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Readers Write: Can Intuitive Software Design Support Better Health?

April 16, 2014 Readers Write No Comments

Can Intuitive Software Design Support Better Health?
By Scott Frederick

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Biometric technology is the new “in” thing in healthcare, allowing patients to monitor certain health characteristics—blood pressure, weight, activity level, sleep pattern, blood sugar—outside of the healthcare setting. When this information is communicated with providers, it can help with population health management and long-term chronic disease care. For instance, when patients monitor their blood pressure using a biometric device and upload that information to their physician’s office, the physician can monitor the patient’s health remotely and tweak the care plan without having to physically see the patient.

For biometric technology to be effective, patients must use it consistently in order to capture a realistic picture of the health characteristics they are monitoring. Without regular use, it is hard to see if a reading is an anomaly or part of a larger pattern. The primary way to ensure consistent use is to design user-friendly biometric tools because it is human nature to avoid things that are too complicated, and individuals won’t hesitate to stop using a biometric device if it is onerous or complex.

Let’s look at an example.

An emerging growth area for healthcare biometrics is wireless activity trackers—like FitBit—that can promote healthier lifestyles and spur weight loss. About three months ago, I started using one of these devices to see if monitoring metrics like the number of steps I walked, calories I consumed and hours I slept would make a difference in my health.

The tool is easy-to-use and convenient. I can monitor my personal metrics any time, anywhere, allowing me to make real-time adjustments to what I eat, when I exercise, and so on. For instance, at any given time, I can tell how many steps I’ve taken and how many more I need to take to meet my daily fitness goal. This shows me whether I need to hit the gym on the way home from work or whether my walk at lunch was sufficient. I can even make slight changes to my routine, choosing to stand up during conference calls or take the stairs instead of the elevator.

I download my data to a website, which provides easy-to-read and customizable dashboards, so I can track overall progress. I find I check that website more frequently than I look at Facebook or Twitter.

Now, imagine if the tool was bulky, slow, cumbersome and hard to navigate. Or the dashboard where I view my data was difficult to understand. I would have stopped using it awhile ago—or may not have started using it in the first place.

Like other hot technology, there are several wireless activity trackers infiltrating the market, each one promising to be the best. In reality, only the most well-designed applications will stand the test of time. These will be completely user-centric, designed to easily and intuitively meet user needs.

For example, a well-designed tracker will facilitate customization so users can monitor only the information they want and change settings on the fly. Such a tool will have multiple data entry points, so a user can upload his or her personal data any time and from anywhere. People will also be able to track their progress over time using clear, easy-to-understand dashboards.

Going forward, successful trackers may also need to keep providers’ needs in mind. While physicians have hesitated to embrace wireless activity monitors—encouraging patients to use the technology but not leveraging the data to help with care decisions—that perspective may be changing. It will be interesting to see whether physicians start looking at this technology in the future as a way to monitor their patients’ health choices. Ease of obtaining the data and having it interface with existing technology will drive provider use and acceptance.

While biometric tools are becoming more common in healthcare and stand to play a major role in population health management in the future, not every tool will be created equal. Those designed with the patient and provider in mind will rise to the top and improve the overall health of their users.

Scott Frederick, RN, BSN, MSHI is director of clinical insight for PointClear Solutions of Atlanta, GA.

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April 16, 2014 Readers Write No Comments

Readers Write: Addressing Data Quality in the EHR

April 16, 2014 Readers Write 1 Comment

Addressing Data Quality in the EHR
By Greg Chittim

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What if you found out that you might have missed out on seven of your 22 ACO performance measures, not because of your actual clinical and financial performance, but because of the quality of data in your EHRs? It happens, but it’s not an intractable problem if you take a systematic approach to understanding and addressing data quality in all of your different ambulatory EHRs.

In HIStalk’s recent coverage of HIMSS14, an astute reader wrote:

Several vendors were showing off their “big data” but weren’t ready to address the “big questions” that come with it. Having dealt with numerous EHR conversions, I’m keenly aware of the sheer magnitude of bad data out there. Those aggregating it tend to assume that the data they’re getting is good. I really pushed one of the major national vendors on how they handle data integrity and the answers were less than satisfactory. I could tell they understood the problem because they provided the example of allergy data where one vendor has separate fields for the allergy and the reaction and another vendor combines them. The rep wasn’t able to explain how they’re handling it even though they were displaying a patient chart that showed allergy data from both sources. I asked for a follow up contact, but I’m not holding my breath.

All too often as the HIT landscape evolves, vendors and their clients are moving too quickly from EHR implementation to population health to risk-based contracts, glossing over (or skipping entirely) a focus on the quality of the data that serves as the foundation of their strategic initiatives. As more provider organizations adopt population health-based tools and methodologies, a comprehensive, integrated, and validated data asset is critical to driving effective population-based care.

Health IT maturity can be defined as four distinct steps:

  1. EHR implementation
  2. Achievement of high data quality
  3. Reporting on population health
  4. Transformation into a highly functioning PCMH or ACO.

High-quality data is a key foundational piece that is required to manage a population and drive quality. When the quality of data equals the quality of care physicians are providing, one can leverage that data as an asset across the organization. Quality data can provide detailed insight that allows pinpointing opportunities for intervention — whether it’s around provider workflow, data extraction, or patient follow-up and chart review. Understanding the origins of compromised data quality help recognize how to boost measure performance, maximize reimbursements, and lay the foundation for effective population health reporting.

It goes without saying that reporting health data across an entire organization is not an easy task. However, there are steps that organizations must take to ensure they are extracting sound data from their EHR systems.

Outlined below are the key issues that contribute to poor data quality impacting population health programs, how they are typically resolved, and more optimal ways organizations can resolve them.

 

Variability across disparate EHRs and other data sources

EHRs are inconsistent. Data feeds are inconsistent. Despite their intentions, standardized message types such as HL7 and CCDs still have a great deal of variability among sources. When they meet the letter of national standards, they rarely meet the true spirit of those standards when you try to use.

Take diagnoses, for example. Patient diagnoses can often be recorded in three different locations: on the problem list, as an assessment, and in medical history. Problem lists and assessments are both structured data, but generally only diagnoses recorded on the problem list are transported to the reports via the CCD. This translates to underreporting on critical measures that require records of DM, CAD, HTN, or IVD diagnoses. Accounting for this variability is critical when mapping data to a single source of truth.

Standard approach: Most organizations try to use consistent mapping and normalization logic across all data sources. Validation is conducted by doing sanity checks, comparing new reports to old.

Best practice approach: To overcome the limitations of standard EHR feeds like the CCD, reports need to pull from all structured data fields in order to achieve performance rates that reflect the care physicians are rendering– either workflow needs to be standardized across providers or reporting tools need to be comprehensive and flexible in the data fields they pull from.

The optimal way to resolve this issue is to tap into the back end of the EHR. This allows you to see what data is structured vs. unstructured. Once you have an understanding of the back-end schema, data interfaces and extraction tools can be customized to pull data where it is actually captured, as well as where it should be captured. In addition, validation of individual data elements needs to happen in collaboration with providers, to ensure completeness and accuracy of data.

 

Variability in provider workflows

EHRs are not perfect and providers often have their own ways of doing things. What may be optimal for the EHR may not work for the providers or vice versa. Within reason, it is critical to accommodate provider workflows rather than forcing them into more unnatural change and further sacrificing efficiency.

Standard approach: Most organizations ignore this and go to one extreme or another: (1) use consistent mapping and normalization logic across all data sources and user workflows, making the assumption that all providers use the EHR consistently, or (2) allowing workflows to dictate all and fight the losing battle to make the data integration infinitely adaptable. Again, validation is conducted using sanity checks, comparing new reports to old.

Best practice approach: Understand how each provider uses the system and identify where the provider is capturing all data elements. Building in a core set of workflows and standards dictated by an on-the-ground clinical advisory committee, with flexibility for effective variations is critical. With a standard core, data quality can be enhanced by tapping into the back end of the EHR to fully understand how data is captured as well as spending time with care teams to observe their variable workflows. To avoid disruption in provider workflows, interfaces and extraction tools can be configured to map data correctly, regardless of how and where it is captured. Robust validation of individual data elements needs to happen in collaboration with providers to ensure completeness and accuracy of data (that is, the quality of the data) matches the quality of care being delivered.

