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Readers Write: Seven Safety Checks Before Diving into the Big Data Ocean

November 20, 2013 Readers Write No Comments

Seven Safety Checks Before Diving into the Big Data Ocean
By Frank Poggio

When I last visited the topic of big data (BD) and analytics, I proposed that big data could easily become a wasteland for health providers and the next EHR boondoggle that could generate wads of cash for system vendors. I noted a large investment in big data could easily go for naught if we do not pay attention to at least two key issues. They were employing bad data as a foundation and blindly accepting analytics or mathematical models that do not correctly represent your world.

I received several responses to that piece, some stating that I was opposed to big data and analytics. Not true. As a one-time practitioner of analytics, back when it was called operations research in commercial industry, I saw firsthand the value of BD but also the very large expense and pitfalls. At the close of my first writing, I promised to follow up with a list of safety checks you should employ to avoid drowning in the big data ocean. Here they are.

Bad data. Big data and bad data do not mix. Before you jump in, you should get clear answers to these questions. Do you thoroughly understand what is in your data? How old is it? Where and how it was originally generated? What coding structures were used? How has the coding structures changed over time? How many system conversions and mutations has the data gone through? What is the consistency and integrity of your data?

Scrubbing your data, particularly if it goes back several years and/or transcends different information systems, is critical. A recent HIStalk piece written by Dan Raskin, MD covered this topic well. If you can’t answer these questions before you apply analytics, then all the conclusions you draw from your sophisticated analytics will be on a foundation of quicksand. And be aware, scrubbing historical data can be very time consuming and costly, which leads us to the next safety check.

Focus. Keep your focus as narrow as possible. When you jump in the BD ocean, keep your eyes on that floating life preserver. If you do not, you’ll get overwhelmed and sink fast. Most big data projects will fail because you tried to do too much or you were too broad in our goals, which led to loss of control, missed target dates, and over budget situations.

It’s very easy to fall into this riptide. For example, with a sea of data at our disposal, we surely should be able to predict census or institution-wide patient volumes for the next five or 10 years. The complexity of such an analytical model could easily overwhelm. As an alternative, try something more restricted and focused. For example, maybe just trying to predict volumes of a narrow specialty practice or identifying the three primary causes of re-admits. With a narrow focus, the probability of your model being useful will be far greater, which takes us to our next safety check.

Validate your model. Run simulations against past time periods with known outcomes. Did you get the answer you expected? If not revise, or replace the algorithm(s). Smaller models are easier to validate. Apply basic common sense against any prediction. Remember the end user, usually an executive or physician group, must buy in to the model logic and have full trust in the data before they can accept any predictions. If they do not understand it, they will not trust the forecasts and it the model will never be used. Once smaller models are validated, you can link multiple ones together to create larger organizational-wide models.

Change can sink your analytics. One of the primary reasons to apply models to big data is to predict change, then use that new knowledge to deal with the change before it becomes a problem. Unfortunately, there are some changes that your historical big data can’t predict. You need to understand them and factor them into any decisions you make. For example, can your model anticipate changes within the practice of medicine? Medical protocols change almost every month due to new research and new technologies. Hardly a week goes by without reading about a new protocol for medications, diagnostic testing, and chronic disease management. Your ocean of big data cannot predict these changes, and yet if you are planning a new medical service, you need to somehow factor in these elements.

Another unpredictable element is government regulations. A good deal of industry change will be driven by what party wins each election. Today it’s MU, ACOs, P4P, value-based purchasing, and many other regulations that did not exist five years ago. Tomorrow it will be something else. If you can predict those changes, you probably would do better in another profession. The analytics and models you build will only reflect past practices and governmental policies, and like they say on Wall Street, past performance may not be indicative of future results. In modeling building, these are known as ad hoc or exogenous variables. You take the model’s output then make a one-time swag adjustment to reflect your best guess for exogenous factors.

Pick the low-hanging fruit first. There are two major kinds of analytics: strategic models and operational models. Strategic analytics try to predict enterprise-wide outcomes and volumes five to 10 years out. They focus on questions such as: What are the population trends in our market? What patient programs should we be moving towards? Can they be financially viable? Where should they be located? What are the competitive factors?

Operational models deal with more immediate issues, such as: How can we handle higher patient volumes using less resources? What can we do to reduce re-admits? What is the ROI on a large capital investment? They are by nature near term and usually address efficiency questions.

Due to their complexity and time horizon, strategic analytics are tough to measure in terms of efficacy. Operational models are far easier to measure, while strategic models are sexier and costlier to build. Until you have had repeated good results with operational models, you should stay away from strategic models. The low-hanging fruit are in operational analytics. Moreover, there are a myriad of them that could quickly generate real ROI and may only require “little data.”

Paralysis by analysis. You could spend a long time drifting in the big data ocean and paralysis by analysis could easily set in. Remember, there will always be flaws in your historical data, and no model can be perfect, so do not let perfection become the enemy of good. This is not an academic exercise and you do not have an unlimited budget. All analytics need to be improved, so do it incrementally. Lastly, after many iterations and revisions and based on your real-life experiences, if the model still does not make sense to you, toss it out and move on.

Educate and understand. What problems are you really trying to solve? Many organizations waste time and money building models for problems they really do not have or understand. Due to hype, department managers come to believe the model will fix operational problems. Department managers need to be trained in how to use and interpret these powerful tools. Understand what the tool can and can’t do and what the real limitations of the model are. This step must come first or analytics projects can easily run amok

If you use outside resources, make sure they understand the healthcare industry and your particular venue. Being expert in quantitative tools is not enough. Having a sound footing in the complex relationships that drive the delivery of patient care is critical to the success of employing analytical tools.

Conclusion

The annual budget is an excellent example of an operational model. Before you jump into BD, take this test. How effective is your organization at budgeting? How close do you routinely come to hitting budget targets? Have you used variable budgeting successfully?

If you can’t answer these questions positively, you are not ready to swim in the BD ocean. Big data and analytics can be powerful tools when used with foresight and care. Applying BD without clearly identifying your objectives, being familiar with the weaknesses of your data, and not understanding the limits of mathematical modeling or analytical tools will be a costly and fruitless exercise.

Frank Poggio is president of The Kelzon Group.

Readers Write: The Three Most Important EHR Decisions (hint, it’s not whether to choose Epic or Cerner)

November 20, 2013 Readers Write 1 Comment

The Three Most Important EHR Decisions (hint, it’s not whether to choose Epic or Cerner)
By Chuck Garrity

11-20-2013 8-36-34 PM

As hospitals and physicians groups replace their current EHRs (and 17 percent of them did last year – either due to merger/acquisition or replacement of a “second tier” system), they traditionally focus on two things. First, which EHR platform to choose, and shortly after, who is going to implement the new EHR.

These are critical decisions on which technology and medical leadership teams rightly spend lots of money and time. And increasingly, they are choosing among a smaller and smaller number of solid partners that have established themselves as the smartest choice – as evidenced by third party rankings and success stories in publications such as this. Beyond these two, however, there are three other key decisions which must be made that have just as much impact on the ultimate success of an EHR switch.

Who goes first? Second? Last?

As we enter 2014 and beyond, practices who are still on paper will be subject to Meaningful Use reimbursement penalties, so they are a natural choice to put onto a replacement EHR first. After them, however, who should be next in line for the new system? Ideally it should be based on quantitative, thoughtful data, not just on the physician or office manager who raises their hand first.

Establishing a baseline of practice health – leadership, EHR usage, workflow, and technology — to stratifying a diverse network is critical. Using this baseline in conjunction with ongoing measurement at go-live to identify challenges, best practices, and areas requiring additional support is critical to a successful program.

How do you manage your legacy systems?

It’s generally a given that systems do not have the capacity or budget to move everyone over at the same time, that old systems will need to be maintained, and their data made accessible for some period of time. Can your support team focus on implementing and supporting the new EHR while keeping the lights on for legacy EHRs? Not by themselves – the core team must focus on the future, and practices can’t be left in the cold.

