Advisory Panel: Alarm Fatigue

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: Is your organization using or considering IT solutions to the challenge of alarm fatigue?

Note that while I was thinking specifically of physiologic alarms at the bedside, I didn’t state that explicitly, so some answers reflect clinical alerts in traditional IT systems. Seven responses indicated a “no” answer with no IT solutions being considered.

We struggle to balance harm prevention and user design.  We are biased toward harm prevention.

We haven’t found a good solution yet. We’re looked at things like alarms that start out low and increase in volume if not addressed, but many/most vendors haven’t embraced that idea yet. We’re looking at routing alarms to phones, but that also has challenges. If you find a good solution, let me know.

We are currently considering a few IT solutions to address this, but no decision has been made to move forward.

We are currently investigating tools to consolidate alarm management but we have not yet developed an RFP or even a vision for the future.

We are currently investigating and likely to pilot a solution to integrate nurse call bells into nursing phones to improve the alarm fatigue of the ears. In the EHR environment, we are continually analyzing the alerts that fire for their utility, appropriateness, and actionability and working to reduce those that are more "noise" than "signal".

Alarm fatigue happens when the technology was not supportive of the end user – it should not exist if each vendor really knew the topic and client being served.

We have explored alarm management systems, but I was left with the realization that the devices can alarm on anything and it’s up to each organization to determine what’s important. I am not aware of any national standards.

We learned early on to be very judicious with alarms and try and keep them to a minimum. As we’ve merged in some additional physician groups, the governance of managing alerts will get increasingly interesting however. I’d be curious what type of IT helps with alarm fatigue (i.e. do they make alarms more sensitive/specific somehow?)

I wish !!! Turning off the drug duplicate alerts would be like manna from heaven as they are invariably uninformative and annoying. For example, renewing a drug always gives a duplicate alert even though the system obviously knows that if you click "Renew" it will automatically stop the current order and start the new one. But the current order is still active when the system compares the new order to the med list. Ergo, duplicate alerts gone wild. One of my other favorite alerts tells me that the patient is taking two non-phenothiazine antipsychotics.  If I was really concerned about duplication, I would want to know if they were taking two antipsychotics period. Whether it’s a non-phenothiazine makes no difference whatsoever.

Primarily focused on refining medication alert rules to reduce unnecessary noise.

I assume you are talking about actual alarms, vents and IVs and tube feeding pumps and such, not EMR alerts. Since noise levels can exceed OSHA standards 80 percent of the time in an ICU, we are keenly interested in the twin problems of noise from alerts and the false positive / false negative rates of the alerts. We do not have a good answer, but I would be happy to buy one that worked.

We’re still trying to reliably deliver secondary alerting. Alarm fatigue getting some notice, but no definite intervention as of yet.

Yes, considering FDB AlertSpace to achieve what should be included in their product in the first place (we’re on Epic/FDB).

Advisory Panel: Telehealth Projects

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: Is your organization running or planning telehealth projects?

Assuming the term telehealth includes scope of technologies included in the HRSA definition, we run remote ICU monitoring across our WAN. In addition, we continue to expand the use of mobile clinics that roam around our geography. These clinics include videoconferencing between clinic providers, patients, and remote specialists. We are planning additional work with a national telehealth provider.

No, my organization is still struggling to implement CPOE, keep the beds full, reduce readmissions, etc., etc., and we have not got that far yet.

This shows up in our annual strategic plan every year and it’s there this year too. But I haven’t been able to generate much interest among my medical staff, even the members who travel hundreds of miles for outreach clinics. We run a telemedicine epilepsy clinic and we have the usual teleconferences, but that’s about it. So I’ve retained some consultants to explore options like e-visits, home monitoring, and video visits using webcams with the med staff.

We have a few telehealth services we consume for a couple of specialties. For example, we have a small pediatric hospital and will perform remote echoes with specialists at a leading children’s facility for special patient cases. We do not have any plans to provide any additional telehealth services within our organization or service areas at this time.  

Multiple coordinated efforts related to telehealth as we are approaching from a number of perspectives. More traditional eICU, using remote monitoring of multiple ICUs from a centralized location where critical care physicians and other clinicians are monitoring beds across multiple hospitals. Tele-psych consults in our emergency departments. Developing newer capabilities for virtual ambulatory visits, more acute or urgent care conditions where audio/video is effective in connecting a patient and a provider. Our EMR is really helping with efficiency in this service area and also with tele-psych and ICU areas. The key being that tele-X software, hardware can help best facilitate the patient encounter but it’s important to realize our EMR is needed for order entry, documentation, communication with the local hospital pharmacy, etc.

We currently have a monitoring station set up in our ICU for pediatrics so that our patients can be “seen” by a specialist at a large teaching hospital in the state.  We are currently proposing to provide healthcare services to our local detention centers. If accepted, we’ll go the telehealth route.

ANGELS – Antenatal & Neonatal Guidelines, Education, and Learning System – consists of 23 hospitals and clinics who receive clinical services from us, as well as 18 hospitals who participate in a tele-nursery with us as the hub. Neonatal mortality rates for Medicaid declined from 4.5 per thousand to 3.3 per thousand. ANGEL EYE – one-way video from NICU to authorized family members. AR SAVES – Stroke Assistance Through Virtual Emergency Support – consists of emergency support for 42 hospitals across the state. Increase delivery of TPA from <1 percent to 29 percent in participating hospitals. Other telemedicine services – psychiatry, pediatrics, geriatrics, rehab medicine, cardiology, internal medicine, burn, trauma, genetic counseling.

We’re doing projects with telehealth, telepsych, home health monitoring, remote hospitalist consulting, and have others we’re thinking about. While telemedicine has been around for decades now, it seems to be really heating up lately.

[from a vendor member] We are working with several organizations who are planning telehealth projects. However, it is like NLP at this point – all talk, no action.

We are on the receiving end in that we use a telehealth service (neurology consults) in our ED. It works well, although the service and support has proved problematic. The cart contains all the video components, but when there was a problem, they had no local service techs. This left it to our staff to troubleshoot – if we were a smaller very rural hospital we may not have had the expertise to troubleshoot their equipment on our end. Overall the service has been a benefit to the hospital in that we have a shortage of these specialists to take call.

We actually do a lot of telemedicine, both inside our health system and with external partners and that program is continually expanding. Our main service lines at this point are Neuro, Pediatrics, and Psychiatry. The primary locations served tend to be emergency departments in order to deliver otherwise unavailable specialty care to patients.

Yes, for various disease states and ethnically diverse populations.

A year and a half ago, we agreed to work with a vendor on a case study to determine if telehealth would positively impact outcomes. Telehealth was new to them and they struggled to develop a website for data collection and patient interaction. For the research study we needed IRB approval and a contract with us. Once the attorneys got involved, everything came to screeching halt. A year later, we have a contract and pending IRB approval. Perhaps in the near future we can begin the study with our diabetes and CHF patients.

We have long offered telehealth via phone and web visits for mild, acute problems (e.g. URI, UTI), and we charge a separate fee for those. We are also now looking at using telehealth technology to do remote care at corporate clients.

Vague talk only about telepsychiatry to local ERs and jails.

Telehealth in use for burn, stroke, and psych consults. All working very well with different technology solutions including iPad and a mobile robot looking device.

To meet requirements for Level 1 nursery, we have neonatology sub-specialists on tap, credentialed and available. This is a great solution to consultations that would otherwise require transfers. It is another question entirely whether early transfers are in the baby’s best interest; it may be that telehealth consultations get an actual consultation in the odd hours, where if the baby were in the actual institution providing the consultants, there would be more of the "I’ll see them in the morning" mentality. Of course, in that setting, the consultant is probably more comfortable with the nursing and ancillary staff, so it may be about the same outcome. Still, it feels good to have an actual clinician to clinician discussion about a specific case.

We’re doing a lot of tele-stroke work. A real smart stroke neurologist with an interest in the technology. He’s serving other organizations and when not on site, he starts care using his tablet and the stroke robot in the ED supported by a stroke nurse-practitioner or neurosurgery PA.

Virtual visits are part of our future plans, none running yet.

We are rolling out telemedicine to support our network of six rural health clinics. This will be essentially to push the access to our specialists. Rollout is over next three months.

Radiology uses NightHawk services from the other side of the globe for night preliminary reads, but that’s it.

Advisory Panel: HIMSS Booth Reps

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: When you are approached by a rep at a vendor’s booth at the HIMSS conference, what factors (their mannerisms, appearance, actions, handouts, etc.) make you most likely to pay attention?

He or she needs to be very outgoing and engage me. I’m generally exhausted and numb from all the activity on that floor. I have trouble sorting the wheat from the chaff.

It’s important that the booth signage and setup communicate something about the products or services the company offers. Weird, techy names and generic descriptions like, "Biodynametric. We enhance interoperability and efficiency across the continuum," and I pass on by. Second, the guy who lunges at me from the booth is another non-starter. Professional dress and demeanor combined with a pleasant introductory line usually works. "Are you having a good show?" Or, "Good afternoon. Are you interested in learning about our new line mobile device integration software?" Something like that.

A drug rep once told me, when I asked her to not waste my time and to tell me something that I did not know already, that in sales training they are told that it takes a doctor eight times to hear a message before they start registering and remembering to write their drug. Needless to say she never set foot in my office again, but later I learned  that Big Pharma  calls this "the rule of seven touches.” It is indeed believed that it takes that long to build a relationship based on trust. Having said that, I like to see a vendor who does not ask for my email after we just got introduced, only to bombard me with their white papers. Who does not act as if they would rather be somewhere else, but who also makes me want to see or speak to again. Who understands that I will not sign a contract at their booth and that I will not be impressed by the size of their booth or the amount of useless goodies but by their humility and knowledge. Also, since the number of doctors walking the hallways at HIMSS is dwindling and the decision and buying power is being stripped away from them, if the vendor sees an MD who is still practicing and  took the time to be there, maybe he or she should listen to him before throwing a sales pitch as it may teach a thing or two about how doctors think and operate. It is ultimately the doctor who is the end user of IT and unless we talk about patients treating themselves( there seems to be no shortage of solutions for "do it yourself" under the disguise of "patient engagement") we cannot take our eyes off that ball or soon the HIT vendors will sell to …each other. And in my exam room it is getting pretty crowded.

