Week 8: 7/10-7/16 Special Topics: Medical/Health Informatics
It seems to me that the field of medical informatics is suffering many of the issues that bedeviled the adoption of information technology in the areas of manufacturing and seems to have not availed itself of the solutions and insights that manufacturers have developed over nearly 60 years of practice. Reading the article Death By A Thousand Clicks: Leading Boston Doctors Decry Electronic Medical Records, I felt a profound sense of déjà vu and a disappointment that lessons learned elsewhere had not been considered and applied in the case of the Electronic Medical Record.
“Typing, filing, mailing results and placing referrals all used to be done by assistants. Now, EMRs put that burden on clinicians, and we must do it during office visits, or “encounters,” as EMRs call them. And when the wrong button is clicked, the wrong test or drug is ordered, or it does not go through at all, delaying medical care” (Levinson et al., 2017).
The most valuable resource in a medical office (i.e., The Doctor) and it’s performing clerical labor that can be performed by minimum-wage labor or by patients themselves. This is profoundly dumb and how could it come to be the norm for American medical practice?
Clearly, there is a profound misunderstanding of the resources in healthcare that would burden the most valuable resources in the system with time-consuming, non-medical tasks in the name of cost efficiency. For this to have become implemented there must be more than simply the collusion of manufacturers of EMR systems, government, and hospital management to create a system of absurd incentives that would use a doctor as a clerical worker. There must be a fundamental belief in a management measurement that is not being challenged by the prevailing wisdom and creates the wrong incentives, wasteful spending, and negative outcomes. This is clearly a Bizarro World – a distorted mirror image of the rational world that would allocate priority to the most valuable resources doing the most valuable work it can do.
Imagine a baseball player who not only had to play his position (for which they are lucratively rewarded) but to record the statistics of the game while they are playing - keeping track of all the data on the game in progress. How effective would they be? Not very. How much energy would be devoted to practice their well-honed skills versus routine – mind-numbing, data entry on an interface that is poorly designed? Any normal, sane person watching a performance like this would be laughing at the absurdity of it or requesting a refund of the ticket price to the game.
However, in healthcare informatics, this acceptance of absurdity seems to be the norm. And instead of a fresh-sheet approach, numerous fixes are applied to the absurdity leading to further distortions, disruptions, and defections.
We must not mistake the digital representation of the patient as represented by the EMR as the real patient. This is another point of the article. As the healthcare practices of the United States become more and more mediated through interfaces and technology something is lost. And that is context and holism. This is not a new trend of course. When the house call went away, doctors lost the contextual information provided by the home environment of the patient. And now we see more context begin lost as doctors become data entry clerks instead of focusing their expertise on the Encounter (marketing speak for doctor-patient meetings and sounds like something out of exploration textbook) and in the process spend as much time with the data representation of the patient as with the patient.
Reality is not its representation unless we fall under the illusion it casts. The shadows on the wall in the Platonic cave that were mistaken for reality illustrate that this is not a new concern.
Let me be clear. I am not denying the efficacy of technology to solve problems. As the Tedtalk video demonstrated, it can make possible outcomes unimaginable before – quicker detection of global pandemics. And the Sphere interface is a good use of ambient affordance interface technologies that make use lessons learned from J.J. Gibson (1966), Donald Norman (1991) and Peter Morville (2005). Wearable sensors, big data analytics, and the other technologies we’ve covered in prior weeks make it clear that technology can be effectively applied.
But…and it’s a big but - with the application of all this technology since the birth of informatics in the 1950s, why haven’t healthcare costs gone down and accessibility improved? Why are records so poorly protected and mediation between systems a major issue? Why is health care quality as measured by (presumably) preventable outcomes (i.e. death from medical error) so high?
“Analyzing medical death rate data over an eight-year period, Johns Hopkins patient safety experts have calculated that more than 250,000 deaths per year are due to medical error in the U.S. Their figure, published May 3 in The BMJ, surpasses the U.S. Centers for Disease Control and Prevention’s (CDC’s) third leading cause of death — respiratory disease, which kills close to 150,000 people per year” (John Hopkins Medicine, 2016) just behind heart disease and cancer.
How in the hell does one get out of a bizarro world like this?
Not by simply applying more technology. Or newer technology.
