latest news on EMR, Meaningful Use, ARRA and Healthcare IT sent straight to your email? Join thousands of healthcare pros who subscribe to EMR and EHR for FREE!

What Are You Doing for #NHIT Week? Does It Matter?

Posted on September 15, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Today is the official start of National Healthcare IT Week (#NHITWeek). Do you have any plans for #NHITWeek? Are you doing anything special? I personally don’t have any huge plans, but I do have one post for #NHITWeek that I hope people will enjoy. Watch for that coming later this week on one of the Healthcare Scene blogs.

If you want a full run down of official #NHITWeek activities, EHR Intelligence has put that together. HIMSS seems to be the real driver behind the week from what I can tell. I’ve never been to Washington during #NHIT Week, so maybe that’s why I haven’t ever seen the impact of the week. I guess I’m skeptical about what it really accomplishes.

What I have enjoyed is following the #NHITWeek hashtag on Twitter. There’s a lot of activity on the hashtag. You just have to filter through the #NHITWeek fluff and marketing. From the looks of Regina Holliday’s tweet, there are quite a few people attending the event she’s attending:

Plus, you get to see other craziness like this QR code connected to Casey Quinlan’s health record that she had tattooed on her chest:

Not to mention, you get links to great resources like this one from Steve Sisko:

I think that Steve has the right spirit for what #NHITWeek is for me. It’s about connecting people in the space. It’s always great when we can share the work that’s being done across the spectrum of health IT. I’m always amazed at how many people are working so hard day in and day out to make healthcare IT work.

The Other Talk: EHRs and Advance Medical Directives

Posted on September 11, 2014 I Written By

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

The Other Talk: EHRs and Advance Medical Directives

Most of us who have adult children can remember that awkward talk we had about life’s origins. We thought, whew, that’s done. Alas, there’s yet another talk. This time it’s with those adult children and it’s about you.

This one’s covered in Tim Prosch’s and AARP’s book, The Other Talk. The talk, or more accurately the process is how you want to spend the rest of your life.

The Other Talk

It’s about your money, where and how you’ll live and your medical preferences. It’s just as hard, if not harder, than the old talk because:

  • It’s hard to admit that you won’t be around forever and your independence may start to ebb away.
  • You don’t want to put your kids on the spot with difficult decisions.
  • Your children may be parents coping with their own problems. You don’t want to add to their burdens.
  • You’ve been a source of strength, often financial as well as emotional. That’s hard to give up.

Prosch and AARP want to make it easier on everyone to deal with these issues.

He covers many topics, but for those of us who live in the EHR world one is of significant importance: Medical directives.

Prosch explains directives and simply says you should give them to your doctor. Easier said, etc. Today, that means not only your PCP, but also making sure that hospitalists etc., know what you want. While the Meaningful Use program helps a bit. It’s still going to take some doing.

Medical Directives and EHRs

EHR MU1 recognizes directives’ importance requiring that they be accounted for:

More than 50% of all unique patients 65 years old or older admitted to the eligible hospital’s or CAH’s inpatient department have an indication of an advance directive status recorded.

This means that the EHR has to have the directives. However, MU 1 only goes halfway to what’s needed. It’s what the EHR does with directives that’s unsaid.

If the EHR treats a directive as a miscellaneous document, odds are it won’t be known, let alone followed when needed. To be used effectively, an EHR needs a specific place for directives and they should be readily available. For example, PracticeFusion recently added an advance directives function. That’s not always the case.

Practice Fusion: Advanced Medical Directives

Googling for Directives

To see how about twenty popular EHRs treat directives, I did a Google site search, on the term directive. I got hits for a directives function only from four EHRs:

  • Athenahealthcare
  • Cerner
  • Meditech
  • PracticeFusion

All the others, Allscripts, Amazing Charts, eClinicalWorks, eMDs, McKesson, etc., were no shows. Some listed the MU1 requirement, but didn’t show any particular implementation.

Directives: More Honored in the Breech

This quick Google search shows that the EHR industry, with a few exceptions, doesn’t treat directives with the care they deserve. It should also serve as a personal warning.

