Readers Write 8/4/12

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Note: the views and opinions expressed are those of the authors personally and are not necessarily representative of their current or former employers.

The Doctor Shortage Calls for Innovation
By Jonathan Bush

It was hard to read the recent sobering article in The New York Times, “Doctor Shortage Likely to Worsen with Health Law,” without picturing a lot of very smart people throwing their hands up in collective despair. Dr. G. Richard Olds, the dean of the new medical school at the University of California, Riverside, summed up the likely scenario in his part of California quite starkly: “We’ll have a 5,000-physician shortage in 10 years, no matter what anybody does.” Not exactly a rousing call to arms.

What, if anything, is to be done about this crisis in the making? In an article otherwise devoid of solutions, Dr. Olds hinted at an answer when he suggested that “changing how doctors provided care would be more important than minting new doctors.” As the article points out, the proportion of medical students going into primary care has declined over the past 15 years as PCP earnings have diverged from those of specialists. But that’s not the whole picture.

Along with low remuneration, a 2009 study of the work conditions of family and general practitioners identified adverse workflow as a major driver of dissatisfaction, with 53% reporting time pressure during exams and 48% burnt out from the chaotic work pace. The same 15 years that have witnessed PCP decline have seen PCPs take on an ever-rising burden of paperwork, a more complex billing landscape, and a dizzying array of new federal requirements and mandates. Despite these rising challenges and seismic shifts in health care, the organization of the typical medical practice looks much as it did 50 years ago.

The narrow focus of the PCP shortage debate on the need for primary care to expand to meet rising demand misses the more significant point that it needs to be redefined through innovations that improve efficiency and restore the sanctity of the physician-patient experience. Technology can, and should, play a central role in this process. Rather than add work to physicians’ plates and hindering productivity, as many electronic health records (EHR) still do, the EHR should reduce work for physicians and delegate it to other clinical staff. Delegating work and empowering clinicians to practice to the top of their licenses not only reduces costs overall, but frees physicians to be fully present with a patient when their complete attention and training is truly required.

Non-clinical, routine work that bogs down PCPs should be removed from the office entirely. Even in our digital age, vast amounts of paper still clog practices and consume valuable staff time. At athenahealth we know that, on average, providers must process more than 1,000 clinical faxes every month, not to mention the forests of paperwork associated with insurance claims and government programs. This routine work can be offloaded to others in the supply chain who can eliminate it, automate it, or execute it more efficiently at scale.

By finding new efficiencies through technology, delegating care, and moving administrative work out of the practice, primary care can not only become more financially sustainable but more attractive to new entrants. Innovation, not just expansion, is the key to success.

Jonathan Bush is CEO, president, and chairman of the board of athenahealth.

Why Device Connectivity Matters Now
By Dave Dyell

Patient data is the cornerstone of many HIT initiatives, including Meaningful Use, health information exchange, and ACOs. Behind these acronyms and initiatives, though, is the real reason to care about patient data: its ability to improve clinical decision making.

Clinical decision-making has always been fueled by information or data. That hasn’t changed. What has changed is the amount of data now available and the ease with which it can be accessed by clinicians. Access to this data is, of course, the aim of electronic records. But what populates the record? Where is the data coming from? In many cases, it’s coming from medical devices.

When devices are connected or integrated with the electronic record, the data from those devices populates the record in real time, giving clinicians access to the up-to-date and error-free patient data they need.

The ECRI Institute sought to remind us of the significance of this relationship between device connectivity and electronic records when it published its annual ECRI Institute’s Top 10 C-Suite Watch List: Hospital Technology Issues For 2012.

The report placed “Electronic Health Records: Is your hospital making all the right connections?” at the top of its list. It also proposed an antidote to this most important HIT issue of 2012: device connectivity, or device integration.

“Hospitals must develop a medical device integration plan,” the report noted. “A strategic approach with the right medical device integration connections will get your hospital moving along the optimal path for success.”

This “optimal path for success” certainly includes the achievement of Stage 2 Meaningful Use. According to the ECRI Institute, “Stage 2 certification requires hospitals to not only have the necessary IT infrastructure, but also the ability to integrate patient care device data into the electronic health record.” In particular, the threshold for electronic recording of vital signs is expected to increase from 50% of all patients in Stage 1 to 80% in Stage 2. Looking ahead, compliance will demand the integration of more than just monitors and vital signs — it will extend towards the data in all medical devices.

The report goes on to state that the successful deployment of device integration solutions should not only ensure Meaningful Use reimbursement but also “facilitate nursing workflow.” This was certainly the case at St. John’s Medical Center in Jackson, Wyoming, where vital signs integration— importing rather than hand-entering vital signs data—resulted in time savings of 60%. Not only did device integration get patient data to the record faster, it also freed up significant amounts of nursing time that could then be spent on direct care.

So why does device connectivity matter now? The answer, put one way, is Stage 2 compliance. Put another way, though, the answer is that device connectivity reduces transcription errors, improves access to data in the record, and increases direct care. “Remember,” the ECRI Institute astutely concluded in its watch list, “medical device integration and Meaningful Use ultimately aim to improve healthcare and patient safety.”

Dave Dyell is founder and CEO of iSirona.

Using the Cloud for Testing and Deployment for Hospitals and HIT companies
By Mark Olschesky

Last week I shot a quick message to Mr. HIStalk, relaying the news that Windows Azure offered to sign Business Associate Agreements (BAA) for some of their cloud deployment and storage packages.

If you’re unfamiliar, Windows Azure and Amazon Web Services are two of the largest “Cloud” service providers. Most plans are pay-as-you-go for usage and differentiate themselves from other “cloud” offerings in that they offer immediate access to computing resources when needed. Even if you’re unfamiliar with the product names, you know their customers: Azure hosts Apple’s iCloud and handles the rendering of your favorite Pixar characters, while Amazon hosts the Washington Post and your favorite outfits and recipes on Pinterest.

Entering into BAAs is an interesting move from one of the larger cloud vendors. Now covered entities can enter into an agreement with this vendor to set terms on how HHS’s Office for Civil Rights (OCR) audits and non-compliance for a patient data breach will be handled. Likely, if the data breach is their fault, the agreement should outline that they will pay the fines and investigation fees, along with cooperating with an audit. This makes it more feasible to store PHI in a responsible manner in virtual, shared remote hosting.

I say responsible, because an entity storing data in the cloud still needs to audit and restrict access to PHI just as it would with locally hosted data. If you think that salt and hash are a great breakfast combination, or the title to a Cheech and Chong beach movie, you may want to consider managed hosting. Microsoft is saying that they are accountable for informing you of access to systems and stopping people from running off with servers with your PHI in the night. This is the same expectation you should have from your other vendors and your staff for handling locally hosted PHI.

So, how can this help you? Allow me to offer an example. Your vendor just released a new version of the software that you are actively installing. Surprise — it requires three Windows servers instead of the two you purchased. You need to take this upgrade. In the past, you would have completed the paperwork to buy a new server or scrambled to find local VM space on another. This would have been passed up the chain and hopefully there was budget available. Then, your already-swamped DBAs would need to handle the installation.

There were a lot of people and moving parts in this. It took months and stopped build and testing from getting off the ground. Instead, if you signed a BAA in advance with a cloud vendor, your existing staff could spin up a VM when a server was needed and install files as necessary. It’s not for all scenarios or for production at first, but if it saves you money, time, and the ire of your project managers, you would consider it, right?

Being able to store data in the cloud with fewer worries is a major benefit to us as a startup. It allows us to keep our costs low and pass the savings along to consumers as we look for a pilot for our first product. There is a certain amount of “keeping up with the Joneses” in remote hosting, so I would bet that Amazon and some of the other major players will begin offering to sign BAAs soon. This is only good for us as consumers looking for flexible options to get HIT projects completed easily and on time.

Mark Olschesky is co-founder and CTO of Moxe Health.

Readers Write 7/20/12

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Note: the views and opinions expressed are those of the authors personally and are not necessarily representative of their current or former employers.

How Obamacare is Driving Healthcare IT Investment
By Stewart Billings

Mandates in the Affordable Care Act and the changes in patient behavior that accompany it, combined with the rising consciousness of the public about the cost of healthcare, are forcing providers to make sustained investments in their IT infrastructure.

Health Information Exchanges

Government action may have been the only thing that could have driven this level of cooperation on sharing data across the entire system. Health information exchanges (HIEs) are possibly the biggest driver of healthcare IT change mandate by the ACA. They also carry high potential for driving change across an entire organization. The efficiencies that can be achieved when clinical data can actually be shared and accessed through HIEs depends largely on how the availability of the data translates into more timely and higher quality continuity of care for patients. Those savings may be years down the road, but the investment in the infrastructure that undergirds HIE needs to happen now and be continued sustainably into the future.

New Payment Paradigms

Electronic funds transfer requirements are pushing an industry standard for processing payments and accessing claims, simplifying the whole payment process and finally giving healthcare IT confidence in the payment frameworks they are building. These new rules also push standardization of claims attachments, unique identifiers for health plans and certifications for HIPAA compliance.

ACOs Will Need Communication Support

Accountable care organizations are likewise going to have to have ways to report, record, and analyze patient care in order to improve the outcome of care. All of that coordination between providers in an ACO will likely go beyond even the necessities of information exchanges. Infrastructure will need to be in place for sharing data about cost, quality, and care plans between providers.

Even Bigger Data Will Drive Efficiency

The big unknown in all of this is what tools IT can provide to help organizations collect and analyze all of the data that these standardized systems will be generating about patients, providers, and even their own operations. That mountain of data is promising in that it can help identify inefficiencies and test policy changes that can improve patient outcomes.

Big data will be a competitive advantage for companies that are able to use it to inform patients about their consumption of services, too. Connecting customers with cogent information about the cost of procedures gives them the ability to make decisions about how they access and pay for care, not to mention making the decisions of their providers more transparent.

All of these changes were probably inevitable, but the Supreme Court decision on the ACA has lit a fire under organizations that were already pushing long-term investment into their information technology resources. The next few years should be very revealing about just how tangible any of these benefits are likely to be for providers, ACOs and patients.

Stewart Billings is marketing manager for ZirMed of Louisville, KY.

Actuarial Informatics: An Emerging Field?
By Digital Bean Counter

I can’t remember the last time I actually enjoyed writing a term paper, let alone writing about a topic I inherently knew nothing about at the time. What kept me going (besides the multiple lattes) was that deep down, I truly believed I was on to something: the emerging field of actuarial informatics. 

You could argue that I simply combined two words so that I would appear intelligent, but Google “actuarial informatics” and you’ll be surprised at what little substantive data and information is readily available. With a deadline looming, and a busy work schedule thanks to Medicare bid season, I did a deep dive into the books hoping that I would learn something.

Fast forward three months: I’m in a new role with a health plan working on something that I’ve only learned and read about as a master’s student. My paper has long since been turned in. I’m thumbing through the day’s meeting minutes, recapping the announcement from CMS that we officially joined the ranks of 153 others in the ACO world today, and I see the header on a report from a leading health plan that we’ve been following: Actuarial Informatics Dept.

Call it what you want, there is much evidence suggesting actuarial informatics is alive and well. In the ACO world, the buzzwords are aplenty: value-based purchasing, risk stratification, bundled payments, and population management, just to name a few. While the rest of the industry continues to debate topics such as the true definition of informatics, I often wonder who or which organization will capitalize on low-hanging fruit such as actuarial informatics.

Now if they would only reopen my favorite coffee shop, my life would be complete.

Single Sign-On: Are Preconceptions Actually Misconceptions?
By Dean Wiech

With single sign-on (SSO), end users log in to accounts once with their credentials and thereafter enjoy immediate access to all of their applications and systems without being asked to log in again. It’s a splendid antidote to the many passwords end users currently have to remember. Typically, that’s not reason enough for organizations to unquestionably implement an SSO solution.

Many IT managers and security officers are skeptical about the implementation of an SSO solution. Their skepticism is the result of a number of preconceptions, which in many cases are misconceptions, about these identity and access management tools. The following is a summary of the most common beliefs held by IT managers and security officers at large and medium-sized companies in a variety of sectors, including enterprise healthcare systems.

Implementing SSO Imposes Greater Pressure on Security

In many instances, IT managers and security officers believe that with one-time logging in to accounts security of information is immediately placed at risk, because if an unauthorized person gets hold of that single log-in credential, that person will have access to all the account’s associated applications.

When using SSO, all the various access entries to applications are replaced by one access point. For example, the software allows users to use just one password for multiple accounts. Once the password is entered, all accounts are accessed. Though this does appear to constitute a risk, the log-in process is actually streamlined for the user. Having to remember just one password essentially does away with the risk that the user will scribble passwords on a piece of paper and place them under their keyboard (as is often the case) like they might if they have to remember 12 password and username combinations (the average number per user) that most users have without SSO.

To protect the critical applications and applications with private and sensitive information, it is possible to add extra security to the primary SSO log-in with a user card and pin code or an extra-strong password. Logging in with a card and pin code is an extremely secure authentication, and users also consider it to be very user-friendly.

An SSO Implementation is a Long, Drawn Out Project

Often, an SSO implementation is part of a broader security policy. Other components might be introducing more complicated passwords, taking more care with authorizations, and complying with standards imposed by the government.

Because SSO affects almost all end users and runs throughout the organization, some see implementation as taking a great deal of time to notify and prepare end users for the change. SSO brings with it a number of questions, like, “How do I deal with people who have multiple log-ins on one application?” or “What do I do if an application offered through SSO gets a new version?” and “What happens if the application itself asks for a password to be reset?”

All these questions often cause SSO implementation to be shifted to the background. However, any potential complexity faced at implementation is no reason to postpone adding a SSO solution because it has long-lasting benefits once up and running. By starting small, say by making the top five applications available through SSO, a considerable time saving on the number of log-in actions can be achieved, justifying buying the solution.

It’s Not Possible to Make Cloud Applications Accessible via SSO

Regarding SSO, one thing is certainly clear: the SSO log-in to cloud applications is possible just as it is with every other application.

An SSO Implementation is Expensive

The nice thing about an SSO solution is that it’s often not necessary to set it up for all the people in an organization. In a hospital, for instance, SSO is only needed for a select group of people. The advice here is to restrict yourself to the most critical applications and the people who have to log in to a variety of different applications. The implementation will then be easy to control in terms of price and complexity. This offers an excellent springboard for any further growth and expansion in accordance with changing future needs.

An SSO Solution is Not Needed Because We Use Extremely Complex Passwords

Insisting on extremely complex passwords is one way to secure the network, but at the same time, it’s also one of the causes of insecure situations. Many end users have difficulty remembering their mandated passwords, certainly when they have to recall more than a dozen username and password combinations. Often, a strict password policy immediately leads to more help desk calls because employees tend to forget their passwords. A highly insecure and undesirable situation arises when end users write their passwords on notes and leave them lying around their computer. Using SSO means employees only have to remember one password for all of their applications, meaning a simple solution to a complex problem, easier access to multiple accounts for all who need access to them, and fewer calls the help desk, ensuring IT staff are able to focus on more important priorities than password resets.

Dean Wiech is managing director at Tools4ever of Baarn, The Netherlands.

Bye, Bye Privacy and Securityl Hello HIPAA, Hello!
By Frank Poggio

Some think there may be a hidden ‘gold nugget’ in the proposed Meaningful Use Stage 2 regulations. ONC is proposing to eliminate the Privacy and Security (P&S) test criteria for EHR Module certification in Stage 2. On the surface, it looks like they want to give niche players and best-of-breed (BoB) vendors a nice break.

If you are not familiar with the P&S criteria required by the Accredited Testing and Certification Bodies (ATCB), here they are along with a short description:

1. Access controls – can you system prevent unauthorized access?
2. Authentication – does you system authenticate each user?
3. Emergency access – can your system allow limited access in emergency situations?
4. Automatic log-off – after no user activity for a specified period of time, does your system clear all PHI and log off all users?
5. System access logs – do you maintain system logs for all inquiries, adds, modifications, and deletions of PHI? Do you generate mandatory reports?
6. General encryption – does your system encrypt PHI at rest using a FIPS 140 compliant algorithm?
7. Integrity – do you use SHA1-compliant tools to maintain file and data integrity?
8. HIE encryption – how does your system ensure integrity and encryption when data is communicated / received to / from outside entities?
9. Account for disclosures – do you track requests for PHI from outside entities?

Most EHR Module vendors that have gone through ONC Certification get certified on 1 through 8. Number 9 is deemed ‘optional’. In my many certification experiences, numbers 6 through 8 can be a hurdle, particularly if you are a SaaS or cloud-deployed system.

Meanwhile on page 125 of the Proposed Stage 2 Rules for Vendor Certification, ONC states:

We propose not to apply the privacy and security certification requirements at §170.550(e) for the certification of EHR Modules to the 2014 Edition EHR certification criteria. Stakeholder feedback, particularly from EHR technology developers, has identified that this regulatory requirement is causing unnecessary burden (both in effort and cost). EHR Module developers have expressed that they have had to redesign their EHR technology in atypical ways to accommodate this regulatory requirement, which sometimes leads to the inclusion of a privacy or security feature that would not normally be found in a certain type of EHR Module. In turn, this has led to EPs, EHs, and CAHs purchasing EHR Modules that have redundant or sometimes conflicting privacy and security capabilities.

And then ONC goes on to state:

In addition, EPs, EHs, and CAHs remain responsible for implementing their EHR technology in ways that meet applicable privacy and security requirements under Federal and applicable State law (e.g., the HIPAA Privacy Rule and Security Rule and 42 CFR Part 2).

But as might be expected in this regulatory maze, when you look at the ONC Stage 2 Draft “Medicare and Medicaid Programs; Electronic Health Record Incentive Program”, which is the basis for provider MU attestation for Stage 2, you will see repeatedly that to meet the Privacy and Security MU requirements, the provider (not the vendor) must:

Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1), including addressing the encryption / security of data at rest in accordance with requirements under 45 CFR 164.312 (a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the provider’s risk management process.

45 CFR 164 is the HIPAA security rules. Just last month, HHS’s Office for Civil Rights published the protocol that it will use to conduct audits of the HIPAA Privacy and Security rules. In that document, they outline the audit procedures the OCR will follow. For example:

164.308 (a) Audit Procedure

Inquire of management as to whether formal or informal policy and procedures exist to review information system activities; such as audit logs, access reports, and security incident tracking reports. Obtain and review formal or informal policy and procedures and evaluate the content in relation to specified performance criteria to determine if an appropriate review process is in place of information system activities. Obtain evidence for a sample of instances showing implementation of covered entity review practices Determine if the covered entity policy and procedures have been approved and updated on a periodic basis.

This audit procedure is repeated frequently throughout 164.308 and applies to all PHI, regardless of whether it is in the primary EHR or resides in a Module(s). In regard to Business Associate agreements under 164.308 (b)(1), OCR further states:

Inquire of management as to whether a process exists to ensure contracts or agreements include security requirements to address confidentiality, integrity, and availability of ePHI. Obtain and review the documentation of the process used to ensure contracts or arrangements include security requirements to address confidentiality, integrity, and availability of ePHI and evaluate the content in relation to the specified criteria. Determine if the contracts or arrangements are reviewed to ensure applicable requirements are addressed.

As you can see, the HIPAA audit does not differentiate between a full EHR and EHR Module. Any and all systems or service contracts that deal with PHI of any type must comply, and the provider must prove it under audit.

Under Stage 1 the ongoing debate was whether a best-of-breed system supplier needed to get ONC certified. Fact is there was never an ONC-mandated requirement that any vendor get certified. But many BoBs underwent certification for competitive reasons and some addressed most of the P&S criteria because they did not want to allow the big EHR vendors a ‘certification edge’.

Now ONC is trying to push the P&S criteria of MU back on the provider and thereby reduce the time and effort for the testing bodies. Their strategy, as they often state in the proposed Stage 2 regulations (see page 119), is to let the market require (demand) it, not mandate it via ONC regulation. Simply put, since the health provider needs to be legally responsible for P&S under HIPAA and MU attestation, ONC expects that providers will demand from their vendors that they meet the HIPAA P&S requirements. HIPAA audits by OCR have started this year, so expect your clients to contact you for help and assistance as OCR asks to see the P&S documentation for all systems that touch PHI. And the best documentation you can show that confirms you the vendor comply with HIPAA P&S will be … ONC certification!

