Readers Write: All Vendors Exit Stage Left

All Vendors Exit Stage Left
By Frank Poggio

Stage 1 product certifications end this year — September 30 for Inpatient products and December 31 for Ambulatory. In many of my conversations with systems suppliers who are considering the next step in ONC Certification, they refer to it as “Stage 2 Certification.” I can’t blame them. I’ve done it myself.

Remember, it all started with Stage 1 two years ago, so naturally you would expect Stage 2 to follow Stage 1. But with the feds and ONC, it could never be that simple.

When ONC issued the final Stage 2 rules last year, they made a very purposeful and distinct break between Stage 2 Meaningful Use and the vendor test criteria. Instead of referring to “Stage 2 Test Criteria,” they labeled them the 2014 Edition Test Criteria. Providers are subject to Meaningful Use Stage 2 rules, while vendors seeking certification come under the 2014 Edition of Test Criteria. There are real differences  — some pretty big ones.

What I usually see is a software firm starts by carefully reviewing the provider MU Stage 2 attestation criteria since they are all over the Web. Next, they try to translate the MU list to product test criteria. Then confusion follows.

Although the MU attestation criteria for Stage 2 resembles the Certification test criteria, there are differences. For example, one big difference is a provider needs to attest to about 25 MU criteria and some Quality Measures to get the Stage 2 money. But you as a vendor need to pass on about 40 certification test criteria and nine QMS elements to become 2014 Edition Certified.

Another example: under Stage 2, a provider would attest to completing a HIPAA compliance risk analysis. That’s just one question (the answer is ‘yes’, subject to audit, of course). But for a vendor completing a certification test under the 2014 Edition, you address eight very specific tests for privacy and security.

ONC now refers to your Stage 1 certification as the “2011 Edition Test Criteria.” No more Stage 1.

A related question ties back to what I said at the top of this piece. Your current Stage 1 certification ends this year. Actually, ONC says your 2011 Edition certification ends and you must test out on the new 2014 Edition to continue to sell certified software.

As of this week, only four vendors have been successful in achieving 2014 Edition Full EHR Inpatient Certifications. Under Stage 1, there were dozens. The 2014 testing is turning out to be a real challenge for many vendors, far more difficult than I think ONC expected.
Some think ONC will extend the Stage 1 vendor certifications if they do not get enough vendors through 2104 Tests by September. That would seem a likely solution. But given Dr. M’s pointed comments about vendors “gaming the system,” I doubt it.

The reason they made the breaks between certification test criteria and MU attestation criteria is that when they decided to extend Stage 1 of provider attestation into 2014 (originally it was to die in 2013) they did not want to extent the vendor certifications as well. Why? I guess they just wanted to keep your feet to the fire.

Which raises the next question. How can a provider attest to Stage 1 in 2014 when all the vendor certifications for Stage 1 die in three or six months? Simple. ONC now allows the provider to MU attest under Stage1 using a 2014 Certified system. If you have clients or prospects that have not attested to Stage 1 and plan to do so in 2014, they must be running your 2014 Edition certified software for at least 90 days in 2014.

It seems that ONC has taken vendors off the Stage, and reduced them to simply an old Edition.

Frank Poggio is president of The Kelzon Group.

Readers Write: Asking the Right Questions: How to Find the Right Technology Development Partner

Asking the Right Questions: How to Find the Right Technology Development Partner
By Lee Farabaugh

We’ve all heard the stories. A hospital implements technology only to discover that it is so complex and confusing that it takes clinicians twice as long to get their work done as it did before, frustrating providers and patients. The hospital tries to work through the issues to no avail, and the organization ultimately abandons the software in pursuit of something else.

Money, time, and resources are wasted, and the organization is still no closer to effectively leveraging technology to improve patient care or streamline efficiencies. On the other hand, there are technology implementations that go smoothly, with providers fully embracing an application and using it appropriately.

What differentiates the good from the bad? User experience design, centered on end user input. Positive outcomes (increased user adoption, for example) occur when end users are actively involved in technology design, development and implementation.

To determine whether your technology partner incorporates user experience into its approach, there are some key questions you should ask. Getting answers to these questions can help you avoid disastrous technology roll-outs and ensure potential applications are a good fit for your organization.

Does your technology partner take a provider-centric approach by involving clinicians as key members of the development team?

These clinicians should be providers who have been actively involved in practicing medicine, so they are aware of the issues clinicians face in their day-to-day work. Getting direct input from providers who will use the system ensures that any potential roadblocks are addressed and resolved. Even if the technology you are considering is more patient-focused, clinicians should still be part of the development team. When people with medical expertise are involved in designing a patient-focused product, they can share the clinical perspective on what is possible and preferable for the technology.

How much of your technology partner’s research and development budget is devoted to garnering information about user experience?

This question can reveal the value your technology partner places on end user input. In other words, are they putting their money where their mouth is and dedicating resources to obtaining and leveraging user feedback?

Have you ever had a usability assessment on your application portfolio?

This puts hard data around your technology partner’s usability claims. By reviewing a usability assessment, you can clearly see whether providers or patients are actually using the software your partner developed on a long-term basis.

Does your technology partner have an end user group to provide ongoing feedback?

This type of forum can be a valuable source for transparent feedback about a solution. Not every software developer has the resources to sustain a user group for each of its clients, but those companies that do communicate their commitment to their customers and end user satisfaction. If your technology partner does have a user group, you may want to ask if you can attend a meeting. Although this may not be possible—some companies prefer to limit the number of attendees at a meeting—it would allow you to gain helpful information directly from other users.

Does your technology partner provide you with easy and intuitive training and support?

While some applications may be “plug and play,” most will require a certain level of training. Getting a sense of how user-friendly the training is can help provide insight around your technology partner’s commitment to user experience design across all of its materials. User-centered training may involve short videos, web-based modules or super-user mentoring. Ideally, you want to avoid day-long didactic training sessions that provide limited value and take providers away from patient care.

User experience design is the linchpin for technology adoption. Technology companies that don’t place value on user experience in the design and development process could offer products that aren’t fully usable and don’t meet the needs of your organization. As such, asking deliberate questions about your partner’s view on the value of user experience is time well spent.

Lee Farabaugh is the chief experience officer at PointClear Solutions.

Readers Write: What to Consider Before Accepting Your Next Healthcare IT Position

What to Consider Before Accepting Your Next Healthcare IT Position
By Frank Myeroff

In a competitive and growing job market like healthcare IT, it might be tempting to accept the next attractive job offer you receive. But before you do, take time to consider certain predictors that could determine whether you will be successful on the job or regretful that you took the job.

Is the organization in line with my values, attitudes, and goals?

You may have heard that people are hired for skill but fired for fit. It’s true. That’s why it’s so important to make sure you mesh with the culture of a healthcare organization. Their culture includes a combination of values, visions, attitudes, beliefs, and habits. These collective behaviors are taught to new organization members and affect the way people interact with each other and the way business is done.

What are the workload expectations?

Ask the hiring manager to address the workload expectations. There’s no doubt if you take the job that your boss will expect you to complete all your tasks on time and accurately. New hires usually want to meet and exceed organizational expectations by going over and above the job. But consider and evaluate if you have the staff support and resources you need to be successful.

Can I handle the commute to this job?

Always consider the commute to your job. Is it too far? How much will it cost? Gas? Parking? Will you need to be a “super commuter,” in other words, fly back and forth? The number of super commuters has increased sharply over the past few years. Be sure to determine your tolerance level and that of your family regarding the job commute.