A non-salesy and personally engaging approach works well for me, particularly ones that don’t make me feel like I’m trying to be picked up in a bar. Don’t glance at my badge before you look me in the eyes. And I particularly dislike the sales pickup lines like, “Do you have any concerns or issues about or around [fill in your self-serving topic]…” They are quite the turn-off and I will say no even if I do. Engage me and let the conversation go where it may. If there is an opportunity for a fit, things will take care of themselves.

To be honest, I generally avoid the stalkers. I put on my “don’t talk to me” face and it’s been pretty successful to date. Also, I don’t generally use HIMSS to research new products. I use it as an opportunity for face time with my current vendors.

If it actually starts with a conversation rather than a sales pitch. (How are you enjoying the show? What have you found interesting so far?)

Personally, I rarely react well to being approached by a vendor rep. My preference is to walk through their booth to get a feel for what I’m seeing on their screens or promotional details, and if I find something I find interesting, I’ll ask a rep to explain it to me then. And when they do, my preference is that they skip all the BS and just hit me with the major points, key facts, concepts etc. of their solutions. I don’t need to spend time hearing how we all understand XYZ (e.g, reimbursement, big data, ACOs, HIEs, whatever). I don’t want to spend any time chatting or building a relationship with them. Suggestion to vendor reps:  think "speed dating," but focusing on your solution, not each other. You don’t really need to know what issues and challenges we’re facing — we’re all facing the same ones. I have 1,000 vendors to see today — make your few minutes count and maybe I’ll come back for more.

I know it sounds superficial, but the first impression is very important. If the person looks dirty or sloppy, I will not take time to talk to them. I feel that if they cannot put their best foot forward when representing the company, then they will not put their best foot forward with me as a customer. I also want someone who is friendly and makes eye contact. My biggest complaint at HIMSS or any show is that a lot of booth reps act like they don’t want to be there or want to be bothered talking to anyone. Friendly, energetic, and knowledgeable wins every time in my book.

Unfortunately, appearance matters. The best sales pitch is lost if  you don’t look like you represent a vendor with its stuff together. I seldom visit booths at which I have not made an appointment, but taking that walk around and getting inundated with pitch after pitch can be fun sometimes. When I do,  I first look to someone who appears like a professional (neat in whatever booth attire they have chosen – but I prefer business attire to the casual polo shirt.) Second, they have to be able to give me the “what we sell” pitch in two minutes or less. If they can accomplish this, the chance of me stepping into the booth to look at the product is greatly increased.

I tend to be uninterested in or entirely put off by being approached at all. The most annoying vendor hall experience I had was a vendor rep that caught sight of my badge and followed me for a while and then approached me by name as if he were another attendee. Very off-putting. I go to the vendors that I want to talk to on my own — don’t approach me. I do my homework ahead of time to determine who will have something I want to learn more about or a possible solution to a problem we have, but I will also skip them and mark them off the list of potential partners if I cannot quickly get a friendly and informed representative to pay attention.

I avoid anyone in stilettos or sexy outfits. I’m not there for sex – I’m there to learn. Someone who looks genuine and actually has a pedigree is someone I walk towards. Sex does not sell in HIT, only when trying to sell Viagra or something. Get rid of the sexy pots at HIMSS booths.

If I don’t know anything about the vendor, I need to hear a compelling elevator speech about what they do. During that speech, if they are articulate and passionate, I may stay longer. If I do, then appearance and mannerisms help keep my attention. If all they know is the elevator speech, I move on. A stunning blonde with nice legs overrides all these professional considerations. If I do know something about the vendor, I would probably just move on.

This falls into two categories. (1) I already know I want to see the vendor, in which case I will look for someone who is experience and can give me the real details. Or said another way, I avoid the young kids who look like it’s their first conference as well as the high-level VPs who can only give me high-level answers. (2) An unexpected surprise… maybe it’s a vendor I had heard about somewhere, or maybe they have a slogan that is intriguing or better some stats that stand out (e.g. "We save our practice 10 percent of costs a year!") Usually these are the smaller booths and there are only 2-3 people there, and they are always very helpful and grateful and give a good talk.  

I’ve never been to HIMSS but I’ve been to plenty of other professional conferences where pharmaceutical reps were trying to lure me into their booths and I’ve been to the user conference of my hospital’s EHR software vendor which has their own reps and those for affiliated products lying in wait. Thus, I’m fairly confident that HIMSS would be similar. In general, I walk up the middle of the aisle slowly, feigning disinterest to get a sense of whether I have any interest at all in the products being offered. Part of my reconnaissance involves watching the interactions of the booth reps with unsuspecting passersby. Then I go back up the aisle and stop at key booths of interest. If the reps do not look professional or are cloying or annoyingly pushy, their product is crossed off my list of stops unless it’s REALLY amazing. When I stop at a booth of interest, I’ll glance at their materials if they’re with someone else (and sometimes move on if it’s not of interest). If they’re available, I’ll ask them to tell me a bit about their product. If they are straightforward, answer questions reasonably, and let their product sell itself, that’s a big plus. If they come on too strong with buzzwords and marketing hype or start asking too many "friendly" personal details (e.g., "Oh, I see from your badge you’re from Badger Falls — my Aunt Bessie’s ex-husband grew up there") I’ll say that I just wanted to get their materials and that I’m not in the market right now. Then I hightail it off to the next booth. This dramatically improves my efficiency and lets me spend quality time at the booths that are of greatest help. Even if I’m really interested in a product, it’s not efficient to deal with a rep who’s not knowledgeable or just trying to sell me a bill of goods (sometimes I’ll go back to such a booth later when a different rep is there.) When I do get a handout, if it’s pure marketing pablum, it goes straight to the circular file. I want to see details that will help me make a decision. With software-related products, a key to try to product for 10 days or a sample CD to get an actual feel for the program gives multiple bonus points in my eyes. Again, the booth is confident enough in its product that it knows it can sell itself.

I try to ignore all sales people as much as possible while waking the halls.

I am rarely approached by vendors, and when I am, I feel I am being treated like the the last girl in the bar at closing time. When I seek out a vendor (I do my homework) or I am attracted by a display, I want the elevator pitch, some literature, and contact information. I pick the person that seems most likely to give me what I am looking for without being clingy. Mannerisms? Professional. OMG, no flirting. Appearance? Sorry, but the middle-aged white guys or the person that the other boothies defer to  is the person with the most efficient pitch. If it helps, it is harder to pick out who is in charge than it used to be.

When I’m asked a question. “Are you interested in learning more about _____ ?” Not a brand name, but rather a function or feature –I can see the brand name since I’m right at the booth. Pitch your product with a question, and I don’t mean of the form, “What are you currently using for _____?” In short, don’t sell—teach.

Mannerisms, appearance, first sentence.

I have found that the art of navigating the HIMSS hall is to have a plan. Know what you are looking for, perhaps even the vendors you are interested in, and so forth. I have found the hall to be more beneficial if you add intentionality to your visits. I do not like gimmicks, but a free beer, water, snack, or other food item helps. I also like vendors that provide trash bags (oh, I mean, brochure bags,)  I do not like vendors that “attack” a passerby.

If I’m in their booth because I haven’t heard of their product or don’t know much about it, then I’m focused on how quickly and clearly they can explain their product’s practical application and how it can provide value to my organization. If I’m there because I have decent knowledge of their product, then my goal is most likely to get specific questions about how their product works answered. In this case, the last thing I want to hear is them talk about the practical application and value proposition of their product. I’m focused on the knowledge of the person I’m speaking to. If they quickly say that they cannot answer my question, kudos. I’ll give you a second chance. If they blow smoke, then I may blackball them when I get home. In either case, if the sales person talks about a partnership or attempts to get to know my personal interests, then they immediately lose points in my book. Their job is to take as much of my health system’s money as they can while ensuring that they provide good enough service for us to perpetually pay upgrade and maintenance fees, not buy me tickets to the World Cup (which would be the right way to bribe me). My advice to the sales folks — open our conversation by asking me why I’m there, what I know about their product, and if I have any specific questions for them. As I answer those questions, ask clarifying questions about my business situation (facility size, location, etc.), and then tackle the problem at hand. It will work way better than the gibberish your marketing person wrote.

A mild manner is preferable (Jimmy Stewart over John Wayne). A working demo of their product and the knowledge to use it – amazing how often this is not available (Alfred Turing over Don Knotts). I am a fan of understanding the challenges of a community hospital and not quoting how they solved a problem at Johns Hopkins or UCLA (i.e. Fred MacMurray over Roseanne Barr).

Appearance and mannerisms. Down to earth “real” people versus salesy used car salesman type folks make me want to stop and talk. The booth babe costumes really turn me off. Because there are so many booths at HIMSS, the signage is also one of the things that gets me to stop for a look.

Advisory Panel: Keeping Peers Informed About IT

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: What methods do you employ to keep your executive peers informed about IT initiatives, spending, and plans?

Regular face to face meetings (or a call) are always the best. 

Annual work plan development. Capital budgeting, especially the part of the process where business execs say yes/no to requests and as a result prioritize investments. Monthly leadership report of IS accomplishments to plan.

It’s all about governance. You have to have the structures in place to meet with your peers and have the decision making process completely transparent. I also use our executive meetings as opportunities to get on the agenda on a quarterly basis to give updates regarding IT activities.

Routine updates at Exec Team meetings. Lots of meetings. Annual report.

Multi-year IT roadmap, status reports, status meetings.

Our admin team is right down in the weeds with us since HIT is such a big expense. They have been reasonably agile and able to understand what we are doing, and actually ask good questions. Sorry, not a very Dilbert response.