If you already have directives or do have that talk with your family, you’ll need to give the directives to your PCP. However, you should also give your family copies and ask them to go over them with your caregivers.

Some day, EHRs may handle medical directives with care, but that day is still far off. Until then, a bit of old school is advisable.

Purpose of EHR Incentive Program According to CMS

Posted on September 9, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

When I was reading through the EHR Certification flexibility final rule, I found a really interesting part of the rule (pg.49-50) that describes what CMS sees as the purpose of the HITECH act and all the money their spending on EHR software:

The entire overarching purpose of the EHR Incentive Program is to move providers towards advanced use of health IT to support reductions in cost, increased access, and improved outcomes for patients.

It’s been one of my pet peeves lately. People always come on this site or on social media and say “that goes against the purpose of the HITECH act.” I often would reply, “what is the purpose of the HITECH act?”

My problem with people’s comments about the purpose of all this spending on EHR software is that purpose changes depending on perspective. I’ve written before about the misalignment between “incentives” and “purpose.”

While I think the purpose for something changes based on whose perspective you’re talking about, I think it’s really important to know where CMS is coming from when it comes to the EHR incentive money and meaningful use. Now we know. They made it quite clear in the final rule.

How do you think the EHR incentive money is doing at achieving CMS’ purpose?

An Example Where an EHR Overcharges Healthcare

Posted on September 5, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In response to my post “Study Says Overcharging by the Hospital Might Be Overstated“, Patrick Duffy from PDA Consulting offered these added insights into the “overcharging” that exists in healthcare.

Some are overcharging thanks to EMR upgrade coding errors. How about $720 for ONE nitro tablet. Insurance company did not catch it either. About 9 months after an EPIC implementation so how many people/Insurance were overcharged and never knew?

In the meantime a gastric band operation in the UK is $7500 average. In the US it is between $15k and $30k depending on State. Is that not overcharging?

I’d never heard of an EHR software doing this, but it’s not surprising at all. In fact, it’s probably not even happening because an organization is trying to be dishonest. When you look at the complexity of an EHR implementation, it’s not surprising at all that things like this happen.

It’s also not surprising that the insurance company hasn’t caught it…yet. Notice how I added in the yet there. We’ll see if this comes back to bite healthcare organizations. Insurance companies do get behind on a lot of things, but they do go back and plug holes and then it hurts.

There are so many issues with the way we reimburse healthcare, that I’m honestly not sure where to start in order to fix it. It’s a complex web of overhead.

In the tech world, a software program has technical debt (also known as design debt or code debt). We see it happen across the EHR and health IT software world. Over time, you accrue a debt of issues in your software that make it easier to scrape the old software that’s encumbered by technical debt and rewrite it from scratch so that you can do it the right way.

When I look at the healthcare reimbursement system it’s got a very similar problem. There’s a healthcare reimbursement design debt that’s grown so large that there are no easy fixes to the system. I guess that’s why I asked the question, “Is Healthcare So Complex That It Can’t Be Fixed with the Existing Parts?

Impact of EHR and Technology on Nurses’ Wellbeing Infographic

Posted on August 29, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Who doesn’t like an informative infographic? I don’t think we’ve talked enough about the ergonomics of EHR. This is going to become a really big issue for nurses, doctors, front desk staff, etc. It’s good news for the chiropractors though.

ergotron_hospital_infographic

One Physician’s Experience Seeing an Ophthamalogist Pre and Post EHR

Posted on August 27, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I always love to hear doctor’s perspectives on EHR and how they’re impacting their day. You can be certain that they’ll lead with a long list of complaints. Many of the initial complaints are minor things that can be easily resolved with workflow or by a small enhancement by the EHR vendor. Once you get past the initial complaints, then you get to the heart of what they really think about the EHR software. I’ve had this experience hundreds of times and it’s always insightful.