 

Build provider buy-in/trust in system and data through ownership

If providers do not trust the data, they will not use population health tools. Without these tools, providers will struggle to effectively drive proactive, population-based care or quality improvement initiatives. Based on challenges with EHR implementation and adoption over the last decade, providers are often already skeptical of new technology, so getting this right is critical.

Standard approach: Many organizations simply conduct data validation process by doing a sanity test comparing old reports to new. Reactive fixes are done to correct errors in data mapping, but often too late, after provider trust has been lost in the system.

Best practice approach: Yet again, it is important to build out a collaborative process to ensure every single data element is mapped correctly. First meetings to review data quality usually begin with a statement akin to “your system must be wrong — there’s no way I am missing that many patients.” This is OK. Working side by side with the providers to ensure they understand where data is coming from and how to modify both workflow and calculations ensure that they are confident that reports accurately reflect the quality of care they are rendering. This confidence is a critical success factor to the eventual adoption of these population health tools in a practice.

 

Missed incentive payments under value-based reimbursement models

An integrated data asset that combines data from many sources should always add value and give meaningful insight into the patient population. A poorly mapped and validated data asset can actually compromise performance, lower incentive reimbursements, and ultimately result in a negative ROI.

Standard approach: A lackluster data validation process can result in lost revenue opportunities, as data will not accurately reflect the quality of care delivered or accurately report the risk of the patient population.

Best practice approach: Using the previously described approach when extracting, mapping, and validating data is critical for organizations that want to see a positive ROI in their population health analytics investments. Ensuring data is accurate and complete will ensure tools represent the quality of care delivered and patient population risk, maximizing reimbursement under value-based payments.

 

We have worked with a sample ACO physician group of over 50 physicians to assess the quality of data being fed from multiple EHRs within their system into an existing analytics platform via CCDs and pre-built feeds. Based on an assessment of 15 clinically sensitive ACO measures, it was discovered that the client’s reports were under-reporting on 12 of the 15 measures, based only on data quality. Amounts were under-reported by an average of 28 percentage points, with the maximum measure being under-reported by 100 percentage points.

Reports erroneously reported that only six of the 15 measures met 2013 targets, while a manual chart audit revealed that 13 of the 15 measures met 2013 targets, indicating that data was not being captured, transported, and reported accurately. By simply addressing these data quality issues, the organization could potentially see additional financial returns through quality incentive reimbursements as well as a reduced need for labor-intensive intensive chart audits.

As the industry continues to shift toward value-based payment models, the need for an enterprise data asset that accurately reflects the health and quality of care delivered to a patient population is increasingly crucial for financial success. Providers have suffered enough with drops in efficiency since going live on EHRs. Asking them to make additional significant changes in their daily workflows to make another analytics tool work is not often realistic.

Analytics vendors need to meet the provider where they are to add real value to their organization. Working with providers and care teams not only to validate integrity of data, but to instill a level of trust and give them the confidence they need to adopt these analytics tools into their everyday workflows is extremely valuable and often overlooked. These critical steps allow providers to begin driving population-based care and quality improvement in practices, positioning them for success in the new era of healthcare. 

Greg Chittim is senior director of Arcadia Healthcare Solutions of Burlington, MA.

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April 16, 2014 Readers Write 1 Comment

CMIO Rant with … Dr. Andy

April 9, 2014 Readers Write 5 Comments

CMIO Rant with … gives CMIOs a place to air their thoughts or gripes. Yours are welcome.

The Great Prescription Pad Race
By Andy Spooner, MD

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Which is more usable: a prescription pad or a computer?

That’s a no-brainer. For writing a prescription, the pad wins, hands down. Consider its features:

  • Instant-on. No booting up. Just reach in your pocket and you are ready to go.
  • Compact, lightweight. Did I mention your pocket?
  • Self-documenting. No need to print a summary describing the prescription.
  • No irritating pop-ups with irrelevant alerts.
  • Patient-centered. The pharmacist can fill in missing information (liquid or tablet or capsule? brand or generic?) based on patient preferences.
  • Flexible. Can be taken to any pharmacy. No need to route it to a specific place, or even to ask the patient about a preferred pharmacy.
  • Streamlined. No need to worry about pharmacy benefit management rules. The pharmacist can sort all that stuff out.
  • Information-persistent. If the family has a question about an apparently erroneous prescription, they can read the details right off the prescription when talking to the after-hours nurse.
  • No record-keeping clutter. Patients can just tell us about their prescriptions next time we see them. They could just bring in the bottle or something.

With all of these advantages, surely only the geekiest of pencil-necked CMIOs would advocate an electronic method of prescribing, right?

Of course not.

The prescription pad is easier only if we define the work as the minimum possible activity that a doctor can do to get a prescription into a patient’s hands. The truth is, we are not done with the task of prescribing when we hand the slip of paper to the patient. If we think we are, then the pad seems far easier to use—more usable—than any electronic health record or e-prescribing system.

The above competition is absurd, of course, in an era when, according to the CDC’s National Ambulatory Medical Care Survey, over 80 percent of office-based physicians in 2013 used electronic prescribing. That rate rose from less than 60 percent over the past three years. E-prescribing is here to stay.

But we still hear about how unusable electronic medical record systems are. In The Atlantic this month, we read that a doctor who sees 14 patients a day spends “1-3 hours” each day entering orders. Assuming that each patient needs some orders for health maintenance (screening lab work), prescription renewals, and maybe a few diagnostic tests and referrals, it’s hard to take that statistic seriously. It’s clear that the writer is irritated at his EMR, and there may be some legitimate design or implementation issues with it. But 1-3 hours of ordering per day? C’mon.

Somewhere between the slapdash paper prescription and the three hours of daily ordering is the truth. Managing clinical information takes some amount of time, and some of it should be done directly by physicians. Some of this activity serves a “compliance” goal that you may not like, but all of it is a part of building a system of healthcare that serves a worthy goal.

If we insist that all clicks are wasted time, then we can’t have a conversation about usability, because under the prescription pad scenario, the only usable computer is one you don’t have to use at all.

On the other hand, if we insist that our current systems are bad because of hyperbolic, data-free assertions about how the EMR is making our lives miserable, we are similarly blocked from making productive plans to improve usability because, well, it’s just too darn much fun to complain.

My thesis, then, is that EMR usability is not as much about design as about expectations. Variations in what these expectations ought to be between different perspectives will lead to unproductive conversations (or no conversations at all) about what it means to have an EMR that’s easy to use.

All I know for sure as a CMIO is that physicians want all of this stuff to be easier to use. We also want these systems to read our minds, but that’s at least a couple of versions away, if I am understanding the vendor presentations at HIMSS correctly.


Andy Spooner, MD, MS, FAAP is CMIO at Cincinnati Children’s Hospital Medical Center. A general pediatrician, he practices hospital medicine when he’s not enjoying the work involved in keeping the integrated electronic health record system useful for the pediatric specialists, primary care providers, and other child health professionals in Cincy.

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April 9, 2014 Readers Write 5 Comments

Readers Write: Advanced Interoperability: Leveraging Technology to Improve Patient Lives and Provider Workflows

April 2, 2014 Readers Write 1 Comment

Advanced Interoperability: Leveraging Technology to Improve Patient Lives and Provider Workflows
By Justin Dearborn

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There’s an increasing need for all of healthcare to be integrated in its approach to accessing, sharing, and storing information. It’s not just patients who could stand to benefit from more advanced interoperability. It’s also healthcare providers who want to meet legislative requirements such as Meaningful Use Stage 2 and Stage 3, as well as reduce costs and improve care quality.

Consider what typically happens in today’s medical imaging environment—often partway between a traditional manual environment and a fully interoperable one—when a patient presents to his primary care physician (PCP) complaining of shoulder pain, for example:

After receiving a comprehensive clinical exam, a patient named Dave heads home with a hand-scribbled order for a shoulder MRI. Before the exam can take place, however, the imaging center must get the order pre-certified by Dave’s health insurer. After receiving the insurer’s faxed approval days later, the imaging center schedules the patient for his exam. Days after that, the radiologist faxes his report to the PCP, who then calls Dave to set another appointment to discuss his torn rotator cuff. Once the decision to seek surgical treatment is made, Dave is asked to bring a CD of his radiology images to the orthopedic specialist.

