On the Other Side of the Quality Chasm

The acceleration of the movement toward electronic health record (EHR) implementation and adoption begun by the Institute of Medicine reports of the late 1990s and fueled by the American Reinvestment and Recovery Act of 2009 has propelled us away from the paper environment at a rate that would undoubtedly not have been present in their absence. It is now possible to conceive of a time when the majority of our healthcare institutions and professionals function entirely in an electronic environment.

Now that the other side of the quality chasm is in sight, it is worthwhile to consider what it may be like when we land there, and prepare for a vastly different environment.

A significant body of evidence has been building over the last decade reflecting medical errors that may occur because of electronic medical records. Examples include default acceptance of all orders in an order set when some may not be applicable to a specific patient, or an inaccurate weight entered manually for a newborn but used to automatically calculate medication doses. Any implementation should include attention to proactively averting such errors by responsible quality control processes.

The practice of medicine in real time and enhanced capabilities for granular auditing bring the considerable exposure to medical liability to the forefront. Standards of expectation should be established for reasonable response times to alerts, e-mails and data generated and delivered in real time. Clear policies, consistent with state law, should be established to define exactly what compromises a legal electronic medical record, what information must be produced in the event of litigation, and consideration of consistency in patient care considerations in implementing new features and functions. (Is a different level of care being delivered to a subsection of patients within a hospital if a new feature or function goes live on one service and not another?)

It will be very long time before most hospitals and practices cease to work in a part paper, part electronic environment, but the common goal is to eliminate as much paper as possible. It is therefore highly probable, if not certain, that a generation of clinicians will eventually evolve who have never worked on paper.

It is also certain that hospitals and practices will experience both planned and unplanned system down time. Downtime policies specify circumstances where documentation and order entry must revert to paper, but do not generally address the possibility that clinicians may not know how to work on paper. As part of disaster planning and down time policy determination, policies should be in place for clinicians to be trained at regular intervals in the use of order forms, progress notes, history and physical notes, medical administration forms, etc. that may be called to use in a disaster environment or system down time. After a few years using fully implemented EHRs, they may simply not know how to use paper.

Similarly, ward clerks, pharmacists, lab technicians, and other support personnel must know how to carry out their responsibilities on paper, and must periodically be retrained.

Paradoxically, we may have to be certifying people to work on paper in the future.

Several years ago, I began to consider the vulnerability of our massively growing medical databases. Even though security measures, redundancy, and backup processes are in place, much of the firewall technology is "off the shelf," which simply means to me that someone sitting in a distant country can find a way through it. Most hospital security and background checks on IT personnel consist of credit reports and other forms of superficial investigation, but are rarely in-depth security evaluations.

In spite of painful mass casualty attacks and natural disasters that we have experienced (the Oklahoma bombing, September 11, Hurricane Katrina), our emergency rooms remain woefully unprepared to handle a massive number of injured people or able to sustain care for a large population of injured individuals for anything other than a very short time. If one considers the potential chaos that could ensue from a combined mass casualty episode combined with an intentional attack on the same regions’ medical databases, the importance of this consideration becomes obvious. Organizations such as HITRUST are bringing the importance of protecting our databases to light. As we move further toward the universal use of EHRs, hospitals and database specialists will need to devote more time, energy and money to protecting our healthcare databases.

I have recently been an active participant in the debate over physician-patient communication by e-mail. The greater issue goes far beyond this particular debate. While the mechanics of physician-patient interactions may be brought into the 21st century by reduction to the 1s and 0s of the binary world, the art of medicine cannot be.

If one has ever engaged in online dating, cyber political debate, or an e-mail argument, they will appreciate that much is lost in the absence of face-to-face interaction. Things are said that would never be said when an immediate reaction can be anticipated with someone who is physically present in real time and not in an untouchable, invisible virtual space. In an electronic environment, as much attention needs to be paid to taking care of the emotions and reactions of patients as is paid to the convenience of the communication vehicle in use. This lesson must not be lost for the upcoming generation of texting / Facebooking / Twittering clinicians. Those of us with grey hair have a teaching responsibility in this arena

Let’s not cross a quality chasm and create an empathy chasm.

