This Week Health

Nancy Beale discusses Death by A Thousand Clicks

Failure! A recent Fortune article paints a picture of cumbersome systems, unattained promises, corruption, and harm done by technology in healthcare. This Week we tackle the issues and try to figure out a way forward. 

Transcript

This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.

 Welcome to this week in Health It where we discuss the news, information and emerging thought with leaders from across the healthcare industry. My name is Bill Russell, recovering healthcare, c i o and creator of this week in health. It, uh, set of podcasts and videos dedicated to training the next generation of health IT leaders.

Today we're gonna talk about a interesting Fortune article that just came out, death by a thousand Clicks, where the Electronic Health records went wrong. Um, this podcast is brought to you by health lyrics. Uh, wanna start your health IT project on the right track, or wanna turn around a failing project.

Let's talk visit health lyrics.com to schedule your free consultation. Our guest today. You know, it's interesting. I, I read this article and I thought, first of all, I need somebody with a clinical background, and then I need somebody who's very familiar with the E H R so that we can have an extensive conversation on that.

I, I put out a call and, uh, Che introduced me to Nancy Beal. So our guest today is Nancy Beal, who is a registered nurse and has extensive background in E H R and E H R implementations and using E H R, and she's an advisor with starbridge Advisors. Good morning, Nancy, and welcome to the show. Hello. Good morning.

Yeah. You know, you're getting the world of the podcast. We're, we're actually recording afternoon, but you know, good morning, , as we know. Uh, why don't you give people a, a little bit of your background? 'cause you, you really have a great background, uh, not only on the health IT side, working with the R but also, uh, a great clinical background as well.

Certainly. Thank you. Um, so I have been a nurse for well over 30 years and spent the first half of my career in clinical practice in a variety of roles from staff, nurse to director, um, and everything in between. And, uh, primarily practice, um, med-surg as well as labor and delivery perinatal nursing. Uh, I left clinical nursing.

To, uh, go to work for Epic. I, um, was a clinical leader at Epic and worked with customers across the country, uh, for close to a decade, and subsequently, uh, did a little consulting and then spent, uh, about six years in, uh, New York City in Manhattan at N Y U Langone Health Systems as a vice president of clinical systems and integration.

Currently, uh, most recently I left that position to pursue, pursue my doctorate. And, uh, my intention is, uh, to pursue studying, uh, clinical IT adoption, technology adoption and nursing Specifically, we talk a lot about, uh, providers, provider adoption. How many clicks for a provider? No one really looks at, uh, technology adoption in nursing, and there are about 4 million nurses across the country.

So I think it's an important, uh, contribution, um, to really evaluate. And I also am doing some, uh, Consulting with Starbridge advisors advisor. It's interesting. So, um, it's interesting, we talk a lot about, uh, physician burnout with the E H R, but I, I assume we're seeing, uh, clinician burnout as well amongst the, the nursing ranks.

Um, because it's, it's really the, the same thing. I mean, there's an awful lot of pressure and complexity and those kind of things. Has that been your experience? Absolutely, absolutely. I have many, um, nurse colleagues and friends who are, once I tell them my area of interest, they're more than willing to talk to me about all of their challenges and frustrations with technology and give me clinical examples where technology actually, uh, became a, a challenge or a hindrance to them providing care.

Now this, this article is pretty scathing and I, I wanted to talk about it 'cause I, I, and I wanted to talk about it with someone with your background. Um, because I think some of the things are fair and some of the things are really unfair in terms of how they're looking at it. 'cause they're, they're looking, they really focusing on the E H R and say the E H R is the problem here, but we also have a regulatory burden that's sort of

Untethered and disconnected that has created this. We have a payment structure that's a little bit untethered and, and doesn't make sense. And we, and then we have, uh, yes, there are some greedy organizations and, and from time to time, and they call those out. Um, but it's, it's all of it. It's, it's an ecosystem.

It's not just, Hey, we've got this E H R and this E H R is causing these problems. And so I want touch on aspects. All right, so this article, fortune, let me pull it up here because I. I can't believe I don't have it in front of me. There it is. Okay. So Fortune, uh, wrote this article, March 18th, 2019, death by a thousand Clicks, where the Electronic health records went wrong.

