Nancy Beale discusses Death by A Thousand Clicks

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

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Bill Russell:                   00:08                Welcome to this week in health it and where we discuss the news information and emerging thought with leaders from across the health care industry. My name is Bill Russell, recovering healthcare CIO and creator of this week in health it, a set of podcasts and videos dedicated to training the next generation of health it leaders today we’re going to talk about it, a interesting fortune article. It just came out death by a thousand clicks where they electronic health records went wrong. This podcast is brought to you by health lyrics, one to start your health it projects on the right track or when a turnaround, a failing project. Let’s talk visit to schedule your free consultation. Our guests today. You know it’s interesting. I read this article and I thought first of all I need somebody with the clinical background and then I need somebody who’s very familiar with the Ehr so that we can have an extensive conversation on that. I put out a call and a Sue Schade introduced me to Nancy Beale, so our guest today is Nancy Beale who is a registered nurse and has extensive background in Ehr. Ehr implementations and using the EHR and she’s an advisor was starbridge advisors. Good Morning Nancy, and welcome to the show. Hello. Good morning. Yeah. You know, you’re getting the world of the podcast. We’re actually recording afternoon, but you know, good morning.

Bill Russell:                   01:21                Why don’t you give people a little bit of your background because you, you really have a great background, uh, not only on the health it side, working with the Ehr, but also a great clinical background as well.

Nancy Beale:                 01:32                Certainly. Thank you. Um, so I have been a nurse for well over 30 years and spent the first half of my career in clinical practice in a variety of roles from staff nurse to director, um, and everything in between and a primarily practice, um, med surge as well as labor and delivery, perinatal nursing. Uh, I left clinical nursing to, uh, go to work for epic. I was a clinical leader at epic and worked with customers across the country, uh, for close to a decade and subsequently did a little consulting and then spent about six years in New York City in Manhattan at Nyu Langone health systems as a vice president of clinical systems and integration. Currently. Uh, most recently I left that position to pursue my doctorate and um, my intention is to pursue studying, uh, clinical it adoption, technology, adoption and nursing. Specifically. We talk a lot about, uh, providers, provider adoption, how many clicks per provider. No one really looks at a technology adoption in nursing and there are about 4 million nurses across the country. So I think it’s an important contribution, um, to really evaluate. And I also am doing some consulting with starbridge advisers.

Bill Russell:                   03:03                It’s interesting. It’s interesting. We talk a lot about physician burnout with the EHR. I assume we’re seeing a clinician burnout as well amongst the nursing ranks because it’s really the same thing. I mean there’s an awful lot of pressure and complexity and those kinds of things has that benn your experience.

Nancy Beale:                 03:22                Absolutely. Absolutely. I have many nurse colleagues and friends who are, once I tell them my area of interests, there are more than willing to talk to me about all of their challenges and frustrations with technology. And give me clinical examples where technology actually became, uh, a challenge or a hindrance to them providing care.

Bill Russell:                   03:43                Now, this, this article’s pretty scathing, I wanted to talk about it because I, and I wanted to talk about it with someone with your background because I think some of the things are fair and some of the things are really unfair in terms of how they’re looking at it because they’re looking at, they really focusing on the EHR. The EHR is the problem here, but we also have a regulatory burden that’s sort of untethered and disconnected that has created this. We have a payment structure that’s a little bit untethered and it doesn’t make sense. And we, and then we have, uh, yes, there are some greedy organizations and from time to time and they call those out. Um, but it’s, it’s all of it. It’s, it’s an ecosystem. It’s not just, hey, we’ve got this EHR and this Ehr is causing these problems. And so I want to, I want to touch on some of those different aspects.

Bill Russell:                   04:32                Um, all right, so this article, fortune, let me pull it up here cause I usually I don’t have in front of me. There it is. Okay. So fortune, uh, wrote this article March 18th, 2019 death by a thousand clicks where the electronic health records went wrong. And uh, let me just give you the, what I would call the summary of it and then we’ll dive into it. So the summary is essentially the case being made by the article is that the government put out a huge pot of money, um, and said, come and get it. The Ehr vendors, some ready, some not took off in an all out sprint to get the money, um, health systems slaying the technology and based on artificial deadlines set by sort of a carrot and stick legislation, creating a risky environment that didn’t meet the intended goals of the legislation, as evidenced by their quotes from a Obama and Seema Verma.