If this process sounds cumbersome, time consuming, and inefficient, that’s because it is. It’s also the rule with respect to today’s medical imaging processes.

While it’s true that anywhere between 10 to 20 percent of imaging orders issued today are processed electronically, that still means the vast majority are processed manually via paper and/or fax. According to the Centers for the Disease Controls and Prevention (CDC), approximately 12 percent of all PCP visits alone result in a referral for diagnostic imaging—some 44 million imaging exams each year—which equates to a lot of wasted time and paper, not to mention money.

The payer-approval process only adds to that burden. Roughly 122 million imaging exams are processed manually by radiology benefits management companies each year, at a cost of about $75 per exam. That adds up to nearly $8 billion of waste a year.

So the question is this: What would happen in an environment of advanced interoperability, where existing electronic health records (EHR) and other technologies are fully leveraged? Take Dave’s scenario again:

After receiving a comprehensive clinical exam, Dave’s PCP electronically orders a shoulder MRI and schedules an imaging appointment for later in the day. Before the exam takes place, the imaging center receives electronic pre-certification. Once the MRI is complete, the PCP automatically is alerted that an image-enabled report is available. Before he leaves his office for the evening, the PCP calls Dave to discuss his torn rotator cuff and to electronically refer him to an orthopedic specialist who already has secure automated access to the image-enabled radiology report.

As this simple scenario illustrates, the entire patient-imaging process can be streamlined by enabling five key services: 1) electronic referrals and ordering; 2) automated pre-certification and approval using clinical decision support; 3) electronic patient navigation and scheduling; 4) image-enabled reporting; and 5) analytics.

Such advanced interoperability provides Dave, his PCP, and his orthopedic specialist with near-instantaneous exam ordering, approval, and scheduling. Ease of access to reports, results, and images is dramatically increased.

By creatively leveraging EHRs and other technologies, healthcare organizations can maximize their interoperability with internal and external providers. All these services, moreover, can be provided without costly point-to-point HL7 interfaces.

With payment reform, it is clear that the days of disjointed, manual image processing are numbered. Indeed, advanced interoperability like that described here not only addresses the challenges that impact physicians, but also pays handsome dividends for patient care.

Justin Dearborn is CEO of Merge Healthcare of Chicago, IL

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April 2, 2014 Readers Write 1 Comment

Readers Write: Competing for Talent in Healthcare IT – Remember, Candidates are Interviewing You, Too

April 2, 2014 Readers Write No Comments

Competing for Talent in Healthcare IT – Remember, Candidates are Interviewing You Too
By Mike Silverstein

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The healthcare IT market is as hot and competitive as ever and the battle for the industry’s top talent is on. If your firm has gone through any recent hiring waves, I probably don’t have to tell you that the buyer’s market of 2008-2012 is over. Strong candidates, regardless of specialty, who have good work records, great performance reviews, and above-average soft skills are being flooded with lucrative and enticing opportunities as soon as they dip their toe in the market.

These concrete, actionable items can help win over a candidate who is evaluating offers from multiple firms.


Tighten Up the Recruitment Process

Companies are making decisions and hiring faster than I have experienced in the past five years. In order to be competitive, make sure your process is swift and efficient and that the proper decision makers are involved. Nothing kills the chances of landing a great candidate faster than not being able to schedule something on a hiring manager’s calendar for a delayed period of time. Talent is the lifeblood of an organization. Make sure managers block off the appropriate time on their calendars so they do not become the bottleneck that kills the process.

Also, make sure there is a good rhythm between calls with the candidate. If the last phone interview was two weeks ago, don’t expect the candidate to be as excited about your job as they were 12 hours after their initial call.


Make Sure Messaging is Consistent

Nothing spooks a candidate more than hearing different things about a position from different people. Make sure everyone involved in the recruitment process understands the reason you are hiring for the position, who it reports to, what the expectations are, what the time frame is, and what is expected from this individual. If anyone is going to bring up the compensation associated with the position, make sure it’s consistent with what your HR team and your recruiter is saying.


Present the Company in the Best Light

From a convenient travel itinerary (even if it costs a few extra bucks) to having a “Welcome Joe Smith” sign on the door, it is important to pay attention to the details. Have a well-organized itinerary of meetings with the hiring team. Schedule a meeting with those same executives within 48 hours to make a go/no-go decision. 

Be to produce a succinct written offer within 24 hours after that decision, including a comprehensive benefits summary, explanation of compensation including (competitive) salary, bonus, and equity. Include a breakdown of how to earn 100 percent of the bonus.

Virtually none of this advice will cost you any more money. It is all about making the candidate recruitment experience more attractive and enjoyable. 

Mike Silverstein is partner and director of healthcare IT of DIrect Consulting Associates of Solon, OH.

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April 2, 2014 Readers Write No Comments

Readers Write: Below the Waterline: Is Your Network Population-Health Ready?

April 2, 2014 Readers Write No Comments

Below the Waterline: Is Your Network Population-Health Ready?
By Nancy Ham

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Historically, health information exchange (HIE) implied the tactical, the plumbing and pipes that enable movement of health-related information among organizations according to national standards. Today an HIE network is a strategic asset vital to population health management.

Health organizations must supply more than bricks and mortar as our industry moves from what was once a conceptual model of healthcare to reality. They must provide a network solution for powering appropriate population health management capabilities.

HIE capabilities are evolving. Existing competencies are being coupled with workflow and care management processes, essential for analyzing and managing populations of patients − a shift from the traditional retrospective version of care to real-time, preventive care. Today’s care management needs to be informed and powered by high-quality, real-time discrete data from myriad sources across the continuum of care.

To affect population health, the entire healthcare ecosystem from acute to ambulatory to long-term and beyond needs to be connected, moving beyond the traditional reach and capabilities that current health information exchanges offer.

We’re all familiar with the phrase “the tip of the iceberg.” The tip of the iceberg is visible. It glints and shines. This iceberg principle applies nicely to many population health management solutions with flashy dashboards and snazzy visualization methods. They look really good on the surface, but what is imperative is what lies beneath the waterline. Is the foundation − the data asset from which the analysis is conducted − a solid one?

Before adding population health visualizations, ensure that your foundation is complete. Ask yourself:

  • Are your patient records correctly and accurately matched?
  • Do you have a sophisticated privacy and security infrastructure?
  • Do you have pointers established to access clinical data regardless of where it exists?
  • Can you manage granular patient consent?
  • Do you have a sophisticated mechanism for driving role-based access, including new network participants such as payers?
  • Is your solution able to scale to bring more and more participants into your network?
  • Does your system represent the entire healthcare community across care settings?
  • Are your referrals managed and communicated among providers?
  • Do you have alerts to notify providers when a patient experiences a health event so they can make informed and timely decisions for that patient’s care?
  • Are your EHR interfaces bi-directional?
  • Do you have patient engagement tools such as patient portals and personal health information?
  • Can you aggregate claims and billing data in conjunction with clinical data?
  • Are you using data standardization methods to furnish mineable data?
  • Can you share patient care plans?

Your HIE should do all of this. Your HIE partner should have a track record of linking hospitals with the entire community of providers.

When you have a sophisticated HIE network to enable clinicians to manage their patient population, you have a scalable foundation for improving the quality and cost of care. The foundation is key. From there you can snap on population health analytics solutions, whether from your HIE vendor or from one or more third-party vendors. Now you have evolved your HIE to a strategic network, curating the data flowing through the network to provide contextual, real-time information that engages both clinicians and patients.

Nancy Ham is CEO of Medicity of Salt Lake City, UT.

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April 2, 2014 Readers Write No Comments

Readers Write: Doctor’s Day and HIMSS

March 31, 2014 Readers Write 5 Comments

Doctor’s Day and HIMSS
By Dr. Wellbeing

On Doctor’s Day, I am reflecting on the morale of my profession. I hope to get away with being the kid who says, "The emperor has no clothes."

I looked long and hard for inspirational writings about doctors, particularly on this day, and there were none. Maybe the closest to a worthy read was Malcolm Gladwell’s article in Forbes about the state of American healthcare, followed by his interview called, "Tell People What It’s Really Like to Be a Doctor." It came as a surprise considering he is not an insider, but he is one of the most insightful thinkers out there. As such, I was happy to see a voice in defense of doctors.

