Password Security - Sanity

Finally some sanity in what has become a ridiculous storm of challenging and sometimes impossible hurdles. Microsoft Research has validated what I am betting the vast majority of users know already that

Many of these irritating security measures are a waste of time

This was featured in an article by Mark Pothier from the Boston Globe - "Please Do Not Change Your Password" and was featured in an NPR news piece on All Things Considered: Study: Computer Security Measures Not All Worth It. As usual with security it is a cost benefit trade off and what is deemed appropriate in one setting is maybe not the case in another. By the study calculation that one minute of collective user time fighting with a new password or alternative password requirements equals about $16 Billion per year!


In health care we manage and maintain confidential information and it does need to be secured but mandated password requirements that remain totally inconsistent across different applications and tools (and in some cases inconsistent within products) places barriers and in particular time loss on an already time challenged set of clinical workers. As the renown security expert Bruce Schneier commented on a failure of employees to adhere to strict computer polices

Schneier speculated that the employees knew following those policies would cut into their work time

And so it is in healthcare. Add complexity and mandated changes with specific rules for password construction (which btw often times are a mystery and unavailable to the user until *after* they have tried to create a password) and you have a recipe for insecure systems. Staff get into trouble for not completing work and while security breaches are a problem they do not represent the bigger risk

Failure to get work done is a bigger risk and outweighs any unspecified consequences of ignoring a security rule or three

Lets hope Healthcare IT folks take note and rather than ramming down security requirements they approach the concept with more flexibility and open mindedness

EMR Complications

Pauline Chen wrote a piece in the NY Times on April 22, 2010 titled: An Unforeseen Complication of Electronic Medical Records which in many respects is an understatement. There are many untended consequences big and small and while the appreciation of the benefits:

• fewer missing charts
• streamlined information and
• efficient work-flow patterns

It was with a smile I read the first specific problem identified at the outset

I realized I had no idea where to sit

With technology overtaking the office space and the design failing to take account of technology that was unimagined when the facility was originally on a drawing board it is not that surprising. The smile gave way to an element of sadness as I realized this was a problem I had faced when we built an innovative facility in Glasgow Scotland in 1993/4 that included a paperless medical record. We built mock up rooms, full size with all the components necessary for care to model the work flow, space an interaction. Including any PC was a challenge and the speed of change was best captured in the computer room. In the short 2 years it took to go from drawing board to build out the space allocated was halved as the technology got smaller, faster and cheaper and it was cheaper to cut the room in half rather than cooling the larger space.

Most doctors agree that the value of an EMR out weighs the costs (financial and personal) of implementing this disruptive technology;

Few, if any, of those interviewed would choose to revert to a paper-based records system. But all the physicians expressed concerns that EMR had less than salutary effects on the patient-doctor relationship, including difficulties replicating the narrative aspect of a patient’s illness and the constant interruptions from alerts and instant messaging

This remains one of the most persistent challenges and was true back in 1993/4 when we were implementing our paperless medical record. Doctors and patients are tuned into the same channel we all are WIIFM (what's in it for me) and to date the focus for most of these systems has been billing

most systems have been designed not with clinical needs in mind but to meet the demands of the fee-for-service payment system

In this rush to digitize the beleaguered clinicians has been forgotten and the rich characteristics of narrative than contains the fine nuanced detail necessary for rapid and complete transmission of information between clinical team participants is lost in digitizing and codification. As Dr Lin is quoted as saying:

How can you possibly point and click your way through a patient’s 10-year history

You can't and that's why the capture of the narrative and in particular facilitating that process without the requirement to, as Pauline Chen puts it:

spinning and wheeling back and forth between patient and computer than I did sitting still and listening

is an imperative in successfully rolling out EMR technology. Center to that is voice and facilitating the capture of this narrative without additional time burdens. To date Speech Recognition remains the only technology that has emerged to capture the narrative without burdening the physician. Historically the medical transcriptionist converted this audio into a structured, grammatically correct nicely formatted document. But today increasing volume of audio is processed using speech recognition technology that provides automation, efficiency and now in the clinical setting immediate conversion of this audio into digitized clinical content that is EMR ready.

