Say No to Paper

Paper came one pill away from killing my 91-year-old mom. Only through luck did we dodge a medical error that could have extinguished a life that survived the Great Depression, World War II, polio epidemics, the birth of two children, the Cold War, the loss of her husband, and more than 60 years of employment. Up until her admission on May 7th, she never experienced being an ill patient in a hospital.

Mom was admitted to a hospital affiliated with her cardiologist located in Westchester, New York, a location close to the home of my sister, a trained endocrinologist with more than 20 years of clinical experience. After treatment for an upper respiratory infection, urinary tract infection, and symptoms of viral pericarditis, Mom was discharged to my sister’s home.

After a week of rest, she returned to Westchester for continued recuperation with my sister. Unfortunately, her condition worsened after a few days, leading her physician to re-admit her to the hospital. At the conclusion of a few days of further tests and treatment, she was transferred to the hospital’s co-located rehabilitation facility for several days to continue her treatments in a less acute care setting. Due to the lack of availability of required therapy over the upcoming Memorial Day weekend, we collectively decided to have Mom discharged to my sister’s home where she could receive better care.

Holiday Weekend Dangers

As Mom suffered from new onset of intermittent atrial fibrillation, the physicians prescribed Pradaxa, an anticoagulation therapy drug that greatly reduces the probability of stroke in patients suffering from atrial fibrillation. The decision to discharge my mom on the Friday before a holiday weekend immediately proved problematic. Pradaxa at the 75 mg dose was unavailable in several pharmacies in the area around the hospital.

Over a 2-hour period, working with a very helpful social worker in the hospital, we convinced the outpatient hospital pharmacy to fill a prescription for the drug. While my sister prepared Mom for discharge, I rushed down to the pharmacy with the paper prescription for 75 mg of Pradaxa. With the prescription bag in hand, I rushed up to meet my mom and sister to help them prepare for discharge.

I handed the prescription to my sister who promptly opened the packaging and looked at the bottle of meds. “This is wrong”, she shouted. “Mom should be on 75 mg not 150 mg.”

Although the prescription was written correctly, the pharmacy dispensed the wrong dose. Knowing my mom had just dodged a potentially fatal medication error, I promptly returned to the pharmacy with the incorrect mediation in hand and explained to the pharmacist what happened. All color left his face as he began to apologize profusely. He just experienced a sentinel event that required immediate and complete reporting.

Anatomy of an Error

Reviewing the sequence of events surrounding the medical error, it becomes clear how it occurred. Although the handwritten prescription was legible and correctly written for 75 mg of Pradaxa, the pharmacist mistakenly selected an unopened, 60 capsule bottle of Pradaxa 150 mg to fill Mom’s prescription. He then placed the medication in a sealed paper bag, attaching the prescription receipt to it. Had the hospital been equipped with ePrescribing and an electronic medication administration system, the system would have immediately alerted the pharmacist of the dosing error. The scanned barcode of the bottle of 150 mg of Pradaxa would not have matched the expected barcode of a bottle of 75 mg capsules.

Going forward I will never allow anyone I know to be treated in a facility that bases its medical care on dangerous paper-based processes. Nor should any American ever be subjected to such inferior care. If we continue our efforts to promote and properly deploy healthcare information technology, this soon will be true.

Excerpts from: Say No to Paper. PSQH, July/ August, 2011

Photo Courtesy of  Don Guerwitz Photography – Gamelan Orchestra. Bali, Indonesia

Watson, Come Here I Need You

Although a call for Watson brings to mind Alexander Graham Bell’s first words on the telephone or Sherlock Holmes greeting to his physician companion, The New York Times heralded another Watson on its February 17, 2011, front page. The artificial intelligence computer system won on the game show Jeopardy! In the television program’s only computer versus machine match-up, Watson defeated Brad Rutter, the biggest all-time money winner, and Ken Jennings, the record holder for the longest championship streak. Watson had access to 200 million pages of structured and unstructured content, which consumed more than four terabytes of disk space.

