Tuesday, November 24, 2009

A Visicalc moment

If you were an early Apple II or IBM PC user, you may remember the first time you saw Visicalc (1979), SuperCalc (1980), MultiPlan (1982), or Lotus 1-2-3 (1983).

The spreadsheet solves a real problem - it saves time, it empowers its users, and people are more productive using it.. No more paper, pencil and calculators. No more days wasted manually computing "what if" scenarios.

I call this joy from the early days of personal computing a "Visicalc moment".

One challenge we face as we roll out electronic health records to every clinician is that the first time they see an EHR (of any type, from any vendor), they rarely have a "Visicalc moment".

Because we have not marketed the benefits of EHRs to clinicians, they are not sure an EHR saves time, streamlines their workflow, or brings them a better quality of worklife.

There are 3 ways to motivate most clinicians
1. Pay them more
2. Offer them more free time
3. Apply Peer Pressure

How can we leverage these principles clinicians so they will have Visicalc moments?

A few thoughts

1. Electronic medication workflow in an EHR saves time, reduces the number of calls/pages due to unreadable prescription and streamlines the refile process.

2. Templates, Macros and voice recognition can speed up clinical documentation. Of course, they must be used wisely to avoid creating inaccuracies that are persisted forever in the record. Electronic clinical documentation can be electronically exchanged between referring clinicians and specialists, leading to a peer preference for those who document electronically.

3. Patient Education can be automated by linking problem lists and prescriptions to resources such as UptoDate, Healthwise, and Preop.com

4. Decision Support such as automated ordering ensures the safest, most effective therapies are given based on evidence and patient specific data. It can also be used to generate alerts and reminders in support of pay for performance programs.

5. Administrative simplification streamlines the revenue cycle, reducing denials and AR days.

Thus, EHRs, especially those offered via the web in software as a service models can generate income, save time, and keep peers happy.

Let's hope the regional healthcare IT Extension Centers and hospitals which rollout EHRs for their community physicians can achieve a few "Visicalc moments".


GreenLeaves said...

Thank you for giving me a Visicalc moment of my own. The Apple II is probably reason that I now live in the USA. When I arrived in December 1978, an acquaintance asked if I could develop a business app for him on the Apple. My work started on DOS 1.0 using a cassette tape for loading what I recall being 16K of RAM. When Visicalc arrived, I was stunned and delighted at the simplicity and power of that application. I still fondly remember using the Peeks and Pokes to work directly with registries with my interpreted Basic program.

You have selected an apt term for what we are about to experience with digital healthcare. Hopefully HIT will see a similar evolution as spreadsheets have since Visicalc’s introduction.

Happy Thanksgiving!

Rick Hays said...

I remember interviewing a guy one time and asking if he was experienced in Lotus 1-2-3. He replied that he knew Lotus 1 and 2 well, but had not worked with 3....

Frank Bresz said...

One of the major challenges is that for those of us computer literate types this seems easy enough, and perhaps as we get more folks that have "grown up" with computers they will not seem so daunting, but for now there are a lot of folks that don't want the trouble of banging on a keyboard when a pen and paper works.

Perhaps when speech recognition, and handwriting recognition gets better we can make this easier. Speaking of which - with all of the horsepower on today's PCs why aren't these things better?

Unknown said...

VisiCalc came closer to instant gratification than EHR does because it solved clearly defined immediate problems (e.g., the hassle of recalculation for 'what if?'). Further, VisiCalc required only small adjustments to conceptual mental models of things ("it's a ledger sheet that automatically recalculates all sorts of useful functions"). Fundamentally, VisiCalc required hardly any adjustment to mental models about how (accounting) work was done.

EHR, on the other hand, pays off in the looooong run, after all those data have been religiously and painstakingly entered, and may actually pay off more for someone other than oneself. EHR shifts record-keeping from a portable, universal set of things (pens and paper) to a whole other way of doing work. Taking full advantage of EHR will require disrupting deeply rooted healthcare management mental models. We have three strikes here.

What is to be done?

We first ask, does "using EHR" - from the perspectives of users - feel punishing in the event of using it? Then we remove whatever punishment we can.

Then we ask, does avoiding use of EHR deliver payoffs that users like? The we remove whatever payoffs for avoidance we can.

