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December 10, 2008 Readers Write 11 Comments

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Low Cost IT Hospital Improvement Project
By Downin Katmandu, CIO


Our Information Services Department is working with our hospital’s Infection Control (IC) Department to create a system that sends a real-time, proactive notification of patients that present at hospital with chief complaints that might trigger operational or policy processes.

Due to the nature of our data collection process, specific diagnosis codes are rarely available during the admission/registration process. That being the case, we use the chief complaint as our primary data field for attempting to notify the IC department of patients that might benefit from more timely intervention by the IC staff.

The basis of our pilot study is to evaluate appropriate HL7 records and segments for keywords (keyphrases) defined by the IC department. If we find one of these words/phrases we will:

  1. Send the IC department an email containing a message that does not contain patient identifiable information (PHI, re: HIPAA), but it will contain the chief compliant. The IC department can use this field to prioritize their processes.
  2. Send a more descriptive file to a secure folder on the network
  3. The file we send will contain the following fields:

Patient Information

Message Information: A04
Patient MRN                 
Patient Account Number        
Patient Name                
Patient DOB                
Patient Sex                 

Admission Information

Admit Source                
Chief Complaint       
Admit Date Time       
Admitting Doctor      
Attending Doctor      
Current Location            
Patient Class               

A04: Patient Registration
A01: Patient Admission

The file naming convention that we are using to store the detailed reports is Lastname-AccountNumber-ccyymmdd-hhmmss.txt.

This same system is used by the Admitting Department to receive real-time notification of incomplete registrations. Our hospital information system does not require a chief complaint during admission and registration processes, but our hospital policy states that it must be entered. We use this system to help audit compliance.

Software: MIRTH Interface Engine (www.mirthproject.org – Open Source)
Hardware: Low end PC or server
HL7 Feed: Clone from ADT Feed from HIS to Laboratory System

Keyword examples: influenza, tuberculosis, lice, pertussis, diarrhea, chlamydia, strep, pinworms, measles, blood in sputum, bloody sputum.

You Can’t Give It Away
By Catherine Huddle, VP Market Development, Sevocity

While the Big Three automakers extend their tin cups on Capitol Hill, we hear that at least one of the first four communities designated by HHS to receive Electronic Health Record (EHR) funding, Louisiana, submitted only half the applications of the 100 available $58,000 grants. So, you can’t even give EHR away?

I believe that part of the problem is that most physicians didn’t know about or understand the HHS program. Our company saw the first four community initiatives as an opportunity to get in front of physicians at the most opportune time. We sent multiple mailers and made calls to hundreds of physicians in the first four communities. What we learned:

  • Mail that is not payment- or insurance-related may be ignored or lost. Less than 5% of our mail was returned, but over 80% of practice managers said they never received our mailing or couldn’t find it.
  • Nearly all the office managers and physicians we talked to were unaware of the HHS program. Those who had heard about it were confused and didn’t understand the difference between the EHR program and the national HHS ePrescribing initiative.
  • Trying to explain the available funding and the timing was difficult. If you review HHS’s Web site, this problem is clear — the process to obtain the funding is long and convoluted and the dollars to be expected is difficult to predict.
  • Physicians do not believe they will see any material funding from HHS.

So, if physicians had a clear program that helped them fund purchase of an EHR would it make a difference? I think the answer is yes — sometimes.

Just like a tax incentive encourages a would-be home owner to become a home buyer, I believe that clear, timely payments for EHR adoption would incent the physicians interested in EHR to go ahead buy EHR. Funding is such a clear motivator for the group already interested that I think it helps explain why our company is achieving record sales in a very weak economy.

The new customers I talk with tell me they purchased after months or years of looking because our solution is CCHIT-certified/complete, but only requires a small down payment and ongoing monthly payments. Their risk is minimized because their personal investment is minimized.

While there is a segment of physicians that is already motivated to buy EHR and will do so with some clear achievable financial assistance, I believe there is another segment that wouldn’t implement EHR if you gave it to them – right now. This is the segment that is downright terrified of implementing EHR. They have read and heard the horror stories of six-figure EHRs that sit unused. They are concerned the EHR will slow them down, knowing their productivity is the lifeblood of their income.

As EHRs evolve, physicians experience the benefits, and EHR vendors improve, I believe this will gradually change. As vendors, it is up to us to make this happen. We must listen to our potential customers and design affordable and easy-to-use systems.

Low Cost IT Hospital Improvement Project
By Julie


Having worked in healthcare for 20+ years in both the hospital and vendor settings, I see many opportunities for low cost IT projects. Many in the hospital setting are not utilizing the power of the Intranet to provide Web-based access to policy and procedure manuals, the automation of manual calculations (e.g. heparin protocols), and the use of paging/text messaging. Many other types of info (links to emedicine, Medline, etc) could be of great help if provided at the clinicians desktop in an easy to use format.

CEO-Express provides a desktop application that I’ve used for years both personally and in business. The generic MD-Express has potential as well, if taken private label and customized. I have no financial ties to the company, but have found it extremely useful.

