healthy4u

A Primer On Why We Have Busywork Generators Masquerading as EMR's: Health IT Reality vs. the Bernard Madoff Version

As many have now observed, electronic medical records products on the market are clunky, fail to support the cognitive and workflow needs of clinicians, contribute to clinician cognitive overload and increased clerical work burden, and may be harming patients at a rate far higher than, say, VIOXX, which was summarily withdrawn from the market to be followed by billions of dollars of lawsuits. Health IT can indeed improve healthcare quality, reduce costs and achieve other benefits claimed of it, but only if it's done well. There is tremendous underlying social and technical complexity underlying those two words "done well", and unfortunately in 2009 most health IT is simply not done well. Yet the technology is actually worshipped in what I see as a Bernard Madoff syndrome, an irrational exuberance in IT for reasons not entirely clear to me considering the existing objective evidence. The motivation to learn how to truly "do HIT well" before embarking on a multi-billion dollar HIT adventure is sorely lacking -- our current approaches being inadequate per such authoritative sources as <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=NRC">the National Research Council</a>. In my transit authority safety officer-trained mind, I sense a train wreck approaching. Further, a federally pushed national HIT initiative using billions of dollars, dollars that might be better spent to prevent events like <a href="http://www.philly.com/philly/news/homepage/42841077.html">this hospital closure in an underserved area</a>, is premature. In regard to doing HIT well, usability and usefulness of EMR's have been largely stifled by traditional approaches to Health IT. Those approaches fail to adhere to "innovation" - innovation, that is, compared to traditional IT practices - that was called for by the pioneers beginning in the 1950's and 1960's. (Should I really use the term "innovation" if it's been called for now for over forty years?) Dr. Don Lindberg in 1969: <blockquote face="arial">"... computer engineering experts per se have virtually no idea of the real problems of medical or even hospital practice, and furthermore have consistently underestimated the complexity of the problems…in no cases can [building appropriate clinical information systems] be done, simply because they have not been defined with the physician as the continuing major contributor and user of the information" (Lindberg DAB: Computer Failures and Successes, Southern Medical Bulletin 1969;57:18-21). </blockquote> Others such as Morris Collen, Octo Barnett, et al. published guidelines on how to best implement clinical IT that if followed would have alleviated many of the problems we have today. Sadly, they published their ideas starting in -- and perhaps even before -- the 1960's. The recommendations of the pioneers are documented in "<a href="http://www.amazon.com/exec/obidos/tg/detail/-/0964774305/qid=1111634652/sr=8-1/ref=sr_8_xs_ap_i1_xgl14/002-5628970-2983252?v=glance&s=books&n=507846">A History of Medical Informatics in the United States 1950-1990</a>", by Morris Collen MD, section 3.4. For example, Octo Barnett's clinical IT "10 Commandments" (written in 1970) as reproduced in Collen's book on page 169, as well as 1960's and 70's material by Lindberg, Lamson, Collen, Davis, Baker, and numerous others address many of the substantial problems that plague health IT today. What we largely have today are "busywork generators masquerading as EMR's." I've only begun to illustrate some of the mission hostile user experiences presented by major vendor "CCHIT Certified" EHR's at <a href="http://tinyurl.com/hostileuserexper">this eight part series</a>. Below is a suggested reading list on the problems we have today. Anyone contemplating policy work in health IT should be intimately familiar with these works, as they illustrate the true HIT environment in 2009, not the Bernard Madoff "unlimited returns no matter what" version. What these articles do not illustrate is the common atmosphere of irrational exuberance and complacency now prevalent about HIT, with healthcare organizations and physicians now being pushed forcefully to adopt these technologies or suffer payment penalties they can ill afford: <blockquote style="font-family: arial;">Joint Commission: <a href="http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm">Sentinel Events Alert on HIT</a>, Dec. 2008. National Research Council report. <a href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572">Current Approaches to U.S. Healthcare Information Technology are Insufficient</a>. Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions, Jan. 2009 <a href="http://www.publications.parliament.uk/pa/cm200809/cmselect/cmpubacc/153/15302.htm"> The National Programme for IT in the NHS: Progress since 2006,</a> Public Accounts Committee, January 2009. Summary points <a href="http://www.publications.parliament.uk/pa/cm200809/cmselect/cmpubacc/153/15304.htm">here</a>. <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/medinfo.htm">Common Examples of Healthcare IT Difficulties</a> (website). S. Silverstein, MD, Drexel University College of Information Science and Technology. <a href="http://jama.ama-assn.org/cgi/content/extract/301/12/1276">Health Care Information Technology Vendors' "Hold Harmless" Clause - Implications for Patients and Clinicians</a>, Ross Koppel and David Kreda, Journal of the American Medical Association, 2009; 301(12):1276-1278 <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/regulation_and_oversight_hoffman.pdf">Finding a Cure: The Case for Regulation And Oversight of Electronic Health Records Systems</a>, Hoffman and Podgurski, Harvard Journal of Law & Technology 2008 vol. 22, No. 1 <a href="http://www.ncbi.nlm.nih.gov/pubmed/18213422">Failure to Provide Clinicians Useful IT Systems: Opportunities to Leapfrog Current Technologies</a>, Ball et al., Methods Inf Med 2008; 47: 4–7, <a href="http://jama.ama-assn.org/cgi/content/extract/301/9/919">IT Vulnerabilities Highlighted by Errors, Malfunctions at Veterans’ Medical Centers</a>, JAMA Mar. 4, 2009, p. 919-920. <a href="http://pediatrics.aappublications.org/cgi/content/abstract/116/6/1506">Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System</a>, Han et al., Pediatrics Vol. 116 No. 6 December 2005, pp. 1506-1512 <a href="http://jama.ama-assn.org/cgi/content/abstract/293/10/1197">Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors</a>. Ross Koppel, PhD, et al, Journal of the American Medical Association, 2005;293:1197-1203 <a href="http://www.ctlab.org/documents/Hiding%20in%20plain%20sight.pdf">Hiding in Plain SIght: What Koppel et al. tell us about healthcare IT</a>. Christopher Nemeth, Richard Cook. Journal of Biomedical Informatics. 38 (4): 262-3. <a href="http://www.jamia.org/cgi/content/short/15/4/408">Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes and Threats to Patient Safety</a>, Koppel, Wetterneck, Telles & Karsh, JAMIA 2008;15:408-423 <a href="http://www.nytimes.com/2009/03/06/opinion/06coben.html">The Computer Will See You Now</a>, New York Times, Armstrong-Coben, March 5, 2009, <a href="http://hcrenewal.blogspot.com/2009/03/health-it-project-success-and-failure.html">Health IT Project Success and Failure: Recommendations from Literature and an AMIA Workshop</a>. Journal of the American Medical Informatics Association. Bonnie Kaplan and Kimberly D. Harris-Salamone (preprint, doi:10.1197/jamia.M2997) <a href="http://iig.umit.at/efmi/badinformatics.htm">Bad Health Informatics Can Kill</a>. Working Group for Assessment of Health Information Systems of the European Federation for Medical Informatics (EFMI). <a href="http://archinte.ama-assn.org/cgi/content/short/167/13/1400">Electronic Health Record Use and the Quality of Ambulatory Care in the United States</a>. Arch Intern Med. 2007;167:1400-1405 <a href="http://archinte.ama-assn.org/cgi/reprint/165/10/1111.pdf">High Rates of Adverse Drug Events in a Highly Computerized Hospital</a>, Nebeker at al., Arch Intern Med. 2005;165:1111-1116. "<a href="http://articles.icmcc.org/2009/01/23/dutch-ehr-postponed-are-they-in-good-company/">Dutch nationwide EHR postponed: Are they in good company?</a>", ICMCC.org, Jan. 24, 2009 “<a href="http://www.ama-assn.org/amednews/2006/12/11/bisa1211.htm">Avoiding EMR meltdown</a>.” About a third of practices that buy electronic medical records systems stop using them within a year, AMA News, Dec. 2006. "The failure rates of EMR implementations are also consistently high at close to 50%", from <a href="http://www.infoclin.ca/assets/emr%20success%20methodologies%20framework%20development%20ishimr%202006%20v2.pdf">Proceedings of the 11th International Symposium on Health Information Management Research</a> – iSHIMR 2006 "Industry experts estimate that failure rates of Electronic Medical Record (EMR) implementations range from 50–80%.", from <a href="https://www.advancedmd.com/pressroom/white_papers/commonsense_to_emrs.pdf">A Commonsense Approach to EMRs</a>, July 2006 <a href="http://www.taxonomer.com/PublishTxgd001/index.htm">Adverse Effects of Information Technology in Healthcare</a>. This knowledge center presents a collection of information on the adverse effects of information technology in its application to healthcare. It also references sources of information on information security, and related media reports. <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/Goldfinch_pessimism_PAR.pdf">Pessimism, Computer Failure, and Information Systems Development in the Public Sector</a>. Shaun Goldfinch, University of Otago, New Zealand, Public Administration Review 67;5:917-929, Sept/Oct. 2007 </blockquote> This is a short list, but if there were such articles about VIOXX or Phen-Fen and pharma or the government not just approved but demanded they be used, (figuratively) there would have been heads rolling. There were outspoken people challenging the <a href="http://en.wikipedia.org/wiki/Bernard_Madoff">Bernard Madoff scheme</a> ... <blockquote style="font-family: arial;">... Concerns about Madoff's business had surfaced as early as 1999, when financial analyst-whistleblower <a href="http://en.wikipedia.org/wiki/Harry_Markopolos" title="Harry Markopolos">Harry Markopolos</a> informed the SEC that he felt it was legally and mathematically impossible to achieve the gains Madoff claimed to deliver. Others felt it was inconceivable that his growing volume of accounts could be competently serviced by his documented accounting/auditing firm, a three-person firm with only one active accountant.</blockquote> ... but they were just disruptive, negative, bad people. -- SS