Historically, there has been a disconnect between what IT sends out the end-user leadership and what actually gets communicated down to the folks in the trenches. If I had a dollar for each time I’ve rounded on floors during downtimes on the weekends and heard, “No one told us the system was going to be down”, I’d be typing this from a warm sunny beach somewhere. To bridge the gap, we have started publishing, at a minimum once a month) a newsletter focused on the team members and what they need to know about  IT initiatives. The plea I have made is for each department leader to discuss the contents at their respective huddles and to place it on the communication boards each department maintains. Thus, any team member who works has an opportunity to review it. (Are they up on all the boards in the hospital? What do you think? ) IT Updates are now a standing agenda item at the Friday weekly leadership huddle attended by senior leaders and department heads. I have two agenda items with the hope that repetition will help them connect the dots: (a) Here is what is happening one to two months out, and (b) here is what is going on next week. Beginning this budgetary cycle, I’m meeting with each department head (instead of their vice presidents) to discuss their goals / dreams / hopes for 2014. Many times IT has been backed into a corner by surprise requests coming from senior leaders that were unaware for whatever reason what their reports were considering. The hope here is if we can deal directly with the department head, we can set up a win/win experience for them and for us in terms of managing expectations.

Monthly updates in executive meetings if within organization – outside organization at regional and national meetings. Email within organization when appropriate. Newsletters to executives when appropriate.

IT leadership directly involved in system leadership councils and directly report to most senior leadership to be sure efforts are aligned with strategy. Involvement of clinical leadership in IT prioritization, governance bodies.

Monthly meetings, inclusion in the distribution announcements, phone calls on surprises, etc. This is most effective if the executive understands the importance of IT and informatics. When they don’t, it’s pretty useless.

IT participates in strategic planning sessions with health system executives. This was not true a few years ago, but is now. IT produces and sends out a monthly dashboard to executives of all key projects, which includes project status and barriers to completion. Each project has a health system executive as the key sponsor.

Lots of financial reports, for one. Those are what matter really, cost projections and cost actual. Outside of that we have a very simply way of showing project statuses. The classic green, yellow, red with only 5-10 lines of detail. There are also numerous meetings with different members of the executive suite on any given week as well. 

Advisory Panel: Three Hospital Improvement Actions

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: What three actions would most improve your hospital overall and how could IT contribute to those changes?

Better understand our variances in high cost procedures. Analytics can help in finding variances and understanding why they happen and then we can work on fixing those problems. Manage high-risk patients better. IT can be used to identify (predictive modeling) and track (registry) these patients, but people will make the difference in helping them. Understand our patients better. IT could be used for better surveying of patients both in real time and retrospectively

Hospitals need to start by realizing that their days of glory are gone and that healthcare is no longer hospital centric and need to regroup. Need to start applying "lean" principles and look for ways to cut cost but not compromise care, which is indeed a balancing act. Invite and involve all the stakeholders in and have a mission statement. Admit that "all healthcare is local" and that certain rules apply in certain markets but are not valid in others where the consolidation is not so pervasive.  Realize once and for all the role of clinicians whose decisions and behavior we are trying to influence and change and  groom real leaders who are in it for the good of the community and not merely to embellish their resumes. Improve communication all the way from the CIO and C-suite to the practicing MD and nurse who are " where the rubber meets the road". It has been my experience that the larger the organization, the more broken the communication and the more bureaucratic the process. IT can do exactly that — improve communication and transitions of care.

Enhance value (improving quality and reducing cost) – IT focused on data analytics to produce actionable descriptions of current conditions and to support experiments planned to move us toward our targets. Wow our patients and families (great service experiences) – right now we’re focused on providing patient portal access. Innovation and partnerships (new models of caring) – deploying and operationalizing health info exchange.

There are three major factors that will determine the viability of hospitals over the next five years that IT has the capability to improve. First and foremost, we absolutely have to reduce the cost of care. Clearly, one of the main ways to accomplish this is through better coordination among providers as well as better clinical decision support mechanisms to reduce unnecessary tests. This is more than just duplicate checking — it is now quickly moving to personalized medicine using the more rapidly available genomic and proteomic information available for patients. Secondly, we must provide better interoperability and analytics for population health between multiple disparate providers of care. We are moving to a model of care where the primary care physician becomes the gatekeeper and we have to be able to communicate in real time the status of every patient and their disease states. This high level of coordination will only be possible with a significant IT support model. Thirdly, we have to optimize our ability to capture charges with payers who still pay in that manner. The list of those payers will continue to shrink, but we need to take advantage while we can. That also includes the ability to capture activity, especially on those newly insured patients that will be creates as a result of the Accountable Care Act.

A few more hours in a day, and a week would be great! Improved collaboration around significant challenges is adversely affected by a lack of time and ability to focus on priorities. Effective use of video technologies might help, but folks are so busy it’s hard to know what can help. Creating a culture of appreciation and not just recognition. Hard to do – perhaps better use of social networking tools? Better financial performance….. if we could drive value from all of our technology investments and truly ensure that we are using 100 percent of everything we deploy and get value from all of it.

Patient safety: better clinical decision support. Patient care: better order sets and workflows. Patient engagement: in-house use of Epic Bedside.

If you are looking for the most bang for your buck in changing the hospital, it would start with the most important determinants of hospital outcome (RNs) and patient satisfaction (CNAs). It is clear to me  but hard to prove that a well-trained RN staff improves outcomes, but a good outcome, at least in the sense of following guidelines and providing consistent, checklist driven care, is now the expectation. Patient satisfaction is proportional to the number and the friendliness of the staff that deals with the personal needs of patients (toiletting, call lights). IT can help with efficient one-click charting, and clinical decision support for the RNs. We should spend a lot of our optimization time on the RN workflow. On the CNA side, a Vocera type solution that allows direct communication to a CNA as well as combining a group into a lift team will speed up response. Oh, and relax the "no personal calls" rule on your devices. These folks, typically ladies, will check on their kids. Let ’em do it quickly, openly, without apology, and back to work.

The government dropping ICD-10 and waiting for ICD-11. The costs of systems, implementations, and training, especially for physicians, is clearly not worth the benefit to a handful of researchers and will do absolutely nothing to directly improve patient care. To complain about the cost of healthcare while spending money that doesn’t directly improve care is ludicrous. The government slowing down the pace of MU and only focusing on those aspects that directly improve patient care. (Seeing a trend here?) The government stopping changes that only impact billing. Let’s put our focus and money to better use improving patient care, not worrying about how to pay less for it or spending more time on record keeping.

A  major issue with us is lack of resources across many of the departments. The Catch-22 is that IT could help by automating some of the workflows, but we do not have the money or the human capital to assist given our EHR implementation. IT is working to generate as many initiatives as possible that would allow team members to better document what we actually did to the patient through documentation and capture applicable charges. The thought here is that we could achieve better reimbursement through increased documentation of what we actually did for the patient. “You can’t manage what you can’t measure”….we are pushing out analytics and other business intelligence deliverables to leaders such that they can have information in a more timely and readable fashion. These deliverables are done real time on a proactive basis and provided at least weekly. In their office, leaders can look at throughput, length of stay, payer mix, etc. without having to call down to have one of my team members run a report and then interoffice or email the output.

Create processes for improved communication between departments – streamline tech services; increased qualified staff – mentoring programs on line; identify marketing opportunities to show case hospital success – social media support.

Reduction of regulatory burdens which consume lets and lots of resources including IT to "remediate" and impedes innovation. Support the digitization of all business processes to align with MU and transition to EMR, etc. Drive true patient engagement very openly and aggressively. IT would benefit from these changes and could work to facilitate patient engagement.

Improved integration of IT and Informatics into Strategic Planning and Business Development. Improved adherence to strategic planning (we spend too much time chasing shiny objects that don’t contribute to strategic gains). Improved measurement and learning from strategic actions taken (i.e., measuring how well we actually did).

Robust report writing capabilities with a clear roadmap of standardized reports across the organization. We have lots of data, but much is not useful. Also have people running reports from various systems that don’t match—lots of confusion! Standardized processes for onboarding employed physicians.  We have chaos that includes HR, Finance, Physician Enterprise, Property Management, Credentialing, and IT, due to a non standardized approach. Better integration between hospital operations and ambulatory operations. With the rapid growth of the ambulatory world over the last few years, these two entities have been separately managed and poorly integrated. IT can and should be a strategic partner for the planning and execution of all three of these actions, providing technology solutions and  facilitating standardization.

A shift of focus back on to patient care and not reimbursements/cost only. In our situation, we are a single-entity, regional non-profit. We have many hospital-owned clinics, of course. The past few years with all the cuts to reimbursements the organization has moved on all types of budget and process improvements. I’m all for process improvements, but the other side of budget cuts if not done well can be damaging. The organization’s competitive advantage was always patient care. The patient came to us because they didn’t want to travel to a larger city and a larger care environment. Now that we’ve eliminated whole scores of patient transport people, floor secretaries, and even furloughed some nursing staff, that advantage is gone. We run positive margins is the crazy part. I fear in time those margins will shrink and it’s not going to be because of costs. It’s going to be because we lost our best patients to other competitors. Even if your payer mix is only 10-12 percent insurance, those are the people getting the cancer/spine/heart treatments that keep a unit/hospital in the black. How can IT help that? That’s hard as that is a human element. We can support the frontline with streamlined systems but IT can’t be there caring for the patient. IT is a force multiplier on many things but not patient-focused staffing. Those patient transport staff who used to move patients out of the ER but now there is backlog getting patients to the floor from the ER.  I suppose IT could find a robotic system from and industrial plant and put that to use to automatically transport a patient to their waiting room! That will really help with patient satisfaction scores!

Advisory Panel: Decisions Regretted

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: What decision did you or your department make recently that you regret the most?

Actually all recent decisions have been good ones.  It’s the sins of the distant past that are still haunting us.

Letting the hospital put "web filters" to reduce inappropriate web surfing… it has slowed normal internet use to a crawl at times!

