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Readers Write: Supply Chain Data Meets Clinical Outcomes: The Holy Grail

November 11, 2015 Readers Write No Comments

Supply Chain Data Meets Clinical Outcomes: The Holy Grail
By Andy Cole


The term “Holy Grail” has always been intertwined with stories of epic searches to find the Holy Chalice used at the Last Supper. From Dan Brown’s bestselling novel “The Da Vinci Code” to the always entertaining Spielberg/Lucas film “Indiana Jones and the Last Crusade,” fans have been drawn to the idea of finding something so elusive…so mysterious….so game-changing.

When I think about what it will take to dramatically change the cost, efficiency, and effectiveness of our healthcare system, the solutions too often seem as unattainable as the Grail itself. It dawned upon me that the “search for the Holy Grail” is a perfect metaphor for the ongoing efforts to deliver high-quality, medically-necessary and cost-effective healthcare across this country and beyond.

But as I think even deeper about the dilemma, I realize that the healthcare providers who are charged with solving this crisis already have the tools they need to do so. It’s at the tip of their fingertips. Literally.

For decades, healthcare providers had been in the dark about how much it cost to deliver their services. More importantly, thanks to inefficient reimbursement models, they really didn’t need to know. As long as payers (both private and public) paid them based on how much they charged, there was no incentive to truly understand those costs, and in turn, wrangle them in.

Soon, payers and policy makers realized this model was unsustainable and changes started to happen. Once they understood that reimbursement was driving care, they realized the only way to drive lower cost of care was to reduce reimbursement. With less money coming in the door for their services, healthcare providers had to undergo a paradigm shift. They had to cut costs wherever they could to meet the thin margins that were now in the marketplace. Efficiency was the name of the game, and classic cost-reduction strategies entered the arena.

Cut throat supply competition and Group Purchasing Organizations began playing a huge role in offering the lowest possible prices for supplies and bringing economies of scale to healthcare providers. CFOs began paying attention to how many supplies were being purchased and at what price. With a keen eye on the bottom line, cutting supply expense was usually low-hanging fruit that met their cost-saving objectives. With this need came slick analytic tools that aggregated supply and service spend data and clearly suggested areas for savings, whether that be utilizing a less-expensive vendor or taking advantage of a GPO contract.

We have fallen into our current state of “quality data” as an unintended consequence. Providers had historically focused on collecting data for every service they performed in order to receive maximum reimbursement from various payers. More services =  more money. As a result, claims data was serving only as an excellent vehicle to capture charges and little else was being done with it. As the environment shifted, and reimbursement focus shifted from fee-for-service to pay-for-value, the industry didn’t have to look very far to find the data they needed to analyze.

Since charge data provides a detailed representation of all of the services rendered in a healthcare facility, it was a logical next step to begin analyzing a patient’s data holistically, rather than just from an episode by episode basis. Payers and providers could now longitudinally piece together a patent’s entire health record and use it either increase reimbursement for positive outcomes or decrease it based on negative ones.

When the government bought in and incented providers to use certified EHRs, this only increased the amount of data that was collected. That’s where we find ourselves now — swimming in a sea of healthcare data. The objective now is to harness the power of data and take that next step to uncover new solutions to our cost problem.

With the right tools, we can now take a look at clinical outcomes and supply cost together, whether that’s for an individual patient stay, across many for the life of that patient, or all patients. For the moment, I’ll put myself in the shoes of the CFO of a multi-facility IDN.

Taking a deeper look at a cardiac rhythm management supply analytics reports may suggest that I could get a better deal on my pacemakers if I buy them from a vendor named Jolt instead of my current vendor, KickStart. In fact, with my agreement that I just signed with my GPO, I could save upwards of 20 percent this coming year if I convert to Jolt. A quick review online of Jolt products show no red flags. My chief cardiologist has heard good things and gives me the go ahead. I sign the deal and warm up my calculator to count my savings.

My argument is that there is a crucial step missing in that process, the one that takes into consideration the universal value of making that conversion. Having access to quality and outcomes-based data allows me to cross-analyze the cost of the new pacemakers with the outcomes of patients that use them across my facilities. Perhaps I would save 20 percent on them next year, but I see that patients who have them have higher readmission rates, which would result in Medicare penalties and reduce my reimbursement.

Additionally, I am now taking on risk for my patients because of the Accountable Care Organization arrangement we have negotiated with a major private payer. My goal is to deliver the highest quality care at the lowest cost. The payer gives me a set fee for each “covered life” I take on. If a patient utilizes an over-abundance of services in my network, I will most likely lose money on them. However, if I keep them healthy and can avoid expensive treatments and services, I keep anything left over from my payment. Since data is telling me that patients with Jolt pacemakers are twice as likely to take a costly trip to the ER than those with KickStart’s, I will take a much harder look to determine if that conversion truly makes sense.

With this “Eureka” moment fresh on the minds of healthcare CFOs around the country, they are now tasked with changing the paradigm of purchasing. Marrying clinical outcomes and supply chain costs takes new tools, a new culture, and a new vision. It is an essential shift that will help providers and payers stay financially solvent, and in the end, keep the patient healthier.

Our industry has the information we need to make smarter purchasing decisions. We just need to act on it. We actually have an advantage over Indiana Jones, who traveled the globe searching for his Holy Grail. We already have the Holy Grail we’ve been searching for at our fingertips. All we need is to look closely, smartly, and polish it to a glittering shine. This is a game changer.

Andy Cole is national director of PremierConnect Supply Chain solutions at Premier,Inc.

Readers Write: All Aboard the Analytics Train! Next Stop, ROI!

November 4, 2015 Readers Write 2 Comments

All Aboard the Analytics Train! Next Stop, ROI!
By Jeff Wu


HIStalk-ers may be familiar with Zubin Damania, MD (aka ZDoggMD), a primary care physician turned health pop star. ZDoggMD has been featured on TED and produces parody videos on YouTube of our dysfunctional healthcare system.

Dr. Damania’s videos are loaded with hilarious and witty lyrics with often deep and powerful commentary on what it’s like to practice medicine in the US. His most recent video pokes fun at EHR implementation and highlights a laundry list of relevant complaints about what EHRs have done to negatively impact many providers’ care of patients. Dr. Damania’s criticisms aren’t so outlandish as to propose going back to paper, but he does make the case that we need a new and better EHR environment.

While he makes a valid argument, we also need to consider that the greatest value that EHRs provide has barely been touched.

As of September 2015, CMS’s Meaningful Use program has doled out approximately $31.6 billion in incentive payments for the adoption of Certified Electronic Health Record Technology (CEHRT). While EHR implementations have proven valuable immediate effects — such as reduction of adverse drug events and medical errors — it would be difficult to make the case that these benefits would provide the magnitude of ROI necessary to justify their costs. CMS’s own projections and several post-MU studies have demonstrated that the types of immediate benefits achieved from CEHRT will recoup only a fraction of the MU program’s cost.

What gives? Why would CMS knowingly implement a program that they knew would not provide the immediate ROI necessary to pay for its implementation?

The intention was never to achieve ROI purely on efficiency gains, optimized billing, or reductions in medical errors. What CEHRT provides is data – to an unprecedented degree.

The real value in CEHRT is the way we are getting insights into how disease and injuries progress and react to treatments. The vast volumes of data mean that we are seeing things in novel ways for the very first time. Advances in both hardware and software means that the old days of manual chart abstraction or fragmented tables in antiquated or siloed databases are being replaced with dynamic analytical platforms that can be leveraged cheaper and more effectively.

Analytics is the way to ROI and the industry is finally moving to embrace this. Several industry reports are already seeing an influx in investments into analytics. Big tech players including Google and Microsoft predict healthcare analytics to be a key area of growth over the next few years.

This is a logical next step in healthcare’s technology maturity that we’ve been talking about a lot, even here on HIStalk. While analytics is a hot topic, who it benefits is surprisingly overlooked.

Our discussions of ROI have to be with our end users in mind. Analytics offers us an important opportunity to re-engage our disenfranchised healthcare workers. Our doctors, nurses, pharmacists, and desk staff all have contributed to the data we now have. They should be the ones to chiefly benefit from the coming data harvest. I have yet to meet a doctor or nurse who didn’t have a dozen questions they knew could be answered from data within the EMR, but did not have the tools to do so. That simple fact should be both a mark of shame and a call to action to every health IT worker.

We are on the verge of shifts in practice that can be truly groundbreaking. The information revolution started by the dot-com boom in the 1990s paved the way for companies like Amazon and Zappos to transform whole industries. These adoptions of technology and analytics are being implemented by other sectors at an even faster rate (Uber, Airbnb, Square). If we in healthcare can embrace the power of analytics and purposefully drive their output to end users, we can start tapping an endless supply of ROI.

The optimism behind analytics does not diminish the challenges the next evolution in healthcare information technology will present. All the “big data” and “data governance” buzzwords are valid, but not insurmountable, and the insights we stand to gain are priceless.