A Primer On Why We Have Busywork Generators Masquerading as EMR's: Health IT Reality vs. the Bernard Madoff Version

As many have now observed, electronic medical records products on the market are clunky, fail to support the cognitive and workflow needs of...

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Pot O' (LEED) Gold

At Google, we strive to be green all year round, not just on St. Patrick's Day. We've been working hard to design our offices around the world to be as environmentally friendly as possible. We have a set of internal Workplace and Sustainability Design Guidelines which we use to ensure that we're providing healthy and productive workplaces for Googlers everywhere. In San Francisco, our office was recently rated Gold by the <a href="http://www.usgbc.org/">U.S. Green Building Council's</a> <a href="http://www.usgbc.org/DisplayPage.aspx?CategoryID=19">LEED</a> (Leadership in Energy and Environmental Design) Green Building Rating System. We're excited about this certification because it means we're on the right track with our approach to building environmentally sound offices. Here are a few of the design strategies we implement to make our office buildings as green as possible. We thought they might even give you some ideas for greening your own home. Reduce, reuse, recycle We have frugal roots from our start-up days, so when we remodel an office, we reuse as many materials as possible. This strategy saves us money, and it avoids the environmental footprint associated not only with manufacturing and transporting new goods, but also with disposing of the old stuff. Construction and demolition waste makes up about 40% of the solid waste stream in the U.S. In the San Francisco office, we reused everything from partition walls and door assemblies to carpet and furniture left behind by the previous tenant. Plus, more than 64% of what we did throw away was recycled. Healthy and sustainable Sometimes, the simplest defense is the best defense, like the "Larry and Sergey Sniff Test": if it smells bad, it's probably bad for you (Larry and Sergey are a little busy to do all the sniffing themselves, so we help them out sometimes). The all-too-familiar new paint or new carpet smell is usually the sign of toxic <a href="http://en.wikipedia.org/wiki/Volatile_organic_compounds">VOCs</a> (volatile organic compounds) off-gassing into the air we breathe. Of course, we have to go on more than just our noses, so we also rely on third-party certification programs (like <a href="http://www.c2ccertified.com/">Cradle to Cradle</a>, <a href="http://www.scscertified.com/ecoproducts/index.html">Scientific Certification Systems</a>, and those incorporated into LEED) and information from manufacturers to ensure that we use the healthiest products available. All the paints, sealants, adhesives, carpet, and furniture we purchased for the San Francisco office had the lowest possible levels of VOCs and formaldehyde, both of which have adverse effects on <a href="http://www.cdph.ca.gov/programs/iaq/">indoor air quality</a> and long-term health. We also looked for sustainable materials that are locally manufactured, high in recycled content, and free of environmentally harmful materials like PVC. Keeping it cool (or warm) We make every effort to heat, cool and light our offices with the minimal amount of energy needed, and use building controls to ensure these systems are only on when we need them. Some of these strategies work everywhere, like installing motion sensors to control lighting and purchasing <a href="http://www.energystar.gov/">Energy Star</a>-rated office equipment in the U.S. Other times, solutions are more site specific. In San Francisco, like many of our offices, we lease space in a building with many other tenants, which can often be an obstacle to implementing measures to save energy. We worked side by side with our landlord to retrofit the existing HVAC (heating, ventilation, air conditioning) system to make it more efficient. At our headquarters in Mountain View, we have a <a href="http://www.google.com/corporate/solarpanels">1.6MW PV system</a>, as well as a cutting-edge building management system that monitors and controls all of our energy use across campus (like <a href="http://www.google.org/powermeter/">PowerMeter</a>, but with a few more bells and whistles). Every drop counts Water is one of our planet's most undervalued natural resources, and we're always looking for innovative and cost effective ways to use it more wisely. In San Francisco, as well as most of our other offices, we installed efficient faucets and flush valves in the bathrooms and kitchens. In locations where we have more green space like Mountain View, we use drought-resistant landscaping when possible. We just opened a new office in Sydney (which is undergoing <a href="http://www.gbca.org.au/green-star/">Green Star</a> certification through the <a href="http://www.gbca.org.au/">Green Building Council of Australia</a>), where waste water will be treated and recycled for toilet flushing and irrigation. Location, location, location If you visit the San Francisco office, you might not notice the low-VOC carpet, but you definitely won't miss the spectacular views of the San Francisco Bay and the <a href="http://images.google.com/images?q=bay%20bridge&oe=utf-8&rls=org.mozilla:en-US:official&client=firefox-a&um=1&ie=UTF-8&sa=N&hl=en&tab=wi">Bay Bridge</a>. Access to natural light and views increases Googler productivity and happiness, and decreases our energy costs by reducing the need for artificial lighting. Plus, like many of our offices, the San Francisco office is centrally located and easily accessible by public transit. We also provide preferred parking for carpools and vanpools, on-site bike storage, showers and changing facilities. We've done a lot of work to be greener, but that doesn't mean we've reached the end of the rainbow and that pot of gold yet. We're constantly learning more about green building and ways to save energy. However, on this greenest of holidays, we're wearing the LEED certification of the San Francisco office as a badge of green pride -- a shamrock, you could say. Posted by Anthony Ravitz, Real Estate and Workplace Services, and Lacy Caruthers, Green Business and Operations Strategy

Pot O' (LEED) Gold

At Google, we strive to be green all year round, not just on St. Patrick's Day. We've been working hard to design our offices aroun...