What is the boss like?

Your career depends on understanding what makes the boss tick. Having a positive relationship with the boss is key to your success, but having a bad boss is the ultimate morale buster. Find out if the boss is a micro-manager or hands-off boss. Know if he or she has realistic or unrealistic expectations for employees. Find out if they foster innovation or discourage it. It’s important to work for a boss who values your efforts and makes it worthwhile to come to work every day.

What are the people like?

There may be a good reason why the job is open. Are the people the kind you want to work with, or are they the type to push buttons? For a workplace to be really great, it’s essential that you have a good relationship with your co-workers since you will see them so often, work with them on projects, or interact with them on a daily basis. For an office to be truly productive, there has to be some sort of harmony and cohesiveness.

What is the career progression?

This is an exciting time in healthcare IT. The demand for talented IT professionals continues to grow and the opportunities for advancement have never been better. The healthcare organization you join should be committed to meeting your current career aspirations as well as foster your future career path.

What is the training offered?

There is a clear, strategic value in continuously training and developing staff. Not only does it enable the healthcare organization to meet its mission, but allows their professional IT staff to stay current and ready for upcoming changes and trends. When considering your next IT position, make sure the organization places a strong emphasis on training and development for all IT levels. Training should focuses on individual needs such as job-related and specialized training and collective needs such as leadership and time management.

Before you jump to accept that job offer, remember that an offer is only half of the equation. The other part is performing your due diligence. Make sure the healthcare IT position and organization match your “must haves” both professionally and personally.

Frank Myeroff is managing partner and VP of business development and operations of Direct Consulting Associates of Solon, OH.

Readers Write: Uncovering the Unexplored Role and Benefits of Clinical Data Abstraction

Uncovering the Unexplored Role and Benefits of Clinical Data Abstraction
By George Abatjoglou

With the industry’s move to electronic health records (EHRs), healthcare information management (HIM) professionals as well as RNs must play a guiding role through implementation and beyond, seeking processes and solutions to manage the conversion of enormous amounts of historical health information into meaningful, structured data. One helpful and often underexplored strategy for getting organizations up and running smoothly on an EHR involves pre-go live clinical data abstraction.

Historically, clinical data abstraction has been used to retrieve meaningful information that exists in unstructured formats – paper or otherwise – to fill in the “holes” in the electronic chart. Typically, this occurs so an organization can perform better financial or quality reporting. However, with the current push to implement EHRs within the ambulatory setting under Meaningful Use, healthcare organizations often underutilize or completely overlook using clinical data abstraction as a strategy for jump starting the EHR rollout process. In short, by populating EHRs with these details from paper charts and unstructured legacy EHRs before organization-wide rollout, physician practices to health systems and ACOs can reap EHR benefits more quickly, while ensuring more optimal data quality and integrity.

Whether patient records are electronic or paper-based, most contain “legacy” health information that requires someone to pluck relevant data from unstructured content and incorporate it in a structured, representative history in the EHR. While you may think it sounds like copying and pasting, the medical and scientific nature of the information makes this more complicated than it seems. In other words, clinical abstraction, when done well, is best left to the experts, including trained and credentialed HIM professionals and RNs who are consistently focused on clinical data integrity in their day-to-day roles.

With practice makes perfect, and experts in this arena are skilled magicians at identifying and pulling nuggets of information that will provide practitioners with the most valuable details moving forward, especially from a continuity of care perspective. Moreover, these individuals understand data in a broader way than a coder might, and as a result, take into consideration different clinical components that shape the picture of a person’s whole health as they mine critical details for the new EHR.

Leveraging clinical data abstraction as a strategic step in EHR population can take two forms.

• Existing resources. Healthcare organizations can facilitate the effort themselves by using staff clinicians and/or hiring additional nurses, medical assistants or students to abstract clinical data.
• Outsourcing. Other healthcare organizations work with partners who embed clinical experts within the organization to facilitate the process.

Although it’s feasible for smaller healthcare organizations—community hospitals, critical access hospitals, and small practices, for example—to abstract and manage data internally, clinical data abstraction becomes increasingly complicated for larger physician groups and health systems that provide care to hundreds if not thousands of patients in a given day. When these large systems try to enlist internal staff to conduct data abstraction and enter historical data into EHRs, they are likely to run into roadblocks.

For example, relying on internal resources for data abstraction will further decrease the productivity of clinicians and HIM professionals already diminished by an EHR implementation and preparing for the ICD-10 deadline. Clinicians typically decrease the number of patients seen during the EHR implementation period in order to adjust to the new workflows demanded by the technology. A physician who normally sees 20 patients per day may need to decrease patient appointments to 12 per day and gradually work back to a normal activity level after several months. If paired with abstraction responsibilities as well, the productivity decline is often viewed as too steep.

Although it may seem counterintuitive, using internal resources also can lead to the generation of even more non-standard, unstructured data. With patient care being the top priority for clinicians, abstracting clinical data and entering historical information may not always be executed in the same way as a full-time abstractor whose sole focus is on that one task, guided by standardization across every record. While some data is better than none, the benefits of unstructured data within an EHR are not much different than working with paper-based records, which defeats the value of EHR implementation.

An EHR implementation can only be as successful as the quality of its data. As the saying goes, “garbage in, garbage out.” Regardless of an organization’s decision to use internal or external resources, clinical data abstraction overseen by seasoned HIM professionals and supplemented by knowledgeable RNs offers several benefits—some of which are more heavily weighted in the interest of utilizing outside consultants:

• Improved data integrity. As healthcare organizations go live with EHRs, data need to be organized in a structured and sustainable format to provide consistent core medical content for clinicians across all patient records.
• Increased patient safety. When data consistently and accurately reflect patient conditions in a streamlined, structured format, EHRs become easier to navigate from a decision-making and care management perspective, contributing to increased patient safety and care quality.
• Enhanced productivity and satisfaction. By relying on outside experts rather than tapping internal resources to abstract and enter historical data, clinicians’ time is maximized and remains focused on providing patient care, while internal HIM professionals are able to focus on other mission-critical tasks like ICD-10 training.
• Better patient experience. Tasking clinicians to enter data does not add value to the delivery of care, nor does it contribute to the clinician–patient interaction. Unfortunately, with the learning-curve that often accompanies EHR implementation, a patient appointment can become rather data-driven and impersonal if clinicians spend more time looking at the computer screen than their patients. Using data abstraction experts allows physicians to maintain a positive “human” interaction with the patient, a critical component to meeting patient expectations.
• Higher return on investment. No matter who facilitates it, there is an absolute cost associated with abstracting clinical data. Outsourcing the process does carry an initial expense, which may then be recouped by physicians’ sustaining their activity loads. On the other hand, revenue lost through decreased provider productivity when clinicians are tasked with performing data abstraction may not be regained. Cultivated by the improved patient experience, outsourcing the clinical data abstraction effort may also lead to additional gains such as practice expansion and patient retention.

The number of provider choices for patients is multiplying and steering healthcare into a more consumer-driven model. The healthcare organizations that thrive into the future will be the ones that safeguard data integrity and use it to streamline the physician/patient interaction. Tapping into the data management expertise of HIM professionals in particular and using clinical data abstraction to improve data quality, patient safety, and clinician productivity is one key to providing a positive experience for patients and clinicians alike – both throughout and beyond an EHR implementation.

George Abatjoglou is CEO of IOD.