This experience with Watson illuminates how artificial intelligence computer systems offer healthcare providers robust, evidence-based clinical decision support. In addition, it identifies the special role humans play in diagnosing and treating patients. If combined together, these capabilities can synergistically offer higher levels of valuable and effective care.

For information technology to play a valuable role in reducing healthcare costs while enhancing quality of care, it must be deployed in a way that completely reinvents how care is delivered, professionals provide the care, and technology is leveraged. Watson’s success on Jeopardy! demonstrates the capabilities of computers to store and retrieve medical knowledge at the point of care, thereby freeing clinician minds from the unnecessary burden of recalling facts. Clinicians are freed to focus on their patients while more effectively utilizing their ability to identify unusual patterns previously obscured by the “noise” inherent in a busy practice.

In 2011, progressive organizations will further the deployment of computer-based clinical decision support, rework the roles of all caregivers, and transform their processes to achieve ever-increasing levels of quality, safety, and efficiency of care delivery.

Excerpts from: Watson, come here. I need you. PSQH, May/June, 2011.

Photo Courtesy of  Don Guerwitz Photography – Loading the Boats after Market. Sanka, Myanmar (Burma).

Seeing Is Not Believing

Consider this scenario. An adventure traveler begins his trek to a remote village in the Andes. Upon arriving at the airport, he rents a car and begins his journey on winding roads to the village. After 90 minutes of driving, he encounters an intersection with a traffic light. Upon seeing the bottom of the light glowing brightly, he continues through the intersection.

Suddenly, his car is knocked sideways by an automobile that crashes into his front passenger side door. No one is injured but both cars are severely damaged. Figuring his “attacker” ran a red light as his light was surely green, he jumps out to accuse the other driver of reckless driving. Upon further investigation, our traveler learns that in this part of the country, traffic lights are constructed differently than in the United States. Although a red light means stop and a green light means go, green lights are placed at the top of a traffic light while red lights are at the bottom, completely opposite what is followed in the U.S. and most of the world.

Who is at fault here? I am pretty sure our traveler saw the bottom light as red but his brain processed it as green, meaning go. In every other situation encountered by this traveler, a glowing light at the bottom of a traffic light was green, and it meant “go.” For human beings to navigate the world efficiently, we generalize our surroundings.

Inference Rather Than Analysis

The effort required to analyze each situation requires too much brain processing and would cripple our ability to do things. Therefore, when we encounter situations that are familiar to us, we infer much of the situation, using only a limited amount of the reality as a template for what we are seeing and experiencing. Only when we encounter completely novel situations, do we dial back our inference and concentrate on the activities in front of us. Yet, even then, we do a significant amount of inference to make efficient our interpretation of the situation.

Workflow and process redesign must consider not only the existing patterns of care delivery and the ways to make them better, but also the inherent way human beings process their environment. As noted above, inferring the environment is critical to our maneuvering through our daily lives. A workflow that does not consider the impact of inference on the actions of human experts can easily lead to medical errors.

As organizations work at deploying health information technology and deliver clinical transformation through redesigned workflows, they need to recognize the basis for many of the errors we, as human beings, make in our everyday lives. By recognizing our limitations and designing around them, we can fully reap the safety benefits of health information technology in our delivery of patient care.

Excerpts from: Seeing Is Not Believing. PSQH, March/April, 2011

Photo Courtesy of  Don Guerwitz Photography – The Burning Ghats. Kathmandu, Nepal

Show Me the Money

The most important lesson in medical care comes from a bank robber who stole more than $2 million and spent more than half his life in jail. Named after Willie Sutton, the one of the most prolific bank robbers in history, Sutton’s law states that when diagnosing, one must consider the obvious. Diagnosticians should first conduct those tests that will confirm the most likely diagnosis, and order them in a sequence that has the highest probability of delivering an accurate diagnosis. This approach also minimizes unnecessary tests and reduces costs.