Bill Russell:                   05:26                And, um, uh, gosh are so, oh, uh, uh, former vice president Joe Biden and their frustrations with it. The outcomes are systems that are challenging to navigate. Uh, they lack proper proper oversight and regulation at this point. Uh, they create risk, risky and stressful work environment for those who are asked to use the systems, uh, leading to errors and burnout. Um, I think that if I had to encapsulate it into one paragraph that’s, that’s the gist of the article so you can understand how this can easily become a, a bashing session. Um, but let’s step back and say, ah, because you’ve been, you’ve been around for all of this and I’ve been around for a good part of it through the meaningful use stages and whatnot. Um, the intentions are good. I mean, the promise of the EHR is, is really makes sense. This is why I sort of came forward, right?

Bill Russell:                   06:18                It was supposed to make medicine safer, bring higher quality care, empower patients, and uh, and even to a certain extent, uh, save money. Um, you know, it was going to bring data together, empower researchers to find new cures. Um, allow people to, uh, be more portable with their health record show up at a place with their health record. Uh, so that you would have the information you needed at the point of care and where life and death decisions are being made, you would have a complete record. And these are that, you know, that’s the promise of the EHR and these are good things. That’s where we started. Um, alright. So that’s enough sort of setting it up. Um, the goals are, the goals are good, right? I mean this is what we were promised and the goals are still, we still believe those goals to be. I think we still believe those goals to be attainable somewhat. Uh, when you say?

Nancy Beale:                 07:10                absolutely. Um, I would say that we, we actually are achieving many of those outcomes in pockets and in certain organizations with certain strategies and set up systems. So I personally have seen positive outcomes with, you know, being able to change, let’s say a practice patterns related to ordering IB Tylenol is one example. I b, Tylenol is extremely expensive and most often not necessary. And so by some of the leverage and how you configure the EHR. Um, at Nyu we were actually able to change practice patterns, eliminate excessive ordering of Ib Tylenol and save a significant amount of dollars. Uh, I think, um, likewise looking at things like, um, over ordering of certain lab tests is another example or over administration of blood when it doesn’t really meet the criteria that the organization has set forth. So I think that absolutely it has enabled us to achieve some of these outcomes, but in some cases it takes an army of people, um, to make those outcomes happen. Um, you have to have an organization that has, you know, talented pool of people to actually, you know, execute a strategy around both from the clinical side to make sure that you’re getting the right buy in and addressing where there are challenges and also from the it side so that people understand what is a very complex system. So I think it’s possible, but it is a very challenging,

Bill Russell:                   09:11                it’s almost like the capstone project or the, the thesis that you’re gonna have to do for your, for your doctorate of, of a leadership team at a health system. I mean to put an Ehr and you’re taking, first of all, a health system is one business. It’s 100 businesses and that are all interconnected and all have very, uh, very complex nature to them. Uh, and then you have all these workflows and all these things that you’re doing. And it is sort of the capstone project where you have to figure out, okay, how do we bring all the right people together? How do we ensure quality is maintained? Every health system you go into and you say, what’s your number one thing? They will say quality people place their trust in us and we want to be trusted. So no one’s starting out with a thing of, hey, we don’t care about quality.

Bill Russell:                   09:55                Just get the EHR in. But it is a, it is a test. So, you know, one of the things they start talking about is, um, pretty early on is that these systems are a unintuitive I guess is the nice word. They would say, uh, in the words get to be like unintuitive and then it gets clumsy, hard to navigate. That’s where the title comes from, death by a thousand clicks. Um, what, what do health systems do well that get beyond that quickly, either in design or in optimization that you’ve seen as really effective practices that get them beyond the death by a thousand clicks or the clumsy interfaces that, uh, that they talk about in this article?