And, uh, let me just give you the, what I would call the summary of it and then we'll, we'll dive into it. So the summary is essentially the case being made by the article is that the government put out a huge pot of money, um, and said, come and get it. The e H R vendors, some ready, some not. Off in an all out sprint to get the money.

Um, health systems slammed the technology in based on artificial deadlines set by sort of a carrot stick legislation. Creating a risky environment that didn't meet the intended goals of the legislation, as evidenced by their quotes from, uh, Obama and sema Verma and, um, uh, guess oh, uh, uh, former Vice President Joe Biden and their frustrations with it.

Uh, the outcomes are systems that are challenging to navigate. They lack proper, proper oversight and regulation at this point. Uh, they create risk, risky and stressful work environment for those who are asked to use the systems, uh, leading to errors and burnout. Um, I think that if I had to encapsulate it into one paragraph, that's, that's the gist of the article.

So you can understand how this can easily become a, a bashing session. Um, but let's step back and say, uh, because you've been, you've been around for all of this and I've been around for, uh, a good part of it through the meaningful use stages and whatnot. Um, the intentions are good. The promise of the E H R is, is really makes sense.

This is why it sort of came forward, right? It was supposed to make medicine safer, bring higher quality care, empower patients, and uh, and even to a certain extent, uh, save money. Um, I. You know, it was going to bring data together, empower researchers to find new cures, um, allow people to, uh, be more portable with their health record, show up at a place with their health record, uh, so that you would have the information you needed at the point of care and where life and death decisions are being made.

You would have a complete record. And these are, you know, that's the promise of etr and these are good things. That's where we started. Um, alright, so that's enough sort of setting it up. Um, the goals are the, the goals are good, right? I mean, this is what we were promised, and the goals are still, we still believe those goals to be.

I, I think we still believe those goals to be attainable, somewhat, uh, wouldn't you say. Absolutely. Um, I, I would say that we, we actually are achieving many of those outcomes in pockets and in certain organizations with certain, uh, strategies and sets of systems. So I personally have seen positive outcomes with, you know, being able to change, um, let's say practice patterns related to ordering.

IV Tylenol is one example. IV Tylenol is extremely expensive and most often not necessary. And so by some of the leverage in how you configure the E H R, um, at N Y U, we were actually able to change practice patterns. Eliminate excessive ordering of IV Tylenol and save a significant amount of dollars. Uh, I think, um, likewise looking at things like, um, over ordering of certain, uh, lab tests is another example, or over administration of blood when it doesn't really meet the criteria, um, that the organization has set forth.

So I think that absolutely. It has enabled us to achieve some of these outcomes. But in some cases it takes an army of people, um, to make those outcomes happen. Um, you have to have an organization that has, you know, a talented pool of people to actually. You know, execute a strategy around both from the clinical side to make sure that you're getting the right buy-in and addressing where there are challenges and also from the IT side so that people understand what is a very complex system.

So I think it's possible, but it is a very challenging. Yeah, it's, it's, um, it's inter, it's almost like the capstone project or the, the thesis that you're gonna have to do for your, for your doctorate of, of a leadership team at a health system. I mean, to put an e h r in, you're taking, first of all, a health system isn't one business, it's.

A hundred businesses and that are all interconnected and all have very, uh, very complex nature to them. Uh, and then you have all these workflows and all these things that you're doing, and it is sort of the, the capstone project where you have to figure out, okay, how do we bring all the right people together?

How do we ensure. Quality is maintained. Every health system you go into and you say, what's your number one thing, they will say, quality people place their trust in us and we wanna be trusted. So no one's starting out with the thing of, Hey, we don't care about quality, just get the c h r in. But it is a, it is a test.

So, you know, you know, one of the things they start talking about is, um, pretty early on is that these systems are. Unintuitive, I guess is the nice word they would say, uh, in the words, get to be like unintuitive, and then it gets clumsy. Um, hard to navigate. That's where the title comes from. Death by a thousand Clicks.

