Readers Write: How Many More Reasons Do You Need?

How Many More Reasons Do You Need?
By Tom Furr

The US Postal Service recently raised the cost of a first class stamp to $0.49, a 6.5 percent increase. Darrell Issa, the Congressman chairing the committee that approved the rate hike, admits, "This rate hike and the ones sure to follow will only push more and more private sector customers to stop using the mail altogether. The rate increase poses a direct threat to the 8 million private sector jobs that are part of the mailing industry as businesses shift from paper-based to electronic communication and mailers are priced out of business."

Think about it. If you had a supplier that said, “We are losing money because nobody really needs our product any more, but we are raising our prices so we can try to hang on a little longer,” how much longer would you stay with them? Or if I told you that your COGS was going up 6.5 percent and you had no alternative in vendors or processes, you might start looking at your business model and thinking about a way to work around that vendor.

In addition, bulk paper costs are expected to rise 2.5 to 6 percent over the next year. I can promise you that your vendors are not going to absorb those costs. If you are responsible for collecting payments from patients on behalf of hospitals and practices, it is a stone cold fact that you are going to see your costs rise next year. I wish I had better news for you, but unless you change something soon, you are going to have some very hard choices to make.

Once choice you can make now is to look at shifting to an online solution that allows you to present patient statements and collect payments easily. It’s not just what you need, it’s what patients want. I was talking to Allen Warren of A&H Billing last week and he explained that he adopted online bill pay because that’s what he prefers when he pays his bills. “When I talk to folks in this business, I ask them, ‘How do you pay your bills?’”, he said. “The funny thing is they all sort of laugh when they think about it. It seems so obvious when you step back from it.”

It’s no secret that I have been looking to drive online payments for our partners, but when the USPS admits that today more than 60 percent of Americans are paying their bills online and their response is to raise rates, how is that good business? It’s going to make consumers look for ways to not use their service. The question is do you want to go for that ride to the bottom with them? I know I don’t, and while I used to look at companies that offered online bill pay as innovative, I now just look at them as sensible.

The cost of postage is going up, the cost of paper is going up, and consumers want to pay their bills online. How many more reasons do you need?

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

Readers Write: The Symbiosis of Care: The Re-Emergence of Professionalism and the Patient Satisfaction Impact

The Symbiosis of Care: The Re-Emergence of Professionalism and the Patient Satisfaction Impact
By Paul Weygandt

As a physician, it’s second nature for us to make sacrifices for the betterment of others, whether that entails missing the first half of your daughter’s soccer game to listen to a husband who is losing his wife to cancer or working 80 hours a week.

Having been in these situations, I can honestly say – and I believe the vast majority of physicians would agree – it doesn’t feel like a sacrifice. It is an unconscious reaction to another person who is in emotional or physical pain. In many ways, being a physician is instinctual – you automatically prioritize others’ needs over your own. And again, quite honestly, in my many years of practicing medicine, I rarely had to deliberate on where I needed to be – when you’re a physician, you just know.

The ability to provide care may come as second nature, but things like using ICD-10 compliant clinical documentation do not. It is no secret that changes in regulatory policies are placing new pressures on physicians and taking our focus away from patient care and practicing the art of medicine. Regulatory requirements are directly impacting the physician-patient relationship. 

While capturing data on the patient experience is important, evaluating the physician experience and then acting on that data is of equal value. According to a recent American Medical Association/Rand study on physician satisfaction, quality of care is inextricably tied to professional satisfaction, and many obstacles to high-quality care are seen as major sources of dissatisfaction. The converse is also true. Any major source of physician dissatisfaction is an obstacle to high quality care.

We’ve found ourselves in a Catch-22. Government regulations are designed to improve patient outcomes, but they are doing so at the expense of those who are providing that care. The two most visible groups in healthcare are patients and physicians, and right now both are suffering under the burdens of a poorly designed system. Patients feel neglected and physicians feel like cogs in a wheel or workers on the healthcare assembly line, devastating medical professionalism and negating the patient benefits of that professionalism.

The ramifications of this situation are severe. After all, everyone has a breaking point. When 60 percent of physicians admit they would retire if they had the means to do so, it’s no longer just an isolated incidence of one or two hospitals’ poor processes or a few old physicians struggling to embrace new technology that is causing the problem. This has become an epidemic that is threatening to decimate our physician community across the country. It isn’t just a handful of luddites refusing to change with the times; it is something much deeper that is cutting at the very core of the medical profession and the physician’s vocation.

Now we’re back to that second nature ability that physicians possess. Physicians willingly made the conscious decision to dedicate their lives to others — to sacrifice for others. They didn’t pledge themselves to filling out onerous paperwork or to looking at a computer screen instead of into the eyes of their patients. It is time for the innovators, particularly those in the health IT community, to listen to physicians, conduct pain tests or do an Apgar score of sorts to closely monitor the health of the profession, and suggest new solutions that can begin to alleviate the discomfort of a sick healthcare system.