Alas he is the exception that proves the rule. Because it seems doctors are blamed for everything that is wrong with the healthcare system these days.

CMS is making physician payment data public. Insurance companies are placing doctors in straightjackets and requiring pages of paperwork just to get one medication approved. Patients have unrealistic expectations of, "I can hardly wait to chat with my doctor at my leisure online."

No wonder the morale of doctors is at an all-time low. It is the equivalent of a big bully chasing the weak kid around on the playground because he is small and cannot fend for himself. Physicians historically have not been well organized, and their representatives – such as AMA — abandoned them a long time ago.

I just returned from my first HIMSS conference, where everybody was busy giving advice on how practices should get ready for ACOs, MU, ICD-10, PCMH, population health etc. I am thinking that maybe the ones who should have their data made public are the HIMSS folks themselves, since just to exhibit there for one week costs more than my salary for a year.

I am not returning anytime soon. Even though I was warned by close friends that HIMSS is physician-unfriendly, I was not prepared for the CEO and chairman to start the conference with an insult to physicians after asking them to stand up in a full room. One IT person who is equally disenchanted with HIMSS and vows to not return suggested that we should invite "60 Minutes " to one of those conferences. Or maybe some patients, for that matter.

The healthcare IT industry has become a bit like the tail that wags the dog. It has lost its sense of purpose and meaning. One of my favorite lines ever is from “Jurassic Park,” which is, “Just because we could does not mean we should.”

One vendor was shocked to find out that I am not paid for “population health.” Another one dressed in a white lab coat could not explain to me who makes the ultimate decision in telemedicine (one genie that left the bottle) when the patient with congestive heart failure whom we try to keep out of the hospital cannot breathe. Who calls 911 — the patient, his doctor, or the “doc in the box?” Nor could he answer whose liability that is. I have yet to see a tele-intubation.

If we are to have some foresight, then maybe we should have some hindsight as well and understand how we got here in the first place. The sickest patients, the elderly, the chronically ill, and nursing home residents are not technology savvy. Nursing homes have been beaten by litigation to the point that the fear of being sued is so ingrained into their psyche that they cannot even give a Tylenol or a laxative without a doctor’s approval. Hence, why every decision in healthcare goes through a doctor’s office whether we like it or not. It is why my inbox is full every day and I have endless hours of mind-numbing work.

Another EMR vendor could not articulate why a hospital should buy its care coordination solution when hospitals are not being paid for care coordination. Little do they know that very few actually participate in ACOs, nor do they plan to do so. As such, their solutions are based on assumptions that we will all be in an ACO one day, an experiment that has yet to show results, also ignoring the fact that 60 percent of doctors have expressed no desire to join one.

The whole premise of the HIMSS technology offerings relies very heavily on the Assume a Can Opener theory. It has very little understanding of how healthcare is being delivered and paid for, which I particularly found very disturbing.

The shortage of physicians and the burnout is real. On this day, let us all remember that in reality what we are paying docs to do is to make decisions. That is far more complex than any of the human endeavors or societal activities, and yet it is the most-intruded upon, most-regulated and most-distrusted of them all. In Greek mythology, Hydra grew two heads each time one was cut off, just as healthcare grows more complex by the day. Yet the ones who should be consulted first seem to be the last.

It seems the harder we try to fix the "broken American healthcare system," the farther we are from fixing it. The recent proof is the ineptitude of Congress, who is not capable  to understand the complexity of what  they are voting on, always approving short-term fixes to long-term problems. The sad part is not that the fee-for-service is broken or that the HMO / capitation / ACO is better, nor that they kicked the  can down the road regarding SGR for the umpteenth time, but that we are forced to practice in a a dual, ambivalent environment where both are equally approved.

While hospitals are paid by DRG, doctors are paid per day. In Medicare Advantage Plans, the Primary Care gets paid capitation, while the specialists get paid fee-for-service. We have created a de facto "divide and conquer" system.

Too often the term "physician alignment" is used along with "patient engagement " and "accountable care." How about if for one day a year  – March 30 — we use "patient alignment and patient accountability“ and "physicians’ engagement?” Because returning from HIMSS, my EMR inbox was full of messages like, "Can the doctor write me a note for early dinner sitting on my cruise since I am a diabetic?" or “Can the doctor write me a note for the airline to allow me to take my dog with me on the plane since I suffer from anxiety?" or "What kind of fiber should I take?"

I do believe strongly that patients should have access to their records and that healthcare records should be digitized, but  I do not subscribe to the assumption that it will resolve our healthcare woes or that it will lower healthcare costs. Just giving patients their data does not mean that they will know what to do with it, nor that they will make wiser decisions. Giving them an app does not mean that they will start eating spinach.

The same is true of physicians. Inundating them with data does not mean they will make better decisions, either. We are in essence data-rich but information-poor.

While I enjoyed networking and meeting people, it was difficult to separate the signal from the noise. I saw what billionaires look like, from Judy Faulkner to Dr. Patrick Soon-Shiong, who was gracious and took a picture with me so I can show my kids that the richest man in LA is a physician and not a movie mogul. But I cannot ignore the fact that not all hospitals can afford Epic and that so many had their credit ratings downgraded due to Epic implementations budget overruns, nor the fact that the orange-clad NantHealth staffers had no idea what their company was about. I also had the opportunity to explain to some why social media for many physicians is a legal minefield and many MDs shy away and don’t want to live in the town where they practice.

One economist said that when the barn is on fire, the farmer by instinct goes inside and saves the cat, the dog, and the livestock and leaves the rest behind. I believe it is time for healthcare IT industry to do the same. If healthcare is on the verge of a cliff, then healthcare IT can either throw us a rope or give us the final push. 

I keep hoping that someday the pendulum will swing back to doctors being respected and trusted and that they themselves rediscover the meaning and calling of their profession amid all the chaos. I should have faith because Mr. H told me so.

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March 31, 2014 Readers Write 5 Comments

Readers Write: What Is Population Health Management, Exactly?

March 12, 2014 Readers Write 1 Comment

What Is Population Health Management, Exactly?
By Steven Merahn, MD

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While at HIMSS, I stopped by the KLAS booth and ended up revisiting the October 2013 KLAS report on population health management. I was both impressed and concerned about its findings. Impressed because of the level of market commitment to population health-related solutions, but concerned because I still don’t think the market gets it when it comes to population health management.

The real power of population health is the opportunity it offers those delivering care to disintermediate those we now call payers — removing or disrupting a layer insulating patients from their providers – or at least put physicians and provider networks in a position of strength in negotiations with those contracting for care (unfortunately, it also puts hospitals at risk for similar disruption, like what happened to the railroads when airline travel began to get traction).

HIMSS was full of vendors hawking analytics and care management platforms, but population health is really not at its heart a technology play. In the executive summary of the KLAS report, author Mark Wagner tried to address this issue when he said,  “…automation is a misnomer for vendor solutions and PHM remains largely a manual process.”

However, the use of the phrase manual process is itself a misnomer. It presumes that automation is even possible for population health management. Elements of a technology stack can enable (and may be necessary for) population management, but these elements – individually and collectively – are wholly insufficient for successful implementation of a population management infrastructure.

Wagner again alludes to this in his reference to the value of “collaborating with physicians early,” but there’s more to this than simply physician engagement. It’s far more fundamental, as physician leaders, provider networks, and healthcare delivery systems are discovering. In successful population management, the databases, software analytics. and care planning platforms — whether EHR-based or independent but interoperable — are largely subordinate to a more dominant factor:  the human factor.

If there’s one thing that has been consistently affirmed to me in the 30+ years since medical school graduation, it is that health and healing is impossible without the human connection. I submit that the value in value-based care – improving quality of care and quality of health based on more efficient use of effective healthcare resources across a cohort or defined population – is more powerfully achieved through reconsideration of the organizational principles and operating relationships among the people, programs, platforms, and partners that comprise healthcare delivery and care management.

Population health management transcends the technological elements that may fulfill some of its specific functional requirements. Product, services, and channels may be necessary, but are insufficient to truly influence the trajectory and quality of a person’s health. That influence occurs at more tactile and emotive levels in people lives, “tactile” referring to the responsiveness, reliability, consistency, and convenience of care; “emotive” referring to the sincerity, authenticity, integrity, and dignity associated with the experience.

