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Readers Write 5/27/2009

May 27, 2009 Readers Write 16 Comments

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CIOs: Sell Your Board and Executives on the Big Picture
By Ivo Nelson

If you think your IT staff and budget will decline in the next five years, think again. By 2010-2013, hospitals will be in full-scale EMR implementation mode. At the same time, they will be reengineering their revenue cycle processes and systems to accommodate some level of healthcare reform, while preparing for conversion to ICD-10.  

All of this activity will be on the same scale as converting to DRGs (1983) AND converting to Y2K (1999) AND implementing HIPAA (2003) times two (or more). And keep in mind, because these changes are mandated by the government, ALL hospitals and physicians will have to comply at the same time.

If you think your vendor contracts will cover all this, think again. If you think you’re at the top of their priority list, think again. If you think you’re going to get a break when you wind down your EMR implementation, think again.


I’ve met with over 60 CIOs in the last couple of months,  looking for insights into their strategies, concerns, and challenges.

The ARRA HIT stimulus bill is on everyone’s mind. Most CIOs have done more PowerPoints in the last couple of months than in the last five years due to inquiries from their CEOs and boards who smell money. The focus is the stimulus money and how their hospital is positioned to receive the maximum amount from the government. They allude to an END, when the EMR is implemented and demonstrates “meaningful use”, some minimal level of interoperability all within the boundaries of HIPAA security and privacy regulatory changes.

The ARRA HIT stimulus is just the start. Healthcare reform will change reimbursement to true pay-for-performance, requiring billing systems to be based on outcomes and quality. Additionally, if bundled payment is adopted, it will require unparalleled coordination to bring the hospital, physician charges, and other services into a single rate. Any emphasis on coordination of care requires a level of interoperability that doesn’t exist today. 

On top of all that, the impending ICD-10 coding conversions requires the number of diagnostic codes to swell from 13,500 to 120,000. For inpatient procedures, the number jumps from 4,000 codes to 200,000 codes. The IT implications are huge. The impact on the hospital operations process and analytics will be even greater.

Quality is the new battleground. Once we are required to produce consistent quality reporting as a requirement for incentive payments (and eventually to avoid penalties), the game changes. Quality comparisons among competitors will be posted on the sides of buses, billboards, magazine ads, and on the TV. Quality care will be the first thing patients look for when it comes to the well-being of themselves, their family, and their community.
The usual Press-Ganey patient satisfaction measure will become almost irrelevant. Patients will endure long lines, rude staff, and will sit on the floor if they believe they will receive higher quality of care.

For the CIO, there will be immense pressure to be agile in producing reports to manage and report quality. Many are already coming to the sad reality that, after spending tens of millions of dollars on their EMR, all they have is a transaction system that doesn’t produce information. An entirely new genre of HIT now emerges around healthcare analytics. Remember, reimbursement will likely be tied to this information. Losing revenue because IT can’t produce reports, systems aren’t integrated, or vendors aren’t responsive isn’t going to be a conversation any CIO wants to have with his/her CEO or board.

Interoperability/Community Connectivity? Obama’s view of community connectivity is the sharing of patient information between heathcare organizations regardless of their competitive stance and strategy with each other. Our president greatly underestimates the power of local political will. Connectivity is contemplated, in the short term, only when organizations use it to capture a greater share of referring physicians – damn the community good. Elaborate arguments  will justify the self-serving, digital capture of community (e.g. referring) physicians. There is a good chance ‘connectivity’, in the Obama sense, will eventually be defined in the courts.

Most CIOs are aware of the issues around interoperability. Most are participating on some committee on the state or local level as per their boss’s direction. Most roll their eyes at the naïve, non-healthcare participants who see the healthcare exchanges and interoperability as the holy grail.

Most realize they are being required to respond to some government mandate that doesn’t completely comprehend the data complexities that exist within the walls of most organizations. One organization has  92 different definitions for glucose and another has 16 different ways to define death. And they’re going to talk to each other? It’s a good thing there are some smart people on the ARRA HIT Standards Committee.

