Readers Write: The Chasm Between the Vision and Reality of Big Data

The Chasm Between the Vision and Reality of Big Data
By Ed Park

I attended the Bloomberg “Big Data” Conference in DC on Thursday, March 14. It was awesome. Folks from big business, big government, and beyond attended. Everyone was talking about the perils and opportunities of data – big data. As one executive creatively stated, “Data is the new oil, and what we want is the gold.”

I was lucky enough to take part in the healthcare panel. In short, my point of view is that healthcare desperately needs to attack and improve its many inefficiencies — much like how Walmart and FedEx have done — before it can successfully leverage big data to drive clinical enhancements. If we can’t get the simple stuff right— ensuring we follow up on lab orders, getting through Meaningful Use, etc. – we have no hope of getting to all of the great things we know are possible.

Athenahealth has brought insight and analysis to the way insurance claims are processed to ensure that the creation of claims and billing in general is streamlined. While this concept might seem simple, it has a powerful trickle effect. If physician practices can get claims and billing in order, they gain valuable time and resources to focus on care.

I tried to talk about the power of data in a tangible way by approaching the conversation from a “first things first” perspective. I tried my best to detail how data can be used to support primary care physicians’ workflow by selectively involving mid-level practitioners and administrators to take on tasks that doctors shouldn’t be doing. This in turn allows doctors to be fully present with patients.

To the dream-filled audience who perhaps thought the time for robot-driven care delivery was near, my goal was to keep it real by saying there is “no greater distance than the chasm between the promise of big data and where we are today.” The applications that healthcare needs to focus on first when it comes to big data are practical things: being more efficient, making administrative process fail-proof, identifying patient populations that are the most sick and most expensive, understanding what’s working and what’s not in the provider workflow, understanding the way patients act (or don’t act) based on a doctor’s order.

With this focus (to be more efficient), in time we’ll be better able to open the doors for healthcare to tackle data-driven clinical intelligence and improvement.

The future of big data in healthcare is bright. There are grand opportunities for patients and the industry at large as vendors, government, and health systems begin to embrace the idea of and build an infrastructure to support broad-based data liquidity. It is from this data openness that patients and providers will be empowered to take control of information to direct the health-related decisions they make.

It was mentioned at the conference that big data is not new, but what is new is “big, fat, messy, distributed data.” The challenge and opportunity is to bring together data to drive change based on evidence, with confidence.

Ed Park is chief operating officer of athenahealth of Watertown, MA.

Readers Write: Improving Patient Outcomes with Real-Time Decision Support and Analytics in the “Connected Home”

Improving Patient Outcomes with Real-Time Decision Support and Analytics in the “Connected Home”
By Fauzia Khan, MD, FCAP

Over the past decade, technology innovations have continually pushed the boundaries in the healthcare industry. Patient information in the hospital and ambulatory settings is now easily accessible through EHR/PHR systems and sophisticated Health Information Exchanges (HIE). With the addition of clinical decision support (CDS) and real-time analytics, clinicians are empowered to develop the best treatment plans for each patient, using intelligent and actionable information to improve care quality while reducing costs.

The mandate to embrace these technology innovations has been driven by federal government regulations, as well as disruption of the fee-for-service model. Although we have just barely embraced this model in the clinical world, what if these technology platforms could also be effectively used in the home setting?

With clinical decision support, patients could take a more active role in their own care. If the last decade was focused on inpatient, outpatient, and ambulatory data integration and interoperability, the next several years should focus on creating the “Connected Home.”

Data at the point of care in the home should be actionable, comprehensive, and increasingly accessible to patients, physicians, and payers. Whether that data is delivered through an HIE, EHR, or a smart device, patient data needs to be accurately captured and widely available, which will allow for the best healthcare decisions to be made. In time, once we move treatment closer to the individual, this will close crucial gaps, provide greater visibility, and accelerate decisions that lead to better outcomes.

All over the world, people want to be involved in their own care while remaining in their homes. Patients can receive attentive care in a comfortable environment, which ultimately improves their quality of life. If successful, home management will result in fewer urgent medical interactions and a reduction in hospital visits. In a recent Wall Street Journal story, the article demonstrated how the hospital-at-home concept is helping to take care of sick patients in the comfort of their homes.

With mobile technologies, ubiquitous Internet, and smart devices, the boundaries between home, hospital, and ambulatory and long-term care facilities will blur. Today, once data is captured through EHR, HIE, PHR etc., the next step is to make that information actionable.

With patient-specific and real-time information accessible at the point of care (the definition of which will also change), physicians could better manage common chronic conditions and patient populations. In addition to clinical decision support (CDS), another necessary layer to develop would be around analytics. CDS would empower clinicians to make more informed, evidence-based decisions, while real-time analytics would allow clinicians to view and analyze at-risk populations from both a preventative and interventional perspective. Analyzing patient populations and outcomes provides vital information for physicians that can significantly impact patients by triggering earlier interventions, reducing avoidable errors, and improving overall health outcomes.

A fully realized “Connected Home” is still in development, but it is certainly within reach. As we strive for more integrated technologies across hospitals and lab systems, we need to also spend our resources on developing a home network that can provide evidence-based data and real-time alerts to providers, patients, physicians, and even network managers. Once this integration takes place, the healthcare industry can focus its attention where it belongs—on better managing patients and populations.

Fauzia Khan, MD, FCAP is chief medical officer and co-founder of Alere Analytics.

Readers Write: Vendors – Welcome to the World of HIPAA

Vendors – Welcome to the World of HIPAA
By Frank Poggio

For the last decade or so, vendors were on the fringes of the HIPAA regulations. Just sign a somewhat innocuous BA agreement and let the provider worry about the details of compliance.

As of January of this year, the Office for Civil Rights (OCR) formally “invited” vendors into the HIPAA labyrinth of rules and regulations. In the new 500-page HIPAA Omnibus Final Rule, Covered Entities (providers) are required to send out new Business Associate agreements to their suppliers and vendors. You should get yours soon, and as an IT supplier, you will see several new requirements.

The biggest one is that system vendors that touch Protected Health Information (PHI) in any way must agree to commit to achieving full compliance with HIPAA rules by September 23, 2013. Touching means  coming in contact with — whether you create, capture, edit, change, store, pass on, reformat, convert, etc. a single piece of PHI even for even one patient. The HIPAA rules do not differentiate between full EHR systems, EHR modules, application type, middleware, report tools, conversion, or archive tools, etc. Basically, if your system touches it, you own it.

As an extreme example, say your software does only parking lot management for a hospital. If you somehow capture any personal ID data, your firm will have to meet HIPAA compliance.

A more realistic example is the typical analytics tool that takes detailed information, aggregates it, and generates only summary, management, or trend reports. Your analytical system (such as grabbing a UB bill file and calculating averages) may never report out or allow access to any specific patient PHI, but since you received the data on a case-by-case basis even though you may have stripped out the PHI before you stored the records, your firm and software must meet HIPAA compliance.

The Final Rule is clear that if you touch PHI, even if you don’t look at it, you must comply. There are no exemptions for encrypted data, servers in locked cabinets, or remote cloud systems.

As a vendor, what must you do to be HIPAA compliant? Your firm must supply documentation of:

1. Policies addressing HIPAA privacy and security issues
2. Privacy and security procedures
3. Workforce HIPAA training
4. HIPAA-compliant workflows
5. Compliance for an audit or data breach investigation
6. HIPAA compliance of any subcontractors you use

Your clients may require an independent audit of the above at your expense as a requirement for you to continue as their vendor. If you do not provide it, their legal counsel may advise them to replace your system with that of a competitor. Remember, the above must be in place before September 23, 2013. Lastly, if you or your provider client has a data breach and OCR finds you lacking in compliance, you could be fined $1.5million per breach.

