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.

Readers Write: Managing the Complexities of Enterprise Platforms

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

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

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

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

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

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

Applying Lean Startup Principles to Optimization
By Tyler Smith

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

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

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

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

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.