Practices on legacy EHRs generally need even more responsive technical and customer support in period of change, especially considering enterprise implementations could take 1-2 years, and the pressing regulatory deadlines of ICD-10, shared savings programs, and PQRS penalties are within that timeframe. This will lead to significant challenges while you’re training a support team on a brand new system while trying to maintain your legacy environment.

Where does the data go?

When implementing a new EHR, there is always the question of whether to migrate data or not. The natural answer is “of course” until you find the proverbial devil in the details. The legacy system may not meet discrete data standards, but rather might rely on custom fields or free text entry. There is rarely the ability to do a true 1:1 mapping and practices either convert a subset of the key data according to important quality and operational measures or the legacy data is migrated to an ambulatory data warehouse.

In either case, however, practices often miss an opportunity to examine and remediate quality of data issues. Using this migration as an opportunity to ensure apples-to-apples measurement based on consistent, dense, and correct data that reflects the quality of care being delivered is one that should not be wasted. Understand that under the future population health model, the quality of how the data is captured in the EHR that will directly drive revenue based on key quality measures. As such, data governance should be a primary consideration in your replacement strategy.

In the coming years, the majority of physician practices will likely move to a new EHR because they are not happy with their current vendor or are forced to adopt a new one due to a merger or acquisition. Multiple implementations are a major grind for physicians and their staff. Implementations should consider readiness and overall practice health.

While the choice of the EHR platform itself and the team that will implement it are the first and most critical decisions to be made, those organizations that focus on a data-based migration strategy from a holistic perspective — one that supports not only the new system but also the old while using the transition as an opportunity to strengthen their core data asset — will ensure they don’t yet another migration in the near future.

Chuck Garrity is regional vice president with Arcadia Healthcare Solutions.

Readers Write: Help Us, Atul Gawande, You’re Our Only Hope

November 15, 2013 Readers Write 7 Comments

Help Us, Atul Gawande, You’re Our Only Hope
By John Gobron

11-15-2013 7-32-39 PM

I recently had the pleasure of reading Atul Gawande’s essay, "Slow Ideas," published in The New Yorker. In it, Gawande discusses two innovations from healthcare’s past that profoundly and forever improved the delivery of patient care: anesthesia and antiseptics. Both advances provided obvious and impactful benefits to patients. One (anesthesia) was immediately and universally adopted, while the other (antiseptics) took a generation to become commonplace.

Why did the use of ether to numb pain "spread like a contagion?" Gawande argues it was because, while the patient was clearly better off in not suffering the agony of the surgeon’s knife, the surgeon himself benefited as well. After all, cutting someone open to practice painful, invasive surgery back then was, in fact, a risky business. Compare that to infection control. Back in 1875, antiseptic efforts were practiced by spraying everything and everybody with carbolic acid.  As the gentle reader might imagine, this wasn’t exactly a welcome or pleasurable experience for physicians.

As I read on, I kept waiting for what seemed to me to be the inevitable extension of the essay to address healthcare IT, where the adoption of the electronic health record promises to forever improve the entire healthcare ecosystem. After completing the article, I asked myself the sad question, "Are EMRs the carbolic acid of our generation?"

It is difficult to argue against the current and future benefit of the electronic medical record. Fourteen years ago, the Institute of Medicine estimated that as many as 98,000 patients per year die as a result of preventable medical errors, many of which were rooted in problems related to paper-based documentation and communications. Four years ago, the US government established a "pay then punish" wealth redistribution system for funding the adoption and actual use of EMRs. Outside of our healthcare biosphere, other industries accomplished similar computerization initiatives years ago. Yet despite the benefits, incentives, and examples, EMR adoption is mired in the 50 percent range. Why?

This really is the $23 billion dollar question, isn’t it? If there is a simple answer, it is that the physician does not benefit enough. Does this make them bad actors? Yes in the case of Travis Stork, but no for most everyone else. No other industry asks its highest-level knowledge workers to document the transactional activity found in most EMR data entry fields. CEOs don’t take minutes at board meetings, CFOs don’t tally balance sheets, lawyers don’t do stenography, and Congressmen don’t … well, I’ll leave this one alone, but hopefully you get the point.

Much has been written, especially here on HIStalk, about usability and design and other factors that go in to the actual EMR technologies. But the simple fact remains that for most physicians who practiced medicine in the paper age, paper was and remains better than anything that appears on a glass screen – for them, that is. Physically writing information down in a paper chart or even on a 3×5 card is much faster and more intimate than using a clunky PC or even a sexy tablet. Faster yet, is just telling someone else what to write down or enter into said computer or Appley gadget.

Let’s face it: physicians become physicians to treat patients and to participate in the miraculous science of medicine. Under that paradigm, paper is really good for the physician workflow and computers are really good for research. A physician can physically maintain her focus on the patient infinitely better when writing than when looking back and forth at a keyboard and screen.

In his summary thoughts on adoption, Gawande notes, "To create new norms, you have to understand people’s existing norms and barriers to change. You have to understand what’s getting in their way." What is getting in the physician’s way? Time, first and foremost. With today’s clinical computing workflow, it simply takes too much time and proves too distracting to document within the requirements and constraints set out by IOM, Joint Commission, HITECH, HIPAA, Meaningful Use, etc.

Much like adopting the use of sterile instruments and working conditions, adopting the use of an electronic health record adds burden to the physicians. As Gawande notes, “although both [anesthesia and antiseptics] made life better for patients, only one made life better for doctors.” Today, for some reason we are asking these same doctors to do what amounts to data entry. Therein I think is our lesson for anyone engaged in the mission of better adoption of EMRs — make life better for doctors. It’s not really as complicated a task when you look at it that way.

Think about all of the unlucky people who died from infection between 1875-1905 while healthcare waited a full generation to adopt an enormously beneficial change. Are we to see the similar fate of 98,000 people per year for the next 30 years to achieve the same outcome? Can the dead teach the living, and 138 years later, make it better this time around?

As I see it, we have three choices:

  1. Send a holographic message to Atul Gawande asking him to figure this out for us (Inga has volunteered to send this message, btw).
  2. Sit back and wait a generation until our digital native teenagers mature to replace today’s clinical computing-averse physicians.
  3. Redesign and bind the disparate processes of clinical workflow, clinical computing, and reimbursement together so that the benefits of healthcare as an electronic medium align with the efforts needed to achieve clinical computing adoption.

Healthcare delivery organizations, if you want to finally realize the benefits of improved outcomes, patient engagement, and ultimately preventative care, make the required workflow and infrastructure easy and economically advantageous for physicians to use-without needing to be bribed by the government.

I believe today’s healthcare executives are in the enviable position of being able to write their names in the history books as the alchemists who transformed their foaming beakers of physician-burning carbolic acid into the clinical computing manifestation of nitrous oxide. In addition to smiling, your doctors, your health system, your nation’s economy, and your patients will thank you when you pull this off.

I close with Atul Gawande’s simple instructions. “Use the force, Luke”, (sorry, I couldn’t resist)  What Dr. Gawande actually said was, "We yearn for frictionless, technological solutions. But people talking to people is still the way that norms and standards change."

John Gobron is president and CEO of AventuraHQ.

Readers Write: Managing the Complexities of Enterprise Platforms

November 15, 2013 Readers Write No Comments

Managing the Complexities of Enterprise Platforms
By Deborah Kohn

During August 2013, a Mr. HIStalk post reported the storing of patient (protected) health information (PHI) using consumer-grade services (a.k.a., enterprise platforms) that are cloud-based rather than on-premise-based. Disturbed by the post’s report, Mr. HIStalk replied with several rhetorical questions, such as,“What system deficiencies created the need to store [patient] information on consumer-grade services in the first place?” Later that month, Mr. HIStalk asked his CIO Advisory Panel to comment on policies or technologies used to prevent clinicians and employees from storing patient information on cloud-based consumer applications, such as Google Docs or Dropbox. Of the 19 replies, 60 percent block access to such services and / or have policies with random audits or other forms of monitoring.