The next buzzword is already circulating—closed-loop analytics. It’s the intentional, purpose-driven effort to get analytics to end users for decision making as near to real time as possible. It’s the attempt to engage end users to a degree that the outputs of our analytics serve purposeful functions in their actual practice rather than a retrospective review of what’s happened.

This progression in healthcare technology is the necessary (and hopefully welcome) change that can make the biggest difference in rejuvenating our staff and demonstrating some much-needed value.

Jeff Wu is a population health researcher with UW Health at the University of Wisconsin-Madison.

Readers Write: Financial Health of Patients Is an Afterthought

November 2, 2015 Readers Write No Comments

Financial Health of Patients Is an Afterthought
By Jonathan Wiik


Most healthcare providers offer exceptional levels of care to their patients. After all, we patients expect it. But what most patients don’t expect is the rising cost of healthcare, and unfortunately, financial health is often an afterthought for both parties.

The average deductible for a single person enrolled in an employer-sponsored health plan reached $1,217 in 2014, just under a 7 percent increase over the previous year, says a 2014 study published in JAMA. What’s more, the Affordable Care Act (ACA) Bronze Plan—the new 2015 HDHP (high-deductible health plan) entry plan for patients—establishes its average annual deductible at $5,203.

By 2019, providers could see a 50 percent increase in the amount of revenue requiring a collection from patients. Of that amount, 30 percent (as much as $200 billion) will be written off as uncollectable, according to estimates from Citi Retail Services, a division of Citigroup. Among households with incomes over 400 percent of the poverty line, almost half cannot afford the higher deductible amounts.

For these reasons, many healthcare consumers are reluctant to pursue adequate and timely medical care. The fact is, they simply cannot afford it.

Consider these facts:

  • A recent report issued by the Consumer Financial Protection Bureau (CFPB) found that medical debts account for a majority of debt-collections actions appearing on consumer credit reports.
  • An earlier Kaiser Family Foundation report found that one in three Americans struggle to pay medical bills, in spite of 70 percent of them being insured.
  • Unpaid medical bills are the highest cause of bankruptcy filings, outranking both credit card and mortgage debt.
  • Once in debt, many people may delay or forego other needed care to avoid incurring further unaffordable medical bills.

The number one complaint from patients typically concerns confusion with their medical bills, an issue that could be alleviated with proactive, data-rich discussions on the front end of the cycle. Accordingly, financial clearance—an industry term—is gaining momentum. Screening patients for eligibility under their insurance plan, confirming benefits are payable for the services they are about to receive, and ensuring they can afford to fund their out-of-pocket costs are paramount processes that should occur as early as possible.

Similarly, 501(r), a component of the IRS tax code covering not-for-profits, is garnering a lot of attention. The rule, which takes effect in January 2016, requires that not-for-profit hospitals demonstrate the effectiveness of their financial screening for charity programs, among other initiatives.

Additionally, under certain provisions in the law, providers must offer charity care to qualified patients and refrain from pursuing aggressive collection actions for those who would have otherwise been eligible. Documentation of charity assistance, processing, discounting, and collections must all occur prior to billing.

From a high level, financial clearance helps ensure three important things:

  1. That patients are paying within their financial means and are receiving financial assistance where possible.
  2. That providers and government programs are maximizing their scarce resources for charity and other programs.
  3. That bad debt, bankruptcy, and collection issues are reduced for provider and patient alike.

A patient’s financial health is becoming increasingly important in healthcare. Providers, for their part, must ensure that they have sophisticated tools and workflows to put both parties on the same page from the start.

Jonathan Wiik is principal consultant at TransUnion Healthcare.

Readers Write: ICD-10 is a Win for Patients

October 21, 2015 Readers Write 4 Comments

ICD-10 is a Win for Patients
By Ken Bradberry

There has been conversation about how the ICD-10 transition will impact unsuspecting patients. Maybe a procedure is delayed due to an inaccurate code or a bill is incorrect. These things will almost certainly happen. While the first days have gone by without significant disruption, it is inevitable that bumps will occur, as with any major technological implementation.

The real story is how much patients have to gain from the transition. ICD-9 was over 30 years old and didn’t keep pace with the dramatic advancements in the healthcare industry. Consider this short list of examples:

  • Laser and laparoscopic surgeries were not performed at the time ICD-9 was implemented, but are common medical techniques today.
  • Treating a heart attack 30 years ago was generally limited to medications to treat pain and an irregular heartbeat. Today, doctors can quickly evaluate what is causing the attack and treat accordingly – bust clots with new drugs, insert a stent to prop open a narrowed vessel, even sew new vessels into the heart during surgery.
  • The first HPV vaccine approved by the FDA in 2006 has significant potential to prevent cervical cancer and is widely recommended by the Centers for Disease Control and Prevention for girls and young women.

This is just the tip of the iceberg in terms of how far medical advancements have come in the last 30 years. There has also been significant change in our health with newly discovered medical conditions and the rate at which diseases are diagnosed. For example, the CDC reports melanoma rates have doubled over the past 30 years, but chickenpox cases in the United States have dropped sharply since the vaccine became available in 1995.

Clearly the healthcare landscape today is almost unrecognizable from where it was 30 years ago. Patients have different healthcare concerns and conditions and have many more options for prevention and treatment.

ICD-10 has about five times as many codes as ICD-9. The codes are much more specific in describing a diagnosis and treatment plan, allowing for providers and payers to have a more detailed and accurate conversation about a patient’s care. This will not only improve accuracy of statements and bills received by a patient, but also improve health safety and outcomes.

Here is an example of ways a patient may benefit from ICD-10 throughout the healthcare experience:

  • Diagnosis. During a routine medical exam, a spot is detected on a patient’s lung that requires additional investigation. The healthcare provider orders a series of procedures that require ICD-10 coding to be completed. Because ICD-10 codes are more granular, scheduling the procedure with the right resources is more likely, and therefore a more accurate and timely diagnosis is possible. The precision offered by ICD-10 will not only lead to a more precise diagnosis, it will also provide the provider with more insightful information to guide treatment plans.
  • Eligibility determination. This same patient has health insurance which requires testing, procedures, and treatment to be authorized. The ICD-10 codes provide the payer more specific information on the services being provided, which can result in a timelier eligibility determination. This can avoid unplanned cost to the patient and frustration working through a billing issue.
  • Quality outcomes. Improved clinical documentation under ICD-10 will help reduce medical errors and also lead to more meaningful discharge data that can help reduce readmissions.

In order to quickly navigate the hiccups caused by the massive transition and quickly get to the point where patients are experiencing real benefits, it’s critical for all stakeholders involved in the delivery of care to choose a partner who can successfully lead them through the complexity of ICD-10.

Ken Bradberry is chief technology officer of Xerox Commercial Healthcare.

Readers Write: The Benefit of Price Discrimination

October 21, 2015 Readers Write 2 Comments

The Benefit of Price Discrimination
By James Foster


In his Monday Morning Update for 10/12/15, Mr. HIStalk first affirmed the effectiveness of the market in selecting among EHR vendors. Later, in response to a price survey, he expressed frustration with disparate costs of services, saying, "I still don’t understand why providers shouldn’t be required to offer their lowest prices to everybody." His complaint here is with what economists call "price discrimination.”

There are two general justifications for price discrimination: (1) differences in costs to the seller and (2) differences in value to the buyer. Cost differences may explain things like quantity discounts, since even if the widgets cost the same to produce, the marketing and sales costs are less if the seller has to deal with fewer buyers.

Even with the same quantity of what seems to be an identical product or service, there may be hidden costs that can justify a difference in price. For example, the price for a television purchased on credit in a poor neighborhood may be much higher than the price for the same model paid for in cash at a suburban Costco. Here the product is not just the electronics, but also the transaction costs involved in offering credit to poor-risk buyers.

Differences in value to the buyer are no less real and can be justified as a way to ensure that the goods are available at all. Most of us are familiar with the fact that adjacent passengers on the same flight can pay very different prices for the trip. On the one hand, this seems unfair ("I still don’t understand why providers shouldn’t be required to offer their lowest prices to everybody"). On the other hand, it is often the case that if everyone were charged the same price, the product or service could not be supplied at all.

That is, if the airline ticket prices were uniformly high, fewer people would make the purchase and the total revenue would not be sufficient to cover total cost. Likewise, if prices were uniformly low, the planes would be full (aren’t they already?) but the total revenue still would not be sufficient to cover total cost.

In order to provide air travel, airlines must segregate buyers into those that place lower value on the trip (vacationers who could drive or choose a different destination) and those that place a higher value on the trip (business travelers). This discrimination serves to benefit travelers who would not make the trip unless they still have some value over the price.