As I noted in a past HIStalk Readers Write piece, ONC in Stage 2 “exempted” EHR Module vendors from testing on the privacy and security criteria (if the vendor so chose), but they did state that the vendor must still be HIPAA compliant. Which means, implement the ONC privacy and security criteria.

Welcome to the wonderful world of HIPAA.

Frank Poggio is president of The Kelzon Group.

Readers Write: Not Safer!

Not Safer!
By Ruth Bowen, MBA, CPHQ, CPHIMS

I’m an HIT professional in Philadelphia who lives in an area that supports multiple competing health networks. I am old enough to have a robust problem history and to have records that span multiple networks.

Having worked in this industry for 30 years, I am definitely a believer in the potential of EMR systems. But frankly, I am less safe.

All of my outpatient providers went from paper to a digital record. There wasn’t an opportunity for a conversion. Each of these practice systems took a different approach in terms of what data would initially populate the EMR. There are no standards here, only guidelines. There can be significant expense in terms of abstracting data from a paper record. Much of the data available in my paper records has just disappeared.

In one case, the paper record was simply scanned. I arrived for a visit with no problem list and no medication history and was treated as a new patient. The practice was dependent on my memory of events over 10+ years. In other cases, there was a subset of data, but in each case, most of the history was unavailable. The paper chart may have been scanned, but physicians do not page through images of paper record, so I consider the information unusable.

None of these EMR implementations has an interface from the laboratory system I use. In most cases, a subset of available laboratory results is transcribed into the electronic record. Although the physician also has a copy of the current paper lab results at the time of visit, the history of results in the EMR is incomplete and likely has transcription errors.

One of my physicians used to manually maintain a paper flowsheet for a subset of results significant to his specialty. That history is gone. His system doesn’t support the view he formerly had and there is no historical data that could populate a flowsheet or graph even if the capability was available.

The result is an increased personal safety risk related to multiple EMRs that are incomplete, each with a different subset of data. As it turns out, my responsibility in terms of patient engagement is record reconciliation at the time of visit, a reconciliation that is totally dependent on my memory. Not, I think, what ONC intended.

Ruth Bowen, MBA, CPHQ, CPHIMS is an independent HIT professional in Chesterbrook, PA.

Readers Write: A Balanced EHR Copy Forward Solution

A Balanced EHR Copy Forward Solution
By Kyle Samani

There’s been a recent wave of media coverage surrounding the topic of EHR copy forward functionality. Many have suggested that this function should be outright banned. The reasons vary, but in general most of the problems cited are related to the fact that the copy forward function in EHRs creates garbage and bloat in the patient’s record.

As someone who has experience designing and programming EHRs, who has deployed an EHR in inpatient and outpatient (PCPs and specialists) environments, and who has talked to hundreds of doctors about the subject in various presentations, I have a unique perspective to offer.

Lyle Berkowitz, MD, CMIO of Northwestern Memorial Hospital in Chicago, recently posted on the subject. He’s right. EHR copy forward is a great tool if used correctly. The problem is that EHRs make it too easy to abuse. Most of the copy forward functions in EHRs look at the last note and quite literally copy every field forward into the current note. This is problematic because full-note copy forward allows the doctor to copy forward too much information before all of it can be digested and understood.

There are easily dozens if not hundreds of data points in a given note. Doctors shouldn’t be encouraged to copy hundreds of data points into the current note before having a chance to complete the current assessment. It’s too much, too early in the examination process. The EHR should make it easy to copy forward information in manageable pieces.

I lead the original design of a function in my company’s EHR called Copy to Present in the latter part of 2011. It’s similar to the copy forward feature in most modern EHRs. The primary difference is that it doesn’t copy the entire note forward, just the active area of focus. The function is available in conjunction with a date dropdown on all major sections of the chart.

For example, the physical exam page contains a date dropdown at the top of the page. When a doctor visits the physical exam page, the date dropdown defaults to the current date. Doctors can quickly review an old physical exam summary by selecting from a date in the dropdown, which is populated with dates of previous physical exams for the active patient. When looking at an old date, the Copy To Present button appears. Clicking it copies forward the selected physical exam to the current note. The Copy to Present button doesn’t affect any part of the chart other than physical exam; all other areas are left intentionally untouched. After clicking the Copy to Present button, the physical exam data is editable as if the doctor had entered the data by hand.

A video demonstration of Copy to Present is above and here.

Copy to Present and the date dropdown are useful for data points that need to be collected and updated during every examination. Examples include chief complaints, physical exams, review of systems, and assessments and plans. In these scenarios, the Copy to Present function allows the doctor to understand what they recorded last time before copying forward to the current note. It provides the quick copy-forward function doctors want and need, while still allowing fine-tuned control over what’s copied forward.

However, Copy to Present is irrelevant when dealing with other types of information. For example, allergy lists, medication lists, problem lists, lab results, medical history, and surgical history. The most up-to-date versions of these data points should always be shown regardless of who last updated the list across any care setting (inpatient, outpatient, ED). EHRs should understand (but most don’t) that these pieces of information aren’t part of a particular note as much as they are relatively static pieces of data about the patient. Once labs and allergies are recorded, they should be available to any clinician that needs access to them, and they should always be up to date independent of any clinical note.

EHRs need to understand the kind of information they’re handling. Different pieces of information should be handled differently depending on what the information is, who is accessing it, and what that person needs to do with it. EHR vendors have a responsibility to ensure they provide the tools to make sure clinicians can get what they need, when they need it, and understand it as quickly as possible.

Kyle Samani is inpatient deployment manager at VersaSuite of Austin, TX.

Readers Write: Practice Management Software, Payment Portals, and the Merchant Service Account Problem

Practice Management Software, Payment Portals, and the Merchant Service Account Problem
By Tom Furr

The more than 300 practice management software vendors in the United States help practices that range in size from individual doctors to multi-office groups made up of thousands of health care professionals manage their most important operations, both clinically and financially.

Attuned to the government’s drive to capture critical data and make it available online along with providing greater cost transparency, these practice management software providers are offering payment portals tangential to their core software. These electronic mail slots are intended to let patients see their statements online and then pay their bills through this technology using their debit or credit cards.

Unfortunately, with every payment portal that comes online, every practice is required to establish a merchant service account. In simplest terms, a merchant service account is a specialized account provided by a bank or other financial institution to enable online transactions. This account, which enables credit card transactions, is an agreement between the practice and the bank that contractually binds the practice to obey the regulations established by the bank.

To secure the agreement, a practice needs to complete an MSA application form which, amazingly typically numbers 18 pages or more. Imagine the office manager of a medical practice taking time out of his or her day to handle that. The list of questions that must be answered run the gamut from the practice’s address to its checking account number, the principal’s SSN, employer ID Number, and much more (and those are the easy ones). Let’s not forget the need to get a voided check on the account to be used, a copy of the driver’s license of application signatory, a detailed list of services offered, credit card processing statements of the previous three months, a copy of the articles of incorporation, as well as business tax returns and business financial statements. All in all it’s almost as much paperwork as that which you waded through when you closed on a house, and you remember how much work that was.

In the end, the unfortunate reality is a practice management software vendor often sees a deal come unraveled because of the obvious problems associated with getting an merchant service account in place. It doesn’t have to be that way. There has to be a better solution.

My issue isn’t with the role of a merchant service account or with the very real need to provide patients with a safe, secure, and simple way to pay for healthcare services online. My problem is with the process of setting up or, for that matter, going through nearly the same time-consuming process should changes occur that relate to an merchant service account.

A solution that can work for all involved resides within the practice management software itself where it has a universal merchant services account, like PayPal or Square, for all its practices and automatically receives, posts, and reconciles payments back into the system. This eliminates the merchant services account set-up problem and makes the practice management software all the more useful to the practices using it. The best part is such an approach could cut down on the amount of paper and time used to bill patients, reconcile patient balances, and more.

For the sake of the practices using their software and their potential clients, practice management software vendors should find and fit the sort of solution I’ve sketched out above into their systems. Their practices and their patients will thank them for it.

