One Physician’s New Year's Resolutions

It's time to make a New Year's resolution. I'd like one that would be of some general use and also help me do a better job making decisions about EHRs. Some current news items have given me an idea.

First, there was an article by Don Fluckinger in Health IT Pulse that noted “the meaningful use Stage 2 schedule has given way to the demands of ICD-10.” He goes on to state that “What HHS is doing ... combines the worst of big bang and slow rollout. A big bang is what we’ve got, with HIPAA 5010, ICD-10, EHR adoption, HIE construction, health reform/ACOs and all the other health IT initiatives happening right now.” The “big bang” brings us a myriad of complex requirements to address concurrently and the “slow rollout” means that each set of requirements undergoes constant change and remains a moving target. Washington is engaging in fuzzy thinking in believing that such a complex set of disparate short-term objectives can be implemented and coordinated in such a way that the end result will have a real, beneficial impact on improving medical care, keeping the costs down, and keeping physicians interested in continuing in practice.

Second was an article by Ezekiel Emanuel in the New York Times that focused on the proposal to cut Medicare costs using a voucher scheme. The people who dreamed this up don't seem terribly concerned about what kind of healthcare people end up with or its total cost; they simply want to limit what the government pays out. The fuzzy thinking here is that unless some attention is paid to what care is actually being provided, both the government's payout and the individual's payout could both end up being wasted and could end up driving the effective cost of healthcare even higher.

Two kinds of fuzzy thinking lie beneath these examples - inappropriate word choices and the confusing expectations with wishes.

Whenever words are chosen, and I say this lacking telepathic powers to read the thoughts of the source, what the words mean to each audience member will be determined only by what each audience member believes the words mean. Politicians often exploit this fact. They are fond of “catch phrases” such as “healthy forests” or “digitize medical records” that can give the audience a warm, fuzzy feeling but have negligible information content. Sometimes, words come into common use and appear everywhere - “occupy” is an example. If the source, intentionally or out of ignorance, fails to choose precise words, and instead resorts to using colloquial jargon, the audience may be moved emotionally without having any clear notion what is really intended.

We are often told that “expectation management” is key to a successful EHR implementation but this is an inappropriate choice of words. An expectation is what is considered to be likely to happen. It may or may not be realistic but it is determined by intrinsic properties of the components and how people react to them, not by what people wish for. A wish, on the other hand, is a hope or desire for something. When people use the phrase “expectation management” they really mean wish management. When considering an EHR, it can be difficult to have an accurate understanding of what is “likely” to happen if you have no experience with or understanding of the product. You may be clear about what you wish for or imagine, but that will have little relationship to what is likely to happen - unless your imagination leads you to take actions that are incompatible with the intrinsic properties of the product. Expectations must be understood but it is the wishes that can and must be controlled.

My New Year's resolution is, therefore, to try to avoid fuzzy thinking even at the risk of being perceived as a curmudgeon. In the next couple of articles I'm going to dissect David Blumenthal's recent two-part commentary that was recently published in the New England Journal of Medicine. It provides some excellent examples that you can study. Perhaps you will agree that they demonstrate fuzzy thinking.

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