Nancy Beale:                 10:43                I think there are three things really design, implementation and optimization and um, what they do, what successful organizations that I have worked with do is really ensure that they have highly qualified clinicians engaged in the design process. And when I say highly qualified, what I mean by that is not just somebody who might be available who happens to have RN or MD after their name, but actually somebody who understands technology and has some level of, uh, experience and or education with technology. So I really believe that clinical informatics is crucial in appropriate design. Um, likewise, those same clinicians are essential when it comes to implementation, implementation, strategy, spotting where the problems are. I’m identifying the folks who are really struggling, how do we solve those problems or identifying, um, what could be really dangerous situations that are occurring that otherwise you may not know because you didn’t have that clinical connection.

Nancy Beale:                 11:53                And then ultimately optimization, you know, we, one of my, one of the things that really encourages me to be interested in pursuing how we measure technology adoption and putting some standardization around that is that we continue to develop all these really wonderful technologies and some are integrated and some are not. But we put some of these things out there and don’t always measure how they’re being used and if they are in fact being used as intended. And, uh, one of the challenges with that of course is if you have work arounds that are occurring, there could be downstream implications of that and in in fact even patient safety implication. So really optimization going back after the fact, making sure that what you implemented is actually working and if it’s not, how we make it better.

Bill Russell:                   12:55                That’s interesting. Um, so how would you address somebody who says, look, we’ve done so many of these implementations. Is it the, can’t you just take epic out of the box, Cerner out of the box? Can you take epic out of the box, put it into a house with them and say, look you, you can’t tell me that practicing medicine in New York City and Chicago and Nashville and Orlando are all that different. Can’t we come up with a common implementation that we know works, that the alerts go where they need to go, that the orders go where they need to go, that the, you know, the flow sort of works. I mean, cause this thing, this article again, they cherish things that I go, yeah, that probably happened. You know, it’s, you know, it’s the same system. It’s, it’s even the same vendor, but you know, an order didn’t get, didn’t move from this place to this place and you’re like, how can that happen? Why can’t we just, you know, it worked over here and then you bought the same system from the same vendor. Why doesn’t it work over here?

Nancy Beale:                 13:55                Well that goes back to my recommendation around clinicians and clinician involvement in the implementation because that change management is really, really crucial. So, um, before we had EHR and a provider order entry, a lot of what would happen is providers would write orders on paper and then rest was really kind of invisible to the provider. It just happened, right? Whether it was the nurse, the lab tech, the medical assistant, the unit clerk, whomever took care of all of those other steps. Well now all of that is transparent to the provider because once they sign, right, um, that’s when those orders become real. If it was a paper situation and it provide a road in order and didn’t sign their name to it, nothing would happen. It’s the same. So I think that two things, one is that there is a level of transparency. Now that is a bit uncomfortable.

Nancy Beale:                 15:01                That implies additional accountability. Um, and second is really at some point we have to address that accountability. And it could be that perhaps somewhere along the way, um, this person didn’t get the right level of training. Right. That’s one example. But, um, you know, there are other ways also to monitor, boy, how many unsigned orders do we have on a given patient. Right? And what do you do with those if you know that they exist, right. The same accountability needs to take place across the entire health care team. Um, so it’s not all the EHR. Um, some of it is the Ehr, but I think that there is a level of accountability that is much more transparent than it used to be. And, um, I think also back to your question about isn’t why can’t we just take it out of the box? Um, well you would be very surprised at how different things actually are across the country in healthcare organizations, in terms of their routines and what’s allowed or not allowed, what people order or don’t order.

Nancy Beale:                 16:19                And I think it’s getting better. And I think that that is one thing that health care is driving healthcare. It is driving is that standardization. And you know, if you look at organizations like the institute for Healthcare improvement, one of the things they consistently say is eliminate unnecessary variation, right? But we’ve got variation in practice from one end of the spectrum to the other across the country. So I think that again, healthcare, it is really kind of putting a window into all of this, making it more transparent. And so sometimes while we say, oh, it’s healthcare it, that’s the problem here. And sometimes it is, but also we have a practice issue. We, we have a need to make sure that we can at least outline what some of these standard practices should be and then enforce them. Right?