Sutton’s law grew out of a famous response to a reporter’s question attributed (perhaps falsely) to Sutton. When asked by a reporter why he robbed banks, Sutton allegedly replied, “because that’s where the money is.” In reality, he probably said, “Go where the money is… and go there often.”

More than 20 years ago, payors and providers experimented with capitated arrangements where IPAs—Independent Practice Associations often constructed from a broad swatch of primary care and/or specialty physicians—contracted with payors to provide services to a population of insured individuals. Although numerous variations of capitation were tried during that time, capitation arrangements did not succeed in reducing costs, increasing provider compensation, or improving quality of care. Many physicians continued to over-utilize services.

Like so many ideas in healthcare, the old, after a time of dormancy, becomes the new. The excitement around accountable care organizations (ACOs) and patient-centered medical home projects is based upon much of the same thinking that excited healthcare policy makers 20 years ago. With ACOs and patient-centered medical homes, primary care physicians would be responsible for both the care and cost of care for patients assigned to them. Those physicians able to keep their patient population healthy while reducing the cost burden associated with treating their population would share in the savings to the payor.

What our healthcare system will look like at the end of 2014, when the final provisions of the Affordable Care Act of 2010 become active, may be fuzzy today, but a rough picture of it can be drawn by following the flow of financial incentives. By 2014 the effects of removing lifetime caps on medical costs, eliminating the process of denying coverage due to pre-existing conditions, emphasizing the use of proven disease treatments, and reducing reimbursement for preventable medical errors and readmissions shifts the care incentive from providing more care to providing only care that is needed.

Healthcare information technology will play a critical role in delivering these new models of care delivery and financing. Only through robust information technology can we track and report on performance, offer clinical decision support to enhance safety and quality, and monitor the health of populations of patients. Healthcare information technology offers the critical tools to move clinicians from their focus on episodic care, where financial incentives were based upon piecework, to much broader population-based care, where financial incentives promote the delivery of favored clinical outcomes that efficiently utilize resources. Therefore, to understand the current and future changes to our healthcare system, you need only to know where the money is and where it is flowing.

Excerpts from: Show Me the Money? PSQH, November/December, 2010

Photo Courtesy of  Don Guerwitz Photography – Breaktime. Jokhang Temple, Lhasa, Tibet

A True Tipping Point?

From the signing of healthcare reform legislation to the release of final rules for “meaningful use,” events in 2010 are driving toward a true transformation in the delivery of healthcare in the United States. Optimism is high that we will finally see tangible benefits from healthcare information technology as measured by enhanced quality, improved access, and lower costs. I recently reviewed some testimony given to a subcommittee of the U.S. Senate Finance Committee that highlighted the role of healthcare information technology in transforming healthcare delivery.

Here are excerpts from that testimony.

“It is with great anticipation I approach this committee today to give testimony on health care issues and the effect new information technologies will have on the delivery of care. Clearly the swirling debate on how to restructure our health care system has raised the awareness of all Americans to this important issue. It is through the management of information, in particular its dissemination, that we can address some of our health care challenges. We need to use new information technologies to provide physicians, patients, providers and payors with the appropriate, relevant information to produce good, acceptable outcomes from appropriate cost-effective care.

“The information technology revolution is changing the way medical care is delivered. These new tools provide physicians with the opportunity to access relevant clinical information on a real time basis to most likely impact on their patient care. Using standards, guidelines, protocols, and information available from profiling using normative data bases, physicians can obtain useful information on their patterns of care. Patients can obtain understandable information on their disease process, thereby becoming an informed consumer of health care. Organizations exist to educate physicians and other health care professionals in the use of these systems. For-profit firms are developing the tools and making the investment needed to convert data into information.

“My final advice to this committee is hold on tight, the medical information superhighway has no speed limit.”

Excerpts from: A True Tipping Point? PSQH, September/October, 2010.

Photo Courtesy of  Don Guerwitz Photography – A Farmhouse, Central Turkey

Is “Meaningful Use” Meaningful?