Of course, all of this is going on while we’re in a recession and CFOs are ratcheting back on capital and asking CIOs when their staff will downsize post-EMR implementation. It is not just that the CFOs are asking for reductions, it’s that the credit markets have tanked and the money simply isn’t there. It’s one thing for a CFO to say we need to reduce expenses; it’s another thing for a hospital to find out they have no credit because the bond market has tanked.

If I were a CIO, I’d be adding a few slides to my PowerPoint presentation to include ALL of the potential changes coming down the pipe, not just the stimulus incentives. I wouldn’t do a full-scale strategic plan, but I would dig deeper into a staffing analysis and make sure I didn’t prematurely reduce or redeploy staff. I’d create some what-if scenarios on the high and low end of change. I’d also take more advantage of the current access to my board and executives to educate and "sell" them on the bigger picture. Yep, and all this needs to be done while you’re trying to get the printer to format labels for the lab accurately.

The budget cycles are starting now for 2010. Make sure you get all of your cards on the table. I know it’s not all defined yet, legislation isn’t passed, and some changes may be a moving target. Like it or not, this is a government that makes decisions. The stakes are high. Now is not a time to be timid.

In the words of the great Wayne Gretzky, “A good hockey player plays where the puck is. A great hockey player plays where the puck is going to be.” Let’s keep the puck on the ice. Go Red Wings!

Ivo Nelson is chairman of Encore Health Resources, a healthcare IT consulting organization.

From DVR-Challenged to an EHR?
By Gregg Alexander

Bringing real change to healthcare information integration will never happen until the focus is off of the “technology” and onto the training, education, implementation, and ongoing usage support of such complicated tools. Period.

Of course you can force the horse, but he he’ll die of dehydration if he can’t figure out how to drink. Geeks docs get it, but most clinicians are not geeks and couldn’t care less about technology if it doesn’t:

1. Make their lives easier;

2. Strengthen their profit margins;

3. Help them be better doctors, AND;

4. Come with ongoing, easy-to-access, stupid-simple support.

Number 4 is probably the most important, yet most often shortchanged component of these quadrangular conditions. Both the technology and the issues it is trying to support (healthcare issues) are far too complex for the general masses of providers to wrap their brains around all together. Just being a clinician is hard enough. Giant new learning curves for techno-tools which – let’s face it – don’t really hold much fascination for most normal folks are off-putting, even repulsive.

Here’s what I hear: “With pen and paper, I can be a decent doctor (#3), get by financially (#2), and I already, almost innately, know how to use them (#1). Sure, paper has a ton of associated problems, but until there are sufficient helpmates (#4) to hump me over that technological learning curve mountain, I’ll do what I know and spend my extra time trying to get the hang of my DVR. By the way, speaking of computers, what’s this Twitter thing? Is it … (hushed) … sexual?”

Dr. Gregg Alexander is a grunt-in-the-trenches pediatrician and geek. His personal manifesto home page…er..blog…yeh, that’s it, his blog – and he – can be reached through http://madisonpediatric.com or doc@madisonpediatric.com. He writes regularly for HIStalk Practice, but we decided to put him on HIStalk this time just for fun.

Blade Server Review – Main Features and Values
By The PACS Designer

There has been a lot of press lately about blade server architectures, so TPD thought it would be a good idea to highlight some of the main features of this type of architecture.

A blade is a plug-in device that is installed in a chassis. Its Wikipedia description reads, "The name blade server appeared when a card included the processor, memory, I/O and non-volatile program storage (flash memory or small hard disk(s)). This allowed manufacturers to package a complete server, with its operating system and applications, on a single card / board / blade. These blades could then operate independently within a common chassis, doing the work of multiple separate server boxes more efficiently. In addition to the most obvious benefit of this packaging (less space-consumption), additional efficiency benefits have become clear in power, cooling, management, and networking due to the pooling or sharing of common infrastructure to supports the entire chassis, rather than providing each of these on a per server box basis."

Blade servers and storage systems generally consume 50% less energy than traditional servers. They also occupy much less floor space, so valuable real estate can be put to better use. They also require fewer cables, have smaller power needs, and fit into 19" slots in a chassis.