Bill Russell:                   17:19                Yep. So a couple of stats to 96% of hospitals have adopted an Ehrs, which is amazing, up from 9% in 2008. Um, but, you know, you sorta look at that and it’s, um, one of the things you said, which was interesting to me is we haven’t standardized clinical practice across, um, across health care. And so because we haven’t standardized clinical practices, you take the tool and you say, why can’t I take the, um, you know, the, the epic from Nyu or the epic from uh, cedars or from Providence and just implemented at the next health system. And the answer is because the clinical processes are, are different is the first answer to that. And actually I know the answer to this because within the health system we struggled to take a, an instance of our Ehr from one hospital to the next hospital because everyone, everyone was like, well, that’s not how we practice. And it requires significant conversations about just that, how do we practice, why do we have that alert? Why do we have that rule? Why do we have that workflow? And those things take a, those are significant conversations with,

Nancy Beale:                 18:33                that’s the role of clinical informatics. That is really where clinicians who understand both technology and also clinical practice can be so invaluable to any technology implementation.

Bill Russell:                   18:46                Yeah. And we’ve talked on the shelf how important those roles are. Here’s some, some call outs from the article. So four thousand four thousand is the number of clicks in a single shift according to the American Journal of emergency medicine. 4,000 clicks. That’s, that’s a lot. I mean, that doesn’t, that doesn’t sort of, uh, that either says they’re doing an awful lot of work, which is probably true, but it also says that’s probably not an efficiently designed system. And the article really makes the case for, um, you know, these systems weren’t really ready for when the, when the starting gun went off on this and they’ve been sort of catching up ever since and trying to become more efficient interfaces. Um, how is a clinician supposed to navigate 4,000 clicks? And this is it, uh, emergency medicine. So this is probably a study that’s really looking at the Ed. Uh, and, and I mean, in that environment, how can they be expected to, to navigate the EHR, which is so complex and give the proper attention to the patient. I mean, is that even realistic and what can we do? And in that case,

Nancy Beale:                 19:58                right, I mean, 4,000 clicks certainly sounds excessive. It certainly sounds like a, a high volume organization. Um, I would say, you know, you absolutely have to step back and say, Whoa, wait a minute. What are we doing and why do we have 4,000 clicks? My guess would be that there’s a lot of, um, organizations that don’t go with an enterprise solution off the bat. And when you don’t have an enterprise solution, that means your having extra clicks to accommodate sometimes for that lack of integration between systems. So,

Bill Russell:                   20:36                oh, sure, you’re popping out into other systems to pull information in.

Nancy Beale:                 20:41                Correct. Or maybe it takes three clicks to do what would otherwise be one click if you had an enterprise system. Right. And I think that’s getting better. I think more and more organizations are seeing the value in having an integrated EHR. But EHR, basic EHR, we’re closest side. You still have other technologies and systems that require thoughtful integration, whether it’s radiology, um, whether it’s, um, labs pretty seamlessly integrated most places. Uh, but um, you have certainly other technologies, right? Um, physiologic monitoring, alarm and alert management, communication, all of these other types of systems that get folded in. And if they’re not well thought out in how they’re architected, you end up with yes, it’s possible. Yes, they’re connected, but it requires the clinician to click, you know, five, six, seven, eight more times. Right. Because they’re not just in the EHR, they’re touching all of these other systems now as well.

Bill Russell:                   21:58                You know, one of the things we’ll touch on burnout again here, the, um, they, you know, they talk about the average 11.4 hour workday that uh, almost six of those hours is spent in the EHR itself. We’ve really turned clinicians into, um, I dunno, uh, I mean they’re navigating the technology and spending a lot awful lot of time in the technology. I was with a CIO, uh, two weeks ago I was in his office and he showed me this report and it was a great report cause it showed, uh, the usage of the Ehr, uh, by physician. And, and he goes, is this the saddest graph you’ve ever seen? I’m like, explain the graph to me. And he said, look, this person woke up at this time and they got into the EHR and they were working on the Ehr from home. Then they came in and they worked a full shift and he goes, now they go home and they’re working an additional couple of hours on the EHR.