If non-essential busy work and non-patient demands can be decreased or eliminated, I think we will find that, once again, that physicians are able to spend their days caring for their patients. Addressing and fixing the myriad of non-clinical issues facing physicians will allow a rebirth of professionalism. That professionalism is, in turn, the basis for high quality care and patient satisfaction.

Paul Weygandt, MD, JD, MPH, MBA, CCS, FACPE is vice president of physician services of Nuance Communications of Burlington, MA.

Readers Write: Ominous Outlook for Meaningful Use

Ominous Outlook for Meaningful Use
By Evan Steele

CMS passed up a golden opportunity to stave off the potential demise of the EHR incentive program when it failed to delay the start of Stage 2. What was already a complex program in Stage 1 becomes exponentially so in Stage 2, and its pace is outstripping the realities of medical practice and of software development. The facts speak for themselves:

• 17 percent of the physicians who successfully attested to 90 days of Meaningful Use at Stage 1 in 2011 walked away from the second incentive ($12,000) in 2012, which required a full year of Meaningful Use. I find this dropout rate very surprising. The requirements were exactly the same as the first reporting period for these physicians, so they and their staffs had already established the necessary workflows. The fact that many of these first attesters were early EHR adopters and therefore already more adept at EHR use than the average physician makes this statistic even more alarming. When surveyed by CMS, many of the dropouts cited the program’s complexity as a key reason for their failure in Year 2. Physicians who gave up on Stage 1 will likely not even attempt Stage 2.
• 12 percent of attesters who used one of the top 25 EHRs to demonstrate Meaningful Use in Stage 1 do not yet have access to a 2014-certified EHR, according to a January report issued by Wells Fargo Securities, while this year’s reporting period must begin within nine months. Some EHRs will never achieve 2014 certification. The first announcement of a vendor abandoning Meaningful Use came a few weeks ago, leaving its physicians out in the cold. Of the 49 ambulatory EHRs that have been 2014 certified to date — winnowed down from a Stage 1 field of 472 — very few have yet been deployed to physicians. This is clear evidence of the complexities associated with Stage 2 and the significant challenges facing vendors in making their EHRs compliant yet practical.
• I would estimate that at least another 15 percent will walk away from Stage 2 because of its dramatically increased complexity, added costs, and impact on productivity, particularly when weighed against the declining incentives (as little as $4,000 and $2,000 for physicians whose first year of Meaningful Use was 2011) and penalties that will average only a few thousand dollars.
• How many additional physicians will be driven to cry “Uncle” and abandon Meaningful Use because they are besieged by the demands of so many other programs at the same time—ICD-10, PQRS, Value-Based Payment Modifier, ACO participation, etc.? Physicians and their clinical teams are weary and can only do so much.

If you add these numbers together (acknowledging some overlap), the conclusion that 40 percent of past attesters will give up on Meaningful Use is inescapable. Then there’s the 37 percent of eligible professionals who have never earned an EHR incentive, including 18 percent who—if failure to even register is an indication of lack of intent—are so overwhelmed by the program that they have no interest in participation even in the “easiest” first stage (Source: CMS Presentation to HIT Policy Committee, January 14, 2014).

The delay of Stage 3 will be too little, too late. What was needed was a more reasonable approach to Stage 2.

Evan Steele is CEO of SRS, Montvale, NJ.

Readers Write: Once a Nurse, Always a Nurse

Once a Nurse, Always a Nurse
By Lisa Cannon

We all wear various hats in our lives, but some experiences are never forgotten. Through the years, I’ve been the road warrior healthcare consultant and then moved to positions supporting consulting operations. Yet nothing remains in my heart more than my early days as a nurse. I never knew how much I would appreciate having been a nurse until my mom’s health took a sizeable downward turn last year.

My mom’s chronic cardiac condition resulted in several hospital visits and treatment by various specialists in her last months. At home, coordinating her care among her medical team was no easy task. Keeping her out of a nursing home meant visits from home health nurses, nurse aides, and multiple therapists. This was a great deal of care synchronization for my aging father to deal with, but he welcomed it, knowing the alternative. He organized her medications and had everything written down. Thanks to my nursing background, I trained him in the art of taking her blood pressure, doing daily glucose checks, and measuring her oxygen saturation.

I was constantly running cover on what was being prescribed for Mom and monitoring how Dad was delivering the recommendations. Sadly, we hit an issue that in hindsight makes me question if it was the action that ultimately caused her death. Could information technology (IT) have made a difference? Perhaps. Maybe the application of common sense and additional family education could have.

Mom’s renal specialist ordered a diuretic water-releasing medication to be given once a day for seven days with a quantity prescribed of 14. The discrepancy between the dose and the quantity wasn’t realized immediately. After Mom fell twice, at a subsequent visit to her primary care physician, my dad indicated he was still giving this medication. That’s when we realized we had a serious issue. This was Day 13, well past the seven-day mark. Mom had received the medication for almost a full week more than had been intended. We realized it was significantly lowering her blood pressure.