Healthcare providers face similar challenges as airlines: capital costs are high and marginal costs are low. Yet charging everyone the same (high or low) price would not yield enough revenue to pay for the equipment and staff. Therefore, quantity discounts are offered to large groups (represented by credit-worthy insurance plans) who can take their business across town, while unknown individuals who buy on credit typically face higher prices.

If this still seems unfair, before calling for more government regulation through price controls, we should investigate how government regulation might be contributing to problem. There are a few areas in healthcare where prices are standard, published, and declining over time, such as Lasik eye surgery. These typically are procedures where the consumer is responsible for the full price of the service and takes time to investigate before making a purchase.

Instead of imposing price controls (which have been disastrous in a variety of industries), we should look for policy changes that encouraged more consumer involvement and responsibility.

James Foster is director of operations for GemTalk Systems of Beaverton, OR.

Readers Write: No One Likes the Waiting Game

October 21, 2015 Readers Write No Comments

No One Likes the Waiting Game
By Janie Tremlett


No one likes waiting in line with seemingly no information about when the wait will end, especially when sick or nervous about seeing a doctor. The frustration doesn’t end when you’re called out of the waiting room. Need to get vital signs captured? X-rays taken? Blood drawn? Most likely each of these steps occur in different locations and with different practitioners.

Confusion on the part of the patients about where to go and who to see, combined with staff confusion about where the patient is in the process, can make for a less than optimal experience for both the staff and the patients. In an age where providers’ revenue is contingent upon their patient satisfaction scores, managing patient flow and delivering a superior patient experience is more important than ever. A few ideas …

Intelligent Patient Queuing

Average wait times by provider or facility can be displayed on queuing display monitors and can be updated dynamically when a patient is called off the queue. For added convenience, patients can be summoned off the queue in method that is preferred by them, whether it be via an SMS text, an email, or a phone call. They don’t have to be tethered to a waiting room chair waiting for their names to be called. Instead, they can grab a bite to eat in the hospital cafeteria or take care of any other issues.

Patient and Family Preferences

It sounds simple, but it cannot be emphasized enough: patient demographics need to be understood. Patients in waiting rooms are often anxious and sometimes frustrated if they’ve been waiting there a while. Giving them a way to keep busy while they wait, over and above the typical waiting room magazines, can go far. Providing toys and games to children in a pediatric waiting room setting makes sense, but how many waiting rooms have you been in that provide Wi-Fi for adults? Likewise, offering entertainment infotainment that is pertinent to a certain demographic — like screening live athletic games in a sports medicine office — would resonate with patients.

Patient Communications

We can expect, if you haven’t seen it already, a significant expansion in regards to mobile communication within healthcare. One of the benefits of this expansion is the new ease it brings in communicating with patients. Providers can send reminders about appointment dates and times to patients via SMS as well as give patients insight into expected wait times pre- and during service. Affording patients the ability to communicate to their providers in this same way is key. When a patient can easily and conveniently communicate any delays or early arrivals he or she is experiencing, the hospital staff can then re-route that patient or other patients to accommodate the change in schedule.

Real-Time Dashboards

With real-time reporting and dashboards, staff can track a patient’s whereabouts and status at any point as well as the time spent in each location. With this information, hospitals and other providers can identify any breakdowns in processes or bottlenecks in certain departments so adjustments can be made quickly. If patients routinely spend too much time waiting to get their blood drawn, staff can be reassigned to the lab so more patients can be seen. Likewise, if a patient is waiting to see the doctor but the doctor is running late, the patient can be directed to the lab to get blood work done if there is availability there.

Way-Finding and Patient Tracking

Way-finding, real-time location systems (RTLS) technologies, and Bluetooth beacon technologies are rapidly becoming part of hospital IT infrastructure. Within the hospital, geo-location services hold great promise for patient flow management, such as being able to guide a patient to locations relevant to their appointment, track assets (such as key equipment used to move or discharge patients), and monitor staff actions, such as time spent with patients and how often a patient was seen.

Patient tracking also enables context-specific messaging for visitors, like targeted health promotion campaigns based on a patient’s specific movements and location. For example, offering reminders to patients to get their annual eye exams as they walk by the eye clinic in a hospital.

Early implementations of way-finding and patient tracking solutions have not married patients’ whereabouts to staff workflow. Tethering these two is helpful so staff can mitigate problems and issues as they arise and where they arise. If staff realize they’re running behind, for example, and a patient happens to be waiting in the hospital cafeteria, the staff could capitalize on their knowledge of the patient’s location and send the patient a voucher for a free coffee or something similar to enjoy during their wait.


Pleasing patients isn’t always easy, but ensuring that they move through their hospital or provider’s office quickly and efficiently can help satisfy them. Leveraging patient self-service, intelligent workflows, and reporting can create an information-rich tool for staff to monitor patient flow and an empowering experience for patients.

Janie Tremlett is GM of patient solutions at Vecna Technologies of Cambridge, MA.

Readers Write: The Patient Perspective (aka, Who Just Knocked the Floor Out from Under My Feet?)

October 21, 2015 Readers Write 15 Comments

The Patient Perspective (aka, Who Just Knocked the Floor Out from Under My Feet?)
By Teri Thomas


On the plane back from a short vacation in the Caribbean, my throat and head began to ache. It worsened until I suspected strep throat. 

After waiting 30 minutes (in a room with other ill people) at the nearest urgent care, I was curtly informed that my insurance no longer covered my care there. Miserably, I drove to the next closest urgent care while I called my insurance company for guidance. They directed me to their web site and asked me for names of individual physicians. However, I just wanted the nearest place to get a strep test. 

I pulled into the next urgent care lot and gave my insurance company their address. Not covered. Third choice was covered, so I waited in the queue and eventually was swabbed. After an hour or so, they informed me it was negative and sent me home with “Tylenol and rest.” I felt a little ashamed to have wasted their time and resolved to toughen up.

Two days later, my sore throat had worsened. I was spiking fevers over 102 and my headache became the worst in my life. My body ached and shook and the pain made light and normal sounds hard to tolerate. I held my head in my hands while my husband drove me to the ER.

The ER nurse gave me a medication. When I asked her what I it was, she said, “la-la.” I found it strange (I had no idea what la-la was), but since it hurt to talk, I let it be. Then the doctor came in and asked me what pain medication I was given. I was embarrassed — all I knew was that the nurse called it la-la. Strangely, he seemed OK with that and he didn’t choose to clarify or comment (it was Dilaudid). They drew blood and did a spinal tap, suspecting meningitis. Things began to move around me, giving me the feeling of being an object instead of a person.

They admitted me to the hospital, bundling me in blankets for chills and medicating the pain, while trying to figure out what my illness was. Each doctor gave me a different diagnosis, often confidently. The epidemiologist said, “It’s dengue.” I had chest x-rays and was told pneumonia. The next doctor said I did not have pneumonia. 

My husband and I wanted the doctors to talk with each other. It didn’t appear that they did, as my husband or I had to inform each doctor about what the others had said. The neurologist asked me questions, but never shared his conclusions. I had to painfully recount the course of my illness to him and the others.

Respiratory therapy was a lifeline because they stayed in the room enough for me to be sure I knew who they were. A curious thing to me was the feeling that I existed “in part” to the various specialists. I was a CNS, or pair of lungs, or a Caribbean vacation. 

Some of the doctors seemed to go as fast as they could in their questions. I felt like a speed bump in their race to their next (maybe more important?) patient. As a patient taking pain medication, it was difficult for me to keep up with them, and since I didn’t have time to prepare for a new visitor (they were a surprise), I gave regretfully jumbled and incomplete information. 

After explaining my history and situation for the third time, I hand wrote the timing, sequence of events, and main symptoms on a piece of paper for new physicians or providers to read. It seemed strange that they didn’t seem to want to read it.

It meant a lot to have someone look me in the eyes.

My attending was a foreign-born hospitalist who directed his dialogue to my husband as if I weren’t there. Being a fairly assertive person, I asked him to please include me. With his mouth, he said, "What can I do for you?" yet his eyes and body language said, "You are wasting my time." 

After being denied by nursing, I asked him for the results of my labs and he said he couldn’t do that. He then asked which ones specifically, and only then verbally answered for those specific tests I could think of the top of my head. A printout or online access would have been much better. Not getting information about my own body was incredibly frustrating. It felt disrespectful, as this was happening to ME.

There was a big sign directly in front of my bed that said, "Medications, always ask– explanation, dosage, side effects." Not once did a doctor or nurse ever offer side effects or dosage information. During times of decent pain control, I found the sign humorous.

In writing this, I struggled to find the best word to sum up how the admission felt. Words that come to mind include humiliating, confusing, and castrating (in the sense of taking away one’s strength). I was a strong, educated, independent woman, used to being on top of things (and directing others) with a solid understanding of healthcare, medical terminology, and hospital operations. Suddenly, I had no control over my schedule, no idea who or what was coming next, was highly vulnerable due to pain and pain medications, and I was afraid — something painful and strange was going on in my body. 