We decided to wait until this week to hold an all-IT-employee appreciation event. In retrospect, I wish we had held the event sooner. My team has been working incredibly hard, long hours for quite some time. We need to celebrate, relax, and break bread more often!

There are so many in hindsight of course. Anything with McKesson Horizon. HIStalk ran the rumors for at least a year before the 20/20 announcement. Anyone with experience in vendor mgmt or software development in general would say the Horizon 20/20 announcement was a sign of problems. It was the start of the best and brightest leaving the Horizon project team. It was a declaration that much if not all of your software licensing money spent was wasted, if you move to Paragon you can recoup, but all that time building a solution. All those hours spent and knowledge built will have to be repeated inside of 24-36 months.  It’s a demoralizing thing, in my opinion, when you could see/feel the winds of change but couldn’t get the ship turned. 

I regret holding on to one of my managers for too long.  I tried for three years to get him where he needed to be, including a management geared towards his weaknesses. I found it difficult to provide tangible measurable criteria with which to push him. Regular staff is much easier to measure/document against, but they are more task based. The role of management really has to do with decision making and overall philosophy ,which is difficult to make tangible. I finally replaced him and can’t be happier. The new manager has the same management style/philosophy and has made significant changes since his arrival seven business days ago!

Hiring someone we thought would want to get EpicCare Certification and then be hired somewhere else and did. Jerk.

Not my decision, but I’d say the state’s decision to try to dictate HIE (without understanding it) after everyone had already made plans.

Picking a vendor for an automated claims processing system that had very little experience with the types of claims adjudication rules that we follow. But, our department really didn’t make the decision. The decision to choose the vendor was made by members of the Board of Directors, overruling the recommendation of the CIO and selection committee. True to form, the decision has been a disaster and we are going to throw the vendor out and re-compete the contract.

A trusted current vendor acquired a new system through acquisition. Because we needed what it did, I jumped on it right away. Only later did I come to realize the trusted vendor didn’t have a clue how to integrate it with what they/we had. By itself it works great – a year later they/we are still trying to figure it out.

Crowdsourcing Results: User Group Meetings

A growing vendor asked me about when and how it should consider hosting its first user group meeting. I surveyed readers for their opinions and received 44 responses. Thanks to all who responded – I’ve read every word carefully and summarized below. I think it’s fascinating.

Reasons for Attending

Attendees attend UGMs to get education and to network with peers. Company interaction isn’t nearly as important.

Meeting Sponsor

Most respondents preferred an event produced by the company itself rather than by a user group.

Most Valuable Education Sessions

These were freeform responses, but the majority of respondents expressed a strong preference for allowing customers to present rather than the vendor. Some ideas:

• Big picture company strategy
• If I had to do it over again ….
• Customer roundtables
• Regulatory compliance training
• Tools and tricks
• Workgroup sessions for customers with a shared market challenge
• Hands-on customer sessions, such as best practices
• Customers describing how they use and derive value rom a product – are they using it in a way I’m not?
• “Did you know” sessions from the vendor
• Training sessions delivered by customers, but with vendor assistance to make sure the information is correct
• Information about upgrades and how to use new functionality
• Product road map sessions from the vendor
• Implementation lessons learned
• Integrating the product with other solutions

Fun Session or Event

• Customer panel
• A concert
• Beach party
• Sailing
• A casual wine tasting the night before the main session
• Closing down an attraction just for attendees
• A session just for newbies who need tips on how to network, how to join a conversation, what  not to say
• CEO new feature rollout
• Dinner out with groups by individual signup – large enough to provide networking, but small enough to force interaction
• A general session with a hired speaker to motivate the audience
• An evening at a local farm with homegrown local foods and wines
• Sporting event
• Competitive events
• Team building exercise, such as group drumming
• Breaking out into groups and being asked to design new functionality
• Company party
• Attendees brainstorm new features and “sell” the idea to the vendor
• Panel session where the company was “roasted” in a professional and non-personal manner
• Theme night dinner
• Surprise slumber party – guests received a tee shirt and slippers, just a few tables, a room full of games like Twister, and finger food — the common dress and surprise nature made networking comfortable
• Group activity to support local charities – build bikes, create care packages for troops overseas, work in the local food bank
• Square dancing and dinner on a farm

Best Experience

• Learn more about product capabilities
• Specific product workshops by users
• Customers create the agenda and run most of the presentations
• Focused networking, like tables by topic
• User case studies about problems solved
• Every best experience involved networking
• Being invited to present about lessons learned and having prospective customers asking questions afterward
• Getting confirmation from other users and presentations that we’re on the right track with our use of the system
• A good keynote speaker from outside the company who presents a motivational message always sets the tone for everything else
• An EDIS competition among top competitor products
• Hearing gotchas from customers so I could avoid them
• “Seeing 30 kids being told they were to become ‘bike testers’ – after ‘testing’ the bikes they were told they could keep them. The squeals of joy, kids tears of happiness, parents of the kids with tears of gratitude, attendees with a lump in their throats seeing what they could do working together to bring happiness to someone else.”

Worst Experience

• Vendor taking control of the meeting
• Standardized lecturing by company employees, more like a trainer session for “one size fits all”
• Company rah-rah at every session – get on with your discussion
• Boring speeches by executives telling me how great their product is
• Company-run presentations that turned it into a two-day sales pitch
• Go easy on trying to sell me something
• Rooms that were too small to hold everyone
• Execs talking about how great the company is and how lucky we are to have them as a vendor
• A pompous executive telling us the same thing every year – if you’re going to share your roadmap, make sure it’s paved
• Hard sell by the vendor of vaporware
• Bad presentations or poorly prepared presenters
• We present real-time issues and company leaders dismiss their significance to healthcare
• Vendor using their “top” customer as a mouthpiece – you attend a session thinking it’s a customer speaking and then learn they’re in bed with the vendor
• Networking events with music that’s too loud and everyone (especially the company’s employees) drinking too much free alcohol
• Sessions that weren’t as advertised
• Condescending speakers
• Lack of signs to get to rooms on time

Ideal Location

Any city that’s easy to get to an inexpensive was the clear choice.

Preferred Type of Educational Sessions

Case studies win, followed by informal chats and roundtables.

Importance of Offering CE Credits

Offering CE credits isn’t essential.

When is it Time to Have the First User group Meeting?

• Size of install base and maturity of product
• Vendors need to lead their customers to what the marketing is doing – if you have multiple products and services, then get your act together and design the meeting
• Sufficient user size where the cost will benefit an expected number and quality of attendees
• User requests
• Number of users, demand for training, frequency of new products that require training, established groups at beginner, intermediate, and advanced levels
• When customers ask for peer references for best practices and when product complexity and changes can’t be explained in an email blast
• If your customers aren’t involved, don’t start one
• Multiple users that are geographically disparate
• At least 20 installs
• Clients are meeting informally on their own
• If at least a third of the user base is asking for it
• If the company doesn’t have a formal process to gather and respond to customer enhancement requests
• Size of the customer base – maybe 30-40 percent will attend
• In the first year, do it close to home so you can learn and get back to the office quickly to make changes
• When there are enough successful to-lives to make sure it doesn’t turn into a giant gripe session – there must be enough true believers for critical mass
• After 2-3 major updates or the first all-new release of the software, especially if the updates coincide with government, payor, or industry changes
• The vendor has at least 20 customers and actually cares about them
• When it seems customers are asking the same question over and over

Should The Meeting Have an Exhibit Hall?

Yes, it should.

What Can a Company Do to Create a Great User Group Experience?

• Keep it orderly, timely, and on track
• Keep the meeting to 1-2 days
• Make it easy to register and attend
• Have a customer panel for Q&A
• Make sure the company staff interacts with customers
• Have engineers attend – they will learn a lot about customer use
• Get topic ideas from customers
• Offer varied events, not just lunches and educational sessions, and include after-hours events
• Crowd source the venue and sessions from active users
• Make sure space is big enough for all attendees
• Repeat popular sessions
• Always offer vegetarian options
• Offer CEUs if possible
• Make it about edification of the current customer base, not a sales pitch
• Choose a location that’s travel friendly and inexpensive
• Make staff available, which is why you have it near your headquarters
• Advertise well in advance so customers can budget travel
• Provide hands on experiences
• Give customers something they can use to make their organization better
• Have good food!
• The company should provide support resources but not control the group
• Fewer sales staff at the meeting and more support and technical staff
• Less pitching of new stuff
• Use an advisory board to set the agenda
• Make sure the people behind the scenes who customers talk with but never in person are there
• Arrange good, clean, and safe accommodations
• Include a lot of case studies
• Allow customers to interact with each other and the real developers in the company

Advice For a Company About to Launch Its First User Group Meeting

• Designate resources to ensure smooth delivery–1 person can’t do it all re strategy, planning, communications, positioning, event aspects, as well as internal communication to staff involved. And don’t assume because the company launches with an email communication that customers will read it and understand what’s in it for them. Customer’s are spending money to attend and time out of their medical practice. Make sure there’s plenty and frequent advance notice and easy registration and staff available to answer my questions–pre and during the group meeting. Seek continual improvement–do a electronic post event survey–both to customers and internal staff.
• Make it as central to your user community as you can to reduce expenses for attending and announce it in enough time for me to get it funded to go.
• If you are going to hand out free swag, don’t make it too cheap. Better to not give anything at all. Also consider location carefully. A mix of a tourist area, easier to get to gives folks a nice excuse to attend. Forget Fargo in winter or any combo of Verona and cheese curds.
• Invite small group of active users (each should represent all regions of the country) to act as ambassadors/advisors to provide recommendations on sessions, venue, fees, etc. This group should also be encouraged to promote event to colleagues via social media channels.
• Try to imagine yourself as an attendee and what kind of service you would expect, and then go beyond that to knock their socks off…in other words, treat your customers like royalty and they’ll respond with loyalty.
• If you don’t already have an enthusiastic group of users who are willing to share ideas – don’t expect it to magically happen at your first event.
• no hard sales pitched. sell via education and solving client problems
• Start planning & advertising to base early. Make sure the location is experienced with handling such events.
• Be a facilitator, not just a presenter. Remember this meeting to to let clients learn from one another, not just from you. Manage the process to insure constructive feedback, not just bitch sessions. Have fun.
• Ask for your users to be active partners in the process. They know & use the product in ways you won’t expect.
• Get at least some of your frontline staff to the meeting, not just marketing. They are your day-to-day contacts with your customers, and they probably want to actually meet the people they spend a lot of time on the phone with. Your customers also want to put faces to names when they can.
• The lower the cost, the more users they will attract. Don’t make it free, because "you will get what you pay for".
• Select users to help set the agenda and overall experience goals of the conference. Select a mix of; great and not so great users; large medium and smaller organizations; encourage networking opportunities; Keep the message clear, simple and honest.
• Plan, plan, plan. Don’t expect to make money – it is an investment and will take several years to break-even.
• Pretty simple. If you make it a big company sales pitch, it will be the last UG meeting I attend. Your goal should be to increase customer loyalty by showing off a community and ideas. Your goal should not be to upsell.
• Re-evaluate if you really should. Make sure you have enough client support.
• Keep costs in line with expectations created, follow the old adage to deliver more than promised.
• Get a major client to host the first few meetings at their location.
• Get input from your customers using a survey or direct calling to gauge interest and get input on the agenda.
• Do It!