I questioned the pharmacy that filled the prescription. They indicated they just did what the physician had written. I was outraged. Could they have provided some family education and made that clear? Since there were still pills in the bottle, Dad merely was continuing to give the medicine. Could a computer system combined with standard operating procedures prompt alerting of education requirements for a time-limited dosing medication helped? I think so.

After subsequent falls, my mom ultimately was admitted to the hospital, where a CT scan showed she had developed a massive brain hemorrhage. Dad and I were told that the combination of falls and blood-thinning medication resulted in a weakened blood vessel in her brain, which finally gave out.

Afterwards, when the renal specialist was asked why the prescription was written the way it was, she remarked that it was so we wouldn’t have to return to the office should we have needed to continue it. In her mind, she was doing us a favor.

This experience made me wonder how patients without involved family members manage their medical care journey as their health deteriorates. While I may have forgotten all of the details of the ICU setting I spent so much time in years ago, I am very thankful for the skills I learned and my ability to recognize the situation regarding the healthcare needs that come to the surface.

Having witnessed firsthand patients struggling with understanding their care requirements, it reiterates to me the imperative that health professionals do their part in educating patients and their families and communicating specifics. Training my dad to take blood pressure and glucose checks was possible (and these days, essential). His recognizing a perfect storm of low blood pressure, over diuresis, and blood-thinning medicines was not.

As healthcare IT professionals, we can’t forget that the role of IT is to supplement common sense and standard operating procedures, not to replace it. There is no fail-proof means to ensure mistakes don’t occur, even with the best of intentions and systems. We must remember that the people, process, and technology changes we’re making impact real people every day. Are we making healthcare better? We must –our families are counting on us. 

Lisa Cannon is director of resource management for Aspen Advisors of Pittsburgh, PA.

Readers Write: The Revenue Cycle’s Transformation with Big Data

The Revenue Cycle’s Transformation with Big Data
By Steve Johnson

Big data is pushing clinical care to new heights as healthcare organizations use it to support diagnoses, target care delivery, and improve patient health outcomes. Organizations can realize a similar level of success in the revenue cycle when they apply data and analytics to the myriad of steps involved in billing and collections.

When organizations effectively leverage financial and administrative information — such as claims, payer payment, cost, patient financial, and patient demographic data — they can see improvement on both the front and back end of the revenue cycle. For example, organizations can use data to increase collections by detecting fraud at registration, quantifying patient payment responsibility, identifying patients who qualify for financial assistance, and revealing errors that impact billing.

Strong data and analytics can also drive more accurate revenue forecasting. Unlike the past, where healthcare organizations relied on historical summary statistics to predict future financial trends, big data empowers a real-time view of individual patients and their financial situations. When aggregated, this data allows an organization to make an accurate bottom-up forecast of revenue. In other words, organizations can leverage specific account information to build a collective model of overall performance based on each patient’s unique financial situation.

Just as big data can improve forecasting, it also can enable more exact patient population benchmarking and assist in decision-making relative to those populations. For instance, data and analytics can show how a facility’s patient population compares with the general patient population regarding financial need. This level of data and analysis facilitates deeper patient segmentation, clearly differentiating those more likely to qualify for assistance compared to the surrounding geographic area. In addition, data and analytics help define optimal workflows or interventions for specific groups.

Organizations already have all the big data they need to effect change: financial, administrative, and claims and payment data are all present in an organization. To get the most out of this data, organizations need to link it together and form one complete picture of the patient experience. This will provide a better understanding of the patient’s current and historical situation and allow for stronger forecasting and risk mitigation as well as enable better financial conversations with patients.

Patients usually welcome conversations about their financial responsibility and how they can meet it, especially those who do not understand the complexity of their coverage and may not know the right questions to ask. By using financial and administrative data to determine the best financial course of action for a patient, staff can proactively offer different payment options and answer patient questions, increasing the likelihood of patient payment, improving collections, and strengthening the revenue cycle. This data-driven, customer-focused approach also reaps the added benefit of higher levels of patient satisfaction.

Clinical use of big data has dramatically impacted care delivery. The time is right to adopt the same philosophy for the revenue cycle and leverage big data as a business tool to strengthen billing, collections, and overall financial operations.

Steve Johnson is chief technology officer and vice president of data and analytics at Experian Healthcare of Austin, TX.

Readers Write: Next Steps at ONC

Next Steps at ONC
By Helen Figge

The new leader, Karen DeSalvo, MD, has been appointed at ONC. It is anticipated that ONC is set to continue  the creation of an interoperable, private, and secure nationwide health information system  with the ultimate goal of supporting widespread distribution of data. More importantly, widespread implementation of Meaningful Use of healthcare technology.  

Many, however, still struggle to gauge what ultimately will be developed to facilitate the electronic exchange of health information. How will we launch the system, maintaining high quality along with security so that patient records are impenetrable to tampering?

The nirvana of the ONC program was to improve healthcare delivery alongside reducing healthcare costs.  But with uncertainty of where Obamacare eventually will land, and with all the other moving pieces like ICD-10, additional worries play into the overall scheme of just what the final healthcare landscape will look like. Not only to the healthcare providers, but to the consumer of healthcare, like you and me.