Access to well-written, searchable policies and procedures is critical, with staff members (both nursing and ancillary) frequently being forced to float due to variations in patient populations and workloads. Also, with the diversity among providers today, communication can be hampered by regional and international accents and dialects. Text-based paging/messaging can be a non-obtrusive method of improving communication.

Having worked for Cerner and seeing real and planned “bleeding edge” technology only to return to a severely challenged community hospital has been extremely frustrating. Financial limitations and the staff’s lack of exposure to or fear of even 20th century technology are disturbing. And to think this organization is not that physically distant from both Partners and BIDMC is amazing! While expert rules firing off text messages to communicate critical values to providers is technology available to some, there have to be workarounds for financially challenged organizations.

Some things to think about: while most people choose a hospital perceived or documented to be the best, most progressive, well-staffed, or well-funded, the reality is that if you or a loved one is involved in an accident or suddenly falls ill, you may not have the choice of where you go for care. The nearest hospital becomes your best or only chance for survival. If that hospital is severely challenged in any way, you or your loved one may not make it. Transport to another hospital depends upon the patient’s stability. For those without the clinical knowledge and understanding to evaluate the limitations of a facility and where the best care would be for a particular condition, you are at the mercy of whoever is providing care.

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Currently there are "11 comments" on this Article:

  1. >>> I believe there is another segment that wouldn’t implement EHR if you gave it to them – right now. This is the segment that is downright terrified of implementing EHR. They have read and heard the horror stories of six-figure EHRs that sit unused. They are concerned the EHR will slow them down, knowing their productivity is the lifeblood of their income.

    The amount is only a band-aid down payment, and to me seems tantamount to placing your finger on a leak in the dyke holding back the flood of future costs. There are real, ongoing costs that have to be paid by the physicians, including:

    1) training
    2) significant hardware power upgrades to handle the back-end SQL database tables
    3) significant tech support for the SQL database
    4) the 15% cost that by law have to be incurred by the physician for the initial software purchase (as per Stark kickback relaxation rules).
    5) the customary yearly 15% (or more) fees for upgrades and support
    6) lastly, some EHRs have licenses that force a repurchase at intervals of 3 years

    So it’s not surprising to me that they can’t give away EHR software systems. These work flow killers offer very little in real gain for the end users, even when free.


  2. I agree with Catherine – you can’t even give EMR away to physicians. I have actually witnessed systems given to physicians and they failed. It is a double edge sword – if you give it to them they have no stake in the game and they fail to implement. However, most grants don’t cover the the true costs and most primary care physicians can’t afford it.

    However, I think the real issue is that to plan and implement an IT project of this scope needs leadership, structure and organization. Which in my experience is lacking in the physician private practice world. This is the real issue.

    Who is going to do it? – the overworked, underskilled office manager? The physician who already only runs on 5 hours of sleep? The nurse who left the hospital world because it was too hectic and demanding? No — most practices cannot even figure out how to get started and have no real level of IT experience.

    Until vendors offer support at that level or physician realize that they have to hire project management consultants or staff with those skills I don’t see EMR successfully implemented on a large scale.


  3. I applaud your idea and the challenge to Hospital IT groups to share their innovations. I am puzzled by the lack of real world solutions that have been posted.

    My question is why is that? I offer three possible causes:
    1) Competition – Could it be that hospitals are so competitive that they don’t want to share ideas with a larger group?
    2) Intellectual property – Could it be that hospitals don’t want to share ideas because that think they regard them as hospital property and are seeking financial gain?
    3) Lack of ideas – Could it be that hospitals in general do not have the organizational processes to solicit, nurture, and promote the use of technology in innovative ways.

    Sadly, based on my experience in Healthcare IT, I submit that it is number 3. To many times there is no processes and structures to develop simple yet effective ways to utilize technology.

    So many times, nursing, pharmacy, ancillaries, medical records, and physicians are all so busy with routine operations within their own areas and very rarely do you find a hospital with a cross functional team who’s job it is review technology to break down barriers to share patient information, improve safety, and overall financial performance.

    Unfortunately, the IT groups mirror this stove pipe mentality. You have IT areas to support finance, ancillary, ed, pharmacy, medical records, and may be physicians. The IT area perseveres to support these groups individually, however this is no longer all that is needed. These efforts have to be coordinated across the organization.

    As well, I believe that to many times, the hospital groups depend solely on the HIS Vendors to provide this coordination. Sure a vendor will be glad to come in and do a consulting engagement to help your process, however this responsibility can not be abdicated to the vendor.

    I assume this mentality comes from the very hierarchical nature of hospitals, however this to has to change. Ideas can come from anywhere, the question is do hospitals have the processes to generate, nurture, and implement these ideas?

    What do others think?

  4. Good stuff! I love reading these kind of stories because I just walked away with one new idea as well as an insight! Golly, my HISTALK BFF list is growing by leaps and bounds. Thanks for sharing!