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Building bridges

Since <a href="http://sketchup.google.com/">Google SketchUp</a> first popped up on the scene in 2006, we've had the pleasure of seeing many of you use it to build 3D models of all kinds of things -- from <a href="http://sketchup.google.com/3dwarehouse/cldetails?mid=4d839abcb1b2547f91378eb3d464fdc3&prevstart=0">college campuses</a> to furniture to <a href="http://googleblog.blogspot.com/2009/01/gingerbread-competition-results-are-in.html">gingerbread houses</a>. Now, we're happy to announce a new challenge -- the <a href="http://sketchup.google.com/competitions/09bridge/index.html">SketchUp 2009 International Student Bridge Modeling Competition</a>. Bridges are some of the most breathtaking architectural structures in the world, and we're sure you have an impressive model of a local, famous or historical bridge right up your sleeve. Students at higher education institutions are qualified to compete, and it's easy to enter. Just model your bridge in Google SketchUp, geo-reference it in <a href="http://earth.google.com/">Google Earth</a>, and upload your submission to the <a href="http://sketchup.google.com/3dwarehouse/">Google 3D Warehouse</a> anytime before June 15. For more information, check out the <a href="http://sketchupdate.blogspot.com/2009/03/help-model-world-one-bridge-at-time.html">Google SketchUp blog</a>. We're excited to see what you come up with! Posted by Allyson McDuffie, SketchUp for Education Program Manager

Building bridges

Since Google SketchUp first popped up on the scene in 2006, we've had the pleasure of seeing many of you use it to build 3D models of a...

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Some Conflicts Grow in Brooklyn

<a href="http://www.nydailynews.com/ny_local/brooklyn/2009/03/15/2009-03-15_an_unhealthy_alliance_wyckoff_mds_deal_w.html">From the New York Daily News</a>, here is a new twist on the conflicts of interest story. This is about two leaders of Wyckoff Medical Center in my hometown of Brooklyn, NY, the hospital's chief of surgery, Dr Addagada Rao, and its CEO, Rajiv Garg. It turns out that Dr Rao has another position, this one far away at <a href="http://www.spartanmed.org/">Spartan Health Sciences University</a>, a medical school located on the Caribbean island of St Lucia: <blockquote> The $400,000-a-year chief of surgery at Brooklyn's Wyckoff Heights Medical Center heads a Caribbean medical school that hopes will funnel medical students - and their money - back to New York, the Daily News has learned. The surgeon, Dr. Addagada Rao, is the <a href="http://www.spartanmed.org/president_message.html">president of Spartan Health Sciences University in sunny St. Lucia</a>. Last year he became one of a handful of owners in hopes of bringing third- and fourth-year medical students to Wyckoff to train - and to aid its ailing coffers. 'My association with Spartan is to fulfill my lifelong goal to educate all who are able and willing to pursue a career in medicine...' Rao is quoted on the medical school's Web site. </blockquote> Mr Garg also has a role at Spartan, <blockquote> Garg, 49, has been Wyckoff's $500,000-per-year CEO since November and is also an investor in Spartan. He told The News he stepped down as Spartan's chief operating officer after he got the top job at Wyckoff. </blockquote> Meanwhile, the Daily News alleged: <blockquote> Rao, 67, is in a position to make hundreds of thousands of dollars from the dual relationships. The ability to train in New York is a big draw for offshore medical schools - especially if the school has an established connection with a hospital, experts said. The state has approved Spartan students to do only 12-week stints in New York hospitals. Students pay between $4,000 and $5,000 for the training. Wyckoff - and Rao - could make far more money if the state okays a pending request for Spartan students to do their full two years training at New York hospitals. </blockquote> Dr Rao was asked about these relationships, and responded, <blockquote> he saw nothing wrong with having outside financial interests. 'I disclosed this to the hospital,' he said, but declined to offer further details. Asked if the hospital's board of trustees, of which Rao and Garg are members, approved the arrangement, he said: 'That was not necessary.' </blockquote> It is still a little hard for me to understand how someone could be chief of surgery at a NY hospital and simultaneously the president of a Caribbean medical school, but setting that aside... This story illustrates another twist on conflicts of interest affecting the leaders of not-for-profit health care organizations. Many of the smaller not-for-profit hospitals, of which there are thousands in the US, may have minimal conflict of interest policies, which may be minimally enforced, without much transparency or accountability. The coziness of the leadership culture of such smaller institutions may preclude anyone within the culture from asking tough questions. The results may be total confusion as to whose interests particular leaders are serving. In particular, the interests of each hospital's patients may get lost in the shuffle. In this case, the interests of medical students may also get lost in the shuffle. Although the institutions involved may be small, and hence the conflicts may seem small in terms of their monetary value, they aggregate to contribute to the moral miasma that now is the atmosphere of health care.

Some Conflicts Grow in Brooklyn

From the New York Daily News , here is a new twist on the conflicts of interest story. This is about two leaders of Wyckoff Medical Center i...

