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NextGen and Vendor/Doctor Dialog: Yet Another Patronizing EHR Company of Certified HIT Experts?

<blockquote style="font-family:arial;">Note 6/9/09: To those reading this post via a link in an email from CCHIT's Mark Leavitt, see this June 7th post "<a href="http://hcrenewal.blogspot.com/2009/06/open-letter-to-mark-leavitt-chairman.html">Open Letter to Mark Leavitt</a>" first. The link you are at now is several months old, one of many posts I've written over the years about the scarcity of leadership-level Medical Informatics-trained professionals in the health IT vendor world. I consider that issue contributory to EHR's often mission hostile user experience (my series on that topic is <a href="http://tinyurl.com/b28s74">here</a>), and ultimately deleterious to patient well-being. I also believe the HIT industry has put its own interests ahead of that of patients in its inattention to HIT safety and <a href="http://jama.ama-assn.org/cgi/content/extract/301/12/1276">rejection of accountability</a>. Additional views on the recent CCHIT NJ Bill are at ePatients.net at "<a href="http://e-patients.net/archives/2009/05/david-kibbe-mark-leavitt-openness-vs-opacity.html">David Kibbe & Mark Leavitt:Openness vs. Opacity</a>" and "<a href="http://e-patients.net/archives/2009/06/dossia-microsoft-healthvault-google-healthillegal-in-nj.html">Dossia, Microsoft HealthVault & Google Health: Illegal in NJ?</a>". There are some now-familiar themes regarding CCHIT civility in those posts. 6/10: As a result of a link sent by a commenter, I am adding the post "<a href="http://www.hcplive.com/mdnglive/The_HIT_Realist/Kibbe_Leavitt">The Kibbe/Leavitt Rumble in the High Tech Jungle!</a>" to the list of interesting views in the note above. -- SS</blockquote> My early medical mentor, cardiothoracic surgery pioneer <a style="font-family: arial;" href="http://mmp.cjp.com/pipermail/openheart-l/2005-June/002000.html">Victor P. Satinsky, MD</a>, believed in public embarrassment (a.k.a. "sunlight") as a tool to fight bureaucracy and discrimination. I quote him on that. He wanted his NSF summer science training progam (SSTP) 10th grade students at Hahnemann Hospital to actually picket a clothing distributor, for example, when that distributor did not deliver our white coats nor a refund in a timely manner. He also was highly politically incorrect, for example having gay activists speak to our group of 200 high school students about bias and discrimination, at a time in the early 1970's when such talks were frowned upon. He took grief for that. Yet fairness and "critical thinking always, or your patient's dead" were his mantras. Dr. Satinsky must be rolling in his grave at what has become of medicine due to the type of bureaucracy we cover here at Healthcare Renewal. He would probably be a healthcare blogger himself were he still alive. At "<a style="font-family: arial;" href="http://hcrenewal.blogspot.com/2009/02/vendordoctor-dialog-on-healthcare-it.html">A Vendor/Doctor Dialog On Healthcare IT?</a>" I wrote that <blockquote>In response to my recent post to the American Medical Informatics Association's clinical information systems (CIS-WG) and organizational issues (POI-WG) workgroups about my <a href="http://hcrenewal.blogspot.com/2009/02/medinformaticsmd-in-wall-street-journal.html">WSJ letter to the editor</a>, Charles Jarvis, an AVP of Healthcare Industry and Government Relations at HIT vendor Nextgen.com thoughtfully suggested I "come and listen to how the government, providers, insurers and yes- HIT providers- can work together for the common good before drawing such strong conclusions." (Soothing blue font original - ed.) Dialog is a useful idea. I am always open to listening. However, dialog must be among equals in an atmosphere of complete transparency. Otherwise it is not dialog, it is politics. How can there be "dialog" in an environment where one side is able to squelch open discussion of the issues? ... p.s. in late 2003 after the <a href="http://www.businessweek.com/technology/content/nov2003/tc20031113_9818_tc119.htm">collapse of Merck's pipeline</a>, I wrote to your [NextGen's - ed.] CEO and HR department in Horsham about my availability to help in their EHR efforts. This was prior to the bulk of my writings on HIT difficulties. I did not so much as even get a response or inquiry, although I live thirty minutes away. Perhaps you could explore why your company showed no interest in perhaps the only formally trained medical informaticist in this area, and former CMIO of a major hospital in the region (Christiana Care).