Tom Furr is CEO of PatientPay of Durham, NC.

Readers Write: The Art and Science of HIMSS Networking

The Art and Science of HIMSS Networking
By Jodi Amendola

By now you have scheduled your meetings, RSVP’d to all your party invitations, and if you’re a Type A personality, you’ve probably already packed your briefcase and most of your suitcase. But you still have some prep work to do if you want to maximize the benefits you receive from attending HIMSS, which remains the best annual forum for networking with prospects, customers, the media, industry analysts, and potential partners.

To achieve success with your networking efforts you must:

1) Know what you want to accomplish (e.g. networking, media interviews, intelligence gathering, lead generation, scouting new partners and/or business opportunities, etc.;

2) Be prepared; and

3) Follow up on your leads after the show.

Sounds pretty simple, right? But the key isn’t accruing a stack of business cards, reciting well-rehearsed talking points, or sending follow-up e-mails before your plane touches down at your local airport. Those activities will probably yield some results, but to achieve the greatest possible success you should think quality vs. quantity.

Just between us… the real secret for getting the most out of HIMSS is getting people to listen—not just hear—you, and to remember you and some of what you discussed. Ideally, you will provide at least one “light bulb” moment that resonates and sticks with your audience. And that’s not simple–or is it?

Below are my secrets for building relationships with the movers and shakers at HIMSS. Remember, you will be competing with lots of noise, hype, giveaways, competitors claiming they’re as good or better than your company, short attention spans, and overstimulated brains. Here’s some tips:

• You never know where your next lead or opportunity will come from. While it might be a pre-planned meeting, you may meet your next business partner or client in the elevator, waiting for or sharing a taxi, or like one of my colleagues, waiting in line at Starbuck’s. Don’t be shy. Smile and take the opportunity to prospect, but do so in a friendly, conversational manner.
• Industry pundits, analysts, and editors are overwhelmed with people and pitches. To break through the trade show tinnitus, you need to be different and compelling. That doesn’t mean you have to be a comedian, the ultimate social butterfly, or the next Steve Jobs. You do have to be you authentic and passionate in certain areas – no one wants to talk to a robot — but be concise and to the point. Why? Because, in reality, you are selling yourself first and your product or company second.
• Get organized. Plan ahead and figure out what you want to say to the various types of professionals who attend HIMSS. You may want to stress different information and benefits depending on whether you’re talking to a CIO, a CMIO, the head of contracting services, or the vice president responsible for performance improvement. Remember you may only have 30 seconds to deliver your elevator pitch and capture someone’s attention so make it relevant. It’s okay to weave in humor if it feels natural, but don’t force it.
• Explain what your company does in simple terms. No marketing fluff — just tell them what you offer and explain why they should care. Be specific about the pain points that your product or services address. This information, framed within a question and answer format, is often an effective means to capture their attention. “How much time do providers waste trying to reach patients about lab results? An average of six calls back and forth. In addition to that time drain, patients become frustrated as they wait for days to hear their diagnosis. With our solution, patients are instantly alerted with a text or e-mail the moment their lab results are available.”
• To break the ice or establish a personal connection, learn and share something personal during your meetings. What’s their best stress reliever during HIMSS or their trick for enduring flight delays? If they are more reserved, start by sharing a story about you, such as how much you’re looking forward to your daughter’s nightly rendition of “If You’re Happy and You Know It” via Skype.
• Try to include easy-to-understand metrics. “Our hospital clients have seen a 40 percent average increase in patient satisfaction within six months of implementation. Patients love it. Providers love it. It’s a win-win.” You can always follow up with more complex data after HIMSS.
• Do some research to prepare for scheduled meetings. For example, if you have media interviews, review their 2013 editorial calendars for relevant future article topics and weave those specifics into your conversations. “Our Chief Technology Officer is deeply involved with helping our customers achieve Meaningful Use Stage 2 requirements. We’d be happy to provide her as a resource for your August Roundup on Meaningful Use or as a sidebar to your October article on EHRs.”
• Express appreciation for their time, reiterate the calls to action, and leave them with a smile. “Thanks again, Bob. I’ll contact you next week regarding the August and October columns,” or, “Great to meet you Steve. I’m impressed with your commitment to ongoing performance improvement. I’ll be in touch next week to go over how we can help.” It’s always a good idea to let them know that, “If you ever need my help, just give me a ring or send an e-mail.” Remember, networking is a two-way street.
• Fulfill your promises. Follow up with an e-mail within a week regarding the opportunities discussed. Don’t forget to mention at least one of the personal aspects that surfaced, such as, “Did you enjoy your tour of the Garden District as much as you expected?” or, “Were you able to get your Starbuck’s before your important meeting?” They’ll notice and appreciate that you cared enough to pay attention.

Truly connecting with people is both an art and a science, as any great leader will tell you, but it’s less daunting if you remember that you’ll mostly be relating to one or two people at a time. The important thing is to be yourself. Smile and they will smile with you. Networking doesn’t have to be a chore or intimidating. Showing up prepared with the right attitude can even make it fun as well as profitable. Have a great HIMSS!

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

Readers Write: Remote Control: Why Remote Consulting Works for HIT

Remote Control: Why Remote Consulting Works for HIT
By Casey Liakos

With the recent proclamation by Yahoo’s CEO Marissa Mayer that all company employees must work in a Yahoo office, the business world and Internet have been abuzz with arguments for or against this decision. Remote work is something that is on our minds often since it is a service our consulting firm offers in the EHR/Epic space. We haven’t seen anybody join the debate with a specific focus on EHR or Epic consulting, so we thought we’d chime in.

What Yahoo is requiring is really an apples-to-oranges comparison to the onsite/remote debate in EHR consulting. These are two different industries with two different sets of circumstances, and Yahoo’s decision clearly has no direct bearing on the HIT world. But there are corollaries between the two, and we think this is a good time to spur some discussion.

It should be pointed out that we are big fans of Mayer. She’s an inspirational figure in many ways, and above all, she’s from Wisconsin. So we have her back.

Time will tell whether this decision will benefit Yahoo, and there’s no shortage of people who feel strongly about it one way or another. But when we look at remote vs. onsite strictly through the lens of EHR/Epic consulting, we think that the logic Yahoo used in this decision is all wrong.

Why EHR projects are a natural fit for remote consulting

We are not advocating for all HIT consulting to be handled remotely. But we strongly believe that there are certain project phases and key areas where it just makes sense.

By now there have been countless philosophical points made on both sides of the Yahoo debate. But to our company, there are two factors that need to be considered, and these are the only two that truly matter when it comes to assessing value of a consulting purchase: productivity and cost.

Productivity

The remote services model that we offer to our clients has several key advantages when it comes to productivity. First, it puts resources on your team for the entire week. Traditional consulting practices have resources working Monday through Thursday – but of course your business doesn’t stop on Friday. Remote consultants can work a schedule to match your team’s hours, which brings an instant productivity boost.

Another factor that people may forget is that the technology available to us today makes remote work nearly seamless. I don’t need to go into detail — we all know many technologies that can put someone “in the room” when needed. With widespread remote system-access tools and file collaboration products already implemented in your organization, the remote consultants don’t miss a beat.

In fact, there are strong arguments to be made that communication can actually improve with a remote services model. A recent Harvard Business Review blog entry about working remotely makes some nice points:

• Proximity breeds complacency. I’ve worked with leaders who sit in the same office with those they manage but go for weeks without having any substantive face time with them. In fact, they may use e-mail as their primary source of communication when they sit less than 50 feet away. It’s even worse if they sit in different parts of a building or all the way on another floor. This is not to say that these leaders are in any way lazy, just that because the possibility of communicating is so easy it is so often taken for granted.
• Absence makes people try harder to connect. When I managed a team of professionals in nine locations, I made a point of deliberately reaching out to each of them by phone at least once a week and frequently more often. I’m not an anomaly here. Most leaders I work with make an extra effort to stay connected to those they don’t ordinarily run into. They can see that taking even a few minutes to talk about what’s happening in their respective worlds before addressing the tasks at hand makes a difference in maintaining the connection with a colleague. What’s more, because they have to make an effort to make contact, these leaders can be much more concentrated in their attention to each person and tend to be more conscious of the way they express their authority.