Consumer-grade service and enterprise platform vendors include Google, Microsoft (MS), Accellion, Box, Dropbox, and others. The services (or applications or tools) provided by these vendors on their platforms include but are not limited to file storage / sharing and synchronization (FSS), mobile content management, document management, and, perhaps, most importantly, project and team collaboration.

For example, Google’s comprehensive suite of cloud-based services, Google Drive (FSS), includes but is not limited to Google Docs (collaborative office and productivity apps, now housed in Google Drive), Google Mail and Calendar, and Google Sites (sharing information on secure intranets for project and team collaboration). Box’s suite of cloud-based services includes but is not limited to mobile content management, project collaboration, a virtual data room, document management, and integration with Google Docs.

Historically, Microsoft SharePoint had been associated with on-premise document management and intranet content management. Over the years, broader, on-premise web applications were added to provide intranets, extranets, portals, and public-facing web sites as well as technologies, which provided team workflow automation and collaboration, sharing, and document editing services. SharePoint 2013 offers services in the cloud (and on-premise) and it includes but is not limited to Office 365 (the famous office and productivity apps, which now can be rented rather than purchased), Outlook (calendar), Exchange (mail), records management, e-discovery, and search.

I have worked with most of the above services and platforms in healthcare organizations. Since today’s digital experience is all about connecting and collaborating with others, I strongly believe the above services and platforms are important and useful for provider organizations, primarily because most of the services (or applications or tools) are not present in provider organization line-of-business systems. For example, with Google Drive, a resident can create a patient location spreadsheet in a cloud application, such as Google Docs, share it with colleagues, edit it on a tablet device, and push revisions to a collaboration site. Blocking access to these services penalizes employees by not allowing them to use robust collaboration tools.

In addition, I strongly believe the internal organizational policies and procedures that are developed for such services are sub-optimal at best. Unfortunately, most FSS services do not encrypt content, possibly exposing content to interception in violation of regulatory obligations, such as HIPAA. Yet organizational policies that manage encryption, backup, and archiving for content sent through email or FTP systems typically are not applied to the content sent through FSS services.

If provider organizations were to deploy formal information governance (IG) principles (e.g., electronic records management principles) with many of these enterprise services and platforms, onerous access blocking could be eliminated and policies and procedures could be improved. Unfortunately, like most services (or applications or tools), deploying IG principles for enterprise services is complex. In addition, deployment requires resources with knowledge of and experience in the information governance principles. However, the trade-off is that provider organizations can meet other legal, regulatory, and compliance requirements, such as e-discovery, without additional resources or effort.

As such, below is a step-by-step, basic, electronic records management guide to help protect what needs to be protected while allowing access to what needs to be shared and to gain value from cloud-based services and platforms while addressing compliance and governance standards.

  1. Clearly define as "documents" all content generated in (for example) GoogleDocs, SharePoint 2013, or Dropbox. A document is any analog or digital, formatted, and preserved "container" of structured or unstructured data or information. A document can be word processed or it can be a spreadsheet, a presentation, a form, a diagnostic image, a video clip, an audio clip, or a template of structured data.
  2. For legal and compliance purposes, declare as “records” those “documents” in GoogleDocs, SharePoint 2013 or Dropbox that 1) follow a life-cycle (i.e., the “documents” are created or received, maintained, used, and require security, preservation and final disposition, such as destruction); 2) must be assigned a retention schedule; and, 3) the content must be locked once the “document” is declared a “record”. Records are different from documents. All documents are potential records but not vice versa.
  3. Again for legal and compliance purposes, designate all the records as either “official” or “unofficial.” Official records include those documents that were generated or received in GoogleDocs, SharePoint 2013 or Dropbox and subsequently declared as records according to the above records characteristics. In addition, official records are created or received as evidence of organizational transactions or events that reflect the business objectives of the organization (e.g., receiving reimbursement for services provided, providing patient care); and qualify as exercises of legal and / or regulatory obligations and rights (i.e., have evidentiary and / or regulatory value). Unofficial records include those documents that were generated or received in GoogleDocs, SharePoint 2013 or Dropbox and subsequently declared as records according to the above records characteristics. However, unofficial records will not further organizational business, legal, or regulatory needs if the records are retained. Typically, unofficial records are retained only for the period of time in which they are active and useful to a particular person or department. Often organizational retention policies allow unofficial records to be retained for x number of years after last modification, but typically no longer than official records. Examples of unofficial records are (what are typically but erroneously called) working “documents”, draft “documents”, reference “documents”, personal copies of documents or records, and copies of official records for convenience purposes.
  4. Retain all the documents and official / unofficial records in GoogleDocs, SharePoint 2013 or Dropbox in separate, physically, but logically-linked electronic repositories. For example, “documents” can be stored on individuals’ hard drives. Once documents are declared “records”, the official records (e.g., patient records [including patient-related text messages / email messages /social media entries], employee records, patient spreadsheets, etc.) must be parsed and placed into a secured electronic repository, similar to the organization’s line-of-business system or systems-of-record repositories; e.g., EHR, Vendor Neutral Archive, financial system — with audit trails, access controls, etc. The unofficial records (e.g., working documents, reference records, etc.) can be stored on organizational shared drives.

Currently, many of the service and platform configurations and capabilities are not intended for long-term electronic record retention and security purposes and should not be used as healthcare organizations’ electronic repositories of official records. For example, no comprehensive, electronic records management, document management, or content management functionality exists on Google Drive. Once the record owners leave the organization and fail to reassign ownership, the official records could be subject to automatic deletion after x number of years. However, Google is introducing new Google Drive tools that might assist in better management of official records.

On the other hand, cloud providers are increasingly supporting content segregation, security, privacy, and data sovereignty requirements to attract regulated industries and are offering service level agreements and HIPAA business associate agreements (BAAs) designed to reduce risks. In September, Google announced a HIPAA BAA for the following Google App services: Gmail, Google Calendar, Google Drive, and Google Apps Vault. Alternatively, Accellion has extended its reach beyond data stored in its application by integrating with enterprise content management (ECM) systems, allowing users to connect right from their mobile devices to secured back end, typically on-premise repositories, such as SharePoint.

Deborah Kohn, MPH, RHIA, FACHE, CPHIMS, CIP is a principal with Dak Systems Consulting.

Readers Write: ACA versus ICD-10: US Media Failure and Why I Really Can’t Sleep At Night

November 15, 2013 Readers Write No Comments

ACA versus ICD-10: US Media Failure and Why I Really Can’t Sleep At Night
By Rebecca Wiedmeyer

11-15-2013 7-17-57 PM

Thanks to the ever-pervasive, sound bite-driven American media outlets, many citizens have predisposed notions surrounding the Affordable Care Act (a.k.a Obamacare) and the “mishandling” of Healthcare.gov (for anyone out of the loop, there has been a struggle for individuals to log on and apply for the payer program offered by the ACA.) The  US mass media, along with the American government, has made this a key election issue and a prequel to the political debates  ahead of us in 2016. If the ACA is keeping you awake at night, I challenge you to consider the opinion of an insider in the field.

In its infancy, the ACA was a platform that immediately drew attention from political parties, physicians, and many in the healthcare field (myself included.) Subsequent to its introduction, this bill has morphed into a 2,700+  page, over-earmarked staple of Congress that, while admirably striving for change in healthcare, is not quite what either side of party lines was aiming to achieve. Meanwhile, there are initiatives and deadlines that loom ominously. Foremost, at least in my mind, is ICD-10 compliance.

Less than a year away, the ICD-10 movement is set to completely disrupt the current workflows, reimbursement  models, and documentation practices within healthcare IT. As a nation, we are set to transition between the current system of ICD-9 (~18,000 codes) to the WHO-approved (as of 20 years ago) system of coding, which utilizes around 146,000 codes. As anyone in HIT can imagine, this will have trickle-down effects that are unfathomable. Revenue will almost certainly be lost, practices will bankrupt, vendors will go out of business, and, the most incomprehensible part to me, this issue seems to be low on the list of agenda items for the American public, but also our field.