As Stage 2 unfolds, I would expect either one of these scenarios;

• Things stay as they are – EHR Modules must meet the eight P&S criteria, or,
• If the Draft regulations stand, module vendors can request to be tested by the ATCBs for P&S so as to satisfy HIPAA Business Associate requirements and address market / competitive issues.

In summary, BoB and niche vendors could in the past casually sign Business Associate agreements. Under proposed Stage 2 and HIPAA, you’ll have to prove you got real P&S. On closer inspection, that nugget is beginning to look more like fool’s gold.

Frank L. Poggio is president of The Kelzon Group.

Readers Write 7/2/12

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Note: the views and opinions expressed are those of the authors personally and are not necessarily representative of their current or former employers.

ICD-10: The ED Effect
By Robert Hitchcock, MD, FACEP

As I visit current and prospective hospital clients, they openly express uneasiness about their organizations’ finances. Market forces are squeezing margins and expectations are high that Medicare and private payers will continue cutting reimbursement rates. These challenges are only intensified by ICD-10 and Meaningful Use mandates.

In the 20-plus years I’ve worked in healthcare, I’ve seen no other initiative with the potential to impact hospitals more greatly than ICD-10. With one-half of all inpatient admissions and 45% of a hospital’s overall revenue, the emergency department in particular can help define whether or not this impact will be positive or negative. As the population ages, patient volumes will continue to multiply, and the ED will need to keep up in order to keep the hospital financially afloat.

Most hospitals are anticipating – and depending upon – their departmental or enterprise EHR vendors to provide the necessary changes that will facilitate the capture of the appropriate information needed for ICD-10 coding. Unfortunately, however, some key hospital executives fail to recognize that very different approaches can be taken when implementing ICD-10 in clinical applications.

It is imperative that these executives evaluate how a solution will achieve compliance. How will content be built and maintained? How will ICD-10 codes be generated? How will the system work to maintain productivity? The method for compliance can represent success on one end of the spectrum and failure on the other end – each with tremendous financial implications.

If the vendor does not provide and maintain standardized encoded clinical content for documentation but instead offers “fully customizable content,” the client will be required to update and maintain an extensive data set with the corresponding ICD-10 terminology and/or codes. While a money-saving approach for the vendor, it will mean significant costs to the client.

If the vendor chooses to simply use an ICD-10 clinical terminology look-up function that is not integrated with other clinical content in the application, it could limit the ability of the application to re-use previously recorded information, requiring duplicate documentation. This presents another productivity burden to the clinician.

In terms of ICD-10 code generation, some software designs will offload to the physician the burden of navigating long lists of possible code-able terms to search for the most appropriate clinical diagnoses. ICD-10 represents a vast increase in the number and specificity of codes from ICD-9. As a result, physicians may fail to complete this part of the documentation or choose less definitive diagnoses when and where it saves time. This can negatively impact reimbursement as well as reporting for regulatory compliance, risk management, conformance to clinical polices, etc. Instead, having codes that are generated automatically based on providers’ documentation will not impede clinician workflow, productivity and, ultimately, documentation quality.

To obtain accurate, discrete data for analysis and reporting, physicians must embrace the user interface design of the application. Good data analysis requires a foundation of good data collection. Like CPOE, if the clinical workflow and user interface is well designed, potential benefits are quickly realized. If designed poorly, the results can be agonizing.

The increased specificity of ICD-10 will drive more than just reimbursement, magnifying the impact of the ICD-10 implementation for better or worse. Additional granularity, if accurate, can facilitate many other processes that also have financial implications to the ED and hospital, such as risk management, regulatory reporting, quality initiatives, clinical decision support, and metrics for productivity, patient throughput, ordering of tests, and resource utilization.

As well, ICD-10 has the potential to offer easier and tighter system interoperability. A standardized coding system requires that all systems speak the same language, freeing hospitals to choose the best possible technology for the ED. Indeed, having disparate but interoperable systems in the ED and inpatient environments no longer has to present the same challenges it has in the past.

My advice to those solving for ICD-10: Look beyond the basic issue of compliance and choose technology that will truly optimize the ED. It is the front door to your hospital, the start of the patient record, and the key to your organization’s prosperity. I would hate for any hospital to have to experience the frustrations and wasted expenses associated with having to rip out a system and replace it. 

Robert Hitchcock MD, FACEP is vice president and chief medical informatics officer of T-System of Dallas, TX.

Standardized Data Just the Start in Making Data Usable at the Point of Care
By Jay Anders, MD

3M Health Systems recently announced it will open access to its Healthcare Data Dictionary, which translates standard terminologies and enables semantic interoperability between disparate systems. 3M made this move to meet contract conditions with the VA and Department of Defense, which are using the Data Dictionary to facilitate interoperability for their joint EHR.

The news is significant for several reasons. By making its Healthcare Data Dictionary free, providers and vendors have access to tools that translate a collection of clinical terms in a variety of standard terminologies such as RxNorm, ICD-9, ICD-10, LOINC, and SNOMED. A common language for clinical terms facilitates data standardization, analysis, and exchange.

When data is available in a standardized format, health information exchange is easier. The interoperability of clinical data is essential for Meaningful Use and the cornerstone for new reimbursement models that emphasize outcomes and accountability for patient health over traditional patient encounter volume.

The need for tools that decipher disparate but related clinical concepts will continue to grow exponentially in coming years. The healthcare industry relies on standard terminologies to move information between providers, and many stakeholders are calling for even more standards for files, codes, and other data.

The proliferation of standards aids data exchange, but the data is of limited value without means to disseminate the information and then to make it usable by clinicians. Clinical data mapping addresses part of this problem.

Payers and clinical researchers, for example, rely on clinical data to analyze financial and health trends. Data mining on a large scale is nearly impossible without technology that identifies common concepts, regardless of the terminology.

Similarly, Accountable Care Organizations and HIEs require tools to make sense of vast amounts of data from physicians, health systems, and other providers. Clinical data mapping enables the efficient identification and accurate interpretation of the information required for ACO and HIE analysis and reporting.

Given the amount of clinical data which is about to flood the industry, organizations must have methods in place to both exchange and store clinical data in standardized formats, and to make the clinical data usable at the point of care.

These are not the same.

In addition to 3M’s Health Data Dictionary, there are clinical data technologies and tools available from Clinical Architecture, Health Language, Inc., Intelligent Medical Objects, Medicomp Systems, and others. Regardless of which one of these is chosen to exchange and store clinical data, it is also necessary to organize and present clinical information to the clinician during the patient encounter.

For example, for a patient with five existing clinical conditions, the provider needs to be able to instantly see the clinical data relevant to renal failure, as opposed to their diabetes, hypertension, arthritis, or migraine headaches. Once the HIEs are up and running, there may be thousands of clinical data points for a single patient.

What is needed is an engine to organize and present clinical information at the point of care. This requires millions of links between data points to filter, analyze, and present data relevant for that specific patient encounter.

This is critical in enabling physicians to follow their own thought process and make sense of the flood of clinical data. Widespread standardization and sharing of clinical data between systems has the potential to enhance the quality of healthcare. The power and potential of clinical data is truly realized when data is delivered and made usable at the point of care.

Jay Anders, MD is chief medical information officer of MED3OOO of Pittsburgh, PA.

Healthcare Cure?
By Vince Ciotti

The idea is simple: keep people healthy. We do a great job of treating those who are already sick, but it is costing us far too much, whether through taxes, premiums, or deductibles and co-pays. How to keep people healthy? Discourage them from getting sick. How to do that? Make the cost of things that make them sick prohibitive. How do we do that? Pass the cost of curing sick people on to those products that cause specific, preventable illness.

One of the leading cancer killers today is lung cancer, pretty directly attributable to smoking. Best way to break the smoking cycle? Turn our capitalist free-market system loose by passing the cost of treating lung cancer directly on to those who smoke, until the price is so prohibitive they cease to buy tobacco. Thanks to PPS and DRGS, we know what treating most specific diseases cost. Let’s say last year the ≈300,000 people who died from lung cancer cost us taxpayers about $100,000 each to treat. That’s roughly $300B in taxes and premiums we all paid for their care. Now allocate that $300B across the tobacco companies based on their revenue. That’s a pretty stiff hit on any company’s bottom line, so they’d have to triple or quadruple the price of cigarettes to $20 or even $30 a pack to maintain a decent profit margin.

By letting the free market accurately reflect the healthcare cost of a given product, we consumers would be a lot wiser in buying unhealthy products, and their manufacturers would have to develop healthy alternatives or see their revenue gradually dry up. Farmers would have to plant other crops, and the many attorneys who file tobacco lawsuits would have to find other segments of society to represent.

Let’s shift to another easy target: obesity. Pass the cost of treating diabetes on to sugar manufacturers. Not a tax, but an invoice for what they are costing us in health care to treat diabetes. Like tobacco manufacturers, they would have to raise the price of their product to cover the resulting health care cost. Now, Wheat Checks and Al Bran would only cost a fraction of what sugar-laden cereals cost and more people would buy them, catching manufacturers’ attention. So on and on, with every disease that is directly attributable to a specific product or ingredient: mesothelioma and asbestos, cirrhosis and alcohol, heart attacks and cholesterol, melanoma and tanning booths. 

It would be a bitch to set up. Many politicians, their PACS, and lobbyists would fight hard every step of the way for each disease being targeted. Maybe we should pass the cost of treating heart attacks and ulcers on to them. Jobs would be created for medical experts, economists, and statisticians. Jobs would be lost for lawyers, doctors, and marketers.

In the long run, consumers would follow their wallets to those products that cost the least, once they included healthcare costs, and avoid those products that cost the most, because of high healthcare costs. That’s the beauty of capitalism’s free-market way. This is an economic problem for which we need an economic solution.

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

Readers Write 6/25/12

Just as healthcare providers were getting serious about progressing toward the much-heralded ICD-10 era, the announcement of a potential deferral in the compliance deadline has spawned a new wave of delays and second guessing about how best to apply limited IT resources. Some organizations are freezing ICD-10 budgets and slowing down, or even halting work completely, until a new date is set. While a one-year deadline delay may be productive, it would be a mistake to assume that planning can be halted until this time next year and then resumed – primarily because most organizations are already far behind the curve in preparing for ICD-10.

Any delay or reallocating of internal resources in an environment where healthcare provider budgets are already tight can result in process inefficiencies and, ultimately, higher implementation costs. Many are concerned with how to make the extension beneficial to their organization. Providers should use the additional time to implement a more sound and strategic approach to collaborative testing with their primary trading partners – the most difficult and unpredictable segment of conducting a successful ICD-9 to ICD-10 migration. As it is, most large IT projects typically require more testing time than is usually allocated – and the current status of ICD-10 readiness demonstrates this case is no different. In fact, given that ICD-10 can have a tangible impact on revenue flows, providers should ensure that they work hard to mitigate their risk of disruption with trading partners that account for 80 percent or more of their revenue. Such systematic testing initiatives with key trading partners are essential for achieving the goal of financial neutrality.

Across the industry, we can look at the progress health plans have made to set the future for providers. This newly found year of extra time will be a critical period for internal and external testing. Collaborative testing should focus on maintaining the operational status quo. This means keeping the business neutral with respect to key performance indicators such as claims acceptance rates, support inquiries, electronic claim adjudication rates and aggregate claim reimbursement amounts. Many ICD-10 codes will result in an increase in clinical complexity and document specificity as compared to ICD-9. Through collaborative testing with health plans, both parties will be assured that migrating claims to ICD-10 will allow benefit and payment neutrality.

To test effectively, providers and their trading partners must develop scenarios that reflect use of high-risk codes, specifically claims that use codes expected to have high volumes, complexity, and high dollar values. The key is to minimize the risk to the business by focusing efforts on testing scenarios that could have the most impact.

Successful external testing requires new levels of collaboration and information sharing among providers and insurers. While it may be uncomfortable to collaborate on such testing, failure to do so may lead to big surprises in payments after the transition date, which will cause even greater discomfort for insurance companies and providers alike.

The ICD-10 transition is the most substantial effort the industry has faced. The scale of the project means that the testing required to fully ensure business readiness, as well as benefit and financial neutrality, is unprecedented. For those organizations that have the determination to keep moving forward as if the delay had never been announced, it will undoubtedly end up being a true gift on the testing front. Take advantage of the time afforded to realize a true benefit from the delay. And devote any newfound hours to ensuring that neutrality is achieved.

Deepak Sadagopan is general manager of clinical solutions and provider sector at Edifecs of Bellevue, WA.

Payback is a CPOE
By Daniela Mahoney

Right from the beginning of a project, I elicit the customer’s motivation for deciding to invest in CPOE. For meeting Meaningful Use requirements only? Or for what I like to hear, which is things such as “an organizational initiative for quality improvement,” or “to reach the highest level of patient safety goals” or even, in some cases, “cost reduction and avoidance.”

But if only about the money, we need to understand that the return on investment for a CPOE project — outside of incentive dollars — is difficult to calculate. Baseline costs of essential processes are hard to define, and often a number of benefits do not lend themselves to a quantifiable measurement process (i.e., improved communication across departments). Additionally, many organizations have difficulties measuring their medication errors and adverse drug events.

Although measurable improvement may be detected in well-defined areas, such as the use of expensive diagnostic and therapeutic procedures and compliance with core measures, CPOE should be viewed as an indispensable supportive technology and should be included in the overall quality improvement strategies of the organization.

And just how much will it cost an organization to implement CPOE?

For starters, we know CPOE is 80-85% clinical transformation, rather than tangible software, hardware, or infrastructure. Costs are more about people and processes than implementing technology. There are a few good studies published in the past few years that discuss the financial impacts of CPOE from a cost to ROI perspective.

One well-known study was initiated by the Massachusetts Technology Collaborative (MTC) and the New England Healthcare Institute (NEHI). The study was led by Dr. Bates and his team of physicians and nurses, who audited 4,200 medical charts from community hospitals in Massachusetts over a 12- to 18-month period. Once Dr. Bates’ team completed its work, PricewaterhouseCoopers did a complete financial analysis of the costs associated with each error identified and, if an error had been prevented, to whom the savings would have accrued.

Based on this study, most hospitals that have considered purchasing and implementing CPOE can expect a return on their investment within 26 months, a quick payback. The acquisition cost for a CPOE system was cited as being about $2.1 million, and hospitals could expect annual operating expenses of about $450,000 a year. After breaking even on the initial investment, hospitals with 70% use ratings for CPOE can expect a net savings of about $2.7 million per year.

Examples of cost:

In the example above, averages are from $7,000 to as high as $17,000 per bed as a total cost of implementation. Also, I looked back at the data I have accumulated over the 20+ years to compare the costs for hospitals I’ve worked in and some of the published case studies. Looking at the cost of the implementation per bed, there does not seem to be a significant difference between the larger facilities and smaller ones.

Looking at a range of lows and highs, I am seeing costs varying from $7,550 to $12,000 per bed, depending on how costs were estimated based on the initial project assumptions. In the latter case where the cost per bed is higher, we have accounted for other items as part of the initial capital investment; things such as servers, devices, end-user support staff, and training hours for staff and the entire implementation team members.

CPOE is not an inexpensive endeavor, to say the least. But in the end, it’s cost vs. effectiveness

Organizations will spend a great deal of their initial investment regardless of whether they implement the minimum requirements to meet Meaningful Use or implement to improve quality care delivery for the entire organization. However, one thing is certain: benefits cannot be anticipated if only a handful of providers are using the system and we constantly have to come up with workarounds to bridge the gaps. There are so many benefits to CPOE and real-time clinical decision support.

So I ask the question: what is more important to your organization, cost or effectiveness? This is a critical question to understand and answer to seek because it will help you fully recognize the value of medical technology and the likelihood of adoption by your organization.

We talked about money and the “richness” of CPOE. Why not take this a step further and complement our topic with a nice summer dessert? Extra-rich strawberry ice cream. I guarantee it you will enjoy it, and it will cleanse your palate from the bitter taste this topic leaves behind.

Daniela Mahoney, RN BSN is vice president of Beacon Partners of Weymouth, MA.

Readers Write 6/6/12

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Moneyball and the Power of Data Analytics
By Gerard Livaudais

I’m not much of a baseball fan, but I really enjoyed the movie Moneyball. If you haven’t seen it (or read the equally excellent book by Michael Lewis), here’s a ten-second synopsis. Billy Beane, general manager of the Oakland As baseball team, bucks traditional scouting methods by using data analytics to find undervalued players. He is pilloried by baseball purists for his stats-obsessed methods, but he builds a winning team on the league’s lowest payroll.

Moneyball may be a baseball movie, but the real story is about the transformative value of data. And as the final credits roll, what’s clear (at least to this viewer) is that even the most under-funded team in baseball uses data more effectively than most healthcare providers.

The use of data as a business intelligence tool is hardly new. In almost every industry on the planet, companies are leveraging data-driven decision-making to realize productivity gains, achieve competitive advantages and improve overall performance. Even the smallest of SMBs (small and medium-size businesses) are getting in on the act, thanks to the simultaneous rise in computing power and drop in hardware and storage costs.

Businesses like the Oakland As are using data to win baseball games. In a hospital, access to the right data at the right time saves lives. Yet healthcare organizations as a whole are failing to use current, accurate data to support their clinical, financial, and operational decisions.

Healthcare should be setting the standard for data-driven business intelligence. Here are three strategies we can use to get there.

1. Focus on the Data that Matter

Healthcare organizations certainly don’t lack for data. Thanks in part to a constellation of regulatory mandates, we already capture, store, and report phenomenal amounts of data. On the other hand, financial incentives – never the top priority but always a factor — for effective use of data are rising. Meaningful Use Stage 2 includes numerous value-based purchasing elements and aggressive penalties for hospitals and physicians who fail to demonstrate the quality of care they deliver.

One way we can leverage data more effectively is by breaking down the data silos that prevent the right information from getting into the right hands. As an industry, we spend billions of dollars building and maintaining the data warehouses that power analytics across healthcare environments. These internally-hosted systems may be great at assembling data and powering analytics for specific departments or functions. But they also isolate that data, inhibiting its value as a decision support tool.

The right business intelligence technology can break down these data silos much more easily and cost effectively, enabling all decision-makers within an organization to access the most relevant metrics and performance indicators. The implementation and support cost factors for Software-as-a-Service (SaaS) solutions are several orders of magnitude less than internal systems.

2. Leverage Internal and External Data

Once internal data silos are torn down, healthcare organizations have the ability to seamlessly share information across departments and business units. Integrating data from outside your organization is essential to enabling true comparative analysis. Inconsistent data formats are a nightmare to normalize and aggregate manually. But industry data standards such as HL7 are helping enable true interoperability among best-of-breed technology solutions.

3. Influence Positive Patient Behavior

Health outcomes are ultimately dictated by patient behavior. One of the most promising frontiers of clinical business intelligence is the ability to blend data that reflect not just clinical activity, but social factors that can help predict how well certain patients will comply with a treatment plan, particularly for chronic illness.

These factors can range from patient-generated measures – such as how patients prefer to interact with their physicians – to the presence of psycho-social indicators such as depression and exercise level. Their economic impact can be profound. The cost to treat diabetes in patients with depression is more than twice that of diabetes patients without depression. By blending clinical and social indicators, providers are able to “personalize” treatment plans that simultaneously raise the probability of successful health outcomes and reduce the overall cost of treatment.

However, some of these measures of efficiency are not universally appreciated just yet. As Billy Beane discovered, prioritizing on-base percentage over batting average may be a more efficient path to building a successful team. But his Oakland As had to win games first – a lot of them – before his industry appreciated his logic.

The good news for healthcare is that everyone – from physicians and providers to device manufacturers, pharmaceutical companies, insurers and other payers, and even academic and research institutes – benefits from more efficient and successful patient outcomes. All parties also benefit from instant access to accurate healthcare data. The right tools can open up a world of opportunity to improve outcomes and save lives.

Gerard Livaudais is chief medical officer of Quantros.

