Book Reviews

AmericanEHR Blog: The Official Blog of America’s Clinician-Powered Health IT Community

April 25, 2013 Posted by Alan Brookstone, M.D. Book Review -- Innovation with Information Technologies in Healthcare

From time to time at AmericanEHR we receive books for review. Innovation with Information Technologies in Healthcare, edited by Lyle Berkowitz and Chris McCarthy, is one of those rare gems that bridges the gap between implementation and use of information technology, drawn from individuals’ experiences who have successfully applied those tools in clinical settings. At the introduction of each chapter, the reader is presented with a clinical scenario based upon a real-life situation. This is followed by a description of the background behind the technology, the reason for the innovation, why the innovation succeeded, lessons learned, and future plans. The book is easy to read and provides a number of fascinating insights into the challenges faced and how barriers were overcome or identified as issues that would need to be addressed in future iterations. The book is divided into three sections. The first focuses on actions that can be taken after implementing an EHR; the second looks at some innovative approaches to virtual interactions and telemedicine; and the final section is forward-looking with new ideas, visions, and approaches. A number of authors will be easily recognizable as thought leaders in their particular areas. A number of chapters that I particularly enjoyed: “Making ‘Right’ Easier” by Dr Peter Basch — highlighting the value of unobtrusive integration of actionable medical prompts. “‘All of None’ Bundle Philosophy” by Dr Thomas R. Graf — bundles of related care processes and outcomes used at Geisinger Health System. “Automatically Getting Better” by Dr David C Stockwell and Dr Brian R Jacobs — Automated Adverse Event Detection at Children’s National in Washington DC. “The Connected Patient” by Dr Jonathan S Wald — Partners Healthcare’s Patient Gateway system — patient portal. Whether you are looking for information on home telehealth, gamification of health technology, or tips to optimize EMRs, there are a number of compelling stories, in addition to practical background information to support innovation in areas that are covered. If I have one criticism of the book, it is that the information provided is limited to specific scenarios and one finishes the book wanting more of the same, but on a wider range of topics. Highly recommended reading, and, from my perspective, two thumbs up!

MEDINNOVATION AND HEALTH REFORM: WHERE HEALTH REFORM, MEDICAL INNOVATION, AND PHYSICIAN PRACTICES MEET – THE LEADING VOICE FOR MEDICAL INNOVATION ON THE INTERNET

May 11, 2013 Posted by Richard L. Reece M.D. Book Review: Innovation with Information Technologies in Health Care, Lyle Berkowitz and Chris McCarthy, editors

Physician attitudes towards electronic health records vary. Two basic schools of thought exist- true believers and rueful skeptics. True believers tend to say, “Look, this thing call health information is the wave of the future. Get with the program. Install EHRs. Live with them. It’s the law of the land.” Rueful skeptics are more prone to say,” Tell me when we get to the future. Tell me when EHRs are useful, don’t cut my productivity, get between me and my patient, and someone else will pay for them.” This book documents the health information technology innovation case for believers and seeks to encourage the skeptics. The book’s two editors, Lyle Berkowitz and Chris McCarthy work for large health innovative health care organizations, Northwestern Memorial Hospital in Chicago and Kaiser Permanente in Oakland, California. They have led the innovation movement at the national level – Berkowitz at the Szollosi Healthcare Innovation Program at Northwestern School of Medicine and McCarthy at the Innovation Learning Network//Innovation Consultancy at Kaiser. Their book features 43 authors at large health care organizations telling their stories of innovation from conception to execution. The stories focus mainly on how EHRs and their various iterations have bettered and transformed health care in their institutions. Berkowitz and McCarthy give three reasons why their book should be read. 1) Information technology is an increasingly important part of everyday life in health care, but a large gap exists between reality and potential. 2) Healthcare innovation is HOT, Everybody is talking about and scrambling to lower costs and improve quality. 3) The delivery and reimbursement of healthcare is in the midst of major changes. This book is not a book about a solitary innovator or great guru, like Steve Jobs, working out of a garage. It is about teamwork in large organizations. It is not about a single transformation idea. It is about multiple ways EHRs are incrementally transforming care. It is not about how Obamacare is driving innovation or how innovators are using EHRs to help implementation or minimize its consequences. The health law is not even mentioned. Instead the book is about how to structure innovative systems and the process of innovation as practiced in large institutions by innovative teams. In the book’s first two chapters, the two editors, in breezy colloquial language, couched in HIT management terms, use stories as told by authors in 20 large health organizations to make their points. The stories relate the Whats, the Whys, the Whens, the Wheres, and the Hows of the reasons why innovations came about, the pitfalls and pratfalls and the successes and where they are headed. The larger story is how EHRs , serve as the basis and inspiration of organizations’ “healing edge,” i.e. as tools to provide the right care , for the right reasons, in the right sequences, in the right places, at the right times, performed by the right people. The literary mechanism gluing these stories together is a fictional Martinez family – Barbara, the mom, Ray, the dad, Cindy, the daughter, and her younger brother, Mike. At the start of each chapter, a family member presents with a health problem. The EHR innovation addresses the problem, alleviates it, or resolves in an efficient, effective manner. The various storytellers share their tales in this sequence: opening problem, background of the organization, what is the innovation, why they created the innovation, how it succeeded, what were the results, what lessons did they learn, what do they conclude, and what do they see in the future.