However, this time a doctor shared something even more interesting. This was a doctor visiting another doctor as a patient. Rather than put words in his mouth, I’ll just share with you what he shared with me (EHR vendor name excluded since this could apply to many different EHR vendors):

I was in my ophthalmologist today. He is a really nice, busy doctor. He is in group practice and used to run his wing with one long time nurse with no hassles. He could previously see a patient in 10 min finish refraction, move from room to room and breeze through cases jotting what he needed to write down on one clean ophthalmology SOAP note. Since 2011 they have had EHR Vendor A. (because a consultant sold them on it and promised rewards from CMS)

Today, It took them a total of 1.5 hours to get my refraction, eye exam done. The workflow seemed to be in a complete disarray (remember this is an installed cloud based software since 2011, supposed to the be cream of the crap for Ophthalmology). What shocked me the most was that he now has 4 ladies doing inane things with EMR, trying to help him. I can also see why errors can creep in because he was reading out numbers for the assistant/ Nurse to enter into EHR Vendor A. Distraction fatigue, EMR ennui can cause errors of entry. So the cost of running crappy software far exceeds the physical costs / monthly service costs of the product. It amplifies personnel costs. It took the lady 20 minutes to take totally pointless history and do ROS!

I did not tell her I was a physician and she was clicking away to glory. I counted more than 50 clicks before anything of substance was even gathered. Based on the EMR prompts she made me do finger counting and asking me if I can see her face etc..>! I had clearly indicated to her that I just wanted a retinal exam and prescription for glasses because I wanted to buy new lenses and that I had not required change of prescription for glasses in 10 years!

Then I walk out with mydriatic in my eyes…and saw a hazy illusion of one of my ex-patients, a severe schizophrenic waiting for his turn to be checked in. He was talking about meeting Jesus and asked if I have had a “meeting Jesus moment” in my life.. I assured him I just did…

In those 1 hr and 45 min, the good doctor had seen just 4 patients and 6 more were still waiting impatiently on one arse looking irate, checking their iphones and smart watches …spreading anxiety.

I’m always torn on sharing these type of stories. I know that this doesn’t have to be the case since I know many EHR users who don’t have these issues. However, far too many of them do that it’s worth keeping this perspective in mind. Plus, regardless of how efficiently someone has incorporated the MU requirements, it’s had a huge impact on everyone that’s participating.

I guess it’s fair to say that the above ophthamologist doesn’t agree that meaningful use saves a doctor time.

Digital Health: How to Make Every Clinician the Smartest in the Room

Posted on August 21, 2014 I Written By

The following is a guest blog post by Dr. Mike Zalis, practicing MGH Radiologist and co-founder of QPID Health.
Zalis Headshot
Remember the “World Wide Web” before search engines? Less than two decades ago, you had to know exactly what you were looking for and where it was located in order to access information. There was no Google—no search engine that would find the needle in the haystack for you. Curated directories of URLs were a start, but very quickly failed to keep up with the explosion in growth of the Web. Now our expectation is that we will be led down the path of discovery by simply entering what’s on our mind into a search box. Ill-formed, half-baked questions quickly crystalize into a line of intelligent inquiry. Technology assists us by bringing the experience of others right to our screens.

Like the Internet, EHRs are a much-needed Web of information whose time has come. For a long time, experts preached the need to migrate from a paper-based documentation systems – aka old school charts—to electronic records. Hats off to the innovators and the federal government who’ve made this migration a reality. We’ve officially arrived: the age of electronic records is here. A recent report in Health Affairs showed that 58.9% of hospital have now adopted either a basic or comprehensive EHR—this is a four-fold increase since 2010 and the number of adoptions is still growing. So, EHRs are here to stay. Now, we’re now left to answer the question of what’s next? How can we make this data usable in a timely, efficient way?

My career as a radiologist spanned a similar, prior infrastructure change and has provided perspective on what many practitioners need—what I need—to make the move to an all-electronic patient record most useful: the ability to quickly get my hands on the patient’s current status and relevant past history at the point-of-care and apply this intelligence to make the best decision possible. In addition to their transactional functions (e.g., order creation), EHRs are terrific repositories of information and they’ve created the means but not the end. But today’s EHRs are just that—repositories. They’re designed for storage, not discovery.

