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January 4, 2010 Readers Write 10 Comments

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

The Direction of Healthcare Industry Technology
By Steve Margolis, MD, MMed, FCS, BSIS, MBA

Regarding the recent John Gomez interview on the direction of healthcare industry technology:

“Interoperability is a huge one where the way that this industry’s worked, has been not embracing the ability to exchange or interoperate between systems. We’ve been kind of proprietary. I think that also creates a challenge and a barrier for hospitals to move.”

I agree that data system interoperability is key to moving the industry forward. The plans for standards of interoperability, privacy, and security will be finalized next year. It’s going to change the landscape and mandate exchange of “semantically interoperable” information among care providers and between providers and patients.

Beyond that, we all know many common applications in healthcare are not available from a single vendor and cannot be made to integrate easily. Supporting third-party integration is extremely helpful, allowing provider organizations access to the latest advances in knowledge and technology, especially when you consider that the fundamental focus of ARRA and other federal initiatives is to take costs out of the nation’s healthcare delivery system.

Content for evidence-based care is dynamic and federal regulations are changing too rapidly for a stagnant platform. I think our industry needs to take lessons from the iPhone app model, i.e., ease of ability to integrate new applications to meet the growing need to keep up with the latest information and technology advances in order to sustain quality and curb costs — especially when the provider’s core vendor is not ready to meet those particular needs.

In short, the right technology approach for the industry is an open technology platform that provides flexibility in both front- and back-end integration, together with the means to easily cater to constituent-specific workflow. This openness is necessary to allow for the cost-effective leveraging of existing and future technology investments.

That’s why we’ve been deeply involved with Eclipsys in developing a platform that provides a services-oriented architecture that allows for third-party integration and multiple applications in context of both the patient and the user. This app integration strategy will enable providers and other third parties to build applets that will enable easier integration between existing vendor solutions, legacy, and/or other in-house developments.

The key benefit for this design approach is that hospitals need not be concerned that prior technology investments will become obsolete if the vendor advances the platform. Conversely, it means that user innovation doesn’t have to cater to the vendor’s development timeline or direction. This type of openness will allow a hospital to integrate with any Web service with a similar open health platform for driving innovation and efficiency.

Another area of important technological development is in the area of visual workflow tools. Many healthcare workers prefer to design visually and iteratively. A visual workflow tool enables rapid prototyping. Examples of this need include the opening of new clinics or the development of a new protocol in response to a pandemic.

Working together, the clinical team can translate their thinking into a devised workflow in very short order and then upload and incorporate that workflow into the system. The beauty would be that the workflow could incorporate third-party systems, such as interacting with NIH or CDC systems and provide biosurveillance data and outcomes data that could help treat pandemics in real time across the country or globe.

This is just one example, but it exemplifies the possibilities we could leverage in open architecture design. To take the monumental steps needed to improve care delivery, we will need this type of open architecture to overcome the challenges we face in delivering quality healthcare in a rapidly changing and ever-demanding environment.

Steve Margolis, MD, MMed, FCS, BSIS, MBA is chief medical informatics officer at Orlando Health of Orlando, FL.

Interoperability 2009
By Jerry Sierra

I’m a nurse who has worked in healthcare IT for over 10 years; six (and counting) for two of the top vendors. However, I feel compelled to share a story that has absolutely nothing to do with my background.

I recently moved my family from Wisconsin to Cleveland. I know you won’t be able to concentrate on my story unless I add it was to be near family (but I also really like Cleveland). My 22-month-old decided months ago to stop the normal progression to solids and instead to stick with bottles. After extensive medical testing, I’ve come to the conclusion that he’s outgrown his reflux, and out of sheer stubbornness (inherited from my wife, of course), refuses to eat anything but M&Ms, goldfish, and yogurt. As much as I like these snacks, I have fears of having to pack these items and a bottle in his lunch box for the next 12 years. To prevent that, we took him in to see our Cleveland pediatrician for a referral to their feeding clinic.