Besides the obvious conversations that we all hear centered around Meaningful Use, ONC has many opportunities to improve healthcare globally, most notably stressing and promoting early detection, prevention, and management of chronic diseases, which account for most of the healthcare expenditures we see today.

As we continue to see ONC evolve, let’s hope that the emphasis will not only zero in on Meaningful Use,  but also be energized for promoting such things as staying well through good health habits – wellness – in the various stages of our life cycles. Regardless of the technologies in play or the governmental regulations already set in motion, the key to the healthcare game is for consumers to stay healthier longer and be rewarded for maintaining a healthy state versus dealing with the aftermath of illness. 

This plays well into the ONC mission of eliminating health disparities among different populations and ensuring best practices regardless of geographic confines as well. There is a lot on the ONC table to continue to execute. Hopefully ONC will also affirm the need to have promotional campaigns for promoting early detection and prevention more effectively in the marketplace. This seems still to be void or at least not very noticeable from some vantage points.

Let’s not forget the ONC charge of establishing a governance for the Nationwide Health Information Network (now coined the eHealth Exchange), which when successfully executed, would be a Web-services based series of specifications designed to securely exchange healthcare related data.  

Independent of the leaders named at ONC, the arduous task of moving healthcare to the next level of quality will be at the forefront. A big sigh and a long pause will be needed to start the conversations with enthusiasm for sure, but in the end it will be just another day in the life of a CIO and the technology teams along with all of the healthcare providers in this era of Obamacare.

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

Readers Write: Alerts versus Alarms – Not Just Semantics

Alerts versus Alarms – Not Just Semantics
By Brian McAlpine

We often hear references to “alerts” in the context of clinicians experiencing overload or becoming fatigued. For example, alert fatigue is a well-known problem whereby clinicians are constantly bombarded with multiple types of alerts, each designed to get their attention.

Alerts can come from many different sources, including the EMR/EHR, lab systems, CPOE, medication administration software, imaging systems, nurse call systems, and many other sources. Almost any system in the clinical environment can generate an alert.

For the purposes of limiting the scope of this discussion, let’s limit the definition of “alerts” to the patient care environment and direct patient care. Using this working definition, I would also say that a nurse’s phone that receives alerts or can process text messages can also generate alerts (i.e. via a beep or vibrate) that let the nurse know when a new message has arrived.

Recently there has been increasing industry discussion and focus on “alarms” and the problem of alarm fatigue. The Joint Commission’s NPSG06.01.01 has raised the awareness of this problem and now hospitals must start to pay close attention to which medical devices and corresponding alarms are contributors to alarm fatigue. 

Both alerts and alarms interrupt the clinician and can be a source of distraction that leads to critical errors, so what’s the difference? There is a big difference, especially when provider organizations attempt to get their arms around these problems.

This is really a problem where healthcare as an industry needs to focus and prioritize what is most critical. When you look at the key differences between alerts and alarms, you can further appreciate why the Joint Commission has taken action for the second time in the last 10 years, the first time being here with the National Patient Safety goal for managing audible alarms.

Alarms are typically derived from medical devices and often communicate an immediate life-threatening patient condition. Think a v-fib or asystole alarm from a patient monitor. Alarms are always more time sensitive and a delay of a few seconds may matter to the safety of the patient. Another key characteristic of alarms is that they are almost always intended for nurses or respiratory therapists (i.e. non-physicians). Physicians do not deal with alarm response – that is for nursing to handle. Finally, alarms are always regulated by the FDA from both the medical device side (alarm generation) and from the perspective of an alarm management middleware. The FDA regulates the alarm management middleware vendors through the 510k process. As a result, only a few vendors can offer an alarm notification capability because of strict FDA 510k regulations.

But what about alerts and vendors that integrate alerts? Shouldn’t these be regulated just like alarms? The answer lies in the definition of alerts and the key differences as compared to alarms. Alerts are usually not associated with medical devices and are not immediately life threatening, but could be very serious. A big difference is that alerts are not always immediately time sensitive — a delay of 30 seconds or even several minutes often does not matter like it does with a patient monitoring alarm. In terms of who typically receives alerts, these can be intended for any clinician, and often physicians receive alerts generated by systems such as the EMR. Another major difference is that alerts are generally not regulated by the FDA like medical device alarms are.

Because of these differences, many vendors can (and do) offer an “alerting” capability. The barriers to developing an alerting or alert notification feature are simply a lot lower when compared to developing alarm management middleware. But what does this mean in practical terms to a hospital looking at the diverse set of vendors that blend alarms and alerts all together into one confusing message about what their solution is really capable of? One key way to cut through all the hype is to follow the Joint Commission’s lead and focus on medical device alarms as a key starting point.

The Joint Commission just recently released its R3 Rationale report in response to its NPSG.06.01.01 for alarm system safety. A key statement in this report outlines clinical alarms as being more critical and a higher threat to patient safety as compared to “alerts”. In fact, the report explicitly states that the NPSG does not address “items such as nurse call systems, alerts from computerized provider order entry (CPOE), or other information technology (IT) systems.” It is obvious that the Joint Commission thinks the best starting point is with an evaluation of medical device alarms.