Bill Russell:                   22:52                He goes, he goes, and I’m like, well now that you describe it, yeah, that’s the saddest chart I’ve ever seen. He goes, this isn’t like a one off one day kind of thing. He goes, this is her consistent pattern of using the EHR. It is multiple hours when she gets up and multiple hours after she goes home and you can understand where burnout is coming from, if, if, uh, if that’s the way. Now is that, is that a result of, do you think that’s a result of the design, the design of the EHR? Is that a result of the, um, the, the changing landscape of healthcare and the dwindling amount of time we have with the patient that we’re saying to people, Hey, you got 11 minutes to be with that patient, get in there, get out, and you have to document outside of that environment. What’s, what’s causing that kind of environment where people are spending, you know, all that personal time on the EHR.

Nancy Beale:                 23:49                I think it’s actually all of the above. Um, I think that there absolutely is increased pressure, um, you know, to compress the amount of time you spend with patients so that you can have higher volume. Um, and you know, I’m hopeful because I’m an optimist that, you know, as we move from volume to value, uh, in a health care model that, you know, there’s potential for that to improve. But I think that said there is still a great variety in terms of skill. Right. And some people have learned how to navigate their practice and, um, engage with patients at the same time as they document and others have not. And in some cases they have not on purpose. Right. And when I say on purpose, I mean, um, they got, they have a higher value on that interaction with the patient. And I think that this is an opportunity for other technologies to really play a part in a voice navigation so that really documentation and ordering and all of the EHR related processes become a byproduct of what we do with the patient as opposed to yet one more thing to do.

Bill Russell:                   25:10                Yeah, I think so. Where I’d like to go, so there’s this article, it talks about the clumsiness and uh, the challenge. Then it talks about interoperability and then it talks about medical errors and I think I’m going to stick to that order. So interoperability, it shares the story of Seema Verma and her husband, her husband had an event and it’s just, I mean, she is at the heart, at the center of this thing and she can’t get all of her husband’s data from all the different records together. To this day, she still can’t do it. And Joe Biden shares the story of his son, Beau Biden and struggle with cancer. And he is the sitting vice president of the United States and he can’t get the medical record together as his son is going from location to location. Um, and there was a, there was sort of this idea and this promise, and I know, I know if I hear aneesh chopra in back of my head, if he were on the show, you’d say, it’s getting better, Bill, it’s getting better.

Bill Russell:                   26:11                But um, but we’re far from the promise of originally that, that you were going to, the clinician would know beyond a shadow of a doubt, but they were looking at a clean medical record with a complete history at the point of care so that they had all the information they needed to address that. Um, and I know there’s fire and I know there’s other things going and some of those things I might be able to talk more about the, then you might be able to, but um, what um, what is, uh, I guess I’ll focus in on an area you would, you really be an expert on, which is, um, do the clinicians trust the record they’re looking at, do they trust that they have the information they need or do they just assume when they’re sitting in front of the patient, I’m going to have to ask these questions again because it may or may not have all the information I need. Um, I made a, I made need to ask them, have you been in another country? Have you, um, and you know, have you been visiting other hospitals? Have you, I mean, do they trust the record that we’re looking at? Um, or do they feel like they need to augment it?

Nancy Beale:                 27:20                Well, I think our variety of, um, there’s not one answer to that. Um, for sure. Uh, I would say that in some cases I feel like they trust it too much. So if it’s in the record, it must be true without actually validating that the data is accurate with the patient. On some cases I feel like it has to do with how the clinicians were trained. Um, and so, uh, you know, if your trained, um, aside from the EHR, your trained that in order for you to know this is valid information, you have to ask the questions that regardless of what’s in the Ehr, those clinicians are going to ask the questions. And I would say that we need to do a better job at teaching and educating and training our clinicians, all clinicians on how to interact with a patient and technology, whether it’s, you know, the Ehr or some other technology in the environment.

