You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


EHR

In his 2015 State of the Union address President Obama announced the launch of his precision medicine initiative, an audacious initiative to address these issues. In a nutshell, precision medicine customizes health care; That is, medical decisions are tailored based on the individual characteristics of the patients, ranging from their genes to their lifestyle. To have a clear understanding of the relationship between individual characteristics of patients and medical outcomes, it is necessary to collect various types of data from a large population of individuals. The precision medicine initiative requires a longitudinal cohort of one million individuals to provide researchers with various data types including DNA, behavioral data, and electronic health records. Assembling such a large sample of many different data types proposes two unique challenges pertaining to healthcare information technology: interoperability and privacy.

The federal government has already spent $28 billion to incent medical providers to adopt electronic health record (EHR) systems. As a result, almost all of the medical providers in the United States currently compile an electronic archive of their patients’ medical records. However, most of the EHR systems are not able to exchange information with each other. This is a strange problem in the age of information technology and Internet connectivity. There are a variety of technical and economic reasons, which make it especially complicated and difficult to solve.

Given the current lack of interoperability between EHR systems, it seems highly unlikely to be able to obtain a complete medical history of one million Americans. To succeed, the precision medicine initiative has to either overcome the lack of interoperability problem in the nation’s health IT system or to find a way around it. Congress members in both the House and Senate are considering new rules that would stop EHR vendors from interfering with medical providers that had already started transferring records. These efforts are fraught with difficulty and will take a very long time to produce tangible results. Continue reading “Precision Medicine’s First Real Patient: The National Health IT System”

Rep. Mike Burgess (R-Texas) has released a draft bill entitled “ensuring interoperability of qualified electronic health records” in which interoperable (Electronic Health Records) EHRs are defined as those that do not block sending and receiving data to and from other EHRs and provide users with complete access to the captured medical data. The draft bill proposes that detailed methods to assess interoperability be defined by a “Charter Organization.” According to the draft bill, this Charter Organization shall consist of one member from each of the standard development organizations accredited by the American National Standards Institute and representatives that include healthcare providers, EHR vendors, and health insurers. To keep its certification after January 2018, an EHR vendor should comply with the definitions of the Charter Organization, publish API’s to enable data exchange with other EHRs and attest and demonstrate that it has not willfully interrupted data exchange with other EHRs. The draft bill suggests that the Inspector General of HHS shall have the authority to investigate both EHR vendors and medical providers with regards to claims that they have interrupted interoperability.

The AMA and about 100 other physician groups urge CMS to develop an ICD-10 contingency plan in the event of a “catastrophic” backlog following the October 1 transition. The organizations want CMS to make public its plans to make advanced payments or reimbursements for services already rendered, work with ONC to ensure EHR systems are ICD-10 ready, and confirm contractors won’t audit for the correct code.

The silver lining here is that these organizations are (finally) not asking for a delay in implementing ICD-10. CMS apparently has drafted a contingency plan in the event of claims process disruptions but does not plan to make it public. In this age of more transparency, CMS needs to make the plan public – even though provider groups will surely find fault with the plan. But, isn’t it better to continue moving the conversation forward, just in case of there is a catastrophe?

It’s always interesting to talk with John Halamka, and last week–after athenahealth bought the IP but apparently not the actual code of the Beth Israel Deaconess Medical Center (BIDMC) web-based EHR he’s been shepherding for the past 18 years–I got him on the record for a few minutes. We started on the new deal but given that had already been covered pretty well elsewhere we didn’t really stay there. More fun that way–Matthew Holt

Matthew Holt: The guys across town (Partners) ripped out all the stuff they’ve been building and integrating for the last 30 years and they decided to pay Judy Faulkner over a billion dollars. And you took all the stuff that you’ve been building for the past 15 to 20 years and sold it to Jonathan Bush for money. Does that make you a better businessman than they are?

(Update Note 2/11/15: While I’ve heard from public & private sources that the cost of the Partners project will be between $700m and $1.4 billion, Carl Dvorak at Epic asked me to point out less than 10% of the cost goes to Epic for their fees/license. The rest I assume is external and internal salaries for implementation costs, and of course it’s possible that many of those costs would exist even if Partners kept its previous IT systems).