</blockquote> More on this below. I found Mr. Jarvis' patronizing "why don't you come and listen" line, sent in a nice soothing blue font, disturbing, since it's vendors (immune from liability and from intra-organization scrutiny even when events such as <a style="font-family: arial;" href="http://hcrenewal.blogspot.com/2009/02/healthcare-it-blamed-in-patient-death.html">this</a> and <a style="font-family: arial;" href="http://iig.umit.at/efmi/badinformatics.htm">these</a> occur), not physicians and physician informaticists, who need to do the listening. However, something else was at the back of my mind, and information saver that I am (I did run Merck Research Lab's science library and historical science archives department, after all), I checked my disk backups. What I found reflects something I've noted numerous times in the past. Interactions with HIT vendors - both their products and their people - have most often been quite annoying. Here is Mr. Jarvis' <a style="font-family: arial;" href="http://web.archive.org/web/20100103141103/http://nextgen.com/about-nextgen/leadership-structure.html#15">bio</a>: [Nov. 2011 editor's note - the bio disappeared from the original link; the link now points to archive.org] <blockquote face="arial"><h5>Charles Jarvis, Assistant Vice President, Healthcare Industry Services & Government Relations</h5> Charles W. Jarvis FACHE is Assistant Vice President for Healthcare Industry Services and Legislative Affairs – having been in this role since January 2005 [this date becomes relevant as below - ed.] Mr. Jarvis' responsibilities include community and partnership business development including overseeing the company grants and funding procurement program, government relations, new business planning, and educational efforts. Mr. Jarvis is active in the Electronic Health Record Vendor Association (EHRVA), currently holding the position of Chairman of the Government Affairs and Affiliated Organizations Workgroup.Prior to joining NextGen, Mr. Jarvis was in hospital and physician group practice management for 25 years in both the New Jersey and Massachusetts markets. Mr. Jarvis holds a Masters Degree in Business with a concentration in Health Administration [i.e., he took a few courses in health admin - ed.] from Temple University and a Bachelors Degree in Economics from the Wharton School of the University of Pennsylvania. [Common to the HIT industry and to observations on HC Renewal about HC leadership in general, I note no clinical experience or credentials - ed.] He is also a Fellow in the American College of Health Care Executives and holds the American Medical Informatics Certification for Health Information Technology [what is that? More below - ed.] </blockquote> Now, it was bad enough my earlier inquiries to the NextGen CEO were ignored. Far worse is the outcome of my application to NextGen for a position as Director of Industry Relations in late 2004: <blockquote>NextGen Healthcare is currently looking for an individual to manage our Industry Relationships. We are a rapidly growing, publicly held company looking for an aggressive, self-motivated individual who is seeking a challenging position with a top tier healthcare IT company. As the Director of Industry Relations, you will be responsible for managing industry relations. This will include relationship management with the consultant marketplace, medical societies, health plans, and our Value Added Resellers. Qualified candidates will have preferably healthcare IT background either as a project manager, consultant, marketing manager, or sales representative . Applicant must also be career oriented, professional, and organized, possess excellent oral and written communication skills and be detail oriented. Working knowledge of MS Excel, Word and PowerPoint a must. Local and national travel required.</blockquote> Here is the relevant email thread: <blockquote style="font-family: arial;">From NextGen: In a message dated 12/27/2004 9:04:43 A.M. Eastern Standard Time, JWong@nextgen.com writes: Hello Dr. Silverstein, We would like to schedule an interview for you the week of January 3, 2005. Would you please advise your schedule? I will be arranging an meeting with the president and one of our vice presidents. Please let me know what day and time are best. Thank you. Jennifer Wong Business Development Coordinator > NextGen Healthcare Information Systems, Inc. 795 Horsham Road Horsham, PA 19044 215.657.7010 (p) 215.657.7011 (f) jwong@nextgen.com Website - www.nextgen.com My reply back: From: ScotSilv@aol.com [mailto:ScotSilv@aol.com] Sent: Thursday, January 06, 2005 12:44 PM To: JWong@nextgen.com Subject: Re: Interview Hi Jennifer, I have been away for the New Year. I'm following up on getting an interview schedule set. I also left a voicemail. Regards, Scot NextGen gets back to me: In a message dated 1/10/2005 11:47:51 A.M. Eastern Standard Time, JWong@nextgen.com writes: Hi Dr. Silverstein, I have forwarded your resume internally to the appropriate persons. Thank you - you should be hearing from someone shortly. Thank you. Jennifer Wong Business Development Coordinator NextGen Healthcare Information Systems, Inc. 795 Horsham Road Horsham, PA 19044 215.657.7010 (p) 215.657.7011 (f) jwong@nextgen.com Website - www.nextgen.com My response after waiting, and waiting: From: ScotSilv@aol.com [mailto:ScotSilv@aol.com] Sent: Thursday, January 20, 2005 To: JWong@nextgen.com Subject: Re: Interview Dear Jennifer, I still await contact from NextGen. Please advise if this opportunity is still available. I am in conversation with other organizations and want to finalize my schedules. Sincerely, Scot </blockquote> Then ... silence. I never heard from the company again. (Dialog? What dialog? There does not appear to have been even fundamental respect.) In summary, an AVP who may very well have -- hypothetically speaking; I'd never heard of him before he responded to my recent workgroup posts -- made a decision about blowing me off as a Director in 2005 (he started in Jan. 2005) now tells me how I should "come and listen to how the government, providers, insurers and yes- HIT providers- can work together for the common good before drawing such strong conclusions." I can also add that NextGen did indeed hire a medical informaticist straight away from the same program I trained in, <a href="http://ycmi.med.yale.edu/research/rgraduates.html">Yale'</a>s, sometime after that person's completion of a postdoctoral fellowship in July 2006, as a "physician consultant." I had finished the fellowship in 1994 after a number of years of medical practice and by 2005 had quite a lot of <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=about">applied and management experience</a> under my belt. (My current bio does not include my time as Medical Programs Manager for quasi-governmental agency <a href="http://www.septa.com/">SEPTA</a>, with much interaction with SEPTA Industrial Relations, and with federal regulators <a href="http://www.dot.gov/">DOT</a>, <a href="http://www.fra.dot.gov/">FRA</a>, <a href="http://www.nida.nih.gov/">NIDA</a> and others on health matters in the transportation industry, but it did then.) So, I was entirely blown off without so much as an explanation in 2005, but a new informatics trainee hired in 2006. This raises a number of questions. Hypothetically speaking, was this due to: <ul style="font-family: arial;"><li>Lack of recognition of my background, which included extensive clinical, medical informatics and EHR experience and working in a critical role in a quasi-governmental organization with links to several federal agencies?</li><li>Age discrimination? I was in my late 40's at the time.</li><li>Perhaps it was felt I had <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=leadership">too much experience for the organization</a>? </li><li>Hiring the young and relatively inexperienced on the basis of "cheap?"</li><li>My patient-centric advocacy views on HIT, as in, "the patient must be protected from defective HIT?"</li></ul> I am not making accusations in any way, only raising questions. Only the company knows the answers, of course, and it is their right to hire someone or not hire them or even have them in for interview. Even basic courtesy of followup with the professional community is optional. However, I rest my case regarding the really annoying nature of health IT vendors beyond just their often <a style="font-family: arial;" href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-idiots-part-1.html">poorly conceived products</a>, and their inability or unwillingness to tap experienced healthcare informatics professionals as I've written about before on HC Renewal. Finally, what is the "American Medical Informatics Certification for Health Information Technology?" claimed in Mr. Jarvis' biography? I have never heard of it before and a <a style="font-family: arial;" href="http://www.google.com/search?client=firefox-a&rls=org.mozilla%3Aen-US%3Aofficial&channel=s&hl=en&q=American+Medical+Informatics+Certification+for+Health+Information+Technology&btnG=Google+Search">Google search</a> seems unrevealing. Could it be an overstated credential to impress stockholders and investors? (We in informatics strive for semantic clarity). AMIA does not "certify" anyone in informatics to my knowledge although they offer a short course in the <a style="font-family: arial;" href="http://www.amia.org/10x10">10x10</a> program that awards a "<a style="font-family: arial;" href="http://www.amia.org/10x10/students.asp">Certificate of Completion</a> in the 10x10 Program." I'm not aware of an American certification board in HIT. Is it like another <a style="font-family: arial;" href="http://hcrenewal.blogspot.com/2008/05/htrea-parallel-world-of-hit.html">Htraesian</a> informatics "certification", CPHIMS, as I described <a style="font-family: arial;" href="http://hcrenewal.blogspot.com/2008/04/is-himss-certified-professional-in.html">here</a>? Is it a certificate like <a style="font-family: arial;" href="http://www.drexel.com/online-degrees/information-sciences-degrees/cert-hci/index.aspx">this</a>, which students get after completing the intensive 3-course graduate program in an accredited university that I created? Perhaps something you get after completing one of <a style="font-family: arial;" href="http://www.nlm.nih.gov/ep/GrantTrainInstitute.html">these</a> programs, created and funded by Don Lindberg and other informatics pioneers, that I spent two years of my life in? Or perhaps it's more like <a style="font-family: arial;" href="http://www.healthitcertification.com/">this</a> three day 10 course miracle certification and button? "<a style="font-family: arial;" href="http://www.healthitcertification.com/regonsite.html">Consists of 10 course, two and a half days curriculum and CPEHR Certification Examination</a>" [is that like a 10 course meal? - ed.] Oh, I forgot. In healthcare informatics, <a style="font-family: arial;" href="http://hcrenewal.blogspot.com/2009/02/informatics-or-infomagic-health-it.html">everyone's an expert</a>. Finally, I guess I won't be applying to <a style="font-family: arial;" href="http://www.nextgen.com/">NextGen</a> again. They might blow me off. Again. -- SS