Samuel R. Bierstock, MD, BSEE is the founder and president of Champions in Healthcare, LLC, a strategic consulting firm specializing in clinical information system implementation and healthcare IT business strategies.

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news development and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a provider organization (hospital, practice, etc.), you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

For this report, I asked panel members what small and/or innovative companies they’ve worked with recently that readers should check out.

AirStrip Technologies. “We are implementing our second solution, Cardiology, and they are doing a great job of meeting our expectations.”

Anypresence. “They have developed a platform so that organizations can create mobile apps.”

AutomateMD. “They call themselves an EMR company with an interesting suite of products, which I like to call more peripheral additions to an EMR solution. The company is looking for investors and claims to have some big-name partners. Marketing rollout for Northern California is supposed to start June 2. The company offers PM/EMR, e-prescribing, EDI, claims, medical transcription, scheduling, billing, document imaging and management, and collections.  They have offices in California and the Philippines.”

Aventura. “You’ve profiled them. We have implemented their clinician access solution.”

CenterX. “Not working with them, but stumbled on an interesting company which is creating competition for Surescripts. This is good, as they are acting like a monopoly – high prices, low innovation. The CEO is an ex-Epic guy.”

Design Clinicals. “They have a standalone medication reconciliation product, MedsTracker, that works very well. I believe they also have a CPOE product for smaller hospitals.”

EGIS Systems. “We’ve used them for HIPAA assessments and vulnerability monitoring. So far, I think we get a lot of value for the cost. They’ve negotiated some great deals to resale other security products (e.g., vulnerability monitoring, e-mail encryption, etc.) for greatly reduced prices. Could be a great offering for small to mid-size organizations. “

Emmi Solutions. “Tracks delivery and consumption of targeted information.“

Ingenious Med. Excellent results for inpatient physician charge capture. Cerner is not quite there yet. Good tool and easily adopted by physicians, replacing either spreadsheets and manual tracking or an older tool that hasn’t kept up with mobile technology.”

Interfaceware. “Its product, Iguana, has a shorter learning curve than HL7 integration and testing. The small, bootstrapped firm is out of Toronto and has an impressive client list of hospitals and vendors. Eliot Muir is founder and CEO.”

Voalte and InterMedHx. “Awesome. Customer service is over the top and products deliver.”

MobileMD. “We’ve been talking with multiple HIE vendors and have great experience with MobileMD. They were recently acquired by Siemens, but still act like the small company they started as. Hopefully they keep it up!”

Nordic Consulting. “We’ve been very pleased with them and their consultants we have engaged.”

Strategic Healthcare Programs. “A solution of choice for real-time decision support and data analytics in the subacute segment. SHP has a dominant position and its partners page reads like a directory of subacute software vendors. Barbara Rosenblum, founder and CEO, is a great lady.”

Tableau. “Fantastic visualization software. Allows presentation of complicated information in a ‘simplified’ graphical format.”

Voalte and InterMedHx. “Awesome. Customer service is over the top and products deliver. “

White Stone Group. “On the rev cycle side. Very cool product and technology that helps hospitals and md offices deal with the nasty payors who don’t want to pay on time or want to create ‘stories as to why they can’t pay. Product is called Trace.”

Top News

HealthCor, which owns 5% of Allscripts, launches a proxy fight for control of the company by suing Allscripts over its nomination process for board members. HealthCor says the resignation of three of the company’s nine directors last month, all of whom had ties to Eclipsys before Allscripts acquired that company, left the Eclipsys product lines unprotected “from the continuing failures of execution of [Glen] Tullman,” whose ouster it had previously demanded. HealthCor wants the June 15 Allscripts annual meeting postponed to give it time to nominate its own candidates for the three open board seats, saying Allscripts should not have put forth its own slate of prospective new board members without giving shareholders the same opportunity. HealthCor is also criticizing Tullman’s $7.2 million compensation in 2011, saying he makes more than the CEOs of competitors whose stock is going up instead of down.