Now that the “meaningful use” rule has been finalized by the Office of the National Coordinator (ONC), many organizations turn their focus to a rapid deployment of electronic medical record (EMR) systems in an effort to achieve transformation of the United States healthcare system. Unfortunately, EMR adoption is just one tool used to transform health care, and not the single transformative activity so many believe it to be. Transformation of healthcare encompasses enhancing quality of care, improving patient safety, expanding access to care, and reducing the cost of care. EMRs deployed to satisfy the criteria for “meaningful use” can impact these factors, but only within a comprehensive framework that recognizes the role of incentives, clinical decision support, and healthcare information technology (HIT) in facilitating transformation.

Introduction of new technology often distracts us from our primary task. Our fascination with the technology leads us to focus on what the technology can do, rather than what we need the technology to do. This misguided use of technology also occurs when it is used for healthcare delivery. Many EMR implementations focused on the impressive features of the EMR software rather than the workflow requirements of the clinician users.

Healthcare transformation requires a comprehensive vision of care delivery that recognizes the interrelationships of the many stakeholders. Technology by itself only helps improve those interrelationships, while the underlying structure that the interrelationships are built on remains.

Therefore, the “meaningful use” criteria are meaningful in that they help ensure the use of EMRs in ways that can enhance healthcare delivery, they do not transform healthcare. The recently passed Patient Protection and Healthcare Reform Act (2010) does much to move us toward a better healthcare system, but it too does not transform healthcare. Transformation requires many factors working together in an iterative process to deliver the expected results. Some of those factors are outlined below.

Until economic incentives of all the stakeholders align, care delivery will remain inefficient and suboptimal in quality and safety. Providers are incented to provide more care, payors are incented to withhold care, and patients, detached from the direct costs of care, have been molded to always expect care. The culture of healthcare in America is based on the false belief that more care is better care.

Transformation of healthcare requires a complete disruption of our current system of healthcare delivery. Clinical roles require redefining. Workflows will change to meet the needs of these new clinical roles, allowing the HIT tools, such as EMRs, to be leveraged to improve care. “Meaningful use” criteria is a nice first step to help ensure the effective deployment of HIT tools such as EMRs. Nevertheless, it is just a very small step towards truly transforming healthcare.

Excerpts from: Is “Meaningful Use” Meaningful? PSQH, July/August, 2010

Photo Courtesy of  Don Guerwitz Photography – First Light. Bhaktapur, Nepal

Regulate HIT Tools as Medical Devices? Yes and No

The Food and Drug Administration recently announced it is reconsidering its previous decision to exclude health information technology (HIT) tools from regulation as medical devices. When last evaluated in the late 1990s, this decision made common sense. At that time HIT consisted of rudimentary clinical documentation systems, electronic reference materials, and administrative applications. As even these tools were not well integrated with each other and into clinical workflow, they represented more of a digitization of paper-based activities rather than something truly transformational.

Today, HIT functionality far outstrips what was even dreamed about 10+ years ago. In addition, applications function in an integrated manner truly providing the clinician with a clinical experience much different than that offered using paper-based clinical documentation or simple clinical decision support tools.

The role of physicians, nurses, and other healthcare professionals is changing. These providers are becoming more dependent upon the clinical content within the HIT tools, often deferring to “decisions” made by these tools. Such examples include differential diagnosis, prescribed diagnostic and therapeutic treatments, choice of drug, and drug dose calculations. Although the previous rationale for not considering such HIT tools medical devices was based upon the intermediation of the provider between the recommended clinical activity and actual actions taken on behalf of the patient, the strong reliance on these very sophisticated HIT tools today puts this premise into question.

The FDA must study in detail the quality and safety issues inherent in integrated HIT applications before rushing to regulate HIT tools as medical devices. An uninformed effort to regulate HIT tools as medical devices may cause more harm than good. Applying the same standards used for medical devices to HIT tools makes little sense as HIT is neither a standalone application nor strictly a medical device. They are integrated applications that can impact quality and safety in ways far dissimilar to standard medical devices.