Not that there are a lack of exceptions. Many EHR vendors I have collaborated with, for instance, have a firm grasp of the gravity of ICD-10. Even more encouraging, there are vendors specializing in the education of physicians and directors, as well as billing offices and coders, with regards to compliance. However, with less than a year to go, the clock is ticking.

I have spoken candidly with industry executives who admitted building into budget up to a 70 percent revenue loss upon the introduction to ICD-10. Physicians deserve better than that and patients deserve better than that, not to mention the vendors that are at the mercy of government policy and its whim (not to mention client demands.) Agenda-setting has gone too far.

For any sleepless nights regarding the ACA, I am the first to concede it is far from perfect, so perhaps your anxiety is not unfounded. However, a lack of understanding of what is ahead looms as a far more dangerous challenge than a lackluster website performance of the moment.

Rebecca Wiedmeyer is chief communications officer of EHR Scope.

Readers Write: Big Data: Enabling the Future of Healthcare

November 6, 2013 Readers Write No Comments

Big Data: Enabling the Future of Healthcare
By Anthony Jones, MD

11-6-2013 12-38-27 PM

Everyone’s talking about the importance of big data in healthcare. Yet as the data piles up – most of it still in different silos – health systems are struggling to turn big data from just a concept into a reality. Here’s how I see big data having the biggest impact on the health of populations, both today and tomorrow.

Most healthcare organizations today are using two sets of data: retrospective (basic event-based information collected from medical records or insurance claims) and real-time clinical (the information captured and presented at the point of care  — imaging, blood pressure, oxygen saturation , heart rate, etc.). For example, if a diabetic patient enters the hospital complaining about numbness in their toes, instead of immediately assuming the cause is their diabetes, the clinician could monitor their blood flow and oxygen saturation and potentially determine if there’s something more threatening — like an aneurism or stroke — around the corner.

Where real pioneering technologies have succeeded is putting these two data pieces together in a way that clinicians can grasp the relevant information and use it to identify trends that will impact the future of healthcare – predictive analytics. So for example, if more diabetic patients start to present a similar trend of numbness in their toes, the coupling of real-time and retrospective data can potentially help doctors analyze how treatments will work on a particular population. This gives hospitals a much stronger ability to develop preventative and longer-term services customized for their patients.

Now what if we take data a step further and introduce gene sequencing into the picture? Today, gene sequencing is used primarily to determine the course of treatment for cancer patients. As we reach an inflection point in the cost of gene sequencing, this data will be routinely added to a patient’s health record. Imagine the kind of impact this data will have on treating infectious diseases, where hours and even minutes matter. The next time there’s a disease outbreak, we could potentially know the genome of the infectious organism, the susceptibility of the organism to various antibiotic therapies, and determine the correct course of action without wasting precious resources in trial and error.

Undoubtedly, we have yet to determine the most practical, cost effective way to manage this kind of data. To put it into perspective, the human body contains nearly 150 trillion gigabytes of information. Imagine collecting that kind of data for an entire population.

There’s no doubt this is a mammoth task, and while we might not be there yet, we are certainly getting closer. There are still challenges ahead: organizations are learning lessons from the early adopters and trying to determine the best ways to cooperate and share data. Undoubtedly the amount of investment required to make big data technologies work is more than what a single segment of the market can afford. That means all stakeholders, including pharma, will have to work toward a common vision. But with Accountable Care Organizations paving the path for payers and providers to work more closely together, we are heading toward success, and more importantly, better patient care.

Anthony Jones, MD is chief marketing officer, patient care and clinical informatics, for Philips Healthcare.

Readers Write: Epic Concerns

November 6, 2013 Readers Write 18 Comments

Epic Concerns
By Long-Time Epic Customer

Wake Forest Baptist is just the tip of the iceberg for Epic clients struggling with revenue, based on conversations I’d had with various contacts at UGM. There was quite the buzz about a large number of customers with revenue concerns who are not hitting the news. Yet.

We installed Epic years ago, but have seen a vast difference between our prior experience and a recent rollout of newer products. The method where time was taken to help us build our own system has been replaced by a rushed, prefab Model system installed by staff where even the advisers and escalation points at Epic have little knowledge of their applications. Epic has always had newer people, but it was much more common to have advisers during the install who did have experience to watch for pitfalls.

Though today’s economy is certainly a large factor in any revenue struggles, I am unsurprised by stories like Wake Forest or Maine and believe Epic should have seen some of it coming. We had enough experience with Epic to spot trouble with new products. New clients likely don’t have that built up yet, and they probably rolled off the cliff with nothing but green lights on Epic’s reviews of their install progress from newbies who didn’t know any better.

It feels like Epic tossed a winning formula in favor of a faster, cheaper install. What many of us are getting ends up being cheaper, indeed. That is a tough contrast to reconcile at UGM. After getting my ears blown out at an expensive, new, rarely-used auditorium that was just built to replace a barely older, rarely-used auditorium, Judy spoke at length about how the campus was cost-efficient and made employees more productive. Many of us are developing an alternative thesis, which is that productivity has been getting squeezed (and compromised) to support the costs of the campus.

I want to keep loving Epic. They are still good, but their services are declining.  The campus strikes a nerve with many clients who justifiably wonder whether our vendor is investing in the things that made them great when we’re getting answers, solutions, fixes, and reports slower than ever.

Readers Write: Applying Lean Startup Principles to Optimization

November 6, 2013 Readers Write 1 Comment

Applying Lean Startup Principles to Optimization
By Tyler Smith

11-6-2013 12-24-41 PM

If you haven’t had the chance to read Eric Ries’ 2011 bestseller The Lean Startup, I highly recommend adding it to your reading list. Typically, I am not a big fan of business literature, but I found the book particularly stimulating, largely because its concepts can be readily applied to that currently hot phase of EMR projects – optimization.

After all, entrepreneurism, Ries insists, is not limited to dorm rooms and Silicon Valley garages. Instead, Ries contends that the processes inherent to entrepreneurism can and should take place in large, established institutions – say large healthcare organizations – via the efforts of "intrapreneurs.” Ries goes on to outline the principles of the lean startup and Ries’ fourth principle of the lean startup – Build-Measure-Learn – provides an excellent framework for the optimization phase of EMR systems projects.

The build-measure-learn feedback loop, according to Ries, is one of the key activities that entrepreneurs and “intrapreneurs” alike must perform. In the build-measure-learn feedback loop, minimum viable products (MVPs) are built by entrepreneurs to test certain product and market hypotheses. These MVPs are launched quickly in order to enable entrepreneurs to gather relevant data fast – prior to making large investments of time or money. Using the data generated by the MVP launch, entrepreneurs must then swiftly validate or refute their hypotheses. If the MVP data does not clearly point to success, then the entrepreneurs must use what they learn about their MVP to iterate by building another prototype based upon a modified or newly formed hypothesis and start the cycle all over again.

Here is an example of how I see the feedback loop being utilized during EMR system optimization:

  1. Hospital administrators have mandated that population management be the first major undertaking of the optimization team.
  2. As the first order of business for the population management initiative, the optimization team is tasked with implementing a health maintenance alert mechanism.
  3. While there are a number of different ways that the activity can be instituted, the optimization team meets and decides that since feedback has indicated that providers prefer mobile alerts to desktop alerts, the team will implement the transmission of daily, HIPAA-compliant text message to providers that will provide the providers with patient specific alerts regarding patient health maintenance.
  4. Using the small batch approach advocated by Ries, the optimization team implements the text messages for breast cancer screening and HIV screening only (their MVP) with the intention to expand the text message content to other conditions if the MVP is successful.
  5. After implementation, the optimization team follows up with the end users every few days to check on the initiative, only to learn that most providers aren’t really using the functionality.
  6. When the team queries staff, they learn that providers are not receiving the daily text message until after having seen the first patient of the day and are complaining that messages are long and cumbersome.
  7. After reviewing the data, the team must decide whether the whole idea should be scrapped or whether a few tweaks will fix the MVP’s obvious issues.
  8. The team theorizes that the lack of effectiveness of their MVP is due to lengthy and poorly timed text alerts.
  9. Based upon their conclusion, the team makes the decision to send shorter messages at 5 a.m. each day.
  10. The team builds and launches this new MVP and thus the loop starts over.