John Halamka: Well, that is hard to say, but I can tell you that smart people in Boston created all these very early systems back in the 1980s. On one hand, the John Glaser group created a client server front end. I joined Beth Israel Deaconess in 1996 and we created an entirely web-based front end. We have common roots but a different path.

It wasn’t so much that I did this because of a business deal. As I wrote in my blog, there is no benefit to me or to my staff. There are no royalty streams or anything like that. But sure, Beth Israel Deaconess receives a cash payment from Athena. But important to me is that the idea of a cloud-hosted service which is what we’ve been running at Beth Israel Deaconess since the late ’90s hopefully will now spread to more organizations across the country. And what better honor for a Harvard faculty member than to see the work of the team go to more people across the country?

MH: There’s been a lot of debate about the concept of developing for the new world of healthcare using client server technology that has been changed to “sort of” fit the integrated delivery systems over the last 10 years, primarily by Epic but also Cerner and others. In particular how open those systems are and how able they are to migrate to new technology. You’ve obviously seen both sides, you’re obviously been building a different version than that. And a lot of this is obviously about plugging in other tools, other technologies to do things that were never really envisaged back in 1998. You’ve come down pretty strongly on the web-based side of this, but what’s your sense for how likely it is that what has happened over the last five or ten years in most other systems including the one across the street we just mentioned is going to change to something more that looks more like what you had at Beth Israel Deaconess? Continue reading “Halamka Speaks: athenahealth & the Future of AMCs as Tech Innovators”

Accenture, the consulting firm that was hired a year ago to fix the troubled HealthCare.Gov insurance exchange, is awarded a five-year, $563 million to continue its work on the federal site. The government hired Accenture Federal Services to repair the online marketplace after dropping its original contractor, CGI Federal.

The long-term contract with Accenture also signals CMS’s acknowledgement that a task as large as HealthCare.Gov is best run with leadership from an experienced, private-sector vendor.

Connecticut HIE Dissolves After Wasting Millions

A former board member for The Health Information Technology Exchange of Connecticut blames management for the failure of the entity, which was tasked to create statewide HIE but dissolved by the legislature last summer. The HITE-CT “wasted” $4.3 million in federal grants over four years “without accomplishing anything,” according to Ellen Andrews, who served as the board’s consumer advocate. State auditors also found deficiencies in state controls, legal problems, and a “need for improvement in management practices and procedures.” The state’s legislature is now developing a new exchange strategy.

Prediction: look for more HIEs to falter this year due to mismanagement and lack of sustainability.

Electronic Prescribing of Controlled Substances on the Rise

Electronic prescribing of controlled substances (EPCS) increased from 1,535 to 52,423 between July 2012 and December 2013, according to a study published in the American Journal of Managed Care. The percentage of pharmacies enabled for EPCS jumped from 13% to 30% during the same period.

The next task: figuring out how to get more than the current one percent of physicians to participate.

ONC Shares Lessons Learned from State HIEs

An ONC report on state HIEs finds that many exchanges lack a critical mass of data and are struggling with data sharing. The case study also found that the technical approaches, services enabled, and use of policy and legislation varied across states; collaboration among HIE participants is critical for success; and states are leveraging a variety of policy and regulatory levers to advance interoperability and data exchange.

CMS Seeks ICD-10 Testers

CMS is seeking approximately 850 volunteers for ICD-10 end-to-end testing in April, according to a CMS bulletin. Volunteers have until January 9to submit applications to participate in the April 26-May 1, 2015 testing week.

Pediatrics Report Increased EHR Use

Seventy-nine percent of pediatricians reported using an EHR in 2012, compared to 58% in 2009, according to a study published in the journal Pediatrics. Only eight percent of physicians say their EHRs include pediatric-specific functionality.

Presumably Modernizing Medicine was most interested in Aesyntix’s RCM component, which may create some concern among Modernizing Medicine’s current RCM partners, which include ADP/AdvancedMD, CareCloud, and Kareo.

The last day of October was the deadline for proposals in response to the U.S. Department of Defense’s call to overhaul its electronic health record software, also known as the Defense Healthcare Management Systems Modernization (DHMSM). PwC’s proposed solution, called the Defense Operational Readiness Health System (DORHS), seeks to bring innovations from the commercial marketplace to the military health system by using technology that is seamless, proven and reliable.