My toilet was set with a plastic catcher to measure my urination, but it sat there overflowing because nobody emptied it. There was a white board in my room with some basic information (e.g. name of my nurse), but it was often incorrect. The pain meds made it hard to track what was going on, yet I seemed to be the owner of communicating my situation to all of the changing players around me. I started taking my own notes in a notebook to ensure I was telling people the correct medications. 

The alarms, blood pressure cuff squeezes, and noise outside my room meant I slept fitfully at best. When I did sleep, I had intense nightmares that caused me to wake in an utter panic. Maybe from my mystery illness, maybe from the medications. Either way, it was intense, and I was grabbing for any sense of control or understanding that I could. 

I was reaching for blocks of reassurances (seeing my labs directly, seeing my problem list or diagnosis notes, being told what or who was coming up and when). Simply hearing my care team collaborate and come to me informed and with a unified hypothesis would have made an enormous difference.

Eventually my blood work showed I was stabilizing. The pain began to subside enough that I — knowing the risks of hospital-acquired infections — asked to go home and recover there. I was told a few weeks after discharge that two blood tests were negative for dengue fever, so I never did find out a definitive diagnosis. I got a copy of my H&P and discharge summary and found it humorous to see how little useful information was included, yet there were numerous references to how pleasant I was (surprising, as I was in terrible pain and struggling to be pleasant, but also not very relevant). 

It certainly could have gone better, and I’m sure for some patients, it does. I can almost hear the comments, “My patients don’t want their lab information; it would just confuse them.” Fair enough. Each patient is different. However what they have in common is a desire to feel respected and listened to. 

If folks are interested, I’m happy to post what happened after that—the experience with post-hospital care coordination, billing, how this relates to HCHAPS, as well as concrete suggestions and lessons learned. Do let me know. Having worked in healthcare for 25 years, this experience has energized me to continue to try to make things better. 

Teri Thomas is vice president of Epic Systems of Verona, Wi.

Readers Write: Mission Impossible: Transitioning to Value-Based Care with Health IT Solutions

October 7, 2015 Readers Write No Comments

Mission Impossible: Transitioning to Value-Based Care with Health IT Solutions
By Victor Lee, MD


Your mission, should you choose to accept it, is to partake in the nation’s efforts to transition our healthcare system from volume-based care and fee-for-service (FFS) reimbursement models to value-based care.

If you are in clinical practice or hospital administration, chances are that you have accepted this mission. Like Ethan Hunt, what choice did you really have?

Earlier this year, the US Department of Health & Human Services (HHS) announced specific goals for shifting Medicare reimbursements from volume to value. Under this plan, 90 percent of all traditional FFS Medicare payments would be tied to quality or value and 50 percent would be tied to alternative payment models by the end of 2018. What does all this mean?

For background information, see this fact sheet which summarizes the payment taxonomy framework that HHS has adopted to categorize its payment reform programs. Briefly, Category 1 is traditional FFS with no link of payment to quality. Category 2 is FFS with a link to quality which includes pay-for-performance programs such as Hospital Value-Based Purchasing, Readmissions Reduction Program, and Hospital-Acquired Condition Reduction Program.

Categories 3 and 4 include alternative payment models, where the difference between them is that category 3 programs are built on top of an FFS architecture (e.g., accountable care organizations, medical homes, bundled payments), while category 4 programs completely move away from FFS and exclusively involve population-based payments (e.g., eligible Pioneer accountable care organizations in years 3-5).

Now that we’ve characterized the impossible mission, let’s look at some tools you can use along your journey. There are no spy trinkets, laser beams, toxin antidotes, or heavy artillery involved. Rather, I am referring to newer, innovative solutions proven to maximize clinical and financial outcomes such as clinical decision support (CDS) and mobile care coordination.

The Office of the National Coordinator for Health Information Technology (ONC) defines CDS as “a process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery.” A classic example of CDS is a pop-up alert that provides guidance to clinicians at the point of care. However, the Centers for Medicare & Medicaid Services asserts that there are many other common forms of CDS in addition to alerts, all of which may be used to satisfy the CDS objective within its EHR Incentive Programs. Which ones have you used on your mission?

Admittedly, many providers have already successfully implemented a variety of CDS interventions in their EHR systems or are somewhere along that journey, so the concept of implementing CDS for quality improvement is not new. However, many organizations struggle with keeping CDS updated over time as new information from clinical trials, guidelines, and performance measures emerges.

Fortunately, there are solutions to help with this part of the impossible mission, including third-party evidence surveillance or software applications that analyze CDS from EHR systems to identify potential deviations from evidence-based best practices.

Care coordination has also been part of a national dialogue, with the Agency for Healthcare Research and Quality (AHRQ) including care coordination as one of its six National Quality Strategy priorities. Care coordination is also explicitly required in certain regulations such as Meaningful Use (mentioned earlier) and the Medicare Shared Savings Program, with the latter specifically requiring the use of “enabling technologies” to support care coordination. So clearly the impossible mission is less likely to be completed in the absence of care coordination, but what solutions are available?

A classic example of a care coordination solution is HIPAA-compliant text messaging. However, newer care coordination solutions take this a step further and incorporate person-centered and evidence-based approaches to ensuring safe and timely transitions of care across providers and venues. Some solutions embrace mobile platforms to ensure accessibility at every point of a person’s care journey.

In summary, our nation’s path toward healthcare reform may appear to be daunting if not nearly impossible. However, the HHS prescription for payment reform and its taxonomy for measuring progress toward its goals includes programs that are dependent on lowering costs, promoting care coordination, and optimizing quality of care. Fortunately, advanced solutions are at your disposal today that transform the mission from one that is seemingly impossible to one that is probable if not inevitable.

This message will self-destruct after we have completed the transition to value-based care.

Victor Lee, MD is vice president of clinical Informatics at Zynx Health of Los Angeles, CA.

Readers Write: HIEs Deliver the Promise of mHealth

September 28, 2015 Readers Write No Comments

HIEs Deliver the Promise of mHealth
By Stuart Hochron, MD, JD


The successful transition from fee-for-service to value-based care will require a high degree of coordination and the sharing of real-time health information among physicians and patients. This article describes how quality and cost incentives are encouraging payers and providers to leverage the information contained within health information exchanges (HIEs) to empower providers and patients.

Patient outcomes improve when timely personal health information (PHI) is shared with and among providers and their patients. Reducing preventable hospital readmissions is an example of the power of this information. As a result of recent successes in the acute care and post-discharge environment, payers and physicians responsible for the care of populations across multiple EHRs are seeking ways to (a) avoid treatment delays and improve care quality by sharing PHI among clinicians, and (b) engage and empower patients. Mobile communications that engage physicians and patients and deliver relevant clinical information can help healthcare organizations coordinate quality care, manage cost, and satisfy physicians and patients.

Until recently, providers seeking PHI from multiple EHRs were required to access and navigate secure HIE websites using personal computers or mobile devices. Web access has generally been less than a user-friendly experience. The fact that many HIE websites are not mobile enabled and rarely push data to user-friendly mobile apps has further limited physician-HIE engagement. Today, however, mobile technology has given rise to an increasing number of user-friendly mobile apps that integrate with HIEs and push the type of information that physicians and patients find most useful.

All sectors involved in value-based care can benefit from mobile delivery of HIE data. Government benefits when the transition to value-based care is facilitated. Payers benefit by more efficiently coordinating care, containing cost, and facilitating quality and member satisfaction. HIEs benefit by expanding their services. Physicians benefit from easy access to critical information and from financial incentives that derive from effective value-based care. Patients benefit from greater security that results from knowing when and why their PHI is being accessed and by whom.

The following case studies represent mobile HIE initiatives that add value in different ways.

Case 1 – Patient Status Notifications to ACO Physicians

An ACO managed by a hospital system is implementing an automated status notification system for primary care physicians. It provides ACO physicians with the opportunity to participate at an early stage in the care of patients presenting to emergency departments or who are hospitalized. In the absence of such information, treating physicians are deprived of the opportunity to discuss details of the patient’s medical history with the patient’s primary care physician. This lack of communication can to lead to otherwise preventable hospital admissions, over-prescribing of diagnostic studies, iatrogenic complications, lower patient satisfaction, poorer outcomes, and increased cost.

Automated patient status notification takes advantage of hospital-HIE data connections, whereby PHI is uploaded in real time to the HIE when a patient presents to a regional emergency department or hospital. ACO-participating physicians are identified by the ACO and HIE using unique numeric codes.

When a patient is registered by an emergency department or is admitted to a hospital, the HIE identifies the patient as part of the ACO, reconciles the physician identifiers, and feeds pre-selected PHI to the patient’s ACO physician(s). This information includes the patient’s name, DOB, diagnoses, emergency facility location and contact information, and the time of ED registration and/or admission. The message is delivered from the HIE to physicians via an HL7 or sFTP (secure fie transfer protocol) data feed that reaches the mobile vender’s server through a VPN (virtual private network).

