Melinda Ashton, M. D., has written a wonderful article entitled “Getting Rid of Stupid Stuff.” She has responsibility for the electronic health record being used by Hawaii Pacific Health in Honolulu, HI. She and her colleagues created a process where any user could nominate an item for removal as being “stupid.” As an example, nurses who recorded incontinence had to specify if it involved urine or stool. Nurses in the newborn nursery pointed out this was stupid when applied to newborns. They fixed the issue and removed three “clicks” from their workflow. She reports they have gotten rid of about 45% of the issues raised and are working on most of the rest. But she notes that 19% of the physician items and 12% of the nurse items were “not possible” because of regulatory requirements.
Many of the issues raised had solutions already in the EMR, but the people raising the issue did not know it or know how to use it. They had also “pared down the database, and everything left is required by regulatory agencies or for billing.” She notes the program has now been accepted, but “it is too early to have seen any measurable improvement in employee engagement from this effort.”
When I was growing up, my father, a career Army officer, used to tell the story of a soldier who was doing guard duty and was posted to guard a park bench. He asked his corporal why he had to guard the bench. The corporal replied he didn’t know; it was in the standing orders of the day. He asked his sergeant, who gave the same reply, but asked the officer of the day. The officer decided to research the order and found that 25 years earlier the bench had been freshly painted when a general walked by and said: “Post a guard on that bench.” While one hopes the story is apocryphal, I suspect there is more than a little truth in the anecdote.
Dr. Ashton notes her organization can’t wish bureaucratic requirements away, which is true, but it raises the question: how much of what we do now is stupid stuff? I am focused on documentation “stuff” so far, but the question could be asked more broadly. I suspect the truthful answer in either sense is “a lot.” Certainly, many of those who are trying to address the issue of physician burnout have identified the “stupid stuff” in electronic record documentation as one of the prime drivers. But asking anyone, regardless of degree, to do stupid stuff is ultimately demoralizing and demotivating.
In the Age of Sailing Ships, when, as the saying goes, iron men sailed the world in wooden ships, it was necessary to stop every so often, pull the ship out of the water, and scrape the barnacles off the hull below the water line. If you didn’t, your speed and maneuverability were negatively affected. I suspect medical enterprises need to stop and scrape off the barnacles their hull, but most feel like they are in a desperate race for survival and can’t afford the time. Of course, there was never a good time for the sailors either, but they knew it had to be done.
So why don’t we try to scrape the barnacles off, or get rid of the stupid stuff? Inertia is part of it—there is the feeling the payers and the bureaucrats aren’t interested. But do we know that for a fact? After all, most insurance companies care about their bottom line, and if they could reduce their cost structures by getting rid of the stupid stuff, they would find motivation.
Changing government rules is more difficult, because the motivation is different. But I am convinced the “regulatory” mindset is the key issue—CMS feels legally and morally obligated to be a responsible fiduciary of the government’s money. As a taxpayer, I am in favor of that. Unfortunately, they usually start with the assumption providers are all crooks and out to steal the government’s money. Sad to say, experience suggests this is a realistic concern. Even those who aren’t out to “steal” the money are certainly motivated to spend money on “correct coding to insure maximum reimbursement.” The practical difference is one of intent, which is difficult to either measure or prove.
So, are we stuck continuing to do stupid stuff that does not lead to better patient care? Perhaps, since the forces of inertia are large. But the organizations that survive this period of retrenchment and reorganization aren’t going to be the ones that become the largest, but the most adaptable. The big dinosaurs all died out—it was the little ones who evolved into birds, lizards and the like. The bigger the organization, the more entrenched in the existing bureaucracy and the less nimble it becomes. And the more rigidly bureaucratic it becomes, the more disengaged the work force becomes. In the meantime, we can take Dr. Ashton’s report to heart. At least somewhere, someone is trying to reduce the burden of stupid stuff.
12 November 2018
 Ashton M. Getting Rid of Stupid Stuff. N Engl J Med 2018(Nov 8);379(19):1789-1791.
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