Tag Archives: EMR

Everything complicated is hard, including writing grant proposals

I was just listening to Tyler Cowen’s conversation with Atul Gawande and noticed this part:

COWEN: Why do surgeons sometimes leave sponges behind in the bodies of patients who are being operated on?

GAWANDE: You zeroed in on one of my very first projects in creating intervention.

COWEN: Great paper.

GAWANDE: We had done a case control study of this problem of surgeons leaving sponges inside people, and got it published in the New England Journal [of Medicine], partly because of our whole method of going about solving this problem, which was, we studied 60 people who had sponges left inside them, compared to 240 people at the same institution at the same time with the same operation who didn’t have sponges left inside them.

I don’t want to focus on the interventions Gawande developed (he is the author of The Checklist Manifesto: How to Get Things Right, the title of which gives you a pretty big clue about one of those interventions); instead I want to focus on the fact that surgeons—who go to four years of undergrad, four years of med school, at least five years (in most cases) of residency—and who are highly motivated to not screw up procedures, because if they do people die—still manage to make seemingly elementary mistakes. Like forgetting a sponge in a patient.

Those mistakes happen, even to brilliant people, because as the cognitive load on a person increases, so does the tendency for error—even simple error. The same kinds of things happen, of course, in grant writing, although our “patients” are unlikely to die as a result. Still, the grant writing process is cognitively complex, which in part explains why so few people can become good grant writers. Interactions among the staff operating the program, the person writing the proposal, the funding agency, and the RFP are complex and can lead to errors. Even the nature of RFPs themselves lend themselves to error.

For example, I was just working on an HIV testing proposal for a client in a big Midwestern city. The narrative section of the proposal is limited to ten pages, with 1.5 line spacing, or about 7 single-spaced pages. The RFP, however, is 111 single-space pages. That’s right, the RFP is about 15 times longer than the allowed response. The possibility for error in such situations is enormous—it is cognitively difficult, and maybe impossible, to hold 111 pages of sometimes contradictory instructions, background on the applicant, and project design in one’s “RAM,” while also keeping to the max page length.

Part of our job as grant writers is to minimize error and understand where and why it might happen, so that we can prevent it to the maximum extent possible. Surgeons, who face life and death issues, don’t always manage to get the sponges out of people, even when they are very highly incentivized to do so. As such, it should not be surprising that the rest of us, who are doing cognitively complex tasks, also face major challenges in getting things right.

Everything is hard. Sometimes there is no way around that. If you’re old enough, you likely remember computers from ten or fifteen years ago that were slow and unreliable by today’s standards. Today, computers are probably more than a thousand times faster (transistor density tends to double every eighteen to twenty-four months) than they were 15 years ago. Yet Firefox is still kind of slow at times, Word still crashes, and various other programs have their foibles. One would expect computers to have transformed medicine, especially now that they’re so fast, yet every doctor hates their Electronic Medical Record (EMR) system. Isaac’s primary care physician uses eClinicalWorks and routinely complains about it being slower and less efficient than hand charting. He says finding the information he needs is harder with eClinicalWorks than it was when he charted by hand. In other words, he likes a millennia-old technology better than the latest software release.

We have faster computers, but EMRs still suck. We have faster computers, but Word still crashes. We have faster computers, but we also demand more of them. As hardware capabilities expand, we demand more of software. The software gets more complex and eats the gains from hardware speed. If I only ran programs from 10 or 15 years ago and made demands like those from that time, I could have a blazing-fast computer, but without the capabilities I like (like the ultra-high resolution 5K display on my iMac). Making software is hard, so it has problems and trade-offs.

The analogy to grant writing seems too obvious to belabor. I’ve also got to get back to the 10 page opus I’m extruding from the 111 page RFP; it’s too early for a cocktail.

Oh, and that story about the sponges? Gawande did come up with a technological fix for lost sponges: bar code each sponge and make sure that each sponge is “checked in” and “checked out.” That simple intervention means that virtually no sponges are lost in patients today. But not all problems lend themselves to technological fixes. Writing doesn’t.

Meaningful Use Regulations, CMS, HRSA FQHCs and the Stalled Push to Electronic Medical Records (EMRs)

According to Mother Jones, the United States has spent billions on electronic medical records (EMRs)* and we’ve got little to show for it. Digitizing healthcare records was supposed to save time, money, and lives. It hasn’t. That news resonates with us because we’ve written dozens of proposals, mostly for Health Resources and Services Administration (HRSA) and Centers for Medicare & Medicaid Services (CMS) RFPs that either explicitly or implicitly require a discussion of our clients’ use of EMR systems. These clients are usually hospitals, Federally Qualified Health Centers (FQHCs) or other primary care providers. From them we’ve heard numerous heard off-the-record stories about the fiascos that ensued for providers that have implemented EMRs. For example, we worked for a hospital in Southern California that interfaced with a much larger, nationally known hospital that attempted to implement a comprehensive EMR system. The large, famous hospital eventually scrapped a $30 million EMR system because the doctors simply refused to use it.

