The Healthcare IT Guy

This summer I wrote about the SEIPS Course on HFE and Patient Safety and that I thought it would be a useful. I was unable to attend it but one of my readers, Satish, did attend it and he was gracious enough to provide a review for us. Satish Duryodhan works as Assoc. VP at Hexaware Technologies Limited and leads Hexaware’s Healthcare Practice. I met Satish during my recent trip to India. He was one of the “bright guys” I talked about. Hexaware is working with Providers and Payers and providing some pretty nice healthcare focused IT-BPO solutions that are worth checking out. I worked with them on SOA, legacy technology management, Independent Testing and BPO at a recent engagement and they seem to know their stuff. Enough on introductions — In this guest posting Satish provides an overview of the course he and several others from Hexaware attended in July. If you attended as well, please drop some comments here and share your thoughts with us as well.

The 2006 Systems Engineering Initiative in Patient Safety (SEIPS) Course on Human Factors Engineering (HFE) and Patient Safety was organized on August 14-18, 2006 at The Pyle Center, University of Wisconsin-Madison. The Course was jointly sponsored by the University of Wisconsin Center for Quality and Productivity Improvement (CQPI) and the University of Wisconsin School of Medicine and Public Health, Office of Continuing Professional Development in Medicine and Public Health. The program was organized in two parts:

Part I The Basics of HFE & Patient Safety – August 14-16

Part II HFE and Healthcare Information Technology (HIT) – August 16-18

The course was attended by over 30 professionals including Physicians, Senior Nursing staff, Pharmacists, patient safety officers and IT professionals etc.

The five day course for professionals was conducted by nationally recognized speakers discussing a variety of Patient Safety topics and Human Factors Engineering(HFE) including:

• Human Factors Engineering                                                   
• Design of the Physical Environment and Ergonomics
• Cognitive Ergonomics 
• Job and organizational Issues
• Technology Design and Usability
• HFE principles of HIT design
• Usability of CPOE Technology
• Impact of HIT on Patient Care Process
• A Provider’s Conversion Experience

The course was designed to provide an understanding of human factors and systems engineering and how this approach to patient safety can improve performance, prevent harm when error does occur, help systems recover from error, and mitigate further harm.

The Key principles of HFE and patient safety were extremely well presented through over 20 sessions covered by different speakers, case studies, group exercises and group presentations. The course was very interactive with participants sharing their experiences and examining how each principle presented would be relevant in their work environment.

The Part I course started with clarifications on misconceptions about HFE and clearly laying out HFE principles from the perspective of Patient safety. Scope of HFE involves Different levels of study and intervention:

- Human: Information Display

– Human: Machine

– Human: Environment

– Human: Job

– Human: Organization

– Human: Community

Each of these interactions was analyzed in detail from conceptual and practical perspective. For example the “Human: Environment” was presented through research findings that relate improved physical environment (Light, Sound, Climate, Arrangement of space etc) to patient and staff in four areas:

1. Reduce staff stress and fatigue and increase effectiveness in delivering care

2. Improve patient safety

3. Reduce stress and improve outcomes

4. Improve overall healthcare quality

A model for analyzing organizational accident causation was presented.

Similarly cognitive (e.g., attention, memory) factors affect the way people process information and make decisions, therefore affecting their cognitive performance (e.g., errors, safety). Models and principles for improved cognitive performance were presented.

The course presented the Donabedian’s framework (for assessing the quality of health care), and the “work system model” (how an individual performs a range of tasks using various tools and technologies). Assessing patient safety can be accomplished by integrating Donabedian’s Structure-Process-Outcome framework and the work system model. Several case studies were presented to illustrate how these frameworks can be effectively utilized for improved patient safety. This part also focused on HFE method of usability testing and how it fits in proactive risk assessment.

This course also presented Rasmussen’s dynamic model of risk and safety to illustrate how it can used to understanding current conditions in modern healthcare delivery and the way these conditions may lead to accidents.

The course enabled participants to acquire skills in the HFE method of usability testing and pro-active risk assessment and developing decision making strategies to determine when to use usability testing for patient safety activities.

The part II presented several topics related to HFE in HIT (Healthcare Information Technology):

· A holistic model of Information System Architecture for Healthcare System

· Overview of systems such as Hospital information system, Electronic Health records, EHealth Portals, CPOE and context of patient care in implementing these systems

· A very interesting case study on how HFE was used to improve usability of CPOE technology.

· Analysis model for assessing impact of HIT on patient care processes and tasks. The group exercise focusing on applying on these principles in live environment provided a great leering value.

Throughout the course many practical exercises were provides including:

· The classic practical model to illustrate that a practical process is extremely complex to document completely with no ambiguity.

· Usability testing using usability principles of Alaris^TM system

· Usability testing with Fat measurement meter

· Usability of injection system under panic situation

Overall the course environment was kept informal and participative. This provided great learning value not only from the sessions conducted by various experts but also from interaction among participants.

– written by Satish Duryodhan, Assoc. VP at Hexaware Technologies Limited

Kathy Sierra ponders why it’s so hard to get users to upgrade. If you’re in the software business upgrades mean income and Kathy’s posting is a good summary on what it might take to get users to upgrade.