I am reminded here of Dr. Lipton, our family physician in the 1950s and 1960s, For him, what we now call population health was just the way he practiced medicine. If my grandfather – who had his first heart attack in his mid-30s – missed his quarterly blood pressure check, we would get a call. After my grandmother’s sigmoidoscopy — then done in an operating room as an inpatient — he stopped by the house.

His technology for this: the work of worry — and a weekly index card tickler file. But despite what would seem to us some technological limitations, time and time again he demonstrated to us that we were very present for him even when we were absent from his waiting room.

He did get paid in cash for services rendered, on a fee schedule and sliding scale, but he also worked to earn our trust. There was no doubt that this was an important form of compensation for him. His value proposition was threefold:  mastery of his craft, demonstrable commitment, and genuine consideration. As such, his responsibilities for our health extended beyond the doors of his office.

For our family, he provided comfort and a safe harbor – despite some looming health threats — because there was a person, and not just a person, an expert, who worried along with us and that was in many ways a more powerful influencer of our healthcare quality then the medicines he prescribed. His recommendations were followed, even when there was intellectual resistance, because we could not imagine letting him down.

Our current approach to technology is focused on “managing measureable variables,” but the real challenge is that quality of health is based on a different set of variables than quality of care. Our technology may allow us to identify and attempt to control dozens of evidence-based clinical factors, but is still not powered by factors representing the capacity to influence a patient in ways that truly matter.

Which means that if we truly want transform care delivery with technology, we need to shift our focus from the meaning of the data to what we mean to each other.

Healthcare technologies should be instruments of human expression in service of health and healing, with a fundamental mission to provide the patient and their family the same sense of comfort, safety, and reliability provided by the Dr. Liptons of the world – where professionals are valued for their commitment to mastery and human service and patients are helped to find the meaning of health in the context of their relationship with themselves and others.

This will require us to reconsider what we mean by population health by designing systems of care that amplify the humanness in our care delivery, where technology supports goal-directed collaboration between humans and machines and where we are allowing people to find meaning and value within themselves and from each other.

Steven Merahn, MD is senior vice president and director of the Center for Population Health Management at Clinovations of Washington, DC.

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March 12, 2014 Readers Write 1 Comment

Readers Write: Why a Unique Patient Identifier is Critical to Improve Patient Matching

March 12, 2014 Readers Write 4 Comments

Why a Unique Patient Identifier is Critical to Improve Patient Matching
By Barry Hieb, MD

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In a recent HIStalk article entitled “National Patient Identifier: Why Patient Matching Technology May Be a Better Solution,” Vicki Wheatley argues that, “… healthcare organizations should instead focus on strengthening their existing enterprise matching strategies” rather than work to implement a national patient identifier (NPI). The article makes several valid points that contribute to the ongoing debate about an NPI:

  • No solution, including an NPI, can solve all patient matching problems.
  • Patient matching errors and healthcare fraud will continue to require special attention.
  • Accurate tracking of an individual’s information across healthcare silos is becoming increasingly important.
  • Any proposed patient matching solutions must not negatively influence privacy, security, or clinical outcomes.
  • Accurate patient matching is essential for activities ranging from clinical care to healthcare analytics to population health management.

In these and several other areas, Ms. Wheatley’s article makes a valid contribution to the ongoing debate concerning a national unique patient identifier.

There were a few areas, however, where we have a somewhat different viewpoint. The first of these is the implied assumption that healthcare organizations must make a choice between having an EMPI and having a national patient identifier. We believe that this is a false dichotomy.

Clearly, healthcare organizations must continue to improve their existing EMPI systems as much as possible. However, years of analysis and experience indicate that this will not allow them to achieve the levels of patient matching accuracy that are being required going forward. Those requirements include identification of individuals across disparate healthcare systems, the need for matching against ever-increasing patient populations, and the fact that patient demographic data has known variability and ambiguities.

These represent just three of the reasons why unassisted EMPI demographic matching cannot represent the sole patient matching strategy. Rather, the EMPI approach will need to be supplemented by techniques such as the use of an NPI, biometrics, digital certificates, and other technologies.

Virtually every EMPI system uses a patient’s Social Security number as a data element to improve the performance of their demographic matching algorithm. I was puzzled by the statement, “… even in theory, every single potential patient in the country would need to be assigned one…” as a condition for an NPI to work. Ms. Wheatley acknowledges that there are many people in the US who require healthcare but do not have an SSN. Despite this deficiency, the use of the SSN clearly adds value in those situations where it is accurately available. Similarly, an NPI would benefit each patient who chooses to use one.

An important point to keep in mind is that there is no mechanism to check for data entry errors in most of the data elements currently used for demographic matching. This includes the SSN, names, and addresses. For example, there is no reliable way to detect transposition of digits when a SSN is manually entered. Nor is there an easy way to automate the capture of a patient’s SSN.

Contrast that with a well-designed national patient identifier system. In most situations, the NPI would be read using automated technology such as a barcode reader or a smart chip that would virtually eliminate errors. Even when the NPI is manually entered, embedded check digits can ensure that any data entry errors are immediately detected and the operator is prompted to re-enter the NPI. When added to a person’s demographic profile, the NPI thus becomes the single demographic element that can lead to accurate patient identification on its own. These proposals represent a major advance from the current situation – i.e., an 8 percent or more error rate in EMPI matches.

It is very clear that healthcare organizations will continue their use of EMPI systems for the foreseeable future. That fact, however, should not blind us to the reality that these EMPI systems need to be augmented by additional capabilities going forward if they are going to meet the patient matching accuracy needs that are emerging in healthcare.

The use of a national patient identifier, even if it is initially only chosen by a subset of providers (or patients, on a voluntary basis), will enhance the patient matching accuracy for those patients and help avoid the medical errors that are associated with patient matching errors.

Barry Hieb, MD is chief scientist with Global Patient Identifiers, Inc. of Tucson, AZ.

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March 12, 2014 Readers Write 4 Comments

Readers Write: The Data Problem

March 5, 2014 Readers Write No Comments

The Data Problem
By Randy Thomas

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Dr. Jayne asked important questions in her Curbside Consult about big data, EHR conversions, the “sheer magnitude of bad data out there,” and how best to insure the integrity of health data.

The best way to address the issue of bad data is to follow the old adage,“Begin with the end in mind.” Implementing an enterprise-wide EHR is a massive, complex undertaking. It involves considering the needs of many stakeholders when defining the build requirements. For example, workflow must support ease of use and not interfere in patient care delivery and related work processes. Furthermore, many implementation decisions focus on driving clinician adoption to ensure that both quality and efficiency objectives are met (not to mention regulatory requirements related to Meaningful Use.)

With all the multi-threaded work streams and decision processes involved in planning and executing an EHR implementation, the re-usability of captured data frequently falls out of scope. That leads to the bad data problem.

Re-usability means using data captured in any source system (EHR, ADT  materials management, patient accounting, registration, operating room, emergency department, etc.) for reporting, measurement, and analytics. Re-using the data captured in these source systems accelerates the value realized from implementing such systems and supports a virtuous cycle of performance improvement across an enterprise.

It all relates to, “You can’t manage what you don’t measure.” That is, you can’t measure something if you don’t have the right data. This leads back to the decisions made in implementing EHRs and other systems. You need to start with what data is required to measure and analyze what’s important to the organization and ensure that data can be consistently, reliably, and accurately captured at the point of origin (e.g., at registration or in the care process).

It’s not realistic, however, to expect that every bit of data about a patient should be captured in a discrete form for re-use. What’s required is a balance between supporting ease of use in the appropriate workflows and the availability of data for reusability.

An effective way to strike this balance is to create a list of data elements the organization agrees is necessary for analytics. Some detective work is required: tracing the journey of that data back to the source system and ensuring that each data element is captured as expected in the intended workflow. This requires collaboration across a multi-disciplinary team — one involving experts in quality reporting, data analysis, and clinical (or operational) workflow.

The inventory of data elements can be used to identify where each data element can be captured in the source system (e.g., EHR, ADT, etc.). This is the “data chain of trust.” Team discussion and compromise are required to design workflows that both support ease of use and capture data reliably and consistently.