Regulation of HIT tools as medical devices is currently premature. Although HIT tools do directly impact patient care and therefore surely require some level of regulation, such regulation cannot be done without the requisite understanding of how HIT works within clinical workflow. The regulations must be constructed to advance HIT use while simultaneously protecting patients.

Excerpts from: Regulate HIT Tools as Medical Devices? Yes and No. PSQH, May/June, 2010

Photo Courtesy of  Don Guerwitz Photography – Running the Rapids, Mae Hong Son, Thailand

Health IT’s Glue

In my last column “Raison d’Être” I wrote about the importance of staying focused on making healthcare IT work to achieve the four important goals noted above: patient safety, quality care, access to care, and cost savings. In March, I addressed the HIMSS membership with these words:

Healthcare information technology is the instrument that will transform healthcare, and it is we—the informaticists, clinicians, management engineers, senior IT executives, IT specialists, and the diverse talents of so many others—who will create the applications, processes and workflows that will improve quality, safety, access and cost-efficiency.

In addition to our effort to transform care delivery through deployment of innovative software, revised processes, and creative workflows, niche applications are becoming available that allow the varied health IT tools to be sewn together to allow us to effectively tap into their potential. Without these applications we could not achieve the necessary integration of systems that permits the construction of meaningful, efficient workflows. Such workflows allow clinicians to deliver quality care safely and efficiently while satisfying the work requirements of caregivers.

The future of health IT over the next five years is in the development of these “glue” applications that allow the seamless linking of large, robust system, such as EMRs or laboratory applications, so that end users can utilize these tools in a coherent, patient-centric manner.

Excerpts from: Health IT’s Glue. PSQH, March/April, 2010

Photo Courtesy of  Don Guerwitz Photography – Angkor Watt. Siem Riep, Cambodia

Keynote Adddress at HIMSS 2010 Annual Conference

(Opening address given at HIMSS 2010 Annual Conference, Georgia World Congress Center, Atlanta, GA, March 1, 2010.)
For PDF of keynote address, click here.

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Our great country is on an unsustainable healthcare cost curve that threatens our ability to bounce back from the severe economic challenges we now face. In addition, healthcare quality and safety, as well as access to care, sit at disappointing levels, especially considering the resources our nation expends on healthcare.

While these healthcare challenges are daunting, I believe the solutions to them must and will come from the professionals sitting in this room and from our colleagues across the country and around the world. Healthcare information technology is the instrument that will transform healthcare and it is we – the informaticists, clinicians, management engineers, senior IT executives, IT specialists and the diverse talents of so many others – who will create the applications, processes and workflows that will improve quality, safety, access and cost-efficiency.

I am confident that we can make this transformation happen because similar revolutions relating to technology and the workplace have happened quite recently. For example, consider the huge changes in how we communicate with each other. Throughout this week, we all will be periodically checking our e-mail inboxes to stay in touch and communicate. According to Merriam-Webster, it was in 1969 that the term “inbox” first entered the American lexicon, to describe a physical tray holding incoming mail and work documents. Over the next 40-plus years, the inbox morphed into an electronic tray where important messages and information are stored. Today, the inbox pervades our working and personal lives, present on our personal computers and mobile smart phones.

The story of the inbox is in many ways the story of the American economy over the past four decades. The inbox tells the story of how a manufacturing-based industrial economy became an information- and knowledge-based service economy driven by data and analytics. The inbox tells the story of how savvy businesses began to share information quickly and inexpensively. These businesses effectively leveraged this information to deliver higher quality products at lower costs. By meeting the needs of their customers, their profits grew while profits of their competitors’ shrank. New ventures sprouted to support these innovators with brand new knowledge-based products. Smart companies thrived in this new data—driven marketplace; others – either unable or unwilling to adapt – could no longer compete.