Note: we’re not necessarily advocating working from home, which can potentially present its own set of distractions. Our remote teams work together in client teams, primarily from our company offices. This minimizes distractions, encourages collaboration, and helps solve customer issues quickly.

Cost

The most obvious cost savings with remote consulting is the rate. When priced correctly, this model can save your organization a boatload of money over the course of the engagement.

The other key savings with remote work come with eliminating travel expenses. Flights, hotels, rental cars, meals… these are very real and often prohibitive factors when your project requires outside help. With tasks like build, testing, and system bug/incident resolution, the work can almost always be done remotely if managed well. Why pay a huge premium to stick the resource in a cube down the hall all day?

The cost savings of using remote consultants go much deeper than just hard dollars saved on rate and expenses. Easy administration indirectly saves you money. Managing office space, computers, telephones, security badges, etc., all carry a cost that you can eliminate. With remote consultants working from their firm’s offices, these costs are incurred by the firm, not the client.

There’s inherent stability associated with remote consultants as well. Turnover is much less of an issue when you have happy team members sleeping in their own beds every night. The cultural and organizational learning curves associated with consultant turnover carry a large cost that can be eased greatly with a remote model.

Most importantly, we feel remote consulting is the most cost-effective way to find and hire the best consultants for the job. Think about it in the context of Epic. Many of the very best Epic minds and most experienced resources are former Epic employees. A great number of these folks no longer work there because of the travel burden associated with being at customer sites every week.

Epic is a great place to work for a million reasons, but it should be no surprise that the #1 reason cited for leaving Epic is the heavy travel. Hiring remote consultants is the best way to gain access to these resources. They still want to work on Epic projects, they just don’t want to travel or can’t due to family obligations.

Tips for making remote engagements successful

Even if the consultants work remotely, you are still the manager. Speak with consultants or get a status report at least weekly. Any resource that is ignored, whether onsite or remote, has the potential to be working on the wrong things at the wrong time.

You and your team should be responsible for funneling work to consultants. This is the #1 hurdle we’ve seen: getting hyper-productive consultants enough work to stay busy. When all else fails, give them a brand new project to plan and execute from the ground up and watch what they can accomplish with a little support from your team and SMEs.

Make remote workers part of your team. Make sure they’re involved in all team meetings, e-mail lists, and communications.

You are not Yahoo

Many have attributed Marissa Mayer’s decision to the need to foster more innovation within Yahoo. Time will tell whether this move helps achieve that goal. HIT projects require organizations not only to be innovative, but to move quickly and get things done in a cost effective way. For this, a remote consulting solution can be an excellent option.

Casey Liakos is client relations director of Vonlay LLC.

Readers Write: What is Product Training Really Worth?

What is Product Training Really Worth?
By Lorre Wisham

“Every line is the perfect length if you don’t measure it.” Marty Rubin

Too often, healthcare information technology (HIT) vendors treat training as a last-minute “check the box” obligation to be met as quickly as possible with the smallest investment possible. It shows. Low KLAS scores and slow or partial product adoption are just two results of this approach.

What’s far worse, though, is the lost opportunity for vendors to differentiate themselves from competitors by showing the direct and measurable results that effective training can bring to their customers.

Smart vendors use proven evaluation methods to demonstrate these benefits:

• Reduced time to competency
• Increased consistency
• Greater and more meaningful product use
• Fewer help calls
• Better support for future employees

What kind of evaluation methods work? I recommend Kirkpatrick’s four-level evaluation model.

Level One

Assess participant reaction to the course.

Rather than wait for KLAS scores, use surveys to find out immediately what end users think about the training, and then modify it as needed to improve results. Capture this data over time to prove to customers that your training is well received.

Level Two

Assess what participants learned.

Build pre- and post-tests into your courses so you can demonstrate increased knowledge and skills. Track scores, run reports, and ask customers whether their other vendors can offer the same.

Level Three

Determine whether participants are able to apply their learning on the job.

Understand what comprehensive product adoption looks like for your customers and assess how your training helps deliver it. For instance, examine the rates of product use or the number of technical support calls among employees who complete training and those who do not.

Level Four

Gather data from customer executives or management to determine the impact the training has had on their organization. Using surveys over time, you can begin to answer key questions like these:

• Has the availability of an online training solution helped the organization manage employee turnover?
• Did training help the organization meet Meaningful Use criteria?
• Did the time available for patient care increase along with HIT proficiency?

As learning professionals, we know organizations that evaluate their training outperform those that don’t. Vendors who work with customers to evaluate training success set themselves apart from those who don’t. After all, training is just an activity if you don’t bother measuring its impact.

By taking the steps described here, you can demonstrate added value to your customers. You can show that you not only know how adults learn, but how they do so within the challenging context of a healthcare environment. Because you measure results, you can show something more — your unique ability to help healthcare professionals translate learning into actions that benefit hospitals, providers, and patients.

Lorre Wisham is president and CEO of Health Technology Training Solutions of Tucson, AZ.

Readers Write: Now That We Have Data, How Do We Improve Patient Care?

Now That We Have Data, How Do We Improve Patient Care?
By Cynthia Davis

I’m a former ICU/ER nurse with three decades in and around healthcare delivery. I understand first hand why we need technology in operating rooms, in the ER, at the patient’s bedside and during clinic visits. It is because technology can have a significant impact on improving care and outcomes. Patients are safer. Doctors have access to data on medical history and allergies when they are making decisions that can save the life of someone’s mother or sister or aunt.

Today we are at a critical juncture. Institutions finally have the right technology tools in place. The question is, how do we make that collective leap from data collection to better care? I think it starts with validating and analyzing the data that we are all so busy collecting.

This should be easy. Isn’t that the promise of technology? In my experience, the answer is both yes and no.

Technology is not magic. It does not fix processes. If you have a patient with impending sepsis and the EHR alerts for potential sepsis through vital sign documentation, assessment data, and labs, it doesn’t tell you the process once the alert triggers. It’s a shift in perspective, but for technology to actually improve care, we need to listen and think as clinicians and reexamine workflows and data points as a basis for care decisions.

The first step is going back and reviewing whether we are capturing data at the right time and point of care. The data that is collected needs to be reliable and clean. This sounds simple and straightforward, but in a clinical setting, the challenges can be enormous.

Recently I asked various departments heads what they considered the source of truth for their clinical information for decision making. Six department heads gave me six different answers. They were all using their department reporting tool as the best source of data. As they went along and identified data discrepancies, they fixed these in their own departmental systems, but problems in the original source data were neither corrected nor investigated. Each thought the problem was that the nursing teams had entered the data incorrectly. No one had focused on the data integrity in the primary system.

This breakdown in the data management process highlights the fundamental importance of adopting an overall data governance structure to support data decisions. It reminds me that we all need to examine data design and data management processes to make sure we are capturing the right information at the right time. This critical analysis can point out workflow problems like the one my client encountered, where well-intended workarounds had compromised the integrity of their whole system

Talking to and observing frontline staff is a great way to discover workflow problems that may be undermining the success of your EHR. For example, I once watched a nurse scan a page full of labels before administering a new medication. He did not scan the wristband where the patient identification data was stored until after he had administered the medication. Therefore, he was using the system and accessing stored data, but the order was out of sequence.

This kind of problem will not turn up in a status report from your CIO, which may be more focused on the number of support tickets generated or the ratio of downtime. Clinical leaders have to get to the front line – to the hospitalists or nursing managers – to find out how well the system is working and where there are difficulties.