During the visit, we filled out a records request for our Wisconsin hospital and prepared to wait a few months for our referral appointment. Being a cynic, I decided to call and make sure that the records had been sent to the Cleveland GI. They, of course, had no idea what I was talking about and suggested calling Medical Records. They, of course, assured me that the doctor had never sent the piece of paper to MR and that it was never scanned into the EMR. They promised to promptly send me out a new form.

After a few short weeks, I received the form, filled it out, and sent a copy to the hospital in Wisconsin. After waiting a few more weeks, we received a letter from the Wisconsin hospital letting us know that they would love to help us out but, because of HIPAA, they could only accept their own records request form (it’s been a while since I waded through the act, so I must have forgotten that section). So I copied the exact same information onto the form with the correct letterhead and sent it off. I called a few weeks later and was told that the records were mailed out.

We arrived at the specialist’s office and asked the doctor if he had received the records. Would anyone care to guess the response? Anyone? Anyone? Bueller? Of course, he had received nothing. So I took out my tattered copy of the Wisconsin EMR report and the doctor photocopied it so that it could be scanned and added as an attachment to the visit note in the Cleveland EMR (which coincidentally, enough is the SAME vendor). There you have it, a shining example of real-world interoperability.

Who was to blame for this mess? The hospitals, for having antiquated workflows and not turning on key features like the ability to e-mail physicians? The vendor for not making it easier to share information and not allowing patients to add to their own records? The government for not mandating the NHIN, CCD exchange, etc.?

As you can see, the interoperability bar is set depressingly low. Let’s hope 2010 is the year we start making some real progress.

A New Reality in Healthcare Systems – Automation, Agility, and Compliance
By Bruce Oliver

The ever-changing administration of healthcare, increased regulatory requirements, cost control demands, clinical quality, patient safety,and satisfaction issues challenge the US healthcare system. The volume of these challenges requires automation, agility, and compliance, plus relentless execution from healthcare organizations who expect to survive and prosper in the new US healthcare system.

The current HIPAA 5010, ICD-10, ARRA (American Recovery & Reinvestment Act), and HITECH Act of 2009 mandates, incentives, and requirements — and the penalties for noncompliance — are forcing all healthcare organizations to adopt new technologies, processes, and standards. Additionally, pending new health reform legislation will add more requirements to an already over-burdened healthcare delivery and administration system.

Making the changes necessary to achieve the mandated requirements should be viewed only as one of many steps. This first step should be a well thought out and comprehensive strategy designed to prepare healthcare administrative organizations to take full advantage of imminent changes, such as secure anytime-anywhere access to patient information and clinical data, improved patient quality, safety, and service standards and real-time processing of medical transactions and claims.

In addition to the new requirements, national healthcare reforms will require healthcare organizations to implement new business processes and workflows to be compliant while being cost effective. It requires foresight to establish corporate standards, project methodologies, and updated infrastructure to adapt to pending and future requirements for process automation, organizational agility, and operational excellence and compliance.

As healthcare provider and payer administrative organizations embark on compliance processes, they can build parallel paths toward business process improvement and operational excellence. This can happen because compliance is an organizational process that includes business process and technical reengineering for healthcare organizations. Therefore, an organization’s overall strategy should be centered on achieving operational excellence as well as implementing new regulations for compliance. This strategy would require the organization to:

  • Establish standardized operational excellence as a corporate strategic priority that is parallel to the implementation of new regulatory mandates, incentives and compliance projects.
  • Reassess how and why the organization conducts business to improve agility, especially in the area of manual business and clinical processing that may provide opportunities for online real-time processing and secure anytime-anywhere information availability for more effective decisions and reductions in operational costs.
  • Define operational excellence as an enterprise wide initiative with measurable goals that extend beyond the regulatory compliance dates. Once initiated, this initiative should continue to scale up or down to improve, evolve and automate business processes to meet the ongoing healthcare mandates requirements as needed.
  • Target compliance areas that can provide high degrees of success in shortest possible time to build momentum and demonstrate compliance. Foster the use of agile technologies and software tools for automation of processes to realize faster results and improved functionality.
  • Create sustainable knowledge transfer processes, staff training infrastructure, and programs to develop the skills required for operational excellence as an extension to the HIPAA 5010, ICD-10, ARRA, and HITECH projects and new health care reform regulatory requirements.
  • Link operational excellence goals to compensation and incentives to focus and reward program efforts.