While most American industries became more efficient and streamlined as a result of these economic realities, healthcare in many ways remained frozen in time. Today, the cost of the American health care system, at 17 percent of GDP, is a millstone around the neck of American businesses, raising the costs of production, stealing wages from the pockets of workers, and restricting the ability of American companies to compete globally. Health care here costs at least 50 percent more than it does in any other industrial country, and according to the World Health Organization, our health care system underperforms in quality, safety, and access to care. In 2006 we ranked 39^th for infant mortality, 43^rd for adult female mortality, 42^nd for adult male mortality, and 36^th for life expectancy. According to a 2008 study reported in the Journal of Health Affairs, the United States trails every single country in the 30-nation Organization for Economic Cooperation and Development in amenable age-standardized death rates, meaning, we are worst at preventing unnecessary death in people under the age of 74. Isn’t the whole point of healthcare delivery to create wellness and prevent unnecessary death? Sadly, we are not doing very well.

In many respects, our health care system still operates like the typical business of 1969 – it is still largely paper-based, it ignores information tools that can facilitate evidence-based best practices, and it functions without analytics to qualify and quantify the care we provide. Medical decisions are made according to implicit criteria – hidden internal knowledge – rather than explicit criteria – external knowledge that can be checked, evaluated, and updated. The Dartmouth Atlas of Health Care provides documented proof of glaring, unacceptable variations in how health care is provided and sheds light on disparities existing across the country. Too many providers are not taking advantage of 21^st-century technologies to access 21^st century information, choosing instead to provide care the same way it was done 40 years ago.

How can we change this? While enacting healthcare reform legislation remains a critical need, any health care bill will primarily impact reimbursement policy, not the transformation of care delivery.  And, because the task of transforming our health care system to meet the challenges of the 21^st century remains to those of us who work in the system, as the HIMSS board chair, I direct these three important messages to your inbox today:

One: HIMSS will play a leading role in the transformation of American health care by effecting positive change in four key areas: quality, safety, access to care and cost.

Two: HIMSS’s purpose – our reason for being – is this health care transformation.

Three: As members of HIMSS, you are the leaders who will create the solutions that will drive this transformation. Through the implementation of compelling healthcare IT solutions, you must transform the way health care is provided in this country. Not the president, not Congress, not clinicians – you. If you don’t do it, it will not happen. You must step forward and you must lead.

As I begin to make the case for why and how healthcare IT will transform health care, I’d like to take us all back to 1981, the year I graduated from medical school. Back then, people spent a good part of each workday managing paper. Upon returning from lunch, a busy executive was handed a pile of pink while you were out messages. She, or more likely he, would find a report draft on top of a bulging inbox. Attached to the report was a brand new, very popular, high-tech item of the day – a post-it note – where the boss scribbled a message to review and advise by writing comments in the margins. On his desk for his signature was a series of letters that his secretary had revised using another technological marvel – white-out. Reminded to call a key contact for advice on an important matter, the executive would quickly thumb through his rolodex to find the telephone number.

During my time as an Epidemic Intelligence Service officer with the Centers for Disease Control back in the 1980s, I do remember working this way. My first outbreak investigation was a foodborne illness on a cruise ship sailing out of Pittsburgh on the Ohio River. When investigating these type of outbreaks, my first task was to construct attack-rate tables that try to statistically identify the food that made people ill. I built these tables by doing all the calculations on a handheld calculator. No PCs were available to me at that time. Needless to say, it took me a few hours to complete the table and identify the cause of the outbreak.

Back then, we were very comfortable going about our business in this fashion and saw no need to change. Still, over the following several years and continuing into the 1990s, the workplace began to change immensely due to personal computers, e-mail and the Internet. Workers did not need to be encouraged to use this technology. They wanted to use it, even demanded to use it, because it made their jobs easier and made them more productive.

Today, in 2010, we must begin to change healthcare in the same fashion – by creating healthcare IT solutions that are so compelling, so irresistible, that people just want to use them. We cannot rely on incentive programs or executive orders.  We must create demand.