Reader Comments

From BoltUpright: “Re: Shantanu Paul. Interesting that he left Allscripts to head up product development at Vitera. He was a major player in the overall integration strategy at Allscripts. Not sure if his departure is motivated by a desire to jump ship because they weren’t listening to him, or if he’s being pushed out as a scapegoat for the integration problems they are having.” Vitera announced Paul’s appointment as SVP of product development here.

From White Lightning: “Re: Dan Michelson, chief marketing officer of Allscripts. Leaving the company.” Unverified, but a purported internal company e-mail sent my way says he’s leaving to become CEO of a private software company after 12 years with Allscripts. He won’t be replaced, according to the e-mail.

From Reverse Transcriptionase: “Re: Transcend. The servers of the former Transcend Systems transcription company that Nuance acquired have been down for days.” E-mails forwarded to me refer to a major system issue that was caused by failed storage devices. The last e-mail I saw, from Monday, said that they were still down and were typing and faxing stat reports, preop H&P, and radiology reports. I tried the Transcend Services Web site on Monday evening and it was down, but it’s working now, so I assume the problem has been resolved. Anybody can have systems fail and I give them credit for communicating thoroughly, although I’d be interested to hear what customers did in the interim.

From Casual Hospital Administrator: “Re: famous highly wired hospital. Patients appear to have been harmed.” The family of a former post-bypass ICU patient of UPMC Shadyside (PA) sues the hospital, claiming the 68-year-old man was somehow not attached to monitors when he died. Documents apparently verify that the patient was not being monitored for a 16-minute period, saying only that “mistakes were made.”

From Don Diego: “Re: HIStalk Advisory Panel. I’m an avid reader and also impressed with the insight, but the post on what Allscripts should do to fix things is absolutely amazing. Way to go, HIStalk.” I appreciate the involvement of the 79 panel members (now 94) who have volunteered to offer their opinions on topics I’ll e-mail them every few weeks. Most of them are CIOs, CMIOs, and practicing doctors, with a few vendor executives added to the mix. They can provide their honest thoughts knowing that even though I won’t identify them in any way, they’re still not potentially untrustworthy anonymous commenters (like Allscripts competitors, for example) since I know who they are. I’ll take suggestions on what I should ask them in the next round of crowdsourcing. In the mean time, I’ll be listing a few companies they mentioned in response to my question about any cool, small companies they’re working with – stay tuned later in the week.

From CDiff: “Re: Chicago CEO pay. The Chicago Tribune set up a Web page so you can do your own sleuthing on any aspect of compensation. Allscripts and Accretive did not bubble up, the the Trib’s lead story was about Debra Cafaro of healthcare real estate investment trust Ventas, who made $18.5 million. As you know, we have no method to compensate you for all you do; you remain the very definition of priceless.” Healthcare well represented on the list: drug maker Abbott ($24 million), supplies vendor Baxter ($14 million), supplies vendor Hospira ($12 million), and drug store operator Walgreen ($12 million) on the first page alone. Glen is on the list at $7.2 million and Mary Tolan of Accretive lags the well-enriched executive pack at $1.6 million.

From Carriage Bolt: “Re: Cerner single revenue cycle product. I’ve heard Adventist Health West is helping them develop a clinic and physician revenue cycle module.” Unverified.

HIStalk Announcements and Requests

Here’s a tip for companies who go to the trouble to issue press releases about their new hires. Include a link to a hi-res photo and insist that the person create a LinkedIn profile that includes a head shot (and not a thumbnail-sized one – a professionally made full-size headshot since LinkedIn automatically creates the thumbnail). You would be surprised at how many press releases I get about folks who have no apparent photographic presence on the Web, or who use a blurry, small, or amateurish snapshot as their LinkedIn photo. I’m less likely to run those announcements. Another gripe is PR companies that e-mail me a press release that hasn’t been posted anywhere else (including the company’s own site), so I don’t have anything to link to. Or, that send Word documents instead of pasting the text into the body of the e-mail or attaching a PDF – I practice safe text, meaning I’m not opening your Word doc unless I know where it’s been.