Advisory Panel: Patient Portals

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: Do you have a patient portal, and if so, what can patients do on it?

We have a new patient portal from Epic that was implemented as of August 1. Currently, you can view results, appointments and prescriptions on-line or on your mobile device, send messages to your provider, and pay your bill. It also has health maintenance alerts. Future functionality will include self-scheduling of appointments.

We’re working on the policy & procedure of what we want patients to do in the portal before we start actually implementing.

We currently have a patient portal from our outpatient EHR vendor. Over the next year we anticipate migrating to an enterprise patient portal that will cover both our hospital and physician practice arenas. Currently patients can: see basics of their medical information, request appointments, request medication refills, send a medical question, receive documents, pay their bill, and research health information using a provided library.

Yes – custom built. Patients can see lab results, see their meds and allergies, request changes to these, request appointments, pay bills, send a message to their PCP. 

We have been live for many years and focus on what we think patients want to do most: Communicate with their doctors, Communicate with admin staff (e.g. billing, referrals), and request appointments. We will eventually add in the ability to view their EMR data, but it has not actually been a big request from most patients. The key has always been around communication. 

We use Epic’s MyChart. It went live last September. In the first release, patients have access to refill requests, appointment requests, and portions of their medical record, visit history, and upcoming appointments. Future releases will increase functionality and data access.

We do but for Allscripts/Clinic services only. Not much right now, scheduling details, and that’s about it. Not all offices have the feature enabled.

Yes but it is not yet live. Includes: access their billing statements; pay bills online; request and manage appointments; view, print, and securely email their medical information; access discharge instructions to improve patient care;  update their information and manage their medical history.

MyChart of course. Pts can: request appts, send messages, view all sorts of stuff (visit summaries, letters, etc.). We are just now going live with questionnaires (health summaries) and health maintenance reminders.

We have a patient portal for the hospitals but due to having disparate systems (hospitals vs ambulatory clinics) will require multiple portals or will use our HIE.

Yes. View lab results, delayed until released by the physician, and browse patient education material, tailored to their age, gender, ICDs and CPTs. Editorial: our patients should be able to see their entire record, and lab results as soon as they are available, not pending review by the physician.

Advisory Panel: PHI on Mobile Devices

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: What policies, practices, and tools are you using to control the use of PHI on mobile devices and apps?

Policies titled “Data Encryption” and “Mobile Device Safeguards” provide the basis for protection regarding mobile devices, emphasizing the requirements for encryption (storage and transmission), not saving PHI to mobile devices unless necessary, deleting the PHI when finished, and basic physical protections. Tools utilized are various methods of VPN, McAfee EMM and ActiveSync, native and container encryption methods, whole disk encryption, complex passwords, training and publications, Citrix, VM View, and custom applications that provide connectivity without storage or print.

We require any device that connects to our mail server to be encrypted.  If the device isn’t encrypted, the server won’t allow a connection.  We’re still working on a secure communication system with our non-employed providers, since they want us to send SMS messages rather than emails. 

We use Good Technology to provide secured access to our corporate email, contacts, and calendar on mobile devices.  Our policies limit the users who can have access by role. My perspective is that we use Good to mitigate our risks, but it has not increased satisfaction among our users.

We force a password protection on mobile devices and enforce a "10 attempts" wipe policy.

The health system adopted an encryption policy as a  CYA effort. We officially prohibit the use of personal computers for health system business, but I can’t see any way that we can control or even police this activity. Employees have external hard drives at home that they use to backup their laptops, at least they should have some backup mechanism. Therefore, when any of these home-based devices is stolen, the health system does not have to report the event, but the patients’ data are still compromised.

Likely not a surprise with all the recent news around this subject, we recently are about to launch the following: (1) Automatically encrypting all outgoing emails which contain PHI (based on whatever detection system the IT team is using). I hope ours is accurate and does not create a painful process in non-PHI circumstances;  (2) Automatically enforcing that any smart phones syncing to the system for emails/calendar have a four-digit device PIN, an inactivity timeout under 15 minutes, and remote wipe ability if device lost or stolen – I did not realize they could do all this automatically (but hopefully most of us do all this already!)

We have a policy that prohibits storage of PHI on mobile devices. We use a mobile device management software tool (MDM) that enables us to securely deliver e-mail, calendar, and contacts from our Exchange environment to iPhones and Android smart phones.

Must enforce passcodes, that is blocking and tackling/101 stuff. All too often you’ll see misconfigured policies for iOS / Android / BlackBerry that are missing that simple setting. Then you must encrypt. We are using a cloud service MaaS360 that segments the device into a personal and a business side. The solution has device encryption and very nice GUIs for policy management. You can deploy your own applications through the solution and it’s been stable. Cheaper solution compared to other MDMs.

DLP for flash drives and any data moved to a mobile device or external drive. The use of computers as kiosks in all patient care areas. These are locked down so that no data can be downloaded. Encryption on phones though this is a self-reporting/self-enrollment process at the present. By policy we require all portable devices to be encrypted. This is difficult to enforce on non-organizationally owned devices.

Currently only supporting Epic apps (Haiku) and don’t require UDID management. Rather we control by security (if you’re a provider, you can use). We just force 5 minute logouts and logout immediately upon exit. We are looking at bringing up policies for mobile management of any device that wants to connect to our Exchange as well. Should be live by end of year. BlackBerry Enterprise server offers these controls.

In the process of implementing an MDM solution, and evaluating DLP solutions.

If employees choose to store PHI on their mobile devices, the device must be protected by encryption and strong passwords; they must fall under central device management, which means we can erase the device, remotely and enforce password policies; and they must agree to declare a "lost PHI device" incident within 1 hour of first realizing the device was lost. Interestingly, we experienced one of these incidents recently. A physician reported his device lost, as required, and we erased it– everything on it. Later, he found it and was angry that we had erased his personal pictures and address book.

We are in process of rolling out a mobile device management strategy utilizing Airwatch. In addition, we limit the individuals and roles that can access particular information already (even a bit more granular/more tightly controlled than the typical role based access) with regard to mobile devices/apps.

Advisory Panel: What Technologies Are You Using to Reduce Hospital Readmissions?

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: What technologies are you using to reduce hospital readmissions?

Midas+

We currently have manual analysis and reporting processes in place to look at readmission reduction. However, we are talking with a number of vendors about solutions they offer. These vendors include our HIE, predictive modeling vendors (like Predixion), EHR vendors, and niche software vendors focused on supporting case management / continuum of care.

Unfortunately, this is currently done mainly through brute force, due to the outdated systems we have now. After our big-bang hospital go-live in March of 2014, we will have a very robust platform and tools to accomplish this through our EMRs. We are also collaborating with our state-based HIE to help in this regard.

The task is daunting. We have worked with the hospitalists and our owned practices to identify potential readmissions and aggressively intervene where possible with PCMH staff. No specific technology solutions except analytics/ reports that look for a variety of potential readmits such as late labs that indicate problems and chronic conditions requiring check ins to be sure the patient is compliant. It really is down and dirty outreach. I’d like to hear of a magic technology solution but I have not see one yet.

Our focus has been on leveraging our EMR and patent portal to make discharge instructions as clear and user friendly as possible. The rest of the process is very low-tech: follow-up phone calls to every family.

Other than standard case management tracking and the EHR, not much at the moment.

We have some simple but accurate, home-grown predictive analytics tools that risk stratify patients for readmission, but they are, for the most part, not that helpful in reality. It’s not the predicting that’s the hard part; it’s the intervention. You don’t need a sophisticated predictive analytics algorithm to realize that a post-CABG, 75-year old man with DM, living at home alone, is likely to be readmitted. Many of our patient profiles for high-risk readmission are that obvious, and even more so. The hard part is having the cultural will and clinical processes in place to intervene when we identify a high risk patient. It’s not rocket science. Many readmissions occur because of simple causes at discharge time or at home– surgical site infections, poor adherence to medications after discharge, poor discharge instructions, no discharge medications administered, etc.  In addition to the simple interventions at
discharge, patients come back to the hospital and ER because we offer them no healthcare alternative such as a skilled nursing facility, or family education or other assistance at home.

I believe it is mostly manual process that includes determining root cause of readmission (can’t afford prescription, can’t get to follow-up appointments, etc.) and then attempting to provide solutions at time of discharge.

We are using an electronic version of the LACE score that we developed in-house.

No special technologies… just good old fashioned time and attention. We make sure every patient has a follow-up appointment with their PCP or appropriate specialist. If they don’t have a PCP, we created a clinic specifically to take care of these patients (usually Medicaid or non-insured), and help transition them to an FQHC or similar.

Use of LACE index to identify patients at risk for readmission, alert generated on registration in the ED prior to the triage/clinician encounter, remote patient monitoring/telehealth.