Readers Write: My Tradeshow High Horse

My Tradeshow High Horse
By Annie Oakley

Perhaps you’ve read HIStalk posts in the past – particularly after HIMSS – lambasting the poor showmanship of exhibitors at tradeshows. Eyes down, phones on, beckoning smiles nonexistent.

You may also have read subsequent reader comments from said exhibitors attempting to explain away their need to ignore attendees for the sake of an incoming service call. I get it. Everyone has multiple jobs to do while at a conference. I’d be surprised to find a healthcare professional – provider or vendor – who doesn’t wear multiple hats these days and gets taken advantage of by 24/7 connectivity.

But, like many others out there in HIStalk land, I say turn your phones off when you’re in the booth. If you need to take or make a call, exit the exhibit hall.

I’ve been on both sides of the booth at tradeshows over the years, and so I feel qualified to get up on my high horse for just a few more paragraphs about my recent trip to the HFMA ANI show. It was an experience that left me optimistic about the tradeshow experience overall, but left me with a bitter taste in my mouth on more than one occasion.

The HFMA staff and volunteers were incredibly helpful, always had smiles on their faces and good attitudes to back them up. The majority of exhibitors that I had a chance to approach were pleasant to speak with. Some were downright engaging, leaving me with lasting positive impressions of their employees and brands. Most were extremely patient in explaining revenue cycle concepts and challenges – not easy completely absorb on first go round.

The “booth babe” phenomenon continues to die a slow death, unfortunately. I found out during an educational session that HFMA membership is 60 percent women. Do exhibitors really think they’ll attract female attendees with models dressed up in racing gear? I saw one male attendee look happy enough as he posed for pictures with them, and I shook my head in shame. Is that really how you want to get your leads? Is that really the impression you want to leave people – mostly female people – with?

Drew Brees was on the show floor for a time signing autographs, an attraction which drew a few dozen folks into a line that crisscrossed the exhibit floor. Now that’s a way to create buzz without alienating anyone.

One more comment, then I’ll get off my high horse. Exhibitors, please don’t be stingy with your giveaways. You and I both know that come the last day of the show, you’ll be moaning and groaning about having to ship them back. I approached one booth BECAUSE of their unique giveaway, but was immediately turned off when the rep, thinking I’d already been by, gave me the cold shoulder. I pleasantly explained to him that we had indeed conversed the day before, but I had not acquired any of his trinkets. He apologized – sort of – and actually said he hates having to talk to people twice! Buddy, if you don’t like talking to people twice, maybe you shouldn’t be in sales.

This particular conference was a great experience for me overall. The positives far outweighed the negatives. But, it’s true what they say: one bad apple can spoil the tradeshow bunch.

Readers Write: Health Data Analytics Provides Greater Value Over Big Data

Health Data Analytics Provides Greater Value Over Big Data
By Joe Crandall

Like you, I’m tired. I am tired of the latest buzzword in healthcare circles: “Big Data.”

The problem I see as a healthcare professional is that most experts are not offering solid, realistic ideas about how to leverage data at the decision-maker level. Most articles and experts are talking about using data to fundamentally change healthcare (genomics, population health, etc.) How many times have you heard that a new something was going to change healthcare forever? These experts are doing a disservice to the large majority of hospitals and health systems out there. I suggest you forget the term “Big Data” and begin to think about Health Data Analytics (HDA).

The truth is that most hospitals have been using health data analytics to some degree for a long time. Because of external and internal drivers, healthcare organizations are now being pushed to do more with less. That means leveraging their data and tools more efficiently. This isn’t about predictive analytics . It is about giving the clinical decision maker the information they need when they need it so they can make better decisions to drive better outcomes.

Six things to think about in regards to HDA:

1. Ignore the hype. Don’t fall for the sales pitches and doom and gloom if you haven’t bought a business intelligence (BI) tool yet. About 90 percent of the hospitals out there are in the same boat as you. The hospitals giving the “Big Data” talks have been on that path for decades and have spent millions of dollars. Not surprisingly, they are only starting to leverage the data for research. You don’t need “Big Data” — you need analytics.
2. Be realistic. Let me say that again: be realistic. You are not going to go from a data-averse culture to a data-driven culture overnight. You aren’t going to be able to convince everyone this is the right project to invest in. Buying the best in KLAS BI vendor is not going to magically transform your organization. If you do decide to buy a BI tool, be realistic when setting expectations with a BI vendor. The implementation won’t be as easy as they say and the people won’t flock to the platform as quickly as they say. In fact, it is like every other platform IT has installed. Focus on the people rather than the technology for lasting success.
3. Conduct an in-depth assessment. Before you start a HDA program, take an honest assessment of your current state of health data readiness. A readiness assessment saves money in the long run by clearly identifying any gaps in skills, tools, or process. Answer some basic questions first. Does our organization have a culture of sharing data? Do we have a good data governance program in place? Do we have data integrity issues? Do our people know how to use the information we can provide? Knowing where you are starting and your end goal is an important part of any project. A great assessment will help you plan to reach your goals with clearly laid out courses of action.
4. Start small. HDA projects need to start small with scalable and sustainable processes that will allow the program to expand intelligently. While in the military, we used the “crawl, walk, run” methodology and it applies to implementing a HDA program at your facility. Do not start running with “Let’s change the discharge process” as your first HDA project. A better and more focused choice could be to crawl with “On the labor and delivery floor, how do we discharge patients before 11 am?” Start small with big results. Then grow.
5. Grow intelligently. Once that first project is a success, look into expanding under the guidance of a strong executive sponsor and a competent governance structure. Keep in mind that you don’t need to duplicate the first project throughout your facility – you need the ability to replicate it. Duplication implies a direct copy, while replication allows variances for each situation that might be encountered while implementing the new way of doing business. Once people start to see the benefit of a data-driven culture, requests for projects will pour in and the organization will need a plan to intelligently address all requests and aggressively pursue the best ones.
6. Focus on your people. Most importantly is the focus on the people. Each person within your organization has a decision-making maturity that may or may not be able to leverage the HDA program effectively. This is why certain programs are successful under the leadership of one person but flounder once that leader moves on. It is why someone can look at raw data and see patterns in the business and make decisions that drive action. It is why a project can be successfully run by staff while being led by an inept leader. It is the maturity of each individual that will determine the success of the HDA program, not the tools or platform.

The requirement of leveraging data to gain a competitive edge is upon us. Healthcare organizations are being asked to improve outcomes as the main driver for improving the bottom line. A data-driven culture will transform an organization from volume based to value based, but it will take time and the right people. Focus on one project initially, guided by a strong executive sponsor utilizing a process that is scalable and sustainable.

If you do this, before you know it, your organization will be utilizing health data analytics to make more intelligent decisions that will ultimately improve outcomes. You will have created a data-driven culture.

Joe Crandall is director of client engagement solutions for Greencastle Associates Consulting.

Readers Write: The Case for One Source of Truth

The Case for One Source of Truth
By Deborah Kohn

The notion of managing and being accountable for the health status of defined populations requires much more sophisticated clinical data collection methods and skills than most healthcare organizations have today. However, for decades, numerous coded systems have been used to successfully capture clinical data for reporting purposes, such as quality initiatives and outcome measurements, as well as for reimbursement and other myriad purposes.