Acquisitions, Funding, Business, and Stock

Apple’s iPad in Business page features HCA’s use of AirStrip, Epocrates, PatientKeeper, Heart Pro, and other apps I didn’t recognize.

Here are iPad screen shots of Nova’s $17.99 Heart Pro, developed with Stanford University School of Medicine as a patient teaching tool. Very cool.

Sales

Iowa Primary Care Association selects Ignis Systems to integrate lab orders and results for 15 community health centers running Centricity EMR.

San Jacinto Methodist Hospital (TX) chooses PerfectServe for clinical communications.

People

Former Optum/Axolotl VP Anand Shroff joins Health Fidelity, Inc. as chief technology and product officer.

Nate Ungerott joins Health Care DataWorks as VP of sales. He was previously with Accuvant.

Investor Sue Siegel is named CEO of GE’s healthyimagination, which is spending billions on healthcare innovation and bringing healthcare IT to rural and underserved areas. She replaces Mike Barber, who has moved to VP/GM of molecular imaging at GE Healthcare.

Teresa Jamison is named VP of customer operations of SciQuest. She was previously with Allscripts.

Announcements and Implementations

Oregon’s statewide HIE implements Harris Corporation’s CareAccord platform and Direct Secure Messaging system.

Anthem Healthcare Intelligence, a provider of healthcare BI solutions and services,  rebrands as Agilum Healthcare Intelligence.

The 319-bed Cooper Green Mercy Hospital (AL) implements Medsphere’s OpenVista EHR and Stockell Healthcare’s Insight CS financial and accounting solution, replacing Meditech. The hospital says it will receive considerably more HITECH money than its five-year costs.

CBORD will offer Horizon Software International’s point-of-sale system that allows cafeterias to handle meal plans, payroll deduction, and gift cards to provide “the best total return on investment for healthcare food service operations.” Pretty cool, but I wish hospitals cared enough about their cafeterias to stop outsourcing them to companies like Aramark or Sodexo, who are given free rein to coldly enforce margin-preserving policies that would drive a real restaurant out of business within days: pre-portioned freezer-to-grease prisoner food from Sysco (the potato peeler has left the building), wildly overpriced drinks with no free refills, and weighing plates so that a modest portion of waterlogged spaghetti with canned sauce ends up costing $8. Nobody cooks, everybody scowls defiantly (especially the cashiers), and they all clear out by mid-evening, leaving the captive audience of off-hours employees and visitors with only the vending machines as a shining example of wellness. The best, cheapest, and most nutritional food that’s anywhere close is usually the hot dog cart out front or the caterers who bring in real food for the executive meetings.

Government and Politics

The VA refines its VistA strategy at the Open Source Think Tank, planning to spend up to $5 billion to tap the open source community and the private sector to advance VistA. Among its significant challenges is the Military Health System, which likes the fat cat contractor approach that turned its own AHLTA EMR into a $10 billion flop. The generals claim they’re leading the military-industrial complex charge, trying hard to win some EMR hearts and minds. In the mean time, the VA and DoD announce that they won’t roll out their integrated EHR until 2017. The excellent NextGov got a copy of the presentation outlining the problems. The only sure thing is that it will be late, over budget, and politicized.

Innovation and Research

A Brigham and Women’s study finds that doctors who dictate their notes instead of using templates or typing free text have lower quality of care, as evidenced by standard quality measures. The authors postulate that doctors who use a keyboard instead of a microphone pay more attention to on-screen discrete data elements and clinical decision support messages.

Technology

Bloomberg profiles Jintronix, a company I’ve mentioned that’s building technology around Microsoft Kinect that helps home rehab patients do their exercises correctly.

Mentioned in the above article is potential Kinect competitor Leap, a $70 iPod-size Minority Report-type pre-order USB peripheral that the company says will be 200 times more accurate than “a game system that roughly maps your hand movements,” able to distinguish individual fingers and track movements down to 1/100th of a millimeter. Assuming it’s not bogus, which seems to be a topic of discussion.