Um, what, what do health systems do Well, That get beyond that quickly, either in design or in optimization that you've seen as really effective practices that get them beyond the death by a thousand clicks or the clumsy interfaces that, uh, that they talk about in this article. I think there are three things really.

Design, implementation, and optimization. And, um, what they do, what successful organizations that I have worked with do is really ensure that they have highly qualified clinicians engaged in the design process. And when I say highly qualified, what I mean by that is not just somebody who might be available, who happens to have RN or MD after their name, but

Actually somebody who understands technology and has some level of, uh, experience and or education with technology. So I really believe that clinical informatics is crucial in appropriate design. Um, likewise those. Same clinicians are essential when it comes to implementation, implementation, strategy, spotting where the problems are.

Um, identifying the folks who are really struggling. How do we solve those problems? Or identifying, um, what could be really dangerous situations that are occurring that otherwise you may not know because you don't have that clinical connection. And then ultimately optimization. You know, we. One of my, one of the things that really encourages me, um, to be interested in pursuing how we measure technology adoption, I.

And putting some standardization around that is that we continue to develop all these really wonderful technologies, and some are integrated and some are not. But we put some of these things out there and don't always measure how they're being used. And if they are in fact, um, being used as intended.

And, uh, one of the challenges with that of course, is um, if you have workarounds that are occurring, there could be downstream implications of that and in, in fact even patient safety implications of that. So really optimization, going back after the fact, making sure that what you implemented is actually working.

And if it's not how we make it better. It's interesting, the, um, so how would you address somebody who says, look, we've done so many of these implementations. Is it, can't you just take Epic outta the box, Cerner outta the box? Can you take Epic outta the box, put it into a health system and say, look, you, you can't tell me that practicing medicine in New York City and Chicago and Nashville and Orlando are all that different.

Can't we come up with a common. Implementation that we know works, that the alerts go where they need to go. That the orders go where they need to go. That the, that, you know, the flow sort of works. I mean, 'cause this thing, this article, again, they, they, she, things that I go, yeah, that probably happened. You know, it's, you know, it's the same system.

It's, it's even the same vendor, but, you know, an order didn't get, didn't move from this place to this place. And you're like, how can that happen? Why can't we just. You know it worked over here and then you bought the same system from the same vendor. Why doesn't it work over here? Well, that goes back to my, um, recommendation around clinicians and clinician involvement in the implementation because that change management is really, really crucial.

So, um, before we had EHRs and uh, provider order entry, a lot of what would happen is providers would write orders on paper and then rest was really kind of invisible to the provider. It just happened, right? Whether it was the nurse. The lab tech, the medical assistant, the unit clerk, whomever, took care of all of those other steps.

Well, now all of that is transparent to the provider because once they sign right, um, that's when those orders become real. If it was a paper situation and a provider wrote an order and didn't sign their name to it, Nothing would happen. It's the same analogy. So I think that two things. One is that.

There's a level of transparency now that is a bit uncomfortable, that implies additional accountability. Um, and second is really at some point we have to address. That accountability. And it could be that perhaps somewhere along the way, um, this person didn't get the right level of training. Right? That's one example.

But, um, you know, there are other ways also to monitor. Boy, how many unsigned orders do we have on. A given patient. Right. And what do you do with those if you know that they exist? Right. The same accountability needs to take place across the entire healthcare team. Um, so it's not all the E H R, um, some of it is the E H R, but I think that there is a level of accountability that is much more transparent than it used to be.

And um, I think also back to your question about. isn't. Why can't we just take it out of the box? Um, well, you would be very surprised at how different things actually are across the country in healthcare organizations in terms of their routines and what's allowed or not allowed what people, um, order or don't order.

And I think it's getting better. And I think that that is one thing that healthcare is driving healthcare, it is driving, is that standardization. And you know, if you look at, um, organizations like the Institute for Healthcare Improvement, one of the things they consistently say is eliminate unnecessary variation.

Right? But we've got variation in practice. From one end of the spectrum to the other across the country. So I think that again, healthcare, it is really kind of putting a window into all of this, making it more transparent. And so sometimes while we say, oh, it's healthcare it, that's the problem here. And sometimes it is.