Nancy Beale:                 28:30                Um, that touches the patient. I think that we don’t always do a good job. We, we say, okay, here are the buttons you have to push. You know, and we’ve put people in a classroom and they go through functional training and in some cases, you know, they’re good about a workflow. Here’s how you admit a patient, here’s how you transfer a patient. Here’s how you place an order of those kinds of functional things. But we don’t do enough of teaching how clinicians can interact with patients. And I think that you can get to a place where you can validate the information with the patient and how you approach the patient says a couple of different things to the patient. Right? So it says, I see here you’re allergic to penicillin and you get a rash. Is that correct? Right. That does two things. One, you’re validating with the patient. The second to the patient that says, oh, they know me. They have my data. Right. And we don’t always do that. We don’t do a good job of that at all.

Bill Russell:                   29:34                Yeah, I, well, I’ve, I’ve had some physicians say to me, I don’t trust anything that’s in there. I validated it all. And to a extent, I, I get that and understand it. Um, but today I’ve also had physicians tell me, you know, when we talk about fire and those kinds of things, that’s a techie way of saying, hey, we could put plumbing in place to move stuff around. But at the end of the day, I’ve had physicians look at me and go, um, you know, they’ll say, look over my shoulder, watch this, and it’ll show me just all these CCD have come across and they’re gone. And it’s just like a file folder with a thousand documents in it. They’re like, which one do I, which one do I have to read? He goes, if it’s in the EHR, I technically I have to look at all of them.

Bill Russell:                   30:14                Im like, there has to be a better way than having a thousand documents in here that are essentially pdf documents. I haven’t gone anything in there and eat no anything in there I need. Um, now I know they get classified and those kinds of things and, and I’m sort of setting a worst case example, but, um, so, so we get the plumbing in place, we’re moving the data around, but until we get to discrete data elements moving around, it’s going to be, it’s still going to remain hard for those physicians to digest all that information to a certain extent. Uh, I mean, do you hear physicians complaining? I mean, I, I think I hear some of them complaining. It’s like, all right, I have too much information right now. Too much information without meaning, I guess is the answer. Okay.

Nancy Beale:                 30:59                Yeah. I think that, uh, nurses and physicians you would hear that from, and I think that really, um, this is where I, I believe that there’s a role for, um,

Nancy Beale:                 31:10                augmented intelligence or artificial intelligence to help call out those meaningful data elements and bring them to the forefront, right? So that we do a better job of dashboarding, if you will, that says, you know, in the background, have the computer and the technology do the searching and find those critical data elements. And then in the foreground, you as a clinician show me what’s important, what I should be looking at. And we don’t do enough of that from a technological standpoint. It also goes back to my very first comments around really needing, you know, highly evolved and talented, um, you know, folks on your, uh, informatics and it team.

Bill Russell:                   31:55                Yeah. You’ve got to create those dashboards that they can sort of get a snapshot at a quick glance. Um, now I want to go into the tougher area, which is a safety and I’m going to, I mean these stories are gut wrenching somewhat. I’m not going to go into the stories that people can read them. Obviously there’s medical mistakes and they’re attributing some of these medical mistakes to the EHR. A, here’s a call out, 3,769 safety related incidences, incidents linked to the EHR, um, or other it sources and that’s from a company called Quantros and 3,243 number of medication errors link to the EHR, usability issues at Three pediatric hospitals from 2012 to 2017 and that’s a health affairs study. Um, I guess it doesn’t surprise me that with systems this complex that there’s going to be errors. In fact, those numbers seem kind of small to me and I realized that each one of those numbers, it could be a catastrophic event.

Bill Russell:                   32:56                I’m not, I’m not downplaying that, but I’m just saying, given the number of transactions that are now going on across 96% of the hospitals, those seem like a small number, small amount of numbers, small number to me and which would leave me in what in two directions, really. One is either, you know, job well done or we’re not reporting enough of these where we’re not capturing and reporting enough of these because it would feel to me that there should be more given the complexity of these systems. And so I guess my first question to you is, um, how, how do you capture these things? How do you escalate them? How do you make them aware and then how far does it go? I would assume that you’re escalating them within the health system, but does it go all the way up to the EHR vendor and does it get reported, um, or is it only reported if it becomes an event, a safety event?