Such coded systems, which health information professionals categorize as either clinical classification systems[1] or clinical terminology systems[2], can continue to be used to assist in determining prospective, pre-emptive care management on covered populations. However, no single classification system meets all use cases. ICD-9 CM does not contain medications. ICD-10 CM does not address functional status. In addition, no single terminology system meets all use cases. LOINC is used to encode laboratory data. SNOMED CT is used to encode clinical care data. RxNorm is used to encode medications.

Consequently, using the existing or newer coded systems to meet any of the fast-growing clinical data collection and analysis initiatives presents a significant challenge: too many systems from which to choose, hindering any efforts to change the collection of the data into actionable information for interoperability and health information exchange. To resolve this challenge, one “one source of truth" or one central authority platform (CAP) for all clinical data capture systems, existing and new, allows all coded systems to be used to capture and exchange information.

© Deborah Kohn 2013

With one CAP, healthcare organizations need not be concerned about when to use which data collection system for which purpose. Organizations are able to capture required clinical, financial, and administrative data once and use it many times, such as for adjudication and information governance purposes. In addition, organizations are able to compare the data for data integrity purposes. More importantly, organizations are assured that electronic healthcare data input by different users is semantically interoperable, i.e. the data are understood and used while the original meaning of the data is maintained.

For example, for typical diabetic patients, Reference Lab #1 might denote glycohemoglobin within the chemistry panel, Physician Office Lab #2 might denote glycohemoglobin as an independent test: HgbA1c, and Hospital Lab #3 might use the embedded LOINC code: 4548-4. The central authority platform recognizes each of the three laboratory information system inputs representing the same value — glucose level. Subsequently, the healthcare organization’s electronic health record (EHR) or business intelligence system makes use of the common meaning, and for example, generates a trend analysis of the patient’s glucose readings over time.

Developing a CAP requires considerable effort. The platform must be able to store all coded values, metadata, and all the content / terms. It must be able to normalize and catalog all the content / terms. It must be able track all changes in content identifiers, watches for differences in terms, cross-maps the content, route the content while preserving the data and context, and regenerate the data and content as it was stored. Finally, it must be able to manage all the content updates / releases. Today both the public and private domains have been moderately successful in developing the platform.

The Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare & Medicaid Services (CMS) collaborated with the National Library of Medicine (NLM) to provide the Value Set Authority Center (VSAC). VSAC is to become the public domain, central authority platform for the official versions of the value sets that support Meaningful Use’s 2014 Clinical Quality Measures (CQMs). However, currently VSAC does not go far enough to cover all use cases.

In the private domain, several health information technology vendors provide most of the required capabilities of the CAP. Interestingly, these vendors collaborated with clinical professionals to create different categories of coded systems to describe their products than those categories created decades ago by health information professionals. For example, the vendors refer to any coded system used for capturing and exchanging data as a “terminology” system, even though some of these systems are categorized by health information professionals as classification systems. In addition, the vendors categorize all “terminologies” as either standard[3] or local terminologies[4]. Some of these vendors go even farther in categorizing all “terminologies” as either retrospective or point-of-care terminologies[5]. Consequently, today not only are there too many coded systems for data capture and exchange from which to choose, but too many categories of coded systems to make sense of it all.

Assuming that both public and private domain CAP options will prevail, healthcare organizations can expect widespread use of the platforms, allowing EHRs and other electronic records, such as financial records, to incorporate multiple coded systems for specified needs. In addition, workforce demands for the clinical informatics skills needed to manage all the coded data will continue to remain strong.

[1] Clinical classification systems, such as ICD-9-CM, ICD-10-CM, and ICD-10-PCS derive from epidemiology and health information management. These systems group similar diseases and procedures based on predetermined categories for body systems, etiology or life phases. As such, they organize related entities for easy retrieval. They are considered “output” rather than “input” systems and were never intended or designed for the primary documentation (or input) of clinical care.

[2] Clinical terminology systems (a.k.a., nomenclature or vocabulary systems), such as SNOMED CT and RxNorm derive from health informatics. These systems are expressed in “natural” language, and, typically, codify the clinical information captured in an electronic health record (EHR) during the course of patient care (because the number of items and level of detail cannot be effectively managed without automation). As such, they are considered “input” systems.

[3] Standard terminologies consist of “administrative” terminologies, such as ICD and CPT, and “reference” terminologies, such as SNOMED, LOINC, RxNorm, and UMLS.

[4] Local terminologies are those that healthcare providers, such as laboratories or physicians, use on a daily basis in their records, on the telephone, etc., to describe specific diagnoses and procedures.

[5] Retrospective terminologies consist of all standard terminologies (administrative and reference) and local terminologies, while point-of-care terminologies are those that are healthcare provider-friendly and used for specific documents.

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

Readers Write: My Notes On Last Week’s Senate Finance Committee Hearing

My Notes On Last Week’s Senate Finance Committee Hearing
By Data Nerd

In a rare twist of fate, I had some down time last week in between deadlines and got to choose between a variety of Congressional hearings to ridicule observe. While I’d really have loved to see Gen. Alexander prove that the NSA has foiled a legitimate terrorist threat, I decided to go with the Senate Finance Committee’s hearing on the dually-pressing grievances of high prices and low transparency in the health care industry as enumerated in Steve Brill’s Time piece, “Bitter Pill: Why Medical Bills are Killing Us.” The hearing lasted about as long as it took me to read the original article and unfortunately I couldn’t “observe” all of it, but here are the questions and responses I found most relevant on the topic.

Sen. Baucus kicked off the questioning by stating that disclosure alone may not be sufficient to bring down healthcare prices and asked each of the panelists to supply a solution to the problem. Mr. Brill pointed out that injecting competition into the insurance market alone doesn’t guarantee price reduction. He brought up the large amounts of campaign contributions made by the healthcare industry to each of the members on the committee, the least of whom accepted half a million dollars in the past five years. Suzanne Delbanco, executive director of Catalyst for Payment Reform, states that consumers tend to assume that higher price means higher quality, while Paul Ginsburg, president of Center for Studying Health System Change, suggests changing benefit design so that consumers care which provider they see.

Sen. Hatch questions what type of data is being released and how reliable and useful it is to consumers. Dr. Ginsburg hones in on insurers and employers as the best source for consumer health care pricing data, stating that data has to be customized and reflect details of particular health plan, and these organizations are in best position to provide that.

Sen. Hatch shifts focus to hospital chargemasters: “If they are only marginally relevant, what steps should we take to move away from these systems and replace them?” Dr. Delbanco responds by agreeing that CMS pricing data released was great education for all concerning price disparities, but that providers and consumers need to understand costs of delivering care and the costs of delivering high-quality care.

Sen. Thune next takes the floor and cites some state measures to publish price lists. He asks Dr. Delbanco if published price lists for elective procedures are effective in putting market pressure on hospitals. Dr. Delbanco states that very little research has been done on whether consumers use this data, but is a beginning. She stresses the need of customization to make usable, vis a vis connecting price data to health care plan specifications.

Sen. Thune astutely acknowledges the role of recent regulations in pushing the industry towards more consolidation and asks what role this plays in pricing and whether antitrust laws need to be reevaluated in light of this shift. Dr. Ginsburg says that the best approach is to take steps to make the market more competitive despite its consolidated state. He mentions a need to revisit FTC Safe Harbor policy to require demonstrations of benefits for patients, and asserts that government can take a legislative approach to outlaw non-competitive contracting practices between health plans and providers.

Sen. Burr asserts that “seniors don’t like choice” and that “faced with healthcare decisions, their [adult] children are increasingly being turned to rather than healthcare providers”. He also offered that it “would be a cheap shot” to say that donations that health care organizations have made to him as informing the healthcare legislation he has written. Mr. Brill pointed out that he didn’t accuse him of such.