HealthLeaders Media

HIT Innovations Spring from Strategy, Design, and Need -- Scott Mace, for HealthLeaders Media , February 5, 2013

Innovation doesn't always come from a brand new invention or idea. Usually, it comes from making improvements to something that already exists. Now Lyle Berkowitz MD, associate chief medical officer of innovation at Northwestern Memorial Hospital, has co-edited an entire book, Innovation with Information Technologies in Healthcare, that riffs on the topic. Subtitled "The Healing Edge," the book contains a surfeit of stories supporting the idea that innovation isn't the sole province of the wizards at Apple or Google. Rather it can emerge from the good ideas and brainstorms of designers working in close concert with healthcare providers. I spoke with Berkowitz last year, and he seems to know everybody who's anybody in healthcare IT. As such, he's a natural choice to edit this 311-page compendium, along with Chris McCarthy of Kaiser Permanente's Innovation Learning Network. An experimental model for solving problems -- The first thing I learned was that innovation can be the result of a methodology. The most common one found in the book is PDSA, which stands for Plan-Study-Do-Act, an experimental model for solving problems. You may encounter PDSA in variations such as Lean (for efficiency challenges), Six Sigma (for quality challenges) and Human-Centered Design (for experience challenges). Kaiser describes this last methodology in Chapter 2, where McCarthy describes Kaiser's Innovation Consultancy as "an internal design firm staffed by creative people who are part design, part strategy, and part healthcare." Sounds like a fun and important place to work, especially since the Center is inspired by design firms such as Ideo and PointForward. Identifying patterns used by technical innovators -- The Kaiser methodology parallels that of tech innovators such as O'Reilly Media, which has made a veritable industry out of identifying patterns used by technical innovators. It's through work such as this that the Web 2.0 paradigm was popularized, and we're now seeing insightful pattern recognition being applied to healthcare innovation. It's a shortcut to spreading innovative ideas more quickly than simply reciting case study after case study. Having said that, there are case studies aplenty in this book. We learn, for example, that patients at Kaiser wanted to have nursing shift changes happen at the bedside, so the EHR system was modified to allow that to happen. Low-tech prototyping -- The book also discusses the notion of "low-fidelity prototyping, a way to use simple methods to prototype enhanced tools and applications. "It turns out that approximating the tool in another system, such as the [Microsoft] Access database and paper print-outs, can allow for increased efficiency, cheaper cost, faster development and more creativity than trying to do so in the EHR system itself," writes McCarthy and his co-author, Christi Dining RN, director of Kaiser's Innovation Consultancy. Other prototyping exercises involve use of egg timers and simple alarms set on iPod touches. It's that kind of combination of low-tech, just-enough-technology thinking that we are going to need to get healthcare to where it needs to go. If providers continue to simply turn over a huge list of requirements to vendors (or the government), we're likely to get more overpriced, overproduced technology that doesn't accomplish the mission of making healthcare safer, more effective, and more convivial. Pathways to process efficiencies --Sometimes innovation simply involves applying a good idea from one part of healthcare to another part of healthcare. By now everyone has heard of Atul Gawande's use of checklists in the operating room. In Chapter 3 of this book, Berkowitz describes application of checklists to primary care and care coordination. This thinking was rolled into the Inflection Navigator, an EHR enhancement that allows physicians to choose "pathways" to activate care coordinators when significant new diagnoses are made. The first three pathways chosen for Inflection Navigator were hematuria, atrial fibrillation, and cancer. Other pathways will follow. According to Berkowitz, the system has increased process efficiencies, ensured consistent use of care standards, and provided financial benefits for patients, providers, and payers, and the book goes on in some depth to describe these benefits. A more-focused workflow -- Also featured in the book is an EHR overlay system for coordinating care in use at MedStar Health, the largest not-for-profit health system in the mid-Atlantic region. I learned that MedStar was the birthplace of what eventually became Amalga, a health information system now offered by Microsoft. At the heart of MedStar's innovation-fueled transformation was a realization that clinicians cannot be counted upon to remember which forms to open and complete in order to perform EHR tasks. I liken this to expecting taxpayers to remember which tax forms they'll need to download and fill out in order to file their annual income taxes. MedStar and others have pioneered efforts to focus workflow onto a single screen, although much, much more needs to be done in this area. These single-screen prompts also need to be customized to the particular role a given clinician provides in care. Designing those customizations is the tricky kind of detail that is essentially to the success of innovative health information technology, and that this book describes. Stories from smaller multi-specialty physician groups also find a place in this book. For instance, there's Southeast Texas Medical Associates (SETMA), designated by the Office of National Coordinator for Health Information Technology as one of 30 exemplary practices in the U.S. for clinical decision support. The screen shots reproduced from SETMA's IT system are a little daunting to me, but then again, they are tracking 200 quality metrics. Still, you can see that ultimately, clinical decision support dashboards are well under construction and in use at many HIT systems today. In this column, I've just skimmed a few of the many highlights of Innovation with Information Technologies in Healthcare. It takes its place on my bookshelf alongside books such as Connected for Health, which describes how Kaiser implemented its EHR. I'll be writing about that in the future. For now, hats off to Berkowitz and McCarthy for one of the most useful aggregations of HIT lessons learned that has been assembled thus far.