NextGen and Vendor/Doctor Dialog: Yet Another Patronizing EHR Company of Certified HIT Experts?

Note 6/9/09: To those reading this post via a link in an email from CCHIT's Mark Leavitt, see this June 7th post " Open Letter to M...

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Google Toolbar 6 beta for Internet Explorer: back to basics

The Toolbar Team has always been focused on improving your web experience. We started with the goal of making search more accessible, and a couple of iterations led to improvements like search suggestions, Google Bookmarks, Autofill, and Custom Buttons and gadgets. Now we're bringing the focus back to our core areas of search and navigation. First of all, in today's Toolbar 6 launch for Internet Explorer we're introducing the <a href="http://www.google.com/support/toolbar/bin/answer.py?answer=81305">Quick Search Box</a> (QSB) feature that provides search functionality outside of the browser. Just click on the Google logo in the taskbar to trigger it (or use the Ctrl+Space shortcut for quicker access). As you type, it will provide search and website suggestions, relevant bookmarks, and even allow you to launch applications directly from the search box. Try typing "solitaire" to see the application launcher in action. And here's the best part: as you use the QSB, it'll customize itself to your usage pattern, so over time you have to type fewer characters to navigate to your favorite sites and applications. <a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhK2gGDBbMJb-niVkJuaMaJJrESRK90rmGpgiUTO3BeG-OLawI7m9-llg5afkiQbNwzZTY8AMJLwKLjCNTEYGm5bZTWHv18D6g_TEl2YXSs_MJPyzNdWdqb3kYKiGg6EFM046z3GPnIwfug/s1600-h/Picture+1.png"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5306512005593767906" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhK2gGDBbMJb-niVkJuaMaJJrESRK90rmGpgiUTO3BeG-OLawI7m9-llg5afkiQbNwzZTY8AMJLwKLjCNTEYGm5bZTWHv18D6g_TEl2YXSs_MJPyzNdWdqb3kYKiGg6EFM046z3GPnIwfug/s400/Picture+1.png" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 368px; height: 242px;" /></a> In addition, we're building on our existing suggest functionality in the Toolbar search box by bringing elements from our search results page directly into the toolbar. We're experimenting with displaying high-quality website suggestions and sponsored links as you type your query. Clicking on these will take you directly to the website (try typing "cnn" in the toolbar to see an example). Going forward, we'll continue to explore new ideas and optimize the search box to give you the best experience possible. Lastly, we wanted to bring the <a href="http://www.google.com/support/toolbar/bin/answer.py?hl=en&answer=115561">new tab page</a> to our Internet Explorer users (our Firefox Toolbar users have been enjoying it already <a href="http://googleblog.blogspot.com/2009/01/google-toolbar-in-firefox-personalized.html">for the last few weeks</a>). You can quickly access your most viewed sites, recently closed tabs and bookmarked pages — all from this new tab page. Editing your most visited sites is easy, and all this data remains locally in your browser, meaning none of your most viewed sites or recently closed pages are sent back to Google. Those who prefer new tabs to open a blank page or a website can do so in the Internet Explorer or Toolbar settings menus. So, <a href="http://toolbar.google.com/T6/intl/en/?tbbrand=GZEZ&utm_campaign=en&utm_source=en-et-gblog&utm_medium=et">give the latest toolbar a shot</a> — it's available in 40 languages — and don't forget to <a href="http://www.google.com/support/toolbar/bin/request.py?contact_type=problem">let us know what you think</a>. Update on 3/24: Google Toolbar 6 is now <a href="http://toolbar.google.com/T6/intl/en/?tbbrand=GZEZ&utm_campaign=en&utm_source=en-et-gblog&utm_medium=et&rd=f" target="_blank">out of beta</a>. Posted by Zelidrag Hornung, Engineering Lead, Toolbar Team