Other

In the UK, NHS announces an initiative to provide patients with online access to their medical records by 2015.

Bond ratings firm Fitch Ratings surveys its client hospitals about capital spending and finds that they consider IT investments to be the most important, ranking much higher than capital spending to increase capacity and align with physicians. The company was surprised to find that hospitals don’t expect the Patient Protection and Affordable Care Act to have significant influence on their capital spending plans regardless of the Supreme Court’s ruling.

Boston Children’s Hospital announces that an employee at a conference in Buenos Aires, Argentina lost an unencrypted laptop containing information on over 2,000 patients as an e-mail attachment. Somehow until trying to track this down I didn’t realize that Boston Children’s Hospital is one facility of Children’s Hospital Boston (if I’m correctly deciphering the seemingly contradictory logos and names on their site).

One of those lame problem-solver type news crews investigates a woman’s 10-hour ED wait, quoting the ED doc’s two mitigating issues: a new EMR system (Cerner from Trinity Health, I believe) and the need to treat sicker patients first.

HIStalk reader Alexander Scarlat MD’s book, Electronic Health Record: A Systems Analysis of the Medications Domain, is now available on Amazon. This is not one of those easy-to-skim books that seem to get published without any real purpose – it is hardcore into the medication domain (prescribing, drug concepts, dispensing, MAR, user interface, etc.) Alex was kind enough to send me an autographed copy since I reviewed a pre-press chapter and provided a quote for the back cover:

… encompasses high-value, high-volume therapeutic transactions of indescribable complexity that touch nearly every licensed professional in a hospital, enrobing drug ordering, dispensing, and administration in sophisticated layers of clinical decision support, caregiver work lists, and back-end charging and continuum of care functions. I am pleased that the topic merits its own formal review and analysis in Dr. Scarlat’s book. I found the user interface chapter immediately useful – in fact, I’m hoping the vendors of my own hospital’s systems take its recommendations to heart.

Weird News Andy is all up in our grill with this story, which he subtitles, “A Brush with Death.” Doctors investigating a man’s suspected appendicitis instead find that his intestine is pierced by a nail-like object later identified to be a bristle from his metal grill cleaning brush, which had become embedded in the steak he ate.

Sponsor Updates

• Greenway Medical and NextGen will participate in a patient data exchange demonstration during the ONC’s 2012 Direct Demonstration Showcase in Washington, DC May 31.
• Healthcare Informatics releases its annual list of top 100 vendors based on revenues from HIT products and services. HIStalk sponsors earning a spot of the list include: 3M Health Information Systems, API Healthcare, Allscripts, Beacon Partners, Capario, CareTech Solutions, Cumberland Consulting Group, eClinicalWorks, GE Healthcare, Greenway Medical, Health Data Specialists, HealthStream, Iatric Systems, Impact Advisors, Lawson Software, maxIT Healthcare, MED3OOO, MEDSEEK, McKesson, MedAssets, Merge Healthcare, NTT Data (formerly Keane), NextGen, Nuance, Optum, Orion Health, Passport Health Communications, SCI Solutions, Sunquest Information Systems, Surgical Information Systems, T-System, TELUS Health Solutions, TeleTracking Technologies, The Advisory Board Company, Vitera Healthcare Solutions, Vocera Communications, and ZirMed.
• ICA and AlliedHIE launch a national health information exchange to identify technology and communications issues within healthcare organizations.
• Michael O’Neil, founder and CEO of GetWellNetwork, gave a patient engagement presentation at Cleveland Clinic’s Patient Experience Summit on Tuesday.
• Hayes Management Consulting reports that eight of the top ten US hospitals listed on US News and World Report’s Honor Roll use MDaudit.
• The hospital authority for Memorial Hospital and Manor (GA) approves a consulting engagement with Vitalize Consulting for the implementation and training of hospital’s eMAR/BMV project.