Blade servers won’t replace mainframes any time soon, but they will be deployed for Web solutions and  cloud computing. An effort to move mainframe software to external users through conversion to SOA and REST solutions would typically be good for installation on blade server/storage systems, provided adequate security methods have been installed.

IBM’s partnership with Sentry Data Systems, which serves pharmacies and hospitals in over 20 states, is an example of a cloud solution that was deployed to reduce power consumption and  meet the growing needs for servers in a smaller operating space with less cabling.

Since the genie is out of the bottle, so to speak, for Web 2.0 and cloud computing, we will be seeing more need for blade systems solutions in the years ahead.

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Currently there are "16 comments" on this Article:

  1. Mr Nelson.

    What a really insighful letter! – I am sure there are plenty of weary CIO’s out there right now, and things are just ramping up! BTW I am a blackhawks fan – boo! the dead wings!

  2. Nice notes from Ivo and Gregg,

    However on the following:

    “Interoperability/Community Connectivity? Obama’s view of community connectivity is the sharing of patient information between heathcare organizations regardless of their competitive stance and strategy with each other…”

    I’m not sure you are totally correct about the democratic stance on the issue. Many states are well along in defining and demonstrating success with IHE’s and RHIO’s. Look at Minnesota, Arizona, Indiana, Ohio, Kentucy, New York, Massachusetts, Virginia, and California to name a few. Many states already realize the benefits and are working through the value proposition. They are all well along the road to developing secure federated environments where data is shared (not referrals). The issue is fear as technology can accomplish this “shared but seperate” integration – so more education is required in the public domain.

    Our observation is that too many providers are in a great rush to purchase and implement EMR’s without an interoperability strategy of any sort.

    For updates on this subject: http://www.interoperant.com



  3. For Gregg-

    Still trying to figure out the real value in twitter…like those twitters sent during brain surgery…?



  4. Mr. Nelson’s predictions sounds to me like “1984” or the “Utopia” novels- interesting dreams, but not based on reality. Kind of scary insight, I’d say.

    The reality is that in 5 years the uptake of certified “significant use” EHRs will still be less than 10% since physicians don’t want the increased electronic “paperwork” and don’t agree with the government required documentation and reporting mandates.

  5. When you look at what is really happening in most of these states very little is actually happening despite all of the self-serving press releases from those involved.

  6. InterOPERANT Guy/Don, thanks for the comment. There are some states that have focused on IHE’s/RHIOs, however, I think those efforts are well underfunded, even with the promise of stimulus money. I also believe the amount of work required to implement standards is greatly underestimated.

    Al Borges, my point wasn’t that physician will be adopting EHR’s anytime soon, rather that there will be a significant amount of activity due to the stimulus momey and health care reform. As is the case with IHE’s, I think success in this area will be measured in decades, not years, baring some heavy handed mandates and more billions of funding.

  7. Hi Ivo,

    I agree with the funding issue. Most states are investing just enough to analyze the value proposition. In New York while I was managing the Bronx RHIO Technical Platform as a contractor, we obtained funding through the State HEAL grant. With that money we became operational with 23 federated providers…and could begin to study the various dimensions of “value.” That model is operational today.

    Are we decades away from and end to end total solution between “disparate” providers – yes. Can we tightly integrate intra-provider environments with IHE solutions now – YES. And, we can help them become more competitive with enhanced analytics on the level of quality “battlefield” – absolutely.

    As to healthcare transaction and process standards – it’s getting much more complex in my view in dealing with them for almost 20 years.



  8. Ivo,
    You know I hate to say you’re right but you are right. As a recently “retired” CIO – – CHIME calls me interim because I’m between CIO gigs, I’ve been talking to a lot of CIOs too – – same story. I’m also talking to a lot of other “C’s” in my search and this stuff just isn’t on the radar.
    This is all about data – – capturing, storing, managing, reporting, retrieving, turning it into information and since we do an awful lot of that electronically everyone will look to the CIO. Doesn’t matter that outcomes or ICD-10s aren’t an IT issue, they will all be IT issues.
    So, add the slides to the PowerPoint and be sure to remind them that it won’t be just IT resources you need to put in the EMR, quality, coding, connectivity, analytics/informatics – – you’ll need clinicians, HIM, billers and everyone else who uses the data.