Care in an Emerging Market
By Arvind B. Deshpande

Recently my father, who is 84, was hospitalized for profuse sweating based on telephonic advice of our family doctor.  I live in a city about 150 km from Bangalore (or Bengaluru). I am describing the care at the hospital.

We arrived on a Saturday around midnight without calling the hospital. As soon as we reached the hospital, staff at the entrance wheeled him to ED. The duty doctor took an ECG and advised moving him to ICCU. By the time I finished the paperwork at billing (where they located his nine-year-old ECG record in less than a minute,) he was in the ICCU on the first floor of the four-floor hospital.

The doc in ICCU immediately connected a vital signs monitor. Noting the low heart rate of 40, he mentioned that an external temporary pacemaker might become necessary. I signed the consent, giving my contact details.

Around 2:30 a.m., I got a call saying they had connected the external pacemaker after his heart rate became irregular and he had been defibrillated. My father stayed in the ICCU until Monday morning, when the interventional cardiologist took a look and advised an angiogram. He mentioned that if there was a heart block, they might have to introduce a stent.

I again signed the consent papers. The whole procedure, including angioplasty, was completed in an hour. My father was moved back to ICCU. Care in ICCU was good, timely, and home-like, to say the least.

The doctor mentioned that he would stay in ICCU for two days, then be shifted to the ward for another 2-3 days. The external pacemaker would still connected as a safety standby. He was moved to the ward after two days and the external pacemaker was disconnected on Day 4. He continued in the ward until Day 6 as a precautionary measure, then was discharged from the hospital.

I had the opportunity to interact with the doctor every morning. The findings were recorded on paper and explained to me daily.  On the last day, all the records were signed off, billing was completed, and we came home,  which is about a 10-minute drive from the hospital.

This 30-bed hospital dedicated to cardiac specialty has its own IT hardware setup and software locally developed to support them. Meaningful Use and EMRAM standards do not exist and are not mandatory. This hospital is ISO 9001 certified ,and one can say they comply with the standard in letter and spirit.

I work for a medical device manufacturer here. I am an avid reader of your blog, from where I have gained some insight into how providers and vendors work towards patient care in the US.

I am not suggesting that the recent measures announced in the US are not necessary. The above incident is only to spread awareness as to how good care is primary and systems are required to support care.

Arvind B. Deshpande is head of quality assurance and regulatory affairs for Larsen & Toubro of Mumbai, India.

Why We Do What We Do
By Dan Herman

I have received a birds-eye view of our healthcare delivery system while tending to my mom over the past couple of months. She had major open heart surgery at a hospital outside of Chicago in late April. She was discharged to rehab and is doing pretty well for a woman who will turn 82 next week.

The hospital that cared for her is part of a large IDN, highly integrated on a single EMR platform for their inpatient and multi-specialty physician group practice.

They are a HIMSS Analytics EMRAM Stage 6 organization. Not only was the care and patient service impressive, but the collaboration and coordination among the care team was practically seamless. Her internist, cardiologist, thoracic surgeon, and anesthesiologist; nursing teams in the med-surg, ICU and SICU units; physical and speech therapists; dietitian; and social worker for discharge planning were all working in synch across her episode of care and had access to her clinical information across the care continuum (including her previous problem list and meds and allergies from her internist that practices at the medical group). Mom also accesses her regular lab results from home (and now the rehab facility) through the health system’s patient portal.

My key observation was the impact of what we do as healthcare IT and operations improvement professionals. The hospital that cared for my mom has long been recognized as a leader in the use of information technology to support care delivery, operational, and financial management processes. They had a paperless business office in the early 80s; standardized the nursing documentation process across their four acute care sites in the 90s; and obtained 90%+ CPOE adoption almost 10 years ago.

During the inpatient stay, I didn’t see any paper. Everything was documented in the system – nursing notes, MD notes, anesthesia and OR record, legal documents, ICU monitoring device results, etc. But more than the IT aspects, I noticed a very streamlined and coordinated care process that was centered on the patient. Patient safety and service was the driver behind the outstanding use of the top-of-the-line technology. Always confirming the patient’s name, medication bar coding that ensured the right meds, doses were delivered to mom at the right time (she really hated being woken up at night or at 7 a.m.)

Mom was transferred there from the hospital down the street (it’s where the ambulance took her). She never felt comfortable and safe at the first hospital. Her doctor didn’t practice there. They didn’t explain what was going on. They didn’t have access to her past clinical history. The caregivers weren’t coordinated. Patient safety was in question (a nurse came in with meds for another patient). The facility wasn’t as nice, and the food was not nearly as good. However, they used the same EMR.

It’s not about systems. It’s about leadership, accountability, and the care delivery process. The contrast between the two hospitals was a case study. This overall experience drove home the significance of what we do. Whatever your specialty is or your role within your organization, it’s essential to never forget our true mission – improving healthcare.

Dan Herman is founder and managing principal of Aspen Advisors.

Readers Write 5/21/12

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

The Art of Medicine: Unlocking the Power of Patient Data
By Nick van Terheyden, MD

We are awash with information and choices in every aspect of our lives, from the selection of our morning coffee to the choice of painkiller in our local pharmacy. Worth noting, Starbucks currently offers 30 variations of espresso beverages, and each comes in three sizes with four types of milk. That’s 360 choices — enough to potentially make you want to not get out of bed in the morning.

This problem is magnified in medicine with a deluge of new information, studies, treatments, and the explosion of genome understanding and its impact on patient care. Based on current estimates, medical information is doubling at least every five years. Cyril Chanter encapsulated today’s medical information challenges best when he said, “Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous.”

There is general agreement in the medical profession that the delivery of quality medical care is no longer possible based on recall and applying what individuals can remember at the point of care. In fact, according to the Kaiser Permanente Institute for Health Policy, “Current medical practice relies heavily on the unaided mind to recall a great amount of detailed knowledge – a process which, to the detriment of all stakeholders, has repeatedly been shown unreliable.”

The digitization of medical records, accompanied by the requirement imposed on the care team to capture discrete data, is setting the healthcare system up for failure. We’re promoting the incomplete capture of the patient note. Discrete data is much like a black-and-white drawing — it contains some of the data, but much of the critical information and nuances are missing. In order to ensure the complete capture of the patient note, discrete data and the clinical narrative must coexist.

The key transport mechanism for medical intelligence is the clinical narrative, which provides the detail that is essential for the execution of intelligent, high-quality medical care. From there, language understanding offers a legend for these pieces of information – the narrative and discrete data – which allows us to view the complete work of art, also known as the patient note.

We are a long way down the path to enabling clinicians to capture complete patient information using the latest advances in voice recognition, which converts spoken word into text. Still, it is with language understanding that we unlock the true meaning of this information, offering a “Rosetta Stone” to tap into the insights of this information and allowing us to connect the dots in our expanding picture of patient care in a digital world.

It is this unlocked data that will link the subtle details of the patient record to vast mountains of medical intelligence; allowing for a guided, evidence-based approach to medicine alongside integrated decision support. This in turn will offer care takers a more complete picture from which they can guide individual care, while enabling possibilities surrounding large health population analysis and insight.

As we unlock the capabilities of clinical data in healthcare, we open the door to new discoveries, associations, and yet-unimagined treatments that will directly affect the care of those we love and look after now and into the future.

Nick van Terheyden MD is chief medical information officer of Nuance of Burlington, MA.

I once heard it said that successful device connectivity in a hospital is like implementing a universal remote on your TV. The consolidation of controls allows for easier training of new users, fewer steps to execute a command, and less room for error. But in today’s age of accountable care and new care delivery models, the health systems that are still operating in the “universal remote” mindset will be left behind as the industry progresses.

It’s great that my DVD player can talk to my TV. But what about when I want to watch the same movie on my laptop in the other room? And while this entertainment glitch is a little frustrating, it’s actually criminal when we think of a similar scenario in the healthcare world. We don’t need to just connect one point solution to another. We need to be able to effectively care for patients, regardless of where they are within the hospital; what systems the hospital has in place; or how many physicians, nurses or other staff are involved in the patient’s care. The sooner hospitals begin to think beyond individual technologies and develop an overarching strategy to connect people and processes, the faster we’ll start to see a real change in patient care.

Historically, hospitals and health systems have approached medical device connectivity tactically, focusing on how to connect a nurse call device to a smart phone, a monitoring device to an iPad, or data from a smart bed to an EMR. Often purchased by IT departments as middleware, a range of IT solutions have been viewed as a solution to one or two key problems, and have typically been implemented one department or one facility at a time.

Because many of these technology investments were made to solve only singular, point-in-time problems, providers still struggle to deliver care that focuses on the patient across the entire care continuum. They need to get smart about implementing solutions that cater to the unique workflow of their personnel – not their hardware – if they want to drive efficiency and improved patient care.

It’s not really the provider’s fault, though. The vast majority of vendors have played into this universal remote mindset by building point solutions that connect a small subset of devices or departmental systems to one another, rather than focusing on the entire system. Providers need solutions that both cater to a department’s unique workflow and enable collaboration from one department to the next, making it possible to efficiently serve patients as they move between these diverse care settings. They need to come to the table with customizable solutions, and with services that help hospitals implement these solutions as part of a broader workflow strategy. It’s not enough to drop off a box and wish them well. Providers need partners to help them learn and improve for years to come.

We need a new movement in healthcare, one that takes a system-wide view to clinical workflow design and leverages clinical technology solutions to both connect devices and foster collaboration across the entire system. This includes everyone from patients to clinical teams to ancillary groups (biomedical engineering, dietary, environmental services, IT, and pharmacy). Clinical workflow is about more than hardware and software. It’s about the clinicians who use these solutions and need them to promote — not hinder – high-quality patient care. Vendors need to offer their customers something better than stale point solutions. 

As an industry, we need to map to the bigger picture, driving teamwork and collaboration among every individual and across the entire care continuum in order to drive dramatic performance improvements for healthcare organizations.

Mary Baum is chief healthcare officer of Connexall USA of Boulder, CO.

The Long Road Ahead: Choose your Traveling Companions Wisely
By Chad Morrill

When hospitals choose a healthcare IT provider, they too often just focus on the same questions many of us consider when buying a car: “How fast does it go?” and “How much does it cost?” But for a successful project, these are just two of the many factors to consider. Another key decision point should be a vendor’s suitability as a long-term partner.

We’re not just talking the equivalent of a 100,000-mile power train warranty, whereby the vendor will fix your system if it breaks, though of course responsive support is important. But beyond that, you’ll be better off working with a company that not only understands its products and services, but also your processes, your staff, and your goals, and will do its best to unite these elements to give you maximum performance and value.

The first thing to consider before getting on the road is your hospital’s needs, both now and for the next few years. What are the pain points you’re trying to overcome, what new compliance mandate are you struggling to satisfy, or which facet of your EMR/EHR project are you finding most troublesome? This then defines the focus of your solution search, which will in turn narrow your list of prospective vendors.

Next, ask for references from facilities like yours and see how they’re solving the very issues you want to solve. Then ask them what else they’ve been able to do with the product. A hospital sometimes picks a solution because it fits neatly into whatever box they’re trying to fill, but yet leaves the full potential of that solution untapped. One of the reasons is that an IT team is typically tasked with solving a very narrow problem, and once they’ve done it, they must move on to putting out the next fire lit by clinicians or the CIO. They then go out and look for other vendors to meet the very needs that could be met by the product they’re already using – a waste of time, effort, and money for everyone involved.

Executives tend to chase the next “shiny object” or respond to the newest tech trend, and this leads to the misconception that something ‘new and improved’ is required. Just like we all want the next iPhone or iPad, many hospital users hanker after the latest IT toys on the market, following the hype rather than putting in the effort to explore the full capability of the applications already deployed.

Despite the need for hospital project managers to be proactive in working with vendors to get the most from their systems, the burden cannot fall solely on the facility. A responsible vendor that cares about its customers and the staff and patients they serve should dedicate time and resources to helping hospitals get the most out of its solutions. A regular onsite “checkup” with both a customer advocate and a member of the vendor’s executive team can provide the hospital with a view of what its products can do now, and what the roadmap is for upcoming functionality. The vendor can explain and even demonstrate how other customers are using its offerings in new ways, and can then help the IT staff put this knowledge into action. Executive buy-in is also crucial on the hospital side, as the CIO and IT director will be key in both understanding the full potential of vendors’ products and services, and then in driving widespread user education and adoption.

The challenge to such leaders: push your IT analysts/project managers to explore each product’s entire feature set and get involved in engaging your vendors to see what else you could or should be doing. Yes, it requires accountability and an upfront time investment. But it will yield the benefits of doing more with existing tools, moving further toward achieving your facility’s goals, and, most importantly, of improving care and service to your patients. Time to start your engine!

Chad Morrill is an account manager at Access of Sulphur Springs, TX.

Readers Write – National Nurses Week 5/7/12

In Honor of One Very Special Nurse
By Lisa Reichard, RN

Our Heroes

Captain Donna Rowe and fellow servicemen

As nurses, we are called to work in emergency rooms, school-based clinics, homeless shelters, and even war zones. I recently had the distinct honor and privilege to meet and interview Army Captain Donna Rowe, RN, for Nurse’s Week. Donna entered the US Army in 1964 through the Student Nurse Corps Program (ROTC). She was assigned to Vietnam: 3rd Field Hospital-Saigon as the head nurse in the emergency room/triage area from 1968-1969.

“At times, Vietnam War veterans have been portrayed as dropouts or drug addicts,” said Rowe. “This is far from the truth. They were the best our country had to offer.“ She said, “I have to tell you about the men and women I went to war with before I can tell you my story.“

“My generation instilled in us courage, compassion, and patriotism. When we entered the army, we were taught duty, honor, and love of our country. This is what our parents had already taught us – how to be good Americans. Halfway was not acceptable. Contrary to popular belief, most who served in Vietnam –74%, actually – were volunteers, not draftees. I was an ‘old woman’ when I was there at 25 years old. The average age of those who served in Vietnam was 21. The average age of the men there was 18,” said Rowe.

In Washington, DC, there are 58,267 names on the Vietnam Veteran’s Memorial Wall.  Of these, 33,000 belong to service members who were 18 years old.

“Today, the average age of those serving is 26,” Rowe explained. “We were very young men and women sent to war by a country that, when we came home, hated us. This is why not many vets told their stories.”

Donna then began to pull out photos to share from her scrapbook.

“There were 11,000 women who served in Vietnam, 98% of whom were Army nurses,” said Rowe. “We were ER nurses cross-trained in OR and we worked to cover trauma seven days a week, 365 days a year. Nurses saw the worst. Eight were killed in action. For those who served, families suffered, the sacrifice was great, and the transition was tough coming home. We came home one by one to ridicule. Many were not welcomed back as heroes. They called us baby killers.”

Baby Kathleen

Specialist Darrell Warren, Baby Kathleen, Richard Hock, and Captain Donna Rowe

This is the true story about brave American men and a nurse who saved a baby’s life in the middle of a war.

It was May 15, 1969. Rowe had only 30 days left on her tour of duty. The ER area at her hospital was capable of handling 225 casualties at a time, and averaged 700-900 per day during the height of the Tet Offensive.

In a Viet Cong attack on a village that day, everyone was killed except a baby girl who had been found severely wounded in her dead mother’s arms. The mother had died trying to protect her child.

Rowe received a radio message that eight medevac helicopters were on their way to the hospital, each with at least 10 casualties aboard. ER triage priority status went to US servicemen, then US civilians, allied forces, South Vietnamese troops, and then Vietnamese civilians. (Rowe explained they were not allowed to treat civilians because they had their own hospitals.)

“We were in the offensive mode and supplies were short,” said Rowe. “We worked at a school turned into a hospital in the heart of Saigon. I got a radio call from a pilot saying he needed immediate permission to land because he had a critically wounded infant on board. The chopper had already been turned down by other hospitals and ours was its last hope.”

“I knew right from wrong,” she recalled. “I remembered what my mother said to me as I was leaving my hometown of Sterling, MA, to go to war: ‘Always do the right thing, Donna.’ So I turned to my sergeant with the radio and said, ‘Tell him that the Third Field Hospital will receive them.’” She accepted the baby against standing military policy.

“My sergeant then said, ‘You’re going to take some hell for this, Captain.’ I said, ‘What can they do to us? Send us to the front lines of Vietnam? We are already in hell.’”

”Our ambulance met the Dustoff at the helipad. Her dead mother’s arms had to be broken to release the baby from her tightly wrapped, protective arms. The medic rushed the baby into the ER and told me, ‘Dear God, Captain, this baby is dying on us and they killed everybody in her village.’ The North Vietnamese had wiped out the village.”

Rowe continued, “Specialist Richard Hock, one of my best combat-trained medics, took the baby from the ambulance drivers. He immediately realized the baby was in respiratory distress due to bleeding and fragmentation wounds in her chest and abdomen. We got a breathing tube into her with the smallest tube we had in triage, put a manual breathing bag on it, and Richard took over breathing for this little one until we turned her over to the operating room staff several distressing minutes later.”

“The Triage doctor ordered a full-body screen on her, so we rushed the baby to the X-ray room to locate shrapnel to be removed in surgery. On the way from X-ray to the operating room, I saw Father Luke Sullivan, our Catholic Chaplain, and pulled him into the crowd that was half-running down the hospital corridor. Fearing the baby might die at any moment and knowing that if baptized she would have a place to stay, if she recovered, at the Saint Elizabeth Catholic orphanage, I told him ‘Father, come with us. You have to baptize this baby.’”

“Father Sullivan used water from the sink to sprinkle on her tiny forehead and said, ‘I baptize thee …” he looked at me for a name. A name, a name …. I remembered the Irish song my father sang to me while dancing me across the floor as a child, ‘I’ll Take You Home Again, Kathleen,’ so I blurted out quickly, “Name her Kathleen Fields!’ Kathleen from the Irish ballad and Fields because we were at the 3rd Field Hospital.”

“Father Sullivan stated the baptismal rights then looked around the gurney moving by fast, and said, ‘And your Godparents are Specialist Medic Darrel Warren, Specialist Richard Hock, and Captain Donna Rowe.’ The three of us became Godparents that day, joining with a Catholic priest to help with a tiny bit of God’s work while rushing this baby to life-saving surgery.”

“A few days after Kathleen arrived, three soldiers in combat gear came into the hospital. They asked if the hospital had treated a wounded baby and if it had survived. Rowe directed them to Kathleen’s room, where they visited briefly, then headed out. As they passed me, one of the men said, ‘Thank you.’ Those combat troops did something exceptional and wonderful because they could have kept right on walking. They were compassionate and caring. They were Americans."

“After about two weeks,” Rowe explained, “Kathleen was healthy enough to be transferred to St. Elizabeth’s orphanage.” Rowe told the men to scrounge extra food from the hospital mess to take with the baby to the orphanage. An American Naval officer and his wife then adopted Kathleen.

The Need For Technology

“We had no Internet or electronic health records,” Rowe explained. “I truly wish that each soldier would have had a flash drive on them with all of their medical history and information instead of a dog tag. The reality is that a lot of times, the boys did not want to wear the dog tags around their necks. They did not want them clanking when they were walking by in the brush. We would receive the injured with no ID, medical history, or any information. Hand-held devices to enter patient data from multiple locations would have been very helpful in the battlefield environment.”

Today, the Department of Defense and the Department of Veterans Affairs operate the two largest health systems in the United States. They now use integrated, comprehensive clinical application suites that work together to create a longitudinal view of the veteran’s electronic health record. Deployed medical professionals use these on the front lines to streamline medical logistics and enhance situational awareness for tactical forces, as well as promote continuity of care.

Reunion and Update

Specialist Richard Hock, Kathleen Epps (" Baby Kathleen"), and Captain Donna Rowe

After 34 years, Rowe and her colleagues got to hold their "baby" again. Rowe, Hock, and Kathleen were re-united in April 2003 in Fort Sam Houston, TX. Kathleen had been Googling names on her baptismal certificate hoping to find answers. She finally got to meet Rowe and Hock. It was a truly special and emotional reunion for all. “Baby Kathleen” is now Kathleen Epps. She lives in California with her husband and their four beautiful daughters.

Hock, who was a paramedic in Georgia at the time of his reunion with Rowe and Kathleen, remembered the baby as, “A bright spot in a very bad time. She made all the rest of it bearable. She became a beautiful woman with a beautiful family. It is the great American dream all over again."