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Make sense of your site: tips for webpage design

This is the second post in <a href="http://googleblog.blogspot.com/search/label/measurement">The Power of Measurement</a> series. These posts are designed to cover ways to make your website as successful as possible, especially in the current economic climate. Here, Website Optimizer whiz Sandra Cheng explores the topic of website design and offers tips to help you get more from your site. -Ed. In our <a href="http://googleblog.blogspot.com/2009/02/stop-bouncing-tips-for-website-success.html" id="vl3v" title="last post">last post</a>, Avinash Kaushik dove into the world of website analytics and explained the power behind the bounce rate metric. With bounce rate, you are able to identify which webpages are turning away the most visitors. And while it's incredibly useful to identify which pages need fixing, what do you do next? Back in the good old days, you would go back to the page and redesign it based on what you or other people thought was right for your site. Now, you can actually run a test on your website and let your visitors decide the best version of your page, instead of just going with a gut feeling. Here, I'll discuss website testing — executing different versions of a page to see what sticks — and the various ways you can make the most of your site's design choices. To begin website testing, start by brainstorming variations of your website. You can decide on small changes, like swapping out a photo, or large changes, like an overhaul of your website's layout or color scheme. Then, by using a free tool like <a href="http://www.google.com/websiteoptimizer" id="x68t" title="Website Optimizer">Website Optimizer</a>, you can test your changes by automatically showing different visitors different versions of your site. From there, Website Optimizer will tell you which version your visitors liked the most by tracking which website variation was the most successful in reaching your goal. You can set your goal to be a sale, someone submitting a form or clicking a link, or any number of other interactions with your site. It's like running a simple experiment — without the complicated data analysis. Testing your site can often reveal surprises. For example, we were surprised by the results of our own test on the Picasa homepage. In version A, we used the word "free," gave it an action-oriented headline, and included a pretty image of the product. In version B, we deleted the photo, used a button instead of a link, and called out the value proposition ("The easy way..."). Which version do you think led more visitors to download Picasa? <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjGQnuF4Z__n2QED_1Vm6oH9CL_iHujtiOJvbsy4WuW5D4NunPJWgk_6pgT1DmOo2kRZb5VE0eiOhcE9IQFBhS_fMySLD4RfCriZSkUbDaLqVegPaxbCdX3GBruuwQv_D4CX9koDsspVSbF/s1600-h/Picture+2.png" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5313469672854582274" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjGQnuF4Z__n2QED_1Vm6oH9CL_iHujtiOJvbsy4WuW5D4NunPJWgk_6pgT1DmOo2kRZb5VE0eiOhcE9IQFBhS_fMySLD4RfCriZSkUbDaLqVegPaxbCdX3GBruuwQv_D4CX9koDsspVSbF/s400/Picture+2.png" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 400px; height: 276px;" /></a>Version A </div> <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHL57kIZOP2I3ADklaPZMWy2Wo-pYoZ1Zff6Q-HSGtjPQmGLGo1k9tT85A1aKzSinfk7-CRQtGoL2F1AJp2vOpy9ImBc-ckVF0_vsSB7ANutZPz1Ad2KvRycfxf2iGRWfg8ORU2GOjDpQW/s1600-h/Picture+3.png" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5313469929418195634" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHL57kIZOP2I3ADklaPZMWy2Wo-pYoZ1Zff6Q-HSGtjPQmGLGo1k9tT85A1aKzSinfk7-CRQtGoL2F1AJp2vOpy9ImBc-ckVF0_vsSB7ANutZPz1Ad2KvRycfxf2iGRWfg8ORU2GOjDpQW/s400/Picture+3.png" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 400px; height: 204px;" /></a>Version B </div> We predicted that Version A would be the clear winner since it had a photo to captivate visitors and a "free" product call-out. However, the data from the tests showed that the cleaner, simpler Version B was more effective. In fact, the changes in Version B increased downloads by 30%! This example illustrates a powerful point: sometimes you need to rely on data — not your gut — to make decisions that will help your website and your bottom line. Now, you might be asking yourself, "With so many different aspects of my website to test, how do I know where to begin?" Here are four design tips to pay attention to: <ul><li> Tip #1: Pass the 8 second test. At first glance, a visitor should understand the purpose of your website within a few seconds. People are busy and have limited attention spans — you want to keep them from hitting the dreaded back button.</li><li>Tip #2: Tell them what's in it for them. Create clear and tangible benefits (e.g., "Save more! Make extra money! Look better with our product!").</li><li>Tip #3: Use compelling images. Try product images instead of generic stock photos, icons with blocks of text, and buttons instead of links. Keep in mind that a low-quality, irrelevant image can kill your site's credibility.</li><li>Tip #4: Close the sale. Help your visitors take the next step. Make that step clear and easy to reach; don't make them hunt for it. Action words like "buy now" may work better than "add to cart," for instance. </li></ul>Once you've decided which details to test — a call-to-action, color, headline, layout, or video, for example — go to Website Optimizer and set up an experiment. For first-time users, we recommend a/b testing, meaning testing one variation of your page against another. After you launch your experiment, Website Optimizer will do the heavy lifting and show you when the data is "statistically significant." (In case it's been a while since your last Stats 101 course, statistical significance means that an event is unlikely to have happened by chance, and that you have enough data to know that there is a true difference in which page variation your visitors prefer.) The results will start showing in your reports page and for each experiment, the corresponding bar will begin to turn red, yellow or green. When the bars start to turn green, you have a winning page variation that is helping you reach the goals you have set for your website: <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg1hAeAcEwN43qa6artIZpFq7nigiIiP2d9G_5uTLd4Ru-rvb4V10AJGHnlfKYdWnqFnR70GnK6DeY_ZBjM4VqL-ekfIXT-JIxeexo0-NCx_LkATNpR8rYG7SBVCZMqc30kJYzfH8ZV3o6U/s1600-h/Picture+4.png" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5313470581308252178" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg1hAeAcEwN43qa6artIZpFq7nigiIiP2d9G_5uTLd4Ru-rvb4V10AJGHnlfKYdWnqFnR70GnK6DeY_ZBjM4VqL-ekfIXT-JIxeexo0-NCx_LkATNpR8rYG7SBVCZMqc30kJYzfH8ZV3o6U/s400/Picture+4.png" style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 400px; height: 287px;" /></a> Remember, best practices may work best for some, but they are not necessarily what's best for your site and your visitors. In the past, a few opinions and a strong hunch determined an effective website design. Now, armed with metrics, data, and tools galore, you can let your visitors tell you what works best for them and for your site. Good luck, and get testing! Posted by Sandra Cheng, Product Manager, Google Website Optimizer