We participate in various collaborations between physicians and hospitals looking at the outcomes of claims billing related to cardiovascular remittance  Technologies employed are interfaces and data analytics solutions such as Hyperion, SSRS, and Cognos.

The readmission programs from various randomized controlled trials. The technology that generally can or should support it comes from analytics platforms found either in the EHRs or possibly the HIE but often times is manual

Technologies is too narrow a question; however, keeping to your question we flag recent discharges at ED and clinic visits in the record so the physician can consider opportunities for intervening other than by admission. Total Care Management a broader, non-technology driven program (early follow-up, calls, home visits, et. al.) focused on congestive heart failure patients–a big cohort of readmissions in our environment.

Timely question. While we need to do what’s right for our patients, we are not ready to cut these out entirely as we need to accept as much business as we can as volume is down across the region. That said, we are evaluating this in the context of analyzing our position on Bundled Payments. Our approach is not all that sophisticated – focus is doing all that we can to identify high risk patients upon admission, using workflow technology to make sure someone will be paying attention, assigning to appropriate care managers and doing what we can to make sure they leave as healthy as possible, re-designing our dc summary output to be as comprehensive as possible and enabling dissemination via our CCD, secure mail, fax, etc – anyway our external providers want it! We are working on strengthening our post acute care relationships and determining how we incorporate our ambulatory care management programs into our pre-dc planning. Connecting the dots sounds so easy but is not pretty….

Good question… we are starting to utilize some ambulatory / outpatient case management strategies that can follow the patient via phone calls for high risk (for readmission) diagnoses. We utilize home health’s involvement whenever possible. In our service area, we have seen the biggest hurdles in avoiding high readmission rates is (a) did the patient get the proper follow-up with a physician and (b) did the patient get (or continue to take) his/her medications. Our patient demographics include highly seasonal farm workers, a high unemployment rate, low / no insurance coverage, and so forth.

Real time alerts when a Medicare patient is admitted to one of our hospitals, triggering rapid intervention by a health coach. Telephone for follow-up calls.  Encouraging patients to enroll in our patient portal to increase engagement.

Advisory Panel: PHI Stored in the Cloud by Clinicians and Employees

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: What policies or technologies do you use to prevent clinicians and employees from storing patient information on cloud-based consumer applications such as Google Docs or Dropbox? Have you discovered this happening?

By policy we prohibit moving PHI/PII outside our firewalls. Early on in using data leakage prevention type tools to prohibit. We do prohibit auto-forwarding emails. 

We use Websense for filtering all of our internet traffic – this includes blocks for sites like Google Docs and Dropbox. We also work to educate providers and staff on the related policies.

We actually had a reportable breach that involved Dropbox. We have developed policies and compensating controls (like random audits), as well as communication through our HIPAA office and inclusion in annual HIPAA training.

We block all file sharing sites. Google Docs have some interest but we have tried to direct all similar requests to internal, secure solutions.

We’re looking at Box, but haven’t done anything to block these sites.

This is almost certainly happening, but we have not been monitoring or preventing it in any systematic way.

Generally speaking, we’ve blocked nearly all access to file sharing services such as Drop Box and SugarSync. These services are opened on an exception basis only upon a justifiable request. We’ve implemented Mobile Device Management software to disable cloud based backup and photo streaming on iPhones and iPads to help prevent data from being stored off the network. We’ve forced password protection of connected device (tethered iDevice backups) to help secure our data.

Our "appropriate use of patient and employee data" policy defines the conditions under which the cloud applications can be used. For example, if a patient’s care is at great risk and using Dropbox will mitigate that risk, we allow for it and in fact, we encourage it. We have a corporate Dropbox account for his very purpose, which is very effective, particularly for sharing images. There’s no way you can expect the cloud applications not to be used. They are going to be used, especially by physicians who are tech savvy and see no other alternative to sharing data that is important to their patient care. So, with that realization, we’ve tried to put in place policies and corporate accounts that make it easier for clinicians to take advantage of the service, but do so with some degree of consolidation and risk reduction. We take the same stance on using Skype for remote consults with patients. For the ultra-paranoid and over-controlling CIOs in the crowd that freak out when they read this approach, they should remember that the data breaches which are plaguing healthcare are about simple sys admin passwords that have never been changed after install; unprotected thumb drives and mobile computers; and the insider that downloads data for resale. Worry about what matters, don’t worry about what doesn’t. That’s the key mindset to information security risk management, but we rarely hit the bullseye in healthcare.

We’ve seen this happen. We’ve blocked the ports so that they cannot use the consumer apps. We have also provided a secure cloud-based replacement for some of our staff that need to routinely share large files with others outside the organization.

Haven’t seen this yet.

I’m a physician, so we like this… shhhhh. 

Give them access to storage drive to network or give them access to private cloud for storage.

All are blocked on hospital network using a proprietary service (Websense? I’m a CMIO, not a CIO so I can’t recall all the vendors.) connected to our proxy. All PHI is available only over Citrix, no fat clients, so download would be screen by screen. Wireless Guest Network does allow connection to Dropbox, Google Docs/Drive, etc.

I think you would call our policy, "don’t ask, don’t tell". We are very concerned about encryption of laptops because we have had problems with lost devices, but so far we have not had problems with these publically-accessible cloud solutions … knock on wood. Therefore, our purely reactive leadership team has not made any pronouncements on this topic. I can’t wait to see what other responses you get so I can forward them to our leadership. Our sister organization has implemented an automated email "filter" that attempts to automatically identify patient-identifiable information included within emails and converts them to a secure messaging solution. Of course this creates so many problems that most people resort to Gmail to send their documents that are inadvertently trapped by the filter.

I don’t think docs even know these things exist!!!!!

Administrative policy prohibiting use of Cloud applications for sensitive data including but not limited to PHI.

Prayer,  and offering better alternatives. 

Policies for now, which are sub-optimal. Yes, it’s happening, and those who think it’s not needs to get their kid’s beach shovel and dig themselves out! We make it difficult by blocking certain known and popular file sharing sites, but it is imperfect. We have been evaluating technologies which have promise but struggled in a proof of concept. Could be a late ’14 initiative but more likely ’15.

These sites are blocked from access from our network. To date, we have not seen this occurring.

Advisory Panel: Physician Order Cost Tools

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: What IT tools do you use to help physicians make cost-effective decisions as they are creating patient orders?

Although our system allows us to create rules that would give the provider options for less expensive selections, we do not use that feature. The pharmacy already has an aggressive substitution policy and the thought of more alerts makes us concerned. I’d love to hear how others are approaching this.

Not as much as we should. We try to build our order sets in a way that makes it easy to make cost-effective decisions. In particular, we try to make it easy to use best practices and make it difficult to order unnecessary tests and therapies. But we haven’t taken the path (yet) of displaying costs next to drug orders, for example.

We have not been very effective in bringing utilization management to the physician ordering workflow. We’ve tried with mixed success to incorporate best practices embedded in Zynx order sets into the standard content, but our physicians have many workarounds to avoid using condition-specific order sets. 

We embedded a link and query tool in Cerner PowerChart to our charge master that allows physicians to review costs of medications, tests, procedures, DME, etc., with their patients in the exam room. In our organization, the charge master reflects our actual charges and reimbursements from the national insurance company. In the course of re-competing our Cerner contract, I asked the EMR vendors to build a prototype equivalent of the Amazon shopping cart in the EMR. That is, as a physician completes the order, the total cost of the order accumulates in the upper right corner of the EMR.  RazorInsights developed a prototype demo that was very slick. None of the other vendors could do it in the timeframe of the re-compete. Of course, because of the laughable situation of the charge master in the US market, it’s not a very easy thing to pull off in a real setting. But at least we could have the functionality in the EMR, waiting for the industry to catch up.

None at the present.

Rank diagnostics and medication choices in increasing order of cost.

Right now, only thing I can say is they can use UpToDate to help make the right choice. We are looking into the option of displaying price and/or cost-effectiveness indicators in the ordering panels. And as we start improving our analytics capabilities so we can better understand variance, I assume we will start using more protocols/pathways to help ensure the right test is ordered for a specific condition.

Having the cost of the ordered test may help…duplicate tests alerts on CPOE, trend value of labs viewable in the clinical summary tile.

[From a vendor member] As a revenue cycle management company, we use various reports to show physicians where they are adequately being paid for the services they render and where there are gaps in the way they bill claims.  We do this retrospectively and not real time as coding is a matter of physician choice.

Our primary interventions to help physicians make cost-effective, appropriate decisions for patient care are actually 1) our actual hospital formularies themselves 2) antibiotic stewardship clinical decision support embedded in electronic orders for antibiotics at some facilities 3) evidence based order sets standardized by diagnosis at the facility level that are designed with high quality, high safety, high reliability and cost effectiveness in mind. Not overly fancy interventions, but they have been successful and really these are truly the basics that everyone should be doing in every hospital in the world (even laggard facilities out there that are still stuck on paper based provider ordering can be making an impact in all three of these areas).

None, yet. We’ve looked at a tool from Nuance for imaging orders–I can’t recall the name. We’re planning a rebuilding of order sets (and I’ll sleep when I’m dead) with fewer options and more guardrails to make it harder for practitioners to deviate from best evidence based practice when available.

Mainly the lab flow from the EHRs and the imaging studies from the  EHRs to avoid duplication of tests already performed.

There are efforts to incorporate the cost of various medications and treatments in the drop down menus. These also include the efficacy of the various treatments. In study after study, we find that the order of the options in the menus is significantly influential in determining the selection. At least if options were listed by least expensive to most expensive (and include efficacy) they would be useful guides to choices

We have been live with CPOE for several years and took the traditional approach of using various third party content providers to provide some insight into the clinicians thinking as they were attempting to build their own content. This helped us move along but didn’t assist in aligning cost to outcomes during their ordering process. We looked at opportunities prior to live hypothesizing on how CPOE would reduce re-tests but didn’t have much support to evaluate post live to assess any benefits realization. For us I think it is a matter of how much time do we have to spend looking back vs. focusing on the road ahead. Perhaps a good example of the unintended consequences of the things that you don’t do given other various obligations (MU2, I10, Bundle Payments, etc.).