Nancy Beale:                 33:47                Well, it’s interesting. So at the health system level, absolutely. Uh, it becomes, you know, you have patient safety officers and they do an entire debrief on what took place, who was involved, what role technology played in that. And um, I know when I was at Nyu, they did a very thorough job of investigating and there were many times where if there was a question was technology involved, I would be, uh, participating to help them understand exactly, you know, what the technology was supposed to do, um, what the clinician was supposed to do, what they did or didn’t do. Um, and any audit trails to support that behind that. However, um, you know, I think that, you know, as I think about, um, well first of all I’ll say on the vendor side, I know that certainly epic has a patient safety escalation process. Um, and even, um, even though I’ve been gone from epic for eight years, back when I was at epic, um, the, uh, patient safety escalation process was in place.

Nancy Beale:                 34:55                And, um, they take a very serious, any concerns that are brought forward to them from their clients and then begin to evaluate what role the technology did or didn’t do. And then push out information to their other customers. To say, Hey, we have this problem at this customer. A, you may be effected, you have this configuration. So they do an absolutely a very thorough job of that. I think to your question about shouldn’t there be more, what I would say about that number is, um, you know, I don’t think we have the transparency. I still don’t think, to your point, I still don’t think we have complete transparency and the number of near misses and actual medication errors, but we certainly didn’t have it when everything was on paper. Right. And so how do we know if this is better or worse? Um, I think that’s very difficult to say. I think what we do know is, um, we, we can know when errors absolutely happen. And, um, in many cases the audit trails are quite robust to say, no, actually you didn’t do this or yes, you actually did document this. So there’s a lot more transparency. And, um, I think again, the EHR though often gets a bad rap. Um, really just becomes a magnifying glass for all that’s really happening in the clinical setting. And we just didn’t have the transparency before.

Bill Russell:                   36:32                No, I think there’s an awful lot of truth to that. I think people would be surprised if they saw the audit logs within EHRs. It captures everything. I mean it’s, and for good reason, it’s like the, it’s like the flight recorder on a plane. I mean, it tells us what we did wrong and what we could do better to make sure that those things don’t happen. Don’t happen again. Um, you know, so part of me as a CIO is kind of terrified to ever be a CIO again because, um, you know, these systems are complex and you see the finger pointing. It’s like, uh, you know, hey, this happened and the EHR vendor saying, well, you customize our software. So it’s probably on your end. And then the, you know, you go down here and you’re like looking at the audit logs, like no no of the clinician didn’t click this thing.

Bill Russell:                   37:19                And then the clinicians looking at you gone, this is the most I look, I have technology all around me. I’m not a luddite. I get technology, I use technology, but this is the worst technology I use. I mean, there’s so many dropdown menus, there’s so many clicks there. So you know, and, and you sort of want to look at everybody and go, yes, you’re right. It’s not your fault. The EHR vendor, yes, we’re customizing this. And actually I want to get to this customization thing again because we are customizing probably a little too much. I mean, most software today, if you were to look at it’s cloud software, whatnot, the reason it’s successful is they don’t customize it all that much. I mean, when you get g-mail, you get Gmail when you get, you know, and it’s a very simple system. But generally speaking, that’s true with a lot of these cloud plays.

Bill Russell:                   38:06                Um, and, and you know, and they have this, uh, gentleman from Wellstar, I don’t have it. It’s gonna be too hard to find it from, from Wellstar. And he has a usability lab where they track the eyes of a physician while they’re using the EHR. And, um, he says the design is so bad that they just lose things in the screen, that their eyes aren’t flowing to where you think they’re going to flow. And I like that level of study because that’s important design matters in these things. And I think we can do a much better job with design. I would love to see a usability design team at um, at epic and Cerner and allscripts and the rest of these just take center stage and just like Redo how we have put all these things together. But let’s get back to, uh, let’s get back to customization.