Healthcare organizations that are able to accomplish this dual effort should be able to differentiate themselves in the marketplace. This differentiation will be evident not only in outcomes and operational performance, safety, and quality measures, but in financial performance as well.

An automation, agility, and compliance approach does not necessarily require an organization to do an enterprise “rip and replace” project and face the monumental risks associated with it. Instead, an operational excellence plan executed with incremental improvement in systems and infrastructures is a risk adverse and affordable approach toward the automation, agility, and compliance the organization is striving to achieve.

Bruce Oliver is the payer practice director at maxIT Healthcare, LLC.

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Currently there are "10 comments" on this Article:

  1. The internet is slow tonight.

    Patient care is delayed.

    The three reports are interesting and well written. Dreams espoused with verbosity do not lead to action and efforts in prose are misdirected.

    For instance, Jerry asks:
    “Who was to blame for this mess? The hospitals, for having antiquated workflows and not turning on key features like the ability to e-mail physicians? The vendor for not making it easier to share information and not allowing patients to add to their own records? The government for not mandating the NHIN, CCD exchange, etc.? ”

    The flaw my dear friends is in massive investment in EMR technology but not in human resources, or in educating the human resources that still want to work in the impersonalized healthcare environment in which the patient is now a computer.

    The response to Jerry was, well, computerized! You asked for it, you got it.

  2. Dear Chromosome,

    Did you say the same thing about ATM machines?? Seems we were able to work through data-sharing issues there…

  3. Jerry, I feel bad for your travails but it’s clear the problem was people, not computers. Computers will never change the damage done by hiring low.

  4. Both those organizations have access to the technology will allow them to exchange records.

    Many sites using that vendor are already exchanging records actively in that scenario.

    It could be that the sites in question here either aren’t on the current version or are still hung up in legal trying to decide how likely it is that one of their patients will sue them for sharing their records.

  5. Perhaps I’m missing something here but Mr Sierra is asking who’s to blame. But, I see he never mentions himself. Why did you not visit your MR and get the record before leaving for Cleveland?

  6. To Jerry Sierra,
    Thank you for your description of a classic example of the broken system as it currently exists. My point…we need interoperability — but what we think we want is based on a paper-based concept – the exchange of the full medical record. In the end of the day, did you really need your child’s entire medical record to be exchanged? Or, is it possible that only certain data actually had meaning? We need to move into a paradigm where data has value only as it pertains to the patient’s care plan, and extraneous data could be removed from the exchange. This is the paradigm of the Virtual Care Plan, an efficient methodology for exchanging pertinent health data. I am interested in your thoughts about this.

  7. Thank you to Dr. Margolis for opening up this pressing topic and making many valid points.

    When hospitals are looking at EMR systems, there is a crucial element that’s often overlooked: and interoperable electronic forms solution. One of the main challenges in moving from paperwork to a hybrid record to a truly electronic record is getting forms completed at registration, patients’ bedsides and other areas into the EMR.

    With paper forms, this requires scanning and manual indexing into the document management system, which is time-consuming and error-prone. Some e-forms solutions allow patients to complete forms on a tablet PC or e-signature pad without ever touching paper. The system can then interface the forms directly into the EMR via the document management system.

    A truly interoperable e-forms system can also capture COLD feeds, reports from an HIS such as MEDITECH Magic or Siemens MS4, and output from glucometers, EKG monitors and other clinical monitoring devices. It then creates secure images and ports them into the EMR, eliminating cumbersome manual steps. Integration like this makes information immediately available to clinical and administrative staff, so patients get the service and care they need more quickly.

    As hospitals examine the integration side of their EMR/EHR project, e-forms management should be part of the discussion.

  8. Steve Margolis

    Can you share some specific examples of “services-oriented architecture that allows for third-party integration?” Examples of specific types of transactions.

    Do these include state-less “get_info” requests as well as “go_do_something” commands?

  9. There is a long way to go before the regression of care caused by such computerization gets back to pre 2005 levels. In the meantime, do not buy. Wait for improvements in the technology.

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