Also we have a practice issue. We, we have a need to make sure that we can at least outline what some of these standard practices should be and then enforce them, right? Yep. It's interesting. So a couple of stats to 96% of hospitals have adopted EHRs, which is amazing, up from 9% in 2008. Um, but you know, you, you sort of look at that and it's.

Um, one of the things you said, which was interesting to me is we haven't standardized clinical practice across, um, across healthcare. And so because we haven't standardized clinical practices, you take the tool and you say, why can't I take the, um, You know, the, the epic from N Y U or the, uh, epic from, uh, Cedars or from Providence and just implemented at the next health system.

And the answer is because the clinical processes are, are different, is the first answer to that. And actually, I know the answer to this because within the health system, we, we struggled to take a, an instance of our E H R from one hospital to the next hospital. Right. 'cause everyone, everyone was like, well, that's not how we practice.

And it, it requires significant conversations about just that. How do we practice? Why do we have that alert? Why do we have that rule? Why do we have that workflow? And those things take, uh, those are significant conversations. With, and that's, that's the role of clinical informatics. That is really where clinicians who understand both technology and also clinical practice can be so invaluable to any technology implementation.

Yeah. And we've talked on the show of how important those roles are. Uh, here's some, some call outs from the article. So 4,000, 4,000 is the number of clicks in a single shift. According to the American Journal of Emergency Medicine, 4,000 clicks.

That's a lot . I mean, that doesn't, that doesn't sort of, uh, that either says they're doing an awful lot of work, which is probably true, but it also says that's probably not an efficiently designed system. And the article really makes the case for, um, you know, these systems weren't really ready for when the, when the starting gun went off on this.

And they've been sort of catching up ever since and trying to become more efficient interfaces. Um, how is a. Clinician supposed to navigate 4,000 clicks, and this is, uh, emergency medicine. So this is probably a study that's really looking at the ed, uh, and, and I mean in that environment, how can they be expected to, to navigate the E H R, which is so complex and give the proper attention to the, the patient.

I mean, is that even realistic? And what can we do in, in that case, Right. I, I mean, 4,000 clicks certainly sounds excessive. It certainly sounds like a, a high volume organization. Um, I would say, you know, you absolutely have to step back and say, whoa, wait a minute. What are we doing and why do we have 4,000 clicks?

My guess would be that there's a lot of, um, Organizations that don't go with an enterprise solution off the bat. And when you don't have an enterprise solution, that means you are having extra clicks to accommodate sometimes for that lack of integration between systems. So, um, so you're, you're popping out into other systems to pull information in, correct?

Correct. Or maybe it takes three clicks to do what would otherwise be? One click. If you had an enterprise system. Right, and I think that's getting better. I think more and more organizations are seeing the value in having an integrated, um, E H R, but. E h r basic e h r. Workflows aside, you still have other technologies, um, and systems that require thoughtful integration, whether it's radiology, um, whether it's, um, labs pretty seamlessly integrated most places.

Uh, but, um, You have certainly other technologies, right? Um, physiologic monitoring alarm and alert management, um, communication, all of these other types of systems that get folded in. And if they're not well thought out and how they're architected, you end up with, yes, it's possible. Yes, they're connected, but it requires the clinician to click, you know, 5, 6, 7, 8 more times.

right? Because they're not just in the E H R, they're touching all of these other systems now as well. Yeah. It's, um, you know, one of the things they talk, and we, we won't touch on burnout again here. The, um, they, you know, they talk about the average 11.4 hour workday that, uh, almost six of those hours is spent in the E H R itself.

Um, we've really turned clinicians into, Um, I don't know. Uh, I mean, they're navigating the technology and spending an awful lot of time in the technology. I was with a C I O uh, two weeks ago. I was in his office and he showed me this report and it was a great report 'cause it showed, uh, the usage of the E H R, uh, by physician.