In this case, all physicians credentialed by the ACO’s hospital are required to participate in the hospital’s mobile communication platform. The time interval between ED registration or admission and ACO physician mobile notification is measured in seconds. Armed with this information, ACO physicians are able to the share key patient information with treating physicians at remote facilities.

Case 2 – Fraud-Protecting Payers and Patients Using HIE Status Notifications

An HIE seeking to expand the scope of its services is developing a mobile patient app that will fraud-protect state Medicaid and its beneficiaries and engage patients. Fraud-protecting Medicaid beneficiaries has the potential to reduce state and federal government annual losses related to fraud. Engaging patients has the potential to improve outcomes, control cost, and improve patient satisfaction. The system will use the HIE’s mobile patient app to authenticate patients and notify patients in real time when a healthcare facility or provider adds, accesses, or requests access to PHI. Patient access to this information requires a paper-based application and considerable time and thus is rarely requested.

Medicaid patients will self-authenticate using the HIE’s secure mobile app. After downloading the app from either the Google Play store or Apple App Store, patients will register by answering a few simple questions including their name, date of birth, and state of residence. The mobile app will connect to Equifax, the HIE’s consumer credit reporting agency, which will ask patients up to five personal financial questions. Questions can be related to a patient’s cable television bill and other commonly purchased product products and services, which broadens the potential applicability of the authentication process. Once authenticated, the patient’s app is activated and protected by a PIN. Patients can present their activated mobile HIE app when accessing Medicaid services at pharmacies, hospitals, and other facilities to document their identity.

Each Medicaid beneficiary has a unique Medicaid and HIE identifier. When a request by a provider for access to a patient’s health record is received by the HIE or when PHI is added, the HIE will store this information, identify the patient as a Medicaid beneficiary, reconcile the patient’s Medicaid and HIE identifiers, and feed pre-formatted notifications specific to each type of status change to the patient’s mobile app. Examples of patient notifications include 

  • Radiology results have been delivered to your physician’s office.
  • Laboratory results have been delivered to your physician’s office.
  • An admission-discharge-transfer summary from a hospital has been delivered through your HIE.

The patient app will also provide patients with relevant health and insurance information and connect patients to network providers and services.

HIEs, like electronic health records in hospitals and physicians’ offices, are repositories of large amounts of PHI. The goal of realizing value from collecting and storing such data is directly related to how quickly and easily relevant PHI is shared with providers and patients. Relevant PHI that is delivered in real time to engaged physicians and patients has the greatest potential to improve outcomes, control cost, and increase physician and patient satisfaction.

Using HIEs to deliver PHI-related information instantly in user-friendly ways to physicians’ and patients’ mobile devices is delivering on mHealth’s promise of adding value through innovation.

Stuart Hochron, MD, JD is co-founder and chief medical officer of Practice Unite of Newark, NJ.

Readers Write: What Do National Patient Identifiers and Donald Trump Have in Common?

August 24, 2015 Readers Write 1 Comment

What Do National Patient Identifiers and Donald Trump Have in Common?
By Catherine Schulten

Over the past several years (decades?), the call for a national patient ID has moved beyond discontented grumblings by hospital CIOs to a hot button topic that has garnered national attention from the likes of CHIME, HIMSS, the US Congress, and practically everyone with an opinion who is involved in healthcare data exchange.

A HIStalk poll conducted 2/8/15 asked, “Should the federal government issue a national patient identifier?” The overwhelming response was yes, as 79 percent said yes while 21 percent said no.

Interestingly, a poll done by the Wall Street Journal asking, “Should patients have unique electronic identification numbers for their medical records?” revealed that 44 percent said yes while 56 percent said no.

Industry leaders who support the use of a national patient identifier point to the use of universal patient identifiers (UPIs) in the UK, Ireland, Canada, and elsewhere. They tout efficiencies gained, increased patient safety, the ability to easily pull together a longitudinal record across disparate systems, lower administrative costs, accelerated medical discovery, and the ability to preserve patient privacy. They also cite patient privacy advocates and the existing ban on any federal funding to study or promulgate a national patient identifier as the reason why no forward momentum on this issue has occurred.

Those opposed to the national patient identifier typically cite two primary deterrents: patient privacy and the role of the federal government in establishing an agency that has the ultimate authority to create, distribute, and manage these identifiers.

But before we get into the pros and cons of each side in this debate, let’s first agree on a few items that seem to be overlooked when we talk about a national patient ID.

First of all, let’s quit calling it a national patient identifier. In practicality, it is actually a national ID. From the moment we are born until the day we die, we all have the potential to be a patient. In all countries that have adopted this type of system, the ID is assigned to the patient by the government at birth. In some cases, not only is this ID used to identify an individual for healthcare purposes, but it is also used when securing other government benefits.

Secondly, healthcare is a service that applies not only to US citizens born in this country, but others who may be here legally or not. Nationalized citizens, foreign visitors, individuals with work or student visas, and even illegal immigrants would need to use the ID. Otherwise, how does one know for sure whether Jean-Luc Picard with an ID and the one without an ID are the same or different individuals? For this design to work, an ID process must be supported for non-US citizens as well.

Back to the question at hand: what do national patient identifiers and Donald Trump have in common?

Both are light on details and heavy on promises. We hear what we want to hear when told that a national patient identifier is the only option that solves for true data interoperability, that privacy advocates and their concerns stand in the way of this enlightened future, and that an ID, once introduced, will be used consistently and accurately.

We seem to forget that HIT systems, no matter how well they claim to be protected, are vulnerable to sophisticated security hacks and low-tech identity theft schemes. We forget that healthcare is a service that anyone can secure even if you purposefully choose to anonymize yourself or — in the case of an emergent care situation — are simply unable to provide identity credentials.

But here’s another way that a national patient ID is like Donald Trump. We are fed up with the status quo. We struggle for a way to achieve the promise of unencumbered health information exchange. We’ve invested millions, more likely billions of dollars into the systems and exchanges that are supposed to support data liquidity and yet we still stumble over the seemingly simple matter of accurate patient identification and record matching. We are fed up and we aren’t going to take it any more! We demand action!

As a result, the promise of a national patient ID takes the spotlight and many cycles are spent touting this concept as the deliverance we need. If only the federal government would get its act together and those pesky privacy advocates would quit proclaiming doom and gloom.

However, the truth – as is typically the case – lies somewhere in between.

A national strategy and design for health information exchange that considers the unique challenges of patient identity and record matching is required. The ability for a patient to manage his or her own credentials if they wish to promote or even prevent exchange is necessary. Ultimately, we need a design that doesn’t rely solely on a set of individual attributes to properly identify or match the patient (I refer to the oft-cited “Maria Garcia in Harris County, TX” study.)

We need visionaries at the table who understand the nuances and challenges and can chart a new path forward. We need to be looking at the role of existing forms of patient identification such as insurance cards, driver licenses, passports, smart cards, and biometrics to assist in the process. National identity standards and concepts such as OpenID and NIST’s Levels of Assurance are paramount to the design. Finally, peer-reviewed pilot studies that reveal the strengths and weaknesses of different approaches will help ensure the best ideas rise to the top.

Catherine Schulten is director of product management with LifeMedID of Citrus Heights, CA.

Readers Write: Connecting Mobile Health and Alarm Safety Strategies

August 24, 2015 Readers Write No Comments

Connecting Mobile Health and Alarm Safety Strategies: A Guide for Hospitals Managing Mobile Alarms and Alerts
By Mary Jahrsdoerfer, PhD, RN


As The Joint Commission’s National Patient Safety Goal on alarm safety inches closer to the January 1, 2016 compliance deadline, hospitals are discovering that long-term, meaningful reductions in alarm-related patient safety risks extend beyond medical device alarms. Although hospitals can satisfy TJC’s alarm safety deadline by presenting a solid strategy for reducing medical device alarms alone, there is an implicit understanding that managing patient monitors and ventilators are only part of a much larger problem related to clinical interruption fatigue.

In addition to medical devices, a comprehensive clinical communications strategy also includes managing the alerts (nurse call, EHR, labs), text messages, and mobile phones/devices that care team members use to facilitate collaboration around any of these patient events. A hospital should certainly follow guidelines that advise changing monitoring leads more often, implementing patient-specific monitoring thresholds, and configuring alarm delays, but these clinical interruptions only target a subset of the overall problem.

Clinical interruptions occur when a nurse continues to receive alarms and alerts while performing a patient-related task that could have escalated to another available caregiver with an integrated platform. The interruption may be an actionable, or even a critical event, but it’s still an interruption if the recipient is unable to respond with the sense of urgency required. Nurses have described frightening scenarios where they were engaged in administering life-saving treatment for one patient while an urgent alarm for another patient blared in the background. This situation could have been easily avoided with automatic escalation of that alarm to the next available nurse.