Finally, fixing workflow issues that compromise data integrity requires a continual emphasis on training. People can only learn so much when you first bring your system live. On an ongoing basis, organizations must invest in management skills training to help clinicians more effectively use these new tools.

Whether it is helping a nurse manager better monitor the nurses who are capturing electronic data or working with a chief medical officer so that they can look at reports and understand what’s happening with their medical staff, training is essential and goes far beyond your go-live.

Cynthia Davis is a principal with CIC Advisory of Clearwater, FL.

Readers Write: What Would Steve Jobs Say?

What Would Steve Jobs Say?  
By Tom Furr

When you purchase a song on your iPhone, do you have to search for it in one application then toggle over to a different application to pay for the tune and then toggle over to another application to listen it? The answer is no. The brilliance of iTunes is that you can do it all within that one application. It is a single application that performs multiple tasks.

What iTunes is and how it works did occur to me while at a conference on “healthcare innovation.” All the speakers there talked about how users would have to exit out of or toggle from the practice management software to log into a payment portal after having downloaded data.

I wondered what Steve Jobs would say about the user experience in healthcare? I imagine it would not be favorable. I asked my fellow attendees this very question. The standard response was, “This is just how healthcare works.” To me, this is just unacceptable.

There are about 300 vendors offering practice management software. I suspect most of those applications require users to toggle out to access a partner’s application. All this raises the question: why don’t practice management software vendors make the user experience a selling point?

A little reconnaissance will show that your users do not like to toggle from application to application. Case in point: moving from your practice management software to a billing application or a clearinghouse portal and then to a reconciliation spreadsheet. Toggle. Toggle. Toggle. Users want to see and do everything on one screen within the practice management software. Have it all in one place.

If you’re not attuned to the usage preferences of those dealing with your software every day, you are putting your long-term viability at risk. A kludgy user experience puts vendors at risk with the rise of new, innovative vendors willing to address design and usability as Steve Jobs did religiously.

Usability is what differentiates and provides an edge when competing for users and market share. I would suggest you look at how BlackBerry is doing today versus Apple or Samsung to see just how much value your consumers place on ease of use.

Like Apple has done, how do you keep your current customers fiercely loyal to your product, attract new ones, and drive your competitors crazy trying to keep up? Keep their experience with your product in mind at all times and move quickly to embed all functions of their day into your practice management software and eliminate the need to toggle. You create a unified user experience, put up significant barriers to switching, and drive greater revenue as your customers become your greatest salespeople. Just like Apple.

It’s worth noting the words of Steve Jobs: “Innovation distinguishes between a leader and follower.” It’s time for you to be the innovator.

Tom Furr is CEO of PatientPay of Durham, NC.

Readers Write: Agile Analytics in Healthcare: Fast Deployment, Low Cost, Short Time to Value

Agile Analytics in Healthcare: Fast Deployment, Low Cost, Short Time to Value
By Jason Monroe, Mark Moffitt, and Satish Jetty, MD

Adena is a regional integrated health system located in southern Ohio serving seven counties around and including Ross County. The system is anchored by Adena Regional Medical Center and includes two critical care facilities, a freestanding cancer center, and 11 clinics employing about 180 providers.

Clinical, financial, and administrative data at Adena is spread across multiple systems including Meditech Magic (acute care), eClinicalWorks (ambulatory), LSS (previous ambulatory system), Lawson, and Kronos. Business intelligence or BI applications were limited to analysis of data in only one of these domains with a few exceptions. This made analyzing data across the enterprise difficult. The annual direct maintenance fees paid to BI vendors was about $500,000 per year and growing.

Adena was looking to improve clinical, financial, and administrative analytics by having a single system that could combine and use data across disparate systems, lower the cost of deploying and supporting these applications, and speed up the time to deploy applications requested by users.

The solution to Adena’s requirements for a BI system was found in a technology called associative query language (AQL). Our commercial BI product’s associative data model is designed for deployment speed and for providing users with an environment that is designed to encourage data exploration. It is easy to program and does not require personnel with specialized skills to build and maintain applications as compared to the traditional model for analytics using a data warehouse and cubes.

Traditional BI vendors use a data warehouse to consolidate data from multiple systems. Data is fed from transactional systems to a data warehouse in real time or in batches at the end of the day.

Once a data warehouse is deployed and populated with data, cubes are built and deployed to users. Cubes contain data from a data warehouse that is aggregated to answer a specific set of questions. A user is working with a subset of the data in the data warehouse rather than the whole data set. The design and build of cubes is an iterative and ongoing process between users and personnel with technical skills in building and optimizing cubes.

Our product uses data in memory in a compressed form with associations defined between data items rather than joins as used in a traditional database. These associations are derived automatically during the data load process into memory based on matching column names across tables. Matching column names from different systems is easy.

AQL makes it possible to load data from multiple transactional systems directly and bypass a data warehouse and cubes. The product does require work to set up and update a data set. However, this effort is much easier than building and maintaining a data warehouse and cubes.

The project was approved in late 2011 and started in January 2012.

Readmission Risk Dashboard

The Readmission Risk Dashboard combines data from Meditech, eClinicalWorks, and LSS (ambulatory PM and EMR used prior to eClinicalWorks) to provide a complete picture of Adena’s inpatient census. The application uses the Modified LACE Tool which assesses patients length of stay, acuity, co-morbidities (20), and emergency room activity as a predictor of the likelihood the patient will be readmitted within 30 days of discharge. Adena has initiated protocols based on a patient’s LACE score that include:

• Nurse navigator consults initiated for patients with a LACE score of ≥ 11.
• Coordinated conversations with the attending physician, nurse navigator, and the patient’s primary care physician initiated for LACE score of ≥ 15 to discuss options such as palliative care.

The initial result of this project is enhanced productivity of our nurse navigators and significant enhancement to the timeliness and pertinence of the data that is presented to care providers. Long term, we expect improvement to the readmission rate at Adena Health System, which has a positive financial impact, but more importantly, allows for improved quality of care and overall patient experience.

The build of this application took less than two weeks from discussion to a beta version available in production. The clinical program is in pilot and will be implemented system-wide.

Figure 2 – Readmission risk dashboard

Readmission risk dashboard summary:

• All inpatients
• Sorted by highest modified LACE score
• Patient detail including problem list, ED and urgent care visits, scheduled appointments
• 30-day readmission tracking dashboard
• Data sources: Meditech, eClinicalWorks, LSS
• Application development time: two weeks
• Time to deploy: four months
• Direct savings through elimination of other system(s) or avoidance of new system(s): $80,000 per year

Patient Centered Medical Home (PCMH) Dashboard

PCMH is an initiative that is being piloted in one primary care provider office. The PCMH dashboard was developed to give providers and staff a view of PCP’s patients admitted to the hospital, patients seen in the emergency room or urgent care in the past 30 days, and inpatient discharges for the past 30 days. This dashboard gives providers easy access to information not previously available. The program gives nurse navigators a tool to identify patients needing discharge follow up or more dedicated attention.

Additionally, the application lists patients scheduled in the next few weeks that have a chronic disease. Clinicians are able to determine if the patient has required lab or imaging tests scheduled so the tests are completed prior to a clinic visit. Previously this was a manual process requiring considerable staff time to assemble the required information. No screen shot is provided because most of the data is patient information.

PCMH dashboard summary:

• PCP’s patients in hospital
• PCP’s patients who have been to the emergency room or urgent care in the past 30 days
• PCP’s patients discharged from hospital in the past 30 days
• Patients with chronic disease scheduled in the next three weeks
• Data sources: Meditech, eClinicalWorks, LSS
• Application development time: 45 days
• Time to deploy: 60 days
• Direct savings through elimination of other system(s) or avoidance of new system(s): $500,000 over three years

Provider Scorecard

Wellness and preventative health is tracked for annual wellness exam (AWE), mammograms, colonoscopy, osteoporosis screening, and BMI capture rate. For comprehensive diabetes care, performance rates are monitored for A1C control, LDL control, and microalbumin screening.