  9. Mr. Nelson –

    Wow, what a great commentary. I think you are one of the few leaders among our group of experienced professionals. Your posing inspired me to review your company’s website and it is one of the few I would look for future partnership. It just goes to show you that values and hard work ethics trump marketing fluff any day. I wish you future success, as we need strong opinions to make light in this current sea of confusion and fluff.

  10. Mr. Nelson,
    I find your posting and comments quite inspirational. As an RN, MSN and former owner of a healthcare staffing company, there are many issues in healthcare that are effecting quality of patient care and outcomes. I have been developing software to assist healthcare facilities with staffing issues, to assist healthcare facilities to rid themselves of outside travel agencies. The travel agency for healthcare workers is a 4 billion dollar a year industry. This is an issue that must be addressed, I have a serious, reliable solution. One in which there is an easy solution, easy access and help desk available, user friendly, and most important will strenghten profit margins. Using this software, larger hospital entities have the potential to save millions of dollars annually. Many problems… several solutions. STATshift!

  11. Thanks for the post Ivo. It hits on many points and all important. All I can say is that I am happy not to be a CIO today.

    One point I would like to address is your pessimistic view on interoperability and HIEs. Although this has been a quagmire – mostly of expense – I blame the EHR vendors for not thinking their customers would ever have to share information. Our thinking and demands for solutions need to be reversed. Instead of thinking about connectivity from the edge (EHRs); it should be thought about at the intersection (HIO). Once this is understood, solutions are easier to sort out. However, technology is the easy part. Practical issues like community competition and misaligned objectives often get in the way of creating successful exchanges. Stakeholders become disillusioned and value is not realized. Instead of discussing how community solutions will improve care and provide value, disproportionate time is spent on how to protect individual turf.

    The ‘holy grail’ I believe you are referring to when speaking of misplaced expectations for HIEs is often around the future promise of semantic interoperability. Many of the CIOs I talk to on this politely smile at the promise of semantic operability which is often a euphemism for ‘vendor cha-ching’. They know very well that the technology de jure in their community is the fax machine. They need simple solutions to send and track documents, let alone having the ability to perform community-wide population reporting. Until a standard vocabulary is adopted, the promise of semantic interoperability will remain illusive.

    In the meantime, the ONC and the Federal Partners have supported the move toward IHE as well as open source. I believe that interoperability solutions will be best solved collaboratively. We should be promoting and supporting the good work that is happening in the open source community to help answer this problem. This requires that we demand the use of standards and require transparency in development. Our reward will ultimately be reduced costs associated with interoperability and better solutions with higher value. With over 90% of the citizens in the US not participating in any exchange, the opportunities to create value are great but the complexities associated with aligning stakeholder value must not be trivialized. With the right focus, dramatic improvements can take years; not decades.

  12. Tim, I agree with your comments. And I actually do believe that HIE’s will be the holy grail for healthcare and personally hope they succeed – soon. My problem is that I know the huge challenges most of the larger healthcare organizations have with integration and standards. Until they can make it work “inside the walls”, it will be hard to interoperate.

    I think we’ll start to see more examples emerge in the market where HC organizations prove they can share information at a basic level. Unfortunately, this may create a false sense of security on our progress. I don’t believe HIE’s will move the needle on controlling HC costs and growth without making an impact on complex chronic disease patients. These patients have between 5-15 doctors who care for them, each of whom need clinical data and images that goes far beyond the easy values. Even with huge amounts of Obama stimulus money dumped into solving this problem, it’s a 10+ year journey.

    I’m 100% supportive of this country moving in this direction and fully expect us to muddle through solutions wasting lots of the money in discovery, however, it will be worth it in the end. And it will take a long, long time to complete.

  13. Good to hear from you again Ivo

    Very sage and timely advice.

    One comment I would like to add is that I have seen many institution’s I.T. departments grow to unsustainable spending levels, typically associated with EMR implementations. Depending on how deep and prolonged this recession is, organizations under financial duress will make cuts. Those I.T. organizations that don’t benchmark well financially with their peers will likely be facing the challenges you mentioned with a smaller staff and budget.

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