Sen. Rockefeller brought up the “public option” and the fact that everyone loved it but no one voted for it, so it was replaced with a “medical loss ratio” that resulted in private insurers being forced to issue rebates to consumers. He brings it all home by praising Congress on the establishment of IPAB to take the power of the purse away from lobbyists and Congress and give it to physicians that can make “wiser” decisions to save Medicare dollars. To this, Dr. Ginsburg responds that IPAB is “constrained,” with only the authority to squeeze money from reimbursement. Reimbursement, he says, is on autopilot and Congress can still lower reimbursement amounts at will. Instead, he expects more savings to come from Innovate Reimbursement models.

Sen. Baucus highlights the price variations and states that “he saw a chart somewhere” that showed that Medicare reimbursement amounts do not vary as much as private insurance reimbursement. He asks why this is so and if CMS has access to private insurance reimbursement data. Dr. Ginsburg agrees with Sen. Baucus’s assessment and asserts that new reimbursement models should address price variances. He mentions regulating private prices like Maryland has done since the late 70s. Brill asserts that a five-column list should be made public: what Medicare pays, what the Chargemaster charges, and what the three largest insurers pay for the same service. Dr. Delbanco asserts the need for quality input. She states that it matters little what you pay for a service unless the quality is satisfactory.

Sen. Menendez quickly launched into an attack, stating that Mr. Brill’s article did little to acknowledge how healthcare reform is addressing price disparities. Brill interjects and refers the senator to a specific paragraph of the article, to which the senator tells him to wait until he is done stating his question. He then attempts to corner Mr. Brill into agreeing that Obamacare addresses price volatility by eradicating low-quality health insurance plans and expanding coverage for citizens. Mr. Brill maintains that, while beneficial in other areas, the ACA does not directly address price variation in the market. Menendez asks him if he believes prices should be controlled by the government. Mr. Brill states that he believes “patented, life-saving drugs” should be controlled, but not procedures, and that “some interference is needed to preserve a free market.”

Sen. Baucus asks why hospitals are so fancy and compares healthcare to education and insurance to student loans. Dr. Delbanco points out that patients do not have data on which to base their provider choice, so they generally go on perception of facilities. Dr. Ginsburg states that consumers are removed from cost.

Sen. Schumer points out that higher costs at teaching hospitals are justified because they typically treat more rare, last-resort patients.

Sen. Baucus proposes an entrepreneurial approach to itemizing costs at a hospital on any given procedure and making that data available to consumers. Ultimately, he asked “What data, if any, should be proprietary?”

Overall, the Senators prepared meaningful questions to ask the panelists and were provided well-thought-out responses that intimate the complex nature of this issue. Consumers do not want raw massive files of data to pore over – they want someone to provide it in a way that is personalized, comprehendible, trustworthy, and ultimately actionable. Doing this will require a complex system of cost to quality analysis coupled with personal health and insurance policy parameters.

In my opinion, any true consumer solution will offer an element of predictive capability on which to base insurance and provider choices. To the entity (or entities) that can provide this in the least-intimidating way go the spoils. Who knows whether it will be insurance companies themselves, a joint venture between them and employers, or an entrepreneurial one-size-fits-all solution? 

I’m giddy to see the day when I can not only predict my tax burden six months in advance and strategize how to minimize it for free online, but also chart out a course for my family’s healthcare and make informed decisions about how much coverage we need and where we should go to get care.

Readers Write: Through a Different Lens

Through a Different Lens
By Kathy Krypel

In the end, it was hepatitis. Not some organized alphabetized version, but a quick, no-holds-barred attack from inside that would give me 10 days in the hospital and a look at healthcare from a very different perspective.

I am a clinician. I am also a healthcare IT expert. And now, I am a patient.

My induction into patient life was abrupt and unexpected. I, who had not been hospitalized in 30 years, was afflicted with sepsis in very short order. The trip to the emergency department, the 103 degree fever, and the 10 days spent in the hospital are all a bit of a blur.

Looking at it weeks later, from the slow recovery side of things, I offer these observations.

The Clinicians

I don’t know if they still teach something called ‘bedside manner’, but my experience with clinicians varied significantly. On the high end of the scale were the infectious disease doctor and hospitalist who coordinated care, modeled teamwork, and went out of their way to explain tests and procedures to me and my family. On the low end was the consulting physician, who referred to me as the ‘bile duct in 52’ in a hallway conversation that I happened to overhear.

The nursing, lab, radiology, and transport staff will forever have my gratitude for the way they fiercely protected my modesty (even when I was too sick to care), kept me informed about test results, and treated me and my family with utmost kindness.

The Electronic Medical Record

Ironically, I actually helped build the EMR and train users at the hospital where I was admitted. It was astonishing and very impressive to see it in action. I was able to see how quickly blood test results came back, watch the multiple ultrasounds and CT scans, and even observe my own liver biopsy.

It was fascinating, but reminded me that the EMR is only a tool that offers safeguards and suggestions. The physicians on my case were dogged in their pursuit of this infection, but even with the best of electronic records, they could not grow a blood culture faster or obtain instantaneous results on lab draws. These just take time. As good as an EMR is, it can help with the diagnostic process, but cannot magically make it faster.

The Patient

At the end of the day, it’s the human things that I will remember most – the infectious disease doctor who held my hand in the ED, the hospitalist who sat on the end of my bed for 30 minutes and explained what was happening and said that she would “tell us when to worry,” and the number of nurses who looked me in the eye and said, ‘I am so sorry this is happening.”

Despite advances in healthcare information technology, there’s still an inherent need for the personal connection – the relationship. That is the vehicle for healing. As the industry tackles the patient engagement challenge, the relationship – the patient experience – truly is at the center.

Kathy Krypel, LICSW, PMP is a master advisor for Aspen Advisors.

Readers Write: What’s in YOUR Medical Record?

What’s in YOUR Medical Record?
By Ken Schafer

If my wife were admitted to the hospital with diabetic ketoacidosis (DKA), I’m pretty sure I wouldn’t want her electronic record to erroneously record a leg amputation (BKA). I’m equally confident that if this documentation mistake were made, I wouldn’t care too much how it happened. I would just want it fixed.

And if incorrect documentation on my diabetic wife resulted in an incorrect treatment course, which resulted in her death? You might end up with a $140 million verdict like this one.

Inga’s post on The Atlantic’s “The Drawbacks of Data-Driven Medicine” (from Big Datty,on 6/12/13) illustrates something that we all know to be true. Our medical records often contain mistakes, and electronic errors perpetuate themselves embarrassingly quickly. But her comments – and the source article – miss two very important points.

Doctors are responsible for the content of the records they create. This is true regardless of the method used to document patient encounters. Blaming the speech recognition system for hearing “DKA” instead of “BKA” makes no more sense than blaming a keyboard for a typographical error. If the physician picked the wrong checkbox on an EHR interface, would that be the fault of the EHR? Of course not.

Speech recognition, keyboarding, and dropdown menus are all methods for data capture. For that matter, so is a more traditional transcription process. But all of these methods have one element in common: the final content should be reviewed and validated by the documenting clinician. Physicians who fail to do this put their patients at risk.