At the provider level, readmission rates are tracked for CHF, AMI, pneumonia, and COPD. Also, patient experience scores are extracted from Press Ganey data and incorporated. Finally, the dashboard displays practice activity, in real time, of patients waiting in the reception area, patients in a room waiting on a physician, and patients in a room with a provider.

Provider scorecard summary:

• Provider and practice level scorecards and performance metrics: wellness and preventative Health is tracked for AWE, mammograms, colonoscopy, osteoporosis screening, and BMI capture rate
• Comprehensive diabetes are: performance rates monitored for A1C control, LDL control, and microalbumin screening
• Readmission rates are tracked for CHF, AMI, pneumonia, and COPD
• Real-time view of patient activity in a clinic
• Data source: Meditech, eClinicalWorks, Press Ganey
• Application development time: 60 days
• Time to deploy: 90 days
• Direct savings through elimination of other system(s) or avoidance of new system(s): $140,000 per year

Revenue Cycle Management (RCM)

Rather than buy a third-party application for RCM, the commercial BI product was used to build an application to provide functionality in the first phase including aged trial balance, summary detail, transactional detail at patient level, coding workflow, self-pay analysis, and account balance in multiple insurance

• Data source: Meditech, eClinicalWorks
• Application development time: 16 weeks for Phase 1
• Time to deploy: 20 weeks
• Direct savings through elimination of other system(s) or avoidance of new system(s): $250,000 per year

Personnel spent the previous year trying to meet the requirements of this project using Excel, and when that failed, another vendor’s BI system that failed to meet the requirements of the program. Using the commercial product, the team was able to produce an application that met all requirements in 90 days.

At the start of the project, there was only Adena employee working on it. Consultants were used for the first four months to accelerate development on RCM applications. A second person was added to the team in July 2012.

Super users are being trained in RCM, finance, clinical, quality, operations improvement, strategy, and the Adena Medical Group. These are not new hires, but subject matter experts in their area with strong Microsoft Excel skills. These super users work with SMEs to build prototypes, deploy applications, and support programs in their respective area.

The first year of deploying the system had expenses of $500,000, mainly licenses, hardware, and consulting services to accelerate work on RCM. Direct savings so far equals $2 million over three years. These savings are from the cancellation of contracts for existing systems or cost avoidance of new systems that were budgeted and planned for deployment.

Another benefit to the system is that applications are being developed faster. Before, clinical programs needing analytics waited as applications were purchased and installed. Using the commercial BI product, prototypes are built in days or weeks and applications are piloted in a few months and at a lower cost than before – hence the term agile analytics. The results have exceeded our expectations.

Jason Monroe is director of enterprise data management with Adena Health System. Mark Moffitt, former CIO at Adena, is senior director with Ascension Health Information Services-Seton. Satish Jetty, MD, is CMIO of Adena Health System.

Readers Write: The Pitfalls of Resource Labeling in EMR Projects

The Pitfalls of Resource Labeling in EMR Projects
By Tyler Smith

In enterprise-wide EMR software implementations, the labels “clinical” and “technical” are often utilized in an attempt to categorize the project’s human resources. When taken to improper extremes, these two labels can give rise to an unhealthy “us vs. them” mentality among project team members which can be highly detrimental to the project’s timeline and team member cohesion.

The us vs. them mentality can hardly be considered de facto in enterprise EMR software projects. The division of clinical and technical team members is often intentionally defined by the leadership of large scale enterprise EMR projects. The division is worked into the project’s staffing plans and subsequent role assignments. There are often defined minimum numbers of clinical and technical team members for each of the project’s teams.

The justifications for role assignments based on clinical or technical skillsets are obvious. A project needs individuals with hands-on experience in the areas where the software will be applied in order to give a necessary perspective to builders and PMs, as well as to increase the legitimacy of the final product. A project also needs individuals with sharp IT skills who can translate flowsheets and labs, along with about everything else in these HITECH days, into computerized workflows. Ownership is important on IT projects, and the labels add ease to the sometimes difficult assignment of ownership.

What I fear most about the division is not hurt feelings, although I’m not saying that hurt feelings can’t directly result from the intentional division. What I really fear is the waste of resource time the labeling can cause if it is taken to its extreme.

Although mostly absent from Washington these days, the willingness of team members to compromise and sometimes share ownership is essential in divvying up tasks between clinical and technical team members. While some project tasks can be clearly divided – and these areas are no doubt a huge reason for the pronounced division – there are often gray areas that are not so easily categorized.

Battle lines are drawn when a group is delegated the task of owning a project or heavily assisting with an assignment that they do not believe is aligned with their label’s responsibilities. I have seen technical team members who refused to complete orders build based on lacking clinical knowledge. I have seen clinical team members refuse to perform easy interface cleanup based on lacking technical skill.

While both of these team members were right to the letter of the law, the project’s thin resource allocation necessitated their somewhat misplaced assignment. When it came down to it, given a little bit of willingness to learn, each team member could have accomplished either task. Validation would have been required, but the compromise would have saved hours of argument that waste resource time and increase the project costs.

Therefore, while divisions may be necessary to create a neatly formatted organizational chart or to meet certain artificial quotas, a culture of flexibility needs to be promoted in concert. Technical people should be encouraged to Google healthcare topics a little more and clinical people should not be afraid of reading up on computer languages.

Deference to each other’s expertise remains a given, but showing respect by attempting to learn the other side’s language goes a long way. After all, team members are not made members of the project to simply live to a label. Project members exist in order to facilitate the project’s ultimate success.

Tyler Smith is a consultant with TJPS Consulting.

Readers Write: Students in the HIT Spotlight

Students in the HIT Spotlight
By Lisa Reichard RN, BSN

Inspiring! That was the word that ran through my mind when I heard that the HOSA team of Harris County High School, Hamilton, GA had won the second annual Student HIT Innovation Award at the Health IT Leadership Summit for its Type 1 diabetes mobile health app.

As a former pediatric nurse who has worked with children newly diagnosed with diabetes, I was thrilled to see an app that can aid in the education and training of newly diagnosed patients developed by 11th grade high school students. Best of all, right here in my own back yard.

In my experience, this can be an isolating disease with challenging daily management. According to the Center’s for Disease Control (CDC), Type I diabetes has spiked 23 percent among children, with a 21 percent increase in Type II diabetes also reported.

The student team from HCHS rose to the challenge and was chosen from 12 semifinalists followed by a final four selection. HIStalk Connect’s own Travis Good, MD was on the judging panel.

Left to right: Todd Bell, senior VP at Verizon; Brooke Grantham; Aleah Harris; Hank Huckaby, chancellor of the University System of Georgia; Christopher Keough; Brittney Wilkins; and Cheryl Batts, Harris County High School HOSA Advisor

I had a chance to chat with team member Christopher Keough to hear more about the experience.

How does your Type 1 Project app work and how does one download it?

Our Type 1 Project app has several links to choose from that provide general information about Type 1 diabetes, informational videos, a link to our website and Facebook page, and even a link to a carb counter. To download our app, search for “Type 1 Project” in the Google Play store, or to access it on your iPhone, visit type1project.conduitapps.com and just add to your home screen.

How will the app help kids recently diagnosed with diabetes?

We feel that kids would rather use a mobile application than receive information from a doctor or a book because most of them own some form of technology. Children and young adults can relate to how to best calculate the amount of carbs in food on the go with the link that we’ve provided through the app. They can also learn more about their condition through our website and the informational videos that we’ve provided.”

What are the plans for the product?

This mobile application started as a project for the Health IT Leadership Summit award, but we plan to keep it live for a limited time and try to make more users aware of the app through Facebook and other methods. We also plan to make ongoing improvements to the mobile application.

I also had the chance to ask Cheryl Batts, Keough’s advisor, how those of us in the health IT community can encourage students to foster future creativity in application development, and succeed in pursuing future IT careers.