20 years ago, we radiologists went through a similar transition of infrastructure in the move to the PACS systems that now form the core of all modern medical imaging. Initially, these highly engineered systems attempted to replicate the storage, display, and annotation functions that radiologists had until then performed on film. Initially, they were clunky and in many ways, inefficient to use. And it wasn’t until several years after that initial digital transition that technological improvements yielded the value-adding capabilities that have since dramatically improved capability, efficiency, and value of imaging services.

Something similar is happening to clinicians practicing in the age of EHRs. Publications from NEJM through InformationWeek have covered the issues of lack of usability, and increased administrative burden. The next frontier in Digital Health is for systems to find and deliver what you didn’t even know you were looking for. Systems that allow doctors to merge clinical experience with the technology, which is tireless and leaves no stone unturned. Further, technology that lets the less-experienced clinician benefit from the know-how of the more experienced.

To me, Digital Health means making every clinician the smartest in the room. It’s filtering the right information—organized fluidly according to the clinical concepts and complex guidelines that organize best practice—to empower clinicians to best serve our patients. Further, when Digital Health matures, the technology won’t make us think less—it allows us to think more, by thinking alongside us. For the foreseeable future, human experience, intuition and judgment will remain pillars of excellent clinical practice. Digital tools that permit us to exercise those uniquely human capabilities more effectively and efficiently are key to delivering a financially sustainable, high quality care at scale.

At MGH, our team of clinical and software experts took it upon ourselves some 7 years ago to make our EHR more useful in the clinical trench. The first application we launched reduced utilization of radiology studies by making clinicians aware of prior exams. Saving time and money for the system and avoiding unnecessary exposure for patients. Our solution also permitted a novel, powerful search across the entirety of a patient’s electronic health record and this capability “went viral”—starting in MGH, the application moved across departments and divisions of the hospital. Basic EHR search is a commodity, and our system has evolved well beyond its early capabilities to become an intelligent concept service platform, empowering workflow improvements all across a health care enterprise.

Now, when my colleagues move to other hospitals, they speak to how impossible it is to practice medicine without EHR intelligence—like suddenly being forced to navigate the Internet without Google again. Today at QPID Health, we are pushing the envelope to make it easy to find the Little Data about the patient that is essential to good care. Helping clinicians work smarter, not harder.

The reason I chose to become a physician was to help solve problems and deliver quality care—it’s immensely gratifying to contribute to a solution that allows physicians to do just that.

Dr. Mike Zalis is Co-founder and Chief Medical Officer of QPID Health, an associate professor at Harvard Medical School, and a board certified Radiologist serving part-time at Massachusetts General Hospital in Interventional Radiology. Mike’s deep knowledge of what clinicians need to practice most effectively and his ability to translate those needs into software solutions inform QPID’s development efforts. QPID software uses a scalable cloud-based architecture and leverages advanced concept-based natural language processing to extract patient insights from data stored in EHRs. QPID’s applciations support decision making at the point of care as well as population health and revenue cycle needs.

An Image Worth 1000 Words Offers a Great Healthcare Perspective

Posted on August 20, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I have no idea where this picture comes from, but it’s a pretty interesting look into some of the history of medicine. As @notasmedicina points out, it’s pretty disturbing to see them working on someone without gloves. Take a look below to see what I mean.

As I saw this, I thought about how far we’ve come with EHR software. I wonder if 20-30 years from now we’ll look at a picture of a paper chart and feel disturbed. I imagine my children will look at it and wonder how a doctor could practice medicine with a paper chart.

Hospital M&A Cost Boosted Significantly By Health IT Integration

Posted on August 18, 2014 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @annezieger on Twitter.

Most of the time, hospital M&A is sold as an exercise in saving money by reducing overhead and leveraging shared strengths. But new data from PricewaterhouseCoopers suggests that IT integration costs can undercut that goal substantially. (It also makes one wonder how ACOs can afford to merge their health IT infrastructure well enough to share risk, but that’s a story for another day.)