We must create electronic systems so appealing that they make physicians want to leave their paper medical records behind. We must create clinical decision support systems that make it routine for physicians to check their internal knowledge with data and evidence. We must offer workflow solutions that improve the efficiency of using health IT. We must make physicians want, yes, demand the enormous power that IT brings to the practice of medicine.

Creating this demand is important because it will improve quality, safety, access to care and cost-efficiency. Simply, we have to change a paper-based system in which most clinical decisions are made primarily by intuitive judgment – based on the ability to recall disparate facts – into an electronic system enabling decisions to be made according to data and evidence.

We must provide clinical decision support tools that reduce the burden of recalling facts and help to assess patients, form diagnoses, and choose therapeutic paths. Healthcare IT opens the door to this higher level of medical practice, one where both physicians and nurses can concentrate on examining, interacting, and motivating patients while technology handles the burdens of collecting, storing and accessing data. The knowledge of best practices and evidence-based care must be delivered to every single clinician at every point of care so that every patient everywhere receives care according this latest knowledge, rather than according to the habits of a clinician disconnected from this knowledge.

American medicine, right now, is relying too heavily on recalling facts. Perhaps the clearest example of this fact is the Pronovost checklist. Each year, about 28,000 Americans die due to I-V line infections. In response, Peter Pronovost, a Johns Hopkins physician, developed a list of five simple steps that intensive-care doctors should take to prevent the introduction of bacteria when inserting an I-V line. Physicians working at 108 hospitals in Michigan adopted the five steps and reduced the infection rate to essentially zero. A paper about their success was published in the New England Journal of Medicine in 2006. But, today, most American intensive-care doctors still don’t use the checklist. They continue to rely on their ability to remember what to do each time they insert an I-V line. Most times, they get it right. The few times they don’t, people die unnecessarily from infections. This is crazy. Every physician I know wants to help patients, not hurt them. Yet, we are hurting them.

It’s up to healthcare IT to make knowledge such as the Pronovost checklist more readily available and its discovery and use more intuitive. This work will require the design of clinical decision-support systems and other tools that merge seamlessly with patient care activities. This work will not just distribute best practices, but embed them into the workflow of medical practice. This work requires a unique multi-disciplinary effort involving not only workflow experts but also virtually any person connected with clinical care.

Bringing this level of sophistication and beyond to American health care will signify true transformation and will require all of the diverse talents represented within HIMSS. No matter who you are, whether you are a senior IT executive, a clinician or an engineer – whether you come from a hospital, a community or public health organization, a clinical practice, a payer or a pharmaceutical company – or whether your primary interest is patient safety, quality, research, privacy, or return on investment – we need you to contribute to the cause of transforming health care through IT.

HIMSS is reaching out to new groups and communities who must engage in the transformation. For example, our Life Sciences Community initiative actively engages pharmaceutical and life science companies, medical researchers, practicing clinicians, the academic community, and device manufacturers. This initiative concentrates on improving the quality, access and usefulness of data through interoperability and interconnectivity – data that can lead to new medical discoveries and treatments. With Board approval, I recently appointed Debra Bremer, Vice President at Pfizer, as an advisor to our Board to offer guidance in these efforts.

Our Payer Community initiative recognizes the shift from the payer playing the role of a transaction manager to one of a care delivery partner focused on improving chronic care management and overall patient outcomes. With Board approval, I also recently appointed Kevin Hayden, President at WellPoint, as an advisor to our Board to provide guidance in these efforts.

Both Debra and Kevin have been working hard with our staff to engage these two communities as we have engaged other industry specialty areas in our effort to transform healthcare through IT. To further involve and educate professionals we need to achieve our goal, HIMSS also has launched a Diversity Business Roundtable, created and delivered numerous distance learning opportunities, and reached out to several academic institutions.