Healia, which I wrote about a few months back, is a consumer-focused health search engine which makes it easier to find healthcare-specific information. A new version of the software is being introduced, with the following added features:

• Enhanced the accuracy and performance of the filtering algorithms

• Additional filters to allow people to filter by the topic of the document when they submit a disease or drug-related search

• New “Suggested Result” feature from a reference site for disease and drug-related searches

• Detection of expanded equivalents to common medical abbreviations and acronyms (try searching on ACL or CVD for example)

It’s nice to see search engines like this which take into account the complexity of healthcare information structure and sources.

In case you haven’t seen them before, it’s interesting to look at how different computer languages implementations fare on different hardware. Check them out at The Computer Language Shootout Benchmarks.

Many of us run to reporting and analytics vendors because our users scream for reports and we think that if we “just give them a tool” they will be able to make things work and get their own reports. Most of us are finding that not to be the case because we underestimate the effort and time necessary to do analytics and run “user friendly” reporting systems.

The main reason we’re surprised is that we believe everything we see during the web analytics demos that vendors present. It’s not their fault, really — they are trying to show us that everything is much easier with their tool. Well, the reason that’s the case is that they (the demonstrators) understand the data they are presenting. Of course, our users who will use the tools with our own data don’t understand the structures we designed.

A simple rule is that unless the data models underneath are pretty well design and just as well understood no tool will be able to do “easy analytics”. Even if you have a free analytics tool it will take hours to setup each report and more hours to maintain the reports as time progresses. This means that no matter how nice the reporting tool, without complete understanding of the data in the data stores you can’t have good reports.

When calculating costs, don’t forget all the time needed to include internal stakeholder participation, testing the reports, and ongoing maintenance. Data collection is an ongoing activity, data structures change, and data is dynamic. Choosing a reporting solution should take that into account.

Dennis de Champeaux, who runs Ontooo, questioned the viability of eHealth last year. He argued the US has not been able to achieve cost effective quality healthcare (which is eHealth’s key potential contribution) and there is no stakeholder that eHealth can do business with. His post was picked up by an east coast VC - who was sick and tired from pie in the sky eHealth business plans - that he put it on his blog at www.sacredcowdung.com. It was actually a devil’s advocate argument against eHealth with the hope to elicit defenses for eHealth. The opposite happened and respondents agreed with the conclusions. I enjoyed his earlier article and asked him what he thought about eHealth, one year later. Here’s his guest article answering the question.

The arguments against eHealth are grounded on an astonishing phenomenon: the nation spending nearly twice as much on healthcare (in terms of percentage of GDP) than other nations while the yield is less. Apparently the nation is not able to cap spending, enforce quality control and do productivity management of this cost component of the economy.

This phenomenon is at the same time the ultimate justification for eHealth: the trend of gobbling up an increasing percentage of the nation’s revenue cannot be sustained. However, this begs the question when the trend will max out, and whether we will live to witness it.

At this point, we can point only to some lights at the end of the proverbial tunnel.

Business CEOs use typically the polite phrase “the healthcare system is broken”. They have been confronted for many years with double digit premium increases for the healthcare benefits of their employees and their dependents. Although these benefits have taxation advantages the money has to be earned first. Many companies have decided that they cannot continue subsidizing the nation’s healthcare largesse. Hence they demand increasing co-payments from their employees or they negotiate programs where the employees are fully responsible for the premiums, with or without a range of deductibles. Unions have organized strikes to counter these developments, but the message is clear: someone else paying the healthcare bills for those in the workforce is slowly becoming a thing of the past. Most people in the workforce are actually light users of the healthcare services - according to the 20-80 rule - and hence are not financially impacted by large expenditures. Still uncertainty is injected in their lives, which makes them potential clients for decision support services provided by eHealth.

New Medicare recipients are confronted as well with multiple choices regarding the programs they can subscribe to, which have their own ranges of premiums, deductibles and co-payments. The current Medicare recipients are not yet computer literate enough to be customers of decision support services and/or of eHealth services for treatments of chronic conditions. The upcoming generation of baby-boomers is a different story. It is hard to envision how to take care of this cohort without increased self help facilities provided by eHealth services.
The key novelty in both preceding developments is that the patient, the care consumer, becomes - at least partially - financially responsible, which is a prerequisite for being a customer of eHealth services.

Rolling back an entitlement can produce counter maneuvers. A recent development in the Netherlands is a baroque illustration. The Dutch government, which is a major force in the Dutch healthcare system, introduced on January 1st new, nationwide procedures. To increase self responsibility they created financial rewards for those that do not use certain healthcare services during a certain period; a kind of no-claim arrangement. Lawyers filed immediately a class action suite arguing that chronic patients were discriminated. A judge rejected the claim, which is surprising since ’solidarity’ is a deeply entrenched principle in the Netherlands that has been used to accommodate the disenfranchised. Creative US lawyers will likely also temporarily derail measures to make individuals more financially responsible for their care.