Google Toolbar 6 beta for Internet Explorer: back to basics

The Toolbar Team has always been focused on improving your web experience. We started with the goal of making search more accessible, and a ...

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The search is on for the Google Search Appliance

The <a href="http://www.google.com/enterprise/gsa/">Google Search Appliance</a> (aka the GSA) provides universal search for businesses of all sizes. This handy yellow box pulls together documents, images, and other files from web servers, intranets, business applications, and more, making all of this accessible from one search box. Now we're holding a contest to see how "<a href="http://www.google.com/enterprise/findability">findable</a>" the GSA is in offices from coast to coast in the U.S. If the GSA has helped your business, we want to hear your story and see your pics with the shiny yellow box. (Don't worry, your photo doesn't have to be <a href="http://googleenterprise.blogspot.com/2006/07/dont-hassle-hoff_115389646940700263.html">star-studded</a> to win.) Two grand-prize winners will receive an all-expense paid trip to the <a href="http://code.google.com/events/io/">Google IO conference</a>. The contest deadline is March 31, 2009 and the winners will be announced on April 17. For more information and to find out how to enter, check out the <a href="http://googleenterprise.blogspot.com/2009/02/show-us-and-win-wheres-your-gsa.html">Enterprise Blog</a>. <a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjA0jhHc-ix85R6FXk1FjJssOsHVM7QFZgPkZWOiysymD2vNNLwbqTA2_HQtk-5eBAGRkOmNn0iG3gMfU1ujuNw9u54Y6GTcnQOzURZoudnMBnWzrT0ztps1uxV2HNAeKM5KGdJvdBxAlS2/s1600-h/appliance.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5306455611386054914" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjA0jhHc-ix85R6FXk1FjJssOsHVM7QFZgPkZWOiysymD2vNNLwbqTA2_HQtk-5eBAGRkOmNn0iG3gMfU1ujuNw9u54Y6GTcnQOzURZoudnMBnWzrT0ztps1uxV2HNAeKM5KGdJvdBxAlS2/s400/appliance.jpg" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 400px; height: 162px;" /></a> Posted by David Kim, Associate Product Marketing Manager, and avid appliance photographer

The search is on for the Google Search Appliance

The Google Search Appliance (aka the GSA) provides universal search for businesses of all sizes. This handy yellow box pulls together docum...

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Are Health IT Designers, Testers and PurchasersTrying to Harm Patients? Part 3 of a Series