Transforming healthcare requires the development of imaginative solutions. Cedars-Sinai Medical Center in Los Angeles did just that to improve hand-washing compliance, according to a story in the New York Times. Several research studies have reported that health care providers wash or disinfect their hands in less than half of situations where they should, with physicians being among the worst offenders. In an effort to achieve 90 percent or better hand-washing compliance in advance of a Joint Commission inspection, Cedars-Sinai first tried a campaign of e-mails, faxes and posters, but that didn’t work.  Then, a group of physicians and hospital administrators – who dubbed themselves the Hand Hygiene Safety Posse – started handing out bottles of Purell to physicians rounding on wards or as they stepped out of their cars in the parking lot. Also, the posse awarded a $10 Starbucks card as a reward to any physician “caught” washing his or her hands. This tactic improved compliance from 65 to 80 percent but still fell short of the 90 percent goal.

After delivering these discouraging results to the medical center’s chief of staff advisory group of roughly 20 doctors, the hospital’s epidemiologist handed each doctor a sterile petri dish loaded with a spongy layer of agar. “I would love to culture your hand,” she said.

The resulting cultures were photographed. The images were – in the exact words of the epidemiologist – “disgusting and striking, with gobs of colonies of bacteria.”

But here’s the best part – and where IT comes into play: the hospital harnessed the power of this disgusting image by making it into a screen saver that haunted every computer in Cedars-Sinai. Reluctance to hand washing vanished in the face of this filthy evidence, and compliance shot up to nearly 100 percent, where it remains today. Cedars-Sinai urologist Dr. Leon Bender said in the Times article: “With people who have been in practice 25 or 30 or 40 years, it’s hard to change their behavior. But when you present them with good data, they change their behavior very rapidly.”

Now, Cedars-Sinai obviously did not employ leading-edge IT sophistication to solve its problem.  But I chose to share this story with you because it’s a wonderful example of fast and practical problem solving. It shows how you can solve an important safety problem, relatively quickly, through multidisciplinary teamwork, data gathering and a little bit of IT. Oh, and let’s not forget about some good marketing. I chose to tell this story because I want you to think of what problem of a similar nature you might solve. And how you can work to gather the team and fix it.

This week we will hear about many other examples of problem solving and achievement. This year’s Davies Award winners, for example, have impressively improved access to care, quality performance, cost-efficiency and safety. The 19 hospitals that have achieved the HIMSS Analytics Stage 7 recognition represent the first of the truly paperless hospitals and give all other hospitals something to emulate.

But I have purposely crafted my remarks today to emphasize that it’s no longer about what others have done or what others are doing.  It’s now about what you and your organization are doing to transform American health care. I suspect that some of you may see yourselves clearly within this context while others may not. Let me suggest to you today that no matter who you are and what your role is, you have an important if not critical role to play to achieve transformation. You can fulfill your role by building a multidisciplinary team with the expertise needed to solve a problem. You can fulfill your role by gathering and sharing data and evidence as you go along. And you can fulfill your role by having the courage to stay the course or to change your mind – whatever the situation calls for. Great science comes from flip-flopping – it’s O-K to change your point of view as you gain new knowledge.

The challenge before us now is to help all health care organizations to achieve the standards set by the leaders. Indeed, we are succeeding in changing the culture. We have reached the tipping point. Health IT isn’t just for early adopters anymore; it is expected of all.

I send this urgent message to your inbox today: the transformation of American health care by improving access, quality, safety and cost-efficiency is a cause to which we all must dedicate ourselves. Identify a project, engage experts different from you, embrace diversity, form a team, try something unique, make mistakes, redouble your efforts, celebrate your successes, and then start again with a new idea. It is you who will discover something new. It is you who will develop the needed solutions. It is you who will effectively implement change. It is you who will transform healthcare. It’s your job to act now upon the message in your inbox and to place your contribution to a transformed American health care system in your out-box in due time. Thank you.

Barry P. Chaiken, MD, FHIMSS
2009-10 Chair HIMSS
CMO, DocsNetwork, Ltd.

News from HIMSS 2010 Annual Conference