In any event, the cost of integrating the IT systems of hospitals that merge can add up to 2% to the annual operating costs of the facilities during the integration period, according to PricewaterhouseCoopers. That figure, which comes to $70,000 to $100,000 per bed over three to five years, is enough to reduce or even completely negate benefits of doing some deals. And it clearly forces merging hospitals to think through their respective IT strategies far more thoroughly than they might anticipated.

As if that stat isn’t bad enough, other experts feel that PwC is understating the case. According to Dwayne Gunter, president of Parallon Technology Solutions — who spoke to Hospitals & Health Networks magazine — IT integration costs can be much higher than those predicted by PwC’s estimate. “I think 2% being very generous,” Gunter told the magazine, “For example, if the purchased hospital’s IT infrastructure is in bad shape, the expense of replacing it will raise costs significantly.”

Of course, hospitals have always struggled to integrate systems when they merge, but as PwC research notes, there’s a lot more integrate these days, including not only core clinical and business operating systems but also EMRs, population health management tools and data analytics. (Given be extremely shaky state of cybersecurity in hospitals these days, merging partners had best feel out each others’ security systems very thoroughly as well, which obviously adds additional expenses.) And what if the merging hospitals use different enterprise EMR systems? Do you rip and replace, integrate and pray, or do some mix of the above?

On top of all that, working hospital systems have to make sure they have enough IT staffers available, or can contract with enough, to do a good job of the integration process. Given that in many hospitals, IT leaders barely have enough staff members to get the minimum done, the merger partners are likely costly consultants if they want to finish the process for the next millennium.

My best guess is that many mergers have failed to take this massive expense into account. The aftermath has got to be pretty ugly.

Could Clinicians Create Better HIE Tools?

Posted on August 13, 2014 I Written By

The following is a guest blog post by Andy Oram.His post reminds me of when I asked “Is Full Healthcare Interoperability a Pipe Dream?

A tense and flustered discussion took place on Monday, August 11 during a routine meeting of the HIT Standards Committee Implementation Workgroup, a subcommittee set up by the Office of the National Coordinator (ONC), which takes responsibility for U.S. government efforts to support new IT initiatives in the health care field. The subject of their uncomfortable phone call was the interoperability of electronic health records (EHRs), the leading issue of health IT. A number of “user experience” reports from the field revealed that the situation is not good.

We have to look at the depth of the problem before hoping to shed light on a solution.

An interoperability showcase literally takes the center of the major health IT conference each year, HIMSS. When I have attended, they physically arranged their sessions around a large pavilion filled with booths and computer screens. But the material on display at the showcase is not the whiz-bang features and glossy displays found at most IT coventions (those appear on the exhibition floor at HIMSS), but just demonstrations of document exchange among EHR vendors.

The hoopla over interoperability at HIMSS suggests its importance to the health care industry. The ability to share coordination of care documents is the focus of current government incentives (Meaningful Use), anchoring Stage 2 and destined to be even more important (if Meaningful Use lasts) in Stage 3.

And for good reason: every time we see a specialist, or our parent moves from a hospital to a rehab facility, or our doctor even moves to another practice (an event that recently threw my wife’s medical records into exasperating limbo), we need record exchange. If we ever expect to track epidemics better or run analytics that can lower health case costs, interoperability will matter even more.

But take a look at extensive testing done by a team for the Journal of the American Medical Informatics Association, recently summarized in a posting by health IT expert Brian Ahier. When they dug into the documents being exchanged, researchers found that many vendors inserted the wrong codes for diagnoses or drugs, placed results in the wrong fields (leaving them inaccessible to recipients), and failed to include relevant data. You don’t have to be an XML programmer or standards expert to get the gist from a list of sample errors included with the study.

And that list covers only the problems found in the 19 organizations who showed enough politeness and concern for the public interest to submit samples–what about the many who ignored the researchers’ request?