(Note: Part 1 of this series is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-idiots-part-1.html">here</a>, part 2 is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and.html">here</a>, part 3 is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and_24.html">here</a>, part 4 is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and_26.html">here</a>, part 5 is <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and_27.html">here</a>, part 6 is <a href="http://hcrenewal.blogspot.com/2009/02/it-makes-healthcare-easier-is-this.html">here</a>, part 7 is <a href="http://hcrenewal.blogspot.com/2009/03/information-technology-makes-healthcare.html">here</a>, and part 8 is <a href="http://hcrenewal.blogspot.com/2009/03/malpractices-of-multitudes-mission.html">here</a>. 2011 addendums: a post that can be considered part 9 is <a href="http://hcrenewal.blogspot.com/2011/04/special-k-red-berries-mission-hostile.html">here</a>, part 10 is <a href="http://hcrenewal.blogspot.com/2011/12/ehr-mission-hostile-user-experience.html">here</a>.) At the (deliberately) provocatively-titled piece "<a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-idiots-part-1.html">Are Health IT Designers, Testers and Purchasers Trying to Harm Patients? Part 1</a>" and <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and.html">Part 2</a>, I wrote that I would be presenting mockups showing the EHR deficiencies I am hearing about. These deficiencies in basic human computer interaction, biomedical information science, and presentation of information create a terrible user experience for clinicians. The title of these posts are deliberately provocative because the stakes of the issues addressed are so high. These hellish user experiences are causing clinician cognitive overload, distracting and tiring them, and due to violations of fundamental good practices in information display, actually promoting error. These violations are primarily due to lack of clinician input at design, sluggish vendor correction of reported critical deficits, programmer convenience, contractual gagging of a healthcare organization's ability to share these defects with other users and the public at large, and vendor immunity from liability on the basis of "learned intermediaries" (clinicians) between the defective IT and the patient. As a medical informaticist who actually studied biomedical information science, user interface design for clinicians and other topics, I am beginning to feel like <a href="http://www.oxforddnb.com/index/101005716/">William Clowes</a>, the famous surgeon of the Tudor period, who inveighed against the skills of many of the practitioners of his own time, characterizing them as: <blockquote style="font-family: arial;"> ".. no better than than runagates or vagabonds ... shameless in countenance, lewd in disposition, brutish in judgment and understanding ... tinkers, tooth-drawers, peddlers, ostlers, carters, porters, horse-gelders, horse-leeches, idiots, applesquires, broom-men, bawds, witches, conjurers, soothsayers, sow-gelders, rogues, and rat-catchers!"</blockquote> That seems to capture the essence of many of the <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=ecosystem">HIT ecosystem players</a> of today. There's nothing new under the sun... Here is another common EHR defect: the problem list presentation page. <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyfxXPkjHFPTdsjBBAM02eciyNmgpxwLRjxhr_3QSXWiErmsyIWd0EW-XL_M_3L-12cc2qwgo_SEil8BWfi0Sor9yuumSfFJfnZQng6kfnh2O2xeIInxNVKYqNVcV1Xjwi0JLuEHSOISoO/s1600-h/prob_list.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5306412523401565074" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyfxXPkjHFPTdsjBBAM02eciyNmgpxwLRjxhr_3QSXWiErmsyIWd0EW-XL_M_3L-12cc2qwgo_SEil8BWfi0Sor9yuumSfFJfnZQng6kfnh2O2xeIInxNVKYqNVcV1Xjwi0JLuEHSOISoO/s320/prob_list.jpg" style="cursor: pointer; display: block; height: 430px; margin: 0px auto 10px; text-align: center; width: 405px;" /></a>(click to enlarge) <div style="text-align: left;"> Note that the actual screen is much more dense with other information and smaller fonts than my sketch above, so clinicians have an even harder time than the screen presented here illustrates. This display gives real meaning to my statement that HIT is designed by MIS (business computing) personnel not as a clinical tool but as an inventory system. What is wrong with this display? Let me count the ways. First and foremost, the list is alphabetical. This is very convenient for the programmer, but very inconvenient for the clinician. While just a little bit of clinical and informatics savvy would tend to mandate a problem list ranked or ordered in a priority fashion (e.g., more serious problems first), it's clear that savvy is lacking in an industry that provides a presentation of information clearly unsuited to the purpose of facilitating the practice of medicine! Clinicians are forced to scan the list and use their own cognitive engine to zero in on the most important problems. Any human being, unfortunately, has a limited supply of "cognitive fuel" during any waking cycle, and when it runs out from overuse, fatigue sets in. Why do EHR designers use up that fuel rather than provide