And, and he goes, is this the saddest graph you've ever seen? I'm like, explain the graph to me. And he said, look, this person woke up at this time and they got into the E H R and they were working on the E H R from home. Then they came in and they worked a full shift, and he goes, now they go home and they're working an additional couple of hours on the E H R.

He goes, He goes, and I'm like, well, now that you describe it, yeah, that's the saddest chart I've ever seen. He goes, this isn't like a one-off, one day kind of thing. He goes, this is her consistent pattern of using the E H R. It is multiple hours when she gets up and multiple hours after she goes home, and you can understand where burnout's coming from, if.

If, uh, if that's the way. Now, is that, is that a result of, do you think that's a result of the des, the design of the E H r? Is that a result of the, um, the, the changing landscape of healthcare and the dwindling amount of time we have with the patient that we're saying to people, Hey, you got 11 minutes to be with that patient.

Get in there, get out, and you have to document outside of that environment and what's, what's causing that kind of, Um, environment where people are spending, you know, all that personal time on the E H R. I think it's actually all of the above. Um, I think that there absolutely is increased pressure, um, you know, to compress the amount of time you spend with patients so that you can have higher volume.

Um, and, you know, I'm hopeful. Uh, because I'm an optimist that, you know, as we move from volume to value, uh, in a healthcare model that, you know, poten, there's potential for that to improve. But I think that said, um, there is still a, a great variety in terms of skill. And some people have learned how to navigate their practice and, um, engage with patients at the same time as they document and others have not.

And, and in some cases they have not. On purpose. Right? And when I say on purpose, I mean, um, they, val, they have a higher value on that interaction with the patient. And I think that this is an opportunity for other technologies, um, to really play a part in, uh, voice navigation. So that really. Documentation and ordering, and all of the, um, E H R related processes become a byproduct of what we do with the patient as opposed to yet one more thing to do.

Yeah. I think where I, so where I'd like to go, so this, this article, it talks about the clumsiness and, uh, the challenge, then it talks about interoperability. . Then it talks about, uh, medical errors and I think I'm gonna stick to that order. So, interoperability, it shares the story of Sema Verma and her husband.

Her husband had an event, and this is, I mean, she is at the heart at the center of this thing, and she can't get all of her husband's data from all the different records together. To this day, she still can't do it. And Joe Biden shares the, uh, story of his son. Uh, Bo Biden has struggled with cancer and he is the sitting vice president of the United States, and he can't get the medical record together as his son is going from, uh, location to location.

Um, and, and there was a, there was sort of this I idea and this promise, and I know, I know if I, I hear Anish Chopra in the back of my head. If he were on the show, he'd say, it's getting better, bill. It's getting better. But, um, We're far from the promise of originally that, that you were going to, uh, the, the clinician would know beyond a shadow of a doubt that they were looking at a clean medical record with a complete history at the point of care so that they had all the information they needed to address that.

Um, and I know there's fire and I know there's other things going and, and some of those things I might be able to talk, um, more about than, than you might be able to. But, um, what. What is, I guess I'll focus in on an area you would, you would really be an expert on, which is, um, do the clinicians trust the record?

They're looking at, do they trust that they have the information they need, or do they just assume when they're sitting in front of the patient? I'm gonna have to ask these questions again because it may or may not have all the information I need. Um, I may, I may need to ask them. Have you been in another country?

Have you, um, you know, have you been visiting other hospitals? Have you, I mean, do they trust the record they're looking at? Um, or do they feel like they need to augment it? Um, well I think there are a variety of, um, there's not one answer to that. Um, for sure. Uh, I would say that, um, In some cases, I feel like they trust it too much.

So if it's in the record, it must be true without actually validating that the data is accurate with the patient. Um, in some cases I feel like it has to do with how the clinicians were trained. Um, and so, uh, you know, if you are trained, um, Aside from the E H R, you are trained that in order for you to know this is valid information, you have to ask the questions.

Yeah. That regardless of what's in the E H R, those clinicians are going to ask the questions. And I would say that we need to do a better job at teaching and educating, um, and training our clinicians, all clinicians on how to interact with a patient. And technology, whether it's, you know, the E H R or some other technology in the environment, um, that.