In many institutions where the build-measure-learn feedback loop is not utilized, optimization projects check off an optimization as complete after Step 4. What appears to be a premature ending of a particular initiative is not necessarily caused by a lack of understanding of the need for follow up, but is often due to the long list of optimizations that need to be executed. Teams falling into this category are often tasked with implementing a large quantity of optimizations or checking off a few high profile optimizations, but not explicitly tasked with actual optimization as the end result.

Teams in this aforementioned category fall prey to what Ries calls vanity metrics. As Ries warns, vanity metrics are sets of data which companies use to bolster their perceived success but do not really measure criteria that contribute to the actual stated goal. Teams tasked with long laundry lists of items to check off are prone to this trap. If simply going through and performing optimizations for a laundry list of topics allows the team to state that they have accomplished x number of optimizations and then tout this metric, but at the same time end users feel as if there has been no real optimization of the system, then this x number statistic is a vanity metric. Teams must avoid the allure of vanity metrics and ensure that a solid feedback loop is in place.

Recently, Dr. Val wrote of EMR, “My initial enthusiasm has turned to exasperation and near despondency.” She cited that she is not sure that simply getting the bugs out will fix the issue. I cannot comment specifically on Dr. Val’s issue, but I can only say that if the bugs are truly ever going to be got out, it is going to require more than checking optimization items off a list. The real optimization is going to come about via a fully robust effort by optimizers to build, measure, and learn. That is why the time is so ripe to apply lean startup principles to optimization.

Tyler Smith is a consultant with TJPS Consulting.

Readers Write: Organizational Mergers

November 6, 2013 Readers Write No Comments

Organizational Mergers
By Anonymous CIO

Last fall, a full asset merger of our hospital into a larger health system in the region was announced. This has become a common event in our state and was strategically important to our organization.

Both organizations had developed working relationships in several clinical areas over the years, so at least some synergy had already been established. Geographically, the merger appears logical and based on sound thinking. Ours will become branded as part of the larger, well-regarded health system, and positioned well to confront the ongoing evolution of health care in our region and the country.

The agreement amongst the parties established the agenda for IT. From the outset, project plans were developed and staffing focused on achieving important goals by the established milestone dates. Fortunately, some date slippage in the regulatory approval process provided us with a bit more breathing room than what was originally expected.

Short-term initiatives have included the following:

  1. Establish connection between the entities and the trust among disparate networks to enable coexistence of e-mail, calendar, and access to each other’s systems.
  2. Migration of all personnel to the health system’s payroll and human resources applications including the replacement of all aspects of time collection, payroll, and people management by Day 1.
  3. Establish the larger health system’s financial systems as the final collector and reporter of all numbers and statistics, meaning that all data from our systems (comprised primarily of a core, integrated, community hospital system) would be fed to the designated systems of the larger enterprise. Support the consolidation of business office functions at the enterprise’s corporate headquarters.
  4. Retain our clinical systems for now due to our progress with Meaningful Use, ICD-10, clinical documentation improvement, and local acceptance of that system. Become part of a larger enterprise-wide clinical system decision and migration within the next two to three years.
  5. Continue local initiatives such as participation with HIE, ARRA Stage 2, expansion of our electronic patient records efforts, physician compliance with on-line documentation, and individual physician bonding efforts such as BYOD, electronic rounding tools, etc.
  6. Replace our physician practice/EHR system deployment efforts with the solution provided by the health system.
  7. Prepare for absorption of our IT infrastructure team (network, hardware, PC support) into that of the health system; retain the core applications team to continue to support our legacy system for the duration of its existence.
  8. Prepare for my own absorption into the health system with a different title along with changing roles and responsibilities. This includes the adjustment of my vision and plans from that of a single entity CIO to a role that will cross all aspects of the enterprise.

Observations on the effort to date:

  1. Attitude. Although it’s clear who will run (or, is running) the larger health enterprise, those who we’re working with from the health system have the strength of character not to conduct this combined work effort as a siege of greater over lesser. As a result, our team does not feel besieged, and cooperation prevails.
  2. Project management. Efforts of this magnitude don’t go well without the expertise of highly engaged and empowered professionals to oversee the details. The health system has several of those and the ones assigned to our project are excellent.
  3. Few versus many. Many project teams have been established to execute each of the planned efforts. It’s truly comical when our community hospital team shows up with so many of the same people for each effort while the health system often brings a unique set of experts. It’s the best visual representation of working vertically versus working horizontally that I’ve seen in a while.
  4. Disagreement management. Both sides need a clear path of hierarchy to resolve differences in understanding of the goals. Even in the best of cases this can (and does) occur so a time-efficient escalation process is needed to discuss, digest, and resolve issues as they arise.

Readers Write: ICD-10: The Race is On and the Clock is Ticking

October 23, 2013 Readers Write 1 Comment

ICD-10: The Race is On and the Clock is Ticking
By Honora Roberts

10-23-2013 9-48-22 PM

For providers, the reality of healthcare has changed greatly in the past couple of years. Practicing medicine now revolves around an electronic health record, clinical decision support, and analytics. Reality will soon change again with a new and expanded coding “formulary,” ICD-10.

It’s no secret that this coding change spreads across every facet of operations, from clinical care and administration to finance, IT, and more. The move from the ICD-9 code set that has been in place since 1979 to ICD-10 represents a five-fold increase in the number of codes to learn, know, and apply. ICD-10 consists of 69,000 diagnosis codes (up from 14,000) and 72,000 procedure codes (up from 4,000.) Administrators, physicians, allied health professionals, billing departments, coding professionals, IT departments, and more face a new reality. The time to begin embracing this new reality is now, but where do you begin?

This shift to ICD-10 is a lot like “The Amazing Race” TV show in which teams race across cities and continents to find clues to their next required destination. While providers know the destination, they face tough terrain and unexpected obstacles. Start by knowing your greatest exposures – physician education and documentation improvements; loss of reimbursement; coder education; computer system and payer readiness; and regulatory compliance. Then focus on a couple of critical areas to avoid getting lost in this amazing race toward ICD-10 compliance.

Prioritize the 141,000. Despite the spike in number of codes, reality is that providers often will use a small subset of codes. To compress the initial transformation, begin prioritizing the codes most relevant to your institutions, physicians, and specialists. Once these are prioritized, you can begin mapping ICD-9 codes to the new ICD-10 code set. In essence, you’re starting by building an initial cross-walk or critical path between the two coding standards.

Test and remediate. Make sure the technical upgrades perform and deliver as designed, then test and remediate before they are used in the real world. When testing, set up real people in real workflows. Include physicians and nurses, specialists, coders, and others who provide a broad view of the systems and workflows. This testing will allow you to pinpoint common errors so that the technology can be customized to catch errors that can harm patients.

Improve documentation. Physicians and clinicians don’t care about ICD-10. They do care about improving the quality of care and doing no harm. Emphasize documentation improvement and provide the education, tools and process improvements to achieve improved documentation that, by the way, also complies with ICD-10.

Pursue proficiency. Your people will make the difference in success. Making sure they succeed requires training. Be sure to target training programs to your personnel’s specific roles and usage of ICD-10 codes. Role-based learning will improve speed to proficiency, improved adoption rates, and overall sustainability of your organization. Once staff members gain confidence on routine tasks, they will quickly gain efficiency that is sustainable over time. Job aids and reusability of learning are tools that reinforce learning and confidence. Start with your coders, if you haven’t already. Track results — comprehensive adoption requires continuous oversight and measurement.