This is clearly only the starting point because we have to go back to the bigger problem as stated at the beginning of this post . Alerts and alarms interrupt the nurse and increase potential for errors in the care environment. You have to start somewhere, and by starting with alarms, you can get a handle on addressing a very key issue. This will lead to a foundation and framework that will enable you to more effectively address the alerting problem in the future.

What do you think? Are alarms the right place to start?

Brian McAlpine is VP of product management and marketing at Extension Healthcare.

Readers Write: Ten Steps for Surviving ARRA and ACA Requirements in 2014

Ten Steps for Surviving ARRA and ACA Requirements in 2014
By Dick Taylor, MD

The 2009 American Recovery and Reinvestment Act (ARRA) changed the healthcare IT landscape for providers by offering money in exchange for the adoption and implementation of electronic medical records. One year later, the Affordable Care Act (ACA) upped the ante with new regulations for privacy, accountable care, and insurance coverage. The combination of the two acts has left most providers and provider organizations struggling to see the forest through the trees as we enter 2014, and the deadlines for both acts draw ever closer.

Controversial from the start, the Affordable Care Act (ACA) was landmark legislation three years ago. It remains front and center after being tested by the Supreme Court, a presidential re-election, and most recently, a government shutdown. Like the ARRA, much of it is yet to be written, requiring tens of thousands of pages of regulations to explain the details. Like the ARRA, it is deeply flawed in places and will require many years of refinement.

The ACA tries to supercharge the required transition from a reactive, episodic care based payment system to one that might reward preventive care, wellness, and patient outcomes. Providers generally see the promise, but they almost universally question the ability of the law to achieve its outcomes, particularly in light of modern medicine’s rapidly changing cost factors.

Healthcare is getting more expensive, and the healthcare IT transition mandated by the ARRA has not yet reached the break-even point for expense control for many (if not most) provider organizations. Demand is down in many segments, particularly for inpatient and elective procedures, and margins are under heavy pressure.

To make matters worse, regulatory oversight is rising and is highly unpredictable. As an example, on September 1, 2012, CMS finalized a rule that gave eligible providers until July 1, 2014 to begin attestation for Meaningful Use. Up to that point, providers generally believed that they had 15 months longer. In contrast, the ICD-10 implementation date was arbitrarily delayed a full year in August 2012 from October 1, 2013 to October 1, 2014. Regulatory changes of this nature are difficult to predict and require both flexibility and preparation from providers.

As we enter 2014, the final sprint toward ARRA and ACA’s deadlines, surviving this environment will require providers to focus on achieving the following goals over the course of the coming year.

1. Reduce expenses, both per-patient and fixed overhead. Admittedly, this is easier said than done.
2. Where practical, grow larger through acquisition or affiliation. This spreads fixed overhead over a larger patient volume and allows much more efficient team-based and whole-patient care. Growth must however, be calculated and managed to capture these savings. Rapidly growing organizations must be especially watchful to avoid operational and cultural traps.
3. Achieve Meaningful Use and avoid ARRA Medicare penalties. Providers who have missed Meaningful Use to date are now looking at reduced awards and penalties (amounting to small but significant percentages of CMS billing) beginning in just over a year.
4. Achieve ICD-10 compliance on time (by 10/1/14) without destroying the organization. While ICD-10 is critical (not billing with ICD-10 is simply not survivable for most providers), this has become the Y2K for healthcare. Caution, particularly around involving physicians and mid-level providers in the minutiae of coding, is strongly advised.
5. Pursue transparency for quality outcomes and cost. Payors, employers, and patients are all watching these very carefully, and organizations who are not forthcoming will become less favored over time.
6. Pursue transformation in long-term healthcare, including population health, chronic disease management, and wellness. Fee-for-service is likely to become far less sustainable as a primary business model over time.
7. Reduce clinical variation, both by pursuing good evidence (where available) and by achieving agreement on leading practices among providers. Much of the variability in clinical care is not associated with improved outcomes and some of it is actively harmful, both in cost and patient outcomes.
8. Recognize and honor the risk you own. Health systems have always owned the risk for charity and self-pay patients. The ones who recognize and accept this are much more likely to provide good care and keep costs under control.
9. Look for whole-patient (“accountable”) care opportunities within your own orbit. While the ACA set out the framework for Accountable Care Organizations, the reality is that these are still embryonic. Organizations that begin at home will be ready for risk-sharing moving forward.
10. Treat your IT expenditures as long-term investments, not expenses. Organizations should expect to spend an increasing percentage of capital dollars building technology assets. Acquire standards-based IT assets that will stand the test of time. Expect, plan, and capture the hard- and soft-dollar returns from them. Organizations that view IT simply as an expense will forego future profits in the pursuit of short-term efficiency.

Dick Taylor is managing director and chief medical officer of MedSys Group of Plano, TX.