Preventing alarm collisions requires a holistic approach to managing clinical communications that must necessarily include the full spectrum of patient events. The challenge is integrating each system in each unit without overwhelming clinical users. Assimilation requires collecting input from affected users, measuring alarm and alert activity, and ensuring the right workflow.

The Joint Commission has provided a starting point for hospitals that are serious about reducing alarm-related patient safety risks. Middleware is the foundation upon which medical device alarm management is built — hospitals must utilize an FDA-cleared platform to deliver alarms to recipients on mobile phones. A long-term alarm safety strategy includes integrating all of a hospital’s clinical systems, which will require planning beyond TJC’s NPSG deadline.

The overall goal of TJC’s alarm safety goal is to reduce medical errors as it relates to medical device alarms, but nurses realize that the broader issue of interruption fatigue is a consequence of many workflow and communication inefficiencies. My admonishment for hospitals grappling with the alarm safety mandate, HIPAA compliance through text messaging, nurse call and EHR alert management, and smartphone and mobile phone deployment is to view them as subsets of the same communication architecture that require a common foundation to solve.

Mary Jahrsdoerfer, PhD, RN is CNO at Extension Healthcare of Fort Wayne, IN.

Readers Write: Interesting Times for ePA and EPCS

August 12, 2015 Readers Write No Comments

Interesting Times for ePA and EPCS
By Connie Sinclair, RPh


These are interesting times in the e-prescribing world. Readers may recall that NCPCP approved the SCRIPT electronic prior authorization (ePA) transaction standard in July 2013. Several state legislatures have passed laws requiring support for the NCPDP ePA transaction 24 months after its adoption, which brings us to right now. With Missouri’s new e-prescribing of controlled substances (EPCS) rules becoming effective July 30, EPCS is allowed in all 50 states and DC, with only Vermont holding out on EPCS of Schedule II substances.

Having been involved with electronic prescription applications for almost 30 years and today tracking what states are legislating and regulating, it is gratifying to see the tremendous progress the industry has made in terms of adoption and in advancing e-prescribing to become the standard of care. Even EPCS, which was considered one of the biggest hurdles, is now legally a done deal.

EPCS not only provides better tracking and deterrence of controlled substance diversion and abuse, it also helps patients get the medication they need in a more timely manner. Orthopedic patients no longer have to hobble into their surgeon’s office when they need pain relief prescriptions. Adults and children who are on ADHD meds can also avoid unnecessary trips to the doctor for maintenance med prescriptions.

Some might say, “Whew, we’re done.” Not so fast. Although EPCS is allowed and transaction flow for controlled substance prescriptions is certainly increasing, we still have a long way to go to get adoption to levels that are equal to non-controlled substance prescribing. Anecdotal evidence suggests that many practices are unaware of the legality of EPCS, most likely because they do not yet have access to an EPCS certified version of their EHR. Also, many states are watching New York very closely to see the impact of mandatory e-prescribing and EPCS effective March 2016, and some are expected to follow suit.

While EHR vendors have been slogging their way through MU requirements, industry stakeholders, prescribers, standards organizations, and legislators have been busy advocating for prior authorization (PA) reform. As I am sure most HIStalk readers are aware, the traditional and cumbersome PA process is a huge sore spot for prescribers and patients alike who believe it hinders patients from getting needed medication per their doctors’ orders. Over the last few years, state legislators have taken note and have approved new laws requiring reform and automation of the process. 

A big part of my current job is to monitor state law. Seven states had July 2015 effective dates for some level of support for electronic prior authorization. In addition, four states already require electronic submission of the PA form and three additional states have laws on the books with future effective dates regarding ePA support. As always, the devil is in the details as each state has a different interpretation of what constitutes an electronic prior authorization. Most states impose the requirement to support ePA on the health plan, but EHR vendors should take note because at least two states impose the requirements on the provider.

As patients and as caregivers for patients as well as EHR stakeholders, we should all be encouraged by the progress of the ePA and EPCS initiatives and do what we can to keep things moving along in the right direction.

Connie Sinclair, RPh is director of the regulatory resource center of Point-of-Care Partners of Coral Springs, FL.

Readers Write: The Bon Secours Health System Convenes to Review the SAFER Guides

July 29, 2015 Readers Write 5 Comments

The Bon Secours Health System Convenes to Review the SAFER Guides
By Patricia P. Sengstack, DNP


Patient safety – have we fixed that yet? Apparently not. Fifteen years after “To Err is Human” was published, we still see errors leading to adverse events in our healthcare settings.

So let’s rely on health IT to take care of the problem. Hmmmm…. It seems that health IT can actually lead to new types of errors when not configured or implemented well. I liken it to a game of Whack-A-Mole. As a new error arises attributed to health IT, we change the system or a process to make it go away. Then a new one that we hadn’t considered pops up that we have to address: orders are written on the wrong patient, a default value is provided for a medication that is inappropriate for a patient in renal failure, a result from an outside lab is manually transcribed incorrectly into a patient’s electronic record.

As we deal with each issue, we hope to become a learning health system, continuously improving to ensure our patients get the best and safest care possible. In looking for resources to support continued safety improvement efforts, we see tools emerging from our industry experts and researchers.

One such tool can be found on ONC’s website and is a collection of nine self-assessment checklists covering safety related areas such as patient identification, system-to-system interfaces, CPOE with CDS, and high-priority practices. These SAFER Guides are available on the ONC website. If you’ve read the recent Sentinel Event Alert (#54) published by The Joint Commission, you know they recommend that organizations develop a proactive, methodical approach to health IT process improvement that includes assessing patient safety risks using tools such as the SAFER Guides.

To do just this, a multi-disciplinary team from across the entire Bon Secours Health System convened to perform a self-assessment and determine areas for health IT safety improvement using the High-Priority Practices SAFER Guide. We wanted to see what this guide was all about and decide if we wanted to move forward with reviewing the other eight guides.

The High-Priority Practices guide consists of 18 evidence-based recommended practices and includes examples of how successful organizations have improved patient safety in each area. A rating scale for each practice is provided that allows organizations to identify areas of vulnerability and to help prioritize follow up activities. These ratings include Fully Implemented In all Areas, Partially Implemented in Some Areas, and Not Implemented.

Since this was the first exposure to the SAFER Guides for almost everyone gathered in the room, our intent was not to create a to-do list with assigned resources for follow up, but simply to review the guide as a group of stakeholders to understand their intent, how to use them, and determine next steps. We had about 25 people in the room that represented clinical, IT, informatics, and patient safety from our entire 14-hospital system.

We started with a discussion on recommended practice #1, “Data and application configurations are backed up and hardware systems are redundant,” then moved on to the next one, and so on. Every single recommended practice generated at least 20 minutes worth of discussion – all good. We only got through recommended practice #11 when time ran out.

Not one of the recommended practices was scored as Fully Implemented in All Areas, but some were almost there. Those were the shorter discussions. We found ourselves wishing that there was another ranking in the scale. If just about everything is “partial” without any differentiation of “partiality,” then it’s hard for an organization to prioritize which partial recommendation to tackle first, second, third. In other words, if we checked off everything as Partially Implemented, where do we focus?

I believe the group felt that the guides were validating. Never before in one place have they seen the importance of their work in black and white with references in a concise checklist. They may have heard that a particular practice was the right thing to do, but having it in this tool provides the necessary focus on things that sometimes get pushed to the back burner for system enhancements that are a bit more sexy and innovative. The list below represents highlights from our self-assessment discussions as well as some questions generated. These will help us to provide focus over the next several months:

  • Backup systems are currently adequate. In process of moving some backup systems to a more remote location.
  • Every downtime is different. If you’ve survived one downtime, you’ve survived one downtime.
  • We need more practice at downtime – decision making, communication, and improvements to downtime forms. If only interfaces are down, should we take the system completely down for all users?
  • Where appropriate, we need to ensure we are using SNOMED/LOINC terminologies, need to assess. Are there free text areas that could be coded?
  • Some of our naming conventions in radiology are unclear, making order entry problematic and error prone. We need to review and make improvements.
  • How much do we police physician use of evidence-based order sets? Do we force their use without exception?
  • Pharmacy build team embraces ISMP guidelines.
  • How do we get our vendor to help us make improvements using this guideline? They should be at the table with us during the next discussion.
  • End user acceptance testing as well as production validation testing are happening, but think we can improve. Problems occur when using test patients in production. (Do not assume there are no real patients in the system with the last name “Test”).
  • We strongly recommend using the patient’s picture for identification. If the system allows it, we should implement (and we have started in our inpatient settings).
  • Usability of the system can be improved. Some of the language is not clear to the end-user, making it misleading while charting. Need more inclusion of end users at both the vendor and organization level during design sessions.
  • We need to develop a “Top 10 Optimization List” based on our safety review.
  • Need better method to assess end user proficiency in order to develop effective, ongoing training programs.

