Readers Write 11/23/09

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

Our Success with EHRs in an Ambulatory Environment
By Stephen L. Badger

Hindsight. It’s the corrective lens which turns progress into a milestone. Imagine that anesthesia, antibiotics, germ theory, and x-rays each once seemed more evolution than revolution. This may be the case, too, with healthcare IT.

A few hundred healthcare institutions are exploring IT — some because the clock is ticking on a federal mandate, and some because their leadership sees value for both practice management and patient care.

The George Washington University Medical Faculty Associates entered the exploration into electronic medical records in 2004. It was a time of tremendous growth in our service capacity. That growth left us drowning in the millions of pieces of paper associated with patient charts. Costs for processing and storing that paper were mounting daily and the records themselves were, at times, unrecoverable. It was an unyielding drag on staff and led to patient dissatisfaction and frustration. For us, electronic healthcare records were like direct pressure on a bleed.

Chart room before and after


Chart room remodeled

The remedy began with a document scan which would play out over nine months and capture over four million bits of paper. It ended with elimination of chart pulls, the elimination of more than 30 full-time staff members, and the elimination of paper records storage. Initial net savings was over $1.5 million, but the dividends are still being delivered through improved accuracy in coding and the conversion of office space. Our old record rooms are now used for executive physicals, nuclear cardiology, digital x-ray, and new physician administrative offices.

The impact on patient care is equally positive on a national scale. Because each physician looks at the same central patient history, redundancy in imaging and other diagnostic orders is reduced at a great savings to the patient and the broader health care system. The prospect of prescription error is controlled, too, because the various treating physicians are working from the same record. That means they are less likely to unwittingly order a prescription which may interact adversely with medication ordered for their patient by another treating physician.

Here at the MFA, our patients can renew prescriptions through an encrypted, private network which processes refill requests typically within 60 minutes. That same system allows the MFA to deliver prompt, targeted alerts about news like FDA drug recalls.

Our records are shielded by firewalls, biometric passwords, and routine data audits which show what staffers have entered a record, what they viewed, and how long they lingered on a page.

MFA patients check in for provider visits at electronic kiosks which are much like those at the nation’s airports. Patients scan in using their unique palm print to preserve security and they answer a brief series of questions to confirm basic demographic data and insurance information. As a result, our records are more up to date and complete.

The kiosk registration will evolve as we extract targeted data which helps us improve an individual patient’s care. We envision that this data may pose tremendous advantage in transforming overall patient care, too, ensuring our patients are being treated on a proactive basis.

These data systems also may be helpful in seeking patients who would likely be helped with clinical trials and research. The potential impact for expediting the quantity and pace of research, especially longitudinal study, is exciting and just one more reason we believe we are living through a milestone in medicine.

Healthcare IT is improving patient care, practice profitability, and has considerable potential as a tool in clinical research. It is nothing short of transformational!

Stephen L. Badger is CEO of The George Washington University Medical Faculty Associates, an academic multi-group practice of world-renowned physicians affiliated with The George Washington University. The MFA consists of over 550 physicians deploying the latest advances of technology and technique through more than 41 medical/surgical specialties.

Are You Sure it’s the Software?
By Fourth Hansen Brother

There’s been a lot of focus on HIStalk lately about the customer side of HIS. Having worked on the “bandit” side of things for a few years, then as a consultant, I’d like to add to what’s been said.

There is an enormous amount of variation in the quality and culture of IT departments serving hospitals and clinics. This has a major impact on the design, quality, and implementation of HIS software. Let me explain.

Most folks on the customer side seem to think that the major vendors don’t consult with the people in the front lines of software. The thought that, “Gee, if only a doctor or hospital IT system created their own software, then we’d finally have a decent system” is common.

Folks, I assure you that every major vendor hires doctors, nurses, pharmacists, and other similar professionals to participate in design, often by the hundreds. There’s no shortage of medical folks willing to be tempted out of healthcare by software vendors. In fact, that’s part of the problem. It’s where they come from.

Your software vendors also find design partners out in the healthcare world, either with formal agreements or informal visits and shadowing. Depending on the luck of the draw, that’s either a good thing or a bad thing.

As noted in a survey that Mr. HIStalk linked to recently, most healthcare workplaces have severe problems. Politics reigns supreme and confrontation about minor issues happens frequently. Refinement or modification of workflows becomes impossible in those environments. These problems are often invisible to vendors at first. Vendors can easily choose a design partner that may have a department that’s become a personal fiefdom of a internal political heavy hitter and has done things the same way for thirty years.