Kathleen and Specialist Hock, who passed away a year after their reunion, are featured in “The Kathleen Story” segment of the World Film Festival’s award-winning Vietnam War documentary film, In the Shadow of the Blade. Darrell Warren, formerly of Tucson, Arizona, is still living out west. 

Never Forget

Donna received the Vietnam Service Ribbon and Army Commendation Medal. Forty years later, she now travels the country, unpaid, to tell her story. Today, Donna lives with her husband, Colonel (Ret.) Al Rowe, former four-term president of the Georgia Vietnam Veteran’s Alliance. They have two sons. She is a real estate broker in Georgia.

Donna said she would like all to remember that we still have women and men serving in harm’s way – the sons and daughters of the Vietnam vets. “Let’s make sure that these men and women do not come home to a country that hates them or treats them with disrespect of disdain like we had to deal with,” she adds.

Finally, I asked Donna, How we can we show our appreciation for veterans who have served?”

“When you are out and you see a serviceman or service woman in uniform,” she replied, “offer to buy them their meal. Look them in the eye and give them a big thank you for their sacrifice and service to our country.”

Lisa Reichard, RN, BSN is director of business development at Billian’s HealthDATA.

Readers Write 4/25/12

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

CDS by the Numbers: Three Useful Frameworks for Developing Clinical Decision Support Applications
By Lincoln Farnum

Clinical decision support, or CDS, is many things to many people. Ask any 10 healthcare providers what clinical decision support is and you’ll very likely get 10 (or maybe 20) different answers, all good ones. The answers are also likely to be tinged with some degree of frustration and mistrust.

CDS as a discipline stems from the original promise of computers developing artificial intelligence — actually practicing medicine, making diagnoses, and managing patient care. Obviously these early expectations have not yet been fully realized. Today, our understanding places computers in medicine into more supportive roles.

In practice today, one commonly seen CDS application is related to medication ordering — alerting for allergies; duplicate orders and therapeutic overlaps; and drug-drug and drug-food interactions. These applications have no doubt saved human lives and resources, but often do so at a high cost to prescribers in the form of confusing messages and alert fatigue from poorly designed or executed rules.

Also, ethical concerns can affect users’ experiences with CDS. Concerns that technology-driven decision making will affect the doctor-patient relationship or that it might fail to take into account the patient’s values, or produce a cumulative de-skilling effect on physician training have all been commonly cited. There are also frequent liability concerns relating to prescribers accepting erroneous advice from a computer. It’s the fallout from these common but very reasonable apprehensions that we as consultants must try to manage on a daily basis.

Designing effective CDS is as much art as science, and it’s a quite a bit of both. Detractors of clinical decision support enthusiastically point to the occasional bad examples, but are quite often not even aware of the good ones. They seldom see “good” CDS — in part because it’s so hard to do, but also because good CDS is often invisible. CDS applications are, at their best, an unseen hand gently guiding patient care and clinical decision making.

There exist today three common frameworks for designing effective CDS: the Three Pillars of Effective Clinical Decision Support, the Five Rights of CDS, and the Ten Commandments of CDS.

Let’s begin with discussing the Three Pillars.

The Three Pillars

Osherhoff, et al, in “A Roadmap for National Action on Clinical Decision Support,” uses an image of three pillars supporting effective CDS. They are represented in the image below:

Pillar 1: Best Knowledge Available When Needed

• Represent clinical knowledge and CDS interventions in standardized formats (both human and machine-interpretable) so that a variety of knowledge developers can produce this information in a way that knowledge users can readily understand, assess, and apply it.
• Collect, organize, and distribute clinical knowledge and CDS interventions in one or more services from which users can readily find the specific material they need and incorporate it into their own information systems and processes.

Pillar 2: High Adoption and Effective Use

• Address policy / legal / financial barriers and create additional support and enablers for widespread CDS adoption and deployment.
• Improve clinical adoption and usage of CDS interventions by helping clinical knowledge and information system producers and implementers design CDS systems that are easy to deploy and use, and by identifying and disseminating best practices for CDS deployment.

Pillar 3: Continuous Improvement of Knowledge and CDS Methods

• Assess and refine the national experience with CDS by systematically capturing, organizing, and examining existing deployments. Share lessons learned and use them to continually enhance implementation best practices.
• Advance care-guiding knowledge by fully leveraging the data available in interoperable EHRs to enhance clinical knowledge and improve health management.

The Five Rights

The Agency for Healthcare Research and Quality (AHRQ) has published a CDS Toolkit in which safe and effective medication management is supported by the use of CDS, though these concepts can easily be extrapolated to health care in general. The Five Rights of Effective CDS — not to be confused with the Five Rights of Medication Administration — proposes that we can achieve CDS-supported improvements in desired healthcare outcomes if we communicate:

1. The right information. Evidence-based, suitable to guide action, pertinent to the circumstance.
2. To the right person. Considering all members of the care team, including clinicians, patients, and their caretakers.
3. In the right CDS intervention format. Such as an alert, order set, or reference information to answer a clinical question.
4. Through the right channel. For example, a clinical information system (CIS) such as an electronic medical record (EMR), personal health record (PHR), or a more general channel such as the Internet or a mobile device.
5. At the right time in workflow. For example, at time of decision, action, or need.

The Ten Commandments

Finally, David Bates, et al in JAMIA published “Ten Commandments for Effective Clinical Decision Support: Making the Practice of Evidence-based Medicine a Reality,” in which he modestly proposes the following ten commandments for CDS:

1. Speed is everything. Even if the decision support is wonderful, if it takes too long to appear, it will be useless.
2. Anticipate information needs and deliver in real time. CDS must be presented at the moment the user needs it.
3. Fit into the users’ workflow. Users won’t go looking for CDS — it needs to be in their workflow.
4. Little things can make a big difference. Small changes in delivery can have an oversized effect in outcomes.
5. Recognize that physicians will strongly resist stopping. Don’t bring clinicians to a dead end when making suggestions.
6. Changing direction is easier than stopping. Propose alternatives when advising against something.
7. Simple interventions work best. Complex and multi-paged guidelines will not be readily accepted.
8. Ask for additional information only when you really need it. Try to obtain all necessary information passively. Ask for additional information only if it is absolutely required.
9. Monitor impact, get feedback, and respond. Verify that interventions are producing the desired outcomes and communicate with your customer base.
10. Manage and maintain your knowledge-based systems. Suggestions based on outdated information are dangerous and worse than no suggestions at all.

Obviously, this is a very high level overview of these frameworks. The below links will provide more information and context. The simple take-home lesson is that effective CDS isn’t easy and even good CDS isn’t always accepted or performs as its developers intend. The development and deployment of clinical decision support should be undertaken with an understanding of the challenges and recommendations for best practices, and with the strong cooperation of and input from the user community.

A Roadmap for National Action on Clinical Decision Support, Jerome A. Osheroff, MD, et al.

AHRQ, Approaching Clinical Decision Support in Medication Management

Ten Commandments for Effective Clinical Decision Support: Making the Practice of Evidence-based Medicine a Reality, David W. Bates, MD, MSc, et al.

Lincoln Farnum MMI, RRT-NPS, CPHIMS is a senior consultant with Vitalize Consulting Solutions, an SAIC Company and a graduate teaching assistant in the Master of Science in Medical Informatics program at Northwestern University.

I’m a Believer in Diagnostic Decision Support
By Scott W. Tongen, MD

When I read a vendor’s brochure about diagnostic decision support software that mirrors how medical students and physicians in training are taught to diagnose patients, I had an epiphany. My peers and I today are not diagnosing patients the way we were instructed in medical school and residency. As a result, we — and our patients — pay a heavy price.

As students and residents, we were asked to provide a list of all possible diagnoses based on patient’s symptoms, medical tests, accumulated medical knowledge, and other information. Next, we would use the data at our disposal to eliminate diagnoses that did not fit until we were left with one diagnosis.

However, advances in imaging software and electronic health records, revenue pressures, and crushing time demands had led us to stop using that “differential diagnosis” methodology on a daily basis, leading to misdiagnoses or missed diagnoses.

None of us likes to admit our mistakes and fallibilities when we’ve misdiagnosed or missed a diagnosis, but it happens: 40,000 to 80,000 patients die annually due to misdiagnosis, according to a 2009 study published in the Journal of the American Medical Association.

I believe a major reason for an inaccurate or incomplete misdiagnosis is due largely in part to the increased use of powerful EHR systems. Those systems are deemed so efficient now that they lull highly skilled and trained professionals into a false sense of security. Too many physicians rely on electronic alerts and images to help them solve the mystery of a patient’s illness, forgetting that technology can be a poor or terrific tool, depending on whether it is used correctly.

Also, doctors and hospitals do not realize that EHRs are not sold “out of the box” with diagnostic decision support that generate potential diagnoses and flag high-risk “Don’t Miss” diagnoses when patient’s symptoms and vital signs are entered into the application. When clinicians do not know what they do not know or are not thinking about a possible diagnosis, they certainly will miss it.

Another reason for misdiagnoses and missed diagnoses is physicians’ busy schedules, as continual reimbursement cuts are forcing them to squeeze in more patients. This, combined with other demands competing for their time, make it impossible for doctors to remember all pertinent details that could potentially explain a patient’s problem, much less keep up with the massive explosion of peer-reviewed studies and medical discoveries published in numerous medical journals.

All those thoughts flashed across my mind as I read the brochure, which ultimately led to my convincing administrators to fund and offer the tool to our physicians. Diagnostic decision support software can help doctors address those problems while minimizing misdiagnoses that harm or kill patients.

For that reason, every physician and hospital in the country should implement diagnostic decision support software that highlights and enables them to access relevant information about potential diagnoses. They will find the tool extremely valuable, particularly when diagnosing difficult as well as rare cases. A useful objective review of these tools was published recently, “Differential Diagnosis Generators: an Evaluation of Currently Available Computer Programs” by William Bond, MD, MS et al from the Lehigh Valley Health Network.

To be clear, I am not proclaiming diagnostic software needs to emulate a physician’s thinking. What I am advocating is that doctors should use it to bring up diagnoses they otherwise would not have considered or remembered. The tool will more than pay for itself if it prevents a single fatality or serious misdiagnosis. More importantly, it will enhance quality and safety of care.

At the time this article was written, Scott W. Tongen, MD was medical director of clinical documentation, compliance, and quality at United Hospital, part of Allina Hospitals & Clinics in Minneapolis. He has since joined Vitalize Consulting Solutions, an SAIC Company as medical director.

Readers Write 4/16/12

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Making More Meaningful Use of Data Through Device Integration
By Stuart Long

Far and away, the main theme of Meaningful Use is an increased focus on making health information exchange not simply a capability, but a reality. As providers seek reimbursement for technology implementations designed to do just this, they need to take a step back to understand what is necessary to go beyond incremental improvements in order to see the larger picture – which means going further than Stage 2 to Stage 3 and beyond.

There has been recent discussion around the importance of medical device integration (MDI) as a necessary component on the path toward achieving health IT (HIT) initiatives such as Meaningful Use, HIE, and ACOs, among others. Healthcare providers need to understand the impact medical device integration can have across the entire hospital enterprise – “the big picture.”

While not addressed in Stage 2 (which takes effect in 2014), medical device interoperability is a stated 2015 objective. Stage 3 criteria are obviously yet to be detailed and finalized, but one of the criteria is for medical devices to be interoperable with EMRs and clinical information systems.

The theory of medical devices being interoperable is a good one. However, the chance of this actually being achieved across all device manufacturers is not realistic under the stated timeframe. Only a small fraction of devices today can send interoperable HL7 data. This means that many of the devices already installed within the hospital are not interoperable. Therefore, hospitals may be required to purchase new devices to meet the objective. With already strained budgets and resources, many hospitals would not be able to do so.

The most realistic means to meet the interoperability objective now and in the future is by implementing a vendor-neutral connectivity solution that would convert all data from all connected devices to HL7 so multiple people receiving information system(s) can accept it. Such a solution would enable interoperability, allow a hospital to use the equipment they have in place today, and minimize the points of integration for easier management, flexibility, and scalability – key ingredients to deriving real value out of required technologies like EMRs, CPOE and others.

Beyond Meaningful Use, the question is: how can hospitals fully leverage MDI to deliver the even greater benefit of transforming patient safety and outcomes? Imagine the ability to take collected data and compare, contrast, and analyze it from multiple sources, and then deliver it back to caregivers in a meaningful way. Imagine the ability to effectively manage smart pump connectivity and bi-directional communication. These are all possible through a middleware, vendor-neutral device integration solution.

However, let’s be realistic about the timeframe to make such possibilities a reality. For true end-to-end and bi-directional communication to become a reality, there are multiple factors that will have to come in to play. Multiple vendors with varying degrees of responsibility and intellectual property will need to communicate and operate with one another in order to make the data collected meaningful and to ensure that such data is presented back to the caregiver or other healthcare professionals in a meaningful way.

While this will take time, there really is only one way to facilitate this exchange of data – through a middleware provider who has established relationships with all the vendors in the mix: device manufacturers, information system providers, system integrators, and predictive outcome vendors. Having middleware that is vendor neutral gives hospitals the advantage of being able to bridge the gap between these worlds.

The point is, device integration is evolving. It is going beyond the simple connection of devices to systems. The next evolution will be using the data collected so it can be compared, analyzed, and delivered back to the healthcare provider and healthcare executives in ways that will truly transform patient care and outcomes. While it will take time, it isn’t a matter of whether it can be done — just when it will be done.

The beauty is hospitals can realize all the many benefits of device integration today (improved patient care, reduced errors, improved decision making, and even Meaningful Use) and position themselves to then realize the many benefits coming in the future. It’s a win/win, really, because device integration aligns with the ever-growing strategic approach to technology investments and implementations — to increase efficiencies and improve patient care.

Meaningful Use requirements will come and go, but hospitals will still remain. Decisions and investments made now will have a long and lasting impact on the future of healthcare. The best approach is to create an agile, scalable healthcare environment that can adapt to the changing needs of patients for years to come. Medical device integration is one technology that aligns with all of these objectives and more.

Stuart Long is president, North America of Capsule Tech, Inc. of Andover, MA.

Clinical Intelligence to Improve Quality and Reduce Costs
By Michael Weintraub

The business model for healthcare is changing very quickly and most providers do not have the information resources to support value and risk-based accountable care. What is needed now is longitudinal information that is patient / population centric, across the continuum of care, outcome and health status oriented. It must support performance improvement and cost management, particularly for disease states such as congestive heart failure, hypertension, diabetes, asthma and others, where better management impacts health status and reduces total costs.

Accountable care requires clinical intelligence – information resources and analytical tools – to improve care to populations, over time and across the care continuum. Analytics is a tool for extracting useful properties from data, but intelligence is about making sense of the data and figuring out what to do about the findings.

Quality improvement in recent decades has been aligned with a volume driven fee for service business model. Claims based data analytics and process measures were adequate, though their value in improving care has been disappointing despite the commitment and best efforts of so many. As Chassin and Loeb conclude, “Health care quality and safety today are best characterized as showing pockets of excellence on specific measures or in particular services at individual health care facilities.” ¹

As we move toward a value-based system with accountability over time, the focus of analytics is shifting as well. Historically the field of “analytics” only encompassed scorecards focused on traditional quality measures (e.g. aspirin on arrival for MI patients). But as the business model of health care shifts from fee-for-service to fee-for-value, organizations have also had to shift their analytic focus from “service” in the form of traditional process-based measures to “value” in the form of population health. This shift has driven expanded requirements for more robust clinical intelligence and predictive analytics to measure, understand and drive improved clinical performance tied directly to the bottom line.

Clinical data is the anchor for clinical intelligence and vanguard IDNs, hospitals, and medical groups are using clinical intelligence (CI) solutions that unlock the value of digital clinical data. Adoption of HIT is an enabling but not sufficient prerequisite for CI. Data warehousing and registries may also be enabling, but they are not CI. CI requires four advanced capabilities: data management, data quality, analytics, and shared learning.

Data Management

Even organizations with the most comprehensive EHRs find their data difficult to access and extract for analysis. Data formats and definitions are not standardized across IT applications or across entities even in the same enterprise. Extracting, organizing, and normalizing clinical, financial, and operational data from disparate systems and across the care continuum — inpatient and ambulatory — is key to unlocking intelligence in the data. Data management functions can be performed behind the scenes on a near real-time basis avoiding costly interfaces. They should tap valuable unstructured data using natural language processing to enhance the value of the extracted and normalized database for population management.

Data Quality Services

One of the persistent concerns of those who use data or are the subject of that data is concern about its accuracy and validity. These concerns are well grounded. The explosive growth of digital information with poor data governance has led to a state of disorder that has done little to improve trust and willingness to act on data.

This problem is compounded exponentially when trying to mine clinical data from EMRs. Unlike the well-understood structures and nomenclatures that support ICD, DRG, and CPT coding, clinical data are unstructured and unlimited in terms of their heterogeneity. CI solutions solve this problem by performing forensics that clean, validate, and map the data. These data quality processes provide insight into the areas ripe for data quality improvement in EHR and other data sources and enables monitoring data quality over time. The result of data management and data quality is a continuously refreshed database ready for use.

Analytic Technologies

CI employs analytic tools that are clinically and statistically rigorous and transparent so it is easy to access and understand the underlying data. Innovations in advanced data visualization and analysis guidance such as report libraries support a broad range of uses from clinical performance profiling to dashboards and analyses of at risk populations. For at risk patients and populations — for example, CHF patients — CI uses predictive analytics to identify where intervention may prevent hospitalization. Valid comparative data for benchmark analyses is an essential component of CI and a prerequisite for sustainable performance improvement. Smart analytic tools also help support employees who are learning to work with expanded data sets and new tools.

Shared Learning Resources

Over and over, it has been shown that quality and performance improvement benefits from collaborative learning. Using normalized and comparative data, CI leaders engage with one another through learning communities, such as those being convened through the American Medical Group Association (AMGA). With CI, the clinical comparative data and analytics are the glue for the community of stakeholders actively engaged in learning from one another.

Leading healthcare organizations preparing for value and risk-based accountable care understand they must move beyond limited purpose process measures and claims data to CI. They are leveraging their investments in HIT and unlocking the power of clinical data for population management and health system improvement.

[1] Chassin, M. and Loeb, J. “The Ongoing Quality Improvement Journey: Next Stop, High Reliability.” Health Affairs, 30, no.4 (2011): 559-568

Michael Weintraub is president and CEO of Humedica of Boston, MA.

How are you Managing your Revenue Cycle?
By John O’Donnell

The complexity of managing the revenue cycle has never been greater than in today’s healthcare environment. From the economic impact on an organization’s bottom line to the continued advancement of healthcare reform, the need to stay three steps ahead has never been more important for your organization’s financial health.

Staying ahead means knowing your strengths and weaknesses. Do you have the right talent? Do you know what the market conditions are doing to your revenue cycle? How do you approach declining reimbursements without impacting quality or strategic initiatives? These are not easy questions to answer.

Knowing what your organization does well and what it does not do well is one way to determine how to best approach your revenue cycle.

Take Business Intelligence (BI), for instance. It’s not just a term for reporting. It applies to the overall approach to your revenue cycle. BI can help you evaluate areas with the greatest impact to your cash—like denials management and follow-up. As you examine these areas, BI will begin to display a picture with areas of concern.

You may come to realize that outsourcing portions of your revenue cycle might be an option. For example, converting to a new billing system is going to impact A/R and denials no matter how good your organization. You cannot install and manage the old A/R at the same time.

Leaders need to look at what makes good business sense for the organization — especially regarding denials management — and ultimately, what’s good for the patient. Can you financially support growth if your cash flow is being impacted?

Cost pressures from staffing and IT costs are all having dramatic effects on the providers, not to mention ICD-10. The implications of ICD-10 on the billing process itself are staggering with regard to workflow, systems, and reimbursement. Documenting the clinical process correctly is critical.

Physician alignment is one area that will be crucial in transforming your revenue cycle. Whether inpatient or outpatient, the revenue cycle will impact physician compensation. This means you have to include physicians in any associated initiatives. Bring them into discussions about charge capture. Educate them on the impact on denials and eligibility. Have the physician sit down next to you as you both look at options in managing the revenue cycle.