Make sense of your site: tips for webpage design

This is the second post in The Power of Measurement series. These posts are designed to cover ways to make your website as successful as po...

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Walmart to Become the Healthcare IT Punching Bag?

At "<a href="http://hcrenewal.blogspot.com/2009/03/wal-mart-to-market-ehr-system-to-small.html">Wal-Mart to market Electronic Medical Records? Has Medicine Gone Bananas?</a>" I noted the entry of Walmart into the healthcare IT fray. As I <a href="http://hcrenewal.blogspot.com/2005/03/wash-post-on-cedars-sinai-cpoe-failure.html">observed here</a> in early 2005, HIT is a field where angels fear to tread. Or should fear to tread. Walmart is <a href="http://www.google.com/search?client=firefox-a&rls=org.mozilla%3Aen-US%3Aofficial&channel=s&hl=en&q=walmart+opposition&btnG=Google+Search">not exactly popular</a> in numerous circles, so let me state I buy from them (most recently my Acer Netbook, clothing and various Christmas gifts) and am neutral on most of the issues that create the opposition. My father ran a business, after all. However, he at least stuck to his core expertise, pharmacy. Walmart is trying to market EMR's, a product far beyond their core competencies. The HIT market and "ecosystem" is also far beyond their competencies, and it's not hard to predict they are going to have a rapid and quite unpleasant learning experience about the dark corners of this industry. Felix Fulmer, a correspondent with longstanding expertise in academic and pharmaceutical research environments conveyed to me the following observations about this arrangement: Deficient as its products often are, the HIT industry was built up by entrepreneurs over many years and by much hard work. They are now being challenged by a very large and very powerful entity. The entry of Walmart into EMR represents a tremendous threat to the HIT industry status quo. This initiative is likely to help doctors and patients at the very least by reducing the cost of EMR (even if not improving the performance), putting downward price pressure on the entire industry. It is also likely to change the marketing and consulting practices in the HIT industry as well, driving wages down among other factors. If successful, Walmart's initiative could in fact cause the extinction of the current monopolistic and parasitical HIT establishment. [In my estimate, a 33% - 50% reduction in companies, revenues and personnel in three or four years would not be an unreasonable figure - not that I would be sad to see some of them go - ed.] Mr. Fulmer continues: The HIT industry must realize this and, based on Walmart's history of capturing other markets and putting smaller competitors out of business, the captains of this industry must be quaking in their boots. These entrepreneurs will fiercely act to defend their territory, using every trick in the book [knowing the industry as well as I do, I cannot fail to agree with that assessment - ed.] Walmart is going to be severely punished. The pushback from the HIT establishment will likely consist of three phases: subversion, obstruction, and agitation for litigation (in a collusive manner) to challenge the newcomer. There will be technical, administrative and political angles. The first phase, subversion, will be the establishment's attempt to try to keep the Walmart arrangement from happening. It may occur through the press and through political means. Antitrust complaints, and a negative campaign of badmouthing and panning may occur. It will be insinuated or stated that Walmart doesn't have the required expertise, that they don't know what they're doing, among other claims to discredit, diminish and minimize the initiative. The second phase will likely be obstruction. HIT products Walmart will carry will be sabotaged by other vendors in terms of passive aggressive measures to complicate or prevent data interoperability. There may be issues such as constant "breakdowns" of interfaces, inexplicable technical glitches blamed on Walmart and its supplier, of course. Walmart's HIT products and services will be scrutinized under a microscope and deficiencies highlighted through the media and printed competitive materials. There may also be attempts to intimidate and misdirect physicians not to go with this product through the medical leadership, through back room paid sponsorship of "influential thought leaders" (as in pharma), through "detail people" (e.g., sales reps as in pharma) and other means. Hospital administrations and CIO's may also be influenced by various means to steer physicians away from this offering, perhaps to the level of marginalizing users or refusing to support this product. Finally, there will be litigation, especially regarding the inevitable medical errors that occur when this technology is pushed into small town physicians offices unused to technology of this complexity. Walmart may be shocked to find the "learned intermediary" principle suddenly and mysteriously not be applied. Why would this be a surprise, considering their immensely deep pockets and the disdain of the the left-leaning, anti-big business judiciary system? Mr. Fulmer concludes with this thought: Walmart may think of their entry into the HIT marketplace as a great business plan, but their executives may need to partake of their own medical clinics to deal with the stress the HIT industry pushback will cause. -- SS