The medical establishment is another inhibitor against eHealth innovation. General practitioners have claimed that tele-diagnosis is “bad medicine” and since patients did not pay for services, and thus could not vote with their feet, there were no incentives for physicians to offer tele-consultation services. Consumers becoming more financially responsible for their care is changing the status quo. At least one company is offering already tele-consultation services. An early report claims that they have to advice only in 8% of the tele-sessions that a face-to-face consultation is required. No law suites were filed thus far and customer satisfaction appears to be OK.

Conclusion: eHealth appears to be viable after all and the lights in the tunnel are brightening.

One of the most difficult tasks I have seen my customers grapple with as I advise them on technology strategy for their information management needs is how to get a handle on those pesky Microsoft Access and Excel “files”. While we tend to treat these ”documents” as simple file management problems they are far more than that: they are real applications and they are real databases with complete enterprise architecture impacts. I remember at one of my clients when were doing analysis of HIPAA privacy concerns related to patient information we calculated over a thousand MS Access and Excel “files” with health data that needed to be protected.

What can be done to rope in these real (small but important) databases and get them under control? First, we need to figure out why people use Access and Excel. Well, that’s simple: with those tools users are in control, they don’t need permission from the CIO to create a new app or database, they can connect to external databases, and most importantly they get their job done. Now, if you can give them those same capabilities but in a centralized manner, would your users use it and let you manage, secure, catalog, backup, and protect the data? The answer is: probably not immediate-term, but certainly yes in the medium- and long-term if you can setup appropriate policies.

So, how do you give your users those features? Well, a new class of end-user-friendly application-creators are hitting the market. There are enterprise-hosted systems like Caspio and Internet-hosted systems like Zoho Creator. Zoho Creator is currently more feature rich than Caspio but Caspio is pretty user friendly and can be installed behind your firewalls and the data goes into your own (SQL Server) databases instead of sitting on the Internet. I’ve spoken to the folks at Zoho Creator and they said they are working on an enterprise-hostable system that should be ready soon as well.

By setting up a server or service and training your users to use the new tools instead of Access and Excel, they can:

• Create applications from scratch
• Create applications using templates that other users (or you) can create for them
• Create applications by importing existing spreadsheets or databases
• Share applications with their colleagues and clients without sending secure data via email
• Get email notifications when records are added/updated but only notifications (not the data) is sent across mail
• Export data in formats that be analyzed in Excel or Access

Here’s what you get out of systems like these:

• Manage the tool and the database server and all your data is in one place instead of strewn across hundreds of spreadsheets and little databases files
• Secure the data and protect health information centrally
• Look at the kinds of applications users are creating and learn from the requirements they’re fulfilling themselves to see if your group should be doing that work instead of users creating custom apps

My friend Eric Spiegel just finished a nice article on working with startups. It’s a great explanation to customers on why they should do it and what some of the challenges are. 

The challenge that early stage firms encounter is that customers don’t usually understand they need to deal differently with a startup than an established technology vendor. Let’s be clear what “early stage” means. A company with 50 employees, a few million in revenue and a version three product is not early stage. A company with a handful of employees and almost no revenue with a version one (or beta) product is most definitely early stage.

…

By working with an early stage vendor, you can gain a competitive advantage on your competitors who aren’t willing to take this risk. You’ll have first access to thought-leaders and an innovative product. This will enable you to build and fine tune processes and best practices to get the most out of the new product. When your competition finally discovers the vendor, you will be light years ahead in getting the most out of this investment.

Read more: The Benefits of Working With Tech Startups

NIST Special Publication 800-95 addresses security needs for networks in which automated Web services are being deployed in service-oriented architectures.  It’s only in draft but it covers the basics fairly well. If you’re doing business with the government and you plan to offer consumable services it’s worth making sure you follow the recommendations since the NIST requirements will start showing up in RFPs soon.

Our health IT databases, like in most other industries, are growing fast and sometime out of control. Every time we turn around there’s another database vendor, small access database, a big Excel file, or embedded database to contend with. Here are some quick but not easy ways to analyze and reduce your database costs:

• Virtualization — instead of putting everything on physical servers, use tools like VMware and Microsoft Virtual Server to store multiple vendor database servers onto a single physical server. This will save management costs in the primary environment and will simplify disaster recovery.
• Consolidate — consolidate servers and pay less money for each instance. By moving multiple databases onto the same logical database instance you can reduce licensing costs.
• Standardize — instead of using different database vendors, try moving to fewer. This one is tough but will have the biggest payout.
• Open Source — if you’re able to standardize, try standardizing on open source databases like MySQL, Postgres, and Enterprise DB. Enterprise DB is the most interesting for Oracle folks since that open source database touts its compatibility with Oracle. Don’t let the commercial vendors scare you away from Open Source databases — the open source vendors have been supporting some of the world’s largest databases in heavy production usage for years. They are ready for your workload, too.
• Automate — decrease the cost of managing lots of databases by automating monitoring and maintenance tasks. I still can believe how many database shops I run into where the DBA’s still do things manually instead of scripting everything.

In a future posting I’ll talk about how to get those pesky Microsoft Access and Excel databases under control.