Then we ask, are the consequences (vs. immediate experiences) backwards? I.e., do users feel worse off later on after they've "used EHR." Again, we must be very careful to gauge this from real users' experience, not our own logic.

Finally, we get to the "are there barriers to EHR use?" question. Then we remove those barriers e.g., response latency to data entry or search.

Chintan Patel said...

Great post!

I wasn't around during the Visicalc era but my "visicalc moment" was with Mint.com - the personal finance website. It automatically pulled info from my credit cards, bank accounts and showed me spending broken down by categories. Then prompted me about APRs, payment deadlines and so on.

I knew I wasn't doing a good job at personal finance and mint.com made it so *easy* with the integrations, visualizations and reminders that now I take it for granted just like email.

On similar lines, we can tackle the areas where physicians can immediately see the benefits of using a new system. Lets say an EHR that shows a *visualization* of health info overlayed on virtual patient body. Or an Augmented Reality display that overlays info on actual patient.

According to recent statistic about 45% of interns/residents have an iPhone and about 64% of physicians use a smartphone - so I don't think technology is a problem. I think we need to do a better job at making simple and cool solutions.

Mark said...

My dentist went the electronic record route when she opened her office 10+ years ago. She and her patients have VisiCalc moments every day, or at least every time they take a look at an xray or print a claim form. I'm not in the health care business, but it seems to me that opportunities for improving diagnoses based on smart software assisted analysis of historical data, for cross checking medications against individual patient histories and for managing billing, claims and payments are plentiful. What could be cooler than nailing a diagnosis or avoiding a prescription error or making administrative overheads less burdensome. The most efficient and articulate doctor I ever saw recorded his observations on audio media in near real time. Maybe smarter input devices, that allow doctors to capture and input data easily are a big part of this. If so, maybe the iPhone is a better metaphor than VisiCalc. I don't have an iPhone yet. When the Keas guys come up with an app that lets me manage my health care data in real time and talks to my doctor's computer, I just may sign up. One of the cool things about Visicalc is that it empowered all of us, not just accounting professionals.

Malcolm Costello said...

The Visicalc/EHR analogy is relevant, and it can be taken a step further. Visicalc, Clarisworks and similar desktop applications were successfully built to compute data, but not to collaborate and manage relationships through data.

Same thing in healthcare with EHRs, where data sharing often is limited to expensive or user-unfriendly file transfer systems, mostly paper print-outs and faxing. Not efficient. Not effective. But sharing data was not inherently what they were designed to do.

When the PC industry recognized users wanted to share and strengthen relationships, it paired data retrieval and computation systems with electronic collaboration tools. Suddenly, email and internet reference tools became de facto. Integrating email into desktop applications, including the ability to attach locally generated data, and reference internet links in the context of an email, has fundamentally transformed how individuals and businesses worldwide collaborate.

We’re long overdue to widely integrate desktop EHRs with familiar, easy-to-use data sharing/collaboration technologies. After all, healthcare is not just about data, but about the relationships between physicians, their colleagues and their patients.

Ubiquitous access to such familiar tools already exist, have been proven in the PC world, and are familiar to physicians and office staffs. Today, thousands of care providers and physicians’ office staffs already share and collaborate on data with other providers, and with their patients. At the same time, they’re achieving remarkable breakthroughs in efficiency, lower costs, and better coordination of care.

How are they doing this? It’s simple: by utilizing fundamental tools like secure email/messaging directly within their desktop EHR application.

picuomaha said...


In addition to the 3 sources of clinician motivation you cite, I would like to offer a 4th:

4. Provide demonstrably better patient care.

When interviewing med school applicants, the single most common answer to the question, "Why do you want to be a doctor?" is--and probably always will be--"Because I want to help people." It's not the most exciting answer the candidate can give, nor is it the most original. But it does have the virtue of truth.

Give clinicians tools that actually reduce medication errors, protect their patients from harm, or help their patients follow their advice, and they will embrace those tools--even if the tools don't put a dime in their pockets or get them home a minute sooner.

Warmest Regards,

George Reynolds

Caston Thomas @ Voalté said...

I advocate George's position. There's a disconnect between IT & nursing that I've come to realize. Succinctly, it's left brained IT "selling" to right brained care givers. There's a disconnect that is systemic. I'm focusing on how to get the buy-in of nursing, engage them in the deployment, & training them in ways that are outside the typical box.