With a documented inventory of data elements married to how that data will be captured in the source systems, data can start flowing into an analytics environment. Applying sound data governance principles and implementing a data profiling discipline will ensure data consistency and reliability.

Organizations don’t have to begin with a large set of discrete data, but they must recognize that any level of measurement, reporting, and analytics requires consistent, reliable, accurate data starting at the point of capture in the source systems. They should begin with the data most important to each organization and ensure that data can flow from origin to analytics in a chain of trust that is known and transparent.

From there, health systems can incrementally increase the available data as they come to understand why it’s important to capture data discretely and accurately and as more stakeholders benefit from access to that data. With the increasing value realized comes the understanding that, “It’s all about the data.”

Randy Thomas is associate partner of health analytics with Encore Health Resources.

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March 5, 2014 Readers Write No Comments

Readers Write: National Patient Identifier: Why Patient-Matching Technology May be a Better Solution

March 3, 2014 Readers Write 3 Comments

National Patient Identifier: Why Patient-Matching Technology May be a Better Solution
By Vicki Wheatley

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Advances in technology, combined with The Patient Protection and Affordable Care Act, have begun to revive calls in the media for a national patient identifier—similar to the national provider identifier (NPI) assigned to physicians. The HIPAA legislation of 1996 included provisions for such an identifier, but they’ve never been enacted out of concerns for privacy and security.

Despite current law prohibiting the use of national patient identifiers, many proponents say creating such an identifier would make it easier to track patients across the continuum of care, leading to more effective treatments and better outcomes for patients. Others believe existing credentials such as Social Security numbers make a national patient identifier unnecessary. Lost in all the debate, however, are patient identification issues that will always exist—whether a national patient ID does or not.

Although adding a national patient identifier would provide one more data element to help confirm a patient’s identity, it still wouldn’t resolve some key record-matching challenges, nor would it fully enable organizations to use data for analytics, population health management or accountable care.

For a national identifier to work, even in theory, every single potential patient in the country would need to be assigned one—and only one—number and use it consistently. This holds true whether we generate a new identification number or use an existing one, such as a Social Security number.

For the sake of argument, let’s say Social Security numbers were to be used as national patient identifiers. Truth be told, many individuals living in or visiting the US don’t have Social Security numbers, like newborns or foreign visitors. Others may be fraudulently using someone else’s number for employment or other purposes. Additionally, using Social Security numbers as patient identifiers likely would raise security and privacy concerns due to the amount of financial and personal information already tied to them.

Just as the NPI has not been the fix-all for helping healthcare organizations exchange provider information, implementing a national patient identifier or using Social Security numbers will not resolve patient identification issues either. The reason: it won’t address concerns regarding existing information discrepancies or duplicate patient records. Additionally, like any identifier, it can be mis-keyed, transposed, or even stolen. Adding yet another identifier does not solve the patient matching conundrum.

Rather than advocating for a panacea that won’t solve the problem, healthcare organizations should instead focus on strengthening their existing enterprise patient-matching strategies, which can be easily implemented within individual organizations.

In order to provide optimal care, clinicians need to have an accurate view of the individuals they treat. Likewise, organizations as a whole must know who their patients are, what coverage they have, and which payer’s rules they must adhere to in order to receive payment. All of this information is particularly valuable when patient data is being used for analytics, accountable care, or population health management.

Thus, resolving patient identification problems is essential not only for enabling quality care, but also for supporting the financial viability of the healthcare organization. The challenges are further compounded by the fact that patient data resides across disparate systems encompassing the patient’s entire continuum of care. As a result, available patient data must be accurately linked together from within and across multiple organizations.

Unfortunately, however, errors occur. Registration staff may inadvertently transpose numbers, record nicknames instead of legal names, or fail to validate and update key data elements. Patients change addresses, phone numbers, insurance coverage, and names all the time. Data provided and collected is not always complete or accurate. Some patients forget information; others even want to hide it. To err is human, but mistakes introduced into patient records lead to discrepancies and duplicate patient records that complicate the patient identification process.

Patient-matching technology within an enterprise master patient index (EMPI) allows hospitals and health systems to bring together disparate information from various IT systems within or across organizations. This is essential for effectively managing the patient population and preparing for payment reforms. For example, an EMPI that compares patient data using probabilistic matching tools and algorithms can generate a unique enterprise identifier for each patient, eliminating the need to change information in source IT systems and enabling exchange of clinical and financial data. With an EMPI, multiple key data elements such as name, birth date, gender, address, other identifiers, and even biometrics can be used to accurately identify patients, ensuring the data in front of providers matches the patients they’re treating.

It’s a fact: as long as people are involved in providing and entering information, some level of human error remains inevitable. Yet by employing a strong strategy to address underlying identification issues, hospitals and health systems can compensate for some of the human elements that will always complicate patient identification—with or without a national patient identifier in place.

Vicki Wheatley is executive vice president of enterprise master person index solutions of QuadraMed of Reston,VA.

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March 3, 2014 Readers Write 3 Comments

Readers Write: Dr. Gregg’s “HIStalk: The Movie”

March 3, 2014 Readers Write No Comments

HIStalk: The Movie
By Dr. Gregg

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It’s Oscar night tonight. I know this because in my house, that’s a pretty big deal; my wife is one of the most star-struck people walking the planet.

And, as it’s a night of glam and glitz and red carpets and such, it seems an appropriate time to announce the upcoming release of the star-studded extravaganza, “HIStalk: The Movie.”

No doubt you’ve heard the rumors… and it’s true! HIStalk is coming to the big screen. Featuring a cast of some of HIT’s biggest stars, including:

The one, the only – MR. H! Nobody tells it like the inimitable, and wholly inscrutable, Mr. HIStalk. Now he tells it like it is in full, glorious Technicolor with thundering DTS surround sound. Hear Mr. H blast the blatantly bland and debunk buffaloing bloggers. See him – fully facially pixelated – tear through HIT hype and tripe. Watch as he snags rumors from the ethers and exposes the raw underbelly of the simmering underworld of HIT.

The perpetually 28 year old party girl – Inga! Nobody glides through the HIMSS exhibition halls with more panache than the sultry Swede. Watch her dance the night away with HIT celebs Farzad, Jonathan, Ivo, and many more meaningfully-used macho men. Sporting in the finest footwear this side of the Champs-Elysées, she’ll dance her way straight to your hard drive.

The ever-running, always stunning – Dr. Jayne! Hear the good doctor call out unscrupulous C-suite commands for harmful cost-cutting. Watch her shoot down ill-considered patient care policies and lambast ludicrous Luddites. She’ll run a marathon of mischief as she bears the banner for CMIOs everywhere.

The million dollar mobile man – Dr. Travis! Once again riding the WiFi waves of justice, Dr. Travis will keep you in mHealth stitches as he exposes new tech that doesn’t deliver and sorts out the portably important from the connectedly comic.

The man – Lt. Dan! Need we say more?

The vivacious new HIStalk vamp – Lorre! Supremely smart and stunningly sassy, this demure little vixen will warm your digital hearts as she becomes HIT’s newest pin-up girl. We’ve no doubt that after the world sees her stunning debut performance that she’ll be adorning screensavers like no one since Farah Fawcett.

You’ll gasp in awe at the beautiful panoramic sets designed and painted by the hand of Regina Holliday.

You’ll be blown away by the homespun humor and heartwarming insights into all things HIT based upon Ed Marx’s award-winning story.

You’ll never forget the effortless flow and seamless style of Dr. Rick’s screen adaptation.

You’ll delight in the scintillating score by the lyrical genious, Dr. HITECH, founder of The American College of Medical Informatimusicology (ACMImimi.) Performed by the entire ensemble of illustrious ACMImimi fellows, you’ll hear health information rock like you’ve never heard it before.

Get out the popcorn and pull up your favorite easy chair for tonight’s Oscars, but get ready really enjoy them next year when “HIStalk: The Movie” will undoubtedly take home all the golden statues setting new standards for both Hollywood and HIT.

From the trenches…

"Never give up. And never, under any circumstances, face the facts.” – Ruth Gordon, Best Supporting Actress, “Rosemary’s Baby”

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, an HIT and marketing consultant, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).