Touches the patient. I think that we don't always do a good job. We, we say, okay, here are the buttons you have to push. You know, and we put people in a classroom and they go through functional training. And in some cases, you know, they're good about a workflow. Here's how you admit a patient. Here's how you transfer a patient.

Here's how you place an order. Those kinds of . Functional things, but we don't do enough of teaching how clinicians can interact with patients. And um, I think that you can get to a place where, You can validate the information with the patient and how you approach the patient says a couple of different things to the patient, right?

So it says, I see here you're allergic to penicillin and you, uh, get a rash. Is that correct? Right. That does two things. One, you're validating with the patient. The second to the patient it says, oh, they know me, they have my data. Right. And we don't always do that. We don't do a good job of that at all.

Yeah, well, I've, I've had some physicians say to me, I don't trust anything that's in there. I validated at all. And to a certain extent, I, I get that and I understand it. Um, but to the, I, I've also had physicians tell me, you know, when we talk about fire and those kind of things, that's a techy way of saying, Hey, we could put plumbing in place to move stuff around.

But at the end of the day, I've had physicians look at me and go, Um, you know, I, they'll say, look over my shoulder. Watch this, and they'll show me just all these CCDAs have come across and they're going and it's just like a file folder with a thousand documents in it. They're like, which one do I, which one do I have to read?

He goes, if it's in the E R I, I, technically, I have to look at all of them. I'm like, there has to be a better way than having a thousand documents in here. Are essentially p d F documents and I'm going, anything in there I need, no, anything in there I need. Um, now I know they get classified and, and those kind of things and, and I'm sort of setting a worst case example, but, um, so, so we get the plumbing in place, we're moving the, the data around.

But until we get to discrete data elements moving around, it's gonna be, it's still gonna remain hard for those physicians to digest. Uh, all that information to a certain extent. Uh, I mean, do you hear physicians complaining? I, I mean, I, I think I hear some of 'em complaining. It's like, alright, I have too much information right now.

Too much information without meaning, I guess is the answer. Yeah. I think that, uh, nurses and physicians you would hear that from, and I think that, um, really, um, this is where I, I believe that there's a role for, um, . Augmented intelligence or artificial intelligence to help call out those meaningful data elements and bring them to the forefront, right?

So that we do a better job of, uh, dashboarding, if you will, that says, you know, in the background, have the computer, um, and the technology. Do the searching and find those critical data elements. And then in the foreground, you as a clinician, show me what's important, what I should be looking at. And we don't do enough of that from a technological standpoint.

It also goes back to my very first comments around really needing, you know, highly evolved and talented, um, you know, folks on your, uh, informatics and IT team. Yeah, you gotta create those dashboards that they can sort of get a snapshot at a, a quick, uh, glance. Um, now I wanna go into the tougher area, which is, uh, safety.

And I'm gonna, you know, I, I'm gonna, I mean, these stories are gut wrenching somewhat. I'm not gonna go into the stories. People can read them. Obviously, there's medical mistakes and they're attributing some of these medical mistakes to the E H R. Uh, here's a call out, 3,769 safety related incidences, incidents linked to the E H R.

Um, Or other IT sources. And that's from a company called Quantros and 3,243. Number of medication errors linked to the E H R, uh, usability issues at three pediatric hospitals from 2012 to 2017. And that's a health affairs study. Um, I guess it doesn't surprise me that with systems this complex that there's gonna be errors.

In fact, those numbers seem kind of small to me, and I realize that each one of those numbers could be a catastrophic event. I'm not, I'm not downplaying that, but I'm just saying, given the number of transactions that are now going on across 96% of the hospitals, those seem like a small number, small amount of number, small number to me.

Which would lead me in, in one in two directions really. One is either, you know, job well done, or we're not reporting enough of these and we're not capturing and reporting enough of these. 'cause it would feel to me that there should be more, given the complexity of these systems. And so I guess my first question to you is, um, How, how do you capture these things?

How do you escalate them? How do you make them aware? And then how far does it go? I would assume that you're escalating them within the health system, but does it go all the way up to the E H R vendor and does it get reported, um, or is it only reported if it becomes an event, a safety event? Uh, well, it, it's interesting.