Doctors make mistakes. I know a radiologist who dictated “liver” when he meant “heart.” The transcriptionist dutifully returned the report with the word “liver,” and it was signed by the physician. When the mistake was discovered, the audio was retrieved. The doctor listened to himself dictate the wrong organ, and blamed the transcriptionist. The point? Doctors are people, and people make mistakes, whether they own up to them or not.

That same physician was convinced speech recognition would eliminate transcription errors, and he was right – sort of. What speech recognition systems really do is eliminate transcriptionists, not errors. If radiologists are involved, there will still be errors. There’s no speech recognition system that will hear the word “liver” and change it to “heart.”

In fact, in our DKA:BKA example, the doctor may have had a bad day and actually said BKA to the speech recognition system. No matter what, though, the doctor made a mistake – either in what he said, or in what he saw on the screen and failed to correct.

Those with experience greater than mine often post to HIStalk about the shortcomings of EHRs in terms of the data they contain, with usability and completeness being favorite topics. My concern for our records is more specific. Especially when speech recognition is involved, what metrics do we have in place to make sure that narrative data is recorded accurately? If doctors are responsible for the content of their documents, and we know they make mistakes, how do we monitor and improve the quality of the narrative components of our EHRs?

As the government, physicians, patients, and the free market determine what systems we are to use and how they should work, we should never lose sight of this one truth: no matter what’s in the record, it should be right.

Ken Schafer is executive vice president, industry relations for SpeechCheck.

Readers Write: Help on the Way for Clinician Work Fatigue with Drug Interactions?

Help on the Way for Clinician Work Fatigue with Drug Interactions?
By Helen Figge, RPh, PharmD

Clinicians are increasingly using an electronic health record (EHR) to enter prescriptions via a computer. Increased utilization of computerized medication order entry is being driven in part by the Meaningful Use program, which includes incentives for the adoption and meaningful use of certified electronic health records for eligible clinicians in both the Medicare and Medicaid programs.

Electronic prescribing is an integral component of the Meaningful Use program. Regardless of whether the prescriber elects to print or electronically transmit the prescription, the prescriber’s EHR can apply a series of edits to check for potential errors that could be harmful to the patient.

Some EHRs display all edits with equal significance. Hence, clinicians are presented with a stream of low-priority or irrelevant edits mixed in with occasional high-value edits. The consequences of this type of presentation are very serious because clinicians become overwhelmed and frustrated with the continuous presentation of low-priority nuisance alerts – hence clinician “alert fatigue.”

Because alert fatigue threatens to potentially jeopardize the entire concept of improving patient safety, the Office of the National Coordinator for Health Information Technology (ONCHIT) awarded a grant to the RAND Corporation and Harvard/Partners HealthCare in collaboration with UCLA to study the problem and develop a solution. The approach taken by the study group was to identify a critical set of interactions that should be implemented universally.

Thirty-one high risk drug-drug interactions were reviewed and a final list of 15 interactions was adopted. The study group considered the final set of 15 interaction pairs to be a starter set that should be identified in all commercial products as high severity because they have high potential for patient harm and are contraindicated for co-administration. The list might not represent all high-severity interactions, so additional research will be needed in this area, but it’s a proactive start.

Deployment of these 15 interaction sets in EHRs as high risk, along with the elimination of clinically irrelevant edits, could greatly reduce the burden of alert fatigue that clinicians overwhelmingly feel in their day-to-day encounters with the technologies. However, the actual commercial implementation of this approach has not been successfully accomplished due to legal issues, particularly due to concerns among database and EHR vendors about liability.

The overarching question to be answered is funding and exact methodology for moving this effort forward at the national level, which has not been identified. Furthermore, it has not been determined whether the database should be maintained by a private entity or by a public agency such as FDA.

But it is progress in the war against what really true drug integration is and what is just a cautionary listing for liability’s sake.

Helen Figge is advisor, clinical operations and strategies, for VRAI Transformation.

Readers Write: Have a Seat

Have a Seat
By Ryan Secan, MD, MPH

Customer service is important. This is not a revelation. We’ve all had our terrible customer service experiences (airlines, banks, utilities, cable companies, and social media, I’m looking at you), but today I’d like to focus on good customer service. There are lots of examples of excellent customer service which don’t cost that much money (like this, or this), mostly just time, effort, and actually caring about providing a high level of service. 

While everyone pays lip service to the notion that customer service is important, somehow there never seems to be money in the budget for it. While some customer service efforts require investment, many can be done at low or no cost. This is a win-win we all hope for – a better experience for our customer that is cost neutral.

I used to own a high-mileage luxury brand car. When it needed service, my wife liked to take it to the dealer for repairs. It cost more money for the service, but to her it was worth it. The drop-off area was clean. There was a place to sit down and talk to a professionally dressed person regarding what was wrong with the car. While the car was being fixed, she always got a nice, new car as a loaner free of charge. The dealer was flexible about when she could pick up the car and bring back the loaner, and her car was always washed and vacuumed when it was done. 

This was high level customer service that was worth paying for. It likely didn’t cost the car dealer much, as any costs were likely covered by the higher prices for service. It may have actually been a source of profit if the cost of providing this level of service was less than the extra money made from the service. 

One of the best examples I’ve read is described in this post by Joe Posnanski about an experience he had at Harry Potter World at Universal Studios. He’s a sportswriter, but writes on a range of topics, and if you aren’t reading him, you’re really missing out even if you aren’t into sports. 

The column is a bit of a long read, but definitely worth it, and if you’re a parent like me, it might make you a little misty at the end. Go ahead and click through and read it right now – you’ll be happy you did.  It wasn’t the $250 million theme park that this little girl (and her dad) is going to remember. It’s the brief, meaningful interaction with a staff member who put forth just a little bit more effort than expected that made all of the difference.

In the clinical world, sometimes even the smallest things can improve a patient’s satisfaction with their healthcare encounter. A study out of the University of Kansas Hospital demonstrated than when physicians sit down during a bedside encounter rather than stand up, despite spending less time with the patient, they were perceived as having spent 40 percent more time in the room. The patients reported that they were more satisfied with the encounter and had a better understanding of their condition. 

High levels of customer service don’t have to cost a significant amount of money, just an understanding of what your customers want and are willing to pay for and a culture that empowers your team members to go the extra mile to meet the customer’s needs. We can provide this high level of service to our provider clients by actively listening to them and selling them what they want or need to do their job effectively (e.g., single sign on, interface between an application and their EHR, automation of a manual process, etc.)

In the health IT world, where technology road blocks can interfere with patient safety, it is critical that we play our part – and play it well.  

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

Readers Write: Time Out for Pre‐Implementation Training

Time Out for Pre-Implementation Training 
By Tiffany Crenshaw 

I’d like everyone to join me in giving a hand to the nurses at Marin General Hospital for bringing a bright spotlight to the specific issue of healthcare IT implementations and patient safety, and  the broader issue of the enormous pressure hospitals are under today.

As recently reported in HIStalk, a group of nurses from Marin General voiced their concerns at a recent board meeting with the hospital’s new CPOE system, citing threats to patient safety as a result of inadequate training and other unspecified problems with the software. Unlike those EMR detractors we’ve read about in the last few months, this group doesn’t want to kick the new technology to the curb. They simply want a “time out” for additional training so they can use it in the most effective way possible to provide the safest care possible. 

This particular hospital’s struggle with new technology highlights the many pressures providers  across the country are facing when it comes to implementing new healthcare IT systems. Many hospitals are enticed by Meaningful Use incentives. Some sign on the vendor’s dotted line, not realizing implementation timelines suggested by vendors are at times too aggressive and don’t typically allow for proper end-user training. But since hospital XYZ down the street is doing it and Meaningful Use deadlines are looming, new systems are being installed rapidly across the US. I’ve heard more than one hospital executive say meaningful utilization is becoming an afterthought. 