Pauline is right clinicians need training to cope with this technology but I would suggest the less training that is required the better the adoption will be - just look at the iPhone, iTouch and most recently iPad. Apple took out complexity and created a device that an untrained 2 1/2 year old could pick it up and start using:

I'm not suggesting that clinicians cannot learn - but I do believe that design simplicity is lacking in clinical system and adding an intuitive and simple interface is essential. Part of that includes voice and intuitive voice control as can be seen here at the CES demo by Kristen Wylie

as well as voice capture as can be seen here in an interview of Dr David Stein here.

The status today - this technology is able to answer some of these challenges. Clinicians will be using EMR technologies in increasing numbers and Speech Recognition provides a bridge to the digital chasm between their need for patient interaction and the necessity to capture clinical data in EMR ready form.

Where are you in your implementation and what is helping and what is not. How does your doctor interact with you and what technology does he use?

Mixed Results from Healthcare IT Technology

In an interesting article in HealthAffairs this month "Mixed Results In The Safety Performance Of Computerized Physician Order Entry" (abstract only - subscription required for full article) the authors carried out a simulation of Computerized Physician Order Entry (CPOE) effectiveness.

It is a unique study with a relatively small sample size (62 facilities) that was self selecting that does represent some bias through small sample size, self selection and simulation vs reality. All that said there is still a surprising conclusion that

Many hospitals only detected 44% of adverse drug events and the best performing only detected 70-80%.

Not only is this wide variation and poor results for a very costly highly disruptive technology that is mandated in meaningful use. There is a clear need to validate the value of technology that is being suggested and especially if it is being mandated in the complex world of healthcare

These are, as many folks have commented to me  "very interesting times" but lets not loose sight of the science that formed the basis of some of the most significant advances in medicine encompassed in Randomly Controlled Trials.

Does your experience vary. Have you seen the value of CPOE or has it been a challenge in your facility?
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Clinical Documentation is at the Core of Healthcare Reform

Everyone agrees we need codified structured data for problem lists, medication, allergies and labs.......or do they?

John Halmka wrote a piece for HealthcareIT News earlier this month titled "Rethinking Clinical Documentation" in which he asks

what is the role of unstructured clinical documentation text

In many instances there has been an attempt to drive unstructured text out of the electronic medical record and while there is a challenge for computers and technology to understand unstructured text - we humans actually prefer the narrative for absorbing information. As John points out referring to the New England Journal of Medicine article in March this year "Can Electronic Clinical Documentation Help Prevent Diagnostic Errors" (full text here) the authors note:

Free-text narrative will often be superior to point-and-click boilerplate in accurately capturing a patient's history and making assessments, and notes should be designed to include discussion of uncertainties

I could not agree more and and have referred to the loss of knowledge and the nuanced information in the narrative resulting in the dumbing down of clinical notes and the Henry VIII's cause of death debate (we still debate this 463 years after he dies) and indeed in recent presentations on the ability to keep the narrative and structured data in harmony in my presentation at AHIMA: "Clinical Narrative and Structured Data in the EHR: Venus and Mars Live in Harmony with CDA4CDT". The Healthstory project allows for the two worlds to coexist happily providing the value John describes in his article for the clinicians while delivering the structured data essential for the clinical systems today. As John says in his blog

I agree. Notes should be included as part of clinical summaries. However, we should do all we can to improve the quality of notes

He is right the quality of these notes need to improve and while I look forward to hearing more about the Daily Patient Wiki (which has similarities to the "Facebook Medical Record") I suspect that we need to pay attention to the process of capture of information. While the keyboard, mouse and other tools are useful, they remain inefficient for many. Contrary to popular belief the QWERTY keyboard was not designed to slow typists down rather to prevent jams when typing at speed, but it is not the most efficient layout placing only one vowel on the home row. Solving this challenge remains the major barrier to adoption of clinical systems.

Clinicians will use whatever method is most efficient for them at the time they need it with different methods suiting at different times. We will see Minority Report concepts of visual interaction, traditional but improved screen, keyboard and mouse systems and even touch screen applications. I am willing to bet we will see an application for clinical data capture on the iPad before too long. But the predominant means of data capture today is using voice. Tools that facilitate the capture of voice and the conversion of this into useful clinical knowledge will remain a large component of any successful implementation and will bridge the adoption barriers that plague clinical system implementations.

Do you agree - where is your facility or practice on data capture and the inclusion of the narrative note?