Master your fehr
Part III
Lara Hopley
Jo van Schalkwyk
www.fehr.org
Where are we?
Part I: Some philosophy
Part II: Get it working
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Part III: The anatomy of fehr
Part IV: Experimentation
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What are the problems?
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Modern medicine is wasteful and inefficient
Our baroque medical systems resist change
Clinicians from all walks are often bewildered, disengaged or even
antagonised by “attempts to fix how they function”
Vast expenditure has so far produced unremarkable results
Naïve fixes usually do more harm than good
Patients continue to be harmed, often in consequence
BMJ. 2011 Oct 17;343:d6054; CMAJ. 2011 Mar 22;183(5):E281-8; J Am Med Inform Assoc. 2015 Jul;22(4):849-56;
BMJ. 2010 Nov 16;341:c5814; Int J Med Inform. 2015 Mar;84(3):198-206
My thesis: “The solutions already exist”
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But then why have they not been implemented?
1. We’re looking in the wrong direction
2. The financial incentives are all wrong
3. Leaders and clinicians are pulling in different directions
4. The principles of “continuous quality improvement” are flouted
5. We are looking for quick fixes, but improvement takes time
6. “Perfection is many small things done well” but we want big, flashy
fixes that ease our pain right now
“The free EHR”
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Free as in:
Freedom of information
Free availability and access
Freedom to use it wisely and well
Price does come into it but this is not the main theme
The human cost of any eHR ultimately overwhelms the financial costs
Are current EHRs “non-free”?
fehr.org
Yes!
Designed to limit inter-operability, thus hiding information
Flaws are hidden beneath:
Legally binding agreements
“Hold harmless” clauses
Arcane and complex code
Stultifying user interfaces
Reasonable modifications are often unreasonably constrained
JAMA. 2009;301(12):1276-1278; Pediatrics 2011;127(4):pp. e1042 -e1047; Journal of American Physicians
and Surgeons 2009;14(2):49-50; Information Technology in Health Care: Socio-technical approaches 2010.
IOS Press, pp 7-14 (Koppel R, Kreda DA).
“Get off your high horse”
I’m not here as a stand-in for
Richard Stallman
I’m happy to be practical,
provided the government
stumps up the first payment of
~$500,000,000
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Two forms of waste
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1. The first waste
Reduplidupliduplication
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A counter-argument
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But…
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2. The more subtle, second waste
Articulating the pieces
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Codd’s solution
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“Normalization”—store just one copy of the data and
Carefully codify relationships between data items in
“third normal form”
“Each datum must depend on the key, the whole key,
and nothing but the key”
… so help me Codd.
A reprise on reduplication
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There’s nothing written into a system like Epic that forbids “doing the
right thing with the data”
There’s nothing written into “NoSQL” databases that forbids doing
the right thing
It’s just a lot easier to do the wrong thing (and let’s face it, you can
do the wrong thing with SQL too)
Our current document-centric systems epitomise the “wrong thing”
How can we make them data-centric?
We need problem lists
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Centre all clinical practice on the problems
Any concerned party can amend, augment and refute problems
Including and especially, the patient
With wiki-like traceability
And complete integration, without duplication
Complete integration
Every problem is clearly associated with:
Primary evidence (‘history’, findings, tests)
Current state (activity, severity, current therapy)
Future plans (investigations, management, prognosis)
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We can answer questions…
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“What are the problems?”
“What is the current medication list?”
“What’s this medicine for?”
“How certain are we in this diagnosis?”
“Why was this drug stopped?”
“Should I recheck this test?” …
A first attempt at “the right thing”
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Documenting a living, virtuous cycle
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Processes extend over time
Clinicians/carers interact with patients within “epochs”
Interventions produce results
Results provide evidence for the existence of problems
Aetiological hypotheses (Cause & effect) tie problems together
Clinicians propose management solutions that engender processes
… and the cycle continues
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“I think
you’ll find
it’s a little
more
complex”
Current system issues
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The GP “of record”
Whom we send our documents to (CCs in particular)
The smoking status
The clinician name on the patient label (“Obsolete when printed”)
Laboratory results (especially the person responsible for actions)
Diagnoses, both accurate and spurious
And this is just the start…
The most dangerous “duplication”
• Allergies
• Drugs
• Adverse drug reactions
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Ultimately, it’s not about the EHR
 The EHR is just a tool
 What matters is the clinical systems
The EHR can however help or hinder these systems
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Continuous Quality Improvement
1.
2.
3.
4.
5.
6.
7.
Show and teach everyone good statistical
practice
Drive out fear by eliminating numerical goals
Maximise overall value through collaboration
Train everyone on the job
Facilitate pride in workmanship
Build this new way into processes of
continuous improvement
Do this forever...
Out of the Crisis. W Edwards Deming. ISBN-13: 978-0262541152
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How can the EHR help CQI?
1.
2.
3.
4.
5.
6.
7.
Support good statistics
Put the numbers in context
Favour collaboration over duplication
Facilitate training especially numeracy
Allow workmen to view their competence
Provide a permanent institutional record
Forever…
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Let’s see…