interfaces that are more fuel-efficient? Second, this list was auto-populated. Problems and diagnoses were not entered manually by the clinician, but through a (perverse) "artificial intelligence" function created by personnel who probably never cared for patients. These items were "extracted" from other parts of the chart. For instance, when an order was placed for Mrs. Jones' glipizide sugar pill and a reason entered, the "diabetes" problem was auto-populated. That seems nice, except for a wee problem. Others in other parts of the record who enter notes and orders might also indicate diabetes specified by a slightly different term variant, producing the repetitive clutter you see in the screen above. It serves the clinician poorly to see "diabetes" repetitively, and in correct and incorrect variants (type I was an accident). This auto-population "feature" results in screen clutter and fosters loss of cognitive focus as a clinician reviews multiple patient charts with this same issue. How can this appear in a production EHR system? Mappings exist in any controlled terminology that permit elimination of such redundancies, which further tax the "cognitive fuel tank" of clinicians. Of course, one has to understand how to utilize these mappings and understand the need to utilize these mappings. The motto of this industry seems to be "let the physicians eat the programmer's dust." (Also note the presence of useless information: "medication use, long term." What is the purpose of this item in the problem list, if not to simply waste a clinician's time skipping over it?) Third: note the diagnosis of "atrial fibrillation," an irregularity of the heart rhythm that if not treated properly can result in strokes and death. This is an important piece of information for the clinician to know. Except, however, when the patient does not have atrial fibrillation. This entry was auto-populated when a nurse ordered a blood clotting test and erroneously entered the reason for the test as "atrial fibrillation" (a common reason, just not the case here) to expedite the order's completion. Voila! Now Mrs. Jones carries this diagnosis, and the next clinician to come along might order her anticoagulated with heparin or coumadin for a history of A. fib, introducing yet more chance of an iatrogenic injury. And I am told it takes going back to the vendor to have this erroneous entry permanently removed. Sheer idiocy! For instance, if the patient moves to a different unit, is discharged and returns to this hospital, or to an outpatient clinic or another hospital branch with this on the record, the chances of a screwup are not insignificant. Fourth, and this is the most incredible, physicians are not supposed to manually populate diagnoses (in a future installment I will show the madness that occurs when they try), nor are they in this particular EHR given an opportunity to verify or abort the auto-population selections. From a medical informatics (and common sense) perspective, that is simply madness. This is cross-occupational piracy. It is computer personnel and hospital executives "stealing" (overriding) physicians' judgment in identifying their patient's problems the way physicians see fit based on their hard-earned expertise. Do the designers, "certifiers" (this system passed CCHIT certification) and corporate purchasers of such systems have any clue about what they are doing? Microsoft seems to "<a href="http://www.mscui.net/DesignGuide/Pdfs/Design%20Guidance%20--%20Displaying%20Graphs%20and%20Tables.pdf">get it</a>!" (PDF) How long will it take the rest of the world? More in Part 4. It gets worse. How about massive screen clutter in some screens (wait until I post the meds list!), and data sparsity and disconnectedness of medically related values in other screens? How about screens that force physicians to use the "finger on screen method" of correlating lab value to test type? -- SS addendum: I am told that some of the vendors with products like this sell products to payers that help the payers deny payments on the basis of detecting diagnoses and problems that don't "match" the documentation in ways they deem appropriate. If that is true, they and their corporate customers are truly using physicians as dupes and patsies, forcing them to use ill-designed IT that both impairs their abilities to practice and facilitates payers in denying (or "floating") payments. <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVIbmBPGK4yrpVqdAThzvd1krrvfd-kUSHK0jy-C6oajvjfcWxGfRIAUD1uEsKgWhb5LX_s0YZo4YPGE4f3V-DanJXv_0bOGODBjjxShJzrv4yex3MgkL04ErCAoPu8XBzNie6KH5PqLcV/s1600-h/EMROPOLY3.png" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5306525587741129330" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVIbmBPGK4yrpVqdAThzvd1krrvfd-kUSHK0jy-C6oajvjfcWxGfRIAUD1uEsKgWhb5LX_s0YZo4YPGE4f3V-DanJXv_0bOGODBjjxShJzrv4yex3MgkL04ErCAoPu8XBzNie6KH5PqLcV/s320/EMROPOLY3.png" style="cursor: pointer; display: block; height: 320px; margin: 0px auto 10px; text-align: center; width: 316px;" /></a>EMR-opoly by <a href="http://www.msofficeemrproject.com/Page3.htm" style="font-weight: bold;">Al Borges MD</a>. Click to enlarge. Perhaps says it all about the "EMR game." </div></div></div>