Optimize beyond the transition. Once you’ve met the deadline, perform a post-deadline assessment and chart review to begin a genuine clinical documentation improvement program. The baseline you established at the start of the process will help you identify problem areas and remediate.

Manage the risk. Knowing your current situation and associated risks is a great place to start. By knowing the risk, you can establish plans to lessen their impact such as:

  • Adjust budgets and develop strategies for potential reimbursement reductions
  • Plan for lower productivity during the transition, which might take up to a year beyond October 1, 2014
  • Developing contingency plans for high-risk areas, such as high-volume departments or adoption concerns.
  • Instituting a well-defined and well-communicated governance and escalation process for issues that arise

Lead the change. Acknowledge that this change isn’t a technology or systems integration project alone. It is a significant organizational change. It involves people, processes, workflows, and technologies that extend beyond walls and buildings. A change this large needs to be managed from the very top of the organization and employees need to hear frequent updates to let them know how the organization as a whole is doing.

Ultimately, most providers in the United States are scurrying to execute a plan to make the transition to ICD-10. You still have time, but the clock is ticking. Don’t get lost in the details; focus on the critical few areas that will make or break the transition for your organization. Through support from your internal team—and the expertise from quality vendors, consultants and other experts—compliance is achievable.

Honora Roberts is vice president of health provider services at Xerox.

Readers Write: ONC Mission Reflections

October 23, 2013 Readers Write 5 Comments

ONC Mission Reflections
By Helen Figge, CPHIMS, FHIMSS

The leadership at ONC will be shifting a bit as Farzad Mostashari and David Muntz return to the private sector, having given the industry another steep dose of healthcare leadership excellence. It has been appreciated for some time now that the Office of the National Coordinator for Health Information Technology (ONC) was meant to be a compass to support the adoption of various pieces of health information technology, to promote a unified health information exchange platform, and to improve health care for us all. But any compass needs great leaders to man the ship. Not only leaders with skills to lead, but character traits steeped in ethical and wisdom offering guidance. Farzad and David were those captains that moved us forward with the national healthcare IT efforts through their decency, ability to lead by example, and just a genuine sense of being a very nice person that anyone would want to follow or work side by side with.

Remembering the inception of ONC, where many of us hold this office with high regard and respect, hoping that policies created for our healthcare delivery will minimize medical errors while simultaneously aspiring healthcare stakeholders to share patient information all to improve patient care. Payer and the government had aspirations these ONC programs would save money by improving efficiency.

We can conclude however that not all healthcare providers have fully embraced these technologies, but many of the healthcare providers have indeed done so and successfully thanks to the leadership of the past ONC leaders but now recently these two respected individuals in healthcare IT today.

So as we see these two individuals depart ONC, their legacies have indeed culminated into an ongoing improvement in the delivery of healthcare and leaving their posts having helped and move forward the agenda for us all in healthcare reform.

Farzad, while intelligent was also extremely charismatic helping to catapult the acronym “EHRs” into our daily healthcare conversations. He talked about EHRs like the latest and greatest gadget we all needed to try. David will leave behind a legacy of true collaboration and mentoring others in the healthcare IT landscape where often times it was a language in and of itself. David made healthcare IT logical and worthy of conversation even to those not so tech savvy. David’s ability of being extremely diligent and insightful while creating the conversation around healthcare technology was welcomed by all the non-CIOs as well as his peers in the industry. That is a true leader.

Often times we hear the phrase “it takes a village” to accomplish something. And yes that is quite true, but a true leader of that village, listens, digests, analyzes, and then reacts to a situation. A true leader does not lead by intimidation or dictatorship, but though consensus and character traits of leaving a place better than how it was found. Farzad and David each had their own attributes, but together created a uniform approach to an otherwise confusing state of healthcare affairs. These two individuals leave legacies of offering leadership through example and while their physical presence will be missed, their polices and professional attributes that have created the current ONC landscape will move forward, with another group of leaders who we all hope have the same level of integrity and respect these two have had from the industry at large.

Remember, someone wise once said, “Tthe world is filled with 99 percent followers and 1 percent true leaders”. Farzad and David fit into the 1 percent group quite comfortably.

Helen Figge, CPHIMS, FHIMSS is is VP of clinical integration for Alere ACS.

Readers Write: Maintaining Customer Loyalty Despite Our Mistakes

October 9, 2013 Readers Write No Comments

Maintaining Customer Loyalty Despite Our Mistakes
By Ryan Secan, MD, MPH

Who can spot the difference between these two uses of the words “I’m sorry”:

  • “I’m sorry you have a black eye” vs. “I’m sorry I punched you in the face”
  • “I’m sorry you lost money in a Ponzi scheme” vs. “I’m sorry I stole all of your money”
  • “I’m sorry you need another operation” vs. “I’m sorry I left an instrument in your abdomen”

In the first cases, “I’m sorry” is an expression of sympathy, in the second, it is an apology. The word that follows “sorry” makes all the difference. “I’m sorry you…” is an expression of sympathy, “I’m sorry I…” is an apology (also note the passive voice in the first examples vs. active voice in the second – this is classic for the “mistakes were made” rhetorical device).

It’s easy to see the difference in the above examples. The tough part is that when we’re deep in a situation (and maybe we’re feeling shame, or embarrassment, or want to avoid responsibility) it is easy to offer sympathy to someone who really deserves an apology. The victim dealing with the bad outcome, while likely appreciative of your sympathy, really wants and deserves an apology. Regardless of how much sympathy you offer, on some level, they are not going to be satisfied without a true apology.

In all aspects of life, there are occasional bad outcomes. As a physician, I unfortunately see these far too frequently. These can be in our business or personal relationships as well. Bad outcomes often take place despite our very best efforts to prevent them. The universe isn’t always fair.

However, sometimes we make mistakes that lead to the bad outcomes. Since we all want to provide great customer service (or have high quality relationships in our personal lives), these bad outcomes need to be addressed. In medicine, culture is finally shifting away from the expression of sympathy to the apology (when appropriate). At the University of Michigan, a comprehensive medical disclosure policy (including an offer of compensation) has been put into place leading to a significant decrease in new claims, lawsuits, and costs. Part of the reason this policy has been successful is that it includes a discussion of the plan for preventing the same mistake for happening again.

Also, don’t use the word “but” in your apology and expect it to mean something. Think of one of the examples above, and how it would sound with a “but” in it:

  • “I’m sorry I punched you in the face, but …”

What can you possibly say after the “but”, that isn’t an attempt to weasel out of responsibility and negate the apology? While you should explain what happened (and what you’re going to do to prevent it from happening again), don’t try to qualify your apology with it. Remember, even if they haven’t heard the saying before, intuitively, people know that “everything that comes before the ‘but’ is BS.”

The next time you make a mistake with a customer or in your personal life (and we know it’s going to happen soon enough), consider offering a sincere apology – (active voice, “I’m sorry I”, no “but”, best possible redress, and plan for prevention in the future). You might be surprised at how well this improves your customer’s loyalty.

Ryan Secan, MD, MPH is chief medical officer of MedAptus.

Readers Write: The True Benefit of Big Data in Healthcare: A Perspective from the Industry

October 9, 2013 Readers Write 1 Comment

The True Benefit of Big Data in Healthcare: A Perspective from the Industry
By Rich Temple

10-9-2013 3-17-55 PM

In response to a September 9, 2013 “Readers Write” article that suggests “big data” is the next boondoggle, I would like to illustrate the promise of big data, also referred to as business intelligence and analytics (BI) in healthcare. In that post, the author alludes to the challenges faced by industries embarking on big data journeys dating back to the 1960s.

While the struggles he noted were valid through those experiences, so much is different now in terms of the absolute necessity of big data in healthcare, as well as the exponentially-improved technology that can crunch numbers in nanoseconds. We need to recognize that the game has changed and now is the time for BI to make a significant impact to improve healthcare.