The management of the physician practice does directly impact all aspects of your revenue cycle, and ultimately your cash flow.

The old manual models are a thing of the past. Technology is woven into our daily lives and needs to be integrated into the revenue cycle. This does not mean a minimal touch approach of writing off denials in advance. It means using people and technology to limit the denials ahead of time.

Accountability will force providers and the business office to work side-by-side to maximize reimbursements, especially as reform advances. Healthcare reform / accountable care organizations — it’s all here and it’s still advancing, whether you’re good, bad, or indifferent about it.

Today’s current economic factors are in some cases crippling providers. Throw in reform and without question a transformation of the current model is needed. Changing from fee-for-service to accountability is going to impact cash flow.

I believe this transformation is forcing mergers and acquisitions across the spectrum, which will impact both your inpatient and outpatient revenue cycles.

For example, if your hospital adds new physician groups to the mix, great. That will feed the inpatient cycle. But what does that mean to your existing revenue cycle? Does that mean a best-of-breed or an integrated system approach? And how do you scale the operations to support growth? You have to look at different options.

We’ve all heard the real estate mantra, “location, location, location.” Well, with your revenue cycle it’s all about cash, cash, cash. Without it, buildings don’t get built, physicians don’t get paid, and the patient is left looking for care elsewhere.

In the end, it’s about knowing how to scale the operations to meet the needs of the organization to support financial stability and growth. It’s also about using BI to monitor performance. None of this means your cash has to be impacted. You just have to know and understand your options.

John O’Donnell is president and CEO of SPi Healthcare of Tinley Park, IL.

Readers Write 4/2/12

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Cloud-Based Medical Data Exchange: Promising Results So Far
By Michael Trambert, MD

At RSNA 2011 and since then, my colleague Mark D. Kovacs, MD and I have been communicating to our peers about the new cloud-based services for exchanging imaging and other medical files.

Based on our study of an early adopter, Virginia Commonwealth University Medical Center (VCU), we’ve concluded that cloud-based medical data exchange has, in its best form at least, neatly addressed all of the major issues associated with older methods such as exchanging files by CD or VPN.

The “new” approach – which is actually about two years old and used by over 400 facilities – works seamlessly. Files are exchanged in minutes – reliably, securely, and at low cost. That includes exchanges between proprietary IT systems that don’t normally “talk to each other.” The cloud mediates the exchanges as easily as if it was e-mail being sent.

To appreciate what an improvement the cloud services represent, it helps to understand previous methods. Before the advent of cloud services, medical institutions turned to workaround solutions to deal with the incompatibility of proprietary healthcare IT systems.

The most popular of these was burning files to CD and sending them by mail, courier, or with the patient. Facilities that had a steady need for such exchanges with each other sometimes used virtual private networks (VPNs). For reports and other non-imaging files, some institutions used faxes.

The inherent problems with each of these methods are well known. But let’s examine the additional downstream problems.

Take, for instance, CDs – by far the most widely used method. This approach fails a significant percentage of the time, for reasons such as lost or misplaced CDs and files that can’t be opened. The significant time delay and risk of loss and or damage due to physical transport also undermines the rapid diagnosis and treatment of critically ill patients. Physical media makes it impossible to access studies contemporaneously from far away and by multiple caregiver / consultant sites.

When imaging studies are not successfully transferred, frustrated physicians at the treating institution often order redundant imaging studies. Studies show this occurs as much as 10% to 20% of the time. This unnecessary imaging exposes patients to excess radiation, which can contribute to cumulative deleterious effects. It also adds billions of unnecessary dollars to national healthcare costs.

VCU has been using a cloud-based service since late 2010. The cloud-mediated file transfers (in VCU’s case using a service called eMix) has been disruptive due to ease of use, speed, and dependability. Transfers are trouble-free.

As with any new approach — even one this simple — minor workflow adjustments were made. VCU is a Level I Trauma and referral center, so data exchanges usually involve other institutions’ sending files to VCU rather than vice versa. Those facilities had to switch over from a workflow built around burning and sending CDs to one requiring uploads to a cloud server. This required a simple change in workflow, much more efficient than burning CDs or utilizing VPNs.

Based on what we observed at VCU, Dr. Kovacs and I feel that change is exactly the right choice in this case. Cloud-based medical data exchange represents a boon to patient care because a patient’s imaging files, reports, and other crucial medical data from multiple previous providers can be sent to the current care provider whenever they are needed – in minutes, not days and with no hiccups in usability. Multiple consultants in geographically different locations can access this data from anywhere they require to provide input for a patient’s care.

These services also represent the efficiency gains that advocates such as the Bush and Obama administrations have been promising for healthcare IT in general. Unlike other forms of IT such as EHRs, some of the cloud-based services require no new capital purchases. That is, an institution does not have to purchase hardware or software. They simply have to pay a metered fee, as they do for electricity and water.

Besides eMix, current cloud-based services include lifeIMAGE and SeeMyRadiology, among a number of others. I cannot speak to the relative merits of each. But I can say that it’s nice to begin seeing the era of CD-burning and VPNs in our rear-view mirror.

Michael Trambert, MD. is the lead radiologist for PACS reengineering for the Cottage Health System and Sansum Clinic in Santa Barbara, CA.

ACHE Impressions
By Darkened Room Observer

After attending my third straight American College of Healthcare Executives’ Congress on Administration in Chicago, I’ve come away with the realization that there is a large vacuum of leadership within our industry.

I have attended the majority of sessions in the healthcare information technology “mastery series.” Each year, executive after executive talks about their success in implementing healthcare IT projects. When the question is asked, “To what do you attribute your success?“ the response is usually, “Well, I’m not really altogether sure.”

The lack of leadership this year was clearly evident a session in which a CEO got up in front of a group of about 200 people and said they decided that they did not want to go down the road of modifying a solution so, “We contracted with a vendor that didn’t allow customization to their product.”

Another CEO boasted that they chose a vendor who required them to hire a certain amount of people with specific talents and skills. The vendor would give the customer a rebate if they met specific milestones.

In another session, the CEO and CIO expounded on how well they were doing, based on the vendor’s established criteria and reporting mechanism.

With both financial and political pressures being applied to the healthcare marketplace at unprecedented levels, leadership to ensure that we are not simply doing things right, but are doing the right things is imperative. Yet we seem to have leadership that is so focused on ensuring that everyone is “happy” that they relegate true leadership, vision, and goal setting to their vendor. Although none of the presenters were allowed to disclose their vendor, it was clear to me that these entities were going to have epic changes to their businesses.

It appears that it may not be the actual technology a vendor brings to the table since the company in question deploys relatively arcane language, hardware technology, and definitely not state-of-the-art functionality by today’s standards. It has much more to do with a their philosophy of leadership by contract that appeals to this crop of hospital executives who lack the intestinal fortitude to ensure that their clinical staff change how they practice medicine as a result of implementing this new tool.

Can you imagine if the people marketing laparoscopic technology were required to modify their products to allow physicians to continue doing business as usual? Yet most vendors, in an effort to sell more in the short run, allow their clients to dictate modifications, enhancements, or wholesale scope changes in their contracts to “keep” clients.

Eventually these vendors suffer from trying to support 300 clients with extremely customized applications, setting the vendors up for failure. Like parenting or growing a good business, strong leadership and discipline are essential for truly happy children. Appeasing clients (like a child) only creates spoiled children.

Every time I turned around, it seemed that the only people exposing the truth were either from outside healthcare or were retired and finally saying what they couldn’t say while still needing a job.

Why Mobile Device Strategies are Missing the Point of the iPad
By Jared Sinclair RN

A friend of mine who has been a bedside nurse for many years has to lock herself in her bathroom whenever she surfs the web so that her elderly mother won’t complain about her wasting time with her laptop. My friend’s mother lived most of her adult life on another continent and without access to a computer. To her, a laptop is just another household object. She observes her daughter using the laptop as if she was mindlessly staring at a hunk of plastic and metal, while in fact, my friend is doing all kinds of things: researching, reading the news, paying bills, etc. The intangible nature of software is missed by her mother, who sees only the physical qualities of the machine itself.

Some of us in the healthcare tech industry have been making a similar mistake by thinking of mobile devices like the iPad as defined by their physical form. The form factor of a mobile device — the lack of a keyboard or a mouse — is what makes a mobile device portable, but portability is not its defining characteristic. A touch interface is what make a mobile device unique. This may seem obvious, but it deserves thoughtful consideration.

For many years, the PC industry itself also misunderstood this fact. While the iPad is far and away the most successful tablet, it is not the first tablet. PC manufacturers have been making tablets for years. Their products were never widely successful. Their approach was, in essence, to remove the keyboard and trackpad from a laptop and call it a tablet.

Because PC manufacturers didn’t write their own operating systems, they had no choice but to ship these tablets with Microsoft Windows. This operating system was not optimized for touch screens, which meant that the hardware had to conform to the limitations of the software and not vice versa. In other words, they had to require the use of a stylus. Smart managers would never have released these products on the market. The mistake of the PC manufacturers was in thinking that the defining quality of a tablet is its form factor.

The defining quality of a tablet is touch.

The iPad does not ship with the same operating system that ships with Apple’s desktops and laptops. It never will. IOS, the operating system that Apple created to run the iPad and the iPhone, was designed from the ground up for a multitouch experience. Other mobile operating systems, like Android and Microsoft’s Metro, have followed suit.

Without a mouse and a mouse cursor, many of the conventions that we take for granted when using traditional desktop or laptop operating systems vanish. Touch-based operating systems have no concept for right clicking, or for hovering the cursor. Because the tip of the human finger is much less accurate than the tiny one-pixel tip of a mouse cursor, on-screen buttons need to be much larger. Because touchscreens tend to be much smaller than desktop or laptop screens, care must be taken to maximize efficient use of screen real estate.

One of the main reasons for the iPad’s success compared to previous tablets is that it uses its constraints as advantages to be enhanced, rather than limitations to be overcome with a stylus. Gestures allow users to swipe, pinch, rotate, and flick through apps. User-interface designers create novel ways for people to interact with their apps based upon these gestures. Angry Birds, an app that everyone by now has enjoyed (or at least endured the sound of it being played), is much more fun on a touchscreen than on a PC.

It’s frustrating to read about hospitals so anxious to use the iPad in a clinical setting that, rather than waiting for a native app to be developed, they deliver a desktop EMR interface via a virtual client like the Citrix app. The experience is always dismal. This is not the fault of the EMR vendors. Their software was designed for a mouse and keyboard. It’s not surprising to hear physicians report that on-screen buttons are too small, or that it becomes tedious to constantly pinch and zoom in and out of a virtual image of a desktop EMR interface.

Healthcare IT leaders need to understand that a mobile device like an iPad is not defined by its hardware alone. Sports fans don’t buy high-definition televisions because they are rectangular. They buy them so that they can enjoy watching games with a clarity that they could not experience with any other kind of TV. For the same reason, consumers buy the iPad because it allows them to use a computer in ways that they could not use a computer before.

"Going mobile" is not a strategy. Any HIT mobile device plan that does not include touch-optimized native apps as part of its mission is doomed to failure or mediocrity. Sheer portability alone is not enough. Rather than cramming software paradigms designed for desktop computers into these brand new devices, we should be using the mobile device revolution as an opportunity to re-think the way we interact with our EMRs.

By the way, this article was dictated on an iPad. In a few years, we will probably all be talking about voice interaction the way I’m talking about touch today.

Jared Sinclair is a registered nurse and an iPhone and iPad developer. He’s the founder of Splint, a startup focused on developing mobile apps for bedside nurses. He is also the creator of Pillboxie, a fun medication reminder for iPhone and iPad. He lives in Nashville, TN.

Readers Write 3/26/12

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

If You Did It, Enter It in the EHR
By Mitch McClellan

I was recently asked the following by a colleague:

We know that every organization has some physicians who just will not fully use the EHR. They will have nurses, MAs, and other clinical staff do all of the data entry. They may just hand the staff a piece of paper and have them enter the problem list. A specific example would be the MU requirement for weight counseling – do you think it is acceptable for an MA to indicate in the record that the physician did the weight counseling? Clearly it makes sense to have nurses and other clinical staff enter medications and even other orders and even start notes, but where do you draw the line?

This question certainly walks the line between facilitating accurate data entry vs.what is appropriate.

If an organization is truly going to embrace this much-needed change in healthcare, they need to enforce that their clinicians do the right thing. In this case, it would be physicians taking 100% ownership of entering the documentation specific to weight counseling. They are the ones actually provided the counseling.

I understand that is a black-and-white response, but I strongly believe that if an organization’s culture accommodates physicians who choose not to do their complete EHR responsibilities (e.g. not documenting the counseling that YOU provided), then it defeats the entire purpose of what we’re doing.

The EHR revolution is strongly driven by the fact that paper is not efficient and creates too many points of failure. Not only is the medium (paper) antiquated, so are many of the policies and processes that support those paper workflows (e.g. documenting a note that you then pass on to someone else to then "document a note" on your behalf).

Unfortunately, I believe most physicians are put into a "get it done now vs. a get it done right" scenario due to the payers’ stringent reimbursement policies. I completely understand the time demands on these physicians. But the rule I try to instill with all of my groups is that, "if you did it, then you must enter it in the HER." Otherwise, the effectiveness and efficiencies of an EHR are lost if the old way of doing things is still embraced.

The groups that I’ve worked with would require the physician enter that piece of documentation themselves instead of the MA. The only groups that I’ve worked with that would allow this scenario to happen would be if it was the physician’s nurse — not an MA –entering the documentation. To me, the issue is twofold. The first is workflow (reasons already stated), the second is the lack of credentials of an MA. I know I’d want a higher-credentialed healthcare provider entering that information if it’s not the physician themselves.

Mitch McClellan is manager of implementations at MBA HealthGroup of South Burlington, VT.

Optimization
By Dave Vreeland

Cumberland brought together a select group of HIT executives from some of the nation’s leading health systems for a recent breakfast discussion The topic: optimization.

Now that many are on track for Stage 1 Meaningful Use and other compliance deadlines, the focus is beginning to shift beyond go-live toward getting the most out of HIT systems. The panel, made up of Cumberland’s Brian Junghans, HCA’s Dr. Divya Shroff, and Memorial Healthcare System’s Jeff Sturman, shared how non-profit Memorial and industry giant HCA are tackling optimization.

The takeaway: success largely hinges on solid communication and the collaboration of two very different worlds – IT and clinical. Clinicians are arguably the keystone in achieving effective system adoption and long-term optimization.

Junghans points out that IT folks tend to think in terms of projects, which have a defined beginning and end. When it comes to IT implementation projects, the end is go-live. In contrast, optimization is an ongoing effort.

Dr. Shroff points out that clinicians have more of an optimization mindset, with a continuous focus on improved quality of care, optimal patient outcomes, and best practices.

With techies and clinicians in different mindsets, speaking two different languages, communication issues are common. HCA has success placing physicians and other clinical professionals like Dr. Shroff in clinical transformation roles. Valuable insight and hands-on experience makes these clinicians effective ambassadors for both the IT and clinical teams. 

Sturman and the Memorial team have incorporated clinical aspects into their approach to optimization. The team makes regularly scheduled rounds to observe workflow, system usage patterns and identify opportunities for improvement throughout each of their six hospitals, clinics, and ambulatory practices.

The importance of a clear distinction between IT support and optimization teams was also stressed. HCA trains the IT support team to triage incoming calls, address specific break/fix issues, and refer optimization matters to the optimization team.

Both organizations have seen success with various efforts to improve clinical/IT relations and are on track with current and long-term efforts toward optimization.

In addition to a number of lessons learned and critical success factors to consider during and after the implementation process (summarized in our presentation Beyond Go-Live: Achieving HIT System Optimization), it was interesting to hear this room of executives from diverse organizations, representing both the clinical and IT fields, reinforce the significant impact collaboration between the two worlds has on the success of end-user adoption and achieving true optimization.  

Dave Vreeland is partner with Cumberland Consulting Group of Franklin, TN.

Stage 2: The Vendor View
By Frank Poggio

On March 7, 2012, a draft for comment on the new Stage 2 rules was published in the Federal Register. Actually there were two separate parts to the rules. They are:

1. The CMS part that is aimed at provider requirements necessary to meet Meaningful Use, and
2. The ONC piece that addressed proposed changes to the certification process for EHR vendors.

On the provider side, there are innumerable blogs and Web sites that are covering the provider issues, which deal mostly with a few added MU criteria such as electronic medication administration records, menu options in Stage 1 that are now mandatory in Stage 2, greater emphasis on exchanging patent care information across care levels, and greater patient access to care information.

This article will focus on the “second side” of the regulations — the elements that most impact the system suppliers, with emphasis on the impact to niche or best-of-breed (BoB) vendors.

The full text of the new ONC Certification proposed rules can be found at here.

Before we hit the high (and low) points of the rules keep in mind these are proposed rules. If there is anything you don’t like about them, have suggestions for improvements, etc. you have from now until June 7 to post comments on the federal Web site. Speak now or forever hold your price! (No that is not a typo … see the Ugly).

Here’s the Good, the Bad, and the Ugly of proposed certification changes for vendors.

The good news:

Privacy and Security — will it go away?

EHR Module certification gets a little easier for niche and best-of-breed vendors (BoB). The big change here is that Module certification no longer requires you to address any of the privacy and security criteria. In the past, there were eight P&S criteria (number nine was always optional), and in our working through many ATCB tests, if you said the right phrase, you could get a waiver on three others (Integrity, General Encryption, and HIE.) Proposed under the Stage 2 as a niche/BoB vendor, you can ignore all the P&S criteria. To get certified under Stage 2, it would seem all you will need to do is pass any one Inpatient, Ambulatory, or General criteria, just ignore the P&S criteria, and you’re home free.

ONC said they made this change because many of the smaller firms complained that the P&S criteria did not apply or were too burdensome. This may sound too good to be true. Maybe it is. Read what ONC says in other parts of the document:

Finally, we propose to require that test results used for the certification of EHR technology be available to the public in an effort to increase transparency around the certification process. We believe that there will be market pressures to have certified Complete EHRs and certified EHR Modules ready and available prior to when EPs, EHs, and CAHs must meet the proposed revised definition of CEHRT for FY/CY 2014. We assume this factor will cause a greater number of developers to prepare EHR technology for testing and certification towards the end of 2012 and throughout 2013, rather than in 2014.

This is classic ONC. They say you don’t have to get certified. There is no law that says any vendor MUST – even a full EMR vendor. They believe the market will tell you. And by the way, ONC will be publishing the details of your certification so the world can compare you against your peers.

As we tell our clients, the MU criteria you choose to test on is dictated more by your competition and clients, not by the ONC.

Gap certification for Stage 2

A question that we have heard frequently was if I was certified on 20 criteria for Stage 1, under Stage 2, would I have to be tested again for those same criteria? Under the proposed Stage 2 rules, you would not need to get re-certified on Stage 1 criteria. You will only have to be tested on new criteria you select, and tested on Stage1 criteria that has changed or been revised by ONC.

A good example is the encryption P&S test. The focus now will be on encryption for data at rest. They state:

EHR technology presented for certification must be able to encrypt the electronic health information that remains on end user devices. And, to comply with paragraph (d)(7)(i), this capability must be enabled (i.e., turned on) by default and only be permitted to be disabled (and re-enabled) by a limited set of identified users.

So if you tested out on encryption under Stage 1 and want to carry it forward into Stage 2, you’ll probably have to show how you default encryption for user devices.

Component EHR vs. Complete EHR

A typical misunderstanding we came across many times during past year taking our clients through the certification process was a CIO at a hospital would say to the vendor that he/she believed they had to install a full EMR from a single vendor to meet all the MU criteria. In the proposed regulations, ONC has clearly addressed this question. On page 104, they say:

Certified EHR technology means: 1. For any Federal fiscal year (FY) or calendar year (CY) up to and including 2013: i. A Complete EHR that meets the requirements included in the definition of a Qualified EHR and has been tested and certified in accordance with the certification program established by the National Coordinator as having met all applicable certification criteria adopted by the Secretary for the 2011 Edition EHR certification criteria or the equivalent 2014 Edition EHR certification criteria; or ii. A combination of EHR Modules in which each constituent EHR Module of the combination has been tested and certified in accordance with the certification program established by the National Coordinator as having met all applicable certification criteria adopted by the Secretary for the 2011 Edition HER certification criteria or the equivalent 2014 Edition EHR certification criteria, and the resultant combination also meets the requirements included in the definition of a Qualified EHR.