So at the health system level, absolutely. Uh, it becomes, you know, you have patient safety officers and they do an entire debrief on what took place, who was involved, what role technology played in that. And, um, I know when I was at N Y U, they did a very thorough job of investigating and there were many times where, um, if there was a question, was technology involved, I would be, uh, Participating to help them understand exactly, you know, what the technology was supposed to do, um, what the clinician was supposed to do, what they did or didn't do.

Um, and any audit trails to support that behind that. However, um, you know, I think that. As I think about, um, well first of all, I'll say on the vendor side, I know that certainly Epic has a patient safety escalation process. Um, and even, um, Even though I've been gone from Epic for eight years, um, back when I was at Epic, um, the, uh, patient safety escalation process was in place.

And, um, they take, uh, very serious any concerns that are brought forward to them, um, from their, uh, clients. And, uh, then begin to evaluate what role the technology did or didn't do. And then . Push out information to their other customers to say, Hey, we had this problem at this customer. A, you may be effective.

You have this configuration. So they, they do a absolutely a very thorough job of that. I think to your question about, shouldn't there be more, what I would say about that number is, um, . You know, I don't think we have the transparency. I still don't think, to your point, I still don't think we have complete transparency in the number of near misses and actual medication errors, but we certainly didn't have it when everything was on paper.

Right. Well, And so how do we know if this is better or worse? Um, I think that's very difficult to say. I think what we do know is, um, we, we can know when errors absolutely happen. And, um, in many cases the audit trails are quite robust to say, no, actually you didn't do this, or, yes, you actually did document this.

So there's a lot more transparency and um, I think again, the E H R. Though often gets the bad rep, um, really just becomes a magnifying glass for all that's really happening in the clinical setting. And we just didn't have transparency before. Yeah, no, I think there's, I think there's an awful lot of truth to that.

Um, and I, I think people will be surprised that they saw the audit logs within EHRs. It captures. Everything. I mean, it's absolutely, and, and for good reason. It's like the, it's like the flight recorder on a plane. I mean, it, it tells us what we did wrong and what we can do better to make sure that those things, um, don't happen, don't happen again.

Um, you know, so part of me as a c I O is, is kind of terrified to ever be a C I O again because, Um, you know, these systems are complex and you see the finger pointing. It's like, uh, you know, Hey, this happened. And the e h r vendor's saying, well, you customized our software, so it's probably on your end. And then the, you know, you go down here and you're like looking at the audit logs, like, no, no, the clinician didn't click this thing.

And then the clinician's looking at you going, this is the most I, look, I have technology all around me. I'm not a Luddite. I, I, I get technology. I use technology. This is the worst technology I use. I mean, there's so many dropdown menus, there's so many clicks. There's so, you know, it's too hard and you sort of wanna look at everybody and go, yes, you're right.

It's not your fault. The e r vendor. Yes, we're customizing this and actually I wanna get to this customization thing again 'cause we are customizing probably a little too much. I mean, most software today, if you were to look at its cloud software and whatnot, the reason it's successful is they don't customize it all that much.

I mean, when you get Gmail, you get Gmail when you get, you know, and it's a very simple system. But generally speaking, that's true with a lot of these cloud plays. And, and, you know, and they have this, uh, gentleman from WellStar. I, I don't have it. I didn't, it's gonna be too hard to find it from, from WellStar.

And he has a usability, uh, lab where they track the eyes of a physician while they're using the E H R. And, um, he says the design is so bad that they just lose things in the screen that they're eyes aren't flowing to where you think they're gonna flow. And I like that level of study because that's important.

Design matters in these things. And I think we can do a much better job with design. I would love to see a usability design team at, um, at Epic and Cerner and Allscripts. And the rest of these just take center stage and just like redo how we have put all these things together. But let's get back to, uh, let's get back to customization.

So the thing that scares me as a C I O is we're gonna be asked to customize the E E H R. We always are. Um, You know, build a new workflow, uh, put in a new alert, uh, whatever. We're, we're just, I mean, some of those things are simple clicks, but, um, but we're gonna be asked to do some things that are more extensive.