Walmart to Become the Healthcare IT Punching Bag?

At " Wal-Mart to market Electronic Medical Records? Has Medicine Gone Bananas? " I noted the entry of Walmart into the healthcare ...

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Healthcare IT: How Much More Out of Control Can An Industry Be?

In a <a href="http://hcrenewal.blogspot.com/2009/03/serious-leak-of-top-secret-classified.html">prior post</a> I had quoted a Healthcare IT News report on the <a href="http://www.healthcareitnews.com/news/docs-may-be-using-it-they-dont-love-it">healthcare IT user experience</a>: <blockquote style="font-family:arial;">Healthcare IT News (3/10, Merrill) reported, a survey conducted by the American College of Physician Executives found "that although more physician leaders are using healthcare information technology, they still find it clunky and unresponsive to their needs." The survey of 1,000 ACPE members "revealed that the biggest source of frustration is a lack of input from physicians when designing and implementing healthcare information technology systems. Many said involving clinicians at the planning stages would pre-empt many of the problems that crop up later." One respondent noted that "systems are chosen according to administrative criteria rather than what physicians need."</blockquote> These same observations have been made by the <a href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572">National Research Council</a> of the National Academies, and many others, in fact dating back decades as I've previously written on these pages, and as at my site on HIT difficulties <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/medinfo.htm">here</a> starting a decade ago. Several issues occur to me that need emphasis: <ul><li>How can it be that in 2009, 1,000 ACPE members opine that the biggest source of frustration is a lack of input from physicians when designing and implementing healthcare information technology systems but do little about this glaring defect in an industry touting itself as the savior of healthcare? </li></ul><ul><li>If the medical leadership notes that HIT is "clunky and unresponsive" to clinician needs, why are they not speaking out vociferously and seeking prolongation of the 2014 "deadline" for IT adoption?</li></ul><ul><li>If HIT is clunky and unresponsive to clinician needs, how can the technology actually do anything but make clinicians' work slower, harder (e.g., by exhausting 'cognitive capital' working around the problems) and less effective, thereby serving as an impediment to healthcare improvement and cost savings?</li></ul><ul><li>Why do grass roots "<a href="http://hcrenewal.blogspot.com/2009/03/disruptive-innovators-at-healthcare.html">disruptive innovators</a>", not the leadership, have to take up the mantle of opposition to an industry as primitive and backwaters as to allow a lack of physician input, and a customer base of healthcare organizations that mismanage what technology they do purchase from the HIT vendors? </li></ul><ul><li>How can the HIT industry continue to develop and push such products?</li></ul><ul><li>How can healthcare organizations still purchase it (at costs of tens of million to 100+ million dollars)? </li></ul><ul><li>How can clinicians and their leadership tolerate such a situation? </li></ul><ul><li>How can our society allow the HIT industry such latitude, without regulation and accountability?</li></ul><ul><li>How did the HIT and healthcare industries manage to fall behind in talent management, causing a lack of clinician leadership and input into HIT, and perhaps worse, causing neglect and underutilization of a growing pool of biomedical informatics expertise, thus exacerbating the noted deficiency of meaningful domain expert input at the critical planning stages? (See below.) </li></ul> Only an unregulated, unaccountable, poorly led industry that is out of control - the vendors and the consumers, i.e., healthcare organizations themselves - can be producing and marketing and acquiring HIT clinical devices that are clunky and unresponsive to clinician needs for a prolonged period dating back decades. Further, if my own personal experiences and that of a group of similarly experienced colleagues are a gauge, and I believe they are, then the HIT industry's talent management, and that of the healthcare organizations who purchase and implement this technology, are similarly out of control. Case in point, one of many dating to at least 1994 when I completed an NIH postdoctoral fellowship in Biomedical Informatics at Yale School of Medicine: About two years ago I had interviews with Siemens Healthcare in Malvern about a HIT leadership role. I presented state of the art information on best practices in HIT, including the critical need for physician input, as well as showed them some of my own work in use at major area medical centers and overseas as well. I did not have even the courtesy of a call back or email as to their decision. Simply silence. Sadly, a decade prior I'd had excellent, frank conversations about these HIT issues with Siemens personnel at their Healthcare headquarters in Erlangen, Germany that led to a position offer (I simultaneously received an offer from Merck & Co., Inc. in the U.S. and went that route). It was clear Siemens America and its American employees did not share the kultur and engineering insights of their German counterparts. The results with other HIT vendors have been similar, such as <a href="http://hcrenewal.blogspot.com/2009/02/nextgen-and-vendordoctor-dialog-yet.html">here</a> and <a href="http://hcrenewal.blogspot.com/2008/11/who-leads-in-intellectually-challenged.html">here</a> and