In effect, a provider could meet the MU criteria using as many suites of BoB systems as they believe necessary. They do not have to be from one or the same vendor.

Now some bad news:

Criteria components

Many BoBs struggled with the make up of the criteria for Vitals and Demographics and several other clinical criteria. On the surface, they seemed easy to pass. The problem was they contained some data elements that were not typically found in BoB systems. For vitals, the hurdle was growth charts. For demographics, the hurdle is date and time of death. To pass these criteria, some vendors would use user-defined fields or create new inputs that they knew their clients would never use. Repeatedly I was asked by niche and BoB clients, “Why would you ask a patient during a registration process, ‘When did you die?’” Now there’s a comforting dialog!

Keep in mind several or the participants in building the HITECH/MU program were academics and researchers who would find that piece of information critical to their retrospective medical data analyses. Also, vendors of full EMR systems would easily have that piece of data readily available in their medical record abstract system. But for an ancillary or niche vendor, not likely. As far as I know, there were no niche or BoB vendors represented on any of the HITECH Policy or Standard Committees.

You may wonder why any firm would go through the trouble of adding a useless data element. Again, keep in mind what ONC said above: market will require certification. It can be virtually impossible to sell an ancillary system such as surgery, ICU monitoring, therapy, anesthesia, etc. if you had to tell your prospect your product was not certified for vitals.

Unfortunately this issue is still there for BoBs. The big change is on the provider side. ONC has greatly liberalized the granting of exceptions to providers for MU attestation if the MU criteria (or element of the criteria) do not apply to their practice of facility. As an example, a psychiatrist does not have to do growth charts for his patients — an exemption will be readily available. But the vendor who sold him the system still must!

Continuing this topic, in a recent interview Dr. Mostashari chided EHR vendors who "aren’t making meaningful use of Meaningful Use." Instead of attempting to seamlessly incorporate MU standards into their interfaces, Mostashari said "vendors did what vendors do—they slammed in the criteria and got certified.”

I submit that ONC slammed these regulations into being as fast as they could due to Congressional and Executive pressure, so one good slam deserves another. Maybe if ONC took a moment to look at the impact of certification on niche and BoBs — which are mostly the smaller, more innovative developers — and adjusted the criteria, we all could stop slamming.

And now the ugly:

As I mentioned in an earlier HIStalk post, ONC wants comments on vendor product price transparency. Here’s the ONC statement:

During implementation of the temporary certification program, we have received feedback from stakeholders that some EHR technology developers do not provide clear price transparency related to the full cost of a certified Complete EHR or certified EHR Module. Instead, some EHR technology developers identify prices for multiple groupings of capabilities even though the groupings do not correlate to the capabilities of the entire certified Complete EHR or certified EHR Module. Thus, with the transparency already required by §170.523(k)(3) in mind, we believe that the EHR technology market could benefit from transparency related to the price associated with a certified Complete EHR or certified EHR Module. We believe price transparency could be achieved through a requirement that ONC ACBs ensure that EHR technology developers include clear pricing of the full cost of their certified Complete EHR and/or certified EHR Module on their websites and in all marketing materials, communications, statements, and other assertions related to a Complete EHR’s or EHR Module’s certification. Put simply, this provision would require EHR technology developers to disclose only the full cost of a certified Complete EHR or certified EHR Module.

As a former CFO, I know that the through definition of ‘full cost’ would take at least another 500 pages in the Federal Register. After the vendors in the audience come down off the ceiling, you’d probably like to share your reaction with ONC. Just click here.

Frank L. Poggio is president of The Kelzon Group.

Readers Write 3/19/12

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Sampling the Legislative Sausage
By Civics 101

Be careful reading the proposed Meaningful Use regulations. Note the “proposed” part. As a Notice of Proposed Rulemaking, it’s unwise to ignore any part of the document.

Every word in the document – even in the preamble — has survived numerous rounds of federal vetting. Every section is important, but especially so are those areas in which public comment is invited. Objectives may be added or removed, so don’t get hung up on those to the exclusion of the preamble or the overall intention.This is not a set of business requirements that is ready to be handed off to programmers to implement.

Read the NPRM as a big picture, keep an open mind, and try to understand the intention, not just the tentative objective list. And above all, don’t forget that while Stage 1 is locked in place, Stage 2 isn’t. My organization and yours need to study the NPRM carefully and comment on what we like or don’t like about what’s been placed before us. Remember all the changes that were incorporated between the Stage 1 NPRM and the final version? Every one of those came as a result of public feedback.

Using the iPad in Surgery
By Michael B. Peterson, MD

I use the iPad every day while rounding at work and connected to the encrypted hospital wireless network, finding web information for patients and showing educational videos. I use a Bluetooth keyboard and sometimes a stylus that fit into a netbook soft case when I need to do heavy typing.

We were doing a complicated vascular surgery, an axillary femoral femoral bypass. I had dissected out the blood vessels on the right groin, but the surgeon working on the left could not locate the critical arteries and branches. The patient did not have any pulses in the groins because of severe vascular disease.

I had the nurse drop the iPad into a sterile sleeve and seal it. I used it to pull up the CT scans on the table and paged to the proper level so we could compare the right to the left. Then we knew where to go. We could place the iPad right on top of the patient and visualize what we needed.

Then while my colleague and our PA completed the left side, I checked my Lotus Notes e-mail, went into the vascular econsult program and triaged some vascular consults to the appropriate clinics, and checked my inbasket in our Epic EMR to read labs and answer messages (the iPad runs Epic very well.) When I was done, we were ready for the rest of the surgery.  

The x-ray viewing is an innovative project on which we are partnering with with Thinking Systems.

We are using the latest Citrix Receiver to host our version of Epic on the iPad and other devices as well. Since the rollout of Epic Summer ’09 across the country in all Kaisers, the old web address we used for Spring ’06 access no longer works for the iPad. In addition, there are additional video requirements for Summer ’09 that our current web servers need that the Citrix receiver cannot handle. Attempting access to the Summer ’09 environment will result in a connection failure with a “USKIN” error message.

Fortunately our Kaiser web engineers were aware of this and understood the need for iPad functionality. They created special web addresses for Kaiser iPad users in Northern and Southern California, Hawaii, and Pacific Northwest. The official term is PNAgent Site. Setting it up is complicated, but the iPad works very well.  

Of course there are ergonomic challenges with a smaller screen, and accurate tapping is critical. But it is so fast and convenient — you don’t have to wander around looking for an unoccupied keyboard and computer. If I need to look up something, I just do it where I am. It has really spoiled me.

I don’t know if there is any way to demonstrate improved outcomes with the iPad. Kaiser is starting to roll it out to other medical centers with different specialties. My general feeling is that with the EMR, there is a 20% productivity hit with data entry and typing your note. It does take longer on the generic computer, but the the iPad is so much faster and it literally puts the medical record at your fingertips… or perhaps the patient’s.  

I plop the iPad down in front of the patient and point out pictures, diagrams, and a quick graphic plot of their rising creatinine. I run the lymphedema pump movie to show them how it works, or review the online video again to remind me or others how that endovascular closure device works again before I actually do it.  

I have invested the time it took to get comfortable with the iPad and arrange it the way I want. I could not do without it. I have very little specialized software on the iPad except for the VPN and the Citrix Receiver. And my medical apps, books, and games!

Michael B. Peterson MD is a surgeon with The Permanente Medical Group in Hayward, CA. His use of the iPad in the operating room was featured in the April 2012 edition of Macworld. Since Mike is an old friend of HIStalk, I asked him for more detailed information, which he provided above.

What Do You Do Regardless? Five ICD-10 Steps To Continue
By Torrey Barnhouse

The AMA lobby is strong. US government program delays are common. The two came together on February 16, 2012 when Health and Human Services Secretary Kathleen Sebelius announced a potential delay in the October 1, 2013 deadline for ICD-10 implementation.

The announcement, made just before the start of the HIMSS12 Annual Conference, left a lot of attendees scratching their heads and asking themselves, “Now what?” Most agreed a delay of one year or less gives everyone more time to prepare, train, and test. However, a delay of greater than one year spells chaos for healthcare providers and payers.

While at HIMSS, TrustHCS had the honor of sponsoring an executive roundtable on ICD-10. During the roundtable, speakers discussed five ICD-10 projects that should continue full steam ahead despite the delay. It’s a good list and worth sharing.

In general, the panel’s advice was to identify ICD-10 tasks that have collateral benefit for ICD-9 coding. These are the tasks that should be continued until such time as HHS makes another announcement regarding their plans, intentions, and deadlines.

Vendor and Payer Assessments

Continue checking with vendors and payers to see when systems will be ready for testing. Know what the ICD-10 upgrade will cost your organization, if anything. If your vendor simply can’t accommodate, start evaluating new systems to replace them. Conduct ICD-10 testing with your payers whenever and wherever possible to help reduce backlogs and denials upon go live.

Clinical Documentation Improvement

Any improvement in clinical documentation specificity and granularity will help support better, higher quality coding and reduce time wasted querying physicians. Coders can only code what is documented. This same core principle applies in ICD-10. CDI programs must be continued regardless of a delay.

Coder Biomedical Training

While educating coders in the finer nuances of ICD-10 coding can be postponed, strengthening their knowledge of the basics can’t. Many coders graduated from programs 10, 15, or 20 years ago. Medical science and our knowledge of anatomy, physiology, and disease processes has grown exponentially. Now’s the time to make sure your coders are brilliant at the basics. Anatomy and physiology training should continue to be conducted: online through a service provider or at a local community college.

Computer Assisted Coding (CAC) Technology

Coder productivity is predicted to drop by 50% during the implementation of ICD-10 and perhaps remain 10-20% below normal output for ICD-9 coding. CAC systems help offset this productivity loss by electronically “reading” the record and suggesting codes to the human coder. While CAC systems don’t replace coders, they do make them more productive and efficient. The delay provides more time for organizations to evaluate and implement this technology.

Assess and Refine Your Work Plan

Conduct a methodical step-by-step review of your initial plan. This process will identify which tasks can be pushed out and which cannot. The review will also uncover other tasks that have collateral benefit for ICD-9. For each task in your work plan, ask yourself, “Does the delay impact this task?”

Industry experts are already predicting the cost of an ICD-10 delay. Other experts are predicting lawsuits by providers to help recoup monies already spent. This expert simply suggests that you stay the course and keep working toward ICD-10 preparedness. We will all have to get there eventually. Better to be early than late on this one!

Torrey Barnhouse is CEO of TrustHCS of Springfield, MO.

Viva la CPOE!
By Daniela Mahoney

According to the HIMSS Analytics EMR Adoption Model , CPOE adoption remains steady at a rate of 13.2% for the past two quarters. And in recent months, many hospitals achieved the first stage of Meaningful Use. Congratulations to all!

However, looking at the story behind CPOE implementations reveals that adoption struggles continue —regardless of the vendor system. Many community hospitals expend great effort and many dollars meeting Meaningful Use criteria, but additional time and money is also spent avoiding a full-blown revolution within their provider community because of CPOE implementation.

Technology is really only 15-20% of a CPOE implementation. Process, acceptance, culture, and constant transformation are the parts that truly define the difference between CPOE failure and success.

At the end of the day, technology’s golden purpose is to support the infrastructure: devices, performance, remote access, integration/interoperability, streamlined single-sign-on, and ease of navigation. But even when working flawlessly, it’s still an uphill battle capturing provider adoption on that much-needed “voluntary basis.”

I can always hear the physician protests, even when left unsaid: “Why should I use it?” “What is in it for me?” “Show me the money, Jerry.”

The question remains: why? Why won’t providers embrace new CPOE technologies and take advantage of the wonderful features, such as clinical decision support or evidence-based order sets that streamline the admission process?

Truthfully, there is nothing wrong with the providers’ feelings here. They simply know what’s at stake. And the odds are not in favor of CPOE, despite the benefits we may see through our own rose-colored glasses:  “Oh, how it benefits the patient! Why don’t you providers just snap out of it and embrace CPOE for the people, or at least for the children?”

Kidding aside, what a new CPOE system takes away from providers is TIME.

… at least for a while.

Time is a provider’s most precious commodity. A new system changes the way they work and takes time away from office hours and family. Time is irreplaceable and invaluable.

But the Meaningful Use mandates say “so what” and to just do it and accept it. CPOE is a reality and must be part of every provider’s future in the hospital or in the office. With that, I sympathize. Providers may have cause to rebel.

I spent some time researching literature while preparing this article, looking at provider efficiency with CPOE. Many studies are relatively old, done in the ‘90s or early 2000s. Not to dismiss their importance, but many issues experienced then have been since resolved with today’s systems. In retrospect, they really aren’t relevant.

But one thing overlooked then and now, to me, is the most important question: what is the right value proposition to the provider?

The answer? One that fits a provider’s community and meets their conditions to accept CPOE into their domain.

With 22 years invested helping providers through CPOE adoption , I found only one simple and effective system pitch. Be truthful and realistic. That’s what works. That’s what opens door and also ears.

For example, we can’t deny that it typically takes significant time to adopt and adjust to a new system, and that efficiency improves only with consistent use. Additionally, never overpromise that CPOE is faster than handwriting an order or checking boxes on a pre-printed order set. I can tell you, that approach doesn’t work.

Once providers are engaged, gather the value proposition’s building blocks by talking and listening to them –  eliciting their concerns, needs, and requirements — and also identify opportunities for compromise.

Usually during interview sessions, similar things are voiced. And believe it or not, it’s less about Meaningful Use (understanding the “benefit” of hospital reimbursement is typically demonstrated by only a few) and more about the direction of technologies in healthcare and reporting requirements and how it affects the way they practice medicine.

For example, for some it is important to have remote access, and not just to CPOE, but to also do other tasks, such as signing their charts. And from others, I often hear how they would prefer using their own laptops or iPads, so they do not need to compete for devices.

Here are some very telling interview quotes from providers about CPOE adoption:

• “Access from outside of the hospital, home access would be great.”
• “CPOE should be a resource for us. It should not make us work harder to accommodate it.”
• “Ease to use and quicker order entry is most important.”
• “Online view of medications administered would be a great value.”
• “Reduces errors and provides clarity of medical orders. There must be a safety net if errors are made, especially with residents. Incorrect orders need to be stopped.”
• “A quick-pick list for providers would be nice.”

In the end, the right value proposition delivers the commitment of the hospital’s leadership to respond to what providers say and need. It engages all providers and can convince them to fully adopt CPOE as part of their workflow—especially with respect to efficiency in daily operations.

Providers become very reasonable and willing to compromise if engaged and their voices heard. Realistically, you cannot fulfill every need, but it is still important to listen and respond. The hospital’s leadership must be proactive and have a solid communication plan to manage expectations at different levels before, during, and after implementation. The direction of CPOE within the organization must be clearly defined, from the adoption and training to the deployment strategy. Lastly, completing a cultural evaluation the provider community provides tremendous insight into defining the value proposition which is the foundation of your CPOE success.

Let them eat cake, because we’re having crepes …

Here is a simple but delicious nutella-banana crepe recipe enjoyed by our family. Bon appetit!

Daniela Mahoney, RN BSN is vice president of Beacon Partners of Weymouth, MA.

Readers Write 2/27/12

Why Device Connectivity Is Hot Now
By Dave Dyell

Tech-based solutions often enjoy a surge or hot period—a moment in the sun if you will. For those of us in the medical device integration (MDI) space, 2011 felt pretty sunny. For one thing, 2011 was the first year in which KLAS, an independent research organization that ranks health information technology vendors in key market segments, recognized MDI.

In an annual report titled Medical Device Integration 2012: Proven Connections, KLAS detailed the major MDI vendors and their individual strengths, as well as the overall benefit of MDI. For those of us who have worked in the MDI space for several years, recognition from KLAS represented a major milestone.

So why did KLAS add MDI to its list of relevant tech spaces in 2011? Why is the HIT spotlight on MDI now?

One reason is that MDI is a necessary component, or stepping stone, on the road toward achieving HIT initiatives such as Meaningful Use, health information exchange, ACOs, etc. In this way, the rise of MDI has been fueled to a certain extent by the passing of the HITECH Act in 2009.

But I believe that the real momentum behind MDI has another, slightly more organic explanation that is rooted in MDI’s payoff. The promises of MDI—improved clinical efficiency and quality—mirror the promises of other large, federally mandated initiatives. The difference with MDI, though, is that it is a much quicker win. The feedback loop with MDI is shorter than, say, the feedback loop with ACOs.

MDI automates the flow of data from devices directly into the hospital’s clinical information system (CIS) or electronic medical record. This automation (as opposed to handwritten transcriptions and keying) immediately improves clinician productivity as well as data accuracy and availably throughout the hospital.

The aforementioned KLAS report also notes this immediacy. When comparing the benefits of MDI to other HIT initiatives, the report states, “In a simple, more immediate way, some healthcare providers are quietly getting a bump in quality and efficiency through medical device integration systems.”

What does “bump” mean in this context? More than 65% of the study’s respondents reported that MDI saves time and provides the ability to make more informed decisions concerning patient care using the data that MDI makes available.

For the hospital trying to figure out which tech-based solutions to purchase, the KLAS report paints MDI as a solid investment with immediate and future payoffs—a synergy that those of us in this emerging industry have always stressed and will continue to. 

Dave Dyell is founder and CEO of iSirona of Panama City, FL.

Walking Through HIMSS
By Carlos Nunez, MD

Walking the aisles of the exhibit hall and participating in HIStalkapalooza at the world’s largest gathering of healthcare IT professionals and the companies that do business with them led to several interesting discoveries. 

All of the usual suspects were well represented in the exhibit hall (Epic, Cerner, GE, etc.), along with the expected collection of smaller IT vendors and specialty niche solutions (did you know that Rubbermaid makes hospital-grade computer carts?) And, of course, you found companies like IBM, Oracle, and Microsoft that also play in this space.

Coming in to the meeting, it was expected that ICD-10 would be a big topic of focus, but with the recently announced delay in the implementation requirement, that story seemed less relevant. There was also the announcement  that the Stage 2 requirements for Meaningful Use were ready to be published in the Federal Register, but likely wouldn’t be available until after HIMSS. The announcement was big news, but it came too late to have any discernible impact on the conference floor. Finally, the trend toward mobile devices and cloud-based solutions is still grabbing a great deal of attention and booth space.

The trend that was most interesting was the rise and growing prominence of companies exhibiting at HIMSS that – at first glance – may seem out of place. For example, I had a meeting with the folks from Lockheed Martin. Yes, the same Lockheed Martin that makes fighter planes and satellites also has a healthcare business and is now partnering with Johns Hopkins on a patient safety and quality initiative. One of the larger booths in the exhibit hall belonged to a collection of IT and benefits management businesses that were recently cobbled together by one of the major insurance companies. I guess it should come as no surprise that as the American healthcare system continues to grab more attention (and more dollars) than any other segment of the economy, businesses new and old would look for their place at the table.

This trend got me thinking about my own place at HIMSS, and more specifically, where CareFusion should be slotted in the spectrum of industry represented there. To the uninitiated, you might think that CareFusion belongs closer to the Rubbermaid end of the spectrum, especially if you only focus on the “things” that CareFusion makes. What do surgical instruments, infection prevention, or infusion pumps have to do with information technology? However, when you realize those “things” are key components in a portfolio of solutions, many of which are tied together by the very technology that defines HIMSS, you begin to see that CareFusion brings a unique perspective and vision to the HIT conversation.

What became vividly apparent this year at HIMSS is that Healthcare IT today, and the concept of Meaningful Use, is much more than an EMR. It is the information ecosystem that supports every patient encounter. It is the millions of clinical data points streaming from a ventilator or an infusion pump, into a server or into the cloud. It is a medication order entered in a CPOE system, tracked and secured through an automated pharmacy system, and the surveillance engine on a constant vigil for inappropriate medication dosing or signs of infection.  It is new technology designed to make devices and HIT systems talk to one another and provide critical patient data to caregivers when and where they need it, seamlessly across hospitals and systems.