“We can start in our classrooms,” she explained. “Last year, the health IT project was directed toward middle school students. Although an estimated 95 percent of students in my classes have cell phones, and this is where our mobile app can come into play, I believe many students have no idea what healthcare IT is. I know when I mention the number of job openings in Atlanta in my classroom, they all start thinking hard about it.”

“The mobile app we developed had a monetary award for our HOSA organization. HOSA, a national student organization, used to be an acronym for Health Occupations Students of America. However, it now stands for just Future Health Professionals. The chapter is for any student interested in a career in healthcare. The mission of HOSA is to enhance delivery of compassionate, quality healthcare by providing opportunities for knowledge, skill and leadership development of students. HOSA provides competitive events and leadership training at conferences that include knowledge and skill competencies through a program of motivation, awareness and recognition as part of the Health Science Education instructional program. Of course, these conferences cost money, so earning money for the organization helps reduce student expenses. The offering of scholarships is a big help to our students as well.”

Congratulations to Harris County High School on the receipt of this milestone award. Let’s all do what we can to support our local students. Who knows? We may start seeing more students demoing apps at trade shows. The future is looking bright!

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

Readers Write: It’s a Matter of “Over Promise and Under Deliver”

It’s a Matter of “Over Promise and Under Deliver”
By Mike Silverstein

As a recruiter in the healthcare IT industry, I attend HIMSS every year and make it a point to know what vendors are hot and what products and solutions are being purchased by the healthcare community. I am always shocked when I walk into the HIMSS exhibit hall and see massive booths of vendors I have never heard of. Even more shocking is the number of these massive booths that were at HIMSS the previous year but are not at this year’s show. I ask myself, “How does this happen?”

The answer took me to the biggest complaint I hear again and again when talking with hospital executives about their feelings toward vendors. It’s a matter of “over promise and under deliver.”

I am not using the over promise and under deliver adage when it comes to the performance of these seemingly fleeting companies’ products. Frankly, as a recruiter in this business, I have no idea what differentiates a good product from a bad one. The lens I look through is that of a search consultant who on occasion gets a call from one of these startup companies which has just received a considerable round of funding and is looking to recruit the top sales talent in the industry.

Their game plan is often the same: spend a bunch of money to hire salespeople who can go out and sell something, then hope something sticks and figure out the rest later. According to these same salespeople, the problem quickly becomes: (a) the product isn’t ready for prime time; (2) the company can’t implement what they sold; ( 3) they don’t get paid until go-live and it doesn’t look that’s going to happen in the next decade, so Mike, can you help me get out of here?

I recognize that the industry is primed for PE and VC investment. As a guy who makes a living by helping companies hire, I’m not going to complain. That being said, I think that the healthcare community could cut down on wasted IT spending, vendors could maintain better relationships with their customers, and I could cut down on the number of candidate resumes I have on my desk who took a chance on a startup. In fact, in the time it took me to write this piece, I received four more of these resumes in my inbox.

If everyone would more appropriately manage expectations and think about building an infrastructure and not just a sales team, the result would stop the over promising and under delivering circumstances.

Mike Silverstein is director of healthcare IT of Direct Recruiters, Inc.

Readers Write: Healthcare’s Crystal Ball – Predictions for 2013

Healthcare’s Crystal Ball – Predictions for 2013
By Terry Edwards

As many have noted, there’s been more innovation in the past five years than in the last 50. But it’s onward and upward, and I spent quite a bit of time over the holidays thinking about what 2013 will look like. With Obamacare here to stay, healthcare executives certainly have more clarity into what their future will look like than they did for most of 2012. Investments in IT and communications are going to continue at a steady pace and likely even increase. But here a few of the biggest shifts that will take hold in the year ahead:

EMRs will be upstaged/usurped by population health management tools. In 2012, the industry finally came to a consensus that EMRs are simply data repositories, and also remembered that they were originally created so that hospitals could capture information to send a bill – and really nothing more. As we move toward business models based on maintaining the health of populations, EMRs will become an afterthought, while population health management, predictive analytics, and actuarial capabilities take center stage. Health systems are going to be focused on putting the technologies, people, and processes in place around the EMR that will enable true population management by 2014.

Clinical integration will take hold. Call me an optimist, but 2013 is going to be (finally!) the year of the integration. Hospitals will continue to reduce the number of systems they manage by making sure the ones they do keep can easily share data. Mobility is going to be key to pushing vendors to collaborate, because it’s going to be more and more critical that clinicians receive patient data on smartphones and other mobile devices, both within and outside the walls of the hospital.

Population health will push healthcare into the cloud. I see a huge opportunity in new applications moving to the cloud – specifically those that facilitate the freer flow of information that’s going to be required under a population health model. An ideal example: there’s a device or application that allows me to manage my weight, and I’m a patient with a chronic condition. I weigh myself every day or take my blood sugar, and that information goes from my smartphone to a database in the cloud, then accessed by my care manager. Or maybe there’s an alert that goes off if there’s a change of a certain percent over a set period of time. That’s an ideal cloud-based healthcare application, and we’ll see more of those move to the cloud in 2013.

Patients will be financially incented and will vote with their pocketbooks. To be blunt, patient accountability is an area where Obamacare really whiffed. Under the ACA, everybody is responsible except for the patient. But in the year ahead, the market will introduce more ways to incent and motivate patients, with financial pressures and rewards related to their health. We’ve already started to see new health plan designs where smokers pay more, putting a price tag on making better lifestyle choices. For those who are already more involved in their care, we’ll see them opt out of private or government-run insurance programs and gravitate toward concierge-type services. They’re also going to drive demand for better access to care, as they pay for faster, easier access to “retail” health care in CVS MinuteClinics, etc. – especially as primary care physicians continue to be spread thin.

Health systems crack the (scarily complex) code on clinician-to-clinician communication. I’m always fascinated by the different methods hospitals and health systems have in place to get information from one clinician to another. I’ve seen everything from NASA-level flow charts to third-party call centers to systems that seem like a step away from carrier pigeons. Effective clinician-to-clinician communication is essential to nearly every initiative a hospital has on its plate these days – meeting new regulations, driving new quality initiatives, moving to new models of care, etc. – but it has often been an afterthought, or as I’ve seen all too often, completely overlooked.

In the year ahead, hospitals will begin to gain an understanding of the complex processes between clinicians both inside and outside the walls of the hospital, and also start to see that there’s no technology solution that will improve efficiency. It’s not about smartphones or text messaging or pager replacement software, but about the process of who needs to talk with whom and when – and what changes need to be made in the current workflow to make that happen in a reliable way. With all the competing priorities hospitals are facing today, many don’t even understand their current workflows – and certainly don’t know what it should or could be. But sticking technology into a flawed workflow will only lead to an automated, flawed workflow. Hospitals need to identify the current state and the needs and concerns of clinicians, make improvements to processes as necessary, and then apply technology to the new and improved workflow. Only with an understanding of the process will hospitals be ready to start thinking about and implementing a successful clinical communications strategy.

Now that my tarot cards are on the table, what are you healthcare predictions for 2013?

Terry Edwards is president and CEO of PerfectServe of Knoxville, TN.

Readers Write: The Transition TO Paper Record Keeping

The Transition TO Paper Record Keeping, Featuring the "King of Desks"
By Sam Bierstock, MD, BSEE

With the digital age has come the rejection and vilification of paper. The entire healthcare industry has been on a writhing, agonal path to the adoption of electronic health records for more than a decade.

Have you ever wondered, though, about the transition to paper record keeping?

In a previous historical perspective, I paid tribute to Joseph Lister and his Herculean efforts to convince physicians and hospitals about the need for asepsis – the champion of champions of physician adoption. Compared to today’s challenges with physician adoption of technology, it took Lister almost 20 years to move past ridicule and 30 years to see his arguments fully appreciated and his recommendations put into practice.

