Solving the Last Mile Problem in Healthcare IT (Part 1)

I was recently speaking with a friend about a new endeavor that he is exploring, and he commented that no one has solved the Last Mile Problem – that’s what he’s working on. If you’re not familiar with the concept, the Last Mile Problem describes how it’s relatively easy and cheap to get a product from a far-away factory to very close to a consumer’s house, but getting that delivery to the front door of the purchaser takes a lot of effort and costs a relatively large amount of money. Even though the distance from a local distributor to a home may represent 2% of the journey, the costs may consume 25% of the potential profit.

Running to Finish line How does the Last Mile Problem relate to healthcare information technology (IT)? I think that might be self-evident to the majority of electronic health record (EHR) users. Many clinicians complain about EHRs (duh!). It’s reasonable to wonder what they’re so upset about. I mean, c’mon, we in healthcare IT have solved so many problems that have plagued doctors for so long. Consider this:

  • Back in the day, when a complicated patient was admitted to the hospital, residents (there were no hospitalists back then) would run down to a place called Medical Records and request something called “the old chart.” I can’t remember what “the old chart” was because I’m very old myself, but I guess it was a paper-based record of what had happened during previous admissions. Not all admissions, mind you, just recent admissions. If you wanted to know what happened years ago, you’d likely have to wait until the “old, old chart” was retrieved from offsite storage and transported back to the hospital. That took half a day if you were lucky; longer if you weren’t. Status of this “old chart” problem today? SOLVED!
  • Back in the day, if you wanted to know what happened in the hospital when you were in the clinic, or what happened in the clinic when you were in the hospital, you had to call the other institution and request someone fax over relevant paperwork. Sometimes you needed to get the patient’s signed permission; sometimes not. If the clinic wasn’t open for the night or the weekend, you had no access to the information. Status of this external data problem today? Somewhat SOLVED if you work at a large institution with an enterprise EHR encompassing inpatient and ambulatory facilities. (If you’re not working at a large integrated health network, you might be able to get data via interoperable EHRs. Then again, you might not be so lucky.)
  • Back in the day, it was common to not be able to read the doctor’s documentation or orders. Many a time a unit clerk called me over and said, “What do you think Dr. Smith is ordering here?” Status of the bad handwriting issue today? SOLVED!
  • Back in the day, you had to write your orders without pre-printed suggestions for common diagnoses or workups. Who remembers ADC VANDALISM? And this mnemonic only gave you high-level sorts of orders. There was no order set for bronchiolitis that reminded physicians to avoid likely-useless orders like chest x-rays or albuterol. And how exactly should we be treating that patient who comes in with the uncommon, but deadly serious, problem of carbon monoxide poisoning? Nowadays, we have order sets to help guide physicians to best practices (and even evidence-based medicine if such a thing exists). Status of the ordering conundrum? SOLVED!
  • Back in the day, if you wanted to trend lab results over time, it was easy: just find the 18 places in the paper chart where those lab results lived, write them down on a piece of paper in consecutive order, and read away. What’s that you say? You want to look at them graphically, not the actual values in a line of text? No problem; you have a med student at your beck and call, right? Status of the interpreting lab results over time? SOLVED!
  • Back in the day, when we wanted to view imaging studies ourselves (and not just the radiologist’s interpretation thereof), we did this weird thing: we walked down (it was always down) to the radiology reading room, spent ten minutes (if we were lucky) hunting down the films, and then studied the images. Nowadays, your friendly PACS system is seamlessly connected to your happy EHR, making viewing of images as easy as pie. Status of the imaging study viewing problem? SOLVED!

We’ve solved all of these problems. Yet still . . . we have physician burnout being blamed principally on the EHR. What gives? I’ll tell you what gives: The Last Mile Problem in healthcare IT.

Doctors asked for data, so we gave them data. Now they can see the entire inpatient and outpatient chart. We can often serve up the entire inpatient and outpatient chart of other hospitals and clinics as well. It’s too much; we’re drowning in data. Doctors wanted to be able to copy previous notes so as to avoid rehashing similar information. They wanted to be able to bring lab results and x-ray results into their notes so they could avoid typing those data points. Now we have multipage notes filled with data but useless as vehicles to convey knowledge (we call this note bloat, and here’s one way to minimize it!) We might think we’ve solved the problem, but in reality we’ve only moved the product from the factory to the distribution center; we haven’t solved the Last Mile Problem.

What’s a poor CIO or CMIO to do to get this Last Mile Problem really solved? Stay tuned for Part 2 coming to an internet near you.

