Friday, October 28, 2011

"Six Months of Strategery?"

I read a story in Modern Healthcare about a discussion with HHS CTO Todd Park at a recent conference in Nashville. He talked about unleashing innovation. I applaud Todd for his bravery in giving out his email address publicly seeking input on innovations, and for his goal of “unlocking the mojo” of HHS staff, rather than having good ideas doomed by “six months of strategery.” I liked that!

There has been plenty of recent discussion, and guidance from NIST about improving EHR Usability (for patient safety, efficiency, and many other reasons). There has also been similar discussion in the HIT Standards Committee implementation workgroup about improving the usability of specifications and standards to remove barriers to adoption so the “little guy” isn’t left behind, and so that everyone doesn’t waste time navigating specs that point to other specs that point to other specs (called “the indirection problem”). Some recent standards efforts, such as the HL7 Consolidated CDA implementation guide, are trying to improve usability of specs in this way.

I plan to write Todd speaking as an individual citizen (remember this blog doesn’t speak for my company though my writing is influenced by working in the Health IT industry). Usability is important for both a positive and a negative reason. Lack of usability (of specs, or software, or anything) tends to waste people’s time and “raise their blood pressure” due to frustration. Wasted a few hours per person multiplied by thousands or millions of people, and you have some serious non-productivity! Worse, it can lead to mistakes (like clinical errors jeopardizing patients) or people throwing up their hands and just not doing things that are too complicated (like refusing to use an EHR). On the positive side, when something is usable, like I consider my search engine, Word processing, email, and blog editing software to be, then people can get amazingly more productive, and can do great things.

What about the usability of the specifications that hover over all of us in the EHR industry, Meaningful Use and Certification regulations? Or for that matter, all Federal regulations published in the Federal Register with its three columns and small print, no index and poor searchability? It’s so “1950’s” and paper-oriented. You can’t just scroll down the page like any normal document or web page, because you have to keep backing up for the next column. Try fitting a page on a screen and you can’t read the tiny font. You can’t search it to find a referenced section number, because the numbers are not a sensible scheme like, where you always know your context: instead section numbers aren’t even contiguous and searchable. For example, the ONC Standards and Certification Final Rule has text like “The standard specified in § 170.207(a)(2)”  OK, if I want to find that paragraph in the document, it’s easily done in the Acrobat search box, right? Nope, can’t be done! It only finds is the references to the paragraph, but not the paragraph itself. The only way to get to § 170.207(b)(2) is by scrolling around and finally locating 170.207 near the end, then finding subparagraph (b) dangling by itself, and finally finding subsubparagraph (2), hopefully still inside of (b) unless I missed a changed letter in between. And when I finally get there, I still can’t see what the standard is, because it says “the code set specified in 45 CFR 162.1002(a)(2)” which isn’t defined in the document. I have to go out to Google. Those like me who have been doing this for a while know some tricks and short cuts and contacts to ask, but a lot of people don’t have that luxury.

So my suggestion to Todd is very low-tech and has nothing to do with HIT, but a lot to do with usability, productivity, and helping folks actually do what the regulations want them to do! First of all, they need to be able to understand the regs in a reasonable amount of time. I’ve spent hundreds of hours reading regulations affecting HIT. I estimate that just their formatting and numbering alone causes me to spend 50-100% more time to digest them than it should. And I probably also miss important information in the process. Multiply that by thousands of others who have the same problem. While it helps that others have created “Readers Digest versions” to simplify and explain the regulations, but why did they have to create them in the first place?

Could this problem be solved by reformatting new regulations for usability, using a few smart people including human factors engineers, armed with common sense and putting themselves in the “consumer’s” shoes? Could this be done without “six months of strategery?” Hopefully yes, if Todd’s right and “mojo gets unlocked” in this area. I admit that I and probably most people and companies have similar entrenched traditions and rules that get in the way of us doing what we ought to do. I just blogged about this today because I read the interview with Todd and connected his ideas with my reading of the regulations. But the Federal Government’s regulations affect thousands of providers, vendors, and others. There’s a real opportunity for a simple low-tech innovation in the government regulation writing and formatting to help many people avoid wasting time, so they can direct more of their energies to creating innovative solutions that will really help people!

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