Readers Write: 2014 Resolutions

2014 Resolutions
By Vince Ciotti

I’m getting ready to wrap up the HIS-tory series with the final episodes on McKesson, so it’s apropos to take a break and look at the future a bit with these 2014 New Year’s resolutions for today’s leading HIS vendors (in order of their 2012 annual revenue).

McKesson

They’re doing so well with Paragon that they made a resolution to rename their other legacy systems:

• Horizon = Parazon
• Series = Seriegon
• Star = Staragon
• Practice Partner = Practice Partagon
• RelayHealth = ParlayHealth
• Homecare = Homecaragon
• InterQual Online = InterQual Paragonline
• Capacity Planner = Capacity Paranagon
• Performance Analytics = Performagonalytics
• Patient Folder = Patient-Paper-Folder-Gone
• (you get the idea…)

On another front, McKesson announced plans to open Paragon’s first international office in either Aragon or Patagonia, depending on negotiations with their governments about minor changes to the spelling of their names.

Cerner

Will make an epic move of their HQ from Kansas City to Salt Lake City and re-name Millennium HNA as Millennium IHCNA.

Siemens

After cutting 15,000 jobs worldwide over the past two years, Siemens will announce several openings in its HR recruiting department for 2014.

Allscripts

Will join Cerner, McKesson, athenahealth, Greenway, and RelayHealth in the CommonWell Health Alliance to promote EHR interoperability in 2014 in 49 states (excluding Wisconsin).

Epic

Will be recognized as the KLAS act in 2014 by becoming the only HIMSS Stage 8 vendor in Gartner’s Magic Quadrant.

GE

Will announce a program in 2014 whereby any hospital buying Centricity will receive a free refrigerator for every nurse station.

Meditech

Will announce the 2014 version of Release 6.0, which will be called Focus, er, MAT, I mean, 6.0.1, that is 6.1, or maybe 6.0.A…

NextGen

Will announce the 2014 re-packaging of Opus, Sphere, and IntraNexus as “ThisGen.”

CPSI

Will sets the goal of having 500 of their clients attest for MU by the end of 2014, a total of over 1,000 beds.

Harris

A subsidiary of Constellation Software Inc. (from Canada) announces a project for 2014 of using the other Harris (from Melbourne, FL) CareFX interoperability workflow solutions to differentiate their company names.

NTT Data

ヴィンスがこれらの不快な言語の策略を用いるのを止めてください。

HMS

After being re-named Medhost, company executives will announce a joint effort with the AHA to launch a campaign in 2014 that re-defines all US hospitals as ancillary departments of their emergency rooms. 

Healthland

Will resolve to combine its two corporate offices in Minnesota (Glenwood and Minneapolis) once the roads are plowed in August 2014.

Vince Ciotti is a principal with H.I.S. Professionals LLC.

Readers Write: ‘Twas the Night Before ICD-10

‘Twas the Night Before ICD-10
By Luke O’Cyte

‘Twas the night before ICD-10, when all through the payer
Not a claims engine was stirring, not even a benefits layer;
The mappings were hung in the systems with care,
In hopes that St. Remediolas soon would be there.

The coders were nestled all snug in their beds,
While visions of F30.2’s danced in their heads;
And the CTO in her ‘kerchief, and I in my cap,
Had just settled down for a long winter’s nap,
When out in the data warehouse there arose such a clatter,
I sprang from the bed to see what was the matter.

Away to the office I flew like a fiend,
Tore open the laptop and threw up the screen.
The moon on the breast of the new-fallen snow
Gave the lustre of mid-day to my screensaver though,
When, what to my wondering H54.2’s should touch base,
But a miniature claim, and eight tiny 278s,

With a little old coder, so lively and fast,
I knew in a moment it must be St. Remediolas.
More rapid than eagles his W55.39XA’s they came,
And he whistled, and shouted, and called them by name;

“Now, Procedure! Now, Diag! Now, Surgical and Provider!
On, Vendor! On Member! On, EPM and Auditor!
To the top of the pend list! to the top of the queue!
Now adjudicate! adjudicate! adjudicate do!”

As invalid claims that before the wild eligibility fly,
When they meet with a benefit rule, mount to the sky,
So up to the mainframe the W55.39XA’s they flew,
With the sleigh full of ICD-10 codes, and St. Remediolas too.

And then, in a twinkling, I heard on the servers
The prancing and pawing of each little W55.32XS.
As I threw down my mouse, and was turning around,
Down the office hall St. Remediolas came with a bound.
He was dressed all in fur, from his S00.93 to his T69.02,
And his clothes were tarnished with rejects and errors too;
A bundle of claims he had flung on his back,
And he looked like a payer just opening his pack.