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I was recently speaking with a friend about a new endeavor that he is exploring, and he commented that no one has solved the Last Mile Problem – that’s what he’s working on. If you’re not familiar with the concept, the Last Mile Problem describes how it’s relatively easy and cheap to get a product from a far-away factory to very close to a consumer’s house, but getting that delivery to the front door of the purchaser takes a lot of effort and costs a relatively large amount of money. Even though the distance from a local distributor to a home may represent 2% of the journey, the costs may consume 25% of the potential profit.

Running to Finish line How does the Last Mile Problem relate to healthcare information technology (IT)? I think that might be self-evident to the majority of electronic health record (EHR) users. Many clinicians complain about EHRs (duh!). It’s reasonable to wonder what they’re so upset about. I mean, c’mon, we in healthcare IT have solved so many problems that have plagued doctors for so long. Consider this:

  • Back in the day, when a complicated patient was admitted to the hospital, residents (there were no hospitalists back then) would run down to a place called Medical Records and request something called “the old chart.” I can’t remember what “the old chart” was because I’m very old myself, but I guess it was a paper-based record of what had happened during previous admissions. Not all admissions, mind you, just recent admissions. If you wanted to know what happened years ago, you’d likely have to wait until the “old, old chart” was retrieved from offsite storage and transported back to the hospital. That took half a day if you were lucky; longer if you weren’t. Status of this “old chart” problem today? SOLVED!
  • Back in the day, if you wanted to know what happened in the hospital when you were in the clinic, or what happened in the clinic when you were in the hospital, you had to call the other institution and request someone fax over relevant paperwork. Sometimes you needed to get the patient’s signed permission; sometimes not. If the clinic wasn’t open for the night or the weekend, you had no access to the information. Status of this external data problem today? Somewhat SOLVED if you work at a large institution with an enterprise EHR encompassing inpatient and ambulatory facilities. (If you’re not working at a large integrated health network, you might be able to get data via interoperable EHRs. Then again, you might not be so lucky.)
  • Back in the day, it was common to not be able to read the doctor’s documentation or orders. Many a time a unit clerk called me over and said, “What do you think Dr. Smith is ordering here?” Status of the bad handwriting issue today? SOLVED!
  • Back in the day, you had to write your orders without pre-printed suggestions for common diagnoses or workups. Who remembers ADC VANDALISM? And this mnemonic only gave you high-level sorts of orders. There was no order set for bronchiolitis that reminded physicians to avoid likely-useless orders like chest x-rays or albuterol. And how exactly should we be treating that patient who comes in with the uncommon, but deadly serious, problem of carbon monoxide poisoning? Nowadays, we have order sets to help guide physicians to best practices (and even evidence-based medicine if such a thing exists). Status of the ordering conundrum? SOLVED!
  • Back in the day, if you wanted to trend lab results over time, it was easy: just find the 18 places in the paper chart where those lab results lived, write them down on a piece of paper in consecutive order, and read away. What’s that you say? You want to look at them graphically, not the actual values in a line of text? No problem; you have a med student at your beck and call, right? Status of the interpreting lab results over time? SOLVED!
  • Back in the day, when we wanted to view imaging studies ourselves (and not just the radiologist’s interpretation thereof), we did this weird thing: we walked down (it was always down) to the radiology reading room, spent ten minutes (if we were lucky) hunting down the films, and then studied the images. Nowadays, your friendly PACS system is seamlessly connected to your happy EHR, making viewing of images as easy as pie. Status of the imaging study viewing problem? SOLVED!

We’ve solved all of these problems. Yet still . . . we have physician burnout being blamed principally on the EHR. What gives? I’ll tell you what gives: The Last Mile Problem in healthcare IT.

Doctors asked for data, so we gave them data. Now they can see the entire inpatient and outpatient chart. We can often serve up the entire inpatient and outpatient chart of other hospitals and clinics as well. It’s too much; we’re drowning in data. Doctors wanted to be able to copy previous notes so as to avoid rehashing similar information. They wanted to be able to bring lab results and x-ray results into their notes so they could avoid typing those data points. Now we have multipage notes filled with data but useless as vehicles to convey knowledge (we call this note bloat, and here’s one way to minimize it!) We might think we’ve solved the problem, but in reality we’ve only moved the product from the factory to the distribution center; we haven’t solved the Last Mile Problem.

What’s a poor CIO or CMIO to do to get this Last Mile Problem really solved? Stay tuned for Part 2 coming to an internet near you.