There is little support to physicians to ensure / suggest more cost-effective treatments via the EHR / CPOE process. We do provide order sets that have some element of cost consciousness in them, but that it somewhat limited in scope.

Standard order sets. Descriptive information on order screens showing relative cost "$", "$$", or "$$$".

Advisory Panel: Industry Publications Read Regularly

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time, suggested by an HIStalk reader: What healthcare IT industry publications do you read regularly? (please indicate whether you read online or by printed copy)

Prefer online. HIStalk, Radiology Today, Advance, Healthcare Informatics.

Healthcare Informatics, JAMIA, Gartner.

Healthcare IT News, ONC blog and website, HealthLeaders  Media, User conferences and Government Health IT, FierceHealthIT as well as HIMSS online groups. Your blog remains my favorite.

Aside from HIStalk, I don’t read too much directly online.  I get e-mail updates from ACHE, HIMSS, Modern Healthcare, CHIME, and Healthcare IT News that I skim through and might follow a story if it is a hot topic for me. I skim through magazines and journals from Modern Healthcare, ACHE, Clinical Innovation+Technology, and Health Data Management. 

HIStalk, of course! Online. Healthcare IT News,  online and get printed copy too. HIMSS  Newsletters online.

I read most major publications for our industry, including Hospitals & Health Networks, Healthcare Informatics, Health Data Management, Applied Clinical Informatics, CIO Magazine, Executive Insights, Healthcare Executive, Health Management Technology, InformationWeek, Journal of Healthcare Management (ACHE), AND Journal of AHIMA.

HIStalk, Modern Healthcare, HIMSS, Healthcare IT News, iHealthBeat. And about a million blogs. Everything is read online.

Your esteemed blog. Then HealthsystemCIO online, Healthcare informatics online, healthcareIT online, mobihealth news online.

HIStalk and a variety of other electronic publications.

Healthcare Informatics, CIO and Information Week (some HC coverage), Modern Healthcare, Advance for something or other in healthcare, and HIStalk, of course!

HIStalk is my primary (daily) read. I used to read several others but I can’t seem to find time to stay up with the amount of information available.  I generally peruse Health Affairs as well as Healthcare Executive.

HIStalk of course! Also Healthcare Informatics, Healthcare IT News, Beckers Hospital Review, Healthcare Advisory Board, and HealthsystemCIO.  I read online versions. In addition I get a pdf from Michael Lake on latest technology which I find very helpful.

All online: HIStalk suite of course, Computerworld, Informationweek,Wall Street Journal,CSO. Printed: Healthcare Informatics, Health Data Mgt, CIO, CMIO,Clinical Innovation + Technology. It seems like the analogy of drinking from a fire hose would apply here with all the publications that are available on-line and in print. I would really like to hear others’ perspective as to what pubs they monitor and target in order to stay current.

Other than HIStalk :)  FierceHealthIT (online), Healthcare Info Security ENews (online, with daily emails), 3M Health Information Systems (online), iHealthBeat (online), PHIPrivacy.net (online), and the HIPPABlog (online).

Health Affairs (online and print), Modern Healthcare (online and print), Government Health IT (online), Health Data Management (online and print), Healthcare Informatics (online and print), Healthcare IT News (online and print), Health Leaders Media (online and print), American Medical News   (online), For the Record (online), Information Week (online and print).

HIStalk of course, healthcare it news, Becker’s newsletters, HDM newsletters, Health Informatics technology.

HIStalk, Modern Healthcare’s Health IT Strategist, & Smartbrief all online. I receive a dozen or more paper publications that are placed in the department bathroom that I may flip through if the cover looks interesting.

Online – healthcareit news and blogs.

Modern Healthcare, Advance, Health Leaders, HFMA Journal, Health Data Management (all in print) Healthcare IT News (digital) and, of course, HIStalk.

JAMIA (online and printed), but that’s about all I have time for these days unfortunately.

I always read HIStalk online, healthsystemcio.com, and HDM printed edition. Sometimes other HIT publications from CHIME and others. The CHIME online newsletter has an app that makes it hard to read on my iPhone.

Fewer and fewer it seems.  I would say I routinely scan healthcare informatics, hospitals and health networks, and health data management.

HIStalk, of course.  I skim through the paper copy of Clinical Innovation + Technology (formerly CMIO Magazine).  I receive the email updates from iHealthBeat.

Health Affairs, Modern Healthcare, JAMIA, For the Record.  All print.

HIStalk (love it because we know you keep everyone honest); Healthcare IT News.

Healthcare Purchasing News and many security related pubs, both online and print. At work I prefer online pubs, but when reading at home, I prefer print.

JAMIA (print), JIMIA, (print) ,  the rest on line:  your stuff, i-health, fierce, AHRQ announcements, ONC advt for HIT.

HIStalk (online), Health Data Management, Healthcare Informatics, Scott Mace in HealthLeaders (Scott Mace has been writing in the IT industry forever. He wrote for InfoWorld circa 1980; I think the world of his reporting.) I also read Journal of AMIA, Applied Clinical Informatics (online only) and everything John Moore of Chilmark writes (online). Unless noted as "online" I get these on paper and mostly read them that way.

Advisory Panel: HIPAA Omnibus Rule

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: Are your organization’s executives paying a lot of attention to the HIPAA Omnibus Rule or is it just business as usual?

It has been difficult to get executive attention on HIPAA security topics in general. We are going to use the HIPAA Omnibus rule to kick start a new education and training program across the entire organization. We will start with executives first.

Pretty much business as usual.

No, or if they do, we are not aware of it, which is just the same. Business as usual — the yearly training from a hired overpaid consultant so we can check the box for compliance.

[vendor member response] We are paying a lot of attention. As part of a recent acquisition, we are now part of a larger organization that is working to extend coverage of HIPAA, HITECH, and the BAA more broadly.

Business as usual.

It’s primarily business as usual, however, there are some provisions of the rule that may require us to revisit many of our third-party contracts. That has the potential to be a major endeavor, so it is something we are evaluating now.

Business as usual.

IT executives are because we are also on the hook for data security. The ability to not share data on specific encounters defined by payer type (insurance vs. self pay) concerns me a lot. I am not sure the HIS/ EMR/ EHR vendors are ready. I can’t say any of our other executives have even read a brief on the Omnibus rule.

[vendor member response] We are very concerned about the increased risk/liability for breaches. This is a big concern when using contractors. Our clients are not knowledgeable about the changes and truly not focused on it at all. On the ambulatory side of things, practices, even larger ones, are so swamped with EMR/EHR, and revenue loss from managed care that they consider HIPAA a done deal.

No. They are not at all, even after several attempts to raise awareness.

The organization is ignoring the rule, but the expectation is that IT and HIM stay on top of it. I don’t have a problem with that and so IT/HIM are finishing up our changes in order to comply.

We hired a CISO out of the military with a background in technology security. She makes sure the execs are paying attention. We have a team that consists of privacy officer, corporate compliance, audit, and CISO. They meet regularly to address all aspects of HIPAA and HITECH requirements including education.

It is business as usual with no real interest from the senior team or the board.

Our Privacy & Security Officer are, and they’re slowly getting the attention of leadership. We addressed a lot of the changes in the proposed rule, so we don’t have as much to address as we would otherwise.

Business as usual.

[vendor member response] Within our customer base I am seeing customers starting to pay attention to making sure all BAAs are updated and signed. However, I have had a couple of folks tell me there is no ‘hurry, since we have until early fall to totally comply.” I personally am not hearing of any urgency to meet the rule within any conversations I am having at the executive level. I am hoping that urgency is there just not being expressed to me!

Business as usual.

Some attention — trying understand implications…

Except for Compliance, Legal, and IT, it hasn’t had a lot of attention. Many vendors, especially small to mid-sized cloud hosting vendors, have not fully realized the implications.

Appropriate attention has been paid by those over that area.

Our executives have reviewed the rule to see where we need to comply and what actions to take.

Yes.  his has been an agenda item for our executive-level compliance, privacy steering committee. As a result we’ve modified our business associate agreement, are in process of rewriting notice of patient’s right to privacy, same with data breach evaluation criteria.

Just business as usual.  Haven’t heard it come up even once.

Business as usual.

Business as usual. We are overwhelmed right now with MU and NCQA. So many regulations, such limited staff to execute.

If anyone is paying attention to this, it is hard to tell.

More of business as usual. The interpretations and evasions are so vast and pandemic that it more of a series of workarounds than a policy.

All with active BAAs are being touched. Mail-merged form letter, follow-up phone call, lawyer letter if still no response.

Advisory Panel: Recent Vendor Experience

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: Can you describe any notably good or bad experiences you’ve had with a  company in the last three months?

Athenahealth

The best has been athenahealth so far.

Dell

Dell SecureWorks managed services. I’d suggest any IT department lift some burden off their security person/persons by letting someone else watch the logs and manage the firewalls. Then the security people can audit the systems and investigation anomalies. 

Harmony HIT

We are working with Harmony to install their Health Data Archiver tool. We are using it to archive data from legacy clinical and financial systems that practices we’ve acquired used to run on.  I wish we’d found it several years ago because it would have avoided a ton of headaches, met customer needs better, and done it more cost effectively.

Impact Advisors

Doing some great planning work with Impact Advisors. They have some good experience in the Epic world.

KLAS

Notably good experience with KLAS and their evolving assessment of the BI/analytics market.

McKesson

We have done a lot of interface work with McKesson over the last three months. They are implementing an EMR at a seven-hospital system and we are working through interfaces with them as each site goes live. They have been wonderful and very helpful. 

NetApp proactively proposed to conduct an end-to-end assessment of our storage environment. Their assessment surfaced a number of gaps, some of which were critical and urgent, needing increased attention from our technical management. It was refreshing to see a storage vendor looking out for our best interests and taking a proactive approach to service. By focusing on NetApp’s recommendations, we likely avoided some major problems that could have affected availability of EMR production and other critical systems.