How do you ensure that those things are designed, well, tested well before they ever get out there to make sure you're not, uh, introducing errors because each one of these things is connected to a thousand other things. . Well, I think that I, you know, it's, it's very basic in some ways. You know, if you look at the system development lifecycle, it's very basic.

You know, having people involved who are knowledgeable about the workflow, as well as the technology and the technologies that are designed and that it touches. Right, that that will be impacted is important. And then doing thorough testing, you know, multiple rounds of testing, not just from an IT perspective, but you know, you'll do your basic unit testing and integrated testing, and then you need to do usability testing.

That involves clinicians. Clinicians who have not been involved in the design, right? Yep. Who don't have intimate knowledge with how it's supposed to work. Right. So that, that's when you'll find things that really, um, you know, are worthy of catching before you deploy the, you know, whatever the new technology is.

But I, you know, I can't stress enough anytime, um, in my role at N Y U if there was a problem, uh, that occurred. My first question was always, how was this tested? When something breaks, um, and you find out about it after it's in production and you have to ask the question, how did we test this? You know? I, I think that that can't be underscored enough.

Yeah. Well, I'm gonna let you have the last word on this article. I mean, is there anything that resonates with you or anything you sort of let go? Yeah. Uh, or anything that you just sort of don't like, um, that they sort of bring up? I think that, um, you know, there are a couple of things. One, one is that acknowledging that, um, You know, the challenge with the E H R is certainly broader than physicians, um, and involves all healthcare providers, um, and clinicians.

Um, I would say that needs a little bit more visibility from my perspective, but also, um, I think that there is some unfair, uh, you know, sort of bias to, to sort of blame the vendor, if you will. And I think that because, We can look and see that these problems are occurring across vendors. It's not really any one vendor.

We have a much bigger problem, and we all have to be part of the solution in bringing that together. And I think that, um, it's, it's the old adage of the three-legged stool. You need the vendor, you, you need the customer. , you know, and the folks who are, uh, actually doing the implementation. All three have to come together to really make sure what you put out there is safe and usable.

Um, and, uh, it's, it's not really any one of those three factors, faults, if you will. Um, I would say that we need. Greater appreciation and understanding at the level of, um, regulation. Yeah. So that there aren't mandates for things that, um, are not reasonable or, uh, you know, things that come are handed down as mandates that, you know, I think frankly the vendors do a fairly good job of trying to rally to that mandate.

But, um, The price is often paid by the end user. Yeah, I agree. And that, you know, I and I, I like the way you sort of wrap that up there. And, um, I think on that, I just, I, I wanna thank you Nancy, for, uh, coming forward. This is a, this is actually one of the more difficult articles I think we've ever covered on the show.

'cause it, it, it, it does expose, I think there's a lot of things that resonate with expose. Challenges that we face and we're trying to overcome, and the listeners of the show are, uh, are, are addressing on a, on a daily basis. And to a certain extent, this article can sort of feel like it's coming down on, on the saying you're not doing enough.

And, and that might be true. We, we might not be doing enough, but it's not for lack of trying and it's not for lack of dedication of the people who are doing it. It's, and even on the government, it's not, it's not. The regulations were not with bad intention. They were with good intention. It was saying, um, and as you say, it's, it's just exposed an awful lot of, uh, challenges.

Uh, thanks. But thank you for coming on the show. Do you, uh, do you write at all or do you have any way that people can follow you on I. Or anything like that? I am on, uh, certainly on LinkedIn, um, and have done some blogs through him, hims as well. I chair the National Nursing Informatics Committee, so, um, have occasion to, uh, Put things out on blog there as well.

And if people wanna contact you for consulting, they can, uh, you know, reach out to you through LinkedIn, reach out through, uh, Starbridge Advisors as well. Um, I really appreciate your time. Appreciate you coming on the show. Uh, this show's production of this week in Health It. For more great content, you check out the website at this week in health it.com or the YouTube channel at this weekend, health it.com/video.

Thanks for listening. That's all for now.

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