In general, broad concepts such as BI do have the potential to run aground in industries where they are treated as “nice to have.” The healthcare industry in 2013 is at a key inflection point where it absolutely cannot move forward without key BI and analytics as an engine for these healthcare reform initiatives, as well as many others:

  • Accountable Care Organizations (ACOs)
  • Population Health
  • Health Information Exchanges (HIEs)
  • Health Insurance Exchanges (HIXs)
  • Value-based purchasing reimbursement initiatives
  • Reporting regulatory requirements around quality and cost coming from the government

BI and analytics become the fuel that powers the healthcare industry’s ability to fulfill its obligations to all its stakeholders under healthcare reform. If we are going to improve the quality of care necessary for the above mentioned healthcare programs, BI will need to be used to provide information with the highest level of integrity possible for accurate decision-making across the healthcare industry. When a concept reaches a critical mass as an essential business driver for growth and sustainability for healthcare providers, it should not be seen as a boondoggle.

While healthcare still has quite a way to go on its journey toward true interoperability across systems, recent initiatives, such as Meaningful Use, ACOs, HIEs, among others, point to just how much has been achieved in mitigating the data integrity challenges that the author notes. These challenges are not only being addressed, but are in the process of being solved by current initiatives to connect systems and organization through:

  • HIEs
  • HIXs
  • Interoperability between hospitals and their affiliated physician networks
  • ACOs

Recent mandates involving coalescing around particular standards (e.g., LOINC) also help facilitate interoperability. As these challenges continue to be worked through, it becomes that much easier to extract truly actionable information from the mounds of data that are housed in our disparate healthcare information systems.

Another key differentiator that makes BI not only possible, but achievable in ways that it could never have been until recently, is the advanced technology that is now available to process staggering amounts of data in time units measured in seconds or minutes, as opposed to weeks, months, or years. With new BI technologies such as Hadoop, it is no longer ridiculous to assume that an organization can mine many terabytes of data in just seconds.

In the past, organizations had no way to access all that data in nearly real-time, rendering a lot of their efforts to come to naught. Today, we do have that capability. When today’s consumer cell phones contain more sophisticated computing technology than the Apollo rockets that landed on the moon, it has to be taken as a given that certain challenges that industries grappled with in the past no longer apply to today’s world of BI.

Given the tumult in healthcare and the new abilities to use data in ways previously thought impossible, I see BI not as a boondoggle, but as an essential component of any healthcare organization’s survivability. The author is spot-on when he expresses concerns about the challenges of harmonizing data across disparate provider and functional systems; all systems, whether they are EHR, payer, decision-support, financial, case management, or one of many others, need to communicate much richer information than ever before. But the changing face of healthcare is pushing these “conversations” along in ways we could not have imagined even a few years ago.

Without BI and analytics, the new paradigm of healthcare will fail if we don’t move forward full speed ahead. Stakeholders will need to bring the commitment and expertise to bear. By working through the challenges together and moving forward, we can finally unlock the potential of the systems we have invested in to provide real improvements in the quality of care and bend the cost curve to make the benefits of healthcare transformation available to all. BI will play a central role in this effort to take healthcare to the next level.


Rich Temple, MBA is national practice director for
Beacon Partners.

Readers Write: Connecting the Divide between Inpatient and Outpatient Care

October 4, 2013 Readers Write No Comments

Connecting the Divide between Inpatient and Outpatient Care
By Michelle R. Troseth, MSN, RN, DPNAP, FAAN

10-4-2013 4-26-01 PM

Premier Healthcare Alliance’s spring 2013 Economic Outlook predicts a major shift in admissions from inpatient to outpatient settings. With such predictions, healthcare organizations must connect episodes of care, closing the gap between inpatient and outpatient care. Only then will healthcare develop integrated networks that include hospitals, health systems, ambulatory care centers, community clinics, long-term care facilities, home care agencies, and medical groups, that can work together to coordinate care and share accountability for quality, cost, and outcomes.  

Accountable care demands the reform of healthcare delivery. The key to successful clinical integration is to build high-performance organizations of physicians, specialists, hospitals, and others that are willing to adopt and use information technology and innovative care systems to prevent illness, enhance safety and quality, and coordinate and integrate care. In the process, these organizations become accountable for the quality and cost of care delivered to a defined patient population.     

Equally relevant to closing the inpatient/outpatient divide are the escalating requirements of Meaningful Use, as well as clinical integration, which demands information systems designed to provide clinicians with access to meaningful, actionable information at the point of care decision making. 

The great challenge to achieving new ways of thinking and practicing in the midst of the shifting landscape remains in the how to best create integrated healthcare systems.  While an interoperable technology platform is unquestionably needed, so is an interoperable practice platform to expedite the seamless transition of care between inpatient and outpatient. 

In developing a common practice framework that can be embedded in any technology platform, the following components have been validated as essential for high-quality seamless care:

  • Shared purpose and values 
  • Dialogue skills
  • Polarity thinking skills
  • Competency in full scope of practice
  • Integrated competency to halt duplication of services
  • Partnerships to support networking across the continuum
  • Evidence-based tools to develop individualized, interdisciplinary, integrated plans of care
  • Integrated documentation that reflects the patient’s story, plan, progress and outcomes across the continuum
  • Exchange processes and handoffs that ensure safe, quality care

If providers hope to close the gap between inpatient and outpatient care, they should adopt such an infrastructure that supports continuity of care. Among the most essential steps are: 

  • Provide teams with interprofessional, evidence-based tools
  • Implement integrated clinical documentation
  • Engage patients and family members
  • Insist on interoperable HIT systems
  • Develop professional exchange/ handoffs processes that ensure safe, quality, coordinated care
  • Allow professionals to practice to their full scope of practice

We can bridge the gap between inpatient and outpatient care if we remain aware of the shifting demands of accountable care, population health management, clinical integration and collaborative, coordinated and consistent care by government, payers, patients, and provider partners. Instead of another high-tech fix, implementation of a comprehensive practice platform that blends evidence-based tools with team competency and compassion should be considered. 

Just as important is the investment in smart content that supports integrated documentation, patient engagement, interoperable systems, professional exchange, advanced practice professionals, and intentionally designed tools to support coordinated, collaborative care.    


Michelle R. Troseth, MSN, RN, DPNAP, FAAN  is chief professional practice officer of
Elsevier.

Readers Write: The Changing Physician-CIO Relationship: Do You have a Strong Partnership?

October 4, 2013 Readers Write 1 Comment

The Changing Physician-CIO Relationship: Do You have a Strong Partnership?
By Rob Culbert

10-4-2013 4-21-46 PM

Building a relationship is hard. Managing a successful and long-term partnership is even harder.

That’s what most healthcare chief information officers (CIOs) are finding out as they examine their rapport with physicians. Productive relationships take effort and a commitment to change. Successful healthcare organizations can strengthen the physician-CIO dynamic by making a concerted effort to involve physicians in their technology adoption efforts.

Consider these questions as you determine how your organization stacks up in fostering positive interactions with your physicians and what you need to do to build a stronger physician-CIO partnership.

What’s driving the changing relationship between your CIO and physicians?

In most healthcare organizations, physician and CIO responsibilities have historically been siloed—the CIO drove technology, physicians drove clinical care. Now the relationship is changing as physicians expect the hospital to provide greater technology support, which in turn allows the physician to provide higher quality care. More than ever, physicians demand a system that provides full access to both ambulatory and inpatient clinical data.

Yesterday’s hands off approach with physicians no longer works. Healthcare CIOs must employ an intentional strategy to involve their physician partners and meet their new requirements for support and information.

What specific roles are physicians playing in your technology deployment?

Technology is becoming more directly linked to patient care, so much so that physicians now expect systems that seamlessly support their work and improve efficiencies. This is even more the case with younger physicians, who grew up using technology and can’t imagine delivering care without it.