NextGen

Hands down my worst experience has been with NextGen, especially their billing "Practice Solutions." 

Advisory Panel: Handling Information Overload

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time, as requested by a reader: How do you manage information overload about new devices, new software, and new services?

"Make the users producers." A good way to keep up with all the new stuff is to engage end users in affinity groups to bring forward their recommendations within a context of a strategic plan. Personally, I keep abreast of new stuff through conferences, reading, talking with physicians and clinical staff, and occasionally meeting with vendors.

It is a zero sum game and always something-else has to give. Like not going to the gym as much or sacrificing some extra time with the family to go to an extra meeting in the effort to stay in the know how. Or reading “Medical Economics” instead of a fiction novel hoping that it will pay off someday by making a smart decision or help  someone else making a smart one for an organization. Or reading your blog instead of watching a show on TV because your blog is so much more fun.

If I’m not talking or listening, I’m reading constantly, 16 hours a day. HIStalk is a very important source of news — very important. I also watch the Advisory Board, Chilmark, and Circle Square. Twitter is a great source of news because of its brevity with links to more detail.

The amount of information we get is absolutely insane! We have taken a formal stand on this. We split different areas up and made them the responsibility of individuals. For instance, one person reads up on new devices, another person reads up on new software, another on new services. Everyone knows who is responsible for which area and forwards pertinent information to them. Once a month, we do an update with each person reporting on what they feel is important. This way, we are all not drowning in e-mails, snail mail, webinars, and conferences. We even split up at HIMSS and AHIMA to explore our own area of update responsibility.  It works for us and no one is overwhelmed with trying to sort through it all.

I try to first see what the demand is from our end users – what are they asking for and for what purpose is the technology needed for? After that I  generally look at KLAS reports to see opportunities to identify best of  breed and go from there.

I make sure to keep my popular blogs to a mall number and read them when time permits. That  is mainly on the weekend or while eating breakfast.  ;)  Boy Genius Report and others on device/mobile. HIStalk on the HIT front, of course! 

We have an Enterprise Architect. Among other things, his job is to stay ahead of new technology and evaluate what might work for our organization and just as important what technology to stay away from. He has a budget to acquire new technology and test it with small pilots (usually using the IS department.) Anytime I get an interesting e-mail (which is rare) regarding new technology, I send it to him for evaluation. I always tell him he has the best job in the organization since he gets to play with new toys.

We let the information enter our consciousness, but only do deep dives if we have a need for a solution or a product replacement or if someone tries to buy something and they need our opinion. It is a never ending task and the first step to not losing your mind over it is to admit it is a never ending task!

(sigh) I don’t have a good answer for this issue. The best I have been able to come up with is regular networking with peers. I tend to target the items that will meet the needs of my current business problems when conducting research. Networking gives me the opportunity to hear about solutions that others have used for problems I have not yet experienced.

Just try to keep from drowning. It is nearly impossible.

You can’t read everything and we focus so much of our time on making sure what we read, communicate, and do is based on quality data. The healthcare space is changing very fast we have to keep up.

We don’t face this issue as frequently as you might expect  However, we rely on our staff to relay back to leadership the market trends – which we in turn take great effort to communicate back to the balance of the client facing staff.

Personally, I will always try something and if it makes my life easier quickly (e.g. within the day), I will stick with it. If it does not, I will move on. At the group level, we are careful to introduce new technologies and do lots of vetting and prototyping to make sure that when we roll it out we have a clear reason to do so and there is a clear ROI to the users.

I listen to everybody and look at anything that any colleague tells me is worth a look — that’s a look, not usually a meeting. Search Twitter, G+ and Google generally for any discussion about that tech.

I am sorry; what did you say? I was too busy checking my iPhone and didn’t hear you. 🙂

Advisory Panel: Hard-to-Fill Positions

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: What positions have been challenging to fill and what creative techniques have you used to fill them?

Many positions are hard to fill.  Some good people have moved into consulting. There is an absence of candidates with desirable skills and experience or expectations applying for some of our positions such as EHR analyst and project managers. At times we have hired strong end users and trained them as one source of talent. 

Medical assistants, receptionists, nurses, all the forgotten heroes down in the trenches without whom a medical office cannot function. They are harder and harder to find as we expect them to: be nice to patients so we do not ruin our Press Ganey scores, learn and operate new billing and EMR systems on the fly, multitask, cross train, be loyal, be health IT and coding experts, show up for work and help see ever more patients, all for almost minimum wages of $9 to $10 an hour at times. All while an EMR vendor, IT consultant, medical device seller, and reseller makes triple the amount of money and not that anybody would miss them if they do not show up for work. ACO stands for " awesome consulting opportunities" and while I am happy that the healthcare reform provided ample employment opportunities to these armies of consultants, the real value in healthcare still gets delivered by those other people… They are grossly underpaid and under-appreciated.

Clinical Analysts for configuring Cerner and Data Analysts. We hired a coder from medical records with a background in computer science to fill the Cerner Analyst position. It’s working out very well, especially since we are reducing our coding staff because of simplification of our reimbursement rules under bundled payments. To fill the Data Analyst positions, I dipped into the finance industry and paired them with a healthcare domain mentor on the data analysis team.

We’ve had challenges filling most of our IT analyst positions. This includes those focused on application development, support, etc. and networking and infrastructure. We’ve started to do some recruiting at college career fairs and looked at a broader market to reach out to.

We have had some degree of difficulty finding programmers and developers that know Delphi and understand healthcare. We will hang on tight to the ones we have because of this. It seems that if someone knows Delphi, they have no idea what an EMR is our how an interface works.

The most challenging this month have been those that actually can understand an implementation plan – not necessarily even having done many as much as someone understanding workflow between the various clinician groups. Individuals are now seeming to get siloed into various career skills and  this could get dangerous as we move forward into unchartered ground.

Where I sit on the tech side, programmer/developer positions. These are the people on your development and interface team that can actual program something from scratch.  Not, oh I know Sharepoint, or I can "read" Visual Basic, C#.  I mean, here is a business process that is junk, go develop a solution based on a platform and programming language. We never have enough of those people and they are so good, the ones you do have get sucked into building templates/screens for your CPOE or outpatient EMR. To fill those positions… man. That’s a tough one because in our organization HR will not work with us on these hard structured pay bands. They treat everyone like a nurse or a millworker. They also have an equation for how much a person should be paid and it’s based more on
age/seniority that experience. When I hired an oracle DBA out of another industry, he wasn’t making that much, but he was older. The equation said I should pay him over $20k more than what he wanted to jump into our org! That kind of stuff is frustrating. So, I would say have an HR department that will work with you on recruiting talent via well-structured pay packages. Also, remove any of those pesky gaps in insurance coverage for when a person starts. Our HR department would make everyone wait 90 days before their medical coverage started. That means all of your new hires have to purchase COBRA for 90 days and that’s almost $700 per month in some cases. 

Anything Epic is a real challenge. We’ve taken the Epic approach to recruiting. Rather than trying to find people with Epic certification or using high-priced consultants, we started a "grow our own" program. We’ve contact local colleges and were able to get access to seniors in engineering, science, and math with GPA of 3.5 and above. They are bright, motivated, and cost about half of a seasoned Epic resource (including certification). They also receive a retention bonus if they stay for a specified time. This program helps with the "brain drain" of the local economy and adds more Epic resources into the national mix. We also don’t have to worry about running afoul with Epic’s non-compete with the existing talent pool. A second program is with a local consulting company that wanted to develop an Epic practice. In return for sponsoring some of their consultants, we received a 50 percent discount on the certified resource and a right to hire after six months. The consulting company paid for all certification training. Lastly, we recruited and hired a CMIO last year. Since everyone has their own definition of CMIO (including the candidates), it took about a year before we found the right fit. As a CIO, I think the best approach is to use the recruitment process as a succession planning process for your job.

None have been a challenge. We have actually reduced our staff by 15 percent since January for cost restructuring purposes.

Database administrators have been the hardest to fill as there are no training programs available locally and very few people have an interest in it. This isn’t very creative, but we found a vendor that specializes in remote database administration at a very reasonable price (a lot cheaper than having an employee). Their team is primarily offshore, but the management is stateside. We have a hard time with project management for the same reasons as above. Again, not a creative solution, but  we are training all of our analysts in basic project management skills and working on standardizing project management for our organization.

Developers and HL-7 experts. Lots of folks with average skills, but few with an inquisitive mind and in-depth skills. Hard to find technical pros with a "healthcare mindset."

Finding the really good Epic consultants to work on projects is the biggest problem. There are so many substandard folks that the expectations have been lowered. We are finding that education is the best medicine to our customers to help them understand to wait for the right person or to set their expectations to a level that they will understand what they are getting. Furthermore the staffing companies who feel they can provide all the staff for the project are doing an injustice to their customers and further damaging the space at this difficult time.

We are a software sales organization. Our greatest challenge is finding good sales people dedicated to thoughtfully selling our solutions. We’ve found that hiring friends of current employees is the best way to find good, competent people.

I think having a good EMR analyst / trainer / optimizer is always a key position. We have had success by looking from within.  The typical person will be a recent college grad who has worked at the front desk in one of our offices for at least 6-12 months. This gives them an understanding of healthcare, as well as the experience of our group culture, while also giving us an understanding of their skillset. They need to have the type of smarts that means they can figure things out when we don’t have the right answer, and they need to have they type of personality which can get along with busy doctors. They enjoy having the ability to extend their career skills and most stay several years. 

Telecommunications manager who is more than a functionary; who understands the urgency for improving clinician-to-clinician communication. Asked our various telecomm vendors who were the best folks fitting that description in the region and hired one who was under-valued where they were then working.

EMR analyst jobs have been the hardest to fill. Our best success in filling these roles has been recruiting internally within our hospitals and medical group and investing in training and experiences to transform them into new IT roles.