His eyes — how they twinkled! his dimples how merry!
His cheeks were like 284.81, his nose like a cherry!
His droll little mouth was drawn up like a bow,
And the beard of his chin was as white as the snow;
The stump of a pipe he held tight in his teeth,
And the E869.4 it encircled his head like a T59.81;
He had a broad face and a little round belly,
That shook, when he laughed like a bowlful of jelly.
He was 278.00 and E66.3, a right jolly old elf,
And I laughed when I saw him, in spite of myself;
A wink of his eye and a W50.2 of his head,
Soon gave me to know I had nothing to dread;

He spoke not a word, but went straight to remediation,
And ICD-10 coded all claims; then turned with attention,
And laying his finger aside of his nose,
And giving a nod, up the elevator he rose;
He sprang to his claims, to his team gave a 271,
And away they all flew like a mainframe batch run.
But I heard him exclaim, ere he migrated from sight,

“Happy Remediation to all, and to all a good-night.”

….with apologies to Clement Clarke Moore

Readers Write: Santa Claus, Flying Reindeer, and the HIPAA-Compliant Data Center

Santa Claus, Flying Reindeer, and the HIPAA-Compliant Data Center
By Grant Elliott

This holiday period will see a rerun of many classic holiday movies, with one of my particular favorites being Miracle on 34th Street. A delightful film about the importance of retaining faith, even in the absence of any evidence – in this case, whether Santa Clause is real. As C.F. Cole puts it in the 1994 remake of the movie, “We invite you to ask yourself this one simple question: do you believe in Santa Claus?” following which all across the city people start putting up signs proclaiming, “We believe.”

As I walked around the exhibition floor of the 2013 mHealth Summit last week, I felt I was being asked to take a similar leap of faith. Specifically, that every company there was HIPAA compliant simply because they said so. For most, it would be part of their sales pitch. The term “HIPAA compliant” would be sprinkled liberally throughout the description of their service. For some, it was actually emblazoned on their wall posters. “HIPAA Compliant Data Hosting” and “HIPAA Compliant Mobile Development” are two I specifically recall.

When I challenged them on what they were actually doing to be HIPAA compliant, the answer was too often limited to, “We store our data in an encrypted database,” or, “We use a HIPAA-compliant data center.” Therein lies a key challenge within the SMB health tech marketplace. Too many companies simply do not know what it means to be HIPAA compliant. That is a particular concern given that recent changes in the law mean they are now federally required to be so.

Why is simply storing data in an encrypted database an insufficient response?

The objective of HIPAA is to protect the “confidentiality, integrity, and security” of electronic Protected Health Information (ePHI). While encrypting data can certainly be a part of this, it does not cover the many other aspects also required, including determining who has access to the data; how and where the data is being shared; who can edit or delete the data; and so on.

The HIPAA security rule alone contains 42 standards and implementation specifications spread across three groups – administrative, physical, and technical. This is separate from the HIPAA Privacy and Breach Notification Rules, both of which are part of the overall HIPAA compliance requirements.

Even if you scratch a little deeper into the companies that claim to offer HIPAA-compliant hosting services, you should pay particular attention to the wording they use. While they may be willing to sign a Business Associate Agreement, they deliberately stop short of promising to provide a HIPAA-compliant solution. This is because they do not control access to the application — the solution provider does.

The next time a company tells you they are HIPAA compliant because they store their data in a HIPAA-compliant database or data center, you are certainly welcome to take a leap of faith. In the movie, after Judge Henry Harper is presented with evidence that the US Postal Service is delivering letters addressed to Santa Clause, he declares that, “…since the United States Government declares this man to be Santa Claus, this court will not dispute it.” However, I doubt that the enforcement arm of the Office for Civil Rights will be as liberal in its judgments.

Grant Elliott is founder and CEO of Ostendio of Washington, DC.

Readers Write: My First Experience at the mHealth Summit

My First Experience at the mHealth Summit
By Kevin Lasser

I was inspired by Mr. H’s comments regarding his experience at the fifth annual mHealth Summit. So much so that I want to share my experiences from a little different vantage point.

I was kindly invited to not only speak on the topic of return on investment,  but also to talk to the press about my participation in mHIMSS Roadmap V2.0. Honestly, I am not sure I would have gone otherwise, but I am happy I went. Here are my thoughts.

Exhibit Hall

It was filled with very large and small companies with a few exceptions. I did not get a sense that the large companies were really doing much in the mHealth space. However, they were happy to be at the Summit because they may be able to form ventures with some of the smaller companies.

Those smaller companies seemed to be primarily looking for three things:

• Validation of product
• Money from “bankers”
• A venture with a larger company

Unabashed Product Pushes

These were also called breakout sessions and executive spotlights.

I did a breakout session on ROI. The thing I was most proud of was the number of audience members who approached afterwards who said, “I have no idea what you do. Can you tell me…..” I considered that a great compliment.

I witnessed one session where a panelist had company logos and diagrams in his slide presentation. He turned every question from the audience into a product pitch. Based on those in the audience rolling their eyes and lack of people who approached this individual afterwards, I would say I was not the only one sick of his vendor pitch.

When are people going to learn that being a self-serving shill pitching your products under the guise of education works exactly the opposite way? (i.e. nobody cares about you or your product – YOU TURN PEOPLE OFF.)