    On another note, HISTALK Radio is worth tuning into. I had a great time hearing stuff I’ve never heard before.

  5. One of the main issues with getting people to buy a ticket on the EMR ride is our mindset of negativity. Yes, many times it is warrented, but this does not have to be the case. I have been on all sides–the customer, the vendor, and the consultant. I have seen the implementation process range from a drive through experience to brain surgery in the OR. The key is to have buy in from everyone. This means everyone from Administration, Physicians, Nurses, and the Front Desk. If the vendor’s product can show what it can offer to each of these positions, then they will have a better chance of gaining buy in. Most importantly, the user has to realize that EMR’s are not magical, and there will be some imperfections that technology has not been able to address yet. However, the positive outcomes that are currently available, definitely outweight the old ways of the paper chart.

  6. Catherine, your insights on EMR adoption, or lack thereof are more than likely, quite representative of the entire country and not just those 4 regions in LA.

    The only way physicians will start adopting EMRs is if ONE key issue is addressed:
    They get some value.

    Value will come in two forms:
    1) It will seamlessly fit into their existing practice.
    2) They get some monetary value.

    Those forms will be addressed by:
    1) EMR solutions that are not a burden on existing staff (SaaS) and easy to use (think Apple iPhone).
    2) Monetary value from P4P/incentive-type payments, eVisits, referrals, and higher customer service/satisfaction (e-Refills, online appt schdling, eVisits).

  7. “Puzzled…”, a very real reason people aren’t sharing more information is they’re afraid they’ll somehow look incompetent.

    I’m speaking from personal experience. I’m not saying everyone else is incompetent; instead, I’m saying that I’ve been hesitant to publish information for fear that I’d be ridiculed.

    Or lets try this from a different angle–think of the report on UTMB* from a couple of years back (which was fascinating). Imagine a parallel universe where their embarrassing report has not been leaked to the public. In this parallel universe, if they take action on one of those items, and it saves them millions of dollars, will they want to submit that as a “cheap and easy way to save money?”

    “Hey everyone. We did an internal audit, and discovered that we were paying millions in consulting fees, to consultants with no real project or goal! We cancelled their contract, which took no time at all, and with this quick and easy step, made lots of room in our budget! I should have done this years ago! Signed, proud CIO.”

    * I don’t mean to pick on UTMB, but their audit was dynamite.

  8. >>> Monetary value from P4P/incentive-type payments, eVisits, referrals, and higher customer service/satisfaction (e-Refills, online appt schdling, eVisits).

    You really think that simply cutting physician payments, then returning said money as an “incentive” to buy a multi-thousand dollar EHR installation fraught with all the HIT issues will entice the majority of physicians not currently on-board to buy into HIT?

    Wrong… Won’t work. Look, CCHIT-EHRs had the backing of the HHS Leavitt and President Bush and the initiative still can be regarded as a failure since it did NOT increase adoption rates by any means. What will happen with incentives is that Medicare and third party payers will see their physician panels decline and on a long-term basis less good applicants will choose to go to medical school. Overall quality of medicine will die out.

  9. Well, Al, I guess we’ll agree to disagree.

    An EMR installation does not have to be multi-thousand. With an SaaS EMR solution, a physician can be up and running pretty quickly with a minimal amt of overhead, no IT staff to speak of and since it is a monthly fee, easily expensed.

    The big problem in this industry is the dated view that you need to have the EMR on-site. This client-server architecture/approach, while find for a large practice is simply too burdensome for smaller ones.

    Thus, getting back to my original comment, which you failed to quote in yours, there are less expensive and less burdensome options for physicians that are critical in the value equation I outlined previously.

  10. plz i want to ask about best way applying infection control policy and in same time satisfy the patient …this is about IC signs that be put on the patient room….

  11. Hi John:

    >>> there are less expensive and less burdensome options for physicians that are critical in the value equation I outlined previously.

    The average cost of a c-EHR nowadays is $33000.00 plus $1500.00/month maintenance. Sure, there are cheaper ones, but overall if they are CCHIT certified, their cost will generally be no less than half those figures, which is still very expensive. SOMEONE has to pay for the HIMSS “CCHIT” tax!

    The most important issue here, though, is not just cost, but also the fact that Medicare is trying to impose more clerical work on physicians that will ultimately slow them down, decreasing from their overall patient contact time, and thus ultimately affecting their incomes. If, say, a physician who sees $100,000.00 in Medicare patients, with average visit time being 20 minutes, and is paid an average of $100 per visit, has to take an extra 5 minutes to do pay for performance reporting and documentation, in just 5 years this will cost him $125,000.00. Ahhh… I guess it all does come down to cost, doesn’t it?

    Do the math:

    $100000.00/$100 = 1000 visits x 5 min = 5000 minutes for P4P/20 min per visit = 250 visits robbed by P4P x $100/visit = $25,000.00 per year x 5 years = $125,000.00 over 5 years

    Amazing, huh? For most docs, it’s just obvious. For me, this will go into my next MDNG column (“The HIT Realist”) later on this month.


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