A slightly different list of complaints came up at the HIT Standards Committee Implementation Workgroup meeting, although along similar lines. The participants in the call were concerned with errors, but also pointed out the woeful inadequacy of the EHR implementations in representing the complexities and variety of patient care. Some called for changes I find of questionable ethics (such as the ability to exclude certain information from the data exchange while leaving it in the doctor’s records) and complained that the documents exchanged were not easy for patients to read, a goal that was not part of the original requirements.

However, it’s worth pointing out that documents exchange would fall far short of true coordinated care, even if everything worked as the standards called for. Continuity of care documents, the most common format in current health information exchange, have only a superficial sliver of diagnoses, treatments, and other immediate concerns, but do not have space for patient histories. Data that patients can now collect, either through fitness devices or self-reporting, has no place to be recorded. This is why many health reformers call for adopting an entire new standard, FHIR, a suggestion recognized by the ONC as valid but postponed indefinitely because it’s such a big change. The failure to adopt current formats seems to become the justification for keeping on the same path.

Let’s take a step back. After all those standards, all those certifications, all those interoperability showcases, why does document exchange still fail?

The JAMIA article indicated that failure can be widely spread around. There are rarely villains in health care, only people pursuing business as usual when that is insufficient. Thus:

  • The Consolidated CDA standard itself could have been more precisely defined, indicating what to do for instance when values are missing from the record.

  • Certification tests can look deeper into documents, testing for instance that codes are recorded correctly. Although I don’t know why the interoperability showcase results don’t translate into real-world success, I would find it quite believable that vendors might focus on superficial goals (such as using the Direct protocols to exchange data) without determining whether that data is actually usable.

  • Meaningful Use requirements (already hundreds of pages long) could specify more details. One caller in the HIT Standards Committee session mentioned medication reconciliation as one such area.

The HIT Standards Committee agonized over whether to pursue broad goals, necessarily at a slow pace, or to seek a few achievable improvements in the process right away. In either case, what we have to look forward to is more meetings of committees, longer and more mind-numbing documents, heavier and heavier tests–infrastructure galore.

Meanwhile, the structure facilitating all this bureaucracy is crumbling. Many criticisms of Meaningful Use Stage 2 have been publicly aired–some during the HIT Standards Committee call–and Stage 3 now looks like a faint hope. Some journalists predict a doctor’s revolt. Instead of continuing on a path hated by everybody, including the people laying it out, maybe we need a new approach.

Software developers over the past couple decades have adopted a range of ways to involve the users of software in its design. Sometimes called agile or lean methodologies, these strategies roll out prototypes and even production systems for realistic testing. The strategies call for a whole retooling of the software development process, a change that would not come easily to slow-moving proprietary companies such as those dominating the EHR industry. But how would agile programming look in health care?

Instead of bringing a doctor in from time to time to explain what a clinical workflow looks like or to approve the screens put up by a product, clinicians would be actively designing the screens and the transitions between them as they work. They would discover what needs to be in front of a resident’s eyes as she enters the intensive care ward and what needs to be conveyed to the nurses’ station when an alarm goes off sixty feet away.

Clinicians can ensure that the information transferred is complete and holds value. They would not tolerate, as the products tested by the JAMIA team do, a document that reports a medication without including its dose, timing, and route of administration.

Not being software experts (for the most part), doctors can’t be expected to anticipate all problems, such as changes of data versions. They still need to work closely with standards experts and programmers.

It also should be mentioned that agile methods include rigorous testing, sometimes to the extent that programmers write tests before writing the code they are testing. So the process is by no means lax about programming errors and patient safety.

Finally, modern software teams maintain databases–often open to the users and even the general public–of reported errors. The health care field needs this kind of transparency. Clinicians need to be warned of possible problems with a software module.

What we’re talking about here is a design that creates a product intimately congruent with each site’s needs and workflow. The software is not imported into a clinical environment–much less imposed on one–but grows organically from it, as early developers of the VistA software at the Veterans Administration claimed to have done. Problems with document exchange would be caught immediately during such a process, and the programmers would work out a common format cooperatively–because that’s what the clinicians want them to do.