To capture physician opinions and requirements for technology, organizations may want to create a physician steering committee, which involves physicians in major decisions about system design, functionality, and content. Organizations are using these committees to fix and improve specific technology. For example, working as a subset of the steering committee, a physician ICD-10 committee may focus on the required workflow changes and corresponding system changes needed to support a smooth implementation of the new code set. After implementation, physician practice user groups can be leveraged to educate physicians on advanced features and to gain feedback for system adjustments.

Are you providing opportunities for physicians who don’t want to be heavily involved in technology?

It’s a fact: some physicians simply want to be doctors, not IT gurus. Yet, they still can provide a wealth of information through their frontline system knowledge. Avenues for feedback include physician surveys, informal focus groups, or even hallway conversations. Site visits to physician practices can clearly reveal how the system is being used and highlight opportunities for improvement. Garnering involvement and feedback from as wide an audience as possible leads to a healthy and dynamic physician-CIO rapport.

What benefits can your organization realize through physician-CIO alignment?

Perhaps the biggest benefit of physician-CIO alignment is that it’s just good for business – for the physician and the healthcare organization. Most practices don’t have the resources for a sophisticated IT structure with 24/7 support, clinical system protection, disaster recovery, and guaranteed uptime performance. However, healthcare organizations often have extensive IT capabilities and can provide the needed support and resources at a reasonable cost.

Healthcare organizations benefit because strong alignment between physicians and technology leaders can ultimately improve patient care and foster greater efficiency. In addition, it can positively impact a physician’s choice where to practice. Because most physicians want to partner with an organization that is responsive to physician involvement, this strengthened relationship allows organizations to be more competitive in recruiting and retaining physicians.

Strong physician-CIO interactions can also help a healthcare organization strategically position itself for quality improvement and agility with the coming healthcare legislation, ultimately improving payment and reimbursement rates for both parties.

Establishing and maintaining strong partnerships between physicians and technology leaders is essential to navigating the evolving healthcare landscape. As information technology becomes more critical to care delivery, the strength and resiliency of the physician-CIO relationship will determine your organization’s ability to successfully deliver quality care and maintain financial viability.


Rob Culbert is president and CEO of Culbert Healthcare Solutions.

Readers Write: The Increasing Enforcement of HIPAA and What It Means To You

September 25, 2013 Readers Write 1 Comment

The Increasing Enforcement of HIPAA and What It Means To You
By Kent Norton

9-25-2013 6-35-21 PM

Since the inception of HIPAA and its enforcement, there have been nearly 100,000 cases or complaints investigated. Among those, many have resulted in fines ranging from thousands of dollars to more than two million. Today the fines have a cap per penalty and per calendar year, restricting the fines to $50,000 per penalty and $1.5 million per calendar year.

Fortunately, the Office for Civil Rights has allowed entities to correct the aberrations of noncompliance within 30 days if the failure to comply was not willful neglect. The likelihood that your organization is audited is small when considering that in 2012 only 150 entities were scheduled to take place. The main issue of concern is that a patient, for whatever reason, will file a complaint about HIPAA noncompliance.

With the addition of the HITECH amendments in 2009, HIPAA enforcement has been on the rise, with more than five times as many cases settling after 2009 than before 2009. HITECH has certainly done more to change the face of protected health information or PHI than HIPAA originally did.

For most organizations the first thing that should be scrutinized when considering HIPAA and HITECH compliance is a risk analysis. This is a terribly large task especially when your IT department must do their analysis while still fielding their daily IT requests. Because of the large strain this puts on an organization, a new section in the IT industry has come about to do this type of risk analysis and HIPAA/HITECH compliance implementation. It may be wise to consider employing an IT risk analysis and implementation team in order to help your organization become HIPAA/HITECH compliant as quickly as possible.

The second thing to examine about your PHI is the defense your IT department has against attacks from both internal and external fronts. An efficient and effective PHI defense needs not only intelligent, self-aware, and careful staff and policies, but also complete control of physical data and data transfer. Once these are in place, your IT department can look at how PHI is accessed and the possible avenues hackers would use to bypass the security measures that are in place. One of the most subtle possible leaks of physical data or PHI is often overlooked and that is personal mobile devices. Developing controls and checks to keep PHI from being transferred, copied, or changed via a personal mobile device can greatly improve an organizations risk of noncompliance.

Lastly, inspecting the systems you have in place in order to determine the necessary frequency of periodic risk evaluations and assessments and to develop a monitoring and security mitigation plan. Having these two systems in place will help keep your organization compliant as the IT industry evolves with the changes in health care and technology.

As enforcement of HIPAA continues its upward trend, more and more organizations will need to take a better look at how they have implemented their compliance programs. They’ll need to make sure that they have taken the right steps in order to be safe from the steep fines and penalties that could come as a consequence.

Kent Norton is a HIPAA security analyst with HIPAA One.

Readers Write: Nay for CMS Proposed Rules on ED Facility Fees

September 25, 2013 Readers Write No Comments

Nay for CMS Proposed Rules on ED Facility Fees
By Robert Hitchcock, MD, FACEP

9-25-2013 6-28-00 PM

The calendar year 2014 Outpatient Prospective Payment System Proposed Rule (CMS-1601-P) proposes several changes that I believe will negatively impact emergency departments (EDs).

The two proposed changes in particular that have me concerned are:

  • Consolidation of the five ED facility level evaluation and management (E&M) codes into a single code
  • Packaging of add-on services

Consolidation of facility level codes

Without clear facility level guidelines, determining accurate codes is challenging for hospitals and potentially responsible for the recent media stories suggesting that upcoding is occurring. Despite repeated requests for CMS to develop guidelines and much industry input and willingness, no action has been taken. I’m concerned that the proposed consolidation is a substitute for clear facility level guidelines. The methodology for determining reimbursement amounts for the proposed codes are unclear and no impact analysis on hospitals has been performed, or could be from the data presented.

The logic currently used by most hospitals to determine facility E&M codes for ED visits relies on evaluation of the resource requirements to care for the patient during the visit. In many cases, the distribution of patient complexities, and thus facility codes, is often a result of multiple factors – many of which the hospital has no control over.

For example, hospitals in areas where Medicare patients have limited access to primary, preventive, and specialty care may see patients with poorly managed chronic diseases who are more complex and resource intensive. These hospitals may well experience a significant decrease in reimbursement, which may negatively affect their ability to continue to provide healthcare services. In addition, increasing the number of lower acuity Medicare patients treated in the ED will significantly increase total federal healthcare expenditures for unscheduled care.

A tiered structure is essential to the financial stability of hospitals and would help protect against shifting care patterns that could unnecessarily raise healthcare expenditures. Clear, concise guidelines should be developed that allow hospitals to accurately and reproducibly assign the appropriate tiered services code for a particular visit. If simplification of coding guidelines and reimbursement is a main goal, I would suggest one approach would be to shift from five tiers to three. This will allow the healthcare system to continue to track and manage the resources required to provide unscheduled care.

Packaging of add-on services

The proposed packaging of add-on services has a commendable goal of simplifying reimbursement and encouraging hospitals to seek efficiencies in the care they provide. However, some of the proposed packaging involved are for specific therapeutic services that are often required to provide high quality care. I believe that the broad brush of unconditional packaging of all add-on services is inappropriate and could lead to circumstances that are directly detrimental to patient care.

The packaging of add-on services in certain circumstances would be beneficial, such when the provision of the service is not directly related to therapeutic delivery of care, especially medications. For instance, providing additional intravenous doses of an identical medication are often required to provide optimal care (e.g., analgesic administration for pain control or additional intravenous hydration for dehydration). There’s really not much opportunity for improving efficiencies here; either we provide appropriate pain management, or not. The concern lies in that packaging these services may create situations where optimal patient care is pitted against the financial pressures of the hospital.

Preservation of EDs

I believe that the proposed modifications to these two areas would have a negative impact on both national healthcare costs and quality of patient care delivered. As a safety net for healthcare in the US, the preservation of EDs is critical.

The final rule is expected around November 1 and will take effect January 1, 2014.

Robert Hitchcock, MD is chief medical informatics officer of T-System Inc.

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