At the end of the session, the group wanted to set up times to complete the remainder of the recommended practices in the High Priorities guide and then move on to the Organizational Responsibilities guide. We have the next date scheduled and will continue our review.

At no other time in our organization’s history have we convened to solely discuss health IT safety. This exercise using the SAFER guide has provided the impetus leading to valuable discussions that are only the beginning of this journey to improved patient safety.

Patricia P. Sengstack DNP, RN-BC, CPHIMS is CNIO of Bon Secours Health System of Marriottsville, MD and immediate past president of the American Nursing Informatics Association.

Readers Write: My EHR Vendor is Losing Market Share – What Should I Do?

July 29, 2015 Readers Write 1 Comment

My EHR Vendor is Losing Market Share – What Should I Do?
By Jason Fortin


These are turbulent times for many EHR vendors. In fact, according to a 2014 report from KLAS, only three vendors – Epic, Cerner, and Meditech – gained hospital market share in 2013; everyone else lost more hospital customers than they won.

What should you do if your EHR vendor is one of the many that is losing market share?

Understand the market dynamics. The reality is the EHR market is shifting quickly right now, with rapid consolidation and distinct winners and losers. A number of vendors are losing customers, but there are many reasons hospitals and health systems decide to change their core EHR. Some of the shift in EHR market share is due to justified concerns about the long-term viability of certain vendors, but increasingly, it is also a result of other factors, such as recently-merged hospitals and health systems looking to align on a single EHR.

Ask the tough questions. Go beyond the headlines and try to determine why your EHR vendor is losing market share. Are these things that can change? For example, is the loss of customers a result of the vendor’s lack of executive leadership and vision? Or is it more due to the current features and functionality of the product?

It is also important to look at what types of customers the vendor is losing and how fast the attrition is happening. Are clients being lost only in a specific segment outside the vendor’s target market (such as smaller community hospitals or large AMCs)? Or are all types of customers looking to switch?

Lastly, evaluate the level and immediacy of risk. Is the loss of market share so severe that the vendor could go out of business in the next one or two years?

Don’t panic, but evaluate if your needs are being met. Look at all the factors involved. Even if your vendor is losing market share, consider how their product specifically supports your business and clinical needs right now. Do they have a clearly defined plan to support your business and clinical needs in the future?

Also consider what your vendor offers in the context of what it will take to stay competitive in your market. For example, “interoperability” is an important characteristic, but it is far more important to have a system that can exchange discrete data with the specific EHRs that are predominant in your region.

Take an objective look at the alternatives and make a decision. Evaluate the market, looking at other core EHRs as well as applicable niche solutions to get a sense of different approaches to functionality that is most important to you (i.e. data exchange, population health, etc.) Compare those to your current EHR and be honest in terms of which capabilities represent a significant improvement over what you have, which are essentially a trade-off, and which might be nice to have but aren’t critical to achieve your specific business and clinical goals.

If you decide to leave your vendor, carefully consider your options for selecting a new one. One course of action is a full system selection, which involves a thorough and comprehensive look at multiple solutions (including detailed demos and interviews), but may not be practical from a timing perspective or in cases when a replacement is urgently needed. An alternative option is a “null hypothesis” selection. This approach is focused on starting with the best potential fit based on your scan of market leaders, and then undergoing an expedited selection process with that one “null hypothesis” vendor to try and disprove why it would not be a good EHR for your organization.

The bottom line is loss of market share is a valid reason for customers to be concerned about their core EHR vendor. In some cases, it is sufficient cause to begin looking at a potential replacement. But it is also important to look at why a vendor is losing customers and to objectively look at your current system and the alternatives in the context of what your organization will specifically need to remain competitive in your market. Committing to an EHR vendor is a big decision, and unfortunately in the current landscape, it is not a decision hospitals and health systems can afford to get wrong.

Jason Fortin is senior advisor with Impact Advisors of Naperville, IL.

Readers Write: Meet Generation Z

July 29, 2015 Readers Write No Comments

Meet Generation Z
By Frank Myeroff


The next generation to enter the workforce has been coined “Generation Z” or “Gen Z.”  Gen Z refers to the group of people born after the Millennial Generation.

There is no agreement on the exact range of birth dates. However, according to Wikipedia, some sources start this generation at the mid or late 1990s or from the mid-2000s to the present day. Right now they comprise about 7 percent of the workforce, but by 2019 it is estimated that 30 million will be employed.

As the father of two Gen Zers, I can tell you that not only is this generation the most digitally connected, but they have no concept about life before the Internet, mobile devices, digital games, or iTunes. This screen-based generation utilizes technology as a tool to communicate, share information, be entertained, receive and complete school assignments, obtain breaking news, and so much more in every aspect of their lives.

What do we as HIT executives and hiring managers need to know about Gen Z’s arrival in the HIT workplace?

  1. Expect leadership to be transparent. Because Gen Z knows the power of sharing and openness, they want leaders to be honest and forthcoming. There will be no place to hide for inept leaders.
  2. Expect leaders to provide immediate results. Gen Z is used to real-time information and moving at a fast pace. They want leaders to offer exposure to new HIT projects as well as show them how to attain a high level position in a short period of time.
  3. Plan on entrepreneurial spirit. Seventy-two percent of Gen Z expects to create and run their own startups at some point in their career. This means heavy competition. Organizations will not only have to compete against each other for talent, but against entrepreneurial startups.
  4. Derive possible cost savings. Expect a savings by hiring Gen Z. Since they’re transient and want to work remotely from any location in the world, you’ll probably save on office space, infrastructure, and relocation costs.
  5. Anticipate faster and easier access to healthcare. From my perspective and their use of technology, Gen Z knows that faster and easier access to healthcare is all about the adoption of emerging technology. They will expect better technical assistance and training and the adoption of HIT best practices in order to transform access to American health care. In addition, Gen Z will be demanding a higher quality of infrastructure and efficiency of operational systems in order to adopt systems that provide better quality of patient care.
  6. Expect higher education. For the most part, when talking to Gen Z, they plan on traditional college careers, but it’s as much for the social benefits and networking connections as it is for honing IT skills. After graduation, most plan to gain higher education and many plan to accomplish this through online learning.
  7. Plan for idealistic generation. They want to change the world, feel that their work in the HIT profession is of value to society, and love the idea of volunteer work, which many are already doing.

As more information about Gen Z emerges, it’s most interesting how they differ from other generations, including the Millennials. What will it take to attract and retain Gen Z HIT Professionals?

  1. Create a young professionals employee group. Starting an employee group for Gen Z will engage and empower these individuals to become future leaders by providing personal and professional development opportunities. Within this group, encourage networking and civic involvement.
  2. Provide the latest and best technology. Gen Z is accustomed to having the latest and greatest technology. They’ve been raised on smartphones, laptops, desktops, iPods, etc. and using multiple screens are the norm. Therefore, to get their attention and keep them happy, continuously invest in new technologies and provide Gen Z with the tech tools that will engage them and make them more successful.
  3. Provide a career path that is tailored to them. As we know, the HIT industry is exploding, which is creating all kinds of employment opportunities. In order to attract and retain Gen Z, offer them a broad range of areas within your organization where they can specialize and succeed. Think about tailoring positions that leverage Gen Z’s quick adoption of technology and their desire to move up quickly.
  4. Expand flexible work hours and remote connectivity. As the tools and technology evolve, make it part of your culture to allow remote participation in meetings. Think about embracing Web-based video conferencing and online meetings if you haven’t already.
  5. Offer coaching and mentoring. Gen Z expects your organization to offer formal coaching and mentoring programs. They will especially need training in interpersonal skills and communication.  They are so accustomed to communicating through the use of technology that most could use pointers on how to have an effective face-to-face dialogue.
  6. refresh your rewards and/or recognition programs. Gen Z professionals need more rewards and recognition programs than any other generation. They look for accolades on even minor accomplishments. You will need to reward often and keep changing the rewards program to keep up with their expectations.

Generation Z is quickly approaching and they’re ready to live and compete in the digital world like no other. This technologically savvy and extremely innovative generation feels that they can achieve anything and they will expect your HIT organization to support them and provide growth opportunities or risk losing them.

Frank Myeroff is president of Direct Consulting Associates of Cleveland, OH.

Readers Write: WikiLeaks for Healthcare

July 16, 2015 Readers Write 11 Comments

WikiLeaks for Healthcare
By Todd D. Johnson


Did you feel the earthquake that hit healthcare this week? If not, you weren’t paying attention. On Monday, ProPublica, an independent, non-profit newsroom, published Medicare data about complication rates for surgeons and hospitals across the country. For the first time ever, the complication rates are reported all the way down to the individual surgeon.

This is big, sort of a WikiLeaks for healthcare. ProPublica has also used the stage to call out some of historically best-regarded healthcare institutions in the world on their outcomes.