numerous others. Further, my CV has been on all the major job boards for years, and I have almost never been contacted by an HIT vendor. What, exactly, are their HR departments doing if formal medical informatics credentials are either invisible or ignored? Further and perhaps worse, I and similarly experienced colleagues have had difficulty even being talked to by major healthcare organizations, such as outlined <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=leadership">here</a>, who appear to believe there's such a thing as "too much experience" in managing HIT investments of tens of millions of dollars and up, investments that impact patient lives. I have sprinkled this blog's pages with many such examples of vendor and provider organization talent management seemingly gone awry, a "wall" against informed clinical input in the form of shunning of those with actual clinical and biomedical informatics credentials in favor of cheaper technical labor. Such patterns should not be lightly ignored. (In actual fact, several members at House Energy & Commerce were simply incredulous when told of this issue. 'Why are hospitals and the HIT companies not actively running after people of your backgrounds?' was their question.) The health IT pioneers noted these same patterns forty years ago. As far back as 1969, EMR and Medical Informatics pioneer Donald A. B. Lindberg, M.D., now Director of the U.S. National Library of Medicine at NIH, made the observation that <blockquote face="arial">"... computer engineering experts per se have virtually no idea of the real problems of medical or even hospital practice, and furthermore have consistently underestimated the complexity of the problems…in no cases can [building appropriate clinical information systems] be done, simply because they have not been defined with the physician as the continuing major contributor and user of the information" (Lindberg DAB: Computer Failures and Successes, Southern Medical Bulletin 1969;57:18-21).</blockquote> Other pioneers in EMR such as Morris Collen, Octo Barnett, and others published guidelines on how to best implement clinical IT that warned against the cornucopia of problems that plague the HIT industry today. Sadly, they did so starting in -- and perhaps even before -- the 1960's. A good source on references to the wisdom of the pioneers is "<a href="http://www.amazon.com/exec/obidos/tg/detail/-/0964774305/qid=1111634652/sr=8-1/ref=sr_8_xs_ap_i1_xgl14/002-5628970-2983252?v=glance&s=books&n=507846">A History of Medical Informatics in the United States 1950-1990</a>", by Morris Collen MD, section 3.4. For example, Octo Barnett's clinical IT "10 Commandments" (written in 1970) as reproduced in Collen's book on page 169, as well as 1960's and 70's material by Lindberg, Lamson, Collen, Davis, Baker, and numerous others address many of the substantial problems that plague health IT today. Yet, here we are in 2009, and we have an industry still mired in the problems noted forty years ago. How much more out of control can an industry be? The technology will only improve when those behind it have a better grasp of the complexities of medicine and end the lack of input from (and I might add, dearth of leadership by) physicians and physician informaticists. The only private response to these observations over more than a decade I've gotten is <a href="http://histalk2.com/2008/05/10/monday-morning-update-51208/">this foolishness</a> from a vendor sponsored gossip site that I: <blockquote face="arial">... don't usually have good things to say about CIOs and IT departments, so if you don’t want to start your Monday morning sputtering and flinging your coffee at your monitor, don’t click the link. He often makes harsh observations from the context of "the IT people didn’t hire me, so they must be insular fools who hate doctors" angle, but he does make an occasional point.</blockquote> I don't think the HIT vendors are fools who hate doctors, but I do believe they are indeed insular and the industry out of control, as any unregulated, unaccountable and lucrative industry might become after time - such as medicine itself prior to Flexner. Who needs smart, knowledgeable experts to reduce margins? About that insularity, at "<a href="http://hcrenewal.blogspot.com/2008/05/htrea-parallel-world-of-hit.html">Earthlings and Htraesians: The Parallel Worlds of Medicine and Healthcare Information Technology</a>" I wrote: <blockquote style="font-family: arial;"> ... In trying to unify my observations, I am postulating that HIT has created for itself its own closed society with its own value system, credentialing, culture, and power stuctures, which piggyback off the hard labor of clinicians. The culture of this closed society is at great odds with that of the community it ostensibly serves, medicine. </blockquote> To summarize, healthcare is in a sad - and may I say alarming - state when its executive leaders can opine that an entire industry's products now being mandated for use by the federal government on a short time frame are "clunky and unresponsive" due to a "frustrating lack of input from clinician endusers", and such a revelation is <a href="http://hcrenewal.blogspot.com/2006/07/anechoic-effect-explained.html">anechoic</a> and relegated to a small corner of the blogosphere. -- SS

Healthcare IT: How Much More Out of Control Can An Industry Be?

In a prior post I had quoted a Healthcare IT News report on the healthcare IT user experience : Healthcare IT News (3/10, Merrill) reported...

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