In my 15 years in this industry, I’ve learned – and I’ve seen my clients learn – that implementing EMRs isn’t a project that affects just one department for a few months. It’s an initiative that touches every facet of a hospital – from IT to operations, from clinical to financial. It can’t be stated enough how big of an initiative the transition to an EMR is. Its size necessitates careful, methodical planning – not only for implementation, but for training; go-live support; and post-implementation optimization, support, and continued education.  

Perhaps it is because of this “project” mindset that healthcare associations have become vocal in their cries to delay the transition to ICD‐10 and the deadline for Stage 2. Providers are realizing these initiatives and the funds they’ve spent on them will be compromised without a proper strategy in place for training, implementation, post go‐live, and continued education around upgrades.

Is there a disconnect when end users such as the nurses at Marin General are filing “assignment despite objection” forms while upper management attributes nurses’ uneasiness as “just to be expected” during times of change, or are both opinions valid?

Human beings by nature are resistant to change. Those in healthcare are doggedly so, and  with good reason. But it’s important to remember that most people are not totally averse to change. Some providers have embraced technology. Many attribute their adoption to being  involved in the decision-making process and/or being well trained in preparation. It’s a debate that will likely go on as more surveys come out around EMR dissatisfaction and HIT/ROI conversations play out.  
 
Tiffany Crenshaw is president and CEO of Intellect Resources of Greensboro, NC.

Readers Write: Shame on Health IT

Shame on Health IT
By Tom Furr

I’m willing to bet were I to ask anyone even remotely associated with healthcare IT, that person would wax poetically about how collective efforts are helping to advance the speed and quality of healthcare. I’d hear boasts of breakthroughs in all areas of medicine, drug discovery, imaging, lab procedures, and surgery as well as recovery and rehabilitation methods.

Be it ambulatory- or hospital-based care, all those advancements have made a big impact on the care and treatment of the patient. I can find nothing wrong with initiatives that yield a faster, better end result for any man, woman, or child who requires medical treatment.

Why, then, after having benefitted from 21st century state-of-the-art healthcare, does the patient get time-warped back to the 1950s when it comes to providing the bill? If the last impression left with a patient after receiving state-of-the-art care is an antiquated management and billing process, could s/he not question everything that’s happened in the examining room?

My point is simple: shame on the health IT industry as the advancements made on the clinical side of patient care have far outpaced the comparably meager improvements that have been made on the financial side. Don’t deny it, especially when you know that healthcare providers have played a major role in maintaining the existence of the US Postal Service, printer companies, toner suppliers, envelope makers, and a bunch of related entities.

Yes, shame for not embracing technology on the business side with the same determination so dramatically shown on the clinical side. What’s worse, the underpinnings for an automated patient bill and balance management system has been in place almost as long as practice management software has helped run practices, from the individual doctor to multi-office physician groups and multi-state hospital networks.

The need for every software vendor and billing company to get to the point where they are actually helping the patient manage and meet her/his financial obligations is very great and very much of the here and now. Not to mention the disservice that they are doing to the very clients who they claim to help … by not providing a tool to help medical practices keep their accounts receivable in check and drive them towards profitability instead of languishing with large back office overhead.

The high deductible health plan (HDHP) isn’t going away. Rather it is only going to grow, bringing with it change that must be dealt with in the business offices of healthcare providers and the homes of all their patients. The shift of the primary payment responsibility coming from the health insurer to an even split with that organization and the patient is here now and not helping practices collect those balances is negligent on health IT’s part.

As a practice’s A/R gets out of hand, one of two things will happen: the practice will be sold, either to a large physicians’ group or a hospital, or the doctor takes down her/his shingle and ends a career. Either way, the practice management software vendor and/or the billing company lose a customer.

But it doesn’t have to be that way.  Unless, of course, you want to continue to keep medical business offices operating like it’s still “Happy Days.”  Keep that attitude and there’s a good chance your company won’t be happy or healthy, especially if it makes practice management software.

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

Readers Write: Accent on Objects

Accent on Objects
By Woodstock

It has been many years since I acknowledged patient record subpoenas for medical malpractice lawsuits and other legal actions as an HIM professional and designated custodian of records (COR). But the process was memorable.

During the 1970s, one was not able to reproduce analog paper and photographic film or send records by postal mail or courier to the courts. Rudimentary paper and film photocopy machines only recently were introduced into healthcare organizations, and the courts required the personal delivery of “original” source documents and records by a COR.

Consequently, upon receiving patient record subpoenas, I took a large cardboard box and collected from each department the “original” source documents required by the subpoenas. The contents included the patient’s paper financial and medical records. The medical records also included all film-based diagnostic images, tape-based medical dictation, cine-based ECGs, and pathology slides.

During the 1980s, when I established my related career in HIT and because of my COR experiences during the “analog” years, I knew well that electronic patient records consisted of more than just the structured data typically found in electronic patient financial and medical records. Structured data are the record’s binary, discrete, and computer-readable data elements that, typically, are stored in relational databases with predefined fields. Electronic medical records (EMRs) also consisted of digital diagnostic images, audio file-based dictation, and ECG waveforms.

In fact, such unstructured data make up at least 75 percent of all the data in a typical patient’s EMR. Unstructured data are the record’s non-binary, non-discrete, and often human-readable data elements that, typically, are contained in text-based reports, e-mails, and Web pages and include symbols, images, video clips, and audio clips. In some vertical markets, unstructured data are referred to as a record’s intellectual substance or content. In technical arenas, unstructured data are referred to as objects.

My 1990s published chart below (note: not to scale) depicts a typical EMR’s structured and unstructured data. Thus began my affinity for marrying the two data types in healthcare provider organizations.

Frequently Mr. HIStalk receives comments and questions relating to an EMR’s unstructured data, particularly digital diagnostic image data around the time of the annual RSNA or SIIM conventions. Since The PACS Designer has been busy developing a growing list of mobile apps, I plan to contribute a Mr. HIStalk column relating only to patient record unstructured data or “objects.” I plan to focus on news, acquisitions, sales, people, implementations, and government, just like you are accustomed to reading in other HIStalk venues. I hope you will find this column important to your work and will reply with many comments and questions.

I’ll begin with a brief opinion piece, which is related to my above comments and subtitled:

When the Writ Hits the Fan

Just like healthcare organizations, the courts finally have entered the digital age. Today, secured electronic files of “original,” electronic source documents and records as well as “copies” of original, electronic source documents and records are admissible in courts as long as the healthcare organization can substantiate (1) the trustworthiness of the system(s) used to store and retrieve the documents and records; (2) the accuracy of the organization’s records management policies and procedures; and (3) the documents and records were not created (or altered!) just for a court case. (NOTE: Always one must verify the courts’ acceptance of digital records on a state-by-state basis.)

Large cardboard boxes have been replaced by EMR (or other system) features that promote single points of personalized access through which to find and deliver electronic information, applications, and services. As such, in either hybrid or full EMR environments, designated CORs, Release of Information professionals, and even patients—after rigorous authorization and authentication processes—merely click on hyperlinks and instantaneously retrieve “original” electronic source documents and records required by subpoenas or other requesters.