Let’s agree that the train of transparency and value based healthcare has already left the station. If you didn’t believe it last Wednesday — when the Secretary of HHS, Sylvia Burwell, sent a strong market signal accelerating the movement requiring physicians to provide a “warranty” for their services — believe it today. Now any individual (patient or referring physician) can (and should) look up complication rates by surgeon and by hospital as they are shopping for doctors.

Furthermore, any payer, medical malpractice carrier, and any physician-employing entity can use the same data to negotiate reimbursement, premiums, and employment terms, respectively. This changes everything.

Arguably, #SurgeonScorecard is simultaneously both the best thing and the worst thing that could have happened for our healthcare system right now. Any physician or hospital that somehow thinks that the market economics aren’t going to shift needs to wake up. They can neither ignore nor hide from these data. Even if payors aren’t going to mandate change, patients ultimately will, and both patients and payors now have the tools at their disposal to do so. Furthermore, this data is public, and physicians and/or hospitals no longer have the only key to the safe containing physician-level outcomes.

Like every empire, the days of Fortress Medicine are now numbered. Those provider organizations that can find and use new tools to help them learn, improve, adapt, and evolve will survive, and those that don’t will succumb to market forces. Ultimately, this is the best thing that could have happened because it will lead to greater patient safety and improved outcomes.

It also might be the worst thing that could have happened to healthcare today. Change is difficult for many of us, including physicians, and therefore it’s hard to adapt and improve. Really hard. Physicians have lost control of their practices and their data. Just ask them. The data held in EMRs and claims data sets are not at the fingertips of the very practitioners who need them.

Furthermore, the retrospective data are being used by third parties to tell physicians about their performance and about how much or little they may be entitled to for reimbursement. This is to say that the data are often used to hold the providers hostage.

Physicians need new tools to empower themselves by using their own data. These tools must enable them to proactively treat patients in more high performance ways at lower costs. Just like ProPublica uses big data to learn about populations, physicians need to use their own data to gain more insight, work more efficiently, get better outcomes and measure them. But their data is are either sitting behind the walls of Fortress Payor or sitting in EMRs (otherwise called “wait-a-bases.”)

Just ask a doctor how easy it is to get data from his or her IT department these days. Most physicians haven’t the slightest idea how to access their own data. This is an unacceptable situation.

How can we ask providers to improve when they are flying blind? You may ask, “But didn’t we just spend $40B of taxpayer money to subsidize the purchase of fancy EMR systems to help providers improve performance?” Sadly, the flaw is that those EMRs can’t tell them which patient is sitting at home three days after surgery with a fever and early signs of an infection. That EMR isn’t telling them that their patients aren’t performing their daily at-home exercises to reduce their risks of blood clots. That EMR isn’t telling them that the patient isn’t understanding their treatment plans and adhering to them. At best, that EMR is only telling them that the patient was admitted to the emergency room after developing an infection.

As its title indicates, the EMR is merely a “record,” of that which has already happened rather than a live stream of what is happening, or a forward-looking tool for what is likely to happen. But more than that, EMRs only “know” the events that occur within the system in which they record.

Research out of the University of California San Francisco, reported last month in the Annals of Internal Medicine showed us that within three days of an emergency room visit, one-third of all return visits happened at another institution. This is worth repeating. One-third of all patients returning to an emergency room within three days of an initial visit occur at a the emergency room of a different hospital.

This means that there is tremendous, costly leakage outside of the walls of the index institution, and the events (and associated costs) around that leakage are unknown to the physician until the claims data (with reduced reimbursement) appear at the door. Just as patients are gaining increasing access to their own data, so too is there a need among providers and provider organizations for self-directed visibility into their own data.

Now is the time that physicians need to challenge themselves and their organizations to embrace value-based agreements. They should advocate for transparency; not hide from it. Some providers and provider organizations will undoubtedly feel victimized by these new and very transparent scorecard data. But those who see the opportunity will realize that with the right tools in place, these data can be extraordinarily empowering.

Use of digital engagement platforms with real-time patient reporting that is built right into the physician workflow can empower healthcare organizations and providers to discover and glean insights like never before about their patients. Furthermore, healthcare organizations needn’t wait to be told by payers what their complications are (and correspondingly what their value-based reduction in reimbursement may be) when they can glean from other digital sources exactly what their complication rates are in real-time.

The Surgeon Scorecard is a wake up call for providers to empower themselves to control their own data and not be victims of it. This is the time that they should critically evaluate and invest in new ways to deliver care that leverages the latest digital health tools, remote monitoring, and data analytics.

Years from now, we may well find ourselves referring to the new era after this pivotal moment in healthcare as “Life after the Surgeon Scorecard.” Really, the surgeon scorecard is just the beginning. Next, we will see similar reports extending beyond the eight elective surgeries covered in the ProPublica article. After that, we will see similar data reported for physicians in non-surgical specialties.

Just as it was the consumer market that has been dragging Fortress Medicine into the digital health era, so too is consumer demand for transparency about physician performance dragging data such as those reported today into full view. But physicians themselves are the ones at risk of being left behind. They must become proactive rather than reactive consumers of their own data, adopting and utilizing any number of the emerging workflow-friendly digital health platforms that put the data right into their hands.

Todd D. Johnson is chief executive officer of HealthLoop, Inc.

Readers Write: How Healthcare Providers Can Get Paid in the Mobile Age

July 8, 2015 Readers Write 3 Comments

How Healthcare Providers Can Get Paid in the Mobile Age
By Tom Furr


Two-thirds of all Americans aged 18 to 29 and nearly 60 percent of those between 30 and 49 years of age use a smartphone, according to a recent study by the Pew Research Center. In addition, the study found about 30 percent of Americans perform banking tasks – like paying bills – via their smartphones.

What does that have to do with your medical practice, you may ask? How well you understand the dynamics of mobile technology and its use in our society has a bearing on your practice’s survival. The management consultancy Deloitte noted that “overall preferences are trending toward mobile use” as it relates to getting information, buying, and paying for things. We can add paying for healthcare.

If there has ever been a reason to finally abandon that creaky old paper-based billing system, it is the ubiquitousness of mobile devices: smartphones, tablets, and even basic mobile phones. Most sources cite 90+ percent of Americans own a cell phone.

Americans prefer to get their bills online and are far more likely to pay them quickly, if not immediately. If you’re sending statements out in paper form, the third time is truly the charm. The Medical Group Management Association calculated that doctors’ offices must send out more than three statements before receiving any payment for services provided.

It’s high time you stopped licking stamps and start to bill electronically with email alerts sent to your patients. If you’re already using some kind of online bill pay method, understand your patients are moving away from the desktop to mobile devices. Adestra, an online marketing firm, found 48 percent of email opens occurred on mobile, 36 percent on desktop, and 19 percent in a webmail client.

Litmus, an email testing and analytics company, reported earlier this year that more email is read on mobile than desktop email clients. It, too indicated about half of all emails are opened on a mobile device. Of the 900 million Gmail users worldwide, 75 percent use their accounts on mobile devices

Campaign Monitor, another email specialist, noted that mobile email opens have grown 180 percent in three years, going from 15 percent in Q1 2011 to 42 percent in Q1 2014.

The changes that have occurred to this country’s healthcare ecosystem in just the last three years have had — and continue to have — profound impact on every person touched by the industry.

The increase in patient responsibility – or should I say liability – as it regards debt has created unprecedented revenue pressure on doctors, clinics, and hospitals. Oddly enough, this intense pressure has not prompted a swift change in most healthcare providers’ mode of operating. A study by JP Morgan noted healthcare providers have been late to turn their focus from clinical applications to their revenue cycle, collections, and payment processing modules. What’s more, this research determined healthcare providers “need to interact with patients in a more direct collections relationship” but “are not providing the level or sophistication of payments services that consumers expect.” This study also observed “the healthcare industry, as a whole still transacts with high volumes of paper.”

Six years ago, a McKinsey survey of retail healthcare consumers showed that 52 percent of respondents would pay from $200 to $500 or more by credit or debit card when they visit a physician if an estimate was provided at the point of care. It appears consumers are not so much unwilling to pay as they are unwilling to pay blindly.

Your patients are telling you what to do. Make payments more convenient and less confusing. Start by moving from paper to electronic and on to mobile

Whether you go the route of email to a secure website or a mobile application, recognize you’re not dealing with a screen more than a couple of inches wide and maybe three or four inches long. More than being “mobile friendly,” your efforts here need to show you’re mobile savvy.

Everything you do for the mobile environment must be simple and with a clear purpose. Simple because there are some technical limitations the wireless infrastructure forces us to handle. Clear because the viewing area is not very big. Intuitiveness is a must. One reason e-retailers are seeing a bump in abandoned shopping carts is their sites and apps aren’t developed with mobile in mind first.

Get the right message presented in the right way to your patients and they will see it on their phones and take action right then. After all, in this mobile age, people check their phone about 150 times a day. It’s how they operate.

Tom Furr is founder and CEO of PatientPay of Durham, NC.

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