Contacts

Mr. H, Inga, Dr. Jayne, Dr. Gregg.

More news: HIStalk Practice, HIStalk Mobile.

Mr. H posted the results of a recent poll asking whether it’s OK to ask emergency department patients to pay before treating them for non-emergent problems. The vast majority of HIStalk readers responding thought it would be OK.

Since I’ve spent the better part of the last week working the ED, I have to say I agree. Normally I don’t work this many shifts, but the combined stresses of recent changes in our nursing ratios that resulted in some “blue flu” among the nursing staff seems to have inspired an unusual number of call-ins among the medical staff as well. (Either that, or my partners just want to get a jump on their summer vacations.)

Most of my shifts were on the lower acuity side of the ED, which suits me just fine. The full-time docs can handle all the gunshots, “fit for confinement” exams, strokes, heart attacks, and major trauma, thank you very much. I’m perfectly happy to handle fractures, asthma exacerbations, lacerations, and minor trauma. This week, however, we had a boom in patients who simply should not have been in the ED.

This was a bit of a bummer from an electronic documentation standpoint. Our recent upgrade brought us the ability to have condition-specific defaults, and I had spent a fair amount of time building out my personal templates for the conditions I typically see. I did not, however, spend any time building templates for problems that might be best handled at home with a wet paper towel and a nap. The highlight reel:

• A teenager with an insect bite. His mother wrote a note giving permission for a neighbor to bring him in. He noticed the bite in the morning before school when it wasn’t bothering him at all, but mom decided at 10 p.m. that she wanted to know what kind of insect it was that bit him. Unfortunately, I am not an entomologist.
• A high school senior with mild sunburn who wanted to know what she could put on it to make it go away before graduation (which was the next day.)
• An adult male with a 0.5 cm lump on his arm that had been there for six months. That prompted him to arrive at 1 a.m. “just to get checked out,” although he couldn’t say why he was coming in NOW.

I’m pretty sure that if someone in the waiting room would have told them it would be a minimum of a two and a half hour wait and a $200 charge, these three musketeers (and the dozens like them) would probably have chosen to go home. I wish we could have a seasoned registered nurse stationed in the waiting room, administering simple first aid and counseling patients to follow up with a primary physician or a walk-in clinic in a day or two rather than using scarce ED resources. While I was dealing with them, we had an elderly woman with a complex fracture of her upper arm, several patients with lacerations, and a chap with a knee the size of a grapefruit that needed my attention.

Unfortunately, fallout from the Emergency Medical Treatment and Active Labor Act (EMTALA) makes it difficult for us to employ creative strategies to reserve the ED for appropriate use. Becoming law in 1986 as part of the COBRA legislation, EMTALA seemed like a good idea at the time. Although EMTALA was intended to ensure that patients presenting with emergent conditions were not turned away for inability to pay or other discriminatory reasons, the unintended consequence is a generalized fear of saying “no” to anyone who walks in the door.

The Code specifically defines an “emergency medical condition.” More than half of my patients this week failed to meet that standard, yet they had full visits anyway. We had to document each visit in detail, including a full review of systems, counseling on advance directives, nutritional screening, and more. (We also had to arrange transportation home for the mom who brought her daughter by ambulance for a splinter, but that’s another story entirely.)

I wasn’t in practice prior to 1986 so I can’t say what it was like, but I can’t imagine it was as chaotic and soul-sucking as it is now. I was, however, in the trenches when E&M Coding appeared on the scene, and I experienced first-hand the ridiculous make-work that ensued.

Looking at the track record for federal meddling in health care, it’s hard for me to think that the changes occurring as a result of Meaningful Use will turn out well in the long run. I may have Certified EHR Technology and full command of the Meaningful Use program. I can cite all the measures verbatim even after a couple of glasses of wine. I have more timely access to old charts (which are now actually legible) and better drug interaction checking, but other than that, the benefits still seem elusive.

How do you think we’ll feel in 25 years when we look back at Meaningful Use? E-mail me.

E-mail Dr. Jayne.