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March 3, 2014 Readers Write No Comments

Readers Write: Little Data

February 10, 2014 Readers Write No Comments

Little Data
By Greg Park

2-10-2014 7-09-35 PM

Today’s topic is the methods by which employees and partners obtain information to perform their function, or as I like to call this, the Push vs. Pull method of information dissemination.

Let’s step inside the way-back machine to observe how this was accomplished in 1986.

I was cutting my HIT teeth first as a computer operator and then as “do-everything” guy at a mid-sized hospital in Philadelphia. There were few standards and no one with HIT degrees. You learned from the vendors, by reading technical manuals, and by putting out fires.

My first big hospital project was implementing Shared Medical Systems Spirit platform, which was SMS’s first turn-key mini platform. This led to managing other tertiary clinical applications and methods of creating information.

Each new platform we installed was bundled with standardized reports focused on daily activities, DNFB accounts, and payments by patient type. All reports were QA’d by vendor and staff prior to go-live to certify accuracy. These standard out-of-the-box reports were the lifeblood of staff’s workflows, and believe me, I would hear it if they weren’t delivered by 6:00 a.m.

Reporting exploded as data became richer and tools emerged to create specialized ad-hoc reports. Soon we were creating ER patient flow analysis, profitability by attending physician, nurse staffing by patient acuity, and then linking data between disparate platforms.

Life was good, but we were killing thousands of trees each month. End users were happy because the process of creating these ad-hoc reports was very personal. I would sit with end users to analyze their needs against the data collected. When required, we would add new data fields and workflows to collect that information accurately in our various platforms. Finally we would validate output structures, ensure accuracy, and finally schedule the reports for the desired timeframe.

Each day or week or month, the report would print. As time marched along into the 1990s, we downloaded all reports into our content management platform. Now all reports were readily accessible and audit trails let us know exactly who was (or was not) reviewing their reports.

My formative years were spent in this way understanding need, locating data, and constructing formats to enable user workflows. These were the “Push” years, because it was our responsibility to ensure the report, spreadsheet, or database was created and pushed to users and business partners in a timely way.

Somewhere in the mid-1990s it became clear that something was changing. During a PeopleSoft implementation, I noted that disk space and CPU resources were significantly more robust than the platforms I had encountered. Data could be kept almost indefinitely and sophisticated queries could be run in real time rather than waiting for a day-end process. The writing was on the wall, but the major HIT platforms would take years to catch up. Many hospitals still operate like its 1985, some with basically the same HIT platforms.

The rest of this writing involves relaying the conversations I have had with my customers, so if this is not your experience, please chime in.

Most new EMRs are fashioned with limited standard reports. End users have become the focal point in the process of generating all reports. Generating reports and pushing them to their intended audience has become an anachronism. Let’s call this new method the “Pull” method, because users are expected to pull the data themselves. In this Pull method, users access report writing tools and pull data on their own terms as needed. To the system designers, this must have been intended as empowerment, but for many users it is a speed bump that did not exist before.

This Pull method can be implemented in various ways. In some, the IT department creates general templates for users to enter query parameters. This works fairly well, but does not address those reporting situations where the timing of data generation is critical. The report will look different if run on August 31 as opposed to September 10, and sometimes this is a problem.

Another method is to provide the user with a full query interface. Now end users are playing the role of IT analyst. Maybe this is fair and is a reflection of how IT is part of everyone’s jobs today, but it can be problematic when users select the wrong data or create a query that is particularly taxing to the EMR or its reporting database. In this world, we have a real problem of focusing on the wrong data, or worst yet, not focusing on the data at all.

For the moment (because I know that once HIT is exposed to big data this will change) patient accounting and general finance are your biggest data consumers. From my perspective, they seem particularly annoyed with this new Pull mentality. Many of these users access these new systems exclusively to generate their own reports.

For me, life is always about balance, and I think both the Pull and Push methods have their place. Pull methods are fine in some scenarios, assuming your end users know how to data mine and construct data exports. But when the situation is time sensitive, I want tools that Push information to responsible parties. This means end users are immediately notified the information exists, that it is readily accessible, and that they are expected to review it immediately.

I know this topic is not at the top of your mind considering MU, ICD-10, and all of your other requirements, but think about it during some downtime and consider whether you are doing your best to get the right information to the right people at the right time.

Greg Park is director of enterprise solutions for Dbtech of Edison, NJ.

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February 10, 2014 Readers Write No Comments

Readers Write: How Many More Reasons Do You Need?

February 10, 2014 Readers Write No Comments

How Many More Reasons Do You Need?
By Tom Furr

2-10-2014 6-32-40 PM

The US Postal Service recently raised the cost of a first class stamp to $0.49, a 6.5 percent increase. Darrell Issa, the Congressman chairing the committee that approved the rate hike, admits, "This rate hike and the ones sure to follow will only push more and more private sector customers to stop using the mail altogether. The rate increase poses a direct threat to the 8 million private sector jobs that are part of the mailing industry as businesses shift from paper-based to electronic communication and mailers are priced out of business."

Think about it. If you had a supplier that said, “We are losing money because nobody really needs our product any more, but we are raising our prices so we can try to hang on a little longer,” how much longer would you stay with them? Or if I told you that your COGS was going up 6.5 percent and you had no alternative in vendors or processes, you might start looking at your business model and thinking about a way to work around that vendor.

In addition, bulk paper costs are expected to rise 2.5 to 6 percent over the next year. I can promise you that your vendors are not going to absorb those costs. If you are responsible for collecting payments from patients on behalf of hospitals and practices, it is a stone cold fact that you are going to see your costs rise next year. I wish I had better news for you, but unless you change something soon, you are going to have some very hard choices to make.

Once choice you can make now is to look at shifting to an online solution that allows you to present patient statements and collect payments easily. It’s not just what you need, it’s what patients want. I was talking to Allen Warren of A&H Billing last week and he explained that he adopted online bill pay because that’s what he prefers when he pays his bills. “When I talk to folks in this business, I ask them, ‘How do you pay your bills?’”, he said. “The funny thing is they all sort of laugh when they think about it. It seems so obvious when you step back from it.”

It’s no secret that I have been looking to drive online payments for our partners, but when the USPS admits that today more than 60 percent of Americans are paying their bills online and their response is to raise rates, how is that good business? It’s going to make consumers look for ways to not use their service. The question is do you want to go for that ride to the bottom with them? I know I don’t, and while I used to look at companies that offered online bill pay as innovative, I now just look at them as sensible.

The cost of postage is going up, the cost of paper is going up, and consumers want to pay their bills online. How many more reasons do you need?

Tom Furr is founder and CEO of PatientPay of Durham, NC.

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February 10, 2014 Readers Write No Comments

Readers Write: The Symbiosis of Care: The Re-Emergence of Professionalism and the Patient Satisfaction Impact

February 10, 2014 Readers Write No Comments

The Symbiosis of Care: The Re-Emergence of Professionalism and the Patient Satisfaction Impact
By Paul Weygandt

2-10-2014 6-25-44 PM

As a physician, it’s second nature for us to make sacrifices for the betterment of others, whether that entails missing the first half of your daughter’s soccer game to listen to a husband who is losing his wife to cancer or working 80 hours a week.

Having been in these situations, I can honestly say – and I believe the vast majority of physicians would agree – it doesn’t feel like a sacrifice. It is an unconscious reaction to another person who is in emotional or physical pain. In many ways, being a physician is instinctual – you automatically prioritize others’ needs over your own. And again, quite honestly, in my many years of practicing medicine, I rarely had to deliberate on where I needed to be – when you’re a physician, you just know.

The ability to provide care may come as second nature, but things like using ICD-10 compliant clinical documentation do not. It is no secret that changes in regulatory policies are placing new pressures on physicians and taking our focus away from patient care and practicing the art of medicine. Regulatory requirements are directly impacting the physician-patient relationship. 

While capturing data on the patient experience is important, evaluating the physician experience and then acting on that data is of equal value. According to a recent American Medical Association/Rand study on physician satisfaction, quality of care is inextricably tied to professional satisfaction, and many obstacles to high-quality care are seen as major sources of dissatisfaction. The converse is also true. Any major source of physician dissatisfaction is an obstacle to high quality care.