Are Health IT Designers, Testers and PurchasersTrying to Harm Patients? Part 3 of a Series

( Note: Part 1 of this series is here , part 2 is here , part 3 is here , part 4 is here , part 5 is here , part 6 is here , part 7 ...

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Update on Gmail

The Gmail outage that affected many consumers and Google Apps users worldwide is now over. Users should find that they’re able to access their email now without any further problems. Before you can access your Gmail, you may be asked to fill in what’s called a ‘CAPTCHA’ which asks you to type in a word or some letters before you can proceed. This is perfectly normal when you repeatedly request access to your email account, so please do go through the extra step – it’s just to verify you are who you say you are. The outage itself lasted approximately two and a half hours from 9.30am GMT. We know that for many of you this disrupted your working day. We’re really sorry about this, and we did do everything to restore access as soon as we could. Our priority was to get you back up and running. Our engineers are still investigating the root cause of the problem. Obviously we’re never happy when outages occur, but we would like to stress that this is an unusual occurrence. We know how important Gmail is to you, and how much people rely on the service. Thanks again for bearing with us. Posted by Acacio Cruz, Gmail Site Reliability Manager

Update on Gmail

The Gmail outage that affected many consumers and Google Apps users worldwide is now over. Users should find that they’re able to access the...

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Current Gmail outage

Current Gmail outage

If you’ve tried to access your Gmail account today, you are probably aware by now that we’re having some problems. Shortly after 10 9:30am...

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The next chapter for Google.org

(Cross-posted from the <a style="font-style: italic;" href="http://blog.google.org/2009/02/next-chapter-for-googleorg.html">Google.org Blog</a>) When Larry and Sergey <a href="http://www.sec.gov/Archives/edgar/data/1288776/000119312504142742/ds1a.htm">laid out their vision for Google.org</a>, they hoped that this "experiment in active philanthropy" would one day have an even greater impact on the world than Google itself. They committed resources from Google's profits, equity and substantial employee time to this philanthropic effort, and they created the mission: "to use the power of information and technology to address the global challenges of our age." They structured <a href="http://www.google.org/">Google.org</a> so that in addition to traditional grant making, it can also invest in for-profit companies, advocate for policies and, most important, tap into Google's strengths: its employees, products and technologies. At first I was skeptical about "going corporate," but I came on board convinced that Google could make real progress on these issues. I think we have made an excellent beginning, but it is just a very few steps on a long path. Now, three years after Google.org was founded, we've been reviewing our progress, and how best to take things forward. It's clear that I am most effective in helping to identify "big ideas" and potential partners, as well as raising awareness about society's biggest challenges. I am therefore very excited to become Google's Chief Philanthropy Evangelist. I think this is the highest contribution that I can make both to Google.org and to fighting the urgent threats of our day: from climate change to emerging infectious diseases, to issues of poverty and health care. By focusing my energy outwards I hope to be able to spend more time motivating policy makers, encouraging public and private partnerships, and generally advocating for the changes that we must make as a global society to solve these problems. Long-time Googler Megan Smith will take over day-to-day management of Google.org, joining as General Manager to lead us through this transition, in addition to her existing role as Vice President of New Business Development. One of the first things that Megan will focus on is how Google.org can best achieve its mission. During our review it became clear that while we have been able to support some remarkable non-profit organizations over the past three years, our greatest impact has come when we've attacked problems in ways that make the most of Google's strengths in technology and information; examples of this approach include <a href="http://www.google.org/flutrends/">Flu Trends</a>, <a href="http://www.google.org/recharge/">RechargeIT</a>, <a href="http://knol.google.com/k/-/-/15x31uzlqeo5n/1#">Clean Energy 2030</a>, and <a href="http://www.google.org/powermeter/">PowerMeter</a>. By aligning Google.org more closely with Google as a whole, Megan will ensure that we're better able to build innovative, scalable technology and information solutions. As a first step, Google has decided to put even more engineers and technical talent to work on these issues and problems, resources which I have found to be extraordinary. In this global economic crisis, the work Google.org is doing, together with our many colleagues around the world, to help develop cheap clean energy, find and fight disease outbreaks before they sweep the globe, and build information platforms for underserved people globally, is more important than ever. We stand behind the commitment made in 2004 to devote 1% of Google's equity and profits to philanthropy, and we will continue to iterate on our philanthropic model to make sure our resources have the greatest possible impact for good. Posted by Dr. Larry Brilliant, Chief Philanthropy Evangelist, Google.org

The next chapter for Google.org

(Cross-posted from the Google.org Blog ) When Larry and Sergey laid out their vision for Google.org , they hoped that this "experiment...

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