The opposite happens as well — a hospital that’s run by a “thought leader” with oddball workflows in place and little sense of practicality. Vendors may not have the perspective to see that the emperors have no clothes. Hitting these problems with a design partner can cause severe problems with early adapter customers, often resulting in years of workarounds and remedial development.

Often, the vendor doesn’t have enough money to have the in-depth relationship with multiple design partners that it takes to put good software together. Healthcare has more than its fair share of egos. And there’s been more than enough research to show that health care professionals don’t keep up in their education or change their ways, at least on the clinical side.

If a vendor chooses the wrong design partner, or selects a good employee from a bad workplace, chances are that it will show up in a major way in the early versions of the product. As the product matures, these problems can get straightened out with the help of good customers and hard work from the customer-facing staff of the vendor. If the vendor is good, then all of the staff are customer-facing, including developers and testers.

The culture of healthcare customers can create some longer term issues. Many customers have major issues with trusting employees. Often certain types of employees want certain other types of employees monitored or their workflows controlled. Management wants all sorts of reporting and controls as well. The mistrust in certain healthcare organizations is pervasive, omnidirectional, and vicious. The mistrust can result in product enhancement that is weighted heavily towards these issues.

If a vendor has a design partner and early adapters with the same cultural issues, the functionality may be there from the start. Otherwise there will be a struggle to keep up. Of course, regulation (can anyone say HIPAA?) can not only force functionality into the system, but require it in a certain timeframe, causing major development schedule disruptions for the vendors.

Quality of HIT departments can severely affect implementations, or course. The early adapter customers are often the higher quality operations. They can handle implementation practices on the vendor side that are still in development, have a good grasp of the workflows in the organization, and have quality folks who can come to agreements on how to proceed in a organized fashion. Then come customers in the next wave, who may not be the bright stars, who need firm implementation processes, vendor help with workflows, etc.

Then comes the average HIT department. They may have an idea on how babies are conceived, but they often don’t know how they’re born or in which departments. Want to have fun? Ask a CIO what happens in the L&D department. Then ask the L&D department! Or ask where in the hospital babies are born. The answer may surprise you.

Vendors eventually develop lists of these customers who need special help when adding new functionality or upgrades — or when the vendor is sending out a new batch of replacement implementers on a project running several years overdue.

Decisions about configuration are either made off the cuff by top executives with little consultation with the subject matter experts in their organizations or worse yet, take months to bring together hundreds of people for a “consensus” decision. Warfare usually exists in the upper levels, with vendors and consultants often getting caught in the crossfire.

Often, a particular piece of software can go through dozens of implementations with quality healthcare organizations, only to run into problems when traversing to the next level of customer. This usually catches both the customer and vendor by surprise. Often, the vendor gets the blame (and often doesn’t dispute blame, since they shouldn’t be saying that the folks that bought their product turn out to be complete idiots).

If you hear of a product having problems at a particular site, ask at what point the vendor is in the introduction cycle and ask what kinds of problems they are having, Investigation might reveal that it’s not the vendor at all.

Concept – Hospitals that Expect People to Rely on Trust
By Healthfreak

Let us think how it would be to go to a hospital where there will no recourse to legal lawsuits, no visits to courtrooms. Patients come in and get treated quickly — no waiting for 5- 8 hours for a small surgery on a finger — and go back HAPPY.

It is possible, provided some mistakes by the hospital, doctor, or staff are considered "human" and patients do not go overboard in demanding legal action.

What can one achieve by all this ? Quite a bit. One, with legal hassles out of the way, the entire staff will be motivated to provide  better and faster service and not resent their jobs. Equipment sold to the hospital  will be economical, since the vendor does not factor legal costs in his pricing. Hospital administrators will offer economical service to the same patients. The overall insurance premium per patient will also come down and drive down healthcare costs as a whole. This is exactly what the US is looking for today.

Yes, there will be a fear that this may allow malpractice to go unchecked, vendors to sell faulty equipment, etc. A small percentage of cases may happen, as in any society. This, however, should not deter the introduction of a concept which will reduce the overall cost of healthcare.

The guru of AoL (Art of Living) has said that " the health of a society is determined by how many empty beds are there in hospitals and how many prison cells are vacant". May be we can add "and how many courtrooms do not have cases relating to hospitals".

Too farfetched? Maybe today. Let us debate this a little more openly and I am sure it will trigger some hospital into leading the way.