We’ve found ourselves in a Catch-22. Government regulations are designed to improve patient outcomes, but they are doing so at the expense of those who are providing that care. The two most visible groups in healthcare are patients and physicians, and right now both are suffering under the burdens of a poorly designed system. Patients feel neglected and physicians feel like cogs in a wheel or workers on the healthcare assembly line, devastating medical professionalism and negating the patient benefits of that professionalism.

The ramifications of this situation are severe. After all, everyone has a breaking point. When 60 percent of physicians admit they would retire if they had the means to do so, it’s no longer just an isolated incidence of one or two hospitals’ poor processes or a few old physicians struggling to embrace new technology that is causing the problem. This has become an epidemic that is threatening to decimate our physician community across the country. It isn’t just a handful of luddites refusing to change with the times; it is something much deeper that is cutting at the very core of the medical profession and the physician’s vocation.

Now we’re back to that second nature ability that physicians possess. Physicians willingly made the conscious decision to dedicate their lives to others — to sacrifice for others. They didn’t pledge themselves to filling out onerous paperwork or to looking at a computer screen instead of into the eyes of their patients. It is time for the innovators, particularly those in the health IT community, to listen to physicians, conduct pain tests or do an Apgar score of sorts to closely monitor the health of the profession, and suggest new solutions that can begin to alleviate the discomfort of a sick healthcare system.

If non-essential busy work and non-patient demands can be decreased or eliminated, I think we will find that, once again, that physicians are able to spend their days caring for their patients. Addressing and fixing the myriad of non-clinical issues facing physicians will allow a rebirth of professionalism. That professionalism is, in turn, the basis for high quality care and patient satisfaction.

Paul Weygandt, MD, JD, MPH, MBA, CCS, FACPE is vice president of physician services of Nuance Communications of Burlington, MA.

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February 10, 2014 Readers Write No Comments

Readers Write: Ominous Outlook for Meaningful Use

January 29, 2014 Readers Write 8 Comments

Ominous Outlook for Meaningful Use
By Evan Steele

1-29-2014 1-18-47 PM

CMS passed up a golden opportunity to stave off the potential demise of the EHR incentive program when it failed to delay the start of Stage 2. What was already a complex program in Stage 1 becomes exponentially so in Stage 2, and its pace is outstripping the realities of medical practice and of software development. The facts speak for themselves:

  • 17 percent of the physicians who successfully attested to 90 days of Meaningful Use at Stage 1 in 2011 walked away from the second incentive ($12,000) in 2012, which required a full year of Meaningful Use. I find this dropout rate very surprising. The requirements were exactly the same as the first reporting period for these physicians, so they and their staffs had already established the necessary workflows. The fact that many of these first attesters were early EHR adopters and therefore already more adept at EHR use than the average physician makes this statistic even more alarming. When surveyed by CMS, many of the dropouts cited the program’s complexity as a key reason for their failure in Year 2. Physicians who gave up on Stage 1 will likely not even attempt Stage 2.
  • 12 percent of attesters who used one of the top 25 EHRs to demonstrate Meaningful Use in Stage 1 do not yet have access to a 2014-certified EHR, according to a January report issued by Wells Fargo Securities, while this year’s reporting period must begin within nine months. Some EHRs will never achieve 2014 certification. The first announcement of a vendor abandoning Meaningful Use came a few weeks ago, leaving its physicians out in the cold. Of the 49 ambulatory EHRs that have been 2014 certified to date — winnowed down from a Stage 1 field of 472 — very few have yet been deployed to physicians. This is clear evidence of the complexities associated with Stage 2 and the significant challenges facing vendors in making their EHRs compliant yet practical.
  • I would estimate that at least another 15 percent will walk away from Stage 2 because of its dramatically increased complexity, added costs, and impact on productivity, particularly when weighed against the declining incentives (as little as $4,000 and $2,000 for physicians whose first year of Meaningful Use was 2011) and penalties that will average only a few thousand dollars.
  • How many additional physicians will be driven to cry “Uncle” and abandon Meaningful Use because they are besieged by the demands of so many other programs at the same time—ICD-10, PQRS, Value-Based Payment Modifier, ACO participation, etc.? Physicians and their clinical teams are weary and can only do so much.

If you add these numbers together (acknowledging some overlap), the conclusion that 40 percent of past attesters will give up on Meaningful Use is inescapable. Then there’s the 37 percent of eligible professionals who have never earned an EHR incentive, including 18 percent who—if failure to even register is an indication of lack of intent—are so overwhelmed by the program that they have no interest in participation even in the “easiest” first stage (Source: CMS Presentation to HIT Policy Committee, January 14, 2014).

The delay of Stage 3 will be too little, too late. What was needed was a more reasonable approach to Stage 2.

Evan Steele is CEO of SRS, Montvale, NJ.

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January 29, 2014 Readers Write 8 Comments

Readers Write: Once a Nurse, Always a Nurse

January 29, 2014 Readers Write 2 Comments

Once a Nurse, Always a Nurse
By Lisa Cannon

1-29-2014 1-11-30 PM

We all wear various hats in our lives, but some experiences are never forgotten. Through the years, I’ve been the road warrior healthcare consultant and then moved to positions supporting consulting operations. Yet nothing remains in my heart more than my early days as a nurse. I never knew how much I would appreciate having been a nurse until my mom’s health took a sizeable downward turn last year.

My mom’s chronic cardiac condition resulted in several hospital visits and treatment by various specialists in her last months. At home, coordinating her care among her medical team was no easy task. Keeping her out of a nursing home meant visits from home health nurses, nurse aides, and multiple therapists. This was a great deal of care synchronization for my aging father to deal with, but he welcomed it, knowing the alternative. He organized her medications and had everything written down. Thanks to my nursing background, I trained him in the art of taking her blood pressure, doing daily glucose checks, and measuring her oxygen saturation.

I was constantly running cover on what was being prescribed for Mom and monitoring how Dad was delivering the recommendations. Sadly, we hit an issue that in hindsight makes me question if it was the action that ultimately caused her death. Could information technology (IT) have made a difference? Perhaps. Maybe the application of common sense and additional family education could have.

Mom’s renal specialist ordered a diuretic water-releasing medication to be given once a day for seven days with a quantity prescribed of 14. The discrepancy between the dose and the quantity wasn’t realized immediately. After Mom fell twice, at a subsequent visit to her primary care physician, my dad indicated he was still giving this medication. That’s when we realized we had a serious issue. This was Day 13, well past the seven-day mark. Mom had received the medication for almost a full week more than had been intended. We realized it was significantly lowering her blood pressure.

I questioned the pharmacy that filled the prescription. They indicated they just did what the physician had written. I was outraged. Could they have provided some family education and made that clear? Since there were still pills in the bottle, Dad merely was continuing to give the medicine. Could a computer system combined with standard operating procedures prompt alerting of education requirements for a time-limited dosing medication helped? I think so.

After subsequent falls, my mom ultimately was admitted to the hospital, where a CT scan showed she had developed a massive brain hemorrhage. Dad and I were told that the combination of falls and blood-thinning medication resulted in a weakened blood vessel in her brain, which finally gave out.

Afterwards, when the renal specialist was asked why the prescription was written the way it was, she remarked that it was so we wouldn’t have to return to the office should we have needed to continue it. In her mind, she was doing us a favor.

This experience made me wonder how patients without involved family members manage their medical care journey as their health deteriorates. While I may have forgotten all of the details of the ICU setting I spent so much time in years ago, I am very thankful for the skills I learned and my ability to recognize the situation regarding the healthcare needs that come to the surface.

Having witnessed firsthand patients struggling with understanding their care requirements, it reiterates to me the imperative that health professionals do their part in educating patients and their families and communicating specifics. Training my dad to take blood pressure and glucose checks was possible (and these days, essential). His recognizing a perfect storm of low blood pressure, over diuresis, and blood-thinning medicines was not.

As healthcare IT professionals, we can’t forget that the role of IT is to supplement common sense and standard operating procedures, not to replace it. There is no fail-proof means to ensure mistakes don’t occur, even with the best of intentions and systems. We must remember that the people, process, and technology changes we’re making impact real people every day. Are we making healthcare better? We must –our families are counting on us. 

Lisa Cannon is director of resource management for Aspen Advisors of Pittsburgh, PA.

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January 29, 2014 Readers Write 2 Comments

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Reader Comments

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