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

The Art of Medicine: Unlocking the Power of Patient Data
By Nick van Terheyden, MD

We are awash with information and choices in every aspect of our lives, from the selection of our morning coffee to the choice of painkiller in our local pharmacy. Worth noting, Starbucks currently offers 30 variations of espresso beverages, and each comes in three sizes with four types of milk. That’s 360 choices — enough to potentially make you want to not get out of bed in the morning.

This problem is magnified in medicine with a deluge of new information, studies, treatments, and the explosion of genome understanding and its impact on patient care. Based on current estimates, medical information is doubling at least every five years. Cyril Chanter encapsulated today’s medical information challenges best when he said, “Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous.”

There is general agreement in the medical profession that the delivery of quality medical care is no longer possible based on recall and applying what individuals can remember at the point of care. In fact, according to the Kaiser Permanente Institute for Health Policy, “Current medical practice relies heavily on the unaided mind to recall a great amount of detailed knowledge – a process which, to the detriment of all stakeholders, has repeatedly been shown unreliable.”

The digitization of medical records, accompanied by the requirement imposed on the care team to capture discrete data, is setting the healthcare system up for failure. We’re promoting the incomplete capture of the patient note. Discrete data is much like a black-and-white drawing — it contains some of the data, but much of the critical information and nuances are missing. In order to ensure the complete capture of the patient note, discrete data and the clinical narrative must coexist.

The key transport mechanism for medical intelligence is the clinical narrative, which provides the detail that is essential for the execution of intelligent, high-quality medical care. From there, language understanding offers a legend for these pieces of information – the narrative and discrete data – which allows us to view the complete work of art, also known as the patient note.

We are a long way down the path to enabling clinicians to capture complete patient information using the latest advances in voice recognition, which converts spoken word into text. Still, it is with language understanding that we unlock the true meaning of this information, offering a “Rosetta Stone” to tap into the insights of this information and allowing us to connect the dots in our expanding picture of patient care in a digital world.

It is this unlocked data that will link the subtle details of the patient record to vast mountains of medical intelligence; allowing for a guided, evidence-based approach to medicine alongside integrated decision support. This in turn will offer care takers a more complete picture from which they can guide individual care, while enabling possibilities surrounding large health population analysis and insight.

As we unlock the capabilities of clinical data in healthcare, we open the door to new discoveries, associations, and yet-unimagined treatments that will directly affect the care of those we love and look after now and into the future.

Nick van Terheyden MD is chief medical information officer of Nuance of Burlington, MA.

I once heard it said that successful device connectivity in a hospital is like implementing a universal remote on your TV. The consolidation of controls allows for easier training of new users, fewer steps to execute a command, and less room for error. But in today’s age of accountable care and new care delivery models, the health systems that are still operating in the “universal remote” mindset will be left behind as the industry progresses.

It’s great that my DVD player can talk to my TV. But what about when I want to watch the same movie on my laptop in the other room? And while this entertainment glitch is a little frustrating, it’s actually criminal when we think of a similar scenario in the healthcare world. We don’t need to just connect one point solution to another. We need to be able to effectively care for patients, regardless of where they are within the hospital; what systems the hospital has in place; or how many physicians, nurses or other staff are involved in the patient’s care. The sooner hospitals begin to think beyond individual technologies and develop an overarching strategy to connect people and processes, the faster we’ll start to see a real change in patient care.

Historically, hospitals and health systems have approached medical device connectivity tactically, focusing on how to connect a nurse call device to a smart phone, a monitoring device to an iPad, or data from a smart bed to an EMR. Often purchased by IT departments as middleware, a range of IT solutions have been viewed as a solution to one or two key problems, and have typically been implemented one department or one facility at a time.

Because many of these technology investments were made to solve only singular, point-in-time problems, providers still struggle to deliver care that focuses on the patient across the entire care continuum. They need to get smart about implementing solutions that cater to the unique workflow of their personnel – not their hardware – if they want to drive efficiency and improved patient care.