Initiatives like Meaningful Use can sometimes make us forget that healthcare IT is more than just software or the systems we build to collect and store data; it’s how those systems enable us to convert data into useful information to help improve workflow, efficiency, and patient safety. As many providers begin to focus on Stage 2 Meaningful Use requirements, broader concepts like interoperability and standardization will emerge as critical objectives in achieving the desired end goal.

Or as ONC chief Farzad Mostashari, MD, asserted in his keynote speech at HIMSS, “We’re on the right track to make meaningful use of Meaningful Use.” What I saw and heard at HIMSS was a promising acknowledgement of our shared responsibility to improve healthcare. It’s a challenge that’s breaking down barriers between providers, suppliers, and companies of all industries and competencies working to make a contribution. I was proud to represent a company bringing so many meaningful solutions to the table.

Carlos Nunez MD is chief medical officer of CareFusion of San Diego, CA.

Readers Write 2/15/12

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

iPad Fatigue: Choose Your Mobile Strategy Wisely
By Chris Joyce

I get the attraction of the iPad … your own personal device that’s sexy and lean, as opposed to the standard-issue, Windows XP desktop locked down by your hospital’s IT group or the clunky computer on wheels. The simple UI and the glossy new apps let you shed the pain of those legacy systems and, most important, you get mobility.

Given the glacial pace of innovation in healthcare, who can fault people for wanting to use these beautiful devices? We are all trying to create a sea change in healthcare IT, much like the iPhone did for telecommunications. But I’m going to say something that’s wildly unpopular: the iPad is not well suited for healthcare in its current state.

I’ve been working in tablet-based mobility for seven years (yes, there were tablets before the iPad). We’ve studied clinician data collection workflow in registration, the ED, home health, cardiology, radiology, orthopedics, and clinical trials. Trust that my opinions are carefully thought out from experience.

I will concede that the Windows-based tablet manufacturers deserved to be smacked around by Apple for their lack of vision and slow progress. Years ago, I, along with my customer (one of the largest health systems in California that had been using tablets in cardiology for years) sat down with the folks at Intel and Motion Computing to tell them that the C5 was too complicated and expensive. I shared what we needed in the ideal tablet: a bright, 12” screen with stylus support that’s ideal for documents, 8-10 hours of battery life, no external ports or other gadgets, and a sub-$1,000 price tag. Our request fell on deaf ears as they paraded out the next incremental chip set improvement in their roadmap.

When the iPad hit the market, we thought we’d finally gotten our ideal tablet. The price was right, the screen was bright, the battery life was unbelievable, it ran coolly and didn’t burn your arms, it booted in seconds, and the 1.5 pound. form factor (half the current tablets) was simple and elegant. Finally, we had the perfect complement to our mobile forms software. This wasn’t just a Windows laptop with the keyboard chopped off – it was an appliance, a tablet.

But it also has some major shortcomings that our customers are now discovering:

10” display
This is subtle because I like the more portable size, but those standard consents, ABNs and Medicare forms you’ve used for years don’t fit on a 10” display without disrupting the layout. Your app has to be “touch-aware” or you’ll interact with the screen when you rest your hand to sign or add a note. Our customers are counting clicks and don’t like the iPad because they have to scroll to use the forms that once fit on their 12” Windows tablets.

No stylus
This makes capturing signatures, annotations on diagrams, and unstructured notes impossible unless you buy a third-party stylus like Pogo. But that’s like writing with a crayon and there is no place to dock your pen. Are your patients going to be comfortable signing an informed consent with their fingers?

No handwriting recognition
The soft keyboard isn’t practical for a lot of data entry because you are still holding the tablet with one hand and pecking out everything with the other. And bouncing back and forth between numeric and alpha characters drives users absolutely mad. Handwriting recognition has its place in documentation, just like voice dictation, and it can be as fast as paper. There is nothing fast about the iPad’s soft keyboard when at the bedside.

Proprietary operating system and deployment isn’t enterprise-friendly
Obviously Apple wasn’t concerned with compatibility with “legacy” apps like Meditech or MS4, but in healthcare, that eliminates about 90% of current systems. Most hospitals have compromised for “runs on iPad” versus “optimized for iPad” using Citrix or a Web interface.

That leaves the end user with an underwhelming experience. Citrix apps don’t get the intimate integration with the display, touch, or the camera for image annotation. Not many vendors were prepared to rewrite their clinical systems in iOS or HTML5. The HTML5 standard hasn’t been published yet and isn’t consistently supported by all browsers (although it is the future). I know of several major healthcare systems that are still standardized on Internet Explorer 7, so I don’t anticipate adoption of HTML5 to be as high in healthcare as Apple would like you to believe. Again, we (healthcare) are not that nimble.

Lack of rugged form factor
Eventually your iPad will come into contact with fluids or the floor and you’ll realize it’s a consumer-grade device. These devices are often in a hostile environment, very unlike the environment in most iPad commercials.

The hype of hardware
One of our best mobile forms customers is a major health system in the Northeast. They gave each clinician an iPad, only to discover that they took them home to watch Netflix versus using them on their rounds. Hardware alone isn’t the answer. You also need software that’s mobile aware.

When you’re developing your mobile strategy, keep this in mind. The iPad is a beautiful device with multiple applications (just not healthcare data collection). It isn’t going to transform your hospital systems’ user experience. But don’t compromise – there are other options to consider. Look for vendors that can fill the gaps in your EMR with mobility solutions optimized for the right tablet for your environment (iPad, Android and/or Windows) and that upgrade your user experience/productivity.

Chris Joyce is director of healthcare solutions engineering for Bottomline Technologies of Portsmouth, NH.

If you have achieved Stage 1 Meaningful Use requirements or are planning to attest in the future, you are likely aware of the required core measure for implementing and tracking at least one clinical decision support (CDS) rule. The goal of this measure — along with maintaining active problem and medication lists and recording vitals and smoking status — is to improve the quality, safety, and efficiency of patient care.

So what exactly is CDS and why is it important? 

In simple terms, CDS gives physicians the clinical information they need for decision-making tasks. For example, during a patient exam, CDS tools can provide prompting to help a doctor determine a diagnosis or select an appropriate treatment plan. Alternatively, a provider may use CDS technology to improve documentation or identify billing codes or determine the most relevant data to forward to a specialist.

CDS technologies are particularly powerful when the engine is mapped to a wide variety of medical concepts and diverse reference and billing terminologies, such as LOINC, RxNorm, SNOMET CT, ICD, and CPT. CDS tools are more robust the wider the engine’s mapping. Strong CDS engines have the ability to identify and interpret patient information from multiple sources, whether the data comes in the form of lab and test results, previous therapies, or patient histories.

It’s important to keep in mind that CDS tools don’t make the actual clinical decisions for a physician, but support a physician’s own decision-making by sifting through existing data and presenting the most relevant information. As more clinical information becomes available online from EHRs and health information exchanges (HIEs), providers will rely more heavily on CDS technologies to identify the most pertinent information for a given situation.

Many commercial EHRs and HIEs have embedded CDS tools to help providers wade through vast amounts of clinical data. CDS technologies work behind the scenes to identify the most clinically relevant information within a practice’s EMR or from a connected reference lab or from HIE records. Search engines consider additional relevant details amongst on thousands of clinical scenarios and then interpret the cumulative data. Physicians are then presented with pertinent information at the point of care and offered details to aid with diagnosis and treatment plans, as well as critical data needed for compliance and reimbursement.

Though Stage 2 Meaningful Use is not finalized, look for the ONC to add additional CDS objectives in the core measures.

Dave Lareau is chief operating officer of Medicomp Systems of Chantilly, VA.

Super-Sized Productivity Gains from Computer-Assisted Coding?
By Akhila Skiftenes

The required migration from the ICD-9 to ICD-10 has significantly increased the demand for computer-assisted coding (CAC), moving beyond its early beginnings in outpatient specialty areas. The potential benefits from using this technology to make the transition to ICD-10 can be very compelling –improved coding productivity, accuracy, consistency, transparency, and compliance.

Yet CAC products require a substantial investment, and implementing one does not a guarantee that these benefits will be realized. Therefore, it is essential for an organization to complete a thorough analysis before investing in a CAC product.

Exceptional productivity gains have been reported by vendors. However, these are based on a number of assumptions and the specific circumstances for the organizations using the system. The following are key considerations when estimating CAC benefits for your organization.

First, estimates are often based on outpatient implementation data. As more and more hospitals move toward using a CAC in their inpatient areas as well, these productivity estimates need to be adjusted accordingly. Inpatient stays are longer and have more variability, making accurate CAC translations much more complex. Vendor products have made great strides toward accurate inpatient coding, but it takes more computing power and more time, so productivity gains will be lower.

Second, CAC works best when the documentation inputs are standardized. There are four standard formats for documentation: consultation note, history and physical, operative note, and diagnostic imaging report. The more variability in documentation formats for your organization, the longer the CAC process will take and the lower the translation accuracy.

Standard medical terminology used by the electronic medical record system also impacts the effectiveness of CAC. Many EMR systems use ICD-9 verbiage rather than SNOMED-CT for physician documentation. In these situations, the CAC application will translate to a lower level of accuracy since SNOMED-CT has a more modern standard for medical terminology and greater levels of specificity.

Finally, there is a general belief built into benefits estimate that optimizing the CAC process is ongoing. Once CAC is implemented, it is vital for the Health Information Management (HIM) department to audit the output and identify any issues with the software’s documentation interpretation. A critical success factor is the working relationship between HIM and IT, with resources assigned on both sides for continued optimization.

When making a decision about CAC implementation and ongoing support, organizations need to incorporate all of these assumptions into the estimate of how much productivity can truly be realized.

Akhila Skiftenes is an associate consultant with Aspen Advisors of Denver, CO.

Virtual Patient Simulation: Strengthening Medical Decisions, Strengthening Outcomes
By James B. McGee, MD

Provide better patient care with fewer resources. Essentially, that is what healthcare reform is asking us all to do. Most providers agree that the only way to maintain the quality of patient care and decrease overall cost is to reduce errors, prevent duplicate or unnecessary tests, and discover more effective yet less expensive approaches to care.

As I see it, that is the simple reality we all have to work within. The real question is: what does it mean from a practical standpoint?

It means that the modern delivery of medical care is far more structured, more measured, and more reported on than I—or anyone—ever could have imagined. Even the most recently educated providers now have to learn new skills and processes in order to respond to federal and third-party payer demands. An entire generation of practicing physicians and physician extenders is being asked to change practice habits, yet still engage in complex decision making.

It is a tall order. However, virtual patients (VPs) offer a way to provide examples and feedback that can help train providers to work within the new constraints. Think about it: clinical decision making is a skill. Like any other skill, it needs to be practiced, refined, and updated regularly. Simulation in general offers a safe environment to assess specific skills and receive personalized, dynamic feedback. VPs can simulate a wide range of clinical decision-making scenarios without requiring dedicated space and time the way physical simulators do.

Simulators such as mannequins are a familiar way to practice clinical skills. VPs are a relatively new development best described as interactive web-based simulations used to develop, enhance and assess clinical decision-making for all types of learners (physicians, physician extenders, nurses, students, etc.). Branched narrative style VPs, in particular, do this by presenting a patient’s story and background information. They then challenge learners with multiple decision paths and show the impact of their decisions—without the risk of actually treating patients, of course.

Training with these realistic computer-based cases strikes a practical blend of simulation with the convenience of web-based delivery and centralized reporting. Think of them as “cognitive” task trainers.

Hospitals have long recognized that providers who pursue learning on a regular basis tend to have better patient outcomes at a lower cost of care. Educational programs like VPs provide a mechanism to make good clinicians better and—perhaps best of all—help novices improve the cognitive skills that lead to expertise.

One good example that I am aware of is Warwick Medical School in the UK, which created VPs to train new doctors to handle life-threatening acute medical emergencies. The doctors can practice over and over again. Through the VPs, they receive immediate, personalized feedback while responding to a rapidly evolving, life-threatening clinical challenge. This type of deliberate practice simply cannot be replicated in real life. In an actual emergency the doctors who practiced decision-making skills are more likely to perform successfully.

Given healthcare’s focus on accountability and other reform efforts, it is important to not lose sight of ways providers and nurses can improve the care and the safety of their patients. VPs provide a safe and objective way to identify variations in practice and decision-making; remediate using real-life examples; reassess until competency is demonstrated; and continually reinforce best practices.

In any given community hospital, providers with a wide range of prior knowledge, skills, and attitudes practice under one roof. Patients expect and deserve the highest level of expertise from all of their caregivers. Payers also expect a certain level of performance and have begun to reward superior performers.

Simulation provides an efficient way to assess clinician performance and provide feedback, whether in the form of clinical guidelines, performance metrics or formal educational programs. By strengthening medical decision making, virtual patients offer one way to reach everyone’s ultimate goal—better patient outcomes.

James B. McGee, MD is the scientific advisory board chairman and co-founder of Decision Simulation LLC, co-chair of the Virtual Patient Working Group at MedBiquitous, and assistant dean for medical education technology at the University of Pittsburgh School of Medicine. Additionally, he is an associate professor of medicine in the division of gastroenterology, hepatology, and nutrition and a practicing gastroenterologist.

Readers Write 2/8/12

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

HIMSS, A Golden Opportunity: Insider Tips for Maximizing Media and Analyst Interviews
By Jodi Amendola

It’s hard to believe that HIMSS is just around the corner. In addition to meetings with new business prospects and partners, networking, and reunions with friends and former colleagues, you can maximize your HIMSS experience by arranging media and analyst interviews during the show.

HIMSS is a golden opportunity to meet one on one with these key industry influencers and differentiate your company from the competition. You can also leverage these meetings to identify and secure opportunities to be included in print or online articles, blog posts, and industry reports.

These industry movers and shakers are incredibly powerful. One positive mention and your sales leads could skyrocket. One negative comment and the opposite can occur. Don’t panic. The following media training “cheat sheet” can help you achieve your goals and generate positive coverage.

• Prepare. One of my most embarrassing HIMSS moments was when a client told an analyst that he “really liked his magazine.” The client obviously hadn’t taken the time to read our prep book! Before a meeting, research the background of the editor or analyst and become familiar with his or her areas of expertise and interest. Always customize your answers to address their audiences’ needs and pain points.
• Listen. Nothing is more annoying than being interrupted. Listen to the entire question being asked and tailor your responses. Address the questions within the context of the target audience(s) and avoid dominating the conversation with a product or service pitch. Sometimes it will be appropriate to share your knowledge, vision, and thoughts on the industry rather than focus on your company.
• Body language. Be confident, enthusiastic, and friendly. Smile, lean forward, and make direct eye contact. Don’t cross your arms or fidget. Remember, how you deliver your message can be as important as the message itself.
• Get to the point. Prepare an elevator pitch, a two- to three-sentence description of your company that is easy to understand. In other words, how would you describe your company and its products and services to your mother or the person sitting next to you on an airplane? Make sure it includes the key points you want editors or analysts to remember.
• Avoid jargon. Explain your product or service in layman’s terms. It’s your responsibility to make the pitch simple, clear, and memorable.
• Power of three. Focus on three main talking points and weave them into the conversation whenever possible. Often a reporter or analyst will ask if there is anything else that you would like to add at the end of an interview. Use this opportunity to restate your three core messages.
• Tie to hot topics. Demonstrate that you are a thought leader and can address hot topics such as Meaningful Use, ACOs, and where the industry is heading, not just talk about your product or company. Share the bigger vision.
• Zen of interviewing. When asked a difficult question, maintain eye contact, control your gestures, and breathe. Listen to the question and request clarification if necessary. Give yourself time to collect your thoughts and then respond. If you don’t know, don’t make it up. Offer to get back to the reporter or analyst with the appropriate information.
• Tell a story. People remember stories. Talk about client successes and lessons learned that highlight how your products deliver real-world value. If possible, include relevant ROI data in your storytelling.
• Relationships. Last but not least, it’s all about relationships. Be yourself, be genuine, and have fun. Let editors and analysts know that you can address multiple topics and to feel free to call on you for commentary or to discuss industry trends. Offer your clients as sources for future articles. Remember, these editors and analysts can have an incredible impact on your company’s reputation and marketplace visibility. Take the time to establish and strengthen these important relationships. Your investors, board members, and employees will be glad that you did.

Jodi Amendola is CEO of Amendola Communications of Scottsdale, AZ.

Comparing CEOS – Steve Jobs and Neal Patterson
By Reflective

Interesting comparison of Neal Patterson to Steve Jobs you made. 

Neal is, like most true visionaries, a complex person. I worked directly with him for many years, and while he can be quite the PIA to put up with at times, he is also incredibly compassionate and human and generous at others. He is a great leader, but not always a great manager  – and those are two entirely different things. He would agree with this assessment and has said as much in the book he wrote – manageIT.

As a leader, he sets clear direction to where he wants the company to go and the role he wants you to play in getting there. He defines aggressive and tangible goals that can be measured – and measure them he does. But he can be an impatient manager who doesn’t like to listen to reasons why goals aren’t accomplished (he views them as excuses). He is incredibly picky about the words you select in presenting your arguments. Words are VERY important to him, nearly as important as your intent. If you use the wrong words, he will come at you ruthlessly until you are embarrassed into retreat – many times, in a public forum. 

This is not an easy thing to deal with, and some might view it as unfair. But he does get his point across, and you surely do choose your words carefully the next time. And he has a great radar for detecting bullshit, so I would advising against trying. For your area of responsibility, you better figure out how to be more prepared than him, more informed than him, and have spent more time on the strategy than him – or you will not survive.

I have worked with several truly brilliant folks over the course of my career, and none of them have been easy. The things that they see aren’t always easy for the rest of us to see. The drive that they have to achieve comes from an inner place that we may not ever understand. They are different. They are difficult to be around because they are constantly judging and evaluating everything and everyone – making split-second decisions that can change the course of people’s careers and lives. 

The decisions aren’t always fair or even right , but they aren’t afraid to make them and live with the consequences. And once made, they do not live in the past. They only move forward. Leaders have it in their DNA to do this. Many managers do not.

But I have also observed that these truly visionary, genius-type folks are also acutely aware of their own mortality. They feel that they have a lot to accomplish in the short time they are on the planet. They are afraid they will run out of time to accomplish all they want to accomplish. They hear the clock ticking and they tend to steamroller over others that they feel will impede their progress, not always choosing a path that may yield less collateral damage. 

They are not always fair, and they sometimes listen to the wrong advice and situation summaries from folks with hidden agendas  because they don’t have the time to do everything themselves. Because they are forced to delegate, they can sometimes be manipulated. They may be brilliant visionaries, but they are not always the best judge of people. 

But leaders like these accomplish things that the rest of us cannot. They probably don’t like being labeled "genius" because they just see it as working harder than others. Being more driven than others. They have tenacity and a refusal to accept failure. I don’t think that they are necessarily put here to become beloved. I don’t think that is what’s important to them. What’s important to them is achieving their goals. Making a difference, leaving their mark, changing the world. The accolades, awards, and adoration are not what drive them, no matter how big their egos might be.

They can be incredibly charismatic when they want to be. They are successful leaders because, inevitably, their followers believe in the direction they are headed. They are leading their team into battle, and the team goes – because they believe their fight is right and just and winnable.

You don’t always love being around these types of folks. They are not easy. They wear you out. But it is their difference from the average that makes them successful. We need them. And most of us are changed by being around them. We are challenged to be better than we had been. We are less average by working up to their standards. For as long as we can stand it.

Too Much Football Without a Helmet
By Mike McGuire

I’ve managed to spend the lion’s share of my career in healthcare informatics. I’m not sure if that says I’m brain damaged or that I really admire not only the industry, but also the dedicated people I’ve met over the last 30 years.

I’m choosing to believe it’s the people, even though my bride believes anyone working in healthcare is brain damaged. Her view was formed by her experiences caring for her mother when it was discovered that she had cancer. We’re all too familiar with the story. Patient has multiple providers that are treating her, each focused on their part of the care. Between the drug interactions and multiple protocols, she managed to survive almost four years before she passed. While we were grateful for the time, the quality of those years will always haunt us.