In the world of paper record keeping, another, less well-known 19th century figure deserves recognition – William S. Wooton.

We have been documenting on paper for centuries. It is fascinating to walk through Jerusalem’s Israel Museum and browse through the ancient, centuries-old handwritten documents dealing with issues that persist to this day – contracts of sale, employment, marriage, divorce, debt, inheritance, and all other matters of transaction, discord, and agreement. Record keeping of the day involved rolling documents and wrapping ties of various sorts around the resultant paper cylinder for storage in jugs or other designated compartments. Copies were reproduced by hand. Larger and longer documents were recorded on scrolls that piled up in corners and on tables.

Paper record keeping progressed slowly, the most major advance in printing of course coming as a result of the invention of the paper press by Gutenberg in the mid-15th century. Still, business transactions were maintained in ledgers and entered by hand. Essentially no written records were kept by physicians, even well into the 19th century. Past history and treatments administered were simply left to the physicians’ memory and the strength of physician-patient relationships over time.

In today’s world, we recognize the need for record keeping to maximize our ability to deliver the best possible care, overcome our limited memories, and ever increasingly, to protect ourselves as caregivers from medico-legal vulnerability.

In ancient civilizations, shamans with consistently poor therapeutic results were often dealt with simply and quickly by being killed. Evidently, iatrogenic patterns have been recognized for a very long period of time. Greece, Rome, and later Europe during the Middle Ages were much more forgiving, often having laws in place to provide immunity for misjudgments of doctors. During the Great Plague in the 14th century, almost one-third of England’s population perished, and people began to wonder if it was possible that physicians of the day didn’t actually know what the hell they were doing. But the idea of medical record keeping still did not occupy the concerns of physician for centuries after the Plague.

It is not clear as to when physicians began to understand the need for complete record keeping. I am old enough to remember my own family doctor maintaining my entire record on a set of index cards, and it’s not that long ago that I saw practices where physicians kept the records of an entire family in single file. It is my personal belief that medical note-taking probably became much more prevalent with the availability of the fountain pen, which made the act of writing much less arduous and certainly more portable. Beginning in the middle of the 20th century, we must reluctantly tip our hats to malpractice attorneys who made it painfully obvious to us that we needed to defend our decisions and actions.

The first recorded malpractice case was probably that heard before the court of John Cavendish of the Court of King’s Bench in 1375. A highly regarded surgeon by the name of John Swanlond had treated the crushed and mangled hand of one Agnes of Stratton. The condition of her hand had not improved after a few weeks and the patient consulted a second surgeon, who informed her that Dr. Swanlond’s treatment was deficient. When her hand became severely deformed, she sued Swanlond. Although the suit was voided because of a technical error made by the patient’s lawyer, the judge made the following note in his written opinion: "If a smith undertakes to cure my horse, and the horse is harmed by his negligence or failure to cure in a reasonable time, it is just that he should be liable." This case set the precedent upon which has rested all subsequent Western malpractice litigation.

The first recorded malpractice case in the United States (Cross v. Guthery) was heard in Connecticut shortly before the American Revolution. “When Mrs. Cross complained that there was something wrong with her breast, her husband sent for a doctor named Guthery. The doctor examined Mrs. Cross, diagnosed her ailment as scrofula, and amputated her breast. Shortly after the surgery, Mrs. Cross hemorrhaged to death. Dr. Guthery expressed his regrets to her husband and then sent him a bill for 15 pounds. Cross hired a lawyer, who persuaded a jury to dismiss Dr. Guthery’s bill and award Cross 40 pounds as compensation for the loss of his wife’s companionship."

In the United States, the years following the Civil War began an age of remarkable industrialization and business growth. Until then, most businesses were run by one or two principals, often in the same family. Services were provided directly and most material products were constructed on site. Paperwork requirements were therefore low. Customer interactions were recorded by hand in ledgers, and payment for employment services was generally in coin or via bank draft. After the war ended, enormous growth of commerce combined with technical advances allowed for massive growth of business. White collar workers were needed and their numbers increased at a very rapid rate. At the same time, the first fountain pens and typewriters appeared, as did carbon paper and the first rudimentary copying machines.

Within the space of one or two decades, businesses had a new problem – a lot of paper and a need to keep it filed in an orderly fashion and readily accessible.

William Wooton was born in 1835. He was employed during the 1860s as a furniture maker in Illinois. The idea struck him that if he could build school desk and chairs in a single unit that folded up and could be moved, a classroom could serve multiple purposes, including such activities as both teaching and gymnastics. After obtaining a patent on his design for a foldable school desk and chair assembly, he opened his own furniture-making company in Indianapolis in 1870 and achieved rapid success selling school and church furniture.

As his business grew, he observed his own employees taking and fulfilling orders, and struggling with paperwork strewn about. Wooton then realized that businessmen needed an efficient way to file and keep their ever-growing accumulations of paper organized. From this realization, came his design which ultimately earned him the title "King of Desks" – the Wooton Patent Desk.

Produced between 1874 and 1885 to 1889 (it is unclear when the actual last desk was produced – some may have been produced into the 1890s), the Wooton Desks were (and are) magnificent pieces of furniture, with 110 compartments for storing documents. Two large swinging doors open to reveal a folded-up desk top, which when lowered, exposes more storage bins. A slot is usually present on the left front of the desk for a built-in mailbox. A horizontal hidden cabinet is present above the desktop for even more paper storage. Wooton also patented and produced a flat desk with pedestals containing rotating sections which contained filing bins and shelves.

The upright Wooton Desk came in four styles: Regular, Standard, Extra and Superior. Although production peaked at one point at 150 desks per month, it is estimated that as few as 12 Superior-grade Wooton desks were produced. Ownership of one of these desks was considered a status symbol and a privilege of the wealthy. They ranged in price from $75 to $750, equivalent of $1,531 to $12,765 in 21st-century dollars. Four US presidents are known to have been Wooton desk owners: Grant, Garfield, Harrison, and McKinley, as well as John D. Rockefeller, Joseph Pulitzer, and railroad magnate and speculator Jay Gould. Queen Victoria also commissioned a Wooton desk. Three are in the possession of the Smithsonian Institute, one being President Grant’s. One of the desks purchased new by the Smithsonian in 1876 has now been in continuous use for 137 years.

William S. Wooton conceived of, designed, patented, and produced the both the Wooton Patent Desk and the Wooton Pedestal “Rotary” Desk between 1872 and 1885. In 1884, he abruptly left his successful company to become a Quaker preacher, leaving the company management to others. Business reversals followed as the company could not keep up with demand, leading to slowed production after 1885 and closure around 1889. Wooton died in 1907 at the age of 72.

I saw my first Wooton Desk in the office of a realtor when I was setting up my practice in 1977 and was instantly smitten. I immediately offered to buy it, but didn’t have the money. Today, I am a proud owner of a Standard style Wooton desk, and find an ultimate irony in placing my laptop on the desk surface. Having spent my professional career advocating the adoption of electronic health record systems and the elimination of paper, beginning almost exactly 100 years after Wooton dedicated his life to maximizing the efficiency of working on paper, the irony seems exceptional. To use a computer on a Wooton desk seems to bring together two completely contradictory forces of history – one representing the ultimate and revolutionary means of its day for controlling paper record keeping, and the other a tool designed as the ultimate solution to the elimination of as much paper as possible.

Original “Standard” style Wooton Desk

“Standard” style Wooton desk with doors open and desktop down

An “Extra” style Wooton desk

A pedestal-style Rotary Wooton Desk

Rare single-pedestal roll-top Wooton Desk

The Ultimate Irony

If anyone is interested in learning more about Wooton desks, please feel free to contact me at samb@championsinhealthcare.com.

Sam Bierstock, MD, BSEE is the founder of Champions in Healthcare, www.championsinhealthcare.com, a widely published author, and popular featured speaker on issues at the forefront of the healthcare industry.