One gets out of the bizarro world by changing the method of measurement, accounting, and management. Cost accounting has clearly not been effective at controlling costs and leads to bizarro world incentives in which policy makers pay doctors to be data-entry clerks. This same kind of bizarro world practice was the norm throughout the manufacturing industry until innovator thinkers applied the scientific method to solve problems that were poorly understood and managed in terms of the conventional wisdom.
Towards a solution.
I am not an expert in healthcare informatics or management and so I can only offer a general outline of an approach based on my experience and readings of the relevant management literature.
Toyota has become the world’s most productive (and profitable) automobile manufacturer building on insights gained from studying Henry Ford, the Supermarket, and W. Edwards Deming along with the tenacity to apply those insights by Taiichi Ohno in the face of intense opposition from workers and manufacturing experts. Techniques they have implemented have become the basis of an operation that continuously cuts costs, increases quality, and offers greater flexibility than standard mass production methods. Continuous improvement is built into their management philosophy. Is there a healthcare informatics operation that can demonstrate anything comparable?
Building on the insights of Taiichi Ohno, The Theory of Constraints is a management approach based “on the premise that the rate of goal (Links to an external site.)Links to an external site. achievement by a goal-oriented system (Links to an external site.)Links to an external site. (i.e., the system's throughput) is limited by at least one constraint. The argument by reductio ad absurdum is as follows: If there was nothing preventing a system from achieving higher throughput (i.e., more goal units in a unit of time), its throughput would be infinite — which is impossible in a real-life system. Only by increasing flow through the constraint can overall throughput be increased” (Wikipedia, 2017). And to measure and direct this system a different method of accounting is derived called Throughput Accounting. This seems in my opinion to offer a measurement process that is more supportive of continuous improvement than traditional cost accounting which is the system in use in most healthcare informatics vendors and service providers (government, hospitals, insurers, etc.). Given the poor track record of cost reduction and operational inefficiencies that seem to be the historic norm in the American healthcare informatics industry, I suggest a few experiments using a different management and accounting approach.
Below are a few articles outlining a TOC approach to healthcare for further exploration:
https://www.researchgate.net/profile/Anne_Tomolo/publication/10965083_Applying_the_Theory_of_Constraints_in_Health_Care_Part_1-The_Philosophy/links/54cfb9890cf29ca811003038.pdf (Links to an external site.)Links to an external site.
http://www.qficonsulting.com/featured-articles/the-theory-of-constraints-in-health-and-social-care (Links to an external site.)Links to an external site.
http://maaw.info/ArticleSummaries/ArtSumKershaw2000.htm (Links to an external site.)Links to an external site.
http://www.aafp.org/fpm/2014/0900/p18.html (Links to an external site.)Links to an external site.
For my final presentation, I would like to see how continuous improvement systems are implemented by healthcare systems. I am not sure if there is much academic research available to support a 20-minute presentation, but I think there is sufficient existing management literature to be effectively applied to the healthcare field to make it a viable topic. And I think the promise of a better management/accounting paradigm has the potential to increase the value of existing and new technological developments.
John Hopkins Medicine. (2016, May 3). Study suggests medical errors now third leading cause of death in the U.S. Retrieved from http://www.hopkinsmedicine.org/news/media/releases/study_suggests_medical_errors_now_third_leading_cause_of_death_in_the_us
Levinson, J., & Price, B. H., & Saini, V. (2017, May 12). Death by a thousand clicks: Leading Boston doctors decry electronic medical records. Retrieved from http://www.wbur.org/commonhealth/2017/05/12/boston-electronic-medical-records?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=20170512
Foraker, R. Ohio State University Center for Clinical and Translational Science Annual Scientific Meeting. (2015, October 15). Visualizing health informatics. [Video file]. Retrieved from https://www.youtube.com/watch?v=7GJ0CVMz-dE
McKendry, R. TEDx Talks. (2015, June 9). Going viral: The digital future of public health. [Video file]. Retrieved from https://www.youtube.com/watch?v=vRK7KKQH9Ck (Links to an external site.)Links to an external site.
Theory of Constraints. (n.d.) Retrieved July 16, 2017 from https://en.wikipedia.org/wiki/Theory_of_constraints (Links to an external site.)Links to an external site.
Throughput accounting. (n.d.) Retrieved July 16, 2017 from https://en.wikipedia.org/wiki/Throughput_accounting