Each of us have gone through a similar scenario or have known someone that has gone through it. Some of us have been around long enough to have survived the ‘80s and the introduction of clinical information systems. In the ‘90s. electronic medical records were introduced, and in the ‘2000s we had RHIOS, then CHINs and now HIEs and ACOs with still no solution in sight.

This weekend, like millions of Americans, I watched the Super Bowl. I marveled at the athleticism of the players, the size of the spectacle, and the precision of the execution of the game. When you think about how these are games scripted beforehand and how the coaches anticipate what the other team will do under certain circumstances, you wonder how they make all those pieces come together? And when they put together the plan, how do they modify it when a new piece of data or a new formation suddenly appears?

Like any battle plan, it’s only good until the first shot is fired, and then it’s constant adjustment. What I saw was that the quarterbacks of those teams had the ability to approach the line of scrimmage, access what they saw, and then had the wherewithal to call an audible. An audible is a new or substitute play called by the quarterback or a defensive formation called by a linebacker at the line of scrimmage as an adjustment to the opposing side’s formation. The audible is communicated by a series of hand signals, numbers, or colors called out by whoever is changing the formation. The players at each position then adjust their attack accordingly.

It’s a tribute to man’s ingenuity that the game of football has figured out a way to seamlessly react to change and adapt, yet we in healthcare can’t even exchange or share basic data. Now I hear the healthcare purists shuddering that the mere thought that I had the audacity to imply that somehow the exchange of patient data is analogous and on the same level as an audible in football. No. My point is that the NFL has figured out that in order to consistently win, you have to continually adjust and be able to communicate those adjustments in real time. This is something we cannot easily do in our healthcare environment.

Our healthcare game plan needs to be built around our two quarterbacks, the patient and the provider. Sustainability can only occur when the 880,000 physician quarterbacks can audible the other members on the patients care team, including the patient. Data exchange must be real time, succinct, and cheap. What we’re building is slow, difficult to maneuver in, and expensive.

Unless we design the game plan around the quarterbacks, my grandchildren will be writing articles about why ACOs and HIEs never delivered the expected results. We are better than this.

Mike McGuire is senior VP of sales for Holon Solutions of Roswell, GA.

Readers Write 1/27/12

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

The Top 10 Mistakes Salespeople Make at the HIMSS Conference
By Beth Friedman

A vendor’s sales staff is one of the company’s most important assets. While marketing, PR, and events management put it all together, the sales staff determines whether or not the HIMSS conference is a success.

Is your sales team engaged, interacting with prospects, and busy with pre-scheduled appointments? Or are they sitting around the booth, eating dinner together, and looking like Las Vegas wallflowers?

Here’s a Top 10 list of sales staff mistakes at HIMSS derived from our 30+ years of combined experience. Avoid them and you’re golden. Make them and you’re history. It’s that simple!

Mistake #1: Sitting Around the Booth

Your booth is crowded with salespeople, but no prospects. This is the most common mistake at any trade show.

Prospects must be enticed to enter your booth. They won’t come into it willingly. It is the job of your sales team to get them in. Yes, that means standing at the edge of the carpet and greeting attendees. A simple “hello” and smile works wonders. Multiply your smiles and see how many you get back. Hey, these guys and gals are competitive – have a contest!

Secondly, ask attendees easy, friendly, open-ended questions as they pass by. Get them engaged in a friendly conversation to start. Before you know it, you’ll be giving a demo! For example:

• How are you enjoying the show so far?
• What did you think of the keynote this morning?
• How are you finding the educational sessions this year?
• Did you go to HIStalkapalooza?

Mistake #2: Smart Phone Syndrome

All year you’ve made cold calls, left messages, and begged for appointments. Guess what? The same folks you’ve been trying to reach for six months via phone are here at HIMSS, live and in person. Dump the cell phone and talk to everyone in real time.

Avoid e-mail or any other electronic-based interpersonal avoidance. This includes time spent in the booth, between exhibit hall and hotel, in the elevators, during lunch breaks, and at the roulette table. Attendees are everywhere. Be “on” and smile at all times.

Mistake #3: Selling Too Much

Keep the sales pitch in the booth. If you meet attendees at events, poolside, or at the casino, keep conversation fun, personable, and low pressure. People are people. Everyone likes to meet someone personally first, professionally second. Overselling is one sure way to drive people away.

Mistake #4: Having Dinner Alone

Even if your company is small, make the most of having all your customers and prospects in one place. Arrange a dinner. Invite customers for cocktails. Host a small reception, focus group, or breakfast.

Breaking bread with fellow employees only is an opportunity lost. Make sure every meal includes a customer or prospect. You’ll be glad you did!

Mistake #5: Assuming One Size Fits All

Sales staff often uses a “one size fits all” approach to HIMSS attendees. Take a moment to ask questions and better understand your audience. See what problems they are trying to solve. If your company can solve it, great! If you company can’t solve it, don’t waste their time. Refer them to a company that can, and remember that smile!

Mistake #6: Avoiding Sessions

HIMSS offers a huge educational opportunity. Hundreds of sessions are offered and your prospects are sitting in each one!

Take the time to attend sessions. Sit next to someone interesting. Introduce yourself. Attending educational sessions is the best investment sales teams can make at HIMSS. Plus, it might make you smarter.

Mistake #7: Negative Selling

Talk your company up, not others down. Negative selling never works. And it especially doesn’t work at HIMSS. Enough said.

Mistake #8: Keeping Your Company’s Presence a Secret

You’ve invested time, money, and effort into HIMSS. Why not shell out a few more bucks to let everyone know? Direct mail is back. E-mail campaigns and promotions help. Unless attendees know you’re there, you’ll get lost in the noise.

And remember to attach promotion to your HIMSS efforts, and some emotion to your promotion. Give attendees a reason to visit your booth. And have some fun!

Mistake #9: Confusing Signage

OK, this mistake is usually made by the marketing folks and not sales. But confusing signage is a nuisance to everyone. Your company has less than three seconds to tell HIMSS attendees what you do. Make those three seconds count! Keep signage brief and communicate in familiar industry terms.

Mistake #10: Not Making Appointments

Failing to make one-on-one appointments with customers and prospects at HIMSS is inexcusable. Even if your company doesn’t have access to the pre-show attendee list, just call them! See if they are going. If your direct contact is not going, chances are that someone from their organization is. Call and introduce yourself. Schedule a cup of coffee or have a drink.

Reach out and touch someone before the conference. Because once everyone is in Vegas, it is too late.

Good luck. Have fun. Make the most of HIMSS. It only happens once a year!

Beth Friedman, RHIT is president of The Friedman Marketing Group of Atlanta, GA.

EHR Systems Can Be “Genius” to Use
By Seth Henry

In proper accordance to government regulations, approximately 50% of doctors’ offices nationwide have implemented some form of electronic health record (EHR) system. However, of these, only 25% have adopted the technology to serve in a meaningful and useful way. Most managers understand the mandatory changes that are underway, and in many cases, have begun the critical transition to these systems. Even if users have implemented the proper technology, they may be unsure of how to effectively incorporate it into their daily protocol or how to operate them with maximum benefits.

Compounding the financial investments required to implement an EHR system, there is an average of 1,000 hours of data entry required within the first year of adoption. Doctors and their staff are already pressed for time and money and do not have the proper resources to accomplish this tedious but crucial task. Moreover, they need to be focused on their real job – providing quality healthcare to patients.

The good news is that EHR systems can become user-friendly with the addition of proper infrastructure. Comparable to personal technologies, EHRs originate as a generic platform, with the responsibility of the owner to engage with the product to create a usable, tailored system.

Compare your iPod to that of your friends. No two are exactly alike after you each have the opportunity to personalize and import desired features and applications. Electronic health record systems are similar. They start with standard capabilities and can be uniquely personalized and adapted to meet individual facility requirements. The EHR technology requires applications to make them accommodate the needs for users to engage with the system on a daily basis to further benefit patients.

The most formidable part of any technical change is the actual use of the product and gaining consensus amongst the staff to implement it accurately and consistently. EHR professionals are constantly looking for better ways to educate, counsel, and instruct their client facilities on the technology as together they identify the most meaningful way to apply the tailored applications.

Taking a bite out of Apple’s famously coined “Genius Bar,” functional, hands-on training and support is the cornerstone to the successful use and implementation of any new product integration. The “Genius Bar” adapts the concept found at global Apple retail stores: in-person assistance for product-related education. Technology providers are retaining onsite, dedicated experts equipped with the skills, solutions, and passion for information sharing to guide facility staff through the program until they are 100%autonomous.

A single-style teaching approach is not an acceptable resolution to ensuring total integration of these technical upgrades. Thoroughly educating users in a personalized method, void of time constraints, will enable them to be properly trained to engage with the systems. Not everyone responsible for use will learn in the same manner or adapt as quickly as others. Therefore, the “Genius Bar” solution allows hands-on training and a continuous resource for resolving practical issues encountered as they implement the systems.

When the facility staff and doctors are comfortable with using the products, they are more inclined to incorporate the processes into their daily routines. In-person, ongoing support from their “Genius Bar” representative will help facilitate a smooth transition and implementation process.

The real benefit of an EHR system lies in generating, analyzing, and, ultimately using patient information to directly improve overall patient care. Tailored applications that enhance the EHR technology allow facilities and users to employ the appropriate features and accommodate their needs without the high cost of in-house IT infrastructure and staffing.

With the value of applying customizable, intuitive features, internal office support, and the help of the “Genius Bar” staff, facilities can succeed in long-term implementation and meaningful use of electronic health records.

Seth Henry is founder and president of Arcadia Solutions of Burlington, MA.

Readers Write 1/18/12

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

The EHR Bubble Will Pop—To the Victor Go the Spoils
By Evan Steele

There is no question that the EHR incentives have created a frenzy of EHR purchasing and that the trend will intensify in 2012 because this is the last year to qualify for the full $44,000. As I look at what’s happening in the market, it becomes apparent that at some point in the not-too-distant future, the EHR bubble will pop and many vendors will face financial challenges that will lead to their demise.

Despite the surge in EHR purchases in 2011 and 2012, it is important to recognize that there will be some unintended consequences of the rush to meet the government’s deadlines and requirements. Many physicians will be unhappy with their newly acquired EHR because, in their haste, they made a poor product choice. Others will face a rude awakening as they are forced to use their EHR in ways they never have before, and discover that it does not support their workflows. In the rush to market, there will also be some products that, while certified, are of inferior quality—possibly developed offshore.

Vendors will be backlogged and unable to manage the surge in new purchases in a timely manner due to insufficient staffing levels. Many will come to market short of the necessary educational resources to help physicians navigate the complexities of Meaningful Use, and physicians will find themselves victims of inadequate, rushed EHR implementations by green, wet-behind-the-ears trainers. Other vendors will be so overwhelmed that they will fail to keep to their promised implementation schedules, preventing their new clients from meeting the government’s timetable entirely.

In the years following the initial boom, many physicians will become disillusioned with the EHR Incentives Program. There will be too many requirements that will seem either burdensome or irrelevant to their practice—or both. As the increasingly stringent Stage 2 demands are weighed against the drastically decreasing dollar value of the incentives, physicians will either abandon the program or trade the EHR they originally purchased for one that supports not only the government’s needs, but also the workflow needs of their practices.

To see what will happen to many of the EHR companies, it is important to understand how they are financed. In order to raise money, companies had to show investors a story anticipating significant new client acquisition. Initial funding for EHR companies was based on “hockey stick” growth projections, fueled by the availability of government incentive money. Each individual company’s projection anticipated rapid, accelerating, and long-term growth in EHR demand.

The first thing to recognize is that these projections were overly optimistic. In fact, if you add the projections of all the EHR companies together, they would grossly overstate the total potential market. To excite investors, a typical start-up EHR company seeking funding was likely to predict that it would have 5,000 customers within five years.

With a population of approximately 600,000 physicians serving the ambulatory market — 25% of whom may never adopt an EHR due either to approaching retirement age or doubting that the penalties will ever be imposed –there is a potential market of 450,000 physicians. ONC’s Certified Health IT Product List (CHPL) website currently lists 472 vendors that offer at least one “Complete EHR” product. A conservative assumption that the top 20 vendors will together secure half of the physician market leaves the other 452 vendors competing for their share of the remaining 225,000 physicians. This represents an average of 498 physicians per vendor—not even a paltry 10% of their projections.

The circumstances described above present a textbook case of a dramatic bubble followed by a dynamic shakeout. Whether at the end of 2012 or in 2013 (when the bulk of the incentives are no longer available and physicians will have to focus on the conversion to ICD-10), the bubble will pop, and the financial fallout will be significant. Missed growth projections, government money drying up, and mounting physician dissatisfaction will leave many companies unable to find investors willing to fund their future growth. Scores of companies will face a cash crunch as revenue growth slows, or revenue declines, in the face of continued and significant expenses for implementations, support, ongoing upgrades and certification requirements, etc.

As in the dot-com era, strong companies will survive. Those that generate other sources of income from a deep set of products that offer alternative growth opportunities will be around to take advantage of the second EHR bubble that will be fueled by the looming EHR penalties, the development of ACOs, and new pay-for-performance programs, among other factors. There will be a trend toward consolidation, and financially strong companies will acquire distressed companies for pennies on the dollar, reaping the benefits of their unique technologies and/or their customer bases. To the victor go the spoils!

Evan Steele is CEO of SRSsoft of Montvale, NJ.

HIMSS Prep: Get Inside the Head of Your Customer
By Rosemarie Nelson

How much is it costing you to exhibit at HIMSS? It’s all about making a connection, developing a relationship, and delivering results. That’s why you’re exhibiting. These are my tips for vendors on the trade show floor.

First, Do Your Homework

What do you know about HIMSS? How many members? How many are attending? How many physicians are in those organizations? What else is important for you to know?

Who is walking the floor? You expect to see the C-level. The significant physician. Directors, administrators, and managers. Those from the academic world of academics. And “other.” Other means influencer. Think of the impact of the media, consultants, attorneys, accountants, and spouses. They know, work, eat, and maybe even sleep with the purchasers. Smile and greet them all.

They’re smart. Chances are they are graduate level. They are ready with questions that delve deeper than your elevator pitch. Prepare your answers.

They are boomers, more than any other generation. Are you Generation X or Y? How do you relate to the boomer’s characteristics? How does the boomer relate to you? Regardless of generation, the attendees will fall into one of the following cohorts:

• Wide-eyed wonder (first-time attendee)
• Seasoned cynic (been here, done it all)
• Social butterfly (came for HIStalkapalooza)
• Loyal customer (wants to learn even more)
• “If it’s free, it’s for me” (expert flea market goer)
• Heads-down tweeting and texting (oh, that’s you, the exhibitor!)

Like a Boy Scout, be prepared. Engage the enthusiastic, be cautious with the cynic, curb the chatty, appreciate the customer, and WALK AWAY from your smart phone while you’re in the exhibit hall.

Next, Know the Buzz

• Reimbursement will continue to decrease.
• Regulation will increase.
• Business and government focus on clinical quality will intensify.
• Payers will increasingly pay for demonstrated performance.
• Hospitals will employ larger numbers of established physicians.
• New physicians will continue to seek hospital employment over private practice opportunities.
• Increased consolidation among hospitals and physicians will result in intense competition for insured patients in local markets.
• Improved technology will facilitate — and force — change in healthcare delivery.

Then, Know the Trends

• Consumerism and patient-centered care.
• Transparency and everyone knowing how much healthcare costs and how effective it is.
• Value, represented by quality and safety in relation to cost.
• Metrics and developing gold standards. 
• Information and technology that delivers real-time data on the patient, processes, and systems.

Consumerism Trend

As the population statistics change and the baby boomers age, health care costs rise. Telemedicine, smart phones, direct-to-consumer marketing and the economic constraints on organizations’ fundraising efforts are all opportunities and threats to the traditional methods for delivering health care.

Mobile Technology Trend

Reduces need for hospital admissions and physician office visits. 40% of physicians say they could eliminate 11% to 30% of office visits through the use of mobile technology (PWC Health Research Institute, Sept. 2010). Why would providers accept technology that hurts incomes?

Insurance and Coverage Trend

Medicare spends more than 25% of its budget on patients in their last year of life. As a society, we can’t keep up with the growing needs for coverage and care: state budget constraints, federal budget pressures, and unwillingness to raise taxes. By increasing the preventive services and by monitoring key measures specific to chronic diseases, payers expect to improve health outcomes and reduce overall costs based on reduced hospitalizations and additional procedures.

ICD-10 Requirement

The costs of transition are almost as much as the costs to acquire an EHR.

And Finally, The Bottom Line

Does your solution address one of these trends? Why does what you do or provide matter to the exhibit hall walker? Each buzz signals a reduction in costs to the health care system, which means reduced income to those delivering the service. Are you signing up for a reduction in your income? No one wants to do that. How can you improve that income picture for your potential client?

“How does this solution/product help me?” is running through the mind of that exhibit hall walker. Do you know enough about them and their issues to answer that question? Challenge the conventional thinking in your sales process. If you keep doing what you’ve always done, you’ll keep getting what you’ve always gotten. Is that really what you want from your investment in HIMSS 2012? 

Rosemarie Nelson, MS is principal consultant with MGMA Health Care Consulting Group of Englewood, CO.

The Biggest Mistakes Companies Make in the War for Healthcare IT Talent
By R. Gaines Baty

“War” is officially declared and the healthcare industry is the battlefield. We speak of “The War for Talent” in healthcare – the perfect storm at the intersection of ballooning demand, limited supply, and mandated urgency, with no viable solutions but to accept mediocrity or fight for the best. 

This is not a new phenomenon, nor is it unique to the healthcare industry. Similar forces were at play in the IT industry leading up to Y2K. We in healthcare, as a result, now find ourselves in a candidate-driven “seller’s market” for executives.

No organization can excel without great leadership. Most chief executives agree that for an entity to ascend to and perform at an optimal level, it must attract and retain the best leaders possible. Some, however, don’t align their own recruiting processes with this fundamental truth.

We’ve pinpointed several of the more common and detrimental mistakes potential employers make in the pursuit of great executive talent. Of course, relevant candidate flow is crucial (and the reason good search firms are in business.) This said, the following issues can derail the pursuit of excellent potential leaders.

1. “Perfect Profile” expectations. It is advisable to first seek the perfect match. However, recruiting is not pizza delivery. When a comprehensive search is producing quality candidate flow, the market will reveal the caliber of talent and credentials available to the company. If and when the elusive “perfect person” does not appear, organizations may be best served by evaluating through a different lens. Prioritization and flexibility are required in this approach, with due credit given for transferrable skills and a recurrent track record of success. The operative question must become, “Can she do the job?” Strong performers come in different packages, and may not appear perfect at first glance. One can find something lacking with anybody, even a candidate fully capable of achieving an organization’s objectives.

2. Failure to “sell” the candidate. Excellent candidates typically have multiple suitors and are not necessarily looking for a job. Therefore, everyone in the recruiting process should reinforce consistent and inspired organizational vision, importance of the role, opportunity for success, potential for recognition and reward, and future career opportunities. Undoubtedly, effective candidate evaluation is paramount. Simultaneously, however, a consistent and compelling value proposition must also be perceived by the candidate. This should be complemented by a prompt decision and an appealing compensation offer. Candidates should be treated like prospective customers. We must bring our “A” games to the interview room.

3. Poor communication, indecision and ineffective processes. Organizations frequently drag out hiring decisions nonchalantly for months; communicate inconsistent visions; utilize inconsistent or ineffective evaluation criteria; inadequately communicate with sponsors or recruiters; conduct distracted or unprepared interviews; and generally create unimpressive or sloppy candidate experiences. This same process may be a candidate’s only window into the soul of a potential employer. In contrast, competitive suitors with crisp, clean recruiting processes will quickly eclipse others for this top performer’s services.

In summary, big game hunting for high quality leadership can reap huge rewards. However, the real stars are rare and may appear differently than we first imagined. Competition is stiff. The hunter only has one shot at the target, before it disappears.

R. Gaines Baty is president of R. Gaines Baty Associates of Dallas, TX.