While our industry continues to pursue the best “highways” to securely transmit the documents to and acknowledge receipt from requesters, today’s day-to-day challenges involve the current mechanisms used to transmit unstructured data and the shameful output of structured data generated by most EMR systems.

For example, the transmission of the large and ever-growing number of patient diagnostic images (primarily radiology images), which remain hand-carried or sent by postal mail or courier from hospitals, physicians / groups, specialty (e.g., cancer) centers, etc., to other hospitals, physicians / groups, and specialty centers on CD storage media, is completely unmanageable. Many of the CDs containing (e.g., radiology) diagnostic images cannot be imported into the receiving radiology PACS due to the way the images were burned into the CDs. Although most of the CDs include the senders’ viewers for measuring, window / leveling, etc., often the CD files arrive corrupted. Frequently the CDs are misfiled and / or lost.

Consequently, transmitting diagnostic images on CDs has lead to duplicate testing with more patient exposure to radiation. In addition, when the CDs contain diagnostic images other than radiology images, often the receivers have no corresponding PACS for these other, “ology” images.

Thankfully, popular, standard, inbound (i.e., CD ingestion and electronic receipt of diagnostic images) and outbound (i.e., report and image distribution to referring physicians, referral centers, etc.) image sharing solutions exist. However, most are too expensive for the healthcare provider masses. In addition, few, if any, non-standard image sharing solutions exist, whereby direct connections are established between two or more organizations for readings, consultations, and second opinions and inbound and outbound electronic reports accompany the images.

Also, there is not a healthcare professional that has not experienced the reams of paper output generated by EMR systems because the systems’ structured data are not report-formatted for output. This is one reason why a patient still cannot receive his or her entire patient record from a portal. Not that I promote hard copy printing; however, healthcare providers still must maintain a legal archive from which to generate the electronic document presentation as proof for exception and dispute handling. In other words, providers must have the document presentation for legal purposes and not an informational statement or data representation of the document, which, unfortunately, remains common in today’s electronic patient record system output.

Yours truly,

Woodstock

Readers Write: What’s More Useful Than Hospital Pricing Data?

What’s More Useful Than Hospital Pricing Data?
By Data Nerd

An HIStalk reader challenged my recent post, “Hospital Pricing Data: Another Step Down the Rabbit Hole” by asking what healthcare data should be publicly available to help consumers make better choices, not just from CMS, but from providers and private insurers.

I cannot fault anyone for their enthusiasm. Trust me when I say I know how demoralizing it is to come up with a data solution that just doesn’t fit the need. That’s precisely why I felt compelled to speak out on the subject. After setting high hopes and expectations of the analytical possibilities from data in CMS’s pipeline, the solution fell drastically short of what I had hoped it would accomplish when it was finally released.

Having said that, the ideal data solution for me as a consumer would use the same or similar claims data sources, but aggregate the data two different ways to come up with a predictive solution that can be tweaked to assist the patient in their own cost containment efforts. This type of solution would involve:

• Risk-adjusted cohorts. Grouping the data not just by DRG, but by patients with similar risks (age, co-morbidities, etc.) to chart out the most likely course of treatment for someone of my age and health facing the same diagnosis. Ideally, this dataset would include all payer types, but the next-best offering that is within CMS’s reach is to combine Medicare and Medicaid datasets to account for a broader age distribution. Data would not be aggregated by hospital, simply by patient characteristics across the country.
• Once we have an idea of possible treatment routes, we can then couple that with charge data. And, yes, I want that broken down by procedure at each hospital. Like there is no such thing as bad data, there is no such thing as too much data. I’ve never seen OSCAR’s backend, so I’m not sure if it’s possible to break apart every claim and get a procedure-level charge, but I do know with the data as it is today, claims with only one procedure can be isolated and charges or reimbursements tend to have low standard deviations. Since I am not insured by Medicare or Medicaid, knowing what hospitals charge or are reimbursed by CMS does me very little good, though. I would need my own insurance company’s network rates with the hospital to analyze how soon I’ll meet my annual deductible, etc. Or, if I have the luxury of time to make a decision, evaluate if I’d be better served investing in an HSA and initializing treatment in the next fiscal year. But, for the millions covered under Medicare and Medicaid, such an analysis based on the data today would assist in forecasting when deductibles will be met and/or what other amounts will not be covered during the course of treatment.
• In the event that I have a long-term illness or a more drawn-out treatment plan, I would want an analysis of whether or not it would behoove me financially to have different procedures performed at different facilities. Outcomes data would be useful here as well.

All of these data components would need to be dynamically updated and processed, probably using software to evaluate each step of the way, much like the way a simple tax form is completed online. Play with one number and see how it affects the final bill, and in this case assess the risk factor involved in hospitals with poorer outcomes. Ideally, the solution would also interject preventative challenges over time to help the patient meet their health goals in a way that saves the health system money as well, but that is more the quantified-self realm than the (current) data realm.

So, to recap the data offerings that would satiate my current appetite for price transparency:

• Claims data, aggregated by DRG and patient characteristics to obtain expected procedures
• Claims data, aggregated by hospital and procedure charge
• Combine these two alongside insurance reimbursement rates to give a patient’s total estimated personal expense at every hospital
• Hospital procedural outcomes data to evaluate cost savings and determine at which hospital(s) to have the necessary procedures performed

This is the type of data that would be useful to me as a consumer.

Readers Write: EMR Installed and Meaningful Attested — Now What?

EMR Installed and Meaningful Attested — Now What?
By Don Sonck

If it’s the spring of an odd-numbered year, then I know it’s time for me to pay a visit to my primary care physician for a biennial physical examination. So a couple of weeks ago, off I went!

As my doctor and I reviewed my medical history from the past seven years, all of which has been well-chronicled in an EMR, he asked me a series of diet- and exercise-related questions. At the conclusion of this exchange, he complimented me on my diligence in maintaining a diet and fitness regimen that promotes good health.

I’m no longer a spring chicken in biological years. Like many Americans my age, I’d like to extend my quality of life and attempt to do so by adhering to the recommendation of an expert in the field who in turn preaches evidenced-based best practices. My wife and two sons are on the same sheet of music. Whether it’s the preventative maintenance of our car, home, or any other major asset, the same discipline is implemented, and again based upon historical and empirical data.

Like anything in life, there are always accidents and anomalies that run counter-intuitive to the expected outcome, but common evidenced, majority outcomes cannot be refuted. To borrow a line from Sergeant Joe Friday of “Dragnet” fame: “Just the facts, ma’am” are words to live by.

This latest encounter with my physician got me thinking about the HIMSS EMR Adoption Model, particularly Level 4. Evidence-based population management is going to be critical if this country is ever to reach Level 7.

For the sake of full disclosure, I am a disciple of Dale Sanders in his conviction that the United States must become “a data-driven culture, incented economically to support optimum health at the lowest cost.” How long will it take for healthcare organizations to even assemble registries for their top 10 patient conditions; let alone share them? The life expectancy of HIEs is unknown, as the migration from public to private funding has yet to be determined.

The cornucopia of complaints spewing forth from health systems and physician practices on the subject of EMR (too expensive, no ROI, minimal patient-physician interaction, etc.), coupled with confusing government mandates, leads this writer to wonder if I’ll live to see the day that EMRAM is fully achieved. If I do, the likelihood is great that Mr. Sanders’ vision came to fruition.

Let’s hope for the sake (and health) of our country that the EMRAM progression marches onward expediently.

Don Sonck is director of EMR staffing solutions for AMN Healthcare of San Diego, CA.