With team members DSS, Inc., Medsphere Systems Corporation, MedicaSoft and General Dynamics Information Technology, PwC’s goal is to enable every healthcare professional to provide the finest medical care possible to members of the military and their families during every phase of service, through retirement, and assist the Defense Health Agency in its continued business transformation to help implement and manage effectively the world’s largest healthcare delivery system.

It’s time to think carefully and look at the large systems (human and technical), institutions, and individuals that contributed to Mr. Duncan’s death. Systems should be designed to protect people and prevent human errors. Certainly we rely on the healthcare system to improve our health and to protect our privacy, especially our rights to health information privacy.

Looking at the death of Mr. Duncan, the poorly designed Epic EHR was a critical part of the problem: the lack of clarity, poor usability, hard to find critical information, and no meaningful quality testing to ensure the system prevents critical errors contributed to his death and endangered many others. Why wasn’t the discharge of a patient with a temperature of 103 from the ER flagged?

EHRs are one of several critical systemic problems.

Current US EHRs were not designed or tested to ensure patient safety or privacy (patient control over the use of PHI for TPO). The Meaningful Use requirements for EHRs don’t address patient safety or ensure patients’ legal rights to control use of PHI. Let’s face it, the MU requirements were set up by the Health IT industry, not by a federal agency charged with protecting the public, such as NIST or the FDA. Industry lobbying resulted in industry ‘self-regulation’, which has failed to protect the public in every other sector of industry. Industry lobbying is another critical systemic problem.

Our public discourse also is a critical systemic problem. The 24/7 US media drives us to play the ‘blame game’—and look at what happens: it’s a sham. A massive public and social media exercise substitutes for a crucial scientific and ethical oversight process by government and industry to face or examine the systemic causes and key actors—both people and institutions. We end up with no responsibility being assigned or addressed. Or the media hoopla and confused thinking leads to the opposite conclusion: everyone and everything is responsible and blamed, which has the same effect: it lets everyone and everything off the hook. Either way, no one and no institutions are to blame.

It was a mistake to send the Liberian national Thomas Eric Duncan home from a Dallas emergency room after he presented with fever and pain, which were early signs of Ebola infection.

It would be a larger mistake to miss an important learning opportunity. This case demonstrates what I believe to be a major threat to patient safety—caregiver distraction.

Doctors and nurses are increasingly prevented from giving full attention to the important things in patient care. The degree of value-added nonsense has reached the point where delivering basic care has gown dangerous. This morning, in Canada, news of a case of deadly drug interaction occurred because of alert fatigue—or distraction.

I am a cardiologist; I am also a patient. I want the Duncan case to be a turning point, a wake up call, a never event that serves as a spark to improve the delivery of medical care. Right now, all that this case has changed are tweaks to EHR protocols and checklists. We need more than tweaks; we need big changes.

An uncomfortable truth is that medical mistakes are normal. Errors, like this one in Texas, have occurred since doctors started treating patients. The good news is that technology has made medical care better. No credible person suggests a return to the paper-chart era. Yet, it is still our duty to face mistakes, learn from them, and in so doing, improve future care. Being honest about root causes is necessary.

Another truth about medical mistakes is the ensuing rush to inoculate against blame–which always comes. In the Duncan case, initial blame was assigned to the electronic health record. The computer software failed to flag the travel history in the physician “workflow.” (Just using the word, workflow, hints of the bureaucracy problem.) And you know there is trouble when hospital administrators use the passive voice. “Protocols were followed by both the physician and the nurse…”

As reported last year at HIMSS and by many online news and opinion sources since, physician dissatisfaction with EHRs is growing. Indeed, while this blog post doesn’t focus on the broader picture, general physician career dissatisfaction is disconcertingly high.

The breakneck push for more and better EHR use as a component of regular medical care is a significant part of that malaise, but it is insufficient as an explanation. For the most part, doctors really don’t like what the health IT industry is giving them to work with. The HIMSS survey proves it, showing that around 40 percent of physicians would not recommend their EHR to a colleague.

One would expect an industry to develop better products and improve usability, acceptance and satisfaction over time. In health IT, the opposite has occurred, with most pointing fingers at Meaningful Use as the culprit for awkward workflows and Rube Goldberg solutions cobbled together so everyone can get paid in a timely manner.

It seems EHRs are taking more time to use rather than less, which was the original goal.

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