It’s not really the provider’s fault, though. The vast majority of vendors have played into this universal remote mindset by building point solutions that connect a small subset of devices or departmental systems to one another, rather than focusing on the entire system. Providers need solutions that both cater to a department’s unique workflow and enable collaboration from one department to the next, making it possible to efficiently serve patients as they move between these diverse care settings. They need to come to the table with customizable solutions, and with services that help hospitals implement these solutions as part of a broader workflow strategy. It’s not enough to drop off a box and wish them well. Providers need partners to help them learn and improve for years to come.

We need a new movement in healthcare, one that takes a system-wide view to clinical workflow design and leverages clinical technology solutions to both connect devices and foster collaboration across the entire system. This includes everyone from patients to clinical teams to ancillary groups (biomedical engineering, dietary, environmental services, IT, and pharmacy). Clinical workflow is about more than hardware and software. It’s about the clinicians who use these solutions and need them to promote — not hinder – high-quality patient care. Vendors need to offer their customers something better than stale point solutions. 

As an industry, we need to map to the bigger picture, driving teamwork and collaboration among every individual and across the entire care continuum in order to drive dramatic performance improvements for healthcare organizations.

Mary Baum is chief healthcare officer of Connexall USA of Boulder, CO.

When hospitals choose a healthcare IT provider, they too often just focus on the same questions many of us consider when buying a car: “How fast does it go?” and “How much does it cost?” But for a successful project, these are just two of the many factors to consider. Another key decision point should be a vendor’s suitability as a long-term partner.

We’re not just talking the equivalent of a 100,000-mile power train warranty, whereby the vendor will fix your system if it breaks, though of course responsive support is important. But beyond that, you’ll be better off working with a company that not only understands its products and services, but also your processes, your staff, and your goals, and will do its best to unite these elements to give you maximum performance and value.

The first thing to consider before getting on the road is your hospital’s needs, both now and for the next few years. What are the pain points you’re trying to overcome, what new compliance mandate are you struggling to satisfy, or which facet of your EMR/EHR project are you finding most troublesome? This then defines the focus of your solution search, which will in turn narrow your list of prospective vendors.

Next, ask for references from facilities like yours and see how they’re solving the very issues you want to solve. Then ask them what else they’ve been able to do with the product. A hospital sometimes picks a solution because it fits neatly into whatever box they’re trying to fill, but yet leaves the full potential of that solution untapped. One of the reasons is that an IT team is typically tasked with solving a very narrow problem, and once they’ve done it, they must move on to putting out the next fire lit by clinicians or the CIO. They then go out and look for other vendors to meet the very needs that could be met by the product they’re already using – a waste of time, effort, and money for everyone involved.

Executives tend to chase the next “shiny object” or respond to the newest tech trend, and this leads to the misconception that something ‘new and improved’ is required. Just like we all want the next iPhone or iPad, many hospital users hanker after the latest IT toys on the market, following the hype rather than putting in the effort to explore the full capability of the applications already deployed.

Despite the need for hospital project managers to be proactive in working with vendors to get the most from their systems, the burden cannot fall solely on the facility. A responsible vendor that cares about its customers and the staff and patients they serve should dedicate time and resources to helping hospitals get the most out of its solutions. A regular onsite “checkup” with both a customer advocate and a member of the vendor’s executive team can provide the hospital with a view of what its products can do now, and what the roadmap is for upcoming functionality. The vendor can explain and even demonstrate how other customers are using its offerings in new ways, and can then help the IT staff put this knowledge into action. Executive buy-in is also crucial on the hospital side, as the CIO and IT director will be key in both understanding the full potential of vendors’ products and services, and then in driving widespread user education and adoption.

The challenge to such leaders: push your IT analysts/project managers to explore each product’s entire feature set and get involved in engaging your vendors to see what else you could or should be doing. Yes, it requires accountability and an upfront time investment. But it will yield the benefits of doing more with existing tools, moving further toward achieving your facility’s goals, and, most importantly, of improving care and service to your patients. Time to start your engine!

Chad Morrill is an account manager at Access of Sulphur Springs, TX.