State of the Industry

As a synopsis, I believe the following as it pertains to the mHealth industry:

• There is a lot of confusion. It is hard to distinguish one app from the next.
• Exhibiting a “real” ROI to prospective clients is a must. If a vendor answers a question regarding ROI with, “Imagine if …” that is not a real ROI.
• That HIMSS designated talented people and monetary resources to mHealth is a very encouraging sign for the future.
• Technology needs to be invisible. Nobody really cares about the technology. It is what the technology can do to lower costs, keep costs contained, and improve healthcare.

Lastly, regarding Mr. H’s comment that he snickers any time she sees someone wearing Google Glass, personally, I get a little nauseous.

Kevin Lasser is CEO of JEMS Technology of Orion, MI.

Readers Write: Musical Commentary on Mr. H’s mHealth Conference Summary

Musical Commentary on Mr. H’s mHealth Conference Summary
By DJ LooptyLoop

I have to say, your synopsis of mHealth sounds a little grim indeed. Chain restaurants lacking personality? Boring. Destination developments? Depressing. Terrible weather? Bearable when inside, but energy-zapping nonetheless.

If you’ve listened to Arcade Fire’s 2010 album “The Suburbs,” you would immediately relate the above description to my favorite track on the album, Sprawl II. “Sometimes I wonder if the world’s so small that we can never get away from this sprawl,” sings frontwoman Régine Chassagne. “Living in the sprawl. Dead shopping malls rise like mountains beyond mountains, and there’s no end in sight.”

But the most disappointing of all is the abandonment of the African public health project speakers. Actually, the abandonment of all global health issues in general is pretty appalling. The mHealth slogan reads, “Where technology, business, research, and policy connect.” One would think the policy research might actually be reflected via keynote speakers who speak to global solutions at this scale. But then again, maybe they don’t exist yet.

Arcade Fire’s new jam from their 2013 Reflektor album “Here Comes the Night Time” touches on this global health issue abandonment. “And the missionaries tell us we will be left behind. We’ve been left behind a thousand times, a thousand times,” cries frontman Win Butler. “If you want to be righteous, get in line.” Well, I suppose it’s back of the line for the emerging countries at the mHealth Summit, though I did see an announcement that mHealth Alliance plans to transition its base of operations in 2014 from the UN Foundation in DC to South Africa, so let’s scratch that and bump them up to the middle of the line.

And, there’s NO MUSIC? I guess conference attendees could throw on Reflektor with just one earbud in whilst walking from speaker to speaker so as not to be completely antisocial. The album hooks listeners at the initial beat-drop with a catchy Talking Heads vibe mixed with the fearless imagination of Daft Punk. Though I’d be careful with the feedback from other conference-goers, if Win Butler’s prediction holds true. “And when they hear the beat coming from the street, they lock the door. But if there’s no music up in heaven [or in our case, the mHealth Summit], then what’s it for?”

On a separate note, I would like to think that LCD Soundsystem and Reflektor producer James Murphy would be beaming to know his music has had a far-reaching impact. He did turn down a job as a writer for Seinfeld to make music, after all. He clearly wanted to make an impact elsewhere – and that impact has reached all the way into the world of healthcare IT.

Readers Write: “To Shag or Not to Shag” is a Really Important Question

“To Shag or Not to Shag” is a Really Important Question
By Shannon Snodgrass

We were laughing about Ricky Roma’s shagilicious request on HIStalk in our staff meeting this morning, but “to shag or not to shag” is actually a really important question. You can spend thousands and thousands (and thousands!) of dollars on your booth and show services. but few things are as important as the staff working your booth.

These are the people who will be telling the story of your company and interacting with your customers and potential customers. Not only do they need to be trained, they also need the tools and support for a successful show. That includes proper flooring that will support them comfortably in the long days that trade shows are famous for. How can you expect your staff to stay focused and upbeat if they are daydreaming about a foot massage while a potential customer is trying to get their attention?

There are many things to consider and plan for when staffing your booth. You need to consider each person, their natural talents, and tolerance and create a schedule for the show that utilizes each person to their best advantage. Shows can be overwhelming with sights and sounds. Even an extrovert can easily be overwhelmed.

Be sure to allow time for breaks to check emails and connect with customers outside of the booth. They also need time to call home and sit down for a minute to enjoy a snack. Even the best booth babes (guys and gals) need a little time to themselves to refresh and powder their noses.

In addition, your staff should be armed with core messages relative to what the company does, each of its products, and also a personal message about their role within the organization. Teach your team to listen and how to use listening as an effective communication and sales tool.

Keeping focused and on message can be tough in the crazy trade show environment, but training your staff ahead of time and providing them with the tools they need will give them the drive and focus to get through the day. Coffee, plenty of sleep, water, and comfortable yet attractive shoes don’t hurt either. 

On the "to shag or not to shag" debate, we have found that a low pile with a premium carpet pad provides support and comfort for most everyone no matter the heel height.

Shannon Snodgrass is senior project manager for Thomas Wright Partners.

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

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)

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

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

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

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.