There seems to be no good solution to the EMR problem. EMRs have been touted for at least the last 15 years as a tech-based way of improving patient outcomes, while reducing healthcare costs or at least bending the cost curve downward (as health policy wonks like to say). EMRs got a got big push with huge amounts of EMR funding included in the 2009 “Stimulus Bill.” The advent of the Affordable Care Act (“ACA,” or, colloquially, “ObamaCare”) escalated the EMR drive. Various Federal and state agencies advocated and then effectively mandated EMRs.

But this well-meaning concept has at best moved sideways. HealthIT.gov promulgates the wonderfully bureaucratically named “Meaningful Use” regulations, which use a combination of incentives (e.g., higher Medicare/Medicaid reimbursements) and threats. The carrots are offered and the threats enforced primarily by CMS. Everyone is supposed to get to Stage 1 of Meaningful Use (data capturing and sharing) on a supposedly smooth trajectory to Stage 3 (improved outcomes). Stage 3 turns out to be like the intergalactic instantaneous travel through spacetime. We’ve yet to find an hospital, FQHC or other client that has reached Stage 3. Most are stuck at Stage 1, with a few bravely claiming Stage 2. We’ve never seen a client hit Stage 3, though they may be out there, perhaps in a galaxy far far away.

The problem is that EMRs are trying to map the extraordinary complexities of the real world into software. The complexity can be seen in the new International Classification of Diseases, ICD-10 Codes, published by our old friend CMS. ICD-10 codes are used by medical providers and billers to track patients and payments, based on the code or codes of the patient’s particular situation. When we talk to FQHCs, they invariably say that coding errors are among their major problems. ICD-10 has an astounding 68,000 individual codes, compared to only 14,000 codes in the previous ICD-9. In recent years, humans have invented or discovered an enormous number of new ways to get hurt. No one can remember more than a few hundred of these mysterious codes, which are easy to mistype into an EHR and/or be misunderstood by harried doctors and mid-level practitioners. The complexity of the codes, combined with human diversity and frailty, inherently generates huge numbers of mistakes.

Folks with too much time on their hands have published various funny ICD-10-CM codes. Some choice ones (we are not making these up) include: “V97.33XD: Sucked into jet engine, subsequent encounter;” Y92.146: “Swimming-pool of prison as the place of occurrence of the external cause” (how many prisons have swimming pools?); and my personal favorite, “R46.1: Bizarre personal appearance.” You can tweet your favorite bizarre ICD-10 codes to @healthcaredive.

Ask your doctor about their EMR system and you’ll likely here a lot of invective. I live with a doctor and so have heard the horror stories from her and her colleagues. Isaac’s primary care physician (PCP) hates EMRs but is more or less forced to use eClincalWorks, an EMR system that is also popular with our FQHC clients. Epic is another popular one. Still, however you feel about whether EMRs is efficacious or horrible or brilliant or whatever, pretty much every healthcare-related proposal has to mention EMRs, statistics, and tracking. That could be as minor as a project that works on childhood obesity or as major as a hospital chain implementing some new facet of EMRs.

Anyway, EMRs are a specialized case of a more general problem described in “Why Software Fails: We waste billions of dollars each year on entirely preventable mistakes.” EMRs, like other forms of software, have numerous moving parts and numerous human users. Anyone working in or around EMRs needs to read “Why Software Fails.” At Seliger + Associates, we expect to keep writing about EMRs for FQHCs and similar clients for years if not decades to come. In the real world, doing EHRs right is simply a Hard Problem—so hard that it deserves capital letters. EMRs are almost impossible to do “right” and yet have to be done right. They’re so hard that we don’t have a solution. “Why Software Fails” explains why a solution may not exist, no matter how badly HRSA or CMS wants one. As the Soviet Union discovered, mandates from above, no matter how strong, do not automatically translate into fixing problems from below.

* EMRs are alternatively referred to as Electronic Health Records (EHRs), particularly in HRSA and CMS RFPs. In ones types “EHR” into Word, or any other word processor, and the autocorrect feature will change it to “HER.” This in annoying, but does result in some unintentionally funny typos. When finished with proposal draft involving EHRs, always do a find and replace for “HER”.