Bill Russell:                   38:56                So the thing that scares me as a CIO is we’re going to be asked to customize the EHR. We always are, um, you know, build a new workflow, uh, putting in a new alert. Uh, whatever were there were just, I mean, some of those things are simple clicks, but uh, but we’re going to be asked to do some things that are more extensive. How do you ensure that those things are designed well tested well before they ever get out there to make sure you’re not introducing errors? Because each one of these things is connected to a thousand other things.

Nancy Beale:                 39:28                Well, I think that I, you know, it’s very basic in some ways. You know, if you look at the system development lifecycle is very basic. You know, having people involved who are knowledgeable about the workflow as well as the technology and the technologies that are designed and that it touches right, but that will be impacted is important. And then doing thorough testing, you know, multiple rounds of testing, not just from an it perspective, but you know, you’ll do your basic unit testing and integration testing and then you need to do usability testing that involves clinicians, clinicians who have not been involved in the design, right? Yup. Don’t have intimate knowledge with how it’s supposed to work. Right. So that, that’s when you’ll find things that really, um, you know, are worthy of catching before you deploy the, you know, whatever the new technology is. But I, you know, I can’t stress enough anytime, um, in my role at Nyu, if there was a problem that occurred, my first question was always, how was this tested when something breaks? Um, and you find out about it after it’s in production and you have to ask the question, how did we test this? You know, I think that that can’t be underscored enough. Okay.

Bill Russell:                   40:56                Yeah. Well, I’m gonna let you have the last word on this article. I mean, is there anything that resonates with you or anything you sort of the go yeah. Uh, or anything that you just sorta don’t like that they sort of bring up?

Nancy Beale:                 41:11                I think that, um, you know, there are a couple of things. One, one is that acknowledging that, um, you know, the challenge with the Ehr is certainly broader than physicians, um, and involves all health care providers and clinicians. Um, I would say that needs a little bit more visibility, my perspective, but also, um, I think that there is some unfair of, you know, sort of biased just to sort of blame the vendor, if you will. And I think that because we can look and see that these problems are occurring across vendors, it’s not really any one vendor. We have a much bigger problem and we all have to be part of the solution in bringing that together. And I think that, um, it’s, it’s the old adage of the three legged stool. You need the vendor, you, you need the customer, you know, and the folks who are actually doing the implementation, all three have to come together to really make sure what you put out there is safe and usable. Um, and uh, it’s, it’s not really any one of those three factors, faults if you will. Um, I would say that we need greater appreciation and understanding at the level of regulation so that there aren’t mandates for things that, um, are not reasonable or, uh, you know, things that come are handed down as mandates that, you know, I think frankly the vendors do a fairly good job of trying to rally to that mandate. But, um, you know, the price is often paid by the end user.

Bill Russell:                   43:05                Yeah, I agree. I like the way you sort of wrap that up there and, um, I think on that, I just, I want to thank you, Nancy for, uh, coming forward. This is actually one of the more difficult articles I think we’ve ever covered on the show because it does expose, I think there’s a lot of things that resonate with us. I mean, you sorta exposes a lot of the challenges that we face and we’re trying to overcome and the listeners of the show or, uh, are addressing on a, on a daily basis. And to a certain extent, this article can sort of feel like it’s coming down on the saying you’re not doing enough. And, and that might be true when we might not be doing enough, but it’s not for lack of trying. And it’s not for lack of dedication of the people who are doing it, even on the government. It’s not, it’s not, the regulations were not with bad intention. They were with good intention, it would saying. Um, and as you say, it’s just exposed to an awful lot of, uh, challenges. Uh, thanks. But thank you for coming on the show. Do you, uh, do you write it all or do you have any way that people can follow you on social media or anything like that?

Nancy Beale:                 44:11                I am certainly on linkedin and have done some blogs through himss well. I chair the National Nursing Informatics Committee, so they have occasion to uh, put things out on blog there as well.

Bill Russell:                   44:29                And if people want to contact you for, they can, uh, you know, reach out to you through Linkedin, reach out through a starbridge advisors as well. Um, I really appreciate your time. Appreciate you coming on the show. Uh, this show’s production of this week in health it for